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Cast splitting after manipulation under anesthesia does not affect loss of position in forearm fractures
The investigators now recommended cast splitting after each manipulation.
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BERLIN — Cast splitting was not a significant factor in loss of position following manipulation under anesthetic after pediatric forearm fractures, researchers from Great Britain concluded.
“The conclusion of our study was that contrary to what many people discuss, we did not find any association with splitting casts and an increase in loss of position,” Richard F.W. Lloyd, MD, said in a presentation at the 13th EFORT Congress 2012, here. “The loss of position is clearly multifactorial, and cast splitting is not as significant as previously thought.”
Wrist and forearm fractures are common, comprising 41% of all pediatric fractures, Lloyd said.
Retrospective study
Loss of position is a known complication of forearm fracture treatment. Several studies have looked at what causes the loss of position, including degree of anatomical reduction, position of the forearm post reduction and using a long-arm cast, he said.
The retrospective study by Lloyd and colleagues examined whether splitting casts after manipulation under anesthesia (MUA) affects the loss of position.
The researchers analyzed data from two large, pediatric trauma centers in the United Kingdom, the Royal Hospital for Sick Children (Yorkhill) in Glasgow, Scotland, and the Royal Belfast Hospital for Sick Children in Belfast, Ireland.
Each center addressed the cast splitting differently. “Quite conveniently, Glasgow did not routinely split any casts, and Belfast split all casts with manipulation,” Lloyd said.
Lloyd and colleagues recorded data for 2 years from Belfast and 1 year from Glasgow and recorded rates of position loss and secondary procedures. Physicians at the Glasgow hospital performed 161 MUAs compared with 467 procedures done in Belfast. “Bear in mind that is over 2 years, so we have twice the data [in Belfast],” he said.
Overall, 64% fractures required some intervention, Lloyd said. Of the patients taken to the operating room, 86% required MUA, 9% needed MUA plus K-wire fixation, and 5% required open reduction internal fixation (ORIF) or flexible nails.
Compartment syndrome avoided
Seven patients (4.3%) in Glasgow needed a secondary procedure, of which five (71%) were repeat MUAs and two (29%) were K-wire fixation. Twenty-three patients (4.9%) in Belfast required a secondary procedure; 17 patients (74%) received a repeat MUA, 2 patients (9%) had K-wire fixation and 4 patients (17%) underwent ORIF.
No cases of compartment syndrome were reported at either center.
Position was maintained reasonably well. Lloyd said 54 cases in the no-split group and 444 cases in the split groups maintained position.
“In Belfast, … we recommend that casts should be split after each manipulation,” Lloyd said. “[MUA] should be mandatory if you expect significant swelling. I think it is sensible to warn parents about the loss of position, whether it is split or not split, and that compartment syndrome can occur similarly in both cases.” – by Colleen Owens
References:
Lloyd RFW, Bell S, Hamlin K, Ballard JD. The efficacy of cast-splitting post manipulation for paediatric forearm fractures: To split or not to split. Paper #12-5008. Presented at the 13th EFORT Congress 2012. May 23-25. Berlin.
Rennie L, Court-Brown CM, Mok JYQ, et al. The epidemiology of fractures in children. Injury. 2007;38:913-922.
For more information:
Richard F.W. Lloyd, MD, can be reached at 274 Grosvenor Rd., Belfast, Ireland BT12 6BA; email: rlloydie@gmail.com.
Disclosure: Lloyd has no relevant financial disclosures.