COMPARATIVE ANALYSIS OF TREATMENTS FOR FOREARM FRACTURES IN CHILDREN: A SYSTEMATIC REVIEW AND META-ANALYSIS

da Costa, Airton Pereira; Rodrigues, Erika Tonarelli; Hauache Neto, Hassan Ahmad; Fujisaki, Mariana Ayumi; Dobashi, Eiffel Tsuyoshi

doi:10.1590/1413-785220253306e290231

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Review Article/Pediatric Orthopedic • Acta Ortop Bras 33 (6) • 2025 • https://doi.org/10.1590/1413-785220253306e290231 linkcopy

COMPARATIVE ANALYSIS OF TREATMENTS FOR FOREARM FRACTURES IN CHILDREN: A SYSTEMATIC REVIEW AND META-ANALYSIS

ANÁLISE COMPARATIVA ENTRE OS TRATAMENTOS PARA AS FRATURAS DO ANTEBRAÇO EM CRIANÇAS: UMA REVISÃO SISTEMÁTICA E META-ANÁLISE

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

To compare the clinical outcomes of children with forearm bone fractures undergoing surgical treatment with intramedullary fixation with TEN rods and Kirschner wires. A systematic review of the literature was carried out, conducting a search for data in the Pubmed/Medline, Science Direct and Scielo databases. The quality of the trials was assessed by the MINORS tool and the meta-analysis of the studies was performed using the R software (version 4.4.0). 16 studies were selected, representing 1,075 patients, with a predominance of males, where the mean age range varied from 8.32 to 14.2 years. Applying the MINORS Scale, the quality of the studies was good (≥ 11). The meta-analysis of the studies revealed a statistically significant increase in the risk of adverse events in the experimental group compared to the control group, with a risk ratio (RR) of 1.35 (95% CI: 1.03 to 1.76). The combined mean difference (raw mean) between the experimental group and the control group was −12.42 minutes (95% CI: −13.75 to −11.10) in the fixed-effect model, indicating a significant reduction in surgical time for the experimental group. In the random-effect model, the mean difference was −21.62 minutes (95% CI: −33.30 to −9.94). Regarding fracture consolidation time, the fixed-effect model indicated a raw mean difference of 0.99 (95% CI: 0.61 to 1.36). Furthermore, heterogeneity was moderate to high, with an I² of 73% (p < 0.01). Intramedullary fixation with TEN nails and Kirschner wires presents a diversity of clinical outcomes and complications. The systematic review highlighted the importance of choosing the appropriate treatment method, considering the patient characteristics and the nature of the fracture. Level of Evidence II; Systematic Review.

Keywords:
Fractures, bone; Forearm; Child; Orthopedic Procedures; Therapeutics; Postoperative Complications

Author/Year	Study Type	Intervention Groups	Sex (M/F)	Age (years)	Follow-up (months)
Barua et al.¹⁶	Retrospective	▪ PO: 20 ▪ TEN: 20	▪ PO: 14/6 ▪ TEN: 14/6	▪ PO: 10.95 ± 2.35 ▪ TEN: 10.40 ± 2.41	▪ PO: NR ▪ TEN: NR
Duran Topak et al.¹⁷	Retrospective	▪ PO: 18 ▪ TEN: 34	▪ PO: 17/1 ▪ TEN: 28/6	▪ PO: 13.66 ± 1.45 ▪ TEN: 11.73 ± 1.60	▪ PO: 29.55 ▪ TEN: 30.85
Freese et al.¹⁸	Retrospective	▪ TENK: 70 ▪ ORIF: 32	▪ TENK: 44/26 ▪ ORIF: 22/10	▪ TENK: 12.1 ▪ ORIF: 14.2	▪ TENK: 6 ▪ ORIF: 3.3
Zeybek, Akti et al.¹⁹	Retrospective	▪ FPP: 19 ▪ TEN: 18 ▪ FH: 14	▪ FPP: 8/11 ▪ TEN: 8/10 ▪ FH: 5/9	▪ FPP: 11.00 ± 2.26 ▪ TEN: 10.11 ± 2.37 ▪ FH: 8.57 ± 2.24	▪ FPP: 6 ▪ TEN: 6 ▪ FH: 6
Soudy et al.²⁰	Prospective	▪ TEN: 18	▪ TEN: 13/5	▪ TEN: 8.88	▪ TEN: 6
Shihora et al.²¹	Cross-sectional	▪ TEN: 35 ▪ CO: 38	▪ TEN + CO: 40/33	▪ TEN + CO: 8.32	▪ TEN + CO: 6
Zhu et al.²²	Prospective	▪ FPD: 30 ▪ FH: 26	▪ FPD: 15/15 ▪ FH: 15/11	▪ FPD: 13.33 ± 1.54 ▪ FH: 13.27 ± 1.64	▪ FPD: 8 ▪ FH: 8
Di Giacinto et al.²³	Retrospective	▪ FK: 23 ▪ ORIF: 20	▪ FK: 15/8 ▪ ORIF: 13/7	▪ FK: 12.86 ± 0.64 ▪ ORIF: 13.02 ± 1.77	▪ FK: 16.86 ▪ ORIF: 16.37
Jain et al.²⁴	Retrospective	▪ TEN: 65	▪ TEN: 40/25	▪ TEN: 9.13	▪ TEN: 5.84
Pogorelić et al.²⁵	Retrospective	▪ TEN: 173	▪ TEN: 126/47	▪ TEN: 11.0	▪ TEN: 68
De Vitis et al.²⁶	Retrospective	▪ FES: 21 ▪ FK: 23	▪ FES: 16/5 ▪ FK: 18/5	▪ FES: 8.4 ± 1.6 ▪ FK: 8.5 ± 1.7	▪ FES: 3.4 ▪ FK: 2.4
Wu et al.²⁷	Case-control	▪ TEN: 15 ▪ FK: 11	▪ TEN: 10/5 ▪ FK: 9/2	▪ TEN: 7.7 ± 2.0 ▪ FK: 6.4 ± 1.6	▪ TEN: 14 ▪ FK: 14
Acharya et al.²⁸	Retrospective	▪ IM: 31	▪ IM: 22/9	▪ IM: 12.90	▪ IM: 8.51
Zheng et al.²⁹	Retrospective	▪ ESIN: 48 ▪ FPD: 44 ▪ Hybrid: 45	▪ ESIN: 30/18 ▪ FPD: 25/18 ▪ Hybrid: 28/17	▪ ESIN: 13.5 ± 1.9 ▪ FPD: 13.4 ± 1.9 ▪ Hybrid: 13.2 ± 2.1	▪ ESIN: 14.8 ▪ FPD: 14.9 ▪ Hybrid: 15.0
Dávid et al.³⁰	Retrospective	▪ ESIN: 45 ▪ RESIN: 41	▪ ESIN: 29/16 ▪ RESIN: 31/10	▪ ESIN: 10.4 ▪ RESIN: 8.4	▪ ESIN: NR ▪ RESIN: NR
Guzel et al.³¹	Retrospective	▪ TEN: 21 ▪ HF: 19 ▪ I-KW: 20 ▪ FPD: 18	▪ TEN: 11/10 ▪ HF: 11/8 ▪ I-KW: 9/11 ▪ FPD: 10/8	▪ TEN: 10.8 ± 2.2 ▪ HF: 11.5 ± 2.1 ▪ I-KW: 10.9 ± 2.1 ▪ FPD: 12.1 ± 1.9	▪ TEN: 12 ▪ HF: 12 ▪ I-KW: 12 ▪ FPD: 12

Author/Year	Complications/Adverse Events
Barua et al.¹⁶	Infections, transient neuropraxia.
Duran Topak et al.¹⁷	Surgical site infection, refracture, pin entry irritation, hypertrophic scar.
Freese et al.¹⁸	Wound dehiscence, superficial infection, difficulty removing ulnar rod, finger flexion contracture, transient neuropraxia, implant migration.
Zeybek et al.¹⁹	Superficial infection, soft-tissue irritation, pseudoarthrosis, delayed union.
Soudy et al.²⁰	Superficial infection, superficial radial nerve injury, residual nonunion of the radius.
Shihora et al.²¹	Elbow stiffness, hypertrophic scar, superficial infection, malunion.
Zhu et al.²²	Refracture, nonunion of the radius, superficial infection.
Di Giacinto et al.²³	Refracture, malunion, nonunion, superficial infection.
Jain et al.²⁴	Superficial infection, nonunion, delayed union, refracture.
Pogorelić et al.²⁵	Skin irritation, refracture, pseudoarthrosis.
De Vitis et al.²⁶	Skin irritation.
Wu et al.²⁷	NR (not reported).
Acharya et al.²⁸	Skin irritation over prominent ulnar nail, superficial infection at nail entry site, ulnar nail backout.
Zheng et al.²⁹	Superficial infection, superficial radial nerve palsy, soft-tissue irritation, refracture, nonunion.
Dávid et al.³⁰	Re-displacement, irritation, skin perforation, superficial radial nerve injury.
Guzel et al.³¹	Superficial infection, soft-tissue irritation, refracture, pseudoarthrosis.

Study	Clearly stated aim (a)	Inclusion of consecutive patients (b)	Prospective data collection (c)	Appropriate endpoints (d)	Adequate follow-up period (f)	Loss to follow-up <5% (g)	Total score	Study quality
Barua et al.¹⁶	2	2 / n = 40	1	2	2	2	11	Good
Duran Topak et al.¹⁷	2	2 / n = 52	1	2	2	2	11	Good
Freese et al.¹⁸	2	2 / n = 102	1	2	2	2	11	Good
Zeybek, Akti et al.¹⁹	2	2 / n = 51	1	2	2	2	11	Good
Soudy et al.²⁰	2	2 / n = 18	2	2	2	2	12	Good
Shihora et al.²¹	2	2 / n = 73	2	2	2	2	12	Good
Zhu et al.²²	2	2 / n = 56	2	2	2	2	12	Good
Di Giacinto et al.²³	2	2 / n = 43	1	2	2	2	11	Good
Jain et al.²⁴	2	2 / n = 65	1	2	2	2	11	Good
Pogorelić et al.²⁵	2	2 / n = 173	1	2	2	2	11	Good
De Vitis et al.²⁶	2	2 / n = 44	1	2	2	2	11	Good
Wu et al.²⁷	2	2 / n = 26	2	2	2	2	12	Good
Acharya et al.²⁸	2	2 / n = 31	1	2	2	2	11	Good
Zheng et al.²⁹	2	2 / n = 137	1	2	2	2	11	Good
Dávid et al.³⁰	2	2 / n = 86	1	2	2	2	11	Good
Guzel et al.³¹	2	2 / n = 78	1	2	2	2	11	Good

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[TFN1] Legend: PO: plate osteosynthesis (plating); TEN: Titanium Elastic Nail (TEN rods); TENK: TEN rods + Kirschner wires; ORIF: open reduction and internal fixation with plate and screws; NR: not reported; FPP: plate–screw fixation; FH: hybrid fixation using elastic intramedullary fixation + plate–screw fixation; CO: conservative treatment with splint and cast; FPD: double-plate fixation (dual plating); FK: intramedullary fixation with Kirschner wires (K-wires); FES: Epibloc system fixation; IM: flexible intramedullary rod; ESIN: elastic stable intramedullary nailing (ESIN); Hybrid: ESIN for the radius and plate–screw fixation for the ulna; HIT: titanium intramedullary rod; RESIN: resorbable intramedullary rod; HF: hybrid fixation; I-KW: intramedullary Kirschner wire.