Insertion through Lister’s tubercle (dorsal entry point) is also well established and offers more versatile nail manipulation and is an alternative for distal 1/3 fractures of the radius.
Opening the canal
Use small scissors or a surgical clip and small retractors to dissect to the bone under direct vision.
Note: Avoid injury to the superficial radial nerve and the cephalic vein.
Place the awl or drill directly onto the bone and perforate the near cortex, under direct vision, perpendicular to the bone.
Do not hammer the awl to avoid perforation of the far cortex.
When the medullary canal is reached, lower the awl or drill 45° to the shaft axis and advance it with oscillating movements to produce an oblique canal.
Precontour the nail to reproduce the geometry of the bowing deformity.
Fix the nail into the inserter and pass it into the canal.
Pearl: insertion of nail tip perpendicular to shaft
Insert the nail with the tip perpendicular to the shaft axis until the far cortex is felt. Rotate the nail 180° and advance it using the curved side of the tip as a gliding aid.
If the tip is stuck in the far cortex and cannot be advanced, remove the nail and bend the tip to give a slightly more pronounced curvature.
Advancing the nail
Advance the nail into the strong metaphyseal bone at the radial tubercle with an oscillating maneuver.
The precontouring and bowing should be in the same plane.
Pearl: A short working length (3-5 cm) between the entry point and the inserter improves control of the nail during insertion.
Pitfall: iatrogenic fracture
In young children, the nail tip may become stuck because of the narrow medullary canal.
Do not use a hammer if the nail is stuck as this risks iatrogenic fracture.
Withdraw by 2 cm, rotate the nail to free the tip and continue advancing.
Pearl: estimation of nail length
If an image intensifier is not available, estimate the optimum nail length with a second identical nail placed parallel to the initial nail.
Rotate the nail 180° to counteract the deformity and re-anchor the tip in the cortex.
Full realignment of deformity may take several days.
Cutting the nail and wound closure
When using the lateral entry point, cut the nail near the bone.
If a dedicated nail cutter is not available, cut the nail slightly shorter as the end will be sharper and this prevents skin perforation.
Gently withdraw the nail by 1 cm, cut the nail outside the skin and reinsert to the original position with an impactor.
Ensure that the nail tip does not irritate the superficial radial nerve.
When using the dorsal entry point, the nail should be left long or protected with small end cap to prevent rupture of the extensor pollicis longus.
Close the subcutaneous tissue and skin in a standard manner.
5. Option: end caps
End caps may be useful for:
Stabilization of length unstable fractures
Protection of soft tissues (eg EPL)
The nail should finally be advanced using the beveled impactor.
A small end cap can be inserted over the nail using the inserter.
6. Final assessment
Check the completed osteosynthesis with image intensification. These images should be retained for documentation or alternatively an x-ray should be obtained before discharge.
Make sure that the desired reduction has been achieved and the nail is of appropriate length.
7. Aftercare following ESIN
Immediate postoperative care
Whilst the child remains in bed, the forearm should be elevated on pillows to reduce swelling and pain.
They should be encouraged to use the arm.
Cast immobilization is not necessary and hinders early recovery of joint movement.
For Monteggia lesions treated with ulnar nailing, the forearm may be immobilized in a cast in the position of maximum stability of the radiocapitellar joint for 2-4 weeks.
Ibuprofen and paracetamol should be administered regularly during the first 4-5 days of injury, with additional oral narcotic medication for breakthrough pain.
If pain is increasing the child should be examined.
The child should be examined regularly, to ensure finger range of motion is comfortable and adequate.
Neurological and vascular examination should also be performed.
Compartment syndrome should be considered in the presence of increasing pain, especially pain on passive stretching of muscles, decreasing range of active finger motion or deteriorating neurovascular signs, which are a late phenomenon.