Surgical Treatment of Pediatric Open Forearm Fractures: A Comparison of Outcomes With or Without Internal Fixation

BACKGROUND: Pediatric patients with open forearm fractures who undergo operative irrigation and debridement (I&D) are often treated with implant fixation due to concern for delayed healing, nonunion, or loss of alignment. For an open forearm fracture treated with I&D, it is unknown whether reduction and casting alone without implant fixation affects outcomes in young patients. We aim to compare the results of pediatric open forearm fractures treated with I&D and cast immobilization with no implant fixation (NIF) to those treated with implant fixation (IF). METHODS: We retrospectively reviewed pediatric patients treated surgically for an open forearm fracture with IF or with casting and NIF from 2010 to 2020. The use of implant fixation was at the discretion of the surgeon. RESULTS: Seventy-seven patients were included (IF 54, NIF 23) without differences between cohorts in sex, fracture type, fracture location, or open grade of fracture. NIF patients were younger (8.2 vs. 10.7 y, P =0.001), as NIF was utilized in 78.3% of patients 10 years or younger. IF was associated with 36 minute longer operative time (77 vs. 41 min, P <0.001), longer length of stay (1.9 vs. 1.6 d, P =0.042), a greater number of radiographic sessions (5.9 vs. 5.1, P =0.038), more follow-up visits (7.1 vs. 5.2, P =0.003), longer time to radiographic healing (110.6 vs. 64.2 d, P =0.003) and longer follow-up (225.8 vs. 80.9 d, P <0.001), as 53.7% underwent elective surgical implant removal. Duration of immobilization was similar (IF 48.9 vs. NIF 55.7 d, P =0.124). There was no difference in incidence of unplanned reintervention (IF 7.4% vs. NIF 4.3%, P =0.999), with 2 deep infections, and 2 refractures requiring reoperation in the IF group and 1 closed reduction and casting in the OR for the NIF group. All fractures were united in satisfactory alignment at final follow-up. CONCLUSIONS: Implant fixation may not be necessary for all open forearm fractures, especially in patients 10 years or younger with remodeling potential. This would contribute to shorter operative time, length of stay, fewer follow-up visits, and avoidance of surgical implant removal, all of which would contribute to lower cost of treatment. LEVEL OF EVIDENCE: Level III-retrospective cohort study.