Question: In children with a displaced metaphyseal fracture of the distal radius, how safe and effective is the addition of Kirschner-wire (K- wire) fixation to closed manipulation under anesthesia and application of an above-the-elbow cast in comparison with manipulation and casting alone?
Design: Randomized (allocation concealed)*, blinded (outcome assessor of clinical function)*, controlled trial with a 3-month follow-up.
Setting: A children's hospital in Edinburgh, Scotland, UK.
Patients: 68 children who were 4 to 14 years of age (mean age, 7.9 years; 62% boys) and had a completely displaced metaphyseal fracture of the distal radius with or without a fracture of the ulna. Patients with physeal injuries were excluded. 96% of the children had radiographic follow-up to union, and 82% returned for a clinical evaluation at 3 months.
Intervention: All patients had manipulation under anesthesia and then were allocated to either application of an above-the-elbow cast alone ( n = 33) or to casting and insertion of a percutaneous Kirschner wire ( n = 35). Patients in the casting-only group were radiographically reviewed weekly for 3 weeks; those in the K-wire group returned at 3 weeks for removal of the wire and a cast change under general anesthesia.
Main outcome measures: Radiographic position at union, clinical function at 3 months, need for additional treatment, and complications.
Main results: Analysis was by intention to treat. Maintenance of reduction was better in the K-wire group than in the casting-only group, both at the time of the initial reduction and at union ( table ). 7 (21%) of the patients in the casting-only group required a second procedure for the correction of a deformity that occurred during follow-up compared with none (0%) of the patients in the K-wire group ( P < 0.01). The groups did not differ for clinical function at 3 months. The wire migrated in 1 patient in the K-wire group and had to be removed.
Conclusion: In children with a displaced metaphyseal fracture of the distal radius, the addition of Kirschner-wire fixation to closed manipulation under anesthesia and application of an above-the-elbow cast was superior to treatment with manipulation and casting alone in maintaining reduction of the fracture.