547 - Risk of Failure in Non-Operative Management of Both-Bone Fractures

Publication Number: 547.6463

Nikita S. Iyer, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States; Nicole Mueske, Children's Hospital Los Angeles, Los Angeles, CA, United States; Michelle Chavez, Children's Hospital Los Angeles, Los Angeles, CA, United States; Jacquelyn N. Valenzuela-Moss, Children's Hospital Los Angeles, Los Angeles, CA, United States; Tishya Wren, Children's Hospital Los Angeles, Los Angeles, CA, United States; Jonas Owen, Children's Hospital Los Angeles, los angeles, CA, United States; Erin Meisel, University of Southern California, Children’s Hospital Los Angeles, Los Angeles, CA, United States

Background: Forearm shaft fractures are common in pediatrics, representing the third most frequent fracture type. While closed reduction and casting remains the preferred initial treatment for many of these fractures, the success rate of non-operative management varies considerably, particularly among older children and adolescents.

Objective: To analyze the factors contributing to failure of non-operative management in adolescent both-bone forearm fractures, excluding distal fractures.

Design/Methods: A retrospective chart review was performed at a single tertiary care institution in a large metropolitan area of patients < 18 years of age diagnosed with a both-bone forearm fracture, who were managed non-operatively from January 2012 to July 2022. Pre- and post-reduction apex volar measurements and percent displacement were assessed. Patients who were treated surgically upon initial presentation, missing pre-operative radiographs, or had fractures in the distal 3rd of the forearm were excluded. Those who were treated non-operatively with success and those who failed non-operative management were compared using Fisher’s exact test, t-tests, and multivariate logistic regression analysis.

Results: Of the 104 patients initially treated with closed reduction and immobilization, 36 (34.6%) required subsequent surgical management. Over 74% of patients were male, and in univariate analysis males were more likely to fail non-operative management than females (40.3% vs 18.5%, p=0.059). Non-operative treatment was also more likely to fail in patients over age 10 years (60.9% vs 13.8%, p< 0.0001), those placed in a splint upon initial presentation (75% vs 31.3%, p=0.02), and those whose fractures were completely displaced (60.9% vs 27.2%, p=0.005). Age and displacement remained significant risk factors for failure of non-operative management in multivariable analysis (all p< 0.03), but sex and initial splinting were no longer significant. Apex volar angulation was significantly greater in patients with successful nonoperative management (24.9° vs. 16.6°, p = 0.001) but radial displacement was significantly less severe (22.5° vs. 76.4°, p = 0.009).

Conclusion(s): A third of pediatric patients fail non-operative treatment of both-bone fractures. Displacement over 25 percent puts individuals at a much higher risk of failing non-operative management. Providers should take into consideration pre- and post-reduction displacement alongside age when deciding whether to move forward with initial nonoperative management to avoid a prolonged course of treatment.