Paediatric forearm refractures with flexible nails in-situ: risk factors and management

To identify risk factors for forearm shaft refractures in paediatric patients treated with flexible nails in situ and explore effective management strategies. From January 2022 to April 2024, paediatric patients with diaphyseal radius and ulna fractures treated with flexible nails were retrospectively reviewed. Patients without refractures were assigned to group A, and those with refractures and flexible nails in situ to group B. Demographics, injury mechanisms, operative details, complications, and time to radiographic union were analyzed. Fifty-six paediatric patients with 105 forearm fractures were divided into group A (50 patients with 94 fractures that healed uneventfully) and group B (six patients with 11 fractures that sustained refracture while having flexible nails in-situ). Group B patients were significantly older (14.92 ± 0.72 vs. 12.09 ± 2.83 years; P  = 0.019), and all had undersized nails occupying less than two-thirds of the canal diameter, compared with 40% in group A ( P  = 0.007). No significant differences in sex, injury mechanism, or reduction method were observed. Refractures occurred, on average, 3.22 ± 1.38 months postsurgery, mainly after early return to sports and low-energy trauma. Treatment included conservative management for undisplaced refractures and exchange nailing for displaced cases, with all achieving complete union and no complications during follow-up. The risk of refracture with flexible nails in-situ is greater in older children approaching skeletal maturity, particularly those who had undersized flexible nails and resumed sports and high-impact activities prematurely. These refractures can be effectively managed using casting, exchange nailing, or plating.