A response to a letter to the editor: Predictors for operative treatment in pediatric proximal third both-bone diaphyseal forearm fractures in children include age and translation,but not initial angulation

We greatly appreciate the interest shown and the insightful comments provided by the reader. These insights shed light on the necessity for a better understanding of pediatric proximal third forearm fractures and a better definition for the surgical indications. Regarding the reader’s concern about categorizing displacement as a categorical variable, we made an attempt to refer to the fracture translation as a continuous variable as a part of our data analysis during our regression modeling. While this analysis had yielded a statistically significant association with increasing displacement and operative treatment, it did not provide useful cutoffs that would serve clinicians in practice. Therefore, we chose to break this continuous variable into categories that can provide the readership with relevant tools for their daily practice in the treatment of these difficult fractures.

In addition, we would like to thank the reader for citing Price (2010) and Pace (2016). While Pace et al. offered post-reduction benchmarks for defining indications for operative treatment, the current study provided predictors for operative treatment that are measured upon presentation. These studies provided context as to acceptable loss of angular alignment, but did not assess nor include displacement as an indicator of ultimate treatment. As such, our article is complementary to their publications, which, when taken together, further guide treatment for these patients.

In addition, the authors feel that the original criteria proposed by Price in 2010 are too strict for the treatment of patients older than age 8, and our surgical indications are more in line for patients who meet the criteria as described by Pace (2016). However, the ultimate indication for surgical intervention is a failure of closed treatment, whether it be with angulation greater than acceptable limits or displacement indicative of instability and a risk of loss of reduction. Thus, our article focused on predictors of failure to maintain alignment, as all patients included had an attempt at closed treatment. Ultimately, initial angulation was not as reliable as initial displacement as a guide for failure of closed treatment, likely due to some amount of periosteal stability inherent in angulated fractures versus translated fractures. A prospective study that takes into consideration the findings offered by all of these articles would be able to provide the information needed for establishing an evidence-based treatment algorithm to provide the best treatment for these patients.