Letter to the editor for “General anesthesia versus locoregional anesthesia in pediatric forearm fractures”

Dear Editor,

I read with great interest the article titled “General anesthesia versus locoregional anesthesia in pediatric forearm fractures” (J Child Orthop 2025; 19(3):2025), which explores whether general anesthesia with neuromuscular blockade reduces the rate of open reduction compared to deep sedation with nerve block.

While the authors rightly acknowledged limitations related to retrospective design and non-randomized anesthesia allocation, I would like to highlight body mass index (BMI) as a potentially influential variable that was not addressed. Prior studies using the Kids’ Inpatient Database (1997–2012) report increased odds of ORIF in obese children (OR 1.436), along with higher complication rates, longer hospital stays, and greater costs. ¹ Obese children are also less likely to achieve perfect initial reductions and more likely to require intraoperative manipulation (28% versus 12%), suggesting that obesity itself may predispose to closed-reduction failure—independent of anesthesia type. ²

Moreover, pediatric obesity complicates sedation due to increased risks of airway obstruction, desaturation, and laryngospasm, as well as challenges in airway management, vascular access, and drug dosing.^3,4 These factors may influence anesthesiologists to favor general anesthesia with neuromuscular blockade, particularly in heavier children.

The authors also commented on functional outcomes, which are closely tied to fracture healing. Literature suggests that obesity may impair bone healing, further supporting the need to include BMI in outcome analyses. ⁵

By not accounting for BMI, the study may be subject to confounding: heavier children are both more likely to experience reduction failure and more likely to receive general anesthesia. A stratified or regression-adjusted analysis by BMI percentile could help clarify these associations.

I commend the authors for addressing an important clinical question. Future studies incorporating BMI as a covariate—ideally in a prospective, randomized design—would enhance the robustness of these findings and guide more tailored anesthetic and surgical decision-making.

Thank you for the opportunity to comment.

Supplemental Material

sj-pdf-1-cho-10.1177_18632521251396654 – Supplemental material for Letter to the editor for “General anesthesia versus locoregional anesthesia in pediatric forearm fractures”

Supplemental material, sj-pdf-1-cho-10.1177_18632521251396654 for Letter to the editor for “General anesthesia versus locoregional anesthesia in pediatric forearm fractures” by Muhammad Bilal Raza Slote in Journal of Children’s Orthopaedics