Flexible nailing versus rigid intramedullary nailing in pediatric and adolescent tibial shaft fractures

This study aimed to compare reamed rigid and flexible intramedullary nailing outcomes in pediatric and adolescent tibial shaft fractures. A retrospective cohort analysis included patients aged 10–17 years with tibial shaft fractures treated by flexible or rigid intramedullary nailing from 2010 to 2024, with greater than or equal to 6-month postoperative follow-up. Individuals with prior tibia surgery, pathologic fractures, or complex medical histories were excluded. Demographics, fracture characteristics, surgical details, clinical outcomes, and radiographic outcomes were analyzed. Analyses were conducted using Wilcoxon rank-sum, Pearson’s χ 2 , and Fisher’s exact tests. A total of 66 patients were included (29 flexible, 37 rigid). Rigid nail patients were significantly older ( P < 0.001), and more skeletally mature (modified Fels: 15.45 vs. 13.01 years; P < 0.001). Open fractures were also more common in the rigid group (41 vs. 17%; P = 0.041). Time to weight-bearing was significantly shorter following rigid treatment (40 vs. 46 days; P = 0.022). Although not statistically significant, delayed union (11 vs. 0%; P = 0.13) and postoperative knee pain occurred more frequently in rigid patients (24 vs. 10%; P = 0.14). Hardware removal was required more often in flexible nails (72 vs. 22%; P < 0.001). There were no significant differences in posterior proximal tibial angle or complication rates (all P > 0.05). No cases of postoperative limb length discrepancy or recurvatum were observed. Rigid nailing was associated with earlier weight-bearing and fewer hardware removal procedures. While delayed union and postoperative knee pain were more frequent in rigid nail patients, these differences were not statistically significant.