Study finds that splints, casts yield similar stability, complication rates for wrist fractures

Boutis K. CMAJ. 2010;182:1507-1512. doi:10.1503/cmaj.100119.

The results of a randomized controlled trial show that the use of a splint was as effective as a cast for recovering physical function in children with wrist fractures.

For their study, Kathy Boutis, MD, of the University of Toronto in Ontario, and colleagues included 96 children who were treated at a tertiary care pediatric hospital for a minimally angulated, <15°, greenstick or transverse wrist fracture between April 2007 and September 2009. The children were aged 5 to 12 years.

The investigators randomly assigned the patients to wear a prefabricated wrist splint or a short-arm cast for 4 weeks. The investigators chose physical function at 6 weeks, which they measured using the performance version of the Activities Scale for Kids, as the primary outcome. They also evaluated angulation, range of motion, grip strength and complications.

Forty-six children wore the splint, and 50 wore a cast. At 6 weeks, the mean Activities Scale for Kids was 92.8 for those who wore a splint and 91.4 for the cast group. There was no statistically significant differences between the groups regarding angulation at 4 weeks, range of motion, grip strength or complications.

The researchers found that, on all counts, minimally-angulated forearm fractures in children managed by splinting obtained equal, if not better, results than a below-elbow cast. While satisfaction of final appearance was equal, the retrospective preference was decidedly better for the splint group.

This article is important to those of us who treat children in many ways. Most important, of course, is content. The study design of the randomization process is a tribute to the researchers and the institution. That being said, this study is current and timely especially when health care economics are such an issue in the southern (United States) segment of North America. The economic cost to the patient, society, medical professional and technician of having patients visit the office to reassure all that the fracture is doing well could be virtually eliminated when the injury fit the authors’ criteria.

I am always impressed when I see adolescents who underwent early childhood cast removal(s) who consider it to have been the most dreadful experience they have ever had; not to exclude the experience of thumb abrasions, ulcers, etc., when the swelling went down and the cast slides a bit. Personal hygiene is also an issue, although not always articulated by the patient.

Finally, the authors clearly state that physician error in assessing whether a splint is suitable for fracture management may occur with greater frequency in less specialized centers, which limits the generalizability of their results. This may not continue to be a problem as the trend to fracture treatment for the majority of pediatric patients is being allocated to pediatric orthopedic-trained surgeons, physicians, technicians, nurse practitioners, etc.

I highly recommend this article to all who participate in the care of musculoskeletal injuries in children.

— Alvin Crawford, MD
Orthopedics Today Pediatrics Section Editor