Above-, below-elbow casts equally effective for pediatric forearm fractures

Children with combined radial and ulnar fractures proved significantly more likely to meet remanipulation criteria.

Both below-elbow and above-elbow casts maintain realignment and reduction of distal forearm fractures in children equally well, a randomized study shows.

Many surgeons recommend above-elbow casts to provide better fracture stability, resulting in less redisplacement and remanipulation risk. Below-elbow casts, however, can be more comfortable for patients and can allow children better hand function for activities of daily living.

But, “When the two cast types were compared with respect to the amount of reangulation ... the below-the-elbow casts were found to maintain the alignment of distal forearm fractures in children as well as above-the-elbow casts did,” the authors said in the study.

“[It] appears that the immobilization of the elbow obtained by extending a below-the-elbow cast into an above-the-elbow cast offers no benefit in maintaining the alignment of these fractures. This may be because the elbow joint is quite distant from the fracture, and the majority of immobilization is secured over the length of the forearm,” they said.

Eric R. Bohm, MD, MSc, FRCSC, and colleagues at the University of Saskatchewan’s Royal University Hospital in Saskatchewan, Canada, conducted the blinded, controlled trial. The study included children aged 4 to 12 years who had displaced fractures of the distal third of the forearm. The researchers excluded children with open fractures or Salter-Harris type III or IV fractures, which typically get surgical treatment, according to the study.

Initially, the researchers enrolled 117 children, but excluded 15 children for one or more of several reasons, including wrong cast type, improper age or no need for reduction. The final data analysis included 56 children who received above-elbow casts and 46 who received below-elbow casts. Both groups were similar in age and gender. Though not significant, the above-elbow cast group did have more children with combined radial and ulnar fractures, however.

Surgeons reduced and immobilized most fractures in the operating room (OR), but treated 15 of 33 (45%) isolated radial fractures and 13 of 69 (19%) combined radial and ulnar fractures in the emergency department (P=.05).

The researchers based criteria for acceptable postreduction alignment and apposition on common guidelines, and on the consensus of the six surgeons involved in the study. They found no significant difference in fracture angulation between those treated in the OR or the emergency department. Additionally, groups did not differ clinically regarding either initial and postreduction fracture angulation or angulation after cast removal.

The researchers determined the need for remanipulation from follow-up radiographs for 100 children. Of these, 23 of 55 (42%) children with above-elbow casts and 14 of 45 (31%) children with below-elbow casts met the remanipulation criteria. This reduction of 11% did not reach significance and is consistent with clinical equivalency between the two cast types, the authors said.

All cases that met remanipulation criteria resulted from fracture reangulation. Children who had combined radial and ulnar fractures proved significantly more likely to meet remanipulation criteria (P<.0001). Also, above-elbow cast-treated children met remanipulation criteria more often than those treated with below-elbow casts, though the difference was not significant.

“Interestingly, of the 37 children who met the remanipulation requirements, only four actually underwent remanipulation,” the authors said. This included three below-elbow cast patients and one above-elbow cast patient. But again, they reported no significant difference between groups.

Both groups demonstrated similar rates of cast-related complications, such as reinforcement for breakdown, cast change due to loosening or breakdown, and splitting due to swelling.

Five children with above-elbow casts also requested and received a conversion to below-elbow casts at three weeks due to comfort issues, the authors noted.

For more information:
Bohm ER, Bubbar V, Hing KY, et al. Above and below-the-elbow plaster casts for distal forearm fractures in children. J Bone Joint Surg Am. 2006;88-A:1-8.