The risk of refracture and malunion in children treated for diaphyseal forearm fractures: a retrospective cohort study.

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.