Interventions for treating wrist fractures in children

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					Interventions for treating wrist fractures in children

Abraham A, Handoll HHG, Khan T, van Dalen EC, Kremer LCM


Objectives

This review aimed to evaluate the evidence from randomised and quasi-randomised controlled
trials comparing the relative effects (benefits and harms) of different methods of managing
fractures of the distal radius in children.


What’s known

Distal radial fractures are common throughout childhood from first walking through to and
including adolescence. The type and severity of the injury influences the management of these
fractures. Areas of management such as the need for immobilisation for minor (buckle) fractures,
and the use of below-elbow casts, arm position during immobilisation, or need for surgical fixation
of displaced fractures form the focus of this review.

What’s new

The review concluded that buckle fractures could be treated by a splint that is removable at
home. Additionally, fractures that have the potential to redisplace could probably be treated safely
with a below-elbow cast. Although surgery helped prevent redisplacement of some types of
fractures, the long-term benefit was not confirmed.

Background

Putting out an outstretched hand to break a fall is a common protective reflex in humans. The
upper limb therefore bears the brunt of the axial force in such an event and is at risk of fracture
along its length if the force exceeds the strength of the bony skeleton.

Fractures of the distal radius and ulna are the most common fractures in children and account for
around a third of all fractures in this age group. The annual incidence of these ‘wrist’ fractures has
been estimated to be 16 per 1000 children in the UK.

Two categories of fractures feature in this review: buckle fractures of the distal radius and
displaced distal radius fracture. The review aimed to examine the effects (primarily in terms of
function, redisplacement and residual deformity) of treating:

    1. buckle fractures of the distal radius with removable splints or bandages versus plaster
       casts;
    2. displaced fractures with below-elbow versus above-elbow casts;
    3. displaced fractures with above-elbow casts positioned in supination, pronation, or neural;
    4. displaced fractures with wire fixation versus plaster cast.

Results

Summary of main results

This review included 10 trials of variable quality involving 827 children.

Four trials compared the removable splintage versus the traditional below-elbow cast in children
with buckle fractures. There was no short-term deformity recorded in all four trials and, in one
trial, no refracture at six months. The Futura splint was cheaper to use; a removable plaster splint
was less restrictive to wear enabling more children to bathe and participate in other activities, and
the option preferred by children and parents; the soft bandage was more comfortable, convenient
and less painful to wear; home-removable plaster casts removed by parents did not result in
significant differences in outcome but were strongly favoured by parents.

Two trials found below-elbow versus above-elbow casts did not increase redisplacement of
reduced fractures or cast-related complications. Below-elbow casts were less restrictive during
use and avoided elbow stiffness. One trial evaluating the effect of arm position in above-elbow
casts found no effect on deformity.

Three trials found that percutaneous wiring significantly reduced redisplacement and
remanipulation. One trial found no advantage for function at three months.

Key findings based on selection of clinical relevant outcomes ‡

Comparison 01. Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome
     Subgroup                                N         N          Method                       Result (95% CI) Inference
                                             Studies   children
Unable to return to regular sporting or
physical play activities
      At 20 days                             1         57         Relative Risk (Fixed) 95% CI 0.47 [0.24, 0.94] Favours splint
      At 28 days                             1         60         Relative Risk (Fixed) 95% CI 0.12 [0.02, 0.86] Favours splint
Comparison 02. Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome                                      N         N          Method                       Result (95% CI) Inference
                                             Studies   children
Deformity                                    1         80         Relative Risk (Fixed) 95% CI Not estimable: 0 No evidence of effect
                                                                                               events in each
                                                                                               group
Comparison 03. Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome
     Subgroup                                N         N          Method                       Result (95% CI) Inference
                                             Studies   children
Fracture redisplacement and rereduction
      Redisplaced fracture               2             213        Relative Risk (Fixed) 95% CI 0.60 [0.36, 1.00] No evidence of effect
      Reangulation > 15 degrees or > 30% 1             113        Relative Risk (Fixed) 95% CI 0.16 [0.01, 3.05] No evidence of effect
      redisplacement
      Remanipulation                     2             213        Relative Risk (Fixed) 95% CI 0.41 [0.04, 3.78] No evidence of effect
Comparison 04. Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone
Outcome
     Subgroup                                N Studies N        Method                         Result (95% CI) Inference
                                                       children
Fracture redisplacement and rereduction
      Redisplaced fracture                   3          125       Relative Risk (Fixed) 95% CI 0.06 [0.02, 0.24] Favours wire + cast
      Remanipulation (and secondary          3          125       Relative Risk (Fixed) 95% CI 0.06 [0.01, 0.30] Favours wire + cast
      procedure for loss of position)
Anatomical deformity
      Coronal angular deformity (degrees)    1          65        Weighted Mean Difference     -3.00 [-5.49, -   Favours wire + cast
      Sagittal angular deformity (degrees)   1          65        (Fixed) 95% CI               0.51]             Favours wire + cast
                                                                  Weighted Mean Difference     -5.10 [-9.74, -
                                                                  (Fixed) 95% CI               0.46]
‡ based on information provided in the review


Quality

Quality of included randomized controlled trials ‡


Quality of included RCTs

Concealment of        Blinding of care          Blinding of outcome   Completeness of
allocation            providers and patients    assessors             follow-up

Adequate              Inadequate                Inadequate            Yes
                                                                      1/10
3/10                  10/10                     10/10
                                                                      No (varying number of
                                                                      patients lost to follow-
Inadequate            In the review it was                            up)
                      stated that blinding of                         9/10
5/10                  care providers and
                      patients was generally
                      not feasible in these
                      interventions.
Unclear
2/10
‡ based on information provided in the review

				
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posted:3/8/2010
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