Comparative Study of Functional and Radiological Outcomes of Antegrade Versus Retrograde Titanium Elastic Nailing for Pediatric Ulnar Diaphyseal Fractures

Background Pediatric forearm fractures account for approximately 40% of childhood skeletal injuries, with ulnar fractures being particularly prevalent. Titanium Elastic Nailing (TEN) offers an effective minimally invasive option for these injuries; however, the optimal nail entry point - antegrade (olecranon) versus retrograde (distal ulna) - remains debated. This study compared functional and radiological outcomes, complication profiles, and implant-related morbidity between the two approaches. Methods A retrospective comparative study was conducted from May 2023 to May 2025 at the R.L. Jalappa Hospital and Research Centre, Karnataka, India. Seventy children aged 5-16 years with closed ulnar diaphyseal fractures treated with TEN were divided into antegrade (n=35) and retrograde (n=35) groups. Radiographic union time and six-month Disabilities of the Arm, Shoulder and Hand (DASH) scores were the primary outcomes. Bonferroni correction was applied to control for comparisons of multiple complications. Results Retrograde nailing showed faster unadjusted union (7.4 ± 0.6 vs. 8.6 ± 0.7 weeks; p<0.001), but the retrograde group had more distal-third fractures. After adjusting for fracture location, the difference narrowed to 0.6 weeks - statistically significant but unlikely to change clinical practice. Functional outcomes were equivalent at six months: full range of motion (ROM) in 91.4% vs. 94.3%, mean DASH scores of 4.2 vs. 3.6 (p=0.198), and near-normal elbow and forearm motion in both groups. The overall complication-free rate strongly favored retrograde nailing (85.7% vs. 42.9%; p<0.001). Olecranon irritation (34.3%) and early implant removal (22.9%) were exclusive to the antegrade group. Two young retrograde patients had nail entry close to the distal physis. Neither showed growth arrest at six months, though longer follow-up is needed. Conclusion Both techniques achieve excellent functional outcomes. The advantage of union time in the case of retrograde nailing was attenuated after fracture-location adjustment. The clearest difference was a significantly lower overall complication burden with retrograde nailing (p<0.001), supporting its preferential use for midshaft and distal fractures in older children. However, careful consideration is required regarding potential physeal damage.