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There has been a trend toward operative management of pediatric diaphyseal forearm fractures (DFFx). We studied our experience with surgical management of these injuries to assess indications, frequency, outcome, and complications.One hundred forty-four consecutive children had surgical management of 149 DFFx over 11 years at our Level 1 pediatric trauma center. A chart/radiographic review established perioperative events, intraoperative findings, time-to-union, range-of-motion, and complications. We developed the Children's Hospital of Philadelphia Forearm Fracture Fixation Outcome Classification to assess postoperative outcomes.Over 11 years, we treated 2297 DFFx; 155 of 2297 (6.7%) had surgical management. Six were lost to follow-up and excluded. A 7-fold increase in operative management was observed over the study period [2 of 143 (1.4%) vs. 28 of 270 (10.4%), P<0.001]. One hundred and three of 149 (69.1%) were treated with intramedullary nailing (IMN); 44 of 149 (29.5%) with plates; and 2 of 149 (1.3%) had combined plate/nail fixation. Thirty of 103 (29.1%) had the fracture site opened to pass the IMN; in 23 cases, open fractures were exploited to assist nail passage. When managed with IMN, open fracture sites showed slowed healing: union was 8.6 weeks for those opened intraoperatively and 6.9 weeks for those remaining closed (P<0.001). Fractures opened secondary to injury achieved union at 9.75 weeks which was significantly longer than those opened intraoperatively (8.6 wk, P=0.04) and those remaining closed (6.9 wk, P=0.001). Compartment syndrome occurred in 6.7% (2 of 30) treated with IMN within 24 hours of injury versus 0 of 73 treated later (P=0.026). Delayed union after IMN occurred in 6 children 10 years of age versus none less than 10 years of age. Poor/fair outcome of IMN increased with age [6 of 47 (13%) ≤10 y of age, vs. 17 of 56 (30%)>10 y of age, P=0.03]. Overall complication rate for IMN was 14.6% (15 of 103).Our center has operatively managed DFFx with increased frequency over the past decade. IMN had a complication rate of 14.6% and was frequently not “minimally invasive.” An open fracture site delayed healing. Compartment syndrome was more frequent when IMN was used the day of injury and older children had poorer outcomes and higher rates of delayed union.Level III, Retrospective Comparative Study.