Acceptable angulation criteria in pediatric midshaft forearm fractures: A systematic review and meta-analysis.

Background: The well accepted standard for the management of pediatric both bone forearm fractures (BBFFs) is closed reduction and cast management. The acceptable angulation guidelines, dictated by patient age and fracture location, help determine when nonsurgical management should be abandoned. Despite their widespread acceptance, angulation guidelines are not evidence-based and have not been critically investigated within the reported literature. Methods: A systematic review and metanalysis was performed after isolating published articles from 1967 to 2021 from a review of MEDLINE, Embase, EBSCO, and Cochrane databases. Articles which reported on closed management of midshaft, pediatric (<16 years old), BBFF, and reported on long term outcomes regarding range of motion restriction or the need for surgical treatment of symptomatic malunion, were included in the systematic review. Pertinent patient data for meta-analysis was extracted from individual studies when feasible. Univariate and multivariate analyses were performed examining the effect of fracture angulation parameters on malunion risk. Results: A total of 11 articles were included which reported on the management of 372 patients with midshaft BBFF. Overall, there was a 15.0% rate of symptomatic malunion ( Conclusions: Although this study would appear to support current acceptable angulation parameters for pediatric midshaft BBFF and the risk for symptomatic malunion development, there was a paucity of available data that precluded a rigorous analysis. Further high-quality research is needed to ascertain if our currently accepted guidelines are indeed best practice guidelines or the representation of confirmation bias in practice. Key Concepts: (1)Although pediatric midshaft bone forearm fracture remain an important component of pediatric orthopedic practice, there is a lack of rigorous data available to guide treatment decisions.(2)In this study only 5 of 84 potential studies met inclusion criteria to accessing the rate of symptomatic malunion, resulting in a pooled malunion rate of 18.8%.(3)Of the potential variables, only final sagittal radius alignment >15° was significantly associated with the development of a symptomatic malunion. Level of Evidence: II.