Should we remove flexible intramedullary nails after diaphyseal forearm pediatric fracture? A cohort study of 288 patients

BACKGROUND AND PURPOSE: Routine removal of elastic stable intramedullary nails (ESIN) after pediatric diaphyseal forearm fractures remains common practice despite limited supporting evidence. We aimed to evaluate refracture risk following ESIN retention compared with implant removal and assessed complications and healthcare resource use. METHODS: In this retrospective cohort study, patients treated with ESIN for diaphyseal forearm fractures at a single center were included. Following a policy change, routine implant removal was discontinued in favor of retaining implants unless symptomatic. Patients were grouped into removal and non-removal. The primary outcome was refracture, analyzed using Cox regression, and early refractures (< 12 months), using logistic regression. Secondary outcomes included complications and healthcare resource utilization (outpatient visits, radiographic examinations during follow-up). RESULTS: 288 patients were included, of whom 136 underwent implant removal and 152 retained their implants. Among patients with implant retention, 9/152 (5.9%) subsequently required removal, most commonly due to implant-related irritation. Refracture occurred in 13/136 (9.6%) after implant removal and 8/152 (5.3%) after implant retention (absolute risk difference 4.3 percentage points, 95% confidence interval [CI] -1.8 to 10.4; HR 1.4, CI 0.5-3.4). Early refracture occurred in 8/136 (5.9%) patients after implant removal and 5/152 (3.3%) after implant retention (absolute risk difference 2.6 percentage points, CI -2.3 to 7.5; OR 1.8, CI 0.6-6.2), including 3 cases within 6 months after removal. Complications occurred in 11/136 (8.1%) patients after implant removal. Infection occurred in 5/136 (3.7%) after implant removal vs 4/288 (1.4%) after the initial surgery (risk difference 2.3 percentage points, CI -1.2 to 5.7). CONCLUSION: ESIN retention was well tolerated and associated with reduced healthcare utilization. No clear difference in refracture risk was observed between groups, although the study was not powered to detect moderate differences in risk.