Retrospective analysis: risk factors predicting failure of closed reduction in pediatric diaphyseal forearm fractures treated with elastic stable intramedullary nails (ESINs)

Abstract

Paediatric forearm fractures are extremely common among children. Surgical treatment instead of casting is necessitated in highly unstable forearm fractures. A widely accepted technique of operative fixation today is via the elastic stable intramedullary nail (ESIN), which was first introduced in 1977. Closed reduction with the ESIN is often attempted first, failure of which may warrant the need for open reduction. However, multiple attempts at closed reduction not only increase the incidence of tissue trauma but also lead to severe postoperative complications such as compartment syndrome. Yet, little information exists to help surgeons anticipate when a child is more likely to require an open reduction. This study aims to determine certain risk factors that would point toward a greater likelihood of open reduction, and thus help surgeons avoid too many unnecessary endeavors at closed reduction. A total of 144 cases of forearm fractures fixated using ESINs between 2014 and 2019 were retrospectively identified in the institution of study. Patient factors, fracture characteristics and surgery details were also gathered from the institution’s database. Statistical analysis was performed using SPSS and comparison was then done between the two groups of patients who underwent closed and open reductions. Results showed that the statistically significant risk factors for predicting unsuccessful closed reduction in forearm fractures were the amount of fractured bone overlap at presentation (P < 0.001) and whether the bones were fractured at different levels (P = 0.032). Other variables examined, including the patient’s biological age, skeletal age, BMI, fractured bone-angulation, site of fracture, fracture pattern and surgical circumstances did not contribute to differentiating between the likelihood of a closed versus open reduction. Children with a higher degree of fractured bone overlap at presentation or if the radius and ulnar bones were fractured at different levels, should be adequately forewarned regarding the increased chances of conversion to an open reduction. Surgeons should also avoid excessive attempts at closed reduction of forearm fractures with the ESIN in such circumstances. Level of Evidence: Level IV.