Changing trends in the management of pediatric distal forearm fractures: a descriptive Danish 20-year nationwide registry study of 175,083 cases

Katrine Rønn ABILDGAARD 1, Per Hviid GUNDTOFT 2,3, Stig BRORSON 1, and Bjarke VIBERG 2,4

1 Centre for Evidence-Based Orthopedics, Department for Orthopedic Surgery, Zealand University Hospital, Køge;
2 Department of Orthopedic Surgery and Traumatology, Hospital Lillebaelt Kolding, University Hospital of Southern Denmark;
3 Department of Orthopedic Surgery and Traumatology, Aarhus University Hospital, Aarhus;
4 Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark

Background and purpose — Management of pediatric distal forearm fractures ranges from no or simple immobilization to surgical fixation. Treatment decisions depend on age and fracture severity, but practices vary widely across countries. As surgical intervention has increased internationally, we aimed to investigate national trends in incidence and treatment of pediatric distal forearm fractures in Denmark from 1999–2018

Methods — We conducted a population-based register study of children aged 0–15 with distal forearm fractures (S525 + S526) registered in the Danish National Patient Registry from 1999–2018. Treatments within 1 week of injury were grouped into: non-surgical (no immobilization, soft bandage or cast immobilization), closed reduction and immobilization, and surgical fixation. Procedure codes included closed reduction, open reduction, K-wires, or other fixations such as external fixation, nail, plate, or screws.

Results — There were 175,083 fractures over the 20 years, yielding a mean incidence of 829/100,000/year in children aged 0–15 years. The highest incidences were 1,494/100,000 among 11-year-old girls and 1,720/100,000 among 13-year-old boys. The primary treatment in all age groups was non-surgical treatment, though decreasing from 92% in 1999 to 89% in 2018. The proportion of closed reduction declined from 7% to 2%, while K-wire fixation increased from 1% to 8%. When stratified by age groups, the same trend was seen in all but the 0–3-year-olds.

Conclusion — The overall incidence remained stable during the study period. Non-surgical treatment remained predominant, whereas closed reductions decreased in favor of more K-wire fixations.

 

Citation: Acta Orthopaedica 2026; 97: 21–27. DOI: https://doi.org/10.2340/17453674.2025.45057.

Copyright: © 2026 The Author(s). Published by MJS Publishing – Medical Journals Sweden, on behalf of the Nordic Orthopedic Federation. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/)

Submitted: 2025-05-12. Accepted: 2025-11-17. Published: 2026-01-19.

Correspondence: katrineroennabildgaard@gmail.com

KA, SB, PG and BV designed the study. BV and PG had access to Forskermaskinen and extracted data from the DNPR. KA performed statistical analysis and drafted the manuscript, and the results were analyzed with and the manuscript revised by SB, PG and BV.

Handling co-editors: Ilkka Helenius and Robin Christensen

Acta thanks Jiri Chomiak and other anonymous reviewers for help with peer review of this manuscript.

 

Distal forearm fractures are the most common pediatric fractures, accounting for ~25% of cases [1]. Management can be non-surgical (no immobilization, soft bandage or cast immobilization), closed reduction and casting, or surgical with reduction and fixation [2,3]. Torus fractures and Salter-Harris (SH) type I fractures are typically treated with a dorsal splint or soft bandage for 3 weeks with no follow-up [3]. Treatment decisions regarding greenstick, complete, and SH type II–IV fractures depend on degree of displacement (angulation and translation), thresholds varying with age and between countries, hospitals, and surgeons [4]. Awareness of treatment trends is important to standardize pediatric fracture care regarding patient burden and cost-effectiveness.

Reported incidences range from 337 to 784 per 100,000 persons/year, with peaks among 7–10-year-old girls and 10–14-year-old boys [5-7]. Variation between studies reflects different inclusion criteria and registries, making comparison difficult.

Indications for surgery vary across countries. Although non-surgical treatment predominates [2], surgical treatment has increased across all fracture types [8]. Closed reduction may be an alternative when non-surgical treatment is insufficient. Whereas some countries perform closed reduction under sedation in the emergency department [9,10], in other countries, including Denmark and Sweden, it is usually performed under general anesthesia with optional Kirschner wires (K-wires) [11,12]. Yet, a Danish report from 2025 recommends closed reduction under sedation in the emergency department for forearm fractures in 4–15-year-old children, provided safety prerequisites are met [13].

The aim of our study was to report incidence and treatment trends of pediatric distal forearm fractures in Denmark over the last 20 years, stratified by age.

Methods

Study design

This population-based register study includes 0–15-year-old children with distal forearm fractures registered in the Danish National Patient Registry (DNPR) from 1999–2018. The study is reported according to RECORD guidelines [14].

Setting

Denmark has a population of nearly 6 million [15]. All citizens are provided a unique CPR (Central Person Register) number [16], which grants free healthcare and ensures registration of all healthcare contacts in national databases. As treatment is free, the mean distance to hospitals is 20 km [17], and radiographs are only available at hospitals. All fracture treatments are provided in public hospitals; acutely in the emergency rooms and during follow-up in outpatient clinics or general practice, depending on severity.

Data sources

The DNPR, linked to the Central Person Register, contains data on inpatients since 1977 and outpatients since 1995 [18]. Registration of all diagnoses and procedures is mandatory whenever a person is treated in the public healthcare system, enabling extensive information on health status, medications, and treatments. Data completeness is nearly 100% [15,18], and the Positive Predictive Value (PPV) of primary diagnoses in orthopedic surgery is approximately 83% [18]. Whereas the exact PPV for childhood fractures is unknown, for adult hip, humerus and ankle fractures, it is >90%, 89%, and 95%, respectively [19-21].

Participants

All patients between 0 and 15 years with ICD-10 diagnosis codes for distal radius fractures (S525) and distal radius and ulna fracture (S526) were included. Because these codes encompass all fracture types, from torus to displaced fractures, they are all represented in the dataset (Figure 1).

Figure 1
Figure 1. Patient flowchart.

Variables

Although the CPR and DNPR are linked, data extraction was performed anonymously. The following data were extracted: sex, age, year of injury, ICD-10 code, and procedure codes. Yearly population counts for each age, defined as survivors by December 31st, were obtained from Statistics Denmark [15]. Fracture incidence was reported for girls and boys overall and within the age groups 0–3, 4–7, 8–11, and 12–15 years. These groups reflect common clinical practice and treatment strategies. Treatment definitions were:

Statistics

All statistical analyses and data visualizations were performed using R (R Foundation for Statistical Computing, Vienna, Austria, version 4.3.3).

Descriptive statistics are presented as numbers and percentages. Incidences were calculated as cases per 100,000 persons/year with 95% confidence intervals (CI) (Poisson distribution), based on the number of cases divided by the at-risk population. Treatment proportions were calculated as the number in each treatment category divided by the total number of treatments, with 95% CI (binomial distribution). No formal statistical comparisons between groups or over time were performed, but 95% CIs were compared for potential overlap.

Data access and cleaning methods

The authors had access to the Danish Health Data Authority’s research database facilities (Forskermaskinen).

Ethics, data sharing, funding, and disclosures

The author group had full access to data but are not allowed to share the raw data. Some cleaned data can be shared upon request. According to Danish legislation, no ethical approval was needed. The study is part of a PhD project, partly funded by Region Zealand and external funders (King Christian the Tenth’s Foundation, The Ville Heise Grant, and Guildal Foundation). None of the authors received commercial funding. The authors declared no conflicts of interest. Complete disclosure of interest forms according to ICMJE are available on the article page, doi: 10.2340/17453674.2025.45057

Results

Incidence

There were 175,083 fractures, with boys accounting for 56% of cases (n = 97,966). Among the 9–13-year-olds, more than 15,000 fractures were registered in each age group, in total constituting 88,794 (51%) of all fractures (Table 1). The mean annual incidence over the study period was 829/100,000 for children aged 0–15 years (Table 2). Boys had a higher incidence (905/100,000) than girls (749/100,000). For boys, the peak incidence was among 13-year-olds with 1,720/100,000, and for girls, the peak incidence was among 11-year-olds with an incidence of 1,494/100,000 (Figure 2). When assessing the incidence time trends, the incidences showed an upward trend, but with considerable annual variations (Figure 3). The incidence per 100,000 for the total population was 840 (CI 822–858) in 1999 and 863 (CI 845–881) in 2018. For boys, the incidence was 913 (CI 887–939) and 960 (CI 934–987), respectively, and for girls it was 763 (CI 739–787) and 761 (CI 737–788). For the total population as well as boys and girls separately, the CI overlapped.

Table 1. Number (counts) of distal forearm fractures in 0–15-year-old children from 1999 to 2018
Total 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Total 175,083 8,575 8,433 8,047 8,690 8,254 8,568 8,646 8,320 8,557 9,202 9,010 8,466 8,825 8,560 8,853 9,566 9,143 9,565 8,938 8,865
Sex
 Boys 97,966 4,780 4,654 4,474 4,863 4,574 4,733 4,740 4,662 4,875 5,202 5,126 4,635 4,902 4,765 5,009 5,328 5,156 5,314 5,117 5,057
 Girls 77,117 3,795 3,779 3,573 3,827 3,680 3,835 3,906 3,658 3,682 4,000 3,884 3,831 3,923 3,795 3,844 4,238 3,987 4,251 3,821 3,808
Age
 0 374 24 22 28 24 20 20 20 18 17 18 16 19 19 11 17 19 12 13 21 16
 1 3,641 232 248 205 242 185 186 213 194 173 177 197 170 173 137 160 148 136 144 155 166
 2 3,514 227 199 202 230 179 178 179 215 171 179 165 172 177 141 151 146 151 149 160 143
 3 5,038 287 292 262 306 275 249 253 245 248 269 264 251 260 204 232 247 219 221 205 249
 4 6,774 359 401 323 348 346 336 367 353 316 330 361 318 298 327 305 367 327 321 353 318
 5 9,359 511 502 465 534 412 450 472 492 444 458 454 480 462 449 458 463 476 482 435 460
 6 11,104 600 587 505 596 554 559 570 515 538 552 586 487 534 526 598 578 548 615 540 516
 7 12,539 705 676 572 653 644 583 609 611 581 593 593 562 625 596 613 705 641 701 640 636
 8 14,135 764 697 663 716 689 690 736 602 675 747 694 644 703 672 732 754 753 790 731 683
 9 16,005 790 777 773 812 774 798 770 705 765 780 841 769 778 756 792 898 857 885 854 831
 10 18,271 835 872 883 927 823 865 925 821 918 987 952 849 940 866 887 1,003 1,033 1,004 918 963
 11 19,659 917 909 879 880 948 986 949 986 980 1,134 985 929 1,040 1,030 917 1,087 1,009 1,084 1,043 967
 12 18,590 794 828 857 817 835 902 889 889 906 1,036 994 959 940 935 1,029 1,001 1,026 1,043 961 949
 13 16,269 659 681 635 739 753 792 763 762 836 910 873 800 813 876 867 947 877 946 850 890
 14 11,951 533 456 483 516 498 555 551 571 630 651 638 630 632 624 663 729 620 712 621 638
 15 7,860 338 286 312 350 319 419 380 341 359 381 397 427 431 410 432 474 458 455 451 440

 

Table 2. Incidence (cases per 100,000 persons per year) of distal forearm fractures in 0–15-year-old children from 1999 to 2018
Weighted mean 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Total 829 840 814 765 817 770 793 798 768 791 852 836 788 827 810 845 923 887 929 869 863
Sex
 Boys 905 913 876 829 891 831 855 854 840 880 940 928 843 896 881 934 1,003 976 1,007 969 960
 Girls 749 763 749 698 739 705 729 740 693 698 759 739 731 754 736 753 838 793 847 762 761
Age
 0 30 36 33 42 37 31 31 31 28 26 28 25 30 30 19 29 34 21 22 34 26
 1 286 341 372 307 358 281 288 327 298 267 269 304 258 272 214 268 252 240 249 262 266
 2 274 332 292 302 344 264 270 277 330 263 275 250 264 267 221 234 243 255 259 273 240
 3 388 404 427 384 456 410 367 384 379 380 412 405 379 398 307 362 382 363 370 354 423
 4 515 504 564 471 508 515 501 542 537 489 506 552 486 448 499 458 572 503 527 586 546
 5 704 742 704 653 775 600 669 704 727 675 708 694 732 705 675 698 694 737 735 708 761
 6 828 864 852 707 834 802 813 847 769 795 839 904 743 813 802 897 878 817 944 818 836
 7 930 1,064 973 827 911 899 843 885 909 868 876 899 865 953 907 933 1,056 969 1,036 975 960
 8 1,047 1,163 1,050 952 1,033 959 962 1,063 876 1,005 1,116 1,024 976 1,081 1,023 1,112 1,145 1,123 1,185 1,073 1,037
 9 1,184 1,242 1,181 1,161 1,161 1,114 1,109 1,074 1,019 1,113 1,159 1,254 1,133 1,178 1,162 1,204 1,361 1,296 1,311 1,272 1,215
 10 1,356 1,363 1,368 1,338 1,387 1,175 1,243 1,285 1,146 1,327 1,434 1,412 1,263 1,383 1,309 1,361 1,522 1,558 1,507 1,352 1,430
 11 1,465 1,565 1,480 1,374 1,327 1,414 1,405 1,362 1,370 1,367 1,637 1,428 1,376 1,545 1,513 1,384 1,664 1,524 1,625 1,557 1,419
 12 1,393 1,369 1,411 1,391 1,271 1,255 1,342 1,266 1,275 1,257 1,443 1,432 1,388 1,390 1,387 1,508 1,507 1,566 1,566 1,434 1,413
 13 1,226 1,164 1,171 1,078 1,194 1,168 1,187 1,134 1,084 1,199 1,261 1,214 1,151 1,175 1,294 1,284 1,385 1,316 1,436 1,270 1,323
 14 907 974 803 827 872 802 859 825 849 896 932 882 874 907 900 976 1,076 903 1,061 938 950
 15 600 630 521 547 596 537 673 586 509 533 540 566 589 596 587 621 695 672 658 668 661

 

Figure 2
Figure 2. Incidence of distal forearm fractures in 0–15-year-old children.

 

Figure 3
Figure 3. Annual incidence of distal forearm fractures in boys, girls and total.

Stratification by age group likewise suggested a slight increase in incidence among children aged 8–15 years; nevertheless, the CI for all age groups overlapped between 1999 and 2018, indicating that distal forearm fracture incidence remained essentially stable during the study period regardless of age and sex.

Treatments

Throughout the investigated period, there were 156,915 (90%) non-surgical treatments, 8,821 (5.0%) closed reductions, 8,749 (5.0%) K-wire fixations, and 598 (0.3%) less commonly used treatments including open reduction, plate and screws, external fixation, and intramedullary nailing (referred to as “other”) (see Supplementary Table). Non-surgical treatment remained most common, though slightly decreasing from 7,864/8,575 (92%) in 1999 to 7,904/8,865 (89%) in 2018, and “other” treatments remained the least common treatment, though slightly increasing from 13/8,575 (0.2%) in 1999 to 52/8,865 (0.6%) in 2018. The second most common treatment changed from closed reduction in 1999 to K-wire fixation in 2018. Closed reduction accounted for 623/8,575 (7.3%) of all treatments in 1999, but only 206/8,865 (2.3%) in 2018, while K-wire fixation accounted for 75/8,575 (0.9%) and 703/8,865 (7.9%), respectively. Stratification by age group revealed the same pattern in all but the youngest children (0–3 years), in whom both treatments accounted for less than 3% of cases and exhibited entirely overlapping CI, limiting the ability to detect any significant change (Figure 4).

Figure 4
Figure 4. Distribution of closed reduction and K-wire with 95% confidence intervals stratified by age groups 0–3 years, 4–7 years, 8–11 years and 12–15 years, with data summarized in 2-year intervals.

Discussion

We aimed to investigate national trends in incidence and treatment of pediatric distal forearm fractures in Denmark from 1999–2018. We found a largely stable incidence of distal forearm fractures in 0–15-year-old children over a 20-year period in Denmark, in agreement with other studies [5,6,22,23]. The mean incidence of distal forearm fractures was 829/100,000/year with higher incidences in boys than girls and no significant age-group differences. The latter contrasts with Monget et al. [24], who, in the period between 1999 to 2019, reported a shift towards younger children sustaining fractures, possibly due to behavioral changes, with more sedentary behavior among older children and younger children becoming more active, thus increasing the risk of sustaining a fracture.

Peak incidences in the present study align with findings in other studies [2,5,7,22,23]. The most comparable is that by Korup et al. [5], which, like our study, used DNPR data, though with data only from the North Denmark Region and reported a slightly lower incidence (738/100,000/year). They included all children below the age of 18 years, thus the differences likely reflects the marked decline in incidence after the age of 15 years (see Figure 2 and [5,22,23]), while population counts among 16–18-year-old children are roughly equal to younger age groups [15]. Discrepancies may also reflect regional population differences within Denmark; however, this was beyond the scope of the present study.

The most interesting finding was the increase in K-wire fixation across almost all age groups, with a corresponding decline in closed reductions. The point at which K-wire fixation surpassed closed reduction was around 2008–2009. This shift is consistent with the trends observed in pediatric diaphyseal forearm fracture treatment [25], where closed reduction has been largely replaced by intramedullary nailing. However, in contrast to Hansen et al. [25], the observed change in our study is unlikely to be explained by the introduction of new implants as, to the best of our knowledge, no new implants for the treatment of distal forearm fractures have been introduced during the study period, particularly not K-wires, which have been used for decades [26].

The trend is also supported by international studies. A Chinese study reported that, among 0–18-year-old children with upper extremity fractures registered between 2015 and 2019, more children were treated with closed reduction with K-wire fixation (10,050/18,066 [56%]), compared with closed reduction and immobilization (114/18,066 [<1%]) [27]. Monget et al. [24] observed a rise in surgical treatment of pediatric upper and lower extremity fractures in 0–15-year-old children between 1999 and 2019. Likewise, Helenius et al. [8] investigated the incidence of pediatric fractures leading to in-hospital treatment and their treatment during 1997–2006 and reported a 23% increase in the incidence of upper extremity fractures managed in hospital and a 182% increase (from 11 to 31 per 100,000) in surgically treated forearm fractures when closed fracture treatment was excluded. The present study demonstrates a substantially greater increase, with the proportion of K-wire fixations corresponding to a rate ratio of approximately 800%. Notably, Helenius et al. observed an acceleration in surgical treatment toward the end of their study period in 2006. The higher proportions observed in the present study may reflect a continuation of this accelerated trend in the subsequent years.

Our study shows a clear shift toward more surgical treatments despite stable fracture incidence and no introduction of new implants. This raises the question of whether fractures have become more severe over time, necessitating surgical intervention, or there has been a shift in the indications for surgery. Several explanations are possible, and likely multifactorial. Insufficient training in casting techniques may lead surgeons to favor K-wire fixation to avoid re-displacement [28], potentially encouraging a more defensive approach. Strengthening theoretical and clinical training of young orthopedic surgeons in reduction and casting, such as simulation-based training [29], may mitigate this tendency. Another explanation for the observed trend may be a general preference for surgery, reinforced by a predominance of studies concerning surgical treatments and limited evidence supporting non-surgical treatment. Results from 4 RCTs conducted in Denmark [30], Finland [31], USA [32] and the UK [33], are expected to be published in the coming years. These studies challenge current practices by comparing non-surgical treatment with reduction with or without fixation, thereby holding the potential to reduce surgical indications. Along with this upcoming evidence to guide decisions between treatments, future qualitative research could help elucidate the underlying incentives and motivations driving the observed changes in practice.

Strengths

The primary strength lies in the large sample size and the good representation of the target population. The DNPR is characterized by high completeness in the registration of diagnostic and treatment codes, and despite lack of validation of pediatric forearm fracture coding, it generally demonstrates a high PPV for accurate coding of orthopedic diagnoses.

Limitations

First, there is a risk of misclassification. Initial diagnoses and treatments are often made in the emergency department by less experienced doctors, increasing the risk of incorrect primary fracture classification. In a survey of 42 doctors with less than 2 years of experience, a high level of uncertainty was reported when interpreting radiographs, underlining the potential for diagnostic inaccuracy in this setting [34]. In addition, the DNPR does not provide clear definitions for diaphyseal versus distal forearm fractures, and miscoding between closely related categories (e.g. radius versus both-bone fractures) may occur. Such misclassification could influence the observed distribution of treatment modalities.

Second, the registry does not include information on fracture displacement, severity, or physeal involvement—factors that are central to treatment decisions. This lack of detail limits our ability to fully interpret observed treatment trends.

As the data was extracted anonymously, it was impossible to validate treatment codes or assess the magnitude of potential misclassification through review of patient records. However, it should be noted that radiographs in Denmark are systematically described or approved by radiologists, which likely reduces the risk of persistent miscoding. Furthermore, Korup et al. [5] validated all 4,316 fractures through manual review of medical records and radiographs, demonstrating that DNPR fracture data can be both accurate and reliable. Given that both their study and the present study are based on DNPR data, and considering the registry’s generally high completeness, positive predictive value, and our large population base, we believe that the relative changes observed in this study are valid despite the limitations.

Conclusion

We found that distal forearm fracture incidence remained stable throughout the investigated period. We observed a clear shift in treatment patterns over time, characterized by increasing use of K-wire fixation and a corresponding decline in closed reduction. These changes have occurred without obvious reasons or convincing evidence to support one approach over the other.

Supplementary data

The Supplementary Table is available on the article homepage, doi: 10.2340/17453674.2025.45057

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