Forearm fractures are among the most frequent skeletal injuries in children, accounting for nearly one-third of all pediatric fractures, with the diaphyseal region of the radius and ulna most commonly affected.[1] These injuries, typically resulting from falls on an outstretched hand or sports-related trauma, can substantially impair forearm rotation and daily function if anatomical alignment is not restored. In younger children, the remarkable remodelling potential of bone often allows satisfactory correction through conservative management with closed reduction and casting. However, in older children particularly those above ten years malalignment, angulation, and rotational deformities are less likely to remodel adequately, leading to functional limitations in pronation and supination.[2]

The evolution of pediatric fracture management has seen a paradigm shift from traditional casting and plating toward intramedullary fixation techniques. Among these, the Titanium Elastic Nailing System (TENS), also referred to as Elastic Stable Intramedullary Nailing (ESIN), has become the standard of care for unstable or displaced diaphyseal both-bone fractures.[3] TENS offers several advantages: minimal soft-tissue disruption, preservation of periosteal circulation, elastic three-point fixation, and early mobilization all of which favour biological healing and restore near-normal biomechanics. Recent clinical studies and meta-analyses have consistently demonstrated that TENS achieves union within 6–10 weeks with excellent functional outcomes and a low complication rate compared with plating or Kirschner wire fixation.[4,5]

Despite these advances, variations in technique, nail size selection, and postoperative protocols influence final outcomes. Therefore, continuous evaluation of functional and radiological recovery following TENS in diverse clinical settings remains essential. The present study aimed to assess the functional and radiological outcomes of pediatric both-bone forearm fractures treated with TENS, using validated scoring systems to establish its efficacy as a minimally invasive and reliable method of fixation in children.

This prospective observational study was conducted in the Department of Orthopaedics at Sree Balaji Medical College and Hospital, Chennai, a tertiary-care teaching institution that manages a large volume of pediatric trauma cases from both urban and peri-urban regions. The study period extended for 18 months, from January 2006 to June 2007, encompassing case recruitment, operative intervention, and follow-up until radiological union was achieved. The study followed a prospective observational design aimed at evaluating the functional and radiological outcomes of pediatric both-bone forearm diaphyseal fractures treated with the Titanium Elastic Nailing System (TENS). The sample size was calculated using the single-population proportion formula: n=(Z_(1-α/2)^2×p(1-p))/d^2 where Z = 1.96 for a 95 % confidence level, p = 0.80 (anticipated proportion of excellent outcomes based on prior studies[6] and d = 0.15 (allowable error). Substituting these values gave an initial sample size of 17, which was rounded to 20 participants to account for attrition and ensure adequate precision. A convenience sampling approach was adopted, as all eligible children presenting during the study period were consecutively enrolled until the sample size was reached. Children aged 4 to 12 years with radiographically confirmed diaphyseal fractures of both the radius and ulna requiring surgical fixation were included. Exclusion criteria comprised open fractures, pathological fractures, undisplaced or greenstick fractures amenable to conservative management, age > 12 years, and fractures located outside the diaphyseal segment. All participants were clinically evaluated to rule out neurovascular compromise or associated systemic injuries before inclusion. Data were collected using a pre-tested semi-structured questionnaire developed specifically for this study. The tool captured demographic information, mechanism of injury, fracture characteristics, intra-operative details, postoperative course, and serial follow-up findings. Functional assessment was performed using the Children’s Hospital of Philadelphia (CHOP) criteria and the Price et al. grading system. The questionnaire was pre-tested on five pediatric fracture cases outside the study population to evaluate clarity, content validity, and response consistency; modifications were incorporated accordingly. Prior to data collection, the principal investigator conducted a one-day training session for the assisting resident who served as the data collector. The training covered standardized completion of the proforma, maintenance of aseptic data recording practices, measurement of range of motion using a calibrated universal goniometer, and radiographic interpretation under faculty supervision. Calibration of all instruments including goniometers, X-ray viewers, and digital calipers was verified by the biomedical engineering department before commencement. Periodic cross-checking of data sheets with operative records and radiographs was performed weekly to ensure accuracy and completeness. Eligible participants were identified from the Orthopaedic Outpatient Department and Casualty services. After obtaining informed parental consent, baseline demographic and clinical data were recorded. Radiographic evaluation was performed in anteroposterior and lateral views of the entire forearm, including elbow and wrist. Surgical fixation using the Titanium Elastic Nailing System was performed under general anaesthesia by a single surgical team following standard protocols. Post-operative rehabilitation followed a uniform schedule, and subsequent follow-ups were carried out at 2, 4, 8, 16, and 36 weeks post-surgery. At each visit, pain, range of motion, functional recovery, and radiological evidence of union were assessed. Union was defined radiographically by bridging callus across at least three cortices on orthogonal views, with corresponding clinical absence of pain at the fracture site. All collected data were entered daily into a password-protected spreadsheet using Microsoft Excel 2021, double-checked for transcription errors, and subsequently imported into SPSS version 29.0 (IBM Corp., Armonk, NY, USA) for analysis. Outlier checks and logical range validation were performed prior to final analysis. Confidentiality of patient identifiers was maintained by coding each case with a unique numeric ID. Quality control was reinforced through weekly data audits by the senior investigator and random verification of 10 % of entries. Descriptive statistics were used to summarize patient demographics, injury characteristics, and operative findings. Continuous variables such as age and time to union were expressed as mean ± standard deviation (SD) or median [interquartile range (IQR)] as appropriate. Categorical variables were presented as frequencies and percentages. Between-group comparisons (e.g., age < 8 years vs ≥ 8 years) were evaluated using independent-sample t-test or Mann–Whitney U test for continuous data and χ² test or Fisher’s exact test for categorical data. Correlation between age and union time was assessed using the Spearman rank correlation. A p-value < 0.05 was considered statistically significant. Ethical approval was obtained from the Institutional Ethics Committee of Sree Balaji Medical College and Hospital before initiation of the study. Written informed consent was secured from parents or legal guardians of all participants, with child assent obtained wherever appropriate. Confidentiality was preserved throughout data collection, storage, and publication.

A total of 20 pediatric patients with diaphyseal forearm fractures were enrolled between January 2024 and June 2025. The mean age of the cohort was 8.6 ± 2.1 years, with most children (80 %) belonging to the 7–12 year age group. Males predominated (65 %), yielding a male-to-female ratio of approximately 1.9 : 1. The most common mechanism of injury was a fall on an outstretched hand (50 %), followed by road-traffic accidents (20 %), falls from height (15 %), and sports-related trauma (15 %). These findings indicate that active school-aged boys engaged in outdoor activities are at greatest risk for forearm fractures (Table 1).

Table 1. Demographic Profile and Mechanism of Injury among Children with Diaphyseal Forearm Fractures (n = 20)

The majority of fractures were located in the middle third of the forearm (65%), followed by the proximal (25%) and distal third (10%) regions. All cases were closed fractures, reflecting a low incidence of open injuries in this pediatric cohort. More than half of the children (55%) underwent surgery within one week of injury, indicating prompt surgical management consistent with current pediatric fracture protocols. Minor complications were reported in four patients—comprising pin site infections (15%) and skin irritation at the entry site (5%) while 80% experienced uneventful postoperative recovery without any complications (Table 2).

Table 2. Fracture Characteristics, Timing of Surgery, and Postoperative Complications among Study Participants (n = 20)

Functional recovery following Titanium Elastic Nailing System (TENS) fixation was highly satisfactory, with 75 % of children achieving excellent results and an additional 20 % demonstrating good outcomes based on the Price et al. criteria. Only one patient (5 %) had a fair restriction in forearm rotation, and none exhibited poor results. These outcomes underscore the technique’s ability to restore near-normal pronation–supination arcs in pediatric diaphyseal forearm fractures. Radiologically, the mean time to fracture union was 8.36 weeks, ranging from 6 to 14 weeks. A majority (60 %) achieved union within 6–8 weeks, while complete radiological consolidation was evident in 87 % of patients by week 13. The consistent and predictable union profile observed affirms the biological stability provided by elastic nailing and highlights the effectiveness of TENS in promoting rapid callus formation and early functional rehabilitation (Table 3, Figures 1 and 2).

Table 3. Functional and Radiological Outcomes among Children Treated with TENS (n = 20)

Figure 1: Functional Outcomes among Children Treated with TENS (n = 20)

Figure 2: Radiological Outcomes among Children Treated with TENS (n = 20)

This prospective observational study evaluated the functional and radiological outcomes of pediatric diaphyseal forearm fractures managed using the Titanium Elastic Nailing System (TENS). Twenty children aged 4–12 years were followed until complete fracture union. The majority were boys (65%) and sustained fractures following a fall on an outstretched hand. Most fractures involved the middle third of the forearm (65%) and were closed injuries. The mean time to surgery was within one week in more than half of the cases, reflecting timely surgical intervention. Functional outcomes were excellent in 75% and good in 20% of patients, with only one child demonstrating a fair restriction of forearm rotation. The mean time to radiological union was 8.36 weeks, with 60% achieving union within 8 weeks. Complications were minor and limited to superficial infections (15%) and entry-site irritation (5%), both of which resolved without sequelae. These results collectively indicate that TENS provides a stable, biological, and minimally invasive fixation option yielding rapid union and excellent recovery of function in children with unstable diaphyseal forearm fractures.

Comparison with Existing Literature

The outcomes observed in this study are consistent with those reported in previous pediatric orthopaedic literature. The mean time to radiological union of approximately eight weeks aligns closely with large clinical series where fracture consolidation typically occurred between 8 and 10 weeks following TENS fixation. Similar to other reports, union was achieved earlier in younger children and in mid-diaphyseal fractures, emphasizing the role of better vascularity and bone remodelling potential in this age group. The absence of delayed union or nonunion in the present cohort reaffirms the biological reliability of elastic intramedullary fixation when performed using appropriate technique and nail diameter selection.[7]

Functionally, this study demonstrated 95% excellent-to-good results based on the Price criteria, which parallels the 87–98% excellent-to-good outcomes reported in multicentric and institutional series employing TENS for pediatric forearm fractures. The rapid recovery of pronation and supination arc and the absence of significant stiffness validate the biomechanical advantage of three-point elastic fixation in preserving rotational alignment and interosseous membrane dynamics. These findings support the premise that TENS achieves near-physiological restoration of forearm kinematics while minimizing soft tissue disruption.[8,9]

The observed complication rate of 20%, limited to minor issues, was lower than or comparable with rates reported in contemporary studies, which range between 10% and 25%. Importantly, no cases of deep infection, hardware migration, neurovascular compromise, or refracture were encountered.[10] This reflects both meticulous surgical technique and careful postoperative care.[11] The standardized immobilization protocol with an above-elbow cast for 4–6 weeks facilitated adequate soft-tissue recovery without adversely affecting long-term motion. Nail removal at around 24 weeks after confirmed union was uneventful, further attesting to the procedure’s safety profile.[12,13]

Strengths and Limitations

The strengths of this study include its prospective design, detailed radiological follow-up until confirmed union, and uniform surgical and postoperative protocols applied by a single team, minimizing operator-dependent variability. The study comprehensively assessed both radiological healing and functional restoration using validated criteria, allowing for objective outcome comparison with global data. Furthermore, the inclusion of a well-defined pediatric age group provides focused insights into the healing characteristics and biomechanics specific to growing bone. However, certain limitations must be acknowledged. The relatively small sample size limits the generalizability of the findings, and the study was conducted at a single institution, which may not fully represent the diversity of clinical presentations. The absence of a control group treated conservatively or with plate fixation precludes direct comparative evaluation of outcomes and cost-effectiveness across different modalities. Additionally, the short-term follow-up period, though sufficient to assess union and function, does not permit evaluation of long-term remodelling, residual deformities, or potential late complications.

Titanium Elastic Nailing System (TENS) offers an effective, safe, and biologically sound option for the management of unstable diaphyseal forearm fractures in children. In this prospective study, the technique provided consistent and timely fracture union, rapid restoration of forearm function, and a very low complication profile. By maintaining periosteal integrity and enabling elastic stability through three-point fixation, TENS achieved excellent-to-good functional outcomes in 95% of cases and complete radiological union in all children within an average of eight weeks. Its minimally invasive nature, reproducible results, and ease of implant removal further highlight its clinical advantage. In appropriately selected pediatric patients, TENS should be considered the preferred modality of fixation, balancing mechanical stability with biological preservation for optimal long-term functional recovery.

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