Percutaneous versus subcutaneous titanium elastic nail tips: complication profiles by age group in pediatric forearm shaft fractures

BACKGROUND: Titanium elastic nailing (TEN) is widely used for the treatment of unstable pediatric forearm fractures. Although subcutaneous nail tips remain the standard technique, superficial (exposed) nail tip placement has been described as an alternative strategy to facilitate implant removal. However, evidence regarding complication profiles associated with different TEN tip management techniques remains limited, particularly with respect to age-related differences. This study addresses three critical gaps: (1) comparative complication rates between superficial and subcutaneous TEN placement, (2) the influence of patient age on outcomes, and (3) identification of age thresholds for complication risk stratification. METHODS: We conducted a retrospective cohort study of 99 pediatric patients treated with TEN for forearm fractures at a tertiary care center (2011-2023). Patients were stratified into Group 1 (subcutaneous TEN, n = 48) and Group 2 (superficial TEN, n = 51). Inclusion criteria required ≥ 1 year follow-up post-removal. Primary outcomes included infection, re-fracture, nonunion, and implant removal time. Secondary outcomes assessed reduction adequacy and age-specific complication patterns. Advanced statistical analyses included ROC curve analysis to identify age cutoffs and logistic regression to evaluate age-technique interactions. RESULTS: No statistically significant differences were identified between the groups regarding infection (p = 1.0), re-fracture/nonunion (p = 0.488), or overall complication rates (p = 0.271). However, subgroup analysis demonstrated that patients aged ≥ 9.8 years in the superficial TEN group showed increased risks of re-fracture/nonunion (OR = 5.826, 95% CI: 1.35-25.2, p = 0.01) and overall complications (OR = 3.158, 95% CI: 1.15-8.7, p = 0.02). Implant removal occurred significantly earlier in the superficial TEN group (1.93 vs. 5.43 months, p < 0.001), reflecting technical convenience rather than accelerated fracture healing. ROC analysis identified 9.8 years as a potential age-related threshold for increased complication risk in the superficial TEN group. CONCLUSION: Superficial TEN tip placement did not increase overall complication rates compared with subcutaneous placement in the overall cohort. However, older children treated with superficial TEN placement demonstrated higher complication risks. The identified 9.8-year threshold should be interpreted cautiously as an exploratory and hypothesis-generating reference value rather than a definitive surgical cutoff. Consideration of patient age and skeletal maturity may assist surgical decision-making regarding TEN tip management in pediatric forearm fractures.