Radial entry for ESIN fixation of pediatric radial fractures: a 10-year cohort study with focus on neurological complications

BACKGROUND: Elastic stable intramedullary nailing (ESIN) is an established treatment for pediatric radius fractures. However, the optimal surgical entry point remains debated due to differing complication profiles. The radial approach carries a risk of superficial branch of the radial nerve (SBRN) irritation, whereas dorsal approaches have been associated with extensor tendon injuries. This study evaluates the neurological complication profile of the radial approach and provides clinically relevant risk factors. METHODS: A retrospective single-center study was performed including 285 pediatric patients treated with ESIN for radius fractures between 2015 and 2024 using a standardized radial entry technique. Neurological complications were assessed at predefined time points. Associations between patient age, fracture characteristics, entry point location, and neurological outcomes were analyzed. RESULTS: New SBRN lesions occurred in 12 of 285 patients (4.2%) after ESIN implantation and in 3 patients (1.1%) after implant removal. Most deficits were transient, while persistent deficits were observed in 2.1% of cases. A more proximal entry point showed a trend toward increased risk of SBRN injury (p = 0.055), with a potential threshold at approximately 18 mm from the distal radial physis. Older patient age was significantly associated with increased risk of neurological complications (p < 0.001). No extensor pollicis longus (EPL) tendon ruptures were observed. CONCLUSION: Radial entry ESIN is associated with a low rate of predominantly transient neurological complications. Entry point positioning and patient age appear to influence the risk of SBRN injury. Based on our data and the available literature, the radial approach represents a safe and clinically favorable option for ESIN of pediatric radius fractures.