Femoral shaft fractures are among the most common long bone fractures in pediatric patients, constituting approximately 1.6% of all pediatric fractures. ^[1] These fractures result from high-energy trauma, such as road traffic accidents (RTAs) and falls from height, making them a significant concern in pediatric orthopedic trauma. ^[2] The management of femoral shaft fractures varies according to patient age, fracture pattern, and associated injuries, necessitating a tailored approach for optimal outcomes. ^[3] 

Traditionally, non-operative management, including spica casting and traction, was the mainstay of treatment for pediatric femoral fractures, especially in younger children. ^[4] However, with advancements in surgical techniques and an increased emphasis on early mobilization, operative interventions have gained preference, particularly in older children and adolescents. ^[5] Among the various surgical options, intramedullary fixation using the Titanium Elastic Nailing System (TENS) has emerged as a gold standard due to its minimally invasive nature, biomechanical stability, and early functional recovery. ^[6]

TENS provides adequate stabilization through elastic fixation, which allows for micro-motion at the fracture site, stimulating callus formation while maintaining axial and rotational stability. ^[7] Compared to rigid fixation methods like plating or external fixation, TENS minimizes soft tissue disruption, preserves the periosteal blood supply, and reduces the risk of physeal damage. ^[8] The elasticity of titanium nails facilitates bone healing while preventing stress shielding and secondary fractures. ^[9]

Several studies have demonstrated superior outcomes with TENS compared to conventional methods, with patients experiencing faster healing times, early weight-bearing, and minimal postoperative complications. ^[10] However, potential challenges such as nail prominence, irritation at the entry site, malalignment, and rare cases of delayed union have been reported. ^[12] Proper patient selection, meticulous surgical technique, and post-operative rehabilitation protocols play a crucial role in ensuring the best possible functional outcomes. ^[12]

This study aims to assess the functional outcomes of pediatric femoral shaft fractures treated with TENS, with a focus on healing time, weight-bearing progression, complications, and overall recovery based on Flynn’s criteria. The findings will contribute to existing literature and aid in optimizing management strategies for pediatric femoral fractures.

A prospective study was conducted over a period of 1 year in the Department of Orthopedics, Shadan Institute of Medical Sciences, Teaching Hospital & Research Centre. Patients aged 5–16 years diagnosed with closed femoral shaft fractures and treated with TENS were included.

Inclusion Criteria:

• Pediatric patients aged 5–16 years
• Closed femoral shaft fractures
• Patients treated with TENS
• Patients with a follow-up period of at least six months

Exclusion Criteria:

• Open fractures
• Pathological fractures
• Polytrauma patients with head injury requiring intensive care
• Patients with metabolic bone disease

Surgical Technique: Under general or spinal anesthesia, two titanium elastic nails were inserted through the lateral and medial entry points at the distal femur. Fracture reduction was achieved under fluoroscopic guidance, and nails were advanced to stabilize the fracture. Postoperatively, partial weight-bearing was initiated after four to six weeks, depending on radiological signs of healing.

Outcome Assessment: Functional outcome was assessed based on:

• Time to radiological union
• Flynn’s criteria for outcome assessment
• Complications such as limb length discrepancy, infection, nail irritation, or re-fracture

Table 1: Demographic Data

Table 2: Fracture Characteristics

The most common fracture type in this dataset is transverse (25 cases), followed by oblique (15 cases) and comminuted (10 cases). This distribution suggests that the majority of fractures in this dataset are relatively stable (transverse and oblique), with a smaller proportion being more complex (comminuted).

Table 3: Healing and Weight-Bearing Progression

The fracture heals on average in 8.2 weeks, but full functional recovery (full weight-bearing) takes longer, at 10 weeks. Patients can begin partial weight-bearing at 6 weeks, which is an important milestone in the rehabilitation process.

Table 4: Complications

The most common complication in this dataset is nail prominence (6%), followed by limb length discrepancy (4%) and infection (2%).

Table 5: Functional Outcome by Flynn’s Criteria

The majority of patients (40 out of 50, or 80%) achieved an excellent outcome. A smaller proportion (8 out of 50, or 16%) had a satisfactory outcome. Only a few patients (2 out of 50, or 4%) had a poor outcome.

The results of this study reinforce the efficacy of TENS in pediatric femoral shaft fractures, showing a high rate of union within an average of 8.2 weeks. The ability to initiate early weight-bearing is one of the primary advantages of this technique, reducing complications associated with prolonged immobilization.

In this study, the most common fracture type in this dataset is transverse (25 cases), followed by oblique (15 cases) and comminuted (10 cases). This distribution suggests that the majority of fractures in this dataset are relatively stable (transverse and oblique), with a smaller proportion being more complex (comminuted).

In current study the most common complication in this dataset is nail prominence (6%), followed by limb length discrepancy (4%) and infection (2%). Our study found a complication rate comparable to existing literature, with minor issues such as nail prominence (6%) and limb length discrepancy (4%). ^[13] These are manageable with proper surgical technique and follow-up. ^[15] A review of previous studies suggests that patients treated with TENS experience better functional recovery compared to traction or plating. ^[16]

TENS is particularly advantageous in skeletally immature patients as it provides stable fixation without disrupting the growth plate. ^[17] Furthermore, the results of Flynn’s criteria demonstrate excellent to satisfactory outcomes in 96% of cases, highlighting the reliability of this technique. ^[18]

TENS is an effective treatment modality for pediatric femoral shaft fractures, ensuring rapid union, early ambulation, and minimal complications. It remains a preferred choice for children aged 5–16 years due to its minimally invasive nature and functional benefits.

1. Luhmann SJ, Schootman M, Schoenecker PL, et al. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop. 2003;23(4):443-447.
2. Sink EL, Faro F, Polousky J, et al. Decreased complications of pediatric femur fractures with a change in management. J Pediatr Orthop. 2010;30(7):633-637.
3. Lascombes P, Haumont T, Journeau P. Use and limits of flexible intramedullary nailing in children. Injury. 2016;47(Suppl 1):S27-S32.
4. Hunter JB. The principles of elastic stable intramedullary nailing in children. Injury. 2005;36(Suppl 1):A20-A24.
5. Beaty JH, Kasser JR. Rockwood and Wilkins’ Fractures in Children. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2015.
6. Saseendar S, Agarwal DK, Klenerman L. Pediatric femoral fractures: is Titanium Elastic Nailing System the best choice? Indian J Orthop. 2010;44(1):73-76.
7. Jubel A, Andermahr J, Schiffer G, et al. Is intramedullary nailing in pediatric femur fractures predictable? J Trauma. 2005;58(6):1002-1007.
8. Moroz LA, Launay F, Kocher MS, et al. Titanium elastic nailing of fractures of the femur in children: predictors of complications and poor outcome. J Bone Joint Surg Br. 2006;88(10):1361-1366.
9. Wall EJ, Jain V, Vora V, et al. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Bone Joint Surg Am. 2008;90(6):1305-1313.
10. Lee SS, Mahar AT, Newton PO. Biomechanical comparison of four pediatric femur fracture fixation techniques. J Pediatr Orthop. 2006;26(4):510-514.
11. Gamal O, El-Adl G, Azzam W. Titanium elastic nail versus hip spica cast in pediatric femoral shaft fractures. J Orthop Traumatol. 2016;17(3):239-246.
12. Kocher MS, Sink EL, Blasier RD, et al. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009;17(11):718-725.
13. Slongo T, Audigé L, Schlickewei W, et al. Development and validation of the AO Pediatric Comprehensive Classification of Long Bone Fractures by the Pediatric Expert Group of the AO Foundation. J Pediatr Orthop. 2006;26(1):43-49.
14. Parikh SN, Jain VV, Denning J. Complications of elastic stable intramedullary nailing in pediatric femoral fractures. Pediatr Orthop. 2014;34(7):704-709.
15. Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg. 2004;12(5):347-359.
16. Gordon JE, Swenson AL, Schoenecker PL, et al. Pediatric femur fractures: a comparison of treatment in the early and late 20th century. J Pediatr Orthop. 2013;33(6):614-618.
17. Sheikh HQ, Aqil A, Irfan A, et al. The role of flexible intramedullary nails in femoral fractures in the pediatric population: a systematic review. Acta Orthop Belg. 2017;83(4):615-625.
18. Agarwal A, Qureshi NA, Khan SA, et al. Pediatric femoral fractures: outcomes of TENS versus hip spica cast. J Pediatr Orthop B. 2020;29(1):45-52.