Pediatric Type I Open Both Bone Forearm Fractures: Predicting Failure of Nonoperative Management
McKenna C Noe1, Robert C Link2, Jonathan R Warren1,2
1Department of Orthopedic Surgery, Children's Mercy Kansas City.
Insights
Nonoperative treatment for pediatric open both bone forearm fractures (OBBFFs) is successful in 88.7% of cases. Higher cast index and postreduction radius translation increase the risk of failure, necessitating surgery.
Area of Science:
- Orthopedic surgery
- Pediatric orthopedics
- Traumatology
Background:
- Nonoperative management of pediatric type I open both bone forearm fractures (OBBFFs) using irrigation, antibiotics, closed reduction, and casting shows low infection rates.
- However, risk factors for failed closed reduction in type I OBBFFs are not well-defined.
Purpose of the Study:
- To describe the management of type I OBBFFs at a single institution.
- To identify factors associated with failed closed reduction in pediatric patients.
Main Methods:
- Retrospective review of patients aged 5-15 years with type I OBBFFs undergoing nonoperative management (2015-2021).
- Primary outcome: success or failure of nonoperative management (requiring surgery).
- Secondary outcomes: infections, compartment syndromes, neuropraxias; variables: demographics, fracture reduction, cast index, antibiotics.
Main Results:
- 88.7% of 62 type I OBBFFs were successfully treated nonoperatively; 11.3% required surgery due to loss of reduction.
- Higher median cast index (0.84 vs. 0.75) and postreduction radius translation (32% vs. 5%) were observed in patients who failed nonoperative management.
- Increased cast index (OR 3.78) and postreduction radius translation (OR 7.39) were significant predictors of failure. No infections or compartment syndromes occurred.
Conclusions:
- Closed reduction is successful in 88.7% of pediatric type I OBBFFs with no associated infections.
- Higher cast index and postreduction radius translation are linked to increased failure rates, indicating a need for surgical intervention.
- Age was not a significant factor in the success or failure of closed reduction.
Background:
In recent years, nonoperative treatment of pediatric type I open both bone forearm fractures (OBBFFs) with bedside irrigation, antibiotics, closed reduction, and casting has yielded low infection rates. However, risk factors for failure of type I OBBFF closed reduction have not been well described. Our purpose was to describe management of patients with type I OBBFFs at our institution and determine what factors are associated with failure of closed reduction in this population.
Methods:
This was a review of patients between 5 and 15 years of age who received initial nonoperative management for type I OBBFFs at one institution between 2015 and 2021. Primary outcome was success or failure of nonoperative management (defined as progression to surgical management). Secondary outcomes included infections, compartment syndromes, and neuropraxias. Other variables of interest were demographic information, prereduction and postreduction translation and angulation of the radius and ulna, cast index, and antibiotic administration.
Results:
Sixty-one patients (67.7% male) with 62 type I OBBFFs were included in this study. Following initial nonoperative management, 55 injuries (88.7%) were successfully treated in casts, while the remaining 7 (11.3%) required surgical intervention following loss of acceptable reduction in cast. Median cast index (0.84, IQR 0.8 to 0.9 vs. 0.75, IQR 0.7-0.8, P =0.020) and postreduction radius translation on anteroposterior films (32.0%, IQR 17.0% to 40.0% vs. 5.0%, IQR 0.0% to 26.0%, P =0.020) were higher among those who failed nonoperative management. Multivariable logistic regression models identified increased odds of failure for every SD (0.7) increase in cast index (OR 3.78, P =0.023, 95% CI: 1.4-14.3) and 25% increase in postreduction radius translation on anteroposterior films (OR 7.39, P =0.044, 95% CI 1.2-70.4). No infections or compartment syndromes and 2 transient ulnar neuropraxias occurred.
Conclusions:
Closed reduction of type I OBBFFs was successful in 88.7% of cases. There were no infections after nonoperative management. Increases in cast index of 0.7 and postreduction radius translation on anteroposterior radiographs of 25% were associated with increased likelihood of failure, thus requiring surgery; age was not.
Level Of Evidence:
Level IV-retrospective comparative study.
