Modified retrograde ESIN for diametaphyseal distal radius fractures in children: a retrospective cohort study

Diametaphyseal distal radius fractures in children represent a therapeutic challenge because conventional elastic stable intramedullary nailing (ESIN) may provide insufficient distal fragment control, while alternative fixation methods are more invasive. This study evaluates a modified retrograde ESIN technique with a 90° distal bend ("crutch-bend technique") designed to improve distal fragment support and alignment.

In this retrospective single-center study, 43 pediatric patients with diametaphyseal distal radius fractures treated between 2022 and 2025 were analyzed. Patients received either standard ESIN (n = 21) or modified crutch-bend ESIN (n = 22). Coronal and sagittal angulation were measured on standard anteroposterior and lateral radiographs. Revision surgery, fracture healing, and clinical status at follow-up were recorded.

Postoperative coronal angulation was significantly lower in the modified ESIN group (3.8 ± 1.2°) compared with the standard ESIN group (8.1 ± 1.5°), corresponding to a mean difference of 4.3° (95% CI 3.5-5.1; p < 0.0001). Sagittal angulation was also reduced (2.1 ± 1.1° vs. 3.2 ± 0.9°; mean difference 1.1°, 95% CI 0.5-1.7; p = 0.0007). Revision surgery for secondary displacement occurred in two patients (9.5%) after standard ESIN and in none after the modified technique (p = 0.233). All fractures achieved radiographic union within approximately four weeks, and no clinically documented functional limitations were reported at follow-up.

The crutch-bend modification of retrograde ESIN was associated with improved postoperative radiographic alignment in this retrospective cohort. Whether this translates into clinically meaningful advantages remains uncertain and requires further investigation in larger prospective studies.