Interventions for treating wrist fractures in children

  • Review
  • Intervention

Authors


Abstract

Background

Approximately a third of all fractures in children occur at the wrist, usually from falling onto an outstretched hand.

Objectives

We aimed to evaluate removable splintage versus plaster casts (requiring removal by a specialist) for undisplaced compression (buckle) fractures; cast length and position; and the role of surgical fixation for displaced wrist fractures in children.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 4), MEDLINE (from 1966), EMBASE (from 1988), CINAHL (from 1982) and reference lists of articles. Date of last search October 2007.

Selection criteria

Any randomised or quasi-randomised controlled trials comparing types and position of casts and the use of surgical fixation for distal radius fractures in children.

Data collection and analysis

Two authors performed trial selection. All three authors independently assessed methodological quality and extracted data.

Main results

The 10 included trials, involving 827 children, were of variable quality.

Four trials compared 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, 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 but one of these found no advantage in function at three months.

Authors' conclusions

Limited evidence supports the use of removable splintage for buckle fractures and challenges the traditional use of above-elbow casts after reduction of displaced fractures. Although percutaneous wire fixation prevents redisplacement, the effects on longer term outcomes including function are not established.

Further research is warranted on the optimum approach, including splintage, for buckle fractures; and on the use of below-elbow casts and indications for surgery for displaced wrist fractures in children.

摘要

背景

治療兒童手腕骨折的處置

將近1 / 3的兒童骨折都發生在手腕,通常是肇因於跌倒時手腕外展的結果。

目標

在沒有位移的壓迫性骨折(鈕扣狀骨折)中,我們分別評估及比較可拆式的護木與樹脂石膏(需要專業人員拆除); 石膏長度與固定姿勢,以及在有位移的骨折中,手術固定所扮演的角色。

搜尋策略

搜索的資料包含了的Cochrane骨骼,關節和肌肉創傷專科名冊(2007年10月) , Cochrane中心註冊的對照試驗(Cochrane圖書館2007年,第4期),MEDLINE (自1966年) , EMBASE資料庫(自1988年) , CINAHL資料(從1982年)和參考文獻目錄的文章。日期2007年10月的最後一個搜索。

選擇標準

任何比較在兒童遠端饒骨骨折中,使用的石膏種類與固定姿勢以及手術固定的隨機對照試驗或半隨機對照試驗。

資料收集與分析

由兩位作者進行試驗的篩選; 全部三位作者分別進行對於試驗方法及衍伸資料的評估。

主要結論

這些包含了827位孩童的10個試驗,品質的好壞參差不齊。有四個試驗比較了孩童鈕扣狀骨折中,可拆式護木與傳統的短臂石膏的差異。在全部四個試驗中,都沒有發生短期間內的肢體變形,其中一個試驗裡,六個月內都沒有再次骨折的報告。富利手腕護木支架是一種較便宜,可拆式且穿戴時對活動的限制較少的護木,讓兒童在洗澡或參與其他日常活動時較放便,因此較為兒童與家長所接受。彈性繃帶較舒服,方便且穿戴時較不會造成疼痛。可由家長拆卸的樹脂石膏雖然在效果上沒有顯著的好處,但較為家長所偏好。有兩個試驗短臂石膏與長臂石膏在復位後的骨折再位移比例與石膏相關的並發症上並無明顯差異,且短臂石膏對於手肘的限制較小,更能避免手肘僵硬。有一個試驗評估比較了使用長臂石膏時,其手臂的固定姿勢所造成的效果,發現對於骨折處的變形上並沒有差異。另外還有三個試驗發現經皮鐵絲固定可以有效的減少骨折復位後的再位移與再次授動的機會,但其中一項試驗發現經皮鐵絲固定對於術後三個月的功能上並無明顯的優勢。

作者結論

在有位移的鈕扣狀骨折復位後,能夠支持使用可拆式護木來取代傳統使用長臂石膏的實證相當有限。即使使用經皮鋼絲固定可以避免骨折再位移的發生,長期的治療效果(包含功能上)仍未被證實。在鈕扣狀骨折中最適當的處置,包含使用護木使用及短臂石膏的使用,以及兒童有位移的手腕骨折中,開刀的適應症,都還需要進一步的研究。

翻譯人

本摘要由臺灣大學附設醫院賴昆鴻翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

治療兒童手腕骨折的處置:將近1/3的兒童骨折都發生在手腕,通常是肇因於跌倒時手腕外展的結果。有些骨折較為輕微,其骨骼表面還有部分相接,這就是鈕扣狀骨折,傳統上是以短臂石膏固定來治療。更嚴重的骨折其骨折處不僅分離且有移位,在骨折復位後,通常有兩種方式可以將斷骨固定在一起。一種選擇是石膏固定,傳統上會包含到肘關節(長臂石膏)。另一種選擇就是手術固定,這通常會包含將鐵絲穿過皮膚來固定骨骼(經皮鐵絲固定術)。本文章包含了十篇隨機對照試驗,試驗對象有827位兒童。其中有些試驗使用的方式並不適當,導致其試驗結果有可能是不可靠的。四篇試驗比較了兒童鈕扣狀骨折所使用的器具,例如可拆式護木以及需要專業人員才能拆除的樹脂石膏。沒有任何一個試驗中有發骨骼變形的情形,在其中一個試驗裡,六個月內都沒有再次骨折的報告。和傳統石膏比較起來,富利手腕護木支架是一種較便宜,可拆式且穿戴時對活動的限制較少的護木,讓兒童在洗澡或參與其他日常活動時較放便,因此較為兒童與家長所接受。彈性繃帶較舒服,方便且穿戴時較不會造成疼痛。可由家長拆卸的樹脂石膏雖然在效果上沒有顯著的好處,但較為家長所偏好。有兩個試驗短臂石膏與長臂石膏在復位後的骨折再位移比例與石膏相關的並發症上並無明顯差異,且短臂石膏對於手肘的限制較小,更能避免手肘僵硬。有一個試驗評估比較了使用長臂石膏時,其手臂的固定姿勢所造成的效果,發現對於骨折處的變形上並沒有差異。另外還有三個試驗發現經皮鐵絲固定可以有效的減少骨折復位後的再位移與再次授動的機會,但其中一項試驗發現經皮鐵絲固定對於術後三個月的功能上並無明顯的優勢。本篇文章歸納認為,輕微骨折(鈕扣狀骨折)可以使用可拆式護木治療。有可能會發生在位移的骨折,保守起見則建議用短臂石膏來固定。雖然手術治療在某些骨折中可以幫助避免再位移的發生,長期的優點卻還未被證實。總而言之,在這三個議題上還需要更多試驗來獲得更明確的實證。

Plain language summary

Interventions for treating wrist fractures in children

Approximately a third of all fractures in children occur at the wrist as a result of falling onto an outstretched hand. Some fractures are relatively minor and involve a bulging of the bone surface. These are buckle fractures and they are traditionally treated with a below-elbow plaster cast. There are other more serious fractures where parts of the broken or fractured bone are displaced from each other. After reduction, where the bone is put back together again, two measures can be taken to keep the bone together. One option is cast immobilisation, where traditionally the cast is extended to include the elbow (an above-elbow cast). Another option is surgical fixation. This generally involves placing wires through the skin and into the bone (percutaneous wire fixation).

This review includes 10 randomised controlled trials, involving 827 children. Some of these trials used poor methods that meant their results were potentially unreliable.

Four trials of children with buckle fractures compared devices such as removable splints with traditional plaster casts that need removal by a specialist. No trial found any participant with bone deformity at follow up and one trial found no refractures at six months follow up. Compared with traditional casts, the Futura splint was cheaper to use and a removable plaster splint was less restrictive to wear, enabling children to bathe and participate more in other activities, and preferred by both children and their parents. A soft bandage was found to be more comfortable and convenient and less painful. Plaster casts that could be removed at home by parents did not result in significant differences in outcome but were strongly preferred 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.

The review concluded that minor (buckle) fractures could be treated by a splint that is removable at home. Additionally, fractures which 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. However, further trials on these three issues are needed to obtain more conclusive evidence.

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. In children this is most likely to occur at the wrist (the fracture occurring in the distal third of one or both of the two forearm bones: the radius and ulna).

The epidemiology of fracture in children has been reported in detail by Worlock 1986. The most common mechanism in their study was a fall in or around the house. Fractures of the distal radius and ulna were the most common fractures and accounted for 35.8% of all fractures in this age group. The annual incidence of these 'wrist' fractures was estimated to be 16 per 1000 children in the UK.

Fractures of the distal radius have been divided into six categories by Herring 2002: buckle, greenstick, metaphyseal, distal radial physeal injuries, distal ulnar physeal injuries and Galeazzi fractures. Buckle or 'torus' fractures are incomplete fractures which appear on X-ray examination to involve compression of only part of the circumference of the cortex of the bone. They are stable injuries and require no more than minimal splintage to alleviate pain and discomfort. Greenstick fractures are somewhat similar, but involve complete disruption of a segment of cortex with associated plastic deformation of the remaining cortex at that level, which may result in significant deformity. If the amount of deforming force transcends the resistance of both cortices a complete (bicortical) metaphyseal fracture occurs. These are often displaced in all planes creating a deformity that requires reduction and immobilisation.

In growing children, a growth plate (physis) is present at the lower end of each forearm bone. Somewhat commoner in older children, fractures close to the physis of the lower end of the radius account for about 20% of childhood wrist fractures (Herring 2002; Worlock 1986). If displaced, these fractures also require reduction and immobilisation.

Fractures of the distal ulna epiphysis and Galeazzi fractures, where there is fracture of the distal radius with disruption of the distal radio-ulnar joint, are rare in children. Neither of these fracture types are considered further in this review.

The management of buckle fractures of the distal radius is relatively uncontroversial, involving splintage for symptomatic relief from pain. Some authors have advocated removable wrist supports, with discontinuation of splintage at the parents' discretion (Symons 2001).

The controversial issues in the management of displaced distal radius fracture in children are:

  • what constitutes a degree of fracture displacement and angulation likely to be compensated by remodelling with growth over time;

  • what are the indications for fracture stabilisation with wires or other invasive methods compared with plaster casting alone;

  • what position should the arm be kept in during immobilisation in a cast;

  • and whether the cast should immobilise the wrist alone (below-elbow or short-arm casting) or both the wrist and the elbow (above-elbow or long-arm casting).

Various research studies have been conducted that aim to inform practice. A recent randomised controlled trial suggests that wire fixation should form part of the treatment in the immobilisation of displaced metaphyseal (region near the end of the bone) fractures (McLauchlan 2002a). This has been especially advocated for displaced distal shaft and metaphyseal fractures in which the ulna is either intact or has undergone plastic deformation (Gibbons 1994a). Traditionally, an above-elbow cast in supination (forearm is positioned so that the palm of hand faces upwards) has been the accepted form of immobilisation following a displaced distal radial fracture. In a randomised controlled trial, Boyer 2002a examined whether there was a difference in the residual angular deformity at the fracture site, at the time of union between above-elbow casts where the arm was in supination, pronation (palm faces downwards) or in neutral. In a large retrospective study of 761 distal radial fractures treated with below-elbow casts, Chess 1994a reported a 10% rate of significant loss of fracture alignment during immobilisation, these cases correlating well with the quality of moulding of the applied cast.

In summary, distal radius fractures are common throughout childhood from first walking through to adolescence. The anatomical site of the injury influences the degree of deformity accepted and the form of immobilisation traditionally practiced. Controversial areas of management such as the use of wire stabilisation, position of immobilisation and below-elbow casts form the focus of this review

Objectives

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

We 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 neutral;
4. displaced fractures with wire fixation versus plaster cast.

We planned to study the outcomes in different age groups and for different fracture types (for instance, radial fractures with or without ulna fracture).

Methods

Criteria for considering studies for this review

Types of studies

Any randomised or quasi-randomised (for example, allocation by date of birth or alternation) controlled trials which compared types of immobilisation, position of immobilisation and the use of wire fixation for distal radius fractures in children.

Types of participants

Babies, infants, children or adolescents who have had a distal radius fracture diagnosed radiographically, with or without ulna fracture.

Types of interventions

Any treatment involving the use of splints or casts. These could be of different materials (e.g. plaster of Paris or fibreglass) and could be incomplete such as the typical plaster backslab, which just covers the back of the wrist and forearm and allows for swelling of the arm to subside, or complete or full casts that encircle the whole arm. The casts could either include the elbow (above-elbow casts) or stop before the elbow (below-elbow or forearm casts). Above-elbow casts could hold the position of the forearm in either pronation, supination or neutral. Surgical fixation, such as wire fixation, was included. Also included was the duration of cast immobilisation and the setting for removal of casts.

Types of outcome measures

These included the following.

  • Redisplacement and residual deformity

  • Function including activities of daily living and impairments such as loss of forearm rotation and wrist range of motion

  • Complications from treatment including pin site infection, nerve or tendon injuries, loss of elbow range of movement

  • Secondary treatment including surgery

  • Pain and discomfort

  • Patient (child) satisfaction and adherence (compliance); parent satisfaction and adherence

  • Resource use and other costs

Search methods for identification of studies

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 4), MEDLINE (1966 to October week 1 2007), EMBASE (1988 to 2007 week 40), CINAHL (1982 to October week 1 2007) and reference lists of articles. We also contacted researchers in the field. One author (HH) checked her database on wrist fractures. No language restrictions were applied.

In MEDLINE (OVID WEB) a subject-specific strategy was combined with the optimal Cochrane trial search strategy (Higgins 2006) and modified for use in other databases (see Appendix 1 for MEDLINE; Appendix 2 for The Cochrane Library; Appendix 3 for EMBASE and Appendix 4 for CINAHL).

Results of a separate search for ongoing and recently completed trials of the Current Controlled Trials register at www.controlled-trials.com (accessed December 2007) were provided by one of the referees of the review.

Data collection and analysis

Selection of studies
The initial searches were carried out by one of the authors (AA) and updated by a second author (HH); both were assisted by the Cochrane Bone, Joint and Muscle Trauma Group's editorial base. Pairs of review authors (AA and KT; AA and HH) assessed potentially eligible trials for inclusion and any disagreement was resolved through discussion. Titles of journals, names of authors or supporting institutions were not masked at any stage. Study selection was reviewed by the third author (HH).

Data extraction and management
All three authors independently performed data extraction, two using a pre-piloted form. Any disagreement was resolved through discussion.

Assessment of methodological quality of included studies
All three authors independently assessed the methodological quality of included studies using modified version of the Cochrane Bone, Joint and Muscle Trauma Group's quality assessment tool (see Table 1). Disagreement was resolved by discussion.

Table 1. Quality assessment tool
ItemsCodingNotes
A. Was the assigned treatment adequately concealed prior to allocation?2 = method did not allow disclosure of assignment.
1 = small but possible chance of disclosure of assignment or unclear.
0 = quasi-randomised or open list or tables.
Cochrane code:
Clearly Yes = A
Not sure = B
Clearly No = C
B. Were the outcomes of participants who withdrew described and included in the analysis (intention to treat)?2 = withdrawals well described and accounted for in analysis.
1 = withdrawals described and analysis not possible.
0 = no mention, inadequate mention, or obvious differences and no adjustment.
 
C. Were the outcome assessors blinded to treatment status?2 = effective action taken to blind assessors.
1 = small or moderate chance of unblinding of assessors, or some blinding of outcomes attempted.
0 = not mentioned or not possible.
 
D. Were important baseline characteristics reported and comparable?2 = good comparability of groups, or confounding adjusted for in analysis.
1 = confounding small, mentioned but not adjusted for, or comparability reported in text without confirmatory data.
0 = large potential for confounding, or not discussed.
The principal confounders were considered to be age, time since injury, previous wrist injury, presence of other wrist and forearm injuries, hand dominance and type of sporting activity.
E. Were the participants blind to assignment status after allocation?2 = effective action taken to blind participants.
1 = small or moderate chance of unblinding of participants.
0 = not possible, or not mentioned (unless double-blind), or possible but not done.
 
F. Were the treatment providers blind to assignment status?2 = effective action taken to blind treatment providers.
1 = small or moderate chance of unblinding of treatment providers.
0 = not possible, or not mentioned (unless double-blind), or possible but not done.
 
G. Were care programmes, other than the trial options, identical?2 = care programmes clearly identical.
1 = clear but trivial differences, or some evidence of comparability.
0 = not mentioned or clear and important differences in care programmes.
 
H. Were the inclusion and exclusion criteria for entry clearly defined?2 = clearly defined (including whether primary or secondary dislocation).
1 = inadequately defined.
0 = not defined.
 
I. Were the interventions clearly defined?2 = clearly defined interventions are applied with a standardised protocol.
1 = clearly defined interventions are applied but the application protocol is not standardised.
0 = intervention or application protocol are poorly or not defined.
 
J. Were the outcome measures used clearly defined?2 = clearly defined.
1 = inadequately defined.
0 = not defined.
 
K. Were the outcome measures/diagnostic tests used in outcome assessment appropriate?2 = optimal.
1 = adequate.
0 = not defined or adequate.
 
L. Was the surveillance active and of clinically appropriate duration?2 = active surveillance and appropriate duration (1 year or more).
1 = active surveillance, but inadequate duration.
0 = surveillance not active or not defined.
 

Data analysis
Relative risks (RR) and 95% confidence intervals (95% CI) were calculated for dichotomous outcomes, and mean differences (MD) with 95% confidence intervals were calculated for continuous outcomes. Results of comparable trials were pooled using the fixed-effect model and 95% confidence intervals. Heterogeneity between comparable trials was tested using a standard chi-squared test and considered statistically significant at P < 0.1. We also considered the I² statistic (Higgins 2003). Where there was significant heterogeneity, we checked the results using the random-effects model and presented these where appropriate.

Sensitivity and subgroup analyses
Lack of data precluded our prespecified sensitivity and subgroup analyses. We investigated loss to follow up in a minimal way, using worst and best case analyses, for one trial (Plint 2006).

Should data become available in future updates, we plan separate outcome analyses of a) patients with first injury compared with those with recurrent injuries, b) older children approaching skeletal maturity and juveniles (under 10 years of age) and c) patients with distal radius fracture only and those with a distal ulna fracture as well. To test whether subgroups are statistically significantly different from one another, we propose to test the interaction using the technique outlined by Altman and Bland (Altman 2003).

Results

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

Of 25 eligible studies, 10 studies were included, nine were excluded, two are ongoing and four await assessment. Further details of the included studies can be found in the 'Characteristics of included studies'.

Included studies

Settings
Five studies were from centres in the UK (Davidson 2001; Gibbons 1994; McLauchlan 2002; Symons 2001; West 2005), three from the USA (Boyer 2002; Miller 2005; Webb 2006) and two from Canada (Bohm 2006; Plint 2006). All were carried out in the acute care setting with six from dedicated children's acute hospitals (Boyer 2002; Davidson 2001; McLauchlan 2002; Miller 2005; Plint 2006; Webb 2006).

Participants
The 10 trials included a total of 827 children, the majority of whom were male. The percentage of male children ranged from 53% (Davidson 2001) to 91% (Miller 2005); no data on gender were provided for West 2005. West 2005 did not provide a summary statistic for age but most participants were between 5 and 10 years of age. The mean age ranged from 8 to 10 years in the other trials, except for Miller 2005 in which the minimum age for inclusion was 10 and the mean was 12 years. The youngest recorded child was two years old (Davidson 2001) and the oldest was 16 years (Webb 2006).

The 10 included studies specified the site of interest as fractures of the distal radial metaphysis. Davidson 2001 and West 2005 defined buckle fractures of the distal radius as failure of bone in compression at the metaphyseal-diaphyseal junction. In Plint 2006, a buckle fracture was defined as compression of the bony cortex with the opposite cortex intact. Symons 2001 did not define their use of the term 'buckle fracture' but stated that these were stable injuries that did not displace. Three studies (Gibbons 1994; McLauchlan 2002; Miller 2005) specified inclusion criteria for defining their population of displaced fractures while three did not (Bohm 2006; Boyer 2002; Webb 2006). Gibbons 1994 stipulated that the ulna needed to be intact, whereas children with ulna fracture in addition to that of the distal radius were explicitly included in Bohm 2006, Boyer 2002 and McLauchlan 2002. While Bohm 2006 and Plint 2006 would also have included isolated ulnar fractures, there were none in these trial populations.

Comparisons
The 10 included trials have been grouped according to the comparisons addressed by each trial. Four comparisons pertain to interventions for treating buckle fractures and three for displaced fractures.

Futura splint versus below-elbow plaster cast for buckle fractures
One study (Davidson 2001) compared the use of Futura splints versus traditional below-elbow plaster cast for buckle fractures in 201 children.

Removable plaster splint versus below-elbow plaster cast for buckle fractures
One study (Plint 2006) compared the use of removable plaster splints, worn for comfort, versus traditional below-elbow plaster cast for buckle fractures in 87 children. (However, 113 were randomised; the largest group of excluded children was 16 with greenstick fractures.)

Soft bandage versus below-elbow cast (plaster then polymer) for buckle fractures
One study (West 2005) compared the use of soft bandaging versus below-elbow plaster cast followed by a "polymer" cast for buckle fractures in 42 children.

Home versus hospital-clinic removal of plaster backslab for buckle fractures
One study of 87 children with buckle fractures (Symons 2001) compared removal of a plaster backslab by parents at home versus removal in the hospital clinic by clinicians.

Below-elbow versus above-elbow plaster cast after reduction of displaced fractures
Two studies (Bohm 2006; Webb 2006) compared below-elbow (short) versus above-elbow (long) plaster casts applied after reduction of displaced fractures in 229 children.

Above-elbow cast (forearm pronated versus neutral versus supinated) after reduction of displaced fractures
One study (Boyer 2002) assessed the effect of the forearm position (pronated versus neutral versus supinated) held by an above-elbow cast in 109 children with displaced (or angulated) fractures reduced under general anaesthesia.

Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone after reduction of displaced fractures
Three studies (Gibbons 1994; McLauchlan 2002; Miller 2005) compared percutaneous wire fixation and above-elbow cast immobilisation versus above-elbow cast immobilisation alone after reduction of displaced fractures in 125 children.

Excluded studies
Nine studies were excluded (see the 'Characteristics of excluded studies' for details).

Ongoing studies
Two trials (Colaris 2008a; Colaris 2008b) are ongoing (see the 'Characteristics of ongoing studies' for details).

Studies awaiting assessment
Of the four trials in this category, one (Yousef 2006) is reported only as a conference abstract, one (Hammacher 2006) has been submitted for publication and two (Hudson 2004; Ziouani 2007) are completed but not yet written up.

Risk of bias in included studies

Table 2 gives the results of the methodological assessment of the included trials using the tool presented in Table 1. Some general comments are given below.

Table 2. Quality assessment results for individual trials
Study IDItems A to D gradesItems E to H gradesItems I to L grades
 Item A: Allocation concealment
Item B: Intention-to-treat analysis
Item C: Outcome assessor blinding
Item D: Comparable baseline characteristics
Item E: Participant blinding
Item F: Treatment provider blinding
Item G: Identical care programmes
Item H: Clearly defined inclusion criteria
Item I: Well defined interventions
Item J: Well defined outcome measures
Item K: Optimal outcome measures
Item L: Active and sufficiently long (at least 1 year) follow up
Bohm 2006Item A: 2 ("blinded"; sealed envelopes)
Item B: 0 (treatment allocations of post-randomisation exclusions not given)
Item C: 0 (attempted blinding of radiographs did not work)
Item D: 0 (insufficient information; some imbalance in involvement of ulna)
Item E: 0 (no)
Item F: 0 (no)
Item G: 2 (very likely)
Item H: 2 (yes, although some retrospective application)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 1 (no functional assessment)
Item L: 1 (18 weeks follow up)
Boyer 2002Item A: 0 (quasi-randomised - by date of birth)
Item B: 0 (treatment allocations of post-randomisation exclusions not given)
Item C: 0 (not done)
Item D: 0 (no data)
Item E: 0 (no)
Item F: 0 (no)
Item G: 2 (yes)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 1 (no functional assessment)
Item L: 0 (variable follow up: 6-8 weeks)
Davidson 2001Item A: 0 (quasi-randomised - by date of attendance)
Item B: 2 (full account of participant flow)
Item C: 0 (not done)
Item D: 0 (no information)
Item E: 0 (no)
Item F: 0 (no)
Item G: 2 (yes)
Item H: 2 (although broad)
Item I: 2 (yes)
Item J: 1 (insufficient description)
Item K: 1 (no functional assessment)
Item L: 1 (3 weeks follow up)
Gibbons 1994Item A: 0 (quasi-randomised - by surgeon allocated to child)
Item B: 0 (participant flow could be inferred but not stated)
Item C: 0 (not done)
Item D: 2 (yes)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (aftercare not specified)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 1 (no functional assessment)
Item L: 1 (6 months follow up)
McLaughlan 2002Item A: 1 (sealed envelopes but no indication of safeguards)
Item B: 2 (definitely, and reported intention-to-treat analysis
Item C: 0 (although independent physiotherapist at 3 months)
Item D: 2 (yes)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (slight differences in timing of clinical review)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (3 months follow up)
Miller 2005Item A: 0 (compromised by the addition of 9 non-randomised patients)
Item B: 0 (no, inclusion of non-randomised patients)
Item C: 0 (not done)
Item D: 0 (no; imbalances in dorsal angulation and shortening)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (aftercare not specified)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (6 months follow up; for whole population)
Plint 2006Item A: 2 ( web-based randomisation, then sealed opaque envelopes sequentially opened by research assistant)
Item B: 1 (participant flow but baseline characteristics and results not given for whole group)
Item C: 0 (not done)
Item D: 1 (balanced for those included in analyses, but no data for whole group)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (possible discrepancy on timing of treatment)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (6 months follow up)
Symons 2001Item A: 1 (computer generated random number sheet)
Item B: 1 (probably but baseline data not available for all randomised patients)
Item C: 0 (not done)
Item D: 1 (balanced for those included in analyses, but no data for whole group)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (insufficient information; differences in explanations to parents?)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (6 weeks follow up)
Webb 2006Item A: 0 (quasi-randomised based on odd and even medical record numbers)
Item B: 1 (participant flow but baseline data not available for all randomised patients)
Item C: 0 (not done)
Item D: 1 (balanced for those included in analyses, but no data for whole group)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (potential for difference in reduction methods)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (8 months follow up)
West 2005Item A: 2 (presealed envelopes selected by parent)
Item B: 2 (yes)
Item C: 0 (not done)
Item D: 0 (insufficient information)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (differences in timing of clinical review)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (4 weeks follow up)

Allocation concealment (item A)
Allocation was concealed in three trials (Bohm 2006; Plint 2006; West 2005) but not in the four studies using quasi-randomised methods (West 2005; Davidson 2001; Gibbons 1994; Webb 2006), nor in Miller 2005 where an additional nine non-randomised patients were included. Insufficient detail was available to determine whether allocation was concealed in the two remaining studies.

Intention-to-treat analysis (item B)
We considered there were sufficient details of participant flow with a high likelihood of a correct analysis being performed in three trials (Davidson 2001; McLauchlan 2002; West 2005). The failure to give the numbers randomised to each group or baseline data for all recruited patients were the main reasons for a low score for this item in the other trials. Intention-to-treat analysis was definitely not carried out in Miller 2005 because of the inclusion of non-randomised patients.

Assessor blinding (item C)
Blinding of radiographic assessment was attempted in Bohm 2006 but apparently did not succeed. No other studies described assessor blinding.

Baseline characteristics (item D)
Only two trials (Gibbons 1994; McLauchlan 2002) fully satisfied the criteria for this item. Most trials failed to provide baseline characteristics for all randomised patients. As well as insufficient information, there was an imbalance in the numbers with ulna fracture in Bohm 2006. The imbalances in radiological parameters in Miller 2005 probably reflected the inclusion of non-randomised patients. Two trials (Boyer 2002; Davidson 2001) failed to provide any data to judge this item.

Participant and treatment provider blinding (items E and F)
Blinding of patients and care providers is generally not feasible in these interventions, and was not done.

Care programme comparability (item G)
Provision of comparable care programmes other than the trial interventions was highly likely in three trials (Bohm 2006; Boyer 2002; Davidson 2001). Lack of information or the potential for minor variation in care (see Table 2) were the reasons for a lower score in the other trials.

Inclusion criteria (item H)
All the included trials provided sufficient trial inclusion and exclusion criteria to define their study populations.

Trial interventions (item I)
All the included trials provided sufficient details of the interventions under comparison.

Outcome assessment (items J, K and L)
Except for Davidson 2001, the trials adequately described their outcome measurement (item J). Four trials (Bohm 2006; Boyer 2002; Davidson 2001; Gibbons 1994) were marked down for item K because they did not include any assessment of function. Aside from Boyer 2002, all trials clearly had active follow up at set times but none followed up all patients for one year or more (item L).

Effects of interventions

Futura splint versus below-elbow plaster cast for buckle fractures
One study (Davidson 2001) compared the use of Futura splints versus traditional below-elbow plaster cast for buckle fractures in 201 children. Significantly more children in the splint group did not attend the three weeks follow-up clinic, possibly because a clinic visit was not necessary to remove the splint (see Analysis 01.01: relative risk (RR) 3.30, 95% confidence interval (CI) 1.16 to 9.39). Adherence (compliance) was good in both groups among those that attended the clinic, with the exception of two young children who tried to remove their splints shortly after application (see Analysis 01.02). A further child allocated a splint was given a cast on the request of her parents. All fractures united clinically and radiologically without loss of position. Davidson 2001 estimated the cost of treatment including materials, plaster technician's time and attendance at clinic was £116.98 for the plaster cast compared with £65.75 for the Futura splint (these probably reflect costs in 2000).

Removable plaster splint versus below-elbow plaster cast for buckle fractures
One study (Plint 2006) compared the use of removable plaster splints, worn for comfort, versus traditional below-elbow plaster cast for buckle fractures in 87 children. Physical function, assessed using the Activities Scale for Kids performance tool (Young 2000; range 0 to 100: severe disability to no disability), was significantly better in the splint group at 14 days (median scores: 93.77 versus 89.29; P = 0.04) but not by 28 days when the median scores were over 99 in both groups, indicating that physical function was normal. By 28 days post-injury there was also no difference between the two groups in the numbers of children who had moderate or severe problems in performing various activities (see Analysis 02.01). However, in the preceding follow-up times, significantly fewer children in the splint group had difficulties bathing or showering (see Analysis 02.02). Significantly more children in the splint group were able to return to regular sporting or physical activities at 20 days and 28 days (see Analysis 02.03). The numbers of children reporting these outcomes were often markedly fewer than those entered into the trial. Analysis 02.04, which presents worst and best case analyses for the 28 day data for physical activities, shows that the result in Analysis 02.03 is not robust. There was no difference in pain scores at any time interval, and no child had wrist pain by 28 days. There were no problems encountered with the plaster splints, which were worn at least some part of each day for 13.7 days on average; continuous use declined rapidly over three weeks. Five problems with casts occurred in the paster cast group: four because of wet casts and one resulting from a pencil inserted under the cast (see Analysis 02.05). There was no refracture found at six months, either by contacting the parents or by checking hospital records. Of those questioned, significantly more children and their parents of both groups indicated that they would prefer a removable splint in future should they sustain the same injury (see Analysis 02.06).

Soft bandage versus below-elbow cast (plaster then polymer) for buckle fractures
One study (West 2005) compared the use of soft bandaging versus below-elbow casts (plaster then polymer) for buckle fractures in 42 children. Significantly more children in the bandage group found the splintage comfortable (see Analysis 03.01: RR 0.01, 95% CI 0.01 to 0.68), convenient to wear (see Analysis 03.03: RR 0.06, 95% CI 0.01 to 0.44), and they experienced less pain during use (see Analysis 03.02: RR 0.31, 95% CI 0.13 to 0.77). Pain was also for shorter duration in the bandage group. There were no adverse effects. The majority of children (83%) in the bandage group had removed their bandage by one week, and all had by two weeks. Parents of one child assigned to wear a bandage requested a change to a cast at one week. All children in the cast group retained their casts until they were removed at a clinic after four weeks. Early bandage removal allowed early mobilisation of the wrist and the range of movement (extension/flexion) was significantly greater in the bandage group at four weeks (median values: 162 degrees versus 126 degrees; reported P < 0.0001). Trial recruitment was reported as being hampered by parental perception that a plaster cast was needed, but of those included in the trial only two parents in the bandage group indicated their worry on entering the trial.

Home versus hospital-clinic removal of plaster backslab for buckle fractures
One study of 87 children with buckle fractures (Symons 2001) compared removal of a plaster backslab by parents at home versus removal in a hospital clinic by clinicians.

At six weeks there was no significant difference between the two groups in the incidence of residual swelling (see Analysis 04.01), tenderness (see Analysis 04.02) or avoidance of hobbies (see Analysis 04.03); and no child had difficulties with writing or activities of daily living. No deformity was reported at six weeks in either group, although this was confirmed radiologically in only 33 children. Although fewer parents in the home-removal group reported difficulties with the care of their child's fracture this did not reach statistical significance (see Analysis 04.05: RR 0.42, 95% CI 0.17 to 1.06). Parents in the hospital group complained about waiting times (N = 10), having to take time off work (N = 5), transport difficulties (N = 3) and hospital parking (N = 2). Significantly more parents in the hospital group indicated that they would not opt for the same treatment again (see Analysis 04.06: RR 0.07, 95% CI 0.01 to 0.47). There were three cases of non-adherence to treatment (see Analysis 04.07). In the home-removal group, one child removed their backslab prematurely (before three weeks), and one parent delayed removal of the backslab until six weeks. One parent in the hospital group successfully removed their child's backslab at home to avoid loss of earnings.

Below-elbow versus above-elbow cast after reduction of displaced fractures
Two studies (Bohm 2006; Webb 2006) compared below-elbow versus above-elbow plaster casts applied after reduction of displaced fractures in 229 children. Though based on different criteria, which may have contributed to the moderate statistical heterogeneity (I² = 48.1%), both trials found a trend to less loss of reduction or redisplacement during immobilisation in a below-elbow cast (see Analysis 05.01: RR 0.60, 95% CI 0.36 to 1.00, fixed-effect model; RR 0.54, 95% CI 0.20 to 1.47, random-effects model). However, only four fractures were remanipulated in Bohm 2006 while none were in Webb 2006. There were significantly fewer limitations in various activities of daily living during cast immobilisation in children allocated below-elbow casts (see Analysis 05.02). Overall, significantly fewer children wearing below-elbow casts reported needing help with activities of daily living (see Analysis 05.02: RR 0.10, 95% CI 0.03 to 0.31). Children in the above-elbow cast group missed on average one extra day of school (see Analysis 05.03).

Upon cast removal, the above-elbow cast group of Webb 2006 had significantly reduced elbow motion compared with the below-elbow group (see Analysis 04.04: mean difference -28.70 degrees, 95% -32.84 to -24.56 degrees). Although the final wrist and elbow mobility deficits were statistically significantly less in the below-elbow group of Webb 2006, the clinical significance of a four and three degree difference is uncertain (see Analysis 05.04). Children in the below-elbow group regained range of motion 10 days earlier than those in the above-elbow group (see Analysis 05.05).

Aside from one child who had three weeks of physical therapy to regain shoulder mobility, the only reported complications were cast related (see Analysis 05.06). Similar numbers in the two groups of Bohm 2006 had cast reinforcement or cast changes due to 'breakdown' or loosening. One below-elbow cast fell off and was changed to an above-elbow cast, and there were five requests for a change to a below-elbow cast from an above-elbow cast to reduce discomfort.

Above-elbow cast (forearm pronated versus neutral versus supinated) after reduction of displaced fractures
One study (Boyer 2002) assessed the effect of the forearm position (pronated versus neutral versus supinated) held by an above-elbow cast in 109 children with displaced (or angulated) fractures reduced under general anaesthesia. Ten children were excluded from the analyses because of insufficient X-rays. Boyer 2002 reported there was no significant effect (P > 0.05) on angular deformity at final follow up of six weeks or over (overall mean = 7 degrees); separate data for angular deformity were not available. Two children (one in the supination group and one in the pronation group) required a second reduction (timing not reported) due to an unacceptable loss of alignment (see Analysis 06.01); both had a satisfactory outcome at final follow up.

Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone after reduction of displaced fractures
Three studies (Gibbons 1994; McLauchlan 2002; Miller 2005) compared percutaneous wire fixation and above-elbow cast immobilisation versus above-elbow cast immobilisation alone after reduction of displaced fractures in 125 children. With the exception of one person in the wire-fixation group of McLauchlan 2002 with wire migration, all fracture redisplacement occurred in the cast alone group (see Analysis 07.01: RR 0.06, 95% CI 0.02 to 0.24). All redisplaced fractures were remanipulated in Gibbons 1994. Of the seven treated in McLauchlan 2002, four had surgery as did one of the six children receiving a secondary procedure for loss of position in Miller 2005. Individual complications other than redisplacement were not significantly different between the two groups (see Analysis 07.02). There were significantly fewer unscheduled secondary procedures in the wire-fixation group (see Analysis 07.02: RR 0.26, 95% CI 0.12 to 0.56, fixed-effect model). However, these results were heterogeneous (I² = 49.5%) and these results were only marginally significant when using the random-effects model (RR 0.28, 95% CI 0.08 to 1.02). Moreover, overall there were more secondary procedures in the wire-fixation group because the wire was routinely removed after three or four weeks. McLauchlan 2002 reported one person in the cast group had a successful outcome after a corrective osteotomy at six months (after the last follow-up time for the trial).

In McLauchlan 2002, five children out of 56 reviewed at three months complained of minor pain after strenuous activity. None had any functional deficit and there were only small and clinically insignificant differences between the two groups in grip strength (22 Kg versus 21 Kg) and range of motion outcomes. Miller 2005 reported no limitations in motion, strength alterations, pain or activity restrictions at follow up. McLauchlan 2002 found residual coronal deformity (see Analysis 07.03: mean difference -3.00, 95% CI -5.46 to -0.51) and sagittal deformity (mean difference -5.10, 95% CI -9.74 to -0.46) were less at three months in the wire-fixation group. In Miller 2005 there was no cosmetic deformity at long-term follow up (mean 2.8 years) and all fractures in 25 children had healed and remodelled to anatomic alignment.

Miller 2005 estimated the cost of treating a patient with percutaneous pinning was less that cast alone when the further procedures due to complications were included (US $3347 versus $3831).

Subgroup analyses
Our plans to study the outcomes in different age groups and for different fracture types were prevented by the lack of data.

Discussion

Limitations of the review and review evidence
Our search culminated in the inclusion of 10 trials, involving 827 children. Four other trials are pending assessment, all of which are unpublished, and two are ongoing. Four of these trials were located by an editor during editorial review and another one subsequently. This supported our previous supposition that it was plausible that we had missed some studies, especially unpublished ones. This is likely to remain the case. However, some trials may never be published and we have found that some registered trials have not taken place. In all, there are surprisingly few trials and few children given the very large numbers of children sustaining wrist fractures in all regions of the world. The trial populations are also restricted to North America and the UK. Nonetheless, the trial populations are generally representative as are the questions examined by these trials, which address generally accepted areas of treatment controversy (see 'Background'). The potential of the included trials to give definitive answers and thus guide practice is hampered by the small sample sizes available for each of the seven comparisons evaluated so far and the lack of data for pooling. Methodological limitations, such as the use of quasi-randomised methods and failure to conduct intention-to-treat analysis, could also invalidate trial findings.

The review addresses three key areas: the management of buckle fractures; the type of casting used after reduction of displaced fractures; and the use of percutaneous wire fixation for after reduction of displaced fractures.

Management of buckle fractures
The four trials examining the management of buckle fractures examined whether conventional below-elbow plaster cast immobilisation is really necessary. Since these commonplace fractures are usually stable, splintage is mainly for pain relief, comfort and support. Therefore the conventional approach might constitute over-treatment and the disadvantages of plaster casts could be avoided. The evidence from the four trials leant support to this argument. Although a quasi-randomised trial with only short-term follow-up, Davidson 2001 provided some evidence that Futura splints, which allowed independent removal, did not adversely affect anatomical outcome and cost less than plaster cast immobilisation. Plint 2006 demonstrated better early functioning and fewer problems with activities, including bathing, in children fitted with a removable plaster splint. Furthermore, Plint 2006 found there were no refractures in either group at six months. More children were lost to follow up in the splint group in both Davidson 2001 and Plint 2006, but Plint 2006 argued that they would have returned if something had been wrong. West 2005 compared plaster cast immobilisation for four weeks to a soft bandage and found that most bandages had been removed by two weeks and, as a likely consequence, wrist mobility was significantly greater in the bandage group. Children found the soft bandage was less uncomfortable, more convenient and less painful than a plaster cast and no adverse effects were reported for either group at four weeks follow up. Symons 2001 found the home removal of a pre-prepared backslab did not affect swelling, tenderness, deformity or activities of daily living at six weeks. Parents favoured home removal and the dissatisfaction in the hospital group was compounded by waiting times, having to take time off work and other practical considerations. Absolute assurance of the safety and longer term clinical benefits is not provided in these trials. Yet with appropriate attention to diagnosis, allowances made for exceptional cases for whom a cast seems warranted and availability of follow up to allay any concerns, it does appear that easily removable and soft splints are less restrictive and uncomfortable than cast immobilisation, enable more activities and are more desirable to patients with buckle fractures and their parents. It is not possible to identify which removable splint is best or whether a soft bandage would do just as well.

Type of cast used after reduction of displaced fractures
Traditionally, displaced distal radius fractures have been immobilised in above-elbow casts. These are believed to reduce the risk of displacement by blocking forearm rotation. Some surgeons have further emphasised the benefits of positioning the forearm in either supination or pronation to further minimise the effects of deforming muscle forces across the fracture. Two small trials (Bohm 2006; West 2005) found a potential trend to less reduction or redisplacement in the below-elbow group but the treatment consequence of this in terms of remanipulation was not significant. Bohm 2006 failed to report on function. Webb 2006 found children allocated the below-elbow cast required less help with activities during cast use and had better elbow mobility after cast removal. The two cast groups did not differ in their cast-related complication rates. Both trials were compromised; the use of quasi-randomised methods in Webb 2006 is particularly disappointing. Additionally, there was an imbalance in fracture types in Bohm 2006. Webb 2006 provided insufficient information on baseline characteristics.

Arm position in the above-elbow cast was not described in the Bohm 2006 or Webb 2006. The one trial (Boyer 2002) investigating this was seriously flawed (e.g. it was quasi-randomised and had intention-to-treat problems), provided very limited outcome data and, in all, does not provide any reliable evidence to determine which, if any, arm position is preferable.

All three trials reported on cast fit, which here provided some assurance of correctly applied casts (Chess 1994a).

Use of percutaneous wires for stabilisation
Strategies to maintain reduction and minimise post-injury deformity have been advocated with a view to maximising forearm and wrist function. This is particularly relevant in children approaching skeletal maturity, in whom remodelling potential is reduced. The most commonly advocated strategy is wire fixation. The three trials (Gibbons 1994; McLauchlan 2002; Miller 2005) testing wire fixation consistently found surgery reduced fracture redisplacement and secondary procedures. This was especially marked in Gibbons 1994, where the distal ulna was intact in all cases. It should be noted, however, that routine wire removal was not considered a secondary procedure. Amongst other biases, major selection bias cannot be ruled out for Gibbons 1994 or Miller 2005 (see Table 2). McLauchlan 2002 inadequately reported long-term results but found that no child had any functional deficit at three months, although there was less deformity in the wire-fixation group. Miller 2005 gave some assurance of eventual restoration to anatomic alignment in generally older children (mean age 12 years at trial entry), which was independent of their treatment group.

Authors' conclusions

Implications for practice

The limited evidence available from randomised controlled trials supports the use of removable splintage or supports for buckle fractures with the option of clinical review rather than plaster cast for three weeks requiring a return for removal and assessment. However, the best type of splintage is not established.

For children whose displaced fractures have been reduced, there is some preliminary evidence suggesting that below-elbow casts do not increase, and may in fact reduce, the risk of redisplacement compared with above-elbow casts. Furthermore, below-elbow casts allow earlier return to activities, avoid elbow stiffness and are more comfortable. If shorter casts are better then the need to consider supinated, neutral or pronated positions of the forearm in above-elbow immobilisation is redundant. Surgical fixation of reduced fractures using percutaneous wiring maintains the reduction more effectively than above-elbow casts. The limited data available indicated no advantage in function at three months. There was insufficient evidence to determine the best treatment for the different types of displaced fracture, including radial fractures where the ulna is intact.

Implications for research

It is prudent to wait on the results of currently unpublished trials on buckle fractures (Hudson 2004; Ziouani 2007) to check whether there remains a need for further randomised trials comparing removable splintage or supports versus plaster cast immobilisation. There is however scope for randomised comparisons to establish the best methods of splinting or supporting buckle fractures. Patient and parental acceptability of less intrusive and restrictive treatment for buckle fractures is predictable and so in choosing and conducting future research the emphasis should be on obtaining reliable evidence to assure safety and cost effectiveness (health service and societal costs), especially given the large numbers of children incurring these injuries.

Further research, involving good quality randomised trials that also consider longer term outcome and cost effectiveness, is needed to establish whether below-elbow casts are sufficient after the reduction of displaced fractures; measures are required to ensure that the types of fractures, including whether the ulna is intact, are balanced in each arm of the study. The same applies for research to determine when surgery is needed.

Acknowledgements

We thank Lesley Gillespie for developing the subject-specific search strategy. We thank the following for helpful comments at editorial and external review of the protocol and/or review: Joanne Elliott, Lindsey Elstub, Andrew Furlong, Lesley Gillespie, Alastair Murray, Ben Vandemeer and Janet Wale. Special thanks are due to Lesley Gillespie for her suggestions for rephrasing and her identification of additional trials.

Data and analyses

Download statistical data

Comparison 1. Futura splint versus below-elbow plaster cast for buckle fractures
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Non-attendance at follow-up clinic1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2 Non-union1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
3 Non-adherence (non-compliance)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
Analysis 1.1.

Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 1 Non-attendance at follow-up clinic.

Analysis 1.2.

Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 2 Non-union.

Analysis 1.3.

Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 3 Non-adherence (non-compliance).

Comparison 2. Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Moderate or severe difficulty levels for different activities at 28 days1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
1.1 Difficulty with printing, writing1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
1.2 Difficulty with drawing1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
1.3 Difficulty with feeding1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
1.4 Difficulty with grooming1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
1.5 Difficulty with bathing/showering1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2 Moderate or severe levels of difficulty for bathing/showering1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2.1 Difficulty at 7 days1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.2 Difficulty at 14 days1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.3 Difficulty at 20 days1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.4 Difficulty at 28 days1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
3 Unable to return to regular sporting or physical play activities1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
3.1 At 20 days1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
3.2 At 28 days1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
4 Unable to return to regular sporting or physical play activities at 28 days: worst/best case scenarios1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
4.1 Worst case for splint group1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
4.2 Best case for splint group1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
5 Complications1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
5.1 Problems with cast1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
5.2 Refracture1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
6 Would prefer not to have the same treatment (splint or cast) in future1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
6.1 Patient preference1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
6.2 Parent preference1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
Analysis 2.1.

Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 1 Moderate or severe difficulty levels for different activities at 28 days.

Analysis 2.2.

Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 2 Moderate or severe levels of difficulty for bathing/showering.

Analysis 2.3.

Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 3 Unable to return to regular sporting or physical play activities.

Analysis 2.4.

Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 4 Unable to return to regular sporting or physical play activities at 28 days: worst/best case scenarios.

Analysis 2.5.

Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 5 Complications.

Analysis 2.6.

Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 6 Would prefer not to have the same treatment (splint or cast) in future.

Comparison 3. Soft bandage versus below-elbow plaster then polymer cast for buckle fractures
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Uncomfortable splintage1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2 Pain while wearing splintage1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
3 Found splintage inconvenient1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
4 Adverse effects (e.g. skin problems)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
Analysis 3.1.

Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures, Outcome 1 Uncomfortable splintage.

Analysis 3.2.

Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures, Outcome 2 Pain while wearing splintage.

Analysis 3.3.

Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures, Outcome 3 Found splintage inconvenient.

Analysis 3.4.

Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures, Outcome 4 Adverse effects (e.g. skin problems).

Comparison 4. Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Swelling1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2 Tenderness1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
3 Avoidance of some hobbies1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
4 Deformity1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
5 Parents reported problems with care of fracture1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
6 Parents would not choose the same treatment again1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
7 Non-adherence (non-compliance)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
Analysis 4.1.

Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 1 Swelling.

Analysis 4.2.

Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 2 Tenderness.

Analysis 4.3.

Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 3 Avoidance of some hobbies.

Analysis 4.4.

Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 4 Deformity.

Analysis 4.5.

Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 5 Parents reported problems with care of fracture.

Analysis 4.6.

Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 6 Parents would not choose the same treatment again.

Analysis 4.7.

Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 7 Non-adherence (non-compliance).

Comparison 5. Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Fracture redisplacement and rereduction2 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
1.1 Redisplaced fracture2213Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.36, 1.00]
1.2 Reangulation greater than 15 degrees or > 30% redisplacement1113Risk Ratio (M-H, Fixed, 95% CI)0.16 [0.01, 3.05]
1.3 Remanipulation2213Risk Ratio (M-H, Fixed, 95% CI)0.41 [0.04, 3.78]
2 Limitations in activities of daily living during cast use1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2.1 Needed help dressing1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.2 Unable to shower1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.3 Needed help using toilet1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.4 Needed help eating1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.5 Needed help at school1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.6 Unable to write1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.7 Patient reported help required because of difficulties with activities of daily living1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
3 Days off school1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
4 Range of movement (differences between injured and contralateral side) (degrees)1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
4.1 Difference at cast removal in arcs of wrist motion1 Mean Difference (IV, Fixed, 95% CI)Not estimable
4.2 Final difference in arcs of wrist motion1 Mean Difference (IV, Fixed, 95% CI)Not estimable
4.3 Difference at cast removal in arcs of elbow motion1 Mean Difference (IV, Fixed, 95% CI)Not estimable
4.4 Final difference in arcs of elbow motion1 Mean Difference (IV, Fixed, 95% CI)Not estimable
5 Time to regain range of motion (days)1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
6 Complications2 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
6.1 Refracture1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
6.2 Compartment syndrome1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
6.3 Cast split for swelling1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
6.4 Cast reinforced for 'breakdown'1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
6.5 Cast changed for loosening or breakdown1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
6.6 Change of cast type (for comfort or other problems)1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
6.7 Physical therapy required to regain shoulder range of movement1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
Analysis 5.1.

Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 1 Fracture redisplacement and rereduction.

Analysis 5.2.

Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 2 Limitations in activities of daily living during cast use.

Analysis 5.3.

Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 3 Days off school.

Analysis 5.4.

Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 4 Range of movement (differences between injured and contralateral side) (degrees).

Analysis 5.5.

Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 5 Time to regain range of motion (days).

Analysis 5.6.

Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 6 Complications.

Comparison 6. Above-elbow cast (forearm pronated versus neutral versus supinated) for displaced fractures
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Second reduction for unacceptable loss of alignment1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
1.1 Pronation versus supination1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
1.2 Neutral position versus supination1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
1.3 Pronation versus neutral position1 Risk Ratio (M-H, Fixed, 95% CI)Not estimable
Analysis 6.1.

Comparison 6 Above-elbow cast (forearm pronated versus neutral versus supinated) for displaced fractures, Outcome 1 Second reduction for unacceptable loss of alignment.

Comparison 7. Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced fractures
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Fracture redisplacement and rereduction3 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
1.1 Redisplaced fracture3125Risk Ratio (M-H, Fixed, 95% CI)0.06 [0.02, 0.24]
1.2 Remanipulation (and secondary procedure for loss of position)3125Risk Ratio (M-H, Fixed, 95% CI)0.06 [0.01, 0.30]
2 Complications3 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
2.1 Failed reduction134Risk Ratio (M-H, Fixed, 95% CI)0.37 [0.02, 8.55]
2.2 Compartment syndrome134Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.3 Pin site infection134Risk Ratio (M-H, Fixed, 95% CI)5.59 [0.29, 108.38]
2.4 Pin migration (wires removed)2102Risk Ratio (M-H, Fixed, 95% CI)4.15 [0.49, 35.21]
2.5 Pain resulting from wire168Risk Ratio (M-H, Fixed, 95% CI)2.83 [0.12, 67.19]
2.6 Nerve damage or irritation257Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.08, 16.55]
2.7 Tendon irritation134Risk Ratio (M-H, Fixed, 95% CI)3.35 [0.15, 76.93]
2.8 Non-union257Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.9 Malunion257Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.10 Prominent scar at K-wire insertion site123Risk Ratio (M-H, Fixed, 95% CI)2.77 [0.12, 61.65]
2.11 Early physeal closure257Risk Ratio (M-H, Fixed, 95% CI)Not estimable
2.12 Secondary procedures (early wire removal, cast adjustment, rereduction, open reduction)3125Risk Ratio (M-H, Fixed, 95% CI)0.26 [0.12, 0.56]
3 Anatomical deformity at 3 months1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
3.1 Coronal angular deformity (degrees)1 Mean Difference (IV, Fixed, 95% CI)Not estimable
3.2 Sagittal angular deformity (degrees)1 Mean Difference (IV, Fixed, 95% CI)Not estimable
Analysis 7.1.

Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced fractures, Outcome 1 Fracture redisplacement and rereduction.

Analysis 7.2.

Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced fractures, Outcome 2 Complications.

Analysis 7.3.

Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced fractures, Outcome 3 Anatomical deformity at 3 months.

Appendices

Appendix 1. Search strategy for MEDLINE (OVID-WEB)

1. Ulna Fractures/ or Radius Fractures/
2. (distal or metaphys$ or epiphys$ or torus or wrist).tw.
3. and/1-2
4. Wrist Injuries/ or Forearm Injuries/
5. fracture$.tw.
6. and/4-5
7. (ulna$1 or radius or radial or forearm$1 or wrist$1).tw.
8. and/2,5,7
9. or/3,6,8
10. exp Pediatrics/
11. Infant, Newborn/
12. Infant/
13. exp Child/
14. Adolescent/ not exp Adult/
15. (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw.
16. or/10-15
17. and/9,16

Appendix 2. Search strategy for The Cochrane Library (CD version)

#1 MeSH descriptor Ulna Fractures explode all trees
#2 MeSH descriptor Radius Fractures explode all trees
#3 (#1 or #2)
#4 ((distal in Record Title or metaphys* in Record Title or epiphys* in Record Title or torus in Record Title or wrist in Record Title) or (distal in Abstract or metaphys* in Abstract or epiphys* in Abstract or torus in Abstract or wrist in Abstract))
#5 (#3 and #4)
#6 MeSH descriptor Wrist Injuries explode all trees
#7 MeSH descriptor Forearm Injuries explode all trees
#8 (fracture* in Record Title or fracture* in Abstract)
#9 (#6 or #7)
#10 (#8 and #9)
#11 ( (ulna* in Record Title or radius in Record Title or radial in Record Title or forearm* in Record Title or wrist* in Record Title) or (ulna* in Abstract or radius in Abstract or radial in Abstract or forearm* in Abstract or wrist* in Abstract) )
#12 (#4 and #8 and #11)
#13 (#3 or #10 or #12)
#14 MeSH descriptor Pediatrics explode all trees
#15 MeSH descriptor Infant explode all trees
#16 MeSH descriptor Child explode all trees
#17 MeSH descriptor Adolescent explode all trees
#18 MeSH descriptor Adult explode all trees
#19 (#17 and not #18)
#20 (#14 or #15 or #16 or #19)
#21 ((paediatr* in Record Title or pediatr* in Record Title or neonate* in Record Title or bab* in Record Title or infant* in Record Title or child* in Record Title or teenage* in Record Title or adolescen* in Record Title) or (paediatr* in Abstract or pediatr* in Abstract or neonate* in Abstract or bab* in Abstract or infant* in Abstract or child* in Abstract or teenage* in Abstract or adolescen* in Abstract))
#22 (#20 or #21)
#23 (#13 and #22)

Appendix 3. Search strategy for EMBASE

1. Radius Fracture/ or Ulna Fracture/
2. (distal or metaphys$ or epiphys$ or torus or wrist).tw.
3. and/1-2
4. Wrist Injury/
5. fracture$.tw.
6. and/4-5
7. (ulna$1 or radius or radial or forearm$1 or wrist$1).tw.
8. and/2,5,7
9. or/3,6,8
10. exp Pediatrics/
11. Newborn/
12. Infant/
13. exp Child/
14. Adolescent/ not Adult/
15. (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw.
16. or/10-15
17. and/9,16
18. exp Randomized Controlled trial/
19. exp Double Blind Procedure/
20. exp Single Blind Procedure/
21. exp Crossover Procedure/
22. Controlled Study/
23. or/18-22
24. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.
25. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
26. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
27. (cross?over$ or (cross adj1 over$)).tw.
28. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw.
29. or/24-28
30. or/23,29
31. limit 30 to human
32. and/17,31

Appendix 4. Search strategy for CINAHL

1. Ulna Fractures/ or Radius Fractures/
2. (distal or metaphys$ or epiphys$ or torus or wrist).tw.
3. and/1-2
4. exp Wrist Injuries/ or Forearm Injuries/
5. fracture$.tw.
6. and/4-5
7. (ulna$1 or radius or radial or forearm$1 or wrist$1).tw.
8. and/2,5,7
9. or/3,6,8
10. exp Pediatrics/
11. Infant, Newborn/
12. Infant/
13. exp Child/
14. Adolescence/ not exp Adult/
15. (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw.
16. or/10-15
17. and/9,16
18. exp Clinical Trials/
19. exp Evaluation Research/
20. exp Comparative Studies/
21. exp Crossover Design/
22. clinical trial.pt.
23. or/18-22
24. ((clinical or controlled or comparative or placebo or prospective or randomi#ed) adj3 (trial or study)).tw.
25. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
26. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
27. (cross?over$ or (cross adj1 over$)).tw.
28. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw.
29. or/24-28
30. or/23,29
31. and/17,30

What's new

DateEventDescription
8 May 2008AmendedConverted to new review format.

History

Protocol first published: Issue 1, 2004
Review first published: Issue 2, 2008

Contributions of authors

AA initiated the review, researched the background, drafted and completed the review protocol, checked abstracts, selected trial reports for inclusion, reviewed selected papers, entered data into RevMan, performed statistical analysis, and completed the first draft of the review.

HH substantively revised the results sections and analyses of the draft review in RevMan after performing independent quality assessement and data collection of the included trials. She updated the search and contacted trialists of registered trials.

TK performed independent study selection, and quality assessment and data collection for the trials included in the first draft of the review. He provided feedback on various drafts of the review.

AA is the guarantor for the review.

Declarations of interest

None known.

Sources of support

Internal sources

  • University of Teesside, Middlesbrough, UK.

  • University Hospitals of Leicester, UK.

  • Central Manchester and Manchester Children's University Hospitals NHS Trust, UK.

External sources

  • No sources of support supplied

Notes

At editorial review, one referee noted the publication of another trial on buckle fractures, the citation of which was only available in MEDLINE after the date of last search for the review. The following trial will be considered in the first update: Khan KS, Grufferty A, Gallagher O, Moore DP, Fogarty E, Dowling F. A randomized trial of 'soft cast' for distal radius buckle fractures in children. Acta Orthopaedica Belgica 2007; 73(5):594-7.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Bohm 2006

MethodsRandomised trial: use of sealed envelopes (claimed blinded randomisation)
ParticipantsRoyal University Hospital, Saskatoon, Saskatchewan. Canada
117 children with closed fracture of the distal third of the forearm (radial or radial and ulnar; no isolated distal ulnar fractures) that required reduction.
Exclusion: open fracture or Salter Harris type III and IV fractures
Sex: 61 male (60% of 102)
Age: mean 8.6 years
Assigned: ? (below-elbow) / ? (above-elbow)
Post exclusion (see Notes): 56 / 46
Analysed: 56 / 46 (at 18 weeks follow up) (see Notes)
Interventions

Closed reduction under conscious sedation in Emergency department (within 4 hours of presentation) or general anaesthesia in operating theatre (within 24 hours).

1. Below-elbow plaster cast (3-point moulding)
2. Above-elbow cast. Once hard, the below-elbow cast was extended to above the elbow.

Follow-up visit to fracture clinic every week for 3 weeks. Cast removal at clinic at 6 weeks. Hospital discharge with a sling and analgesia.

OutcomesLength of follow up: 18 weeks
Redisplacement and remanipulation
Angular deformity (radial and ulnar)
Complications: reinforced or changed cast, cast split because of swelling, compartment syndrome (none)
Conversion to other cast (adherence)
Notes

Fifteen patients were excluded after enrolment: nine didn't require fracture reduction, two had wrong cast applied, two were of the wrong age, one had wrong fracture type, and one had surgery.

Radiographs were inadequate for two participants (1 versus 1).

Cast fit (a confounding factor) was assessed by calculating a 'cast index': there was no difference reported between the two groups.

Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate

Boyer 2002

MethodsQuasi-randomised trial: according to date of birth
ParticipantsChildren's Hospital in Akron, Ohio, USA
109 children with displaced (or angulated) fractures of the distal third of forearm (distal radius or radius and ulna) requiring closed reduction (based on judgement of attending physician).
Exclusion: closed metaphyses
Sex: 71 male (65%)
Age: mean 8.7 years
Fracture: 59 "displaced"; 40 "angulated"
Assigned: ? (supinated) / ? (pronated) / ? (neutral)
Analysed: 35 / 26 / 38 (at minimum 6 weeks follow up ) (see Notes)
Interventions

All participants had a closed reduction under general anaesthesia. A below-elbow plaster cast was then applied. After confirmation of the reduction with fluoroscopy, fibreglass casting material was used to complete an above-elbow cast. The forearm was positioned in one of three positions:

1. Supinated forearm position
2. Pronated forearm position
3. Neutral forearm position

Routine clinical and radiographic follow up; first check at 1 week. Duration of splintage was not stated but assumed to be at fracture union (6 to 8 weeks).

OutcomesLength of follow up: minimum 6 weeks (6-8 weeks)
Clinical and radiological union (no report)
Residual fracture angulation (mean 7 degrees overall)
Secondary reduction (for unacceptable loss of alignment)
Notes

Ten children were excluded from the analyses because of insufficient X-rays.

Cast fit (a confounding factor) was assessed by calculating a 'cast index': there was no difference reported between the three groups.

Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Davidson 2001

MethodsQuasi-randomised trial: allocation based on day of attendance at fracture clinic
ParticipantsChildren's Hospital in Liverpool, UK
201 children with buckle ("torus") fractures of the distal radius.
Exclusion: none stated
Sex: 107 male (53%)
Age: mean 8.9 years, range 2 to 15 years
Assigned: 116 (splint)/ 85 (cast)
Analysed: 98 / 81 (at 3 weeks follow up) (see Notes)
Interventions

After initial diagnosis at A&E, fractures were immobilised by a metal splint held in place by a crepe bandage. Trial interventions were provided upon attending the fracture clinic, usually the next day.

1. Futura splint sized and fitted by doctor or nurse
2. Below-elbow plaster cast applied by plaster cast technician

Splints or casts were removed after 3 weeks.

OutcomesLength of follow up: 3 weeks
Clinical and radiological union (all healed)
Loss of position (none)
Adherence
Non-attendance at clinic
Costs
NotesTwo participants were excluded from follow up: one because parents requested child was given a cast rather than a splint and the other (group not stated) who was discovered at follow up to have a greenstick fracture.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Gibbons 1994

MethodsQuasi-randomised: child received the preferred treatment used by the consultant surgeon who was responsible for care
ParticipantsJohn Radcliffe Hospital, Oxford, UK
23 children with isolated distal radius fracture with an intact ulna. Indications for manipulation: > 15 degrees angulation for children under 10 years or > 10 degrees angulation if age > 10 years.
Exclusion: patients aged 15 years or over.
Sex: 15 male (65%)
Age: mean 9 years, range 5 to 14 years
Assigned: 12 (wire) / 11 (cast only)
Analysed: 12 / 11 (6 months: numbers assumed)
Interventions

Manual reduction under general anaesthesia.

1. Percutaneous (stab incision) Kirschner wire inserted from the radial styloid. Use of fluoroscopy. Above-elbow plaster cast. Wire removed under sedation or general anaesthesia after 3 weeks, then below-elbow cast applied for a further week
2. Above-elbow plaster cast.

OutcomesLength of follow up: 6 months
Loss of reduction and remanipulation
Non-union (none)
Hypertrophic scar
Superficial radial nerve damage (none)
Early physeal closure (none)
NotesBaseline characteristics similar for the two groups except for pre-reduction dorsal angulation: mean 26.4 degrees versus 13.4 degrees. Completely displaced fractures: 8 in each group.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

McLauchlan 2002

MethodsRandomised trial: use of sealed envelopes, opened after closed reduction.
ParticipantsRoyal Hospital for Sick Children, Edinburgh, UK
68 with completely displaced metaphyseal fractures of the distal radius, with of without ulnar fracture
Exclusion: physeal injuries
Sex: 42 male (62%)
Age: mean 7.9 years, range 4 to 14 years
Assigned: 35 (wire) / 33 (cast only)
Analysed: 34 / 31 (radiological review); 56 for clinical review (3 months) (see Notes)
Interventions

Reduction under general anaesthesia within 18 hours of admission, checked with image intensifier.

1. Single percutaneous Kirschner wire introduced across the fracture to the radial side of Lister's tubercule. Then above-elbow cast (probably plaster). Review at 3 weeks when wire removed and cast changed.
2. Above-elbow cast (probably plaster). Weekly radiological review for 3 weeks.

Casts removed between 4 and 6 weeks after injury depending on age of child.

Outcomes

Length of follow up: 3 months

Loss of position and secondary procedure
Wire migration
Grip strength
Residual pain
Range of motion (flexion, extension, radial and ulnar deviation, supination, pronation)
Prominant scarring
Pain requiring early wire removal
Angular deformity

NotesIntact ulna: 3 versus 5.
Paper did not provide the numbers of participants in the two groups available for clinical review.
Corrective osteotomy was performed at 6 months in one participant of the cast only group.
Small discrepancies between abstract and full reports of the trial.
Seven children who parents refused consent for trial inclusion were treated conservatively.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Miller 2005

MethodsRandomised by sealed envelopes for consenting participants (25). A further 9 patients enrolled and treated according to surgeon's preference (see Notes)
ParticipantsChildren's Hospital, Boston, MA, USA
34 children with displaced metaphyseal fractures of the distal radius. Aged 10 years or over. Angulation > 30 degrees or complete fracture displacement.
Exclusion: open fracture, history of injury or surgery of the affected wrist, fractures requiring open reduction, swelling or neurovascular compromise precluding circumferential cast immobilisation. Skeletal maturity.
Sex: male 31 (91%)
Age: mean 12.4 years, range 10 to 14 years
Assigned: 16 (wire) / 18 (cast only)
Analysed: ? / ? (25 followed up at mean 2.8 years)
Interventions

Closed reduction under general anaesthesia with fluoroscopic guidance.

1. Percutaneous wire fixation. Small incision made over radial styloid. Wire directly proximally and ulnarly across fracture site engaging in opposite cortex. Optional second wire inserted through small dorsal incision. Then above-elbow cast. Wires removed at 4 weeks.
2. Above-elbow cast.

Above-elbow cast comprised plaster cast overwrapped with fibreglass casting material. All patients had above-elbow cast for 4 weeks and then a further 2 weeks in a below-elbow cast.

OutcomesLength of follow up: 6 months (average 10.5 weeks); also long-term follow up mean 2.8 years (numbers in each group not stated).
Overall complications
Loss of reduction and secondary procedures
Nerve hyperesthesia
Tendon (extensor carpi ulnaris) irritation
Wire migration
Pin-site (wire-site) infection
Failed closed reduction
Non-union (none)
Permanent nerve damage (none)
Compartment syndrome (none)
No long-term pain or limitations in range of motion, strength, or activities noted. No neurovascular compromise, growth arrest or deformity.
NotesSeparate data were not provided for the 9 children treated according to the surgeon's preference. Discrepancies between the two groups in initial dorsal angulation and shortening may have reflected some bias in the surgeon preference group.
A retrospective cost analysis was based on charges for operating room, anaesthesia services, orthopaedic surgery, office visits, radiology, plaster cast services.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

Plint 2006

MethodsRandomised trial: initial use of web-based computer generated allocation with a block size of 4. Changed due to web access problems to sealed opaque envelopes sequentially opened by a research assistant.
ParticipantsChildren's Hospital of Eastern Ontario, Ottawa, Canada
113 children with buckle fractures of the distal radius or ulna confirmed by a radiologist. (No child had an isolated distal ulna fracture.) Age 6 to 15 years.
Exclusion: another fracture of the same limb, bilateral wrist fractures, pathological fracture, language barrier, lived outside hospital catchment area.
Sex: male 57 (66% of 87)
Age: mean 9.7 years
Assigned: 57 (splint) / 56 (cast)
Analysed: 42 / 45 (at 4 weeks follow up) (see Notes)
Interventions

All treated within 7 days of injury.

(1) Removable plaster splint: individually fitted plaster splint attached with a wrap (tensor bandage). Verbal and written instructions to wear splint for comfort only; to remove as desired; and to discontinue when desired.
(2) Below-elbow plaster cast. Written and verbal instructions (e.g. avoid getting cast wet). Cast removed at 3 weeks.

All children instructed to avoid contact sports until follow-up clinic.

OutcomesLength of follow up: 4 weeks; also long-term follow up at 6 months for refracture.
ASKp (Activities Scales for Kids performance) scores
Pain (visual analogue scale)
Problems with various activities (printing or writing; drawing; feeding; grooming; bathing or showering)
Problems with casts
Length of immobilisation and usage
Report to clinic with a problem
Treatment preference
Refracture
Notes

Sixteen children (7 versus 9) were excluded post-randomisation because they did not have buckle fractures (all had greenstick fractures); one child in the splint group was too young and four in the same group withdrew their participation. Five children (2 versus 3) were lost to follow up.

Pre-study power calculation to detect 80% chance of a 15 point difference in the ASKp score.

Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate

Symons 2001

MethodsRandomised trial: use of computer generated random-number sheet
ParticipantsLeicester University Hospital, Leicester, UK
87 children with buckle fractures of the distal radius
Exclusion: pathological fractures, previous problems with wrist, bicortical fractures, unwilling to enter study, parents not available, unable to understand study, not in local catchment area.
Sex: male 47 (59% of 80)
Age: mean 9.2 years
Assigned: 40 (home)/47 (hospital)
Analysed: 38 / 42 (at 6 weeks follow up) (see Notes)
Interventions

After initial diagnosis at A&E, referral was made to the study team on the same day. After randomisation, both groups were treated with a below-elbow plaster backslab.

1. Home group: backslab removed by parents at 3 weeks. The backslab was cut and rewrapped to avoid the need for scissors during removal at home. Parents were given an explanation and assured of access to the fracture clinic if required.
2. Hospital group: return to clinic at 3 weeks for removal of backslab by nursing staff and for medical review.

OutcomesLength of follow up: 6 weeks
Swelling
Tenderness
Deformity (none)
Writing and activities of daily living
Ability to partake in hobbies
Range of movement (wrist and forearm)
Problems with care
Complaints
Adherence
Satisfaction with treatment
NotesAll 7 children not attending the 6 weeks follow-up examination were reported to have "no difference in outcome from those who came for review"
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear

Webb 2006

MethodsQuasi-randomised: allocation based on odd and even medical record numbers
ParticipantsWomen and Children's Hospital, Buffalo, New York, USA
127 children with displaced fractures of the distal forearm
Exclusion: age under 4 years old, open or pathological fracture, closed physes, non consent, refracture along pre-existing fracture lines
Sex: 85 male (75% of 113)
Age: 9.8 years, range 4 to 16 years
Assigned: 63 (below-elbow) / 64 (above-elbow)
Analysed:53 / 60 (at 7.7 months follow up) (see Notes)
Interventions

Fracture was reduced (manual or fingertraps methods) under analgesia and sedation at Emergency department.

1. Below-elbow plaster cast
2. Above-elbow plaster cast; the below-elbow cast was extended to above the elbow.

Strict elevation for first 24 to 48 hours. First follow-up visit at 7-10 days. At 4 weeks, cast were removed if healed. Otherwise, casts left in place but above-elbow casts were cut down to below-elbow casts. Clinical examination at 8-10 weeks and physical; therapy if restricted mobility

OutcomesLength of follow up: mean 7.7 months (3.5 to 11 months)
Lost reduction in cast
Rereduction (none)
Radiological outcome (displacement, angulation, deviation)
Wrist and elbow motion
Time to regain range of motion
Days missed school
Activities of daily living during cast use
Complications: refracture (none), restricted shoulder motion
Notes

Of 10 children in the below-elbow cast group who were not included in the analyses, seven were lost to follow up and three were excluded because of surgery. Of four children in the above-elbow cast group not included in the analyses, three were lost to follow up and one was excluded because of surgery.

Cast fit (a confounding factor) was assessed by calculating a 'cast index': there was no difference reported between the two groups.

Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate

West 2005

  1. a

    A&E: Accident and Emergency Department
    K-wire: Kirschner wire
    MUA: manipulation under anaesthesia
    ROM: range of motion

MethodsRandomised trial: presealed envelopes selected by parent
ParticipantsRoyal Gwent Hospital, Newport, UK
42 children with buckle fractures of the distal radius
Exclusion: not stated
Sex: not stated
Age: < 5 years = 1; 5-10 years = 26; > 10 years = 12 (of 40)
Assigned: 21 (bandage)/ 21 (cast)
Analysed: 18 / 21 (at 4 weeks follow up) (see Notes)
Interventions

Recruited on the day of presentation to A&E. After randomisation, treatment started on the same day.

1. Bandage: orthopaedic wool and cotton crepe held by tape. Patient assessed at weekly intervals up to 4 weeks
2. Cast: below-elbow plaster backslab applied for 1 week and then changed to full below-elbow polymer (probably fibreglass) cast for further 3 weeks. Seen at 4 weeks for cast removal.

OutcomesLength of follow up: 4 weeks
Comfort
Pain (in bandage/cast)
Range of movement (flexion/extension)
Adherence (all bandages were removed at home by end of week 2) Convenience
Parental concern (regarding trial)
Adverse effects or skin problems (none)
NotesOne participant allocated bandage was withdrawn from follow up because parents requested the child was given a cast at first appointment at fracture clinic. Two other participants in the bandage group failed to return for follow up; their parents reported these had no problems.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Bratt 1996Randomised trial of low- versus moderate-dose lidocaine regional anaesthesia for forearm fractures in children. Excluded as it is an anaesthesia trial.
Chang 1999Randomised trial of nurse practitioners versus medical officers for wound management and treatment of blunt limb trauma. Excluded as it is not specific for distal radius fractures in children.
Chess 1994Retrospective series of below-elbow plaster cast treatment of 761 distal one-third paediatric forearm fractures with an independent retrospective radiographic review.
Clarke 2006Recruitment into the original and second stage of a randomised trial comparing Kirschner-wire fixation versus plaster cast in children under 12 years of age was reported to have been difficult with insufficient numbers.
Davidson 2002Blinded randomised study, comparing prilocaine and lidocaine for intravenous regional anaesthesia for forearm fracture reduction in children. Excluded as it is an anaesthesia trial.
Duncan 1999This randomised trial was not started after an initial pilot study completed in 1999 found no differences between pins and plaster for unstable wrist fractures in children.
Gregory 1996A randomised trial of intravenous regional anaesthesia compared with nitrous oxide gas in children with forearm fractures requiring manipulation. Excluded as it is an anaesthesia trial.
Hargreaves 2004Randomised trial compared the results of burying the wire ends under the skin to leaving them above the surface in children and adults with isolated distal radial fractures. Excluded because separate data for children were not available.
Pierce 1997Randomised, double-blind trial evaluating ketorolac for pain relief and an opioid-sparing effect in children with forearm fractures requiring reduction. Excluded as it is an anaesthesia trial.

Characteristics of ongoing studies [ordered by study ID]

Colaris 2008a

Trial name or titleDislocated stable distal both-bone forearm fractures in children
Methods 
Participants

Aim: 110 children with stable dislocated distal both-bone forearm fracture.

Inclusion Criteria:
both-bone forearm fracture
distal
dislocated
stable after reposition
age < 16 years

Exclusion Criteria:
fracture older than 1 week
no informed consent
refracture
open fracture (Gustillo 2 and 3)
both fractures of type torus

InterventionsK-wire fixation versus no K-wire fixation of the fracture after a stable reposition
OutcomesFollow up: 6 months
number of re-dislocations, re-operations, consolidation and dislocation on X-ray, function of both arms, complaints in daily living and complications.
Starting dateJanuary 2006
Contact informationDr Joost Colaris
Juliana Children's Hospital, Den Haag, Zuid Holland, Netherlands
Tel: +31642220265
Email: joostcolaris@hotmail.com
Notes 

Colaris 2008b

  1. a

    K-wire: Kirschner wire

Trial name or titleDislocated unstable distal both-bone forearm fractures in children
Methods 
Participants

Aim: 60 children with unstable dislocated distal both-bone forearm fracture.

Inclusion Criteria:
both-bone forearm fracture
distal
dislocated
unstable after reposition
age < 16 years

Exclusion Criteria:
fracture older than 1 week
no informed consent
refracture
open fracture (Gustillo 2 and 3)
both fractures of type torus

InterventionsK-wire fixation versus no K-wire fixation of the fracture after an unstable reposition
OutcomesFollow up: 6 months
number of re-dislocations, re-operations, consolidation and dislocation on X-ray, function of both arms, complaints in daily living and complications.
Starting dateJanuary 2006
Contact informationDr Joost Colaris
Juliana Children's Hospital, Den Haag, Zuid Holland, Netherlands
Tel: +31642220265
Email: joostcolaris@hotmail.com
Notes 

Ancillary