Systematic review finds similar efficacy for splinting vs. casting of minor pediatric wrist fractures

Removable splints and plaster casts appear to be equally safe and effective for treating minor buckle wrist fractures in children, according to a meta-analysis published in the Cochrane Database of Systematic Reviews.

Conversely, one orthopedist argues that splints have a major disadvantage: Children can easily remove them at will.

"There are minor, or buckle, fractures of the wrist, particularly in toddlers and preschool infants, which are currently being over-treated with a plaster cast and clinic follow-up," Alwyn Abraham, MD, a consultant pediatric orthopedic surgeon at the Leicester Royal Infirmary, and lead investigator for the literature review, stated in a press release from the Health Behavior News Service, a program of the Center for the Advancement of Health. "Provided these are accurately diagnosed in an emergency department, these minor fractures can be treated with a removable splint. Removal can be done at home with no further follow-up."

However, practical considerations work both ways when choosing between splints and casts, according to Leon Benson, MD, an orthopedic surgeon and a spokesperson for the American Academy of Orthopaedic Surgeons.

"Yes, you can treat a child's buckle fracture with a splint, but I don't," Benson stated in the release. "In my experience, a child under 10 [years of age] is not going to keep a splint on, and who is going to take responsibility for that fact — the doctor? And, given that fact, what parent wants to sit on pins and needles waiting for it to happen when a safe plaster cast insures it won't?"

Abraham and colleagues reviewed 10 studies involving 827 children with wrist fractures. The researchers analyzed data on the treatment of buckle fractures as well as displaced fractures, although the findings regarding treatment for displaced fractures were inconclusive.

Of the studies that compared plaster casting for buckle fracture to removable splints, none reported an ensuing bone deformity in any patient using either treatment. The reviewers also found no significant difference in healing of buckle fractures between traditional plaster casts extending either below or above the elbow.

However, removable splints were less expensive and less restrictive, and were preferred over traditional casts by both children and parents, according to the study's authors. Plaster casts that parents could remove at home did not lead to different outcomes and parents strongly preferred these to traditional casts.

"Minor [buckle] fractures could be treated by a splint that is removable at home," the reviewers concluded.

While Benson, an associate clinical professor of orthopedic surgery at the Northwestern University Feinberg School of Medicine, agreed in theory with the review's conclusions, he argued that they do not necessarily translate to a real-world setting.

"My experience is that the younger child's pain decreases dramatically more quickly with plaster casting than a splint, and adolescents in splints often remove them around their friends because they find them embarrassing," Benson noted in the release. "With a plaster cast, everyone can sleep at night; nothing can make that cast fall off. Yes, having a plaster cast for a few weeks is a hassle in ways, though it is possible to cover it and bathe or shower. But for the whole child and the whole family, it is a more reasonable treatment."

Benson said the economic implication of the findings could have potential negative effect: "A review like this could be used, in the U.K. system, to force people to use cheaper splinting methods of treatment rather than have a choice for plaster-casting for their child for reasons beyond narrow measures of clinical efficacy. This would be unfortunate."

For more information:
Abraham A, Handoll HHG, Khan T. Intervention for treating wrist fractures in children (Review). Cochrane Database Syst Rev. 2008; Issue 2. Art. No.: CD004576. DOI: 10.1002/14651858.CD004576.pub2.