股骨干骨折逆行弹性髓内钉固定&尾帽技术
体位：仰卧位，透光手术床。对大年龄儿童（>8岁）或轴向不稳定病例牵引床有助于骨折复位。
弹性钉直径选择：根据术前股骨全长1:1正侧位片选择弹性钉，每枚直径为髓腔最狭窄处直径35~40%。
预弯：根据股骨全长1:1正侧位片将预计进入髓腔内部分弹性钉折弯成C形，弧高为骨折端髓腔直径3倍，弧形顶点位于骨折水平。
入钉水平：距离股骨远端骺板上1.5~2cm处，皮肤切口自髌上缘向远纵行延长约2cm。
开路锥开路：垂直骨面，突破部分皮质后逐渐转为与骨干成45°夹角，转动开路锥，达对侧髓腔内壁，并经C臂确认。
入钉：将经预弯的弹性钉装入打入器，如图沿入钉点插入髓腔内，后转动180°。
C臂指示下推进弹性钉达骨折端，对位骨折端后维持复位并推进弹性钉进入骨折近端（在经过骨折端时可临时转动钉尖方向以利通过，在通过后尽快转回到“正常方向”；复位可借助F复位器、克氏针辅助复位等）。在弹性钉打入达目标深度前停止。
同法操作推进另一枚经相同预弯弹性钉。
C臂指示下调整内外侧钉打入深度，在达目标深度1cm水平时停止继续打入，准备断钉。
如图所示，用断钉器在离入钉点2~2.5cm处截断，用打入器继续打入约1cm，准备拧入尾帽。
尾帽两个规格：紫色用于1.5~2.5mm弹性钉，绿色用于3.0~4.0mm弹性钉。如图所示沿钉尾拧入尾帽达干骺端骨质内，C臂证实钉尾与尾帽底部接触。
如上图所示为一例长斜行骨折（轴向不稳定型）单纯弹性钉固定后骨折端发生相对短缩，弹性钉尾端部分退出（Slongo"s case）。
病例应用：8岁男孩，滑雪致右股骨近端骨折。入院后即刻行右胫骨近端骨牵引，伤后3天行骨折闭合复位弹性钉内固定术。
PEARLS AND PITFALLS
Indications ■ The flexible nailing technique is most successful for children ages 5 to 12, weighing less than 50 kg, withlength-stable fractures. Very proximal, distal, or length-unstable fractures can be treated with flexible nailing, but the complication rate is higher and immobilization in a cast may be necessary as an adjunct to treatment.
Preoperative planning ■ Proper selection and preparation of the nails are crucial. as well as proper patient selection. The nailsizes and the entry points should be symmetric.
Fracture fixation ■ Proper nail configuration must be achieved to obtain three-point fixation. The nails should be gently curved before insertion to ensure maximum cortical contact. If insertion or nail passage may be difficultor the entry site is complicated by soft tissue injury, an anterograde method of insertion through thegreater trochanter may be used for one or both nails.
Difficulty in reduction ■ An instrument referred to as the “F tool” is a great aid to reduction.
Skin irritation ■ To avoid skin irritation, the nails should be cut so that they lie flush with the metaphysis of the distalfemur, with only about 1 to 2 cm of the nail outside the cortical entry site.
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本文基于以下资料整理，不做商业用途，如涉及版权问题请与我们联系：
1）Titanium/Stainless SteelElastic Nail System. For elastic stableintramedullary nailing (ESIN).Technique Guide；
2）Teddy Slongo"s talk ():ESIN and End caps in femoral fractures;
3)John M. Flynn，Sam W. Wiesel:Operative Techniques in Pediatric Orthopaedics()
