Short Arm plasters are as effective as Long arm plasters for distal forearm fractures in children

Report By: Dr Muhammad Urfan Saleem - Senior House Officer in Trauma Orthopaedics
Search checked by Mr Fahad G Attar - SpR Pilgrim in Trauma Orthopaedics
Institution: Birmingham Heartlands Hospital
Date Submitted: 20th October 2006
Last Modified: 13th December 2006
Status: Blue (submitted but not checked)

Three Part Question

In[children with closed distal forearm fractures] is [ below arm cast as effective as upper arm cast] in [immobilizing these fractures and decreasing chances of remanipulations]

Clinical Scenario

A 7 year old boy attends the emergency department following a fall in school. Clinically he has sustained closed fracture of his distal radius and ulna. The patient definitely needed manipulation under anaesthesia for reducing the fractures. You wonder whether below arm cast is as effective as above arm cast for these fractures.

Search Strategy

Medline 1966-2006 using the MeSH database and OVID interface
(below elbow plaster cast as effective to above elbow plaster cast for distal forearm fractures in children) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) AND (English[lang]) AND (child, preschool[MeSH] OR child[MeSH:noexp])

Search Outcome

198 papers were found, out of which 3 papers were relevant but only 2 papers answered the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bohm ER, 2006 canada	4-12 yrs of age group with closed distal forearm fractures treated at tertiary care hospital. Total of 102 children were enrolled.	A blinded randomized controlled trial	Rate of remanipulation in above and below elbow cast.	Below elbow cast appear to offer an absolute reduction of 11% compared with the above elbow cast. 95% upper confidence limit of this difference equals to an increase of 5%.	Small number of patients.
Webb GR 2006 USA	Children 4 years and above with closed distal forearm fractures not requiring any surgical intervention. One hundred and thirteen of 151 patients were analyzed and followed up.	Prospective randomized trial	Clinical and radiographic outcomes of treatment with the short arm cast were compared with those of treatment with the long arm cast.	More patients treated with a long arm cast lost reduction (p=0.045).	10 patients were lost to follow up. The mean cast index cannot accurately represent a molded cast as it can be affected by the amount of padding and by the assymetrical swelling due to fractue.
Webb GR 2006 USA		Prospective randomized trial		The cast index differed significantly (p=0.001) between the group that lost reduction and group that maintained reduction.

Comment(s)

The studies presented are the only randomized controlled studies which answer the three part question. These trials demonstrated no difference in the ultimate outcome following treatment with long and short arm casts for distal third forearm fractures. Howerver, factors that can influence the loss of reduction can be; combined distal radius and ulna fractures, residual angulation after reduction and proper casting techniques which are assessed by the cast index.

Clinical Bottom Line

Short arm casts perform as well as long arm casts in trating and maintaing reduction of distal third forearm fractures in children.

References

Bohm ER Journal of Bone and Joint Surgery, American volume 2006 Jan;88(1):1-8
Webb GR The Journal of bone and joint surgery. American volume 2006 Jan;88(1):9-17