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The fracture of the distal radius is frequent . It is estimated that 150,000 people sustain a distal radius fracture every year in France . The simplicity, the efficiency and the low cost of the surgical procedure are decisive factors in terms of public health. Therefore, their mechanism should better be fully understood [3-5]. In order to operate on those patients with very few skin damages, an appropriate reduction is necessary before the nailing procedure. And, when the nail is placed, the material must fit to prevent any secondary collapse. Overall, if the spongious bone underwent a deep crush. But if the material is correctly adapted, it is reasonable to offer a stable and non-invasive osteosynthesis of those kinds of fractures. The radius is a long, relatively straight bone, and frequently subject to fractures because of its protective role in the event of a fall or accident. The long wires were first used during the first World War while the flexible pins were described as early as the 1950s. Several types of flexible nails dedicated to distal fractures appeared in the early 2000s. Today, there are specifically designed wires for fractures of the radial diaphysis.
During a fall, the wrist undergoes a force of compression and flexion which causes a crush of the bony trabecular structure of the distal radius. The cortical break comes along with the flattening of the deep cancellous bone. The first principle of a closed nailing is to recognize the existence of a “compaction chamber”, that is to say a void of bone. The aim is to reopen this chamber and keep its banks well apart to restore the length of the radius. The elasticity of the nail has to enable to maintain this opening. This principle was described by Desmanet in 1989 . Some implants have even been specially designed to fill the void of the compaction chamber. They have the disadvantage of being bulky and not providing any mechanical stability. However, they widely open the fracture focus and they offer the advantage of showing the volume of bone loss at the distal metaphysis level (Figure 1).
The fracture of the distal radius is reduced by manual traction. It dis impacts the fracture site and reopens the metaphysis. The nail, as a central stake, maintains the reduction and the void thus created (Figure 2-4).
The nailing of long bones was described by R. Danis of the
University of Brussels (Belgium) in 1938 and by G. Küntscher at
the University of Kiel (Germany) in 1939. The later used his nails
on the wounded of the Finnish front during the Second World
War . The transverse locking of the nail has been described
by Modny and Bambara in 1953 . This lock was improved by
Kempf & Grosse  in 1978 to the point where it prevailed over
the screw plate osteosynthesis which popular in the 1960-1980.
This method has revolutionized the treatments of long bones
fractures. Since de year 2000 it has been applied to the upper
limbs. The real goal was to go back to closed focus osteosynthesis
as done for the lower limbs. Most recent series seem to show
the equivalence of radiological and functional results, between
closed nailing and the anterior plates. “The present study
supports the view that intramedullary nail fixation and flat
fixation for the treatment of displaced extra-articular distal
radius fractures have equivalent radiographic and functional
outcomes. Garcia said  (Figure 5).
The Nail-o-flex® nail was introduced in 2005. It is a specific
nail for fractures of the distal radius. It comprises a distal portion
which is perforated and a long, smooth proximal part that is thin
and flexible to ensure elasticity. The nail-o-flex® nail application
technique is directly derived from the long bones nailing of the
lower limb. The radius fracture is reduced by manual traction.
The nail is inserted at the level of the snuffbox, outside the
tendinous areas. The entrance is perforated with a small square
point. The nail has an “S” shape. It is inserted with curvature
upside down to fit the metaphyseal angle, it is then turned over
and entirely inserted. It is stopped by the aiming frame which
stumbles on the radial styloid. Locking is performed as for the
femur or tibia. The nail is freestanding thanks to its “S” design
and its 3 points of support. It is also elastic since the 2/3 of the
nail are fine as a pin (2mm) and automatically realigns the distal epiphysis and keeps the focus open. It must be locked at its distal
part, with at least two epiphyseal screws (Figure 6).
Between May 2008 and May 2015, the Nail-o-flex® nail
was used to treat fractures of the lower end of the radius. All
cases presenting an extra-articular fracture (Colles or Smith)
and/or an intra-articular fracture (except marginal fracture and
comminuted fractures with 4 fragments or more) have been
treated. The preliminary series includes 83 cases. Of these 83
cases, the female/male ratio was 7 to 1. The average age was 67
years, ranging from 18 to 89 years. Average operating time was
45 minutes. The hospital stay was 2 days up to 2013, when all
these fractures were then treated as outpatients. A Velcro splint
has been routinely used for a period of 5 weeks. The clinical
results were analyzed with the Constant score: 55 excellent, 20
satisfactory and 8 poor result. There was no redo for insufficient
result. Fractures have been classified according to Laulan &
Bismuth . The purpose of this Clinical Series was to confirm
that metaphyseal bone defect could be treated with an elastic
nail according to the principle of Desmanet, without graft or
surrogate, and that the distal epiphyseal lock was sufficient to
keep the epiphyseal fragments in a good position during the
entire consolidation period. In this series, we have shown that
75/83 cases had retained a radio-ulnar index less than or equal
to 0. This shows a good restoration of the length of the radius.
These cases correspond to the 75 cases of the pre-series (Figure
The nailing of the fractures of the radius is an outsider
because there is a kind of unanimity about the anterior screwed
plate. One can criticize plates to be inserted openly opposite
to the damaged area. This can be the source of additional pain.
However mini-nails of the radius have been compromised
by unreliability and limited indications. None of them had
incorporated the need for an elastic recall force to oppose the
natural compaction of the compaction chamber. This is the
originality of the nail-o-flex® nail. The nail-o-flex® nail is a
“nail-pin” that combines distal locking of Kempf and Grosse and
the proximal elasticity of Desmanet. As so it can behave like
an internal distractor. Improvements have been made on the
quality of the locking screws and the accuracy of the viewfinder.
Today this nail is a simple to use for any operator familiar with
the femur or tibia nails.
a) The Compaction Chambers
The first question in the distal radius fractures seems the
loss of bone matter in the metaphyseal region due to the
flattening of the spongy bone. The clinical series has shown
that the radius only recoils in 10% of cases (75/83), whereas
this complication was frequent with the Kapandji type
entanglements. Efficiency seems to be due to the fact that
the nail acts as a central guardian, without shear stress.
b) The Reduction must be Accurate. And secondarily, to
Maintain A Self-Stable
epiphyseal reduction is obligatory. The use of palmar plates
may seem paradoxical since the bone comminution is mainly
on the opposite side [11-13]. The operator does not have
access to it. Even self-stable screws cannot replace a missing
bone. Many authors question themselves about this method
which is widely diffused [13-15]. The intramedullary
percutaneous nail is mechanically more logical. It is central,
thus more neutral and simpler to use. Lateral approach is
direct and offers more security.
c) To maintain a good orientation of the radial epiphysis:
The functional result is good if the 15° epiphyseal
anteversion is restored. One tolerates a tilting of only a few
degrees because it does not have any impact on the degree
of flexion of the wrist. But a retroversion of the epiphysis
was considered a poor result, even if the index radio-ulnar remained equal to zero. We found 7 poor cases, mainly at the
beginning of the series. However, the absence of shortening
of the radius made it possible to maintain normal pronosuppination.
Patients therefore did not feel the need for a
d) The painful assessment is favorable. It is recognized
that closed osteosynthesis are less painful than open
procedures as screwed plates. (Kempf I., Leung KS, “Practice
of intramedullary locked nails.” Springer, 2002).
e) The aesthetic aspect is interesting. The intervention is
conducted by 3 or 4 holes of 2 or 3 mm (Figure 8).
f) And its cost is low (the implant costs 250 euros) .
Distal radius pinning is proving itself to be logical and
reliable. The Nail-o-flex® nail was designed in 2005. Its aim
was to offer an immediate stability along the radial shaft with an
effective grip on the proximal diaphysis (3 support points). This
seems to offer indeed a stable length restoration of the radius
bone. With its 12 years of success records, the nail is a simple
and inexpensive osteosynthesis implant. Its use is easy for any
surgeon familiar with the pinning of the tibia. Its reliability is
comparable to the best series of palmar plates. It requires only
moderated X-ray irradiation.
Kempf I, Grosse A, Lafforge D (1978) L’apport du verrouillage dans l’enclouage centro- médullaire des os longs Rev Chir Orthop 64: 635-1
Obert L, Leclerc G, Blanchet P, Vichard P, Garbuio P (2008) Fractures of distal radius with dorsal displacement treated with palmar plates: fashion trend or real progress? In: maîtrise orthopédique, N°171, Fé