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Casting vs. Splinting for Wrist Fractures in Children
Am Fam Physician. 2011 May 1;83(9):1103-1104.
Background: Fracture of the distal radius is the most common fracture in children. These fractures are traditionally placed in a short arm cast for four to six weeks, but this can lead to poor hygiene and can cause additional damage if the cast fits poorly. Additionally, use of the cast saw can cause distress in children. Evidence from studies involving adults has shown splinting to be a safe alternative, but it has yet to be confirmed in children. Boutis and colleagues conducted a randomized controlled trial to determine if splinting was as effective as casting in the treatment of minimally angulated wrist fractures in children.
The Study: The authors enrolled children five to 12 years of age with minimally angulated (15 degrees or less) greenstick or transverse fractures of the distal radius. Of the 96 children who met inclusion criteria, 46 were placed in a splint and 50 were placed in a cast, each for four weeks. Children in splints were advised to remove the splint only for hygienic reasons. The angle of displacement of the bone was determined in the sagittal plane of the radiography. The authors defined 15 degrees or less as translation displacement of 5 mm or less on the frontal plane. Children with an injury that was older than five days; who had a buckle, open, or pathologic fracture; or whose fracture involved the growth plate were excluded from the study. Additionally, children with congenital wrist anomalies, coagulopathies, multisystem trauma, multiple injuries to the same limb, or developmental delay were excluded. Six weeks after the initial application of the immobilization device, physiotherapists assessed the children's physical function, using single-blinded methodology. Parents completed a weekly diary to record pain scores and compliance with treatment and were contacted three months after treatment to assess recovery.
Results: The authors found no significant differences between the groups based on each patient's range of motion, grip strength, and ability to complete activities six weeks after initiation of treatment. There were also no significant differences between the immobilization devices in the irritation, itching, and discomfort reported. Six children had to wear their immobilization device for an additional two weeks because the angulation of their fracture had increased to 25 degrees by the fourth week; these children were evenly divided between the two groups. Based on parental reports, splint use became less frequent by the end of four weeks. The primary difference between the groups occurred at week 6 when 5 percent of parents and 12 percent of children in the splint group reported they would have preferred a cast, whereas 60 percent of parents and 68 percent of children in the cast group reported they would have preferred a splint. None of the children required surgical intervention during the follow-up period.
Conclusion: The authors conclude that splinting appears to be safe, effective, and preferred by patients and parents. However, care must be taken to correctly diagnose fracture type to determine whether splinting is an appropriate alternative to casting.
Boutis K, et al. Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial. CMAJ. October 5, 2010;182(14):1507–1512.
Copyright © 2011 by the American Academy of Family Physicians.
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