Influence of titanium elastic nail pre-contouring on fracture reduction of paediatric diaphyseal forearm fractures

Influence of titanium elastic nail pre-contouring on fracture reduction of paediatric diaphyseal forearm fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Influence of titanium elastic nail pre-contouring on fracture reduction of paediatric diaphyseal forearm fractures Yavor Pukalski, Jocelyne Auroi, Parvan Yanev, Mihail Rashkov, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8193814/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Mar, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose: To radiologically investigate in a human cadaveric model the effect of nail shape on fracture reduction in pediatric transverse diaphyseal fractures of the radius and ulna using straight nails, pre-contoured, or a combination of both. Methods: Twelve human cadaveric forearms from six adult donors were used and standardized AO PCCF 22-D/4.1 transverse diaphyseal fractures of the radius and ulna were created. Titanium elastic nails (TENs) were inserted retrograde in the radius and anterograde in the ulna creating 3 groups with either 2 straight TENs (Group1), 1 straight and 1 curved TEN (Group2), or 2 curved TEN (Group3). Anteroposterior radiographs of each intact and instrumented specimen in each group were taken in supination. Parameters of interest included total bone length and maximal radial bow (MRB) Results: After TEN instrumentation MRB decreased significantly in Group1 and increased significantly in Group2 (p≤0.003), however, it was without a significant change in Group3 (p=0.113). In addition, MRB in instrumented state was significantly lower in Group1 versus both Group2 and Group3 (p ≤0.005). Both total bone lengths remained nearly unchanged after instrumentation across the groups (p≥0.608). Conclusion: The use of two curved TENs resulted in smallest deviation from the natural anatomical alignment after reduction of both-bone pediatric forearm fractures. Fixation of these fractures with one straight and one curved TEN leads to overcorrection of the radial bow whereas utilization of two straight TENs leads to the most inferior results, with reduction of the radial bow and anticipated loss of range of motion in the forearm. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Forearm fractures represent the third most common type of fracture in the pediatric population 1 , 2 and are clearly more frequent in children than in adults 3 . Diaphyseal forearm fractures involving both the radius and ulna account for approximately 5.4% of all pediatric fractures in individuals younger than 16 years 4 and in children under the age of 7, whereas both-bone fractures occur at nearly the same frequency as isolated radial fractures 3 . An unexplained increase in the incidence of pediatric distal forearm fractures has been observed in multiple studies over the recent 30 years 5 , 6 with some authors reporting its four-fold raise 7 . Optimal treatment of these fractures depends on both fracture morphology and patient's age 8 . The intrinsic remodeling ability of pediatric bones allows for effective conservative treatment in the majority of radial and ulnar shaft fractures that show minimal or no displacement 5 but both-bone forearm shaft fractures are the most common reason for surgery of the forearm in children 10 . Since its introduction in the 1980s, the elastic stable intramedullary (IM) nailing (ESIN) technique has gradually become the gold standard in the treatment of diaphyseal long bone fractures in children 11 . In shaft fractures of both forearm bones it has proven to be a safe and technically less-demanding method to achieve stability with low risk of complications and good long-term results. Implants for ESIN are most commonly made of titanium alloy (Ti-6Al-4V) in the form of Titanium Elastic Nails (TENs) or made of stainless steel (316L), with diameters ranging from 1.5 to 4.0 mm. By reducing the diameter of a titanium nail its rigidness also decreases. Stainless steel nails are stiffer and can be used when a nail with a smaller diameter is required for stabilization 12 . Muscular traction can sustain fracture displacement, especially in long bones. ESIN counters these forces by applying internal pressure against the cortex from within the IM canal. The use of TENs offers two main advantages, namely biocompatibility and elasticity 13 . A pre-bent elastic nail, as long as it remains within its elastic range, constantly attempts to return to its original shape 14 . This creates a dynamic stabilization effect by exerting pressure at three key points: the proximal end, the distal end, and the apex of the curve (Fig. 1 ). This mechanism allows for both elastic reduction and stabilization of the fracture. In case of fractures of both forearm bones, standard recommendations are to pre-bend both nails in a C-shape and to select implant diameters corresponding to 40–50% of the IM canal diameter. The opposing curvatures create balanced elastic forces transmitted through the interosseous membrane and improving construct stability. Most authors recommend using implants of the same diameter for fractures involving both forearm bones, although some reports suggest selecting different nail sizes based on the individual anatomy of each bone 15 . Surgical techniques using only straight nails are still in use; however, most studies investigating this technique focus on procedures that fix only one of the two forearm bones 16 , 17 . Some authors even support the concept of single-bone fixation, regardless of the nail’s shape 18 , 19 . On anteroposterior view, the intact radius shows a C-shaped bowing, with the radial bow corresponding to a mid-diaphyseal deviation not exceeding 10% of its total length 20 . The ulna, although considered as a straight bone for clinical purposes, has a lazy-S shaped diaphysis with anterolateral deviation in the proximal third and anteromedial deviation in the distal fifth of the bone. Variations in IM canal diameter are common. It is important to consider the radius and ulna as a functional unit, given that they are interconnected by the interosseous membrane. Forearm rotation is highly dependent on regular anatomy, especially on a normal contour of the radial bow 21 . Given the anatomical and biomechanical characteristics of the pediatric forearm, ESIN has become a widely adopted technique. The substantial rise in the operative management of both-bone forearm fractures in recent decades 22 , coupled with the absence of a clear consensus on the optimal surgical technique, highlights the need for further investigation. It was therefore the aim of this study to radiologically investigate postoperative radiological outcomes after stabilization of artificially created AO PCCF 22-4D/4.1 fractures with either two straight TENs, two pre-contoured TENs, or one straight and one pre-contoured TEN in human cadaveric forearm bones. Materials and methods Specimen preparation Twelve paired fresh-frozen (-20°C) human cadaveric forearms from 6 adult donors (3 males, 3 females) aged 62.9 years on average (range 29–89 years) were used. All donors gave their informed consent inherent within the donation of the anatomical gift statement during their lifetime. Radiological imaging, including computed tomography (CT) at a 0.3 mm slice resolution (Somatom Emotion, Siemens, Camberley, UK), was performed to exclude pathologies, prior surgeries, and defects affecting the integrity of the specimens. The specimens were thawed for 12 hours, dearticulated at the elbow and radiocarpal joints, while all soft tissues were left intact. Based on the CT data, measurements at the narrowest part of the IM cavity, namely the central portion of the radius and the junction between the distal and the middle third of the ulna, were performed to define the isthmus diameter of both radial and ulnar bones of each specimen in order to determine the appropriate diameter of the TEN. Subsequently, anteroposterior (AP) radiographs in supination of all intact forearms were obtained using a digital radiography system (Bucky Diagnost Trauma II, Amsterdam, The Netherlands) on a Picture Archiving and Communication System (PACS, easyIMAGE, VetZ GmbH, Isernhagen, Germany). Subsequently, transverse osteotomies were performed at the same level in both radius and ulna of each specimen, at 50% of the radial length as measured with a digital caliper, to simulate an AO PCCF 22-D/4.1 fracture since transverse and short oblique fractures are most frequent 23 . Study groups The 12 forearms were assigned pairwise to two groups, each consisting of six specimens (three left and three right). In Group 1, the specimens were initially selected for stabilization using two straight TENs (non-contoured). After accomplishment of all measurements, each radial nail was replaced with a pre-contoured nail (Group 2), resulting in two distinct osteosynthesis configurations from the same specimens. The contralateral forearms were selected for stabilization using two identically curved pre-bent nails for both radius and ulna (Group 3). This methodology resulted in 3 study groups, each comprising 6 osteosynthesis constructs. Surgical technique For instrumentation of all specimens, an appropriate implant size was selected to match 50% of the isthmus diameter of each specimen as previously measured via CT. In case of a difference in the canal diameters between the radius and the ulna, the smaller canal was used as reference. Implant size values were rounded for implant selection (eg, 2.4mm to 2.5mm; 2.1mm to 2.0mm) following the recommendation by Lascombes et al. 24 , stating that when the measurement was halfway between available implant sizes (eg, 2.3mm), the bigger must be chosen. TENs with diameters of 2mm, 2.5mm or 3mm (Königsee Implantate GmbH, Allendorf, Germany) were used and all procedures were performed by an experienced surgeon who routinely performs one to two TEN procedures per week on average. All radii were instrumented in a retrograde fashion after a longitudinal incision. A lateral entry point of 4cm above the radiocarpal joint line was selected with a drill of an appropriate diameter (2mm, 2.5mm, or 3.0mm), angulated at 45°. The nails were advanced and rotated with the aid of a T-handle and gentle hammer blows to reach the level of the middle of the radial tuberosity facing towards the ulna. All ulnae were instrumented in an antegrade fashion via a typical anconeus portal approach. The entry point was chosen posterolaterally, 4cm distally to the olecranon, using a drill of an appropriate diameter angulated at 45°. The nail was advanced and rotated with the aid of a T-handle and gentle hammer blows until reaching a level of 15mm proximally to the distal radioulnar joint facing towards the radius. All implants were cut above the level of the soft tissues for practical purposes and AP radiographs in supination were taken for each instrumented specimen in each group (Fig. 2 ). Data acquisition and evaluation Based on the AP radiographs, the following 7 parameters were measured for intact and instrumented specimens, following the method of Schemitsch and Richards 25 (Fig. 3 ): total ulnar length (UL); total radial length (RL); length from tuberosity radii to a point on a line between the tuberosity radii and the sigmoid notch where a perpendicular line to the radial bone marks the greatest distance (RLx); length from tuberosity radii to sigmoid notch (RLy); maximal radial bow defined as the maximum length of a perpendicular line from the point defined by RLx to the radial bone (MRB); maximal radial bow as percentage of RLy (MRB%); location of the maximal radial bow as percentage of RLy (LMRB%). In addition, ulnar angulation (UA) and radial angulation (RA) were defined and measured on the AP radiographs as the angle between the longitudinal axes of the proximal and distal radial segments of the instrumented forearms (Fig. 4 ). Statistical analysis Statistical analysis was performed using SPSS software package (SPSS Statistics, IBM, Armonk, NY, USA). Normality of data distribution was checked and proved with Shapiro–Wilk test. Significant differences between the specimens’ states and groups were screened using Paired-Samples t -test and General Model Repeated Measures with Bonferroni post-hoc tests for multiple comparisons. Level of significance was set to 0.05 for all statistical tests. Results Nail diameter of all instrumented specimens was 2.6 mm on average (standard deviation, SD 0.5), being consistent across the groups (p = 0.994). Mean UL of the intact specimens was 267.5 mm (SD 27.8) in both Group 1 and Group 2, and 268.3 mm (SD 27.6) in Group 3 (p = 0.436). It remained nearly unchanged after instrumentation, with mean values of 267.0 mm (SD 28.1) in both Group 1 in Group 2, and 268.2 mm (SD 26.6) in Group 3 (p = 0.992). Similarly, mean RL of the intact specimens was 235.5 mm (SD 22.6) in both Group 1 and Group 2, and 237.4 mm (SD 20.6) in Group 3 (p = 0.616) and also remained nearly unchanged after instrumentation, with mean values of 235.2 mm (SD 22.5) in both Group 1 in Group 2, and 237.0 mm (SD 20.7) in Group 3 (p = 0.608). The osteotomy level as measured from the most proximal part of the radius was 11.8 mm (SD 1.1) in both Group 1 and Group 2, and 11.9 (SD 1.0) in Group 3 (p = 0.997). Outcome measures for the other parameters of interest are summarized for each separate group and specimen’s state in Table 1 . MRB and MRB% before and after instrumentation are depicted in Fig. 5 a, and RA after instrumentation – in Fig. 5 b. After instrumentation both MRB and MRB% decreased significantly in Group 1 and increased significantly in Group 2 (p ≤ 0.003). Moreover, MRB and MRB% in instrumented state were significantly lower in Group 1 versus both Group 2 and Group 3 (p ≤ 0.005) and significantly different between Group 2 and Group 3 (p ≤ 0.040). RA was significantly lower in Group 1 versus both Group 2 and Group 3 (p ≤ 0.013), and significantly different between Group 2 and Group 3 (p = 0.017). Discussion The current study investigated experimentally postoperative radiological outcomes after TEN fixations of artificially created AO PCCF 22-4D/4.1 fractures in human cadaveric forearm specimens. Three groups were compared, namely implementing either two straight TENs, one straight and one pre-contoured TEN, or two pre-contoured TENs. As a main finding, transverse fractures fixed with two pre-contoured nails achieved a more anatomical alignment compared to the other fixation techniques, closely matching the intact forearm. This effect was particularly evident when compared with osteosynthesis performed using two straight nails. Younger children, particularly under 10 years of age, can tolerate up to 100% translational displacement (ad latus) due to their high remodeling capacity 26 . Additionally, angulation of up to 10–15° is generally considered acceptable in this age group. Above the age of 10 years this threshold decreases to 10° 27,28 . Loss of range of motion (ROM) due to angulation can alter the rotation of the forearm, which was extensively studied by Matthews et al 29 on forearm specimens with midshaft fractures. The authors concluded that 10° angulation (dorsal, volar or towards the interosseous membrane) of any of the two bones leads to practically no loss of motion (< 3°). On the other hand, 10° angulation of both bones leads to larger deficits (10° of pronation and 20° of supination), whereas 20° deformity equaled approximately 40° pro-supination loss. Outcomes also strongly correlate with the level of the fracture 30 , 31 and additional rotational malalignment. The fact that angular malalignment leads to an impaired ability to rotate the forearm is explained due to its anatomy. The radius has a physiological bow that enables it to rotate around the ulna. The measurement of MRB is therefore particularly important for assessing forearm function, specifically pronation and supination 32 . While loss of pronation can be somewhat compensated by shoulder abduction, supination does not have such a compensatory mechanism 33 , 34 . A reduction in MRB has also been associated with a loss of strength 32 , 35 . When comparing the maximal radial bow, the specimens instrumented with two straight nails showed the biggest loss of radial bowing, with а mean decrease of 3.7mm. A similar pattern was observed for MRB%, with a mean decrease of 1.85%. As noted by Goldfarb et al., a MRB decrease of more than 2.3mm leads to a reduction in rotation exceeding 20% 36 . In contrast to other deformities, however, the exact magnitude of its clinical consequences cannot be predicted with certainty, although its potential impact on forearm function is well recognized 36 . The specimens in Group 2, instrumented with one straight and one curved nail, also demonstrated significant changes compared to intact forearms. However, in contrast to Group 1, this fixation method produced an overcorrection (increase) of radial bowing by 1.88mm on average. To our knowledge, no study has demonstrated a correlation between overcorrection of the radial bow and restriction in forearm ROM so far. Balaji et al 35 reported a non-significant increase in the extent of pronation with greater radial bow, though further investigation into this potential relationship is warranted. Comparison of the intact and instrumented forearms in Group 3 showed no significant changes in the parameters explored and had the best radiographic results with close to anatomic reduction of the bones. One of the main surgical indications for pediatric forearm fractures is axial shortening greater than 1cm 27 , 33 . In the current study, no significant change in length was observed after osteosynthesis among the groups for both radius and ulna. It is important to keep in mind that approximately 70 to 80% of the longitudinal growth of the radius and ulna occurs at the distal physis 37 – a region that should be preserved during surgical intervention. Physeal closure of both bones is variable and gender dependent; the proximal physis closes firstly near 14–15 years of age, followed by the distal physis at around 15–18 years 38 , 39 . The alternative treatment method to the insertion of a TEN is plating. However, it may endanger the growth plate if improperly positioned. Interestingly, Reinhardt et al found no significantly higher risk after plating versus intramedullary nailing when performed correctly 40 . This study has some limitations inherent to all experimental investigations. First, although anatomical differences exist between pediatric and adult bones, adult cadaveric forearms had to be used due to the unavailability of pediatric donors. Second, the growth-related remodeling potential of pediatric bone could not be replicated, however, existing literature on acceptable tolerances allows indirect interpretation of the obtained results. Third, although using cadaveric bones provides an anatomy closely reflecting reality, they lack the dynamic muscular traction forces that are fundamental to the ESIN fixation principle. This limitation is common to many experimental studies; however, it is hypothesized that in clinical practice any adverse effect of imperfect nail contouring would likely be mitigated – rather than amplified – by muscle forces. Fourth, despite efforts to optimize anatomical homogeneity across the groups, slight variations persisted. A larger sample size would have reduced the influence of this variability. Fifth, due to the limited number of specimens, the same forearm was reused in Groups 1 and Group 2 by exchanging the radial nail from straight to pre-contoured, which could have influenced the results. Clinically, nail exchange is considered acceptable and does not compromise outcomes 41 , 42 , justifying this approach as reasonable. Sixth, all measurements were performed on X-ray images only, making them susceptible to projection errors. However, this study serves as a pilot and further research is needed to evaluate the influence of different TENs on pediatric forearm fractures using three-dimensional measurements. Lastly, only titanium implants were tested. Future research should evaluate whether stainless steel implants with their different mechanical properties 43 , 44 result in similar outcomes. Conclusion The use of two curved TENs resulted in the smallest deviation from the natural anatomical alignment after reduction of both-bone pediatric forearm fractures. Fixation of these fractures with one straight and one curved TEN leads to overcorrection of the radial bow whereas utilization of two straight TENs leads to the most inferior results, with reduction of the radial bow and anticipated loss of range of motion in the forearm of treated patients. Declarations Ethics approval and consent to participate. All procedures performed in this study were followed in accordance with relevant guidelines. This study was approved by the institutional internal review board, based on the approval of the specimens' delivery by Science Care Ethics Committee. All donors gave their informed consent inherent within the donation of the anatomical gift statement during their lifetime, as registered by Science Care. Conflict of interests The authors declare that they have no competing interests. Acknowledgments and funding information The authors are not compensated and there are no other institutional subsidies, corporate affiliations, or funding sources supporting this work unless clearly documented and disclosed. This study was performed with the assistance of the AO Foundation Authors' contributions YP, JA, TaP, BG, AB, IZ and ToP: designed the study. PY, MR, FS and IZ performed instrumentation and measurement. YP, CS, AB and IZ obtained data. BG and IZ performed statistical analysis. TaP, YP, JA, IZ, BG, DE and ToP interpreted results. GR, BG and ToP supervised the study. YP, JA, TaP, DE wrote the original draft of the manuscript, which was next revised in detail first by IZ, ToP and BG. Subsequent drafts were prepared by all authors. All authors read and approved the final manuscript. Acknowledgements This investigation was performed with the assistance of the AO Foundation. Funding The authors are not compensated and there are no other institutional subsidies, corporate affiliations, or funding sources supporting this work. This study was performed with the assistance of the AO Foundation References Kwas K, Mostowy M, Szatanik K, Małecki K. Elastic stable intramedullary nailing in paediatric diaphyseal forearm fractures - a retrospective analysis of 201 cases. BMC Musculoskelet Disord. 2024;25(1):855. 10.1186/s12891-024-07959-0 . Joeris A, Lutz N, Wicki B, Slongo T, Audigé L. An epidemiological evaluation of pediatric long bone fractures — a retrospective cohort study of 2716 patients from two Swiss tertiary pediatric hospitals. BMC Pediatr. 2014;14:314. 10.1186/s12887-014-0314-3 . Husum HC, Kold S, Rahbek O. The Distribution of Paediatric Forearm Fractures: A Five-Year Retrospective Cohort Study of 4546 Forearm Fractures in Children. Children. 2025;12(6):711. 10.3390/children12060711 . Rafi BM, Tiwari V. Forearm Fractures. In: StatPearls . 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Supplementary Files Table1.docx Cite Share Download PDF Status: Published Journal Publication published 13 Mar, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 06 Dec, 2025 Reviews received at journal 04 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers invited by journal 03 Dec, 2025 Editor assigned by journal 03 Dec, 2025 Submission checks completed at journal 25 Nov, 2025 First submitted to journal 24 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8193814","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":555260475,"identity":"9adc7f33-61d5-4b9c-914d-6ac5a5c2b7d9","order_by":0,"name":"Yavor Pukalski","email":"","orcid":"","institution":"AO Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Yavor","middleName":"","lastName":"Pukalski","suffix":""},{"id":555260476,"identity":"80446931-30fb-45c3-8a69-d6ba5e81f606","order_by":1,"name":"Jocelyne Auroi","email":"","orcid":"","institution":"Praxis Hand Chirurgie de la 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07:50:58","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":139297,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8193814/v1/263f70a47c9aeaff1691f056.html"},{"id":97660767,"identity":"2bee4797-af10-4545-9eb2-f55d18ff8ed2","added_by":"auto","created_at":"2025-12-08 07:50:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26943,"visible":true,"origin":"","legend":"\u003cp\u003eScheme of ulnar and radial bone shaft fractures treated with TENs. The arrows correspond to the force exerted by the nails. At the fracture level, each nail is rotated 180° using the T-handle.\u003c/p\u003e","description":"","filename":"OnlineFig1.png","url":"https://assets-eu.researchsquare.com/files/rs-8193814/v1/b9288f5e2d6eb5eb76cadee3.png"},{"id":97674848,"identity":"b17c9b95-3407-497b-b7b9-2c561b5d9558","added_by":"auto","created_at":"2025-12-08 09:44:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":171782,"visible":true,"origin":"","legend":"\u003cp\u003eAP radiographs of exemplified instrumented specimens from Group 1 (2 straight TENs, left), Group 2 (1 straight TEN and 1 curved TEN, middle), and Group 3 (2 curved TENs, right).\u003c/p\u003e","description":"","filename":"OnlineFig2.png","url":"https://assets-eu.researchsquare.com/files/rs-8193814/v1/00598935cee494c65f82176b.png"},{"id":97660772,"identity":"a43c66ea-7f81-466a-b835-45ca03c7e7c1","added_by":"auto","created_at":"2025-12-08 07:50:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21431,"visible":true,"origin":"","legend":"\u003cp\u003eDrawing used for measurements of the total ulnar length (UL), total radial length (RL), length from the tuberosity radii to a point on a line between the tuberosity radii and the sigmoid notch where a perpendicular line to the radial bone marks the greatest distance (RLx), length from tuberosity radii to sigmoid notch (RLy), and maximal radial bow (MRB).\u003c/p\u003e","description":"","filename":"OnlineFig3.png","url":"https://assets-eu.researchsquare.com/files/rs-8193814/v1/05eb53929344ffd5742288e7.png"},{"id":97660770,"identity":"35b7cd08-d8d5-4303-b2ce-57197671557c","added_by":"auto","created_at":"2025-12-08 07:50:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":13011,"visible":true,"origin":"","legend":"\u003cp\u003eDrawing used for measurement of the radial angulation (RA), defined as the angle between the axes of the proximal and distal radial segments of the instrumented radius using a best-fit circle centered at a distance of 30mm from the osteotomy level on its both sides. The ulnar angulation (UA) was measured according to the same principle.\u003c/p\u003e","description":"","filename":"OnlineFig4.png","url":"https://assets-eu.researchsquare.com/files/rs-8193814/v1/1b4b884a020532d52a7eef3e.png"},{"id":97660781,"identity":"c15d5e06-88bf-4adb-8f63-856a8514b661","added_by":"auto","created_at":"2025-12-08 07:50:58","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":18775,"visible":true,"origin":"","legend":"\u003cp\u003e(a) maximal radial bow and relative maximal radial bow in intact (blue) and instrumented (red) state, presented in terms of mean value and standard deviation in each separate group with either 2 straight nails (Group 1), 1 straight and 1 curved nail (Group 2) or with 2 curved nails (Group 3); (b) radial angulation in instrumented state, presented in terms of mean value and standard deviation in each separate group. * Indicates significant difference.\u003c/p\u003e","description":"","filename":"OnlineFig5.png","url":"https://assets-eu.researchsquare.com/files/rs-8193814/v1/1704061aafc73e8ccd87b285.png"},{"id":104740248,"identity":"a1ebc5b7-ca28-43be-8b64-2bc1267bd04c","added_by":"auto","created_at":"2026-03-16 16:16:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1009497,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8193814/v1/1641e2b7-5d7f-4a0a-abc8-1581fd8eef78.pdf"},{"id":97673266,"identity":"405b1271-7cbc-4c98-b895-23b3b5c915ad","added_by":"auto","created_at":"2025-12-08 09:39:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":46998,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8193814/v1/b9cc529a11c09660036aec99.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Influence of titanium elastic nail pre-contouring on fracture reduction of paediatric diaphyseal forearm fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eForearm fractures represent the third most common type of fracture in the pediatric population\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and are clearly more frequent in children than in adults\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Diaphyseal forearm fractures involving both the radius and ulna account for approximately 5.4% of all pediatric fractures in individuals younger than 16 years\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e and in children under the age of 7, whereas both-bone fractures occur at nearly the same frequency as isolated radial fractures\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. An unexplained increase in the incidence of pediatric distal forearm fractures has been observed in multiple studies over the recent 30 years\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e with some authors reporting its four-fold raise\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Optimal treatment of these fractures depends on both fracture morphology and patient's age\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. The intrinsic remodeling ability of pediatric bones allows for effective conservative treatment in the majority of radial and ulnar shaft fractures that show minimal or no displacement\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e but both-bone forearm shaft fractures are the most common reason for surgery of the forearm in children\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSince its introduction in the 1980s, the elastic stable intramedullary (IM) nailing (ESIN) technique has gradually become the gold standard in the treatment of diaphyseal long bone fractures in children\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In shaft fractures of both forearm bones it has proven to be a safe and technically less-demanding method to achieve stability with low risk of complications and good long-term results.\u003c/p\u003e\u003cp\u003eImplants for ESIN are most commonly made of titanium alloy (Ti-6Al-4V) in the form of Titanium Elastic Nails (TENs) or made of stainless steel (316L), with diameters ranging from 1.5 to 4.0 mm. By reducing the diameter of a titanium nail its rigidness also decreases. Stainless steel nails are stiffer and can be used when a nail with a smaller diameter is required for stabilization\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eMuscular traction can sustain fracture displacement, especially in long bones. ESIN counters these forces by applying internal pressure against the cortex from within the IM canal. The use of TENs offers two main advantages, namely biocompatibility and elasticity\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. A pre-bent elastic nail, as long as it remains within its elastic range, constantly attempts to return to its original shape\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. This creates a dynamic stabilization effect by exerting pressure at three key points: the proximal end, the distal end, and the apex of the curve (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This mechanism allows for both elastic reduction and stabilization of the fracture.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn case of fractures of both forearm bones, standard recommendations are to pre-bend both nails in a C-shape and to select implant diameters corresponding to 40\u0026ndash;50% of the IM canal diameter. The opposing curvatures create balanced elastic forces transmitted through the interosseous membrane and improving construct stability. Most authors recommend using implants of the same diameter for fractures involving both forearm bones, although some reports suggest selecting different nail sizes based on the individual anatomy of each bone\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSurgical techniques using only straight nails are still in use; however, most studies investigating this technique focus on procedures that fix only one of the two forearm bones\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Some authors even support the concept of single-bone fixation, regardless of the nail\u0026rsquo;s shape\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOn anteroposterior view, the intact radius shows a C-shaped bowing, with the radial bow corresponding to a mid-diaphyseal deviation not exceeding 10% of its total length\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The ulna, although considered as a straight bone for clinical purposes, has a lazy-S shaped diaphysis with anterolateral deviation in the proximal third and anteromedial deviation in the distal fifth of the bone. Variations in IM canal diameter are common. It is important to consider the radius and ulna as a functional unit, given that they are interconnected by the interosseous membrane. Forearm rotation is highly dependent on regular anatomy, especially on a normal contour of the radial bow\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eGiven the anatomical and biomechanical characteristics of the pediatric forearm, ESIN has become a widely adopted technique. The substantial rise in the operative management of both-bone forearm fractures in recent decades\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, coupled with the absence of a clear consensus on the optimal surgical technique, highlights the need for further investigation.\u003c/p\u003e\u003cp\u003eIt was therefore the aim of this study to radiologically investigate postoperative radiological outcomes after stabilization of artificially created AO PCCF 22-4D/4.1 fractures with either two straight TENs, two pre-contoured TENs, or one straight and one pre-contoured TEN in human cadaveric forearm bones.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSpecimen preparation\u003c/h2\u003e\u003cp\u003eTwelve paired fresh-frozen (-20\u0026deg;C) human cadaveric forearms from 6 adult donors (3 males, 3 females) aged 62.9 years on average (range 29\u0026ndash;89 years) were used. All donors gave their informed consent inherent within the donation of the anatomical gift statement during their lifetime. Radiological imaging, including computed tomography (CT) at a 0.3 mm slice resolution (Somatom Emotion, Siemens, Camberley, UK), was performed to exclude pathologies, prior surgeries, and defects affecting the integrity of the specimens.\u003c/p\u003e\u003cp\u003eThe specimens were thawed for 12 hours, dearticulated at the elbow and radiocarpal joints, while all soft tissues were left intact. Based on the CT data, measurements at the narrowest part of the IM cavity, namely the central portion of the radius and the junction between the distal and the middle third of the ulna, were performed to define the isthmus diameter of both radial and ulnar bones of each specimen in order to determine the appropriate diameter of the TEN.\u003c/p\u003e\u003cp\u003eSubsequently, anteroposterior (AP) radiographs in supination of all intact forearms were obtained using a digital radiography system (Bucky Diagnost Trauma II, Amsterdam, The Netherlands) on a Picture Archiving and Communication System (PACS, easyIMAGE, VetZ GmbH, Isernhagen, Germany). Subsequently, transverse osteotomies were performed at the same level in both radius and ulna of each specimen, at 50% of the radial length as measured with a digital caliper, to simulate an AO PCCF 22-D/4.1 fracture since transverse and short oblique fractures are most frequent\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy groups\u003c/h3\u003e\n\u003cp\u003eThe 12 forearms were assigned pairwise to two groups, each consisting of six specimens (three left and three right). In Group 1, the specimens were initially selected for stabilization using two straight TENs (non-contoured). After accomplishment of all measurements, each radial nail was replaced with a pre-contoured nail (Group 2), resulting in two distinct osteosynthesis configurations from the same specimens. The contralateral forearms were selected for stabilization using two identically curved pre-bent nails for both radius and ulna (Group 3). This methodology resulted in 3 study groups, each comprising 6 osteosynthesis constructs.\u003c/p\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eFor instrumentation of all specimens, an appropriate implant size was selected to match 50% of the isthmus diameter of each specimen as previously measured via CT. In case of a difference in the canal diameters between the radius and the ulna, the smaller canal was used as reference. Implant size values were rounded for implant selection (eg, 2.4mm to 2.5mm; 2.1mm to 2.0mm) following the recommendation by Lascombes et al.\u003csup\u003e24\u003c/sup\u003e, stating that when the measurement was halfway between available implant sizes (eg, 2.3mm), the bigger must be chosen. TENs with diameters of 2mm, 2.5mm or 3mm (K\u0026ouml;nigsee Implantate GmbH, Allendorf, Germany) were used and all procedures were performed by an experienced surgeon who routinely performs one to two TEN procedures per week on average.\u003c/p\u003e\u003cp\u003eAll radii were instrumented in a retrograde fashion after a longitudinal incision. A lateral entry point of 4cm above the radiocarpal joint line was selected with a drill of an appropriate diameter (2mm, 2.5mm, or 3.0mm), angulated at 45\u0026deg;. The nails were advanced and rotated with the aid of a T-handle and gentle hammer blows to reach the level of the middle of the radial tuberosity facing towards the ulna. All ulnae were instrumented in an antegrade fashion via a typical anconeus portal approach. The entry point was chosen posterolaterally, 4cm distally to the olecranon, using a drill of an appropriate diameter angulated at 45\u0026deg;. The nail was advanced and rotated with the aid of a T-handle and gentle hammer blows until reaching a level of 15mm proximally to the distal radioulnar joint facing towards the radius. All implants were cut above the level of the soft tissues for practical purposes and AP radiographs in supination were taken for each instrumented specimen in each group (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eData acquisition and evaluation\u003c/h3\u003e\n\u003cp\u003eBased on the AP radiographs, the following 7 parameters were measured for intact and instrumented specimens, following the method of Schemitsch and Richards\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e): total ulnar length (UL); total radial length (RL); length from tuberosity radii to a point on a line between the tuberosity radii and the sigmoid notch where a perpendicular line to the radial bone marks the greatest distance (RLx); length from tuberosity radii to sigmoid notch (RLy); maximal radial bow defined as the maximum length of a perpendicular line from the point defined by RLx to the radial bone (MRB); maximal radial bow as percentage of RLy (MRB%); location of the maximal radial bow as percentage of RLy (LMRB%). In addition, ulnar angulation (UA) and radial angulation (RA) were defined and measured on the AP radiographs as the angle between the longitudinal axes of the proximal and distal radial segments of the instrumented forearms (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using SPSS software package (SPSS Statistics, IBM, Armonk, NY, USA). Normality of data distribution was checked and proved with Shapiro\u0026ndash;Wilk test. Significant differences between the specimens\u0026rsquo; states and groups were screened using Paired-Samples \u003cem\u003et\u003c/em\u003e-test and General Model Repeated Measures with Bonferroni post-hoc tests for multiple comparisons. Level of significance was set to 0.05 for all statistical tests.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eNail diameter of all instrumented specimens was 2.6 mm on average (standard deviation, SD 0.5), being consistent across the groups (p\u0026thinsp;=\u0026thinsp;0.994). Mean UL of the intact specimens was 267.5 mm (SD 27.8) in both Group 1 and Group 2, and 268.3 mm (SD 27.6) in Group 3 (p\u0026thinsp;=\u0026thinsp;0.436). It remained nearly unchanged after instrumentation, with mean values of 267.0 mm (SD 28.1) in both Group 1 in Group 2, and 268.2 mm (SD 26.6) in Group 3 (p\u0026thinsp;=\u0026thinsp;0.992). Similarly, mean RL of the intact specimens was 235.5 mm (SD 22.6) in both Group 1 and Group 2, and 237.4 mm (SD 20.6) in Group 3 (p\u0026thinsp;=\u0026thinsp;0.616) and also remained nearly unchanged after instrumentation, with mean values of 235.2 mm (SD 22.5) in both Group 1 in Group 2, and 237.0 mm (SD 20.7) in Group 3 (p\u0026thinsp;=\u0026thinsp;0.608). The osteotomy level as measured from the most proximal part of the radius was 11.8 mm (SD 1.1) in both Group 1 and Group 2, and 11.9 (SD 1.0) in Group 3 (p\u0026thinsp;=\u0026thinsp;0.997). Outcome measures for the other parameters of interest are summarized for each separate group and specimen\u0026rsquo;s state in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. MRB and MRB% before and after instrumentation are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003ea, and RA after instrumentation \u0026ndash; in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eb. After instrumentation both MRB and MRB% decreased significantly in Group 1 and increased significantly in Group 2 (p\u0026thinsp;\u0026le;\u0026thinsp;0.003). Moreover, MRB and MRB% in instrumented state were significantly lower in Group 1 versus both Group 2 and Group 3 (p\u0026thinsp;\u0026le;\u0026thinsp;0.005) and significantly different between Group 2 and Group 3 (p\u0026thinsp;\u0026le;\u0026thinsp;0.040). RA was significantly lower in Group 1 versus both Group 2 and Group 3 (p\u0026thinsp;\u0026le;\u0026thinsp;0.013), and significantly different between Group 2 and Group 3 (p\u0026thinsp;=\u0026thinsp;0.017).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study investigated experimentally postoperative radiological outcomes after TEN fixations of artificially created AO PCCF 22-4D/4.1 fractures in human cadaveric forearm specimens. Three groups were compared, namely implementing either two straight TENs, one straight and one pre-contoured TEN, or two pre-contoured TENs.\u003c/p\u003e\u003cp\u003eAs a main finding, transverse fractures fixed with two pre-contoured nails achieved a more anatomical alignment compared to the other fixation techniques, closely matching the intact forearm. This effect was particularly evident when compared with osteosynthesis performed using two straight nails. Younger children, particularly under 10 years of age, can tolerate up to 100% translational displacement (ad latus) due to their high remodeling capacity\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Additionally, angulation of up to 10\u0026ndash;15\u0026deg; is generally considered acceptable in this age group. Above the age of 10 years this threshold decreases to 10\u0026deg;\u003csup\u003e27,28\u003c/sup\u003e. Loss of range of motion (ROM) due to angulation can alter the rotation of the forearm, which was extensively studied by Matthews et al\u003csup\u003e29\u003c/sup\u003e on forearm specimens with midshaft fractures. The authors concluded that 10\u0026deg; angulation (dorsal, volar or towards the interosseous membrane) of any of the two bones leads to practically no loss of motion (\u0026lt;\u0026thinsp;3\u0026deg;). On the other hand, 10\u0026deg; angulation of both bones leads to larger deficits (10\u0026deg; of pronation and 20\u0026deg; of supination), whereas 20\u0026deg; deformity equaled approximately 40\u0026deg; pro-supination loss. Outcomes also strongly correlate with the level of the fracture\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e and additional rotational malalignment.\u003c/p\u003e\u003cp\u003eThe fact that angular malalignment leads to an impaired ability to rotate the forearm is explained due to its anatomy. The radius has a physiological bow that enables it to rotate around the ulna. The measurement of MRB is therefore particularly important for assessing forearm function, specifically pronation and supination\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. While loss of pronation can be somewhat compensated by shoulder abduction, supination does not have such a compensatory mechanism\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. A reduction in MRB has also been associated with a loss of strength\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWhen comparing the maximal radial bow, the specimens instrumented with two straight nails showed the biggest loss of radial bowing, with а mean decrease of 3.7mm. A similar pattern was observed for MRB%, with a mean decrease of 1.85%. As noted by Goldfarb et al., a MRB decrease of more than 2.3mm leads to a reduction in rotation exceeding 20%\u003csup\u003e36\u003c/sup\u003e. In contrast to other deformities, however, the exact magnitude of its clinical consequences cannot be predicted with certainty, although its potential impact on forearm function is well recognized\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe specimens in Group 2, instrumented with one straight and one curved nail, also demonstrated significant changes compared to intact forearms. However, in contrast to Group 1, this fixation method produced an overcorrection (increase) of radial bowing by 1.88mm on average. To our knowledge, no study has demonstrated a correlation between overcorrection of the radial bow and restriction in forearm ROM so far. Balaji et al\u003csup\u003e35\u003c/sup\u003e reported a non-significant increase in the extent of pronation with greater radial bow, though further investigation into this potential relationship is warranted.\u003c/p\u003e\u003cp\u003eComparison of the intact and instrumented forearms in Group 3 showed no significant changes in the parameters explored and had the best radiographic results with close to anatomic reduction of the bones.\u003c/p\u003e\u003cp\u003eOne of the main surgical indications for pediatric forearm fractures is axial shortening greater than 1cm\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. In the current study, no significant change in length was observed after osteosynthesis among the groups for both radius and ulna.\u003c/p\u003e\u003cp\u003eIt is important to keep in mind that approximately 70 to 80% of the longitudinal growth of the radius and ulna occurs at the distal physis\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e \u0026ndash; a region that should be preserved during surgical intervention. Physeal closure of both bones is variable and gender dependent; the proximal physis closes firstly near 14\u0026ndash;15 years of age, followed by the distal physis at around 15\u0026ndash;18 years \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. The alternative treatment method to the insertion of a TEN is plating. However, it may endanger the growth plate if improperly positioned. Interestingly, Reinhardt et al found no significantly higher risk after plating versus intramedullary nailing when performed correctly\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study has some limitations inherent to all experimental investigations. First, although anatomical differences exist between pediatric and adult bones, adult cadaveric forearms had to be used due to the unavailability of pediatric donors. Second, the growth-related remodeling potential of pediatric bone could not be replicated, however, existing literature on acceptable tolerances allows indirect interpretation of the obtained results. Third, although using cadaveric bones provides an anatomy closely reflecting reality, they lack the dynamic muscular traction forces that are fundamental to the ESIN fixation principle. This limitation is common to many experimental studies; however, it is hypothesized that in clinical practice any adverse effect of imperfect nail contouring would likely be mitigated \u0026ndash; rather than amplified \u0026ndash; by muscle forces. Fourth, despite efforts to optimize anatomical homogeneity across the groups, slight variations persisted. A larger sample size would have reduced the influence of this variability. Fifth, due to the limited number of specimens, the same forearm was reused in Groups 1 and Group 2 by exchanging the radial nail from straight to pre-contoured, which could have influenced the results. Clinically, nail exchange is considered acceptable and does not compromise outcomes\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e, justifying this approach as reasonable. Sixth, all measurements were performed on X-ray images only, making them susceptible to projection errors. However, this study serves as a pilot and further research is needed to evaluate the influence of different TENs on pediatric forearm fractures using three-dimensional measurements. Lastly, only titanium implants were tested. Future research should evaluate whether stainless steel implants with their different mechanical properties\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e result in similar outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe use of two curved TENs resulted in the smallest deviation from the natural anatomical alignment after reduction of both-bone pediatric forearm fractures. Fixation of these fractures with one straight and one curved TEN leads to overcorrection of the radial bow whereas utilization of two straight TENs leads to the most inferior results, with reduction of the radial bow and anticipated loss of range of motion in the forearm of treated patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study were followed in accordance with relevant guidelines. This study was approved by the institutional internal review board, based on the approval of the specimens\u0026apos; delivery by Science Care Ethics Committee. All donors gave their informed consent inherent within the donation of the anatomical gift statement during their lifetime, as registered by Science Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments and funding information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are not compensated and there are no other institutional subsidies, corporate affiliations, or funding sources supporting this work unless clearly documented and disclosed. This study was performed with the assistance of the AO Foundation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYP, JA, TaP, BG, AB, IZ and ToP: designed the study. PY, MR, FS and IZ performed instrumentation and measurement. YP, CS, AB and IZ obtained data. BG and IZ performed statistical analysis. TaP, YP, JA, IZ, BG, DE and ToP interpreted results. GR, BG and ToP supervised the study. YP, JA, TaP, DE wrote the original draft of the manuscript, which was next revised in detail first by IZ, ToP and BG. Subsequent drafts were prepared by all authors. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis investigation was performed with the assistance of the AO Foundation.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are not compensated and there are no other institutional subsidies, corporate affiliations, or funding sources supporting this work. This study was performed with the assistance of the AO Foundation\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKwas K, Mostowy M, Szatanik K, Małecki K. Elastic stable intramedullary nailing in paediatric diaphyseal forearm fractures - a retrospective analysis of 201 cases. BMC Musculoskelet Disord. 2024;25(1):855. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12891-024-07959-0\u003c/span\u003e\u003cspan address=\"10.1186/s12891-024-07959-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoeris A, Lutz N, Wicki B, Slongo T, Audig\u0026eacute; L. An epidemiological evaluation of pediatric long bone fractures \u0026mdash; a retrospective cohort study of 2716 patients from two Swiss tertiary pediatric hospitals. 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J Bone Joint Surg Am. 2012;94(24):e184. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.L.00668\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.L.00668\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee PY, Chen YN, Hu JJ, Chang CH. Comparison of Mechanical Stability of Elastic Titanium, Nickel-Titanium, and Stainless Steel Nails Used in the Fixation of Diaphyseal Long Bone Fractures. Mater (Basel). 2018;11(11):2159. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ma11112159\u003c/span\u003e\u003cspan address=\"10.3390/ma11112159\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMani US, Sabatino CT, Sabharwal S, Svach DJ, Suslak A, Behrens FF. Biomechanical comparison of flexible stainless steel and titanium nails with external fixation using a femur fracture model. J Pediatr Orthop. 2006;26(2):182\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.bpo.0000218525.28739.7e\u003c/span\u003e\u003cspan address=\"10.1097/01.bpo.0000218525.28739.7e\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8193814/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8193814/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose: To radiologically investigate in a human cadaveric model the effect of nail shape on fracture reduction in pediatric transverse diaphyseal fractures of the radius and ulna using straight nails, pre-contoured, or a combination of both.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: Twelve human cadaveric forearms from six adult donors were used and standardized AO PCCF 22-D/4.1 transverse diaphyseal fractures of the radius and ulna were created. Titanium elastic nails (TENs) were inserted retrograde in the radius and anterograde in the ulna creating 3 groups with either 2 straight TENs (Group1), 1 straight and 1 curved TEN (Group2), or 2 curved TEN (Group3). Anteroposterior radiographs of each intact and instrumented specimen in each group were taken in supination. Parameters of interest included total bone length and maximal radial bow (MRB)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: After TEN instrumentation MRB decreased significantly in Group1 and increased significantly in Group2 (p≤0.003), however, it was without a significant change in Group3 (p=0.113). In addition, MRB in instrumented state was significantly lower in Group1 versus both Group2 and Group3 (p ≤0.005). Both total bone lengths remained nearly unchanged after instrumentation across the groups (p≥0.608).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusion: The use of two curved TENs resulted in smallest deviation from the natural anatomical alignment after reduction of both-bone pediatric forearm fractures. Fixation of these fractures with one straight and one curved TEN leads to overcorrection of the radial bow whereas utilization of two straight TENs leads to the most inferior results, with reduction of the radial bow and anticipated loss of range of motion in the forearm.\u003c/p\u003e","manuscriptTitle":"Influence of titanium elastic nail pre-contouring on fracture reduction of paediatric diaphyseal forearm fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 07:50:53","doi":"10.21203/rs.3.rs-8193814/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-06T23:25:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-04T12:43:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136175158172245694518607685158287053264","date":"2025-12-03T13:12:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-03T12:59:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-03T12:58:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-25T05:31:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2025-11-24T12:54:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"aa73911d-468c-4917-b710-225b48dafc6f","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:12:57+00:00","versionOfRecord":{"articleIdentity":"rs-8193814","link":"https://doi.org/10.1007/s00068-026-03100-z","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2026-03-13 15:59:53","publishedOnDateReadable":"March 13th, 2026"},"versionCreatedAt":"2025-12-08 07:50:53","video":"","vorDoi":"10.1007/s00068-026-03100-z","vorDoiUrl":"https://doi.org/10.1007/s00068-026-03100-z","workflowStages":[]},"version":"v1","identity":"rs-8193814","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8193814","identity":"rs-8193814","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}