Rigid intramedullary nailing with suprapatellar approach for tibial shaft fractures in adolescents with open physes

Rigid intramedullary (IM) fixation is avoided in skeletally immature patients because of the risk of physeal injury, causing subsequent growth disturbances. However, with the increasing numbers of high-energy injuries and complex fractures in older adolescents, suprapatellar rigid IM nailing (RIMN) has emerged as an alternative. This study evaluated whether RIMN in skeletally immature adolescents results in coronal or sagittal deformities and to evaluate the clinical outcomes.

We retrospectively reviewed skeletally immature patients who underwent suprapatellar RIMN for tibial shaft fractures between January 2014 and October 2024. The inclusion criteria were an open proximal tibial physis, a diaphyseal fracture pattern, and > 12-month follow-up. Radiographic parameters, including the mechanical medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA), were measured twice on standardized anteroposterior and lateral radiographs by a single senior pediatric orthopaedic surgeon. Malalignment was defined as a deviation greater than 5° in the coronal plane or 10° in the sagittal plane relative to the contralateral side. Discrepancies in limb length were considered significant when exceeding 2 cm. Statistical comparisons between the immediate postoperative and final radiographs were performed using the paired t-test and equivalence test.

Twenty-four patients (mean age 15.9 ± 1.3 years) were included, and 17 (70.8%) were classified as having proximal tibial ossification stage III and seven (29.2%) as stage II. All fractures achieved union at a mean of 14.3 ± 5.3 weeks. No significant changes were observed in MPTA or PPTA. Two patients with open fractures developed nonunion requiring secondary surgery. Mild anterior knee pain occurred in ten patients (41.7%) without activity limitation, and four (16.7%) experienced compartment syndrome requiring fasciotomy. No patient demonstrated coronal or sagittal deformity, limb-length discrepancy, or growth disturbance.

Although physeal preservation remains fundamental in pediatric fracture management, suprapatellar RIMN can provide stable fixation and satisfactory outcomes in adolescents nearing skeletal maturity. For selected patients in whom plating or flexible nailing are suboptimal, rigid IM fixation represents a reasonable alternative.

Level IV, retrospective cohort study.