1011 Above- vs. below-elbow casts for distal forearm fractures

Forearm fractures are common in children with ~80% occurring in the distal third, 15-18% in the mid-third, and up to 7% proximally. Because of children’s propensity to heal rapidly and the capacity for bone remodeling of residual deformity, the treatment of these childhood fractures is typically non-operative, involving closed reduction and cast application. Historically it has been the practice to immobilize the elbow joint by applying an above-elbow cast, thereby neutralizing deforming forces of muscles that originate above the elbow. The consequence of the aforementioned forces could be re-displacement of fracture fragments. History and experience aside, some paediatric orthopaedic surgeons have used short-arm casts for these fractures and claim good results, their explanation being that a well-molded short arm cast can reduce potentially-problematic supination and pronation. Clearly what is/was required is a well-conducted randomized controlled trial, and a group of researchers from Nepal and India have now reported on a study involving 85 children aged between 4 and 12 years. Study subjects had displaced fractures of the distal third of the forearm and were randomized to receive conventional treatment (above-elbow) or below-elbow casting. Positive results aside, under these circumstances one must carefully consider what goes into the informed consent process given that conventional wisdom and history apparently favour above-elbow casting. However the results appear to justify the study: 42 children (mean age 8.8 yrs) were treated with above-elbow casts and 43 (mean 8.1 yrs) with below-elbow application. Pain and swelling at one-day and one week after cast application were significantly higher in the above-elbow group, and three children required slitting of the cast. Re-manipulation was required more often in the above-elbow group, cost of treatment was three times higher, and more days off school were experienced by the group with ‘more/better’ fixation. Below-elbow treatment was comparable in terms of re-displacement, union-time and subsequent wrist movement.

Read more:
J Child Orthop 2010 DOI 10.1007/s11832-010-0250-1
Clin Orthop Relat Res 2005; 432: 65-72
J Bone Joint Surg Am 2006; 88: 1-8