Quadruple Versus Double Flexible Intramedullary Nails to Treat Pediatric Distal-third Tibial Shaft Fractures: A Biomechanical Comparison

Adnan Zubair, Eric M. Samuelson, Randal P. Morris, Mark Foreman, Johann A. Gagnon-Bartsch, Scott B. Rosenfeld

Research output: Contribution to journalArticlepeer-review


Background:The vast majority of pediatric distal-third tibial shaft fractures can be treated with closed reduction and casting. If conservative measures fail, then these fractures are usually treated with 2 antegrade flexible intramedullary nails. A postoperative cast is usually applied because of the tenuous fixation of the 2 nails. Recent studies have described the use of 4 nails to increase the stability of the fixation, a technique that may preclude the need for postoperative casting. The purpose of this biomechanical study is to quantify the relative increase in stiffness and load to failure when using 4 versus 2 nails to surgically stabilize these fractures.Methods:Short, oblique osteotomies were created in the distal third of small fourth-generation tibial sawbones and stabilized with 2 (double) or 4 (quadruple) flexible intramedullary nails. After pilot testing, 5 models per fixation method were tested cyclically in axial compression, torsion, and 4-point bending in valgus and recurvatum. At the end of the study, each model was loaded to failure in valgus. Stiffness values were calculated, and yield points were recorded. The data were compared using Student's t tests. Results are presented as mean±SD. The level of significance was set at P≤0.05.Results:Stiffness in valgus 4-point bending was 624±231 and 336±162 N/mm in the quadruple-nail and double-nail groups, respectively (P=0.04). There were no statistically significant differences in any other mode of testing.Conclusions:The quadruple-nail construct was almost 2 times as stiff as the double-nail construct in resisting valgus deformation. This provides biomechanical support for a previously published study describing the clinical success of this fixation construct.

Original languageEnglish (US)
Pages (from-to)487-491
Number of pages5
JournalJournal of Pediatric Orthopaedics
Issue number9
StatePublished - Oct 1 2020
Externally publishedYes


  • ESIN
  • FIMN
  • biomechanics
  • distal tibia
  • fixation
  • flexible intramedullary nails
  • fractures
  • pediatrics
  • tibia shaft fractures

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Orthopedics and Sports Medicine


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