Letter to the editor: “Forearm fractures treated with elastic stable intramedullary nailing: Is casting still necessary?”

Dear Editor,

We commend Herdea et al. ¹ for their innovative and timely investigation into the necessity of postoperative casting following elastic stable intramedullary nailing (ESIN) in pediatric forearm fractures. Their prospective, controlled study offers valuable insights into the potential for early mobilization to expedite fracture healing and improve patient-reported outcomes. Nonetheless, while the findings are promising, a comprehensive critical appraisal reveals several additional limitations and avenues for future research that merit detailed discussion to contextualize these results within the broader landscape of pediatric forearm fracture management.

One of the notable limitations pertains to the randomization methodology employed. The authors describe using an odd-even allocation, which, although simple, is susceptible to allocation bias and may not provide the same level of rigor as concealed, computer-generated randomization. This approach could inadvertently introduce selection bias, especially in a single-center setting where clinicians or researchers may influence group assignments, consciously or unconsciously. Such bias could affect the distribution of fracture characteristics, severity, or patient demographics, thereby confounding the results. Future studies should incorporate more robust randomization procedures, such as computer-generated randomization with allocation concealment, to enhance internal validity and minimize bias.

The sample size, although adequate for detecting differences in radiographic callus formation, remains modest considering the wide variability in pediatric fracture healing and the relatively low incidence of certain adverse events. The study’s power to detect rare but clinically significant complications such as refracture, hardware irritation, delayed union, or growth disturbances is limited. ² Consequently, the safety profile of omitting postoperative casting cannot be definitively established based solely on this data. Larger, multicenter randomized controlled trials are essential to ensure sufficient statistical power to detect such rare events and to generalize findings across diverse populations and healthcare settings.

Another significant limitation concerns the follow-up period. A duration of 6 months, while sufficient for initial fracture union, may not be adequate to evaluate long-term outcomes, including remodeling in children, potential growth disturbances, or late complications such as hardware failure or deformity. Pediatric bones have a remarkable capacity for remodeling, but certain deformities or functional deficits may only become apparent after extended periods. Longer follow-up, extending to at least 12 or 24 months, would provide a more comprehensive understanding of the durability and safety of early mobilization protocols, especially in the context of growing skeletons. ²

The assessment of outcomes also warrants further elaboration. While the study utilized the PedsQL instrument to gauge quality of life, it did not include detailed, objective functional assessments such as range of motion measurements, grip strength, or specific upper limb functional scores. ³ These parameters are critical for determining the true functional impact of early mobilization and could reveal subtle deficits not captured by quality-of-life questionnaires alone. Incorporating standardized functional scoring systems would enhance the robustness of outcome measures and better inform clinical decision-making regarding early movement protocols.

Furthermore, although the surgical technique was described as standardized, variations in postoperative physiotherapy and patient compliance could influence recovery trajectories. The authors did not elaborate on specific physiotherapy regimens or adherence monitoring, which are known to significantly affect functional outcomes after forearm fractures. Additionally, the surgeon’s experience and institutional protocols can influence surgical and postoperative management, affecting reproducibility. Future research should aim to standardize rehabilitative protocols and include adherence monitoring, possibly utilizing wearable technology or patient diaries, to better understand the influence of these factors on healing and function.

The study population was drawn from a single center in Romania, raising concerns about the external validity and generalizability of the findings. Socioeconomic factors, access to physiotherapy, parental engagement, and healthcare infrastructure vary across regions and can influence outcomes. The authors did not explicitly analyze or control for these variables, which could confound the observed benefits of early mobilization.^2–4 Multicenter studies encompassing diverse populations and healthcare systems are necessary to confirm these findings and to develop widely applicable guidelines.

Another important aspect that was not addressed involves the biological and nutritional factors influencing fracture healing. Emerging evidence underscores the critical role of vitamin D in bone metabolism, remodeling, and healing. ⁵ Vitamin D deficiency is common in pediatric populations and has been associated with delayed union, increased fracture risk, and suboptimal healing outcomes. The authors did not measure or consider vitamin D or other nutritional parameters, which could significantly influence the healing process and the success of early mobilization protocols. Future research should include assessment of vitamin D status, calcium levels, and other relevant biomarkers, to identify potential modifiable factors that may optimize healing and functional recovery in children. Addressing nutritional deficiencies through supplementation could enhance outcomes, especially when early movement is encouraged, and may mitigate risks associated with compromised bone health.

The variability in fracture characteristics beyond classification also warrants attention. Factors such as initial displacement, angulation, comminution, and soft tissue injury influence stability and healing potential.^2–4 The authors focused on specific fracture types but did not provide detailed data on these parameters. Stratifying outcomes based on fracture stability and initial injury severity could identify subgroups that benefit most from early mobilization and those that may require more conservative management.

Cost-effectiveness analyses also remain an important future direction. While early mobilization may reduce hospital stay, decrease material costs, and facilitate faster return to daily activities, the economic implications of potential increased complication rates or re-interventions need to be carefully evaluated. A comprehensive health economic analysis incorporating direct and indirect costs would provide valuable insights for policymakers and clinicians contemplating protocol modifications.

Finally, the integration of emerging technologies offers exciting possibilities. Tele-rehabilitation programs, wearable sensors for movement tracking, and advanced imaging modalities could enhance postoperative monitoring, ensure adherence to early movement protocols, and provide objective data on functional recovery. Incorporating these innovations into future research could optimize early mobilization strategies and improve patient-centered care. ⁶

In conclusion, while the study by Herdea et al. ¹ provides promising evidence supporting early mobilization following ESIN in pediatric forearm fractures, there are several limitations related to study design, sample size, follow-up duration, outcome assessment, nutritional considerations, and generalizability that should be addressed in future research. Larger, multicenter trials with extended follow-up periods, comprehensive functional evaluations, assessment of nutritional status, and detailed fracture characterization are essential to validate these findings and to inform clinical guidelines. Incorporating health economic analyses and leveraging technological advances could further refine and personalize management approaches. Recognizing the multifaceted nature of fracture healing—including biochemical, nutritional, biomechanical, and psychosocial factors—will be critical in advancing pediatric orthopedic care.

Supplemental Material

sj-pdf-1-cho-10.1177_18632521261444252 – Supplemental material for Letter to the editor: “Forearm fractures treated with elastic stable intramedullary nailing: Is casting still necessary?”

Supplemental material, sj-pdf-1-cho-10.1177_18632521261444252 for Letter to the editor: “Forearm fractures treated with elastic stable intramedullary nailing: Is casting still necessary?” by Marko Bašković, Tonko Čolić and Domagoj Pešorda in Journal of Children's Orthopaedics