Peds Fracture? Skip the Cast

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Children often present to our emergency departments with buckle fractures, non-displaced fractures and minimally angulated fractures.  They are often placed in casts which can be difficult to care for and then patients return to the ED for cast-related issues. This journal club will review the latest articles on the use of removable splints for fracture care in children.

Educational Objectives:

After evaluating this article, participants will be able to:
1. Incorporate immobilization strategies into clinical practice resulting in improved function without increased complications
2. More effectively utilize splinting as an alternative to casting in selected pediatric patients
3. Recognize the value of splinting, as opposed to casting, in low-risk pediatric fractures.


Q1 What is the comparative value of removable splintage versus plaster casts (requiring removal by a specialist) for undisplaced compression (buckle) fractures; cast length and position; and the role of surgical fixation for displaced wrist fractures in children?  

A. Limited evidence supports the use of removable splintage for buckle fractures and challenges the traditional use of above-elbow casts after reduction of displaced fractures. Although percutaneous wire fixation prevents redisplacement, the effects on longer term outcomes including function are not established. Further research is warranted on the optimum approach, including splintage, for buckle fractures; and on the use of below-elbow casts and indications for surgery for displaced wrist fractures in children.

Abraham A, Handoll HH, Khan T. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004576.


Methodology: Approximately a third of all fractures in children occur at the wrist, usually from falling onto an outstretched hand (FOOSH). We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 4), MEDLINE (from 1966), EMBASE (from 1988), CINAHL (from 1982) and reference lists of articles. Date of last search was October 2007. For our selection criteria, we used randomized or quasi-randomized controlled trials comparing types and position of casts and the use of surgical fixation for distal radius fractures in children. For data collection and analysis, two authors performed trial selection. All three authors independently assessed methodological quality and extracted data.  

Findings: The 10 included trials, involving 827 children, were of variable quality. Four trials compared removable splintage versus the traditional below-elbow cast in children with buckle fractures. There was no short-term deformity recorded in all four trials and, in one trial, no refracture at six months. The Futura splint was cheaper to use. This removable plaster splint was less restrictive to wear, enabling more children to bathe and participate in other activities, and this option was preferred by children and parents. The soft bandage was more comfortable, convenient and less painful to wear. home-removable plaster casts removed by parents did not result in significant differences in outcome but were strongly favored by parents. Two trials found below-elbow versus above-elbow casts did not increase redisplacement of reduced fractures or cast-related complications, were less restrictive during use and avoided elbow stiffness. One trial evaluating the effect of arm position in above-elbow casts found no effect on deformity. Three trials found that percutaneous wiring significantly reduced redisplacement and remanipulation but one of these found no advantage in function at three months.

Q2 Do children with distal radius and/or ulna buckle fractures treated with a removable splint have better physical function than those treated with a short arm cast for three weeks?
A. Children treated with removable splinting have better physical function and less difficulty with activities than those treated with a cast.

Background: Wrist buckle fractures are a frequent reason for emergency department visits. Although textbooks recommend 2 to 4 weeks of immobilization in a short arm cast, management varies. Treatment with both casts and splints is common, and length of immobilization varies.


Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006 Mar;117(3):691-7.

Methodology: This was a randomized, controlled trial in the emergency department of an academic, tertiary care children’s hospital. Participants were children 6 to 15 years of age with distal radius and/or ulna buckle fractures who were randomly assigned to treatment with a short arm cast for 3 weeks or a removable splint. Cast removal was at 3 weeks. A validated self-reported outcome tool, the Activities Scales for Kids performance version (ASKp), was used to measure physical function over a 4-week period. The main outcome was the ASKp score at 14 days postinjury.

Findings: We randomly assigned 113 patients, and 87 were included in the final analysis: 42 in the splint group and 45 in the cast group. Study groups were similar in age, gender, bone fractured, and dominant hand injured. There were significant differences in ASKp score at day 14 and change in ASKp from baseline at days 14 and 20, indicating better functioning in the splint group. Splinted children had less difficulty with bathing throughout the entire study. There were no significant differences in pain between groups as measured by visual analog scale. There were no refractures.

Q3 Do children who have low-risk ankle fractures that are treated with a removable ankle braces have at least as effective a recovery of physical function as those that are treated with a cast?    

A. The removable ankle brace is more effective than the cast with respect to recovery of physical function, is associated with a faster return to baseline activities, is superior with respect to patient preferences, and is also cost-effective.

Background: Isolated distal fibular ankle fractures in children are very common and at very low risk for future complications. Nevertheless, standard therapy for these fractures still consists of casting, a practice that carries risks, inconveniences, and use of subspecialty health care resources.

Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007 Jun;119(6):e1256-63.

Methodology: This was a noninferiority, randomized, single-blind trial in which children who were 5 to 18 years of age and treated in a pediatric emergency department for low-risk ankle fractures were randomly assigned to a removable ankle brace or a below-knee walking cast. The primary outcome at 4 weeks was physical function, measured by using the modified Activities Scale for Kids. Additional outcomes included patient preferences and costs.

Findings: The mean activity score at 4 weeks was 91.3% in the brace group (n = 54), and this was significantly higher than the mean of 85.3% in the cast group (n = 50). Significantly more children who were treated with a brace had returned to baseline activities by 4 weeks compared with those who were casted (80.8% vs 59.5%). Fifty-four percent of the casted children would have preferred the brace, but only 5.7% of children who rec
eived the brace would have preferred a cast. The cost-effectiveness acceptability curve was always >80%; therefore, the brace was cost-effective compared with the cast.

Q4 In skeletally immature children 5-12 years with acceptably angulated transverse or greenstick distal radius fractures, when is a wrist splint at least as effective as a cast with respect to recovery of physical function, measured by the Activities Scale for kids at six weeks?

A. The wrist splint was non-inferior to the cast with respect to recovery of physical function in children with minimally displaced distal radial fractures, maintained comparable fracture stability, and was superior with respect to parental and patient preferences.

Background:  Minimally angulated distal radius fractures have excellent cosmetic and functional outcomes due to the unique capacity of children’s bones to remodel. Standard therapy with casting is associated with inconveniences. A strategy that is more convenient while offering comparable stability is preferable.
The secondary objective of this study was to determine differences in fracture angulation, wrist range of motion, strength & pain, return to baseline activities, and parent/patient preferences at 6 weeks.    

Kathy Boutis, Andrew Willan, Paul Babyn, Ron Goeree, Andrew Howard. Pediatrics, Hospital for Sick Children, Toronto, ON, Canada. ;A Randomized Controlled Trial of Cast Versus Splint in Children with Acceptably Angulated Wrist Fractures. Pediatric Academic Societies Meeting, Vancouver, Canada. May 2010.

Methodology: A randomized controlled, non-inferiority, single (evaluator) blinded, single-center trial in a tertiary care pediatric institution. Minimal required sample size of 76 patients was based on testing the null hypothesis (H0) that the brace is 7% less effective at the 2.5% level, having an 80% probability of rejecting H0 if brace and cast are equally effective, assuming a 20% drop-out/lost to follow up rate. H0 was tested by a t-test for a non-zero difference. For the other outcomes, proportions and means were compared with the Fisher Exact and Students t-test, respectively.

Findings: Of the 100 randomized patients, 4 were excluded due to non-eligibility on radiographic review. Thus, 96 were included in the analysis, 46 splinted and 50 casted. Mean (SD) ASK at 6 weeks was 92.8 (7.17) in the splint group compared with 91.4 (8.08) in the cast group, with a mean difference of 1.4, and the lower bound of a one-sided 95% confidence interval =-1.8, p<0001. In the splint group, the mean (SD) angular deformity at four weeks was 8.2° (8.66) compared with 9.8° (8.42) in the cast group (p=0.348). Complications did not differ between groups, nor did range of motion with the exception that pronation was better (84° versus 74°, p=0.007) in the splint group at the end of treatment. No patient required a surgical procedure. 76.4% of parents and 77.3% of children preferred splinting over casting.

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