Conservative versus surgical management of pediatric forearm fractures: A narrative review of evolving practices and age-based decision making

Background: Historically, many pediatric closed diaphyseal forearm fractures have been treated conservatively with closed reduction and casting due to their osseous remodeling potential. However, surgical fixation has become more frequent, especially in older children, due to the concerns for refracture, malunion, and residual functional limitations. Treatment strategies vary widely across institutions and a shared decision-making treatment plan must account for many factors, such as potential of osseous remodeling, fracture alignment, and ability to obtain follow-up care. Methods: A structured literature search of PubMed, Embase, and Scopus was conducted for studies published between 1998 and 2025. Eligible articles included children aged 2-16 years old with closed diaphyseal forearm fractures treated with casting, intramedullary nailing or plating. Data was abstracted from retrospective cohort studies, randomized control trials, and systemic reviews were synthesized to evaluate for union rates, complications, and predictors of treatment failure. Results: Studies have shown children under five-years-old reliably achieve good outcomes with casting, while those aged seven to 10 face higher failure rates when displacement or shortening is present outside of the commonly accepted parameters. In patients over the age of 10, reduced remodeling capacity makes surgical fixation the predominant management. Both approaches, surgical and conservative management achieve high osseous union rates when appropriately selected using shared-decision making with parents. Conclusions: The variability in practice among institutions and attending preferences underscore the need for multicenter trials, comparative studies, and integration of patient-reported outcomes to guide care among the different age groups.