Forearm fractures treated with elastic stable intramedullary nailing: Is casting still necessary?

Abstract

Introduction: Elastic stable intramedullary nailing is widely recognized for treating pediatric forearm fractures due to its stable fixation and minimal impact on soft tissue. Traditionally, casting has followed elastic stable intramedullary nailing; however, recent studies question its necessity. This study evaluates the outcomes of omitting casts post-elastic stable intramedullary nailing, examining healing speed and quality of life compared to cases where casting was applied.

Materials and methods: A prospective study was conducted from 2022 to 2024 in an urban hospital, where children with both-bone midshaft forearm fracture were randomized to receive or not receive casting after elastic stable intramedullary nailing. Age- and sex-matched patients were selected to allow for accurate comparison. The study included patients aged 5 to 14 years. Outcomes were measured using radiographic scores and quality-of-life assessments.

Results: From a total of 355 patients, 136 cases were included in the assessment. Analysis indicated faster healing in patients without postoperative casting, as evidenced by higher REBORNE scores at 3 weeks and 2 months. Quality of life, measured by the Pediatric Quality of Life Inventory, was also significantly improved in the no-cast group at 6 weeks.

Discussion: Our findings suggest that elastic stable intramedullary nailing provides sufficient stability for both-bone midshaft forearm fracture, making additional casting unnecessary. Early mobilization led to better functional outcomes without increasing complications. Although some minor early discomfort was reported, the cast-free approach proved effective and safe.

Conclusion: Elastic stable intramedullary nailing remains the gold standard for treating pediatric forearm fractures. Our preliminary results indicate that for both-bone midshaft forearm fracture, elastic stable intramedullary nailing can be safely performed without postoperative casting, promoting faster healing and better patient satisfaction.

Keywords: ESIN; Forearm shaft fractures; both-bone midshaft forearm fracture; casting; children.

Figure 1.

A diagram that shows the patient selection for the study. To enhance the data quality, after establishing the study group through randomization, we were able to match a control group from the entire patient pool treated in the selected timeframe.

Figure 2.

AP and lateral views pre- and postoperative of a 14-year-old who suffered a transverse radial and oblique ulnar BBFF. AP: anteroposterior.

Figure 3.

Paired AP radiographs showing fracture healing in two boys aged 12, in three moments: on admission, after 3 weeks, and after 6 weeks. The first row represents a control case, and the second row represents a study case. AP: anteroposterior.

Figure 4.

Differences between REBORNE callus scores at 3 weeks postoperative between the study group and the control group.

Figure 5.

Two 8-year-old girls with left BBFF with AP X-rays at 3 weeks of follow-up. The image on the left (A) corresponds to a patient in the study group, while the image on the right (B) represents a patient in the control group. AP: anteroposterior.

Figure 6.

Differences between REBORNE callus scores at 6 weeks postoperative. Both the median values and the margins (whiskers) were notably higher in the study group, suggesting a faster radiological healing time for the patients who did not receive plaster casts.

Figure 7.

The AP X-rays presented here depict the forearms of two 10-year-old boys with similar bone ages, taken at a 6-week follow-up. The right image shows the patient treated with postoperative casting, while the left image highlights a case with noticeably faster healing compared to the corresponding patient. AP: anteroposterior.

Figure 8.

Median PedsQL scores at 6 weeks postoperative. The patients who started early active movement scored a better return to daily activities and tasks at 6 weeks postoperative. PedsQL: Pediatric Quality of Life Inventory.