Diaphyseal fractures of the radius and ulna in children are a classic in pediatric orthopedics. Precisely because of this, however, they risk being approached with automatic responses: reduction and casting for younger children, surgery for older ones, and so on. The reality is a bit more nuanced. And recent literature, if read carefully, doesn't so much tell us that one path is "right" and the other "wrong," but rather that the two approaches have different strengths [1–4].
The systematic review with meta-analysis published in 2025 in JPOSNA is a good starting point. It included 24 studies and 1,157 patients with diaphyseal fractures of both forearm bones, comparing surgical and conservative treatment [1]. The first piece of data, which deserves to be stated clearly, is reassuring: consolidation was 100% in both groups [1]. Final functional outcomes, in general, were also good with both strategies [1].
If we stopped here, we might conclude that "it doesn't make much difference." But it's not that simple. Because the real difference emerges not so much in the absolute final outcome, but in the stability of the treatment course.
In the conservatively treated group, overall complications were more frequent: 24% versus 12% [1]. Even more marked was the difference in redisplacement: 26% in the conservative group versus 3% in the surgical group [1]. The need for further procedures was also higher with casting: 14% versus 5% [1]. This, in my opinion, is the core of the problem. Casting doesn't "work less"; casting is more exposed to the risk that an initially satisfactory reduction may not hold over time.
This is a very concrete point. In the clinic, it's common to see a reduction that, at the moment, seems acceptable, especially in a younger child. Then, at the follow-up, something changes: an angle that opens up a bit, a rotation that is less convincing, an unexpected loss of alignment. This doesn't always translate into a poor final result, thanks to remodeling. But it changes the treatment course, and sometimes it also changes the peace of mind with which the case is managed.
The meta-analysis, however, also has an important limitation: it primarily measures consolidation, complications, and redisplacement, but it doesn't truly focus on one of the aspects that often makes TEN/ESIN preferable in practice, namely the possibility of significantly reducing postoperative immobilization [1].
And this is where more specific studies on ESIN become useful.
A prospective randomized trial published in 2025 in the Journal of Children’s Orthopaedics compared children treated with ESIN with or without postoperative casting [2]. The interesting finding is that the group without casting showed better callus scores at early follow-ups and a higher quality of life at 6 weeks, without an increase in complications in the studied sample [2]. This result, while not definitive for all scenarios, points in the direction that many of us already perceive in practice: when elastic stable intramedullary nailing is well performed, postoperative casting can become superfluous in a significant number of cases [2].
The large retrospective series by Pogorelić and colleagues, on 173 patients treated with ESIN, also confirms this impression. In that study, children were not immobilized after surgery, and the authors reported complete radiographic consolidation with a low rate of major complications [3]. It's not a randomized trial, of course, but it's a piece of literature that reinforces a practical concept: surgery with TEN not only serves to "hold the fracture," it can also radically change the management of the first few weeks [3].
The 2025 narrative review on ESIN is even more explicit in outlining this role. In older children, adolescents, and unstable fractures, ESIN is described as the surgical gold standard precisely because of its minimally invasive, physeal-sparing profile, and sufficient stability to allow for a more linear recovery [4].
This, in my opinion, is the point truly worth emphasizing. The advantage of TEN is not so much "healing the bone faster" in a biological sense. The meta-analysis, in fact, reports a longer average time to radiographic consolidation in the surgical group compared to the conservative group [1]. But that data should be read with caution, because the operated children were on average older and, in all probability, less favorable to spontaneous remodeling [1]. The real gain of TEN is another: more mechanical stability, less risk of losing reduction, less need to revise the case, and, in many cases, less immobilization.
And this has enormous weight in real life. Less casting often means less discomfort for the child, fewer limitations for the family, simpler hygiene, less perceived stiffness, and greater acceptability of the treatment course. It's a difference that doesn't always fit well into study tables, but that matters a great deal in daily life.
Naturally, conservative treatment remains central. In younger children, with good remodeling potential and a fracture that holds reduction well, casting continues to be an excellent solution [1]. It would be a mistake to transform this literature into an invitation to operate more "on principle." The correct message, if anything, is the opposite: operate when surgery truly changes the course, not just when it changes the day-zero X-ray.
If I had to summarize the meaning of recent literature in one sentence, I would say this: in diaphyseal fractures of the radius and ulna in children, casting and surgery can both lead to a good final outcome, but TEN/ESIN offers a concrete advantage when the main problem is not just achieving a good reduction, but reliably maintaining it and reducing the burden of immobilization [1–4].
It's a less ideological difference than it seems. And, probably, much more useful.
Disclaimer
This content is for informational purposes only and does not replace individual clinical evaluation.
References
[1] Sharma O, Hamidi D, Bozzo I, Alrajhi K, Bernstein M. Surgical and Conservative Management are Both Effective for Pediatric Both Bone Forearm Fractures: A Systematic Review and Meta-Analysis. J Pediatr Soc North Am. 2025;13:100267. doi:10.1016/j.jposna.2025.100267. PMID: 41126900.
PubMed: https://pubmed.ncbi.nlm.nih.gov/41126900/
[2] Herdea A, Dragomirescu MC, Tiron M, Ulici A. Forearm fractures treated with elastic stable intramedullary nailing: Is casting still necessary? J Child Orthop. 2025;19(4):276-283. doi:10.1177/18632521251352323. PMID: 40692964.
PubMed: https://pubmed.ncbi.nlm.nih.gov/40692964/
[3] Pogorelić Z, Gulin M, Jukić M, Nevešćanin Biliškov A, Furlan D. Elastic stable intramedullary nailing for treatment of pediatric forearm fractures: A 15-year single centre retrospective study of 173 cases. Acta Orthop Traumatol Turc. 2020;54(4):378-384. doi:10.5152/j.aott.2020.19128. PMID: 32442119.
PubMed: https://pubmed.ncbi.nlm.nih.gov/32442119/
[4] Reddy E, Sriwastwa A, Patel S, Gupta R, Parikh SN. Elastic stable intramedullary nailing for pediatric forearm fractures: A review article. J Clin Orthop Trauma. 2025;71:103249. doi:10.1016/j.jcot.2025.103249. PMID: 41245351.
