Following partial reduction, advance the nail into the head.
Disimpact the head with gentle hammer blows to the nail end to free impacted annular ligament.
Turn the nail clockwise (right arm) or counterclockwise (left arm) to anatomically reduce the head.
If reduction is not anatomical, withdraw the nail tip to the metaphysis, turn it back to the initial position, advance it and repeat the reduction maneuver.
This correction should only be performed once.
Perforate the growth plate in Salter-Harris type I and II fractures to obtain sufficient hold in the head fragment. A sharpened tip is helpful to fix the nail in the final position.
In metaphyseal fractures, the tip of the nail is usually anchored in the head fragment provided the nail is of the correct length.
In very proximal metaphyseal fractures, perforate the growth plate to obtain sufficient hold.
Most of the head is unossified and not radiologically visible in young children.
If the tip of the nail is advanced just beyond the visible ossification center, it will be within the chondral tissue and not in the joint.
Pearl: If the ossification center is not visible on a normal x-ray, an arthrogram may be performed .