O2100: Outcomes of Nonoperative Management of Pediatric Grade I Open Forearm Fractures

Background: In recent years, Grade I open both bone forearm fractures have been treated conservatively with bedside washout in the emergency room, antibiotics, and closed reduction with very low infection rates. However, risk factors for failure of conservative fracture management in these cases has not been well described. Our purpose was to determine what risk factors, if any, exist for failure of nonoperative treatment in this population.

Methods: This was a review of patients between 5 and 13 years of age, from 2015-2021. Both those who underwent nonoperative management of their injuries as well as those who received operative management were included. Outcomes of interest included measurements of initial displacement, displacement post-reduction, displacement after cast removal, infection rate, treatment failure, surgical intervention, and surgery outcomes.

Results: 63 total patients (64% male) were included. 57 (90%) underwent nonoperative management with bedside washout, antibiotics, and closed reduction with no infections. Three patients (5%) failed nonoperative treatment due to loss of reduction and developed malunions, and all remodeled spontaneously over time. Casting index was significantly lower in those who had successful nonoperative management compared to those who did not (0.75±0.1 vs. 0.9±0.1, p=0.02). Similarly, final follow-up angulation of the ulna on the lateral radiograph was significantly lower in those who had successful nonoperative management (3.5±4.2 vs. 14±7.9, p=0.03). Because so few patients failed conservative management, appropriately powered statistical analysis to determine risk factors was not possible. Of the 6 patients who underwent initial surgical management, four underwent open reduction internal fixation (three fixed with plates and one fixed with flexible intramedullary nail), and two underwent closed reduction with flexible intramedullary nails. Four of these six (67%) had complications after surgery. Two had postoperative pain and underwent implant removal and two developed ulnar neuropraxia.

Conclusion: Nonoperative management of Grade I open both bone forearm fractures is safe and effective. There were no infections after conservative management in this cohort and overall complication rate was 5% compared to 67% in the group that underwent early surgical management.