Both bone forearm fractures in children and adolescents, which fixation strategy is superior - plates or nails? A systematic review and meta-analysis of observational studies.

OBJECTIVES To determine which method of operative fixation, plate and screw, or intramedullary nails (IMN) fixation is superior for pediatric both bone forearm fractures (BBFF). DATA SOURCES PubMed, EMBASE, and Cochrane, from 1980 to 2011, in English. STUDY SELECTION We selected for detailed review all studies with children or adolescents with comparative data (or individual patient data) for BBFF fixed with IMN or open reduction internal fixation with plates and screws. Selected studies also required outcomes of interest including fracture union, complications, functional outcome, cosmesis, and the need for hardware removal. DATA EXTRACTION Data were extracted from each study; publication bias was assessed using funnel plots and Egger statistic. Study quality was assessed using the standardized method described by Zaza et al. DATA SYNTHESIS A DerSimonian and Laird random-effects model was used to assess differences between dichotomous variables. A continuity correction was applied in cases of zero events. A sensitivity analysis was performed with studies that separated out older children and adolescents. CONCLUSIONS All studies identified were observational. IMN and plate and screw constructs are acceptable options in the fixation of pediatric BBFF. The literature fails to demonstrate a difference between IMN and plate and screw constructs. Outcomes were excellent in nearly 9 of 10 patients regardless of fixation strategy. Delayed unions and nonunions were rare and slightly more common in IMN, although the difference was not statistically significant. These results suggest that complication rates are similar, although the type of complication may vary. IMN provides improved cosmesis but, in general, requires a second operation to remove hardware.