Femoral shaft fractures represent a significant proportion of musculoskeletal injuries in the pediatric population, often resulting from high-energy trauma [1]. Effective management of these fractures is crucial to ensure timely healing, restore limb alignment and function, and minimize long-term complications [2]. Traditionally, treatment options ranged from non-operative management with spica casting in younger children to open reduction and internal fixation (ORIF) with plates and screws in older children and more complex fracture patterns [3]. However, spica casting, while effective in certain age groups, can be associated with prolonged immobilization, skin breakdown, and mobility difficulties [4]. ORIF, although providing rigid fixation, carries the risks of a larger surgical incision, increased periosteal stripping potentially affecting healing, and the need for hardware removal [5]. In the late 1980s, the Titanium Elastic Nailing System (TENS) was introduced as a minimally invasive surgical technique for pediatric long bone fractures, including the femur. This technique involves the percutaneous insertion of flexible titanium nails into the medullary canal, providing three-point fixation and promoting indirect fracture healing through callus formation [6]. TENS offers several advantages, including smaller incisions, reduced blood loss, shorter operative times, and earlier mobilization compared to ORIF [7]. Numerous studies have demonstrated the efficacy of TENS in managing pediatric femoral shaft fractures, highlighting its high union rates and favorable functional outcomes. However, the specific outcomes and complication profiles can vary depending on factors such as patient age, fracture pattern, surgical technique, and follow-up duration. This observational study aims to evaluate the effectiveness of TENS fixation in a cohort of pediatric patients with femoral shaft fractures treated at a tertiary care center, providing insights into the real-world application and outcomes of this widely adopted surgical technique. The study analyzes patient demographics, fracture characteristics, surgical outcomes, radiological healing, time to weight-bearing, and the incidence of complications to contribute to the existing body of knowledge on TENS fixation in pediatric femoral shaft fractures.

Study Design This was a prospective, single-center observational study conducted in the Department of Ortho Surgery at Jamalpur Medical College, Jamalpur, between June 2023 to June 2024. This setting provided access to a consistent patient population with pediatric forearm fractures and the necessary facilities for diagnosis, surgical intervention (TENS fixation), and post-operative follow-up. All eligible patients presenting with diaphyseal fractures of the femur were consecutively enrolled after meeting the inclusion and exclusion criteria. Patient Selection Inclusion criteria were patients aged 5 to 15 years with a primary diaphyseal fracture of the femur treated with TENS fixation. Exclusion criteria included open fractures of Gustilo-Anderson grade III or higher, pathological fractures, fractures associated with neurovascular injury, and patients with incomplete medical records or follow-up of less than 3 months. Data Collection Data were collected from electronic medical records and radiographic images. Demographic data included age, sex, and mechanism of injury. Fracture characteristics were documented according to the AO/OTA fracture classification. Surgical details recorded were the number and diameter of nails used, the entry point (retrograde or antegrade), and any intraoperative complications. Outcome Measures The primary outcome measures were radiographic union, defined as bridging callus visible on at least three out of four cortices on two orthogonal views, and clinical union, defined as the absence of pain on palpation at the fracture site and the ability to bear weight without support. Secondary outcome measures included the time to full weight-bearing, length of hospital stay, final radiographic alignment (angulation in the coronal and sagittal planes, rotational deformity), functional outcomes (assessed clinically at follow-up visits, documenting any gait abnormalities or limitations in daily activities), and the incidence of complications, such as superficial or deep infection, malunion (angulation >15 degrees or rotational deformity >30 degrees), non-union (lack of radiographic progression after 16 weeks), refracture, limb length discrepancy (>1 cm), nail migration, and other hardware-related issues requiring reoperation. Surgical Technique All TENS fixation procedures were performed by or under the direct supervision of experienced pediatric orthopaedic surgeons. Closed reduction was attempted in all cases under general anesthesia and fluoroscopic guidance. Two appropriately sized pre-bent titanium elastic nails were inserted percutaneously through metaphyseal or epiphyseal entry points (either retrograde from the distal femur or antegrade from the proximal femur, based on fracture pattern and surgeon preference) and advanced across the fracture site into the opposite cortex, achieving three-point fixation. Nail size was selected based on the patient's weight and femoral canal diameter. Postoperatively, a period of protected weight-bearing was typically allowed, progressing to full weight-bearing as tolerated based on clinical and radiographic assessment. Follow-up Protocol Patients were followed up at regular intervals (2 weeks, 4-6 weeks, 3 months, 6 months, and 12 months post-operatively, or until fracture union and full weight-bearing were achieved). Clinical and radiographic assessments were performed at each follow-up visit. Hardware removal was typically considered after fracture consolidation and when the patient was asymptomatic, usually between 6 to 12 months post-operatively. Data Analysis Descriptive statistics were used to summarize patient demographics, fracture characteristics, and outcomes. Continuous variables were presented as means with standard deviations and ranges, while categorical variables were presented as frequencies and percentages.