Background: Closed fractures of the distal third of the forearm are
the most common fractures of childhood, but the method of immobilization after
closed reduction is controversial. This study was undertaken to determine
whether below-the-elbow casts are as effective as above-the-elbow casts in
immobilizing these types of fractures and to identify patient and treatment
considerations that are related to loss of reduction.
Methods: We designed a blinded, randomized, controlled trial. The
criteria for reduction and remanipulation were set a priori. The primary
outcome measure was fracture immobilization as reflected by reangulation in
the cast and by the need for remanipulation. Exploratory analysis with use of
stepwise logistic regression analysis was undertaken to search for factors
predictive of loss of reduction.
Results: A total of 102 children were enrolled in the study and were
allocated to two groups: the above-the-elbow cast group (fifty-six children)
and the below-the-elbow cast group (forty-six children). The mean age was 8.6
years, and sixty-one patients were boys. The groups did not differ with
respect to the initial fracture angulation, postreduction angulation,
reangulation during cast immobilization, and angulation of the fracture at the
time of cast removal. In the above-the-elbow cast group, twenty-three (42%) of
fifty-five children with adequate radiographs met the criteria for
remanipulation compared with fourteen (31%) of forty-five children with
adequate radiographs in the below-the-elbow cast group (p = 0.27); only four
of these thirty-seven children actually underwent remanipulation. Children
with fractures of both the radius and ulna (p = 0.01) and those with residual
angulation after reduction (p = 0.0001) were at the highest risk of meeting
the criteria for remanipulation. The rates of complications related to the
cast did not differ between the groups.
Conclusions: Below-the-elbow casts perform as well as
above-the-elbow casts in maintaining reduction of fractures in the distal
third of the forearm in children, and the complication rates are similar.
Factors that are associated with a higher risk of loss of reduction include
combined radial and ulnar fractures and residual angulation of the fracture
after the initial reduction.
Level of Evidence: Therapeutic Level I. See Instructions
to Authors for a complete description of levels of evidence.