The risk of refracture and malunion in children treated for diaphyseal forearm fractures: a retrospective cohort study
DOI:
https://doi.org/10.2340/17453674.2025.42851Keywords:
Fractures, Paediatric orthopaedicsAbstract
Background and purpose: The optimal treatment modality for pediatric diaphyseal forearm fractures is debated. While nonoperative treatment and closed reduction reduces the need for surgery and surgical complications, flexible intramedullary nailing (FIN) may reduce refracture and malunion rates. We aimed to compare the relative risk (RR) of refracture and malunion between nonoperative, closed reduction (CR), and surgical treatment in children treated for diaphyseal forearm fractures.
Methods: We performed a retrospective cohort study of children treated for a primary diaphyseal forearm fracture over a 9-year period at 2 university hospitals. Risk of refracture and malunion in the year following the fracture across treatment modalities was assessed by a modified Poisson regression while adjusting for the age of the patient at the time of fracture.
Results: We included 837 patients for analysis, of whom 4% were treated nonoperatively, 6% were treated with closed reduction, and 90% with FIN. Compared with FIN, the RR of refracture was higher for the nonoperative group (9.8, 95% confidence interval [CI] 5.9–16.3) and CR group (2.5, CI 1.2–5.3). Compared with the FIN group, the nonoperative and CR groups had higher risk of malunion with RR of 15.3 (CI 11.0–21.4) and 8.5 (CI 5.8–12.5) respectively. Of those treated non-surgically, 84% remained without any surgery. In FIN patients, surgical revision due to infection was seen in 1.4% of patients.
Conclusion: The risk of refracture and malunion in children treated for diaphyseal forearm fractures was significantly higher for closed reduction and nonoperative treatment compared with FIN treatment.
Downloads
References
Caruso G, Caldari E, Sturla F D, Caldaria A, Re D L, Pagetti P, et al. Management of pediatric forearm fractures: what is the best therapeutic choice? A narrative review of the literature. Musculoskelet Surg 2021; 105(3): 225-34. doi: 10.1007/s12306-020-00684-6. DOI: https://doi.org/10.1007/s12306-020-00684-6
Fuller D J, McCullough C J. Malunited fractures of the forearm in children. J Bone Joint Surg Br 1982; 64(3): 364-7. doi: 10.1302/0301-620X.64B3.7096406. DOI: https://doi.org/10.1302/0301-620X.64B3.7096406
Bowman E N, Mehlman C T, Lindsell C J, Tamai J. Nonoperative treatment of both-bone forearm shaft fractures in children. J Pediatr Orthop 2011; 31(1): 23-32. doi: 10.1097/BPO.0b013e318203205b. DOI: https://doi.org/10.1097/BPO.0b013e318203205b
Noonan K J, Price C T. Forearm and distal radius fractures in children. J Am Acad Orthop Surg 1998; 6(3): 146-56. doi: 10.5435/00124635-199805000-00002. DOI: https://doi.org/10.5435/00124635-199805000-00002
Leuba A, Ceroni D, Tabard-Fougère A, Lutz N. Clinical and financial impacts of flexible intramedullary nailing in pediatric diaphyseal forearm fractures: a case-control study. J Child Orthop 2022; 16(3): 220-6. doi: 10.1177/18632521221106380 DOI: https://doi.org/10.1177/18632521221106380
Sinikumpu J J, Lautamo A, Pokka T, Serlo W. Complications and radiographic outcome of children’s both-bone diaphyseal forearm fractures after invasive and non-invasive treatment. Injury 2013; 44(4): 431-6. doi: 10.1016/j.injury.2012.08.032. DOI: https://doi.org/10.1016/j.injury.2012.08.032
Hansen R T, Borghegn N W, Gundtoft P H, Nielsen K A, Balslev-Clausen A, Viberg B. Change in treatment preferences in pediatric diaphyseal forearm fractures: a Danish nationwide register study of 36,244 fractures between 1997 and 2016. Acta Orthop 2023; 94: 32-7. doi: 10.2340/17453674.2023.7132. DOI: https://doi.org/10.2340/17453674.2023.7132
Flynn J M, Jones K J, Garner M R, Goebel J. Eleven years experience in the operative management of pediatric forearm fractures. J Pediatr Orthop 2010; 30(4): 313-19. doi: 10.1097/BPO.0b013e3181d98f2c. DOI: https://doi.org/10.1097/BPO.0b013e3181d98f2c
Lyman A, Wenger D, Landin L. Pediatric diaphyseal forearm fractures: epidemiology and treatment in an urban population during a 10-year period, with special attention to titanium elastic nailing and its complications. J Pediatr Orthop B 2016; 25(5): 439-46. doi: 10.1097/BPB.0000000000000278. DOI: https://doi.org/10.1097/BPB.0000000000000278
Zilliacus K, Nietosvaara Y, Helenius I, Laaksonen T, Ahonen M, Grahn P. The risk of nerve injury in pediatric forearm fractures. J Bone Jt Surg 2023; 105(14): 1080-6. doi: 10.2106/JBJS.22.01392. DOI: https://doi.org/10.2106/JBJS.22.01392
Peterlein C D, Modzel T, Hagen L, Ruchholtz S, Krüger A. Long-term results of elastic-stable intramedullary nailing (ESIN) of diaphyseal forearm fractures in children. Medicine (Baltimore) 2019; 98(11): e14743. doi: 10.1097/MD.0000000000014743. DOI: https://doi.org/10.1097/MD.0000000000014743
Lieber J, Dietzel M, Scherer S, Schäfer J F, Kirschner H J, Fuchs J. Implant removal associated complications after ESIN osteosynthesis in pediatric fractures. Eur J Trauma Emerg Surg 2022; 48(5): 3471-8. doi: 10.1007/s00068-021-01763-4. DOI: https://doi.org/10.1007/s00068-021-01763-4
Cruz A I, Kleiner J E, DeFroda S F, Gil J A, Daniels A H, Eberson C P. Increasing rates of surgical treatment for paediatric diaphyseal forearm fractures: a National Database Study from 2000 to 2012. J Child Orthop 2017; 11(3): 201-9. doi: 10.1302/1863-2548.11.170017. DOI: https://doi.org/10.1302/1863-2548.11.170017
Korhonen L, Perhomaa M, Kyrö A, Pokka T, Serlo W, Merikanto J, et al. Intramedullary nailing of forearm shaft fractures by biodegradable compared with titanium nails: results of a prospective randomized trial in children with at least two years of follow-up. Biomaterials 2018; 185: 383-92. doi: 10.1016/j.biomaterials.2018.09.011. DOI: https://doi.org/10.1016/j.biomaterials.2018.09.011
Syed A N, Ashebo L, Lawrence J T R. Refracture following operative treatment of pediatric both bone forearm fractures. J Pediatr Orthop. Published online October 31, 2023. doi: 10.1097/BPO.0000000000002552. DOI: https://doi.org/10.1097/BPO.0000000000002552
Han B, Wang Z, Li Y, Xu Y, Cai H. Risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing. Int Orthop 2019; 43(9): 2093-7. doi: 10.1007/s00264-018-4184-4. DOI: https://doi.org/10.1007/s00264-018-4184-4
von Elm E, Altman D G, Egger M, Pocock S J, Gøtzsche P C, Vandenbroucke J P. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61(4): 344-9. doi: 10.1016/j.jclinepi.2007.11.008. DOI: https://doi.org/10.1016/j.jclinepi.2007.11.008
Price C T, Scott D S, Kurzner M E, Flynn J C. Malunited forearm fractures in children. J Pediatr Orthop 1990; 10(6): 705-12. doi: 10.1097/01241398-199011000-00001. DOI: https://doi.org/10.1097/01241398-199011000-00001
Christensen R, Ranstam J, Overgaard S, Wagner P. Guidelines for a structured manuscript: statistical methods and reporting in biomedical research journals. Acta Orthop 2023; 94: 243-9. doi: 10.2340/17453674.2023.11656. DOI: https://doi.org/10.2340/17453674.2023.11656
Tisosky A J, Werger M M, McPartland T G, Bowe J A. The factors influencing the refracture of pediatric forearms. J Pediatr Orthop 2015; 35(7): 677-81. doi: 10.1097/BPO.0000000000000355. DOI: https://doi.org/10.1097/BPO.0000000000000355
Tarr R R, Garfinkel A I, Sarmiento A. The effects of angular and rotational deformities of both bones of the forearm: an in vitro study. J Bone Joint Surg Am 1984; 66(1): 65-70. http://www.ncbi.nlm.nih.gov/pubmed/6690445. DOI: https://doi.org/10.2106/00004623-198466010-00010
Ömeroğlu H, Cassiano Neves M. Tendency towards operative treatment is increasing in children’s fractures: results obtained from patient databases, causes, impact of evidence-based medicine. EFORT Open Rev 2020; 5(6): 347-53. doi: 10.1302/2058-5241.5.200012. DOI: https://doi.org/10.1302/2058-5241.5.200012
Additional Files
Published
How to Cite
License
Copyright (c) 2025 Hans-Christen Husum, Ole Rahbek, Per Hviid Gundtoft, Hans Christian Bang, Søren Kold, Jan Duedal Rölfing, Ahmed Abood
This work is licensed under a Creative Commons Attribution 4.0 International License.
