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Comparative Study of Functional and Radiological Outcomes of Antegrade Versus Retrograde Titanium Elastic Nailing for
Ankit Hooda1, Hariprasad Seenappa1, Tarun Kumar Somisetty Venkata Sai1,2
1Orthopedics, Sri Devaraj Urs Medical College, Kolar, IND.
Insights
Retrograde Titanium Elastic Nailing (TEN) in pediatric ulnar fractures shows fewer complications than antegrade nailing, with similar functional outcomes. This suggests retrograde TEN may be preferable for certain fractures despite potential physeal concerns.
Area of Science:
- Orthopedic surgery
- Pediatric orthopedics
- Traumatology
Background:
- Pediatric forearm fractures are common, with ulnar fractures being a significant subset.
- Titanium Elastic Nailing (TEN) is a minimally invasive treatment for pediatric ulnar fractures.
- The optimal nail entry point for TEN (antegrade vs. retrograde) is debated.
Purpose of the Study:
- To compare functional and radiological outcomes between antegrade and retrograde TEN for pediatric ulnar diaphyseal fractures.
- To evaluate complication profiles and implant-related morbidity for both TEN approaches.
- To determine the preferred TEN technique based on outcomes and complications.
Main Methods:
- A retrospective comparative study of 70 children (5-16 years) with closed ulnar diaphyseal fractures treated with TEN.
- Patients were divided into antegrade (n=35) and retrograde (n=35) groups.
- Primary outcomes included radiographic union time and six-month Disabilities of the Arm, Shoulder and Hand (DASH) scores; Bonferroni correction was used for multiple comparisons.
Main Results:
- Retrograde nailing demonstrated faster unadjusted union, but this difference narrowed after adjusting for fracture location.
- Functional outcomes were equivalent at six months, with high rates of full range of motion and similar DASH scores.
- The complication-free rate was significantly higher with retrograde nailing (85.7% vs. 42.9%), with olecranon irritation exclusive to the antegrade group.
Conclusions:
- Both antegrade and retrograde TEN achieve excellent functional outcomes in pediatric ulnar fractures.
- Retrograde nailing offers a significant advantage in terms of reduced overall complications.
- Retrograde TEN is supported for midshaft and distal ulnar fractures in older children, with caution advised regarding potential physeal proximity.
Abstract:
Background Pediatric forearm fractures account for approximately 40% of childhood skeletal injuries, with ulnar fractures being particularly prevalent. Titanium Elastic Nailing (TEN) offers an effective minimally invasive option for these injuries; however, the optimal nail entry point - antegrade (olecranon) versus retrograde (distal ulna) - remains debated. This study compared functional and radiological outcomes, complication profiles, and implant-related morbidity between the two approaches. Methods A retrospective comparative study was conducted from May 2023 to May 2025 at the R.L. Jalappa Hospital and Research Centre, Karnataka, India. Seventy children aged 5-16 years with closed ulnar diaphyseal fractures treated with TEN were divided into antegrade (n=35) and retrograde (n=35) groups. Radiographic union time and six-month Disabilities of the Arm, Shoulder and Hand (DASH) scores were the primary outcomes. Bonferroni correction was applied to control for comparisons of multiple complications. Results Retrograde nailing showed faster unadjusted union (7.4 ± 0.6 vs. 8.6 ± 0.7 weeks; p<0.001), but the retrograde group had more distal-third fractures. After adjusting for fracture location, the difference narrowed to 0.6 weeks - statistically significant but unlikely to change clinical practice. Functional outcomes were equivalent at six months: full range of motion (ROM) in 91.4% vs. 94.3%, mean DASH scores of 4.2 vs. 3.6 (p=0.198), and near-normal elbow and forearm motion in both groups. The overall complication-free rate strongly favored retrograde nailing (85.7% vs. 42.9%; p<0.001). Olecranon irritation (34.3%) and early implant removal (22.9%) were exclusive to the antegrade group. Two young retrograde patients had nail entry close to the distal physis. Neither showed growth arrest at six months, though longer follow-up is needed. Conclusion Both techniques achieve excellent functional outcomes. The advantage of union time in the case of retrograde nailing was attenuated after fracture-location adjustment. The clearest difference was a significantly lower overall complication burden with retrograde nailing (p<0.001), supporting its preferential use for midshaft and distal fractures in older children. However, careful consideration is required regarding potential physeal damage.