Cochrane review: Interventions for treating wrist fractures in children
Authors: Abraham Alwyn , Handoll Helen HG , Khan Tahir 
Published: March 2009

Background

Approximately a third of all fractures in children occur at the wrist, usually from falling onto an outstretched hand.

Objectives

We aimed to evaluate 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.

Search strategy

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 October 2007.

Selection criteria

Any randomised or quasi‐randomised controlled trials comparing types and position of casts and the use of surgical fixation for distal radius fractures in children.

Data collection and analysis

Two authors performed trial selection. All three authors independently assessed methodological quality and extracted data.

Main results

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; a removable plaster splint was less restrictive to wear enabling more children to bathe and participate in other activities, and the option 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 favoured 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.

Authors' conclusions

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.

Plain language summary

Interventions for treating wrist fractures in children

Approximately a third of all fractures in children occur at the wrist as a result of falling onto an outstretched hand. Some fractures are relatively minor and involve a bulging of the bone surface. These are buckle fractures and they are traditionally treated with a below‐elbow plaster cast. There are other more serious fractures where parts of the broken or fractured bone are displaced from each other. After reduction, where the bone is put back together again, two measures can be taken to keep the bone together. One option is cast immobilisation, where traditionally the cast is extended to include the elbow (an above‐elbow cast). Another option is surgical fixation. This generally involves placing wires through the skin and into the bone (percutaneous wire fixation).

This review includes 10 randomised controlled trials, involving 827 children. Some of these trials used poor methods that meant their results were potentially unreliable.

Four trials of children with buckle fractures compared devices such as removable splints with traditional plaster casts that need removal by a specialist. No trial found any participant with bone deformity at follow up and one trial found no refractures at six months follow up. Compared with traditional casts, the Futura splint was cheaper to use and a removable plaster splint was less restrictive to wear, enabling children to bathe and participate more in other activities, and preferred by both children and their parents. A soft bandage was found to be more comfortable and convenient and less painful. Plaster casts that could be removed at home by parents did not result in significant differences in outcome but were strongly preferred by parents.

Two trials found below‐elbow versus above‐elbow casts did not increase redisplacement of reduced fractures or cast‐related complications. Below‐elbow casts 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. One trial found no advantage for function at three months.

The review concluded that minor (buckle) fractures could be treated by a splint that is removable at home. Additionally, fractures which have the potential to redisplace could probably be treated safely with a below‐elbow cast. Although surgery helped prevent redisplacement of some types of fractures, the long‐term benefit was not confirmed. However, further trials on these three issues are needed to obtain more conclusive evidence.