Surgical Discussion

Patient positioning:  The patient was positioned supine on a radiolucent operating table to facilitate intraoperative imaging with a C-arm fluoroscope.

Anatomical surgical approach:  A medial distal thigh incision was made to access the femoral medullary canal. The canal was opened proximal to the growth plate using an awl, ensuring no damage to the physis. A pre-bent titanium elastic nail was then inserted and advanced across the fracture site under fluoroscopic guidance until it reached the proximal fragment. A similar approach was used on the lateral side to insert a second nail, achieving bicortical purchase and ensuring proper alignment and rotation.

Intraoperatively, the fracture was slightly distracted initially, but was successfully compressed after nail insertion to minimize the gap, achieving good axial alignment. The nails were bent and cut below skin level to prevent soft tissue irritation. The rotational alignment was confirmed with fluoroscopy, as wel as clinically comparing both legs to ensure symmetry.

Postoperative protocol:   Postoperative management involved functional, pain-oriented rehabilitation without the need for immobilization. Weight-bearing as tolerated was encouraged based on the child's comfort level.

Follow up:   Clinical follow-up at 6 months postoperatively showed satisfactory healing of the fracture with no signs of malalignment or leg length discrepancy. The ESINs were removed at this time, and the patient was able to resume normal activities without restrictions.

Orthopaedic implants used:   Two titanium elastic stable intramedullary nails (ESIN)