Management of Distal 1/3rd Closed Forearm Fractures in Children above Elbow Plaster Cast versus Below Elbow Plaster Cast

Abstract

Objective: To determine if below-elbow casts are as effective as above-elbow casts in the treatment of the distal third closed forearm fractures in children.
 Materials and Methods: This was a prospective comparative study and was conducted at orthopaedic department of Liaquat University of Medical and Health Sciences (LUMHS). Children 4 to 12 years of age who presented to, distal 1/3rd fractures of the forearm were randomized in order to manage with either an above-elbow or below-elbow cast after closed reduction under fluoroscopic guidance. Radiographic analysis was done for angulation and displacement at the injury time, following reduction, and at subsequent intervals of follow-up. At the fracture level, the cast index for evaluating the cast moulding quality was assessed from the post-reduction radiographs. Variations between post-reduction and final values for displacement and angulation, the range of motion of elbow, forearm and wrists and cast indices between the two groups were compared.
 Results: Of total 50 study subjects, 26 underwent above-elbow cast and 24 subjects underwent below-elbow cast techniques. Mean age of above-elbow cast group patients was 9.42 year and the mean age in of below-elbow cast group patients was 9.13 years. 15 male and 11 female patients were present in above-elbow cast group; 14 male and 10 female patients were present in below-elbow cast group. The mean cast index of above-elbow cast group was 0.71 and the mean cast index of below-elbow cast was 0.70. In terms of patient demographics, injury mechanism, characteristics of initial fracture, cast index or shift in displacement and angulation during treatment, no significant variances were observed between both groups. In above-elbow cast group, the mean elbow arc of motion on cast removal at six weeks was only 78° compared to 141.6° in below-elbow cast group. There was a significant decline in arc of motion of elbow joint in above-elbow cast group compared to below-elbow cast group in six weeks which became normal at final follow-up in three months. The complication rates in both the groups were similar.
 Conclusion: Below-elbow cast is the safe reliable and cost-effective method of cast immobilization in distal third forearm fractures in the children of 4 to 12 years of age.

Below- versus above-elbow cast treatment of displaced distal forearm fractures in children: A systematic review and meta-analysis of randomized controlled trials

“…After applying eligibility criteria, nine articles remained for the analysis addressing BEC versus AEC treatment of displaced distal forearm fractures in pediatric patients. 8 , 9 , 14 – 19 , 24 One publication reported the long-term follow-up of the same study as the original RCT. 25 The kappa statistics for interobserver agreement on study eligibility was 1.0.…”

“…Of those, 519 (49.5%) of whom were treated with BEC and 530 (50.5%) were treated with AEC. 8 , 9 , 14 – 19 , 24 The mean age of all children was 8.4 years. Cast application time ranged from 4 to 6 weeks, whereas follow-up duration ranged from 6 weeks to 8 months.…”

“…Five studies reported data regarding cast-related complications with a total of 411 children. 8,14,15,18,24 Forty out of 202 children (19.8%) had cast-related complications in the BEC group compared to 64 out of 209 children in AEC group (30.6%). Analysis of cast-related complication rate demonstrated that BEC treatment was associated with a pooled RR of 0.59 (95% CI = 0.16, 2.22, p = 0.17, I 2 = 38%).…”

“…Eight out of the nine studies reported loss of fracture reduction rates. Memon et al 18 described only the mean loss of fracture reduction for each group, resulting in an incapability to pool data for the meta-analysis. Sensitivity analysis was conducted and excluded studies with high risk of bias (15,17,19).…”

“…14,15 Due to heterogeneity, the meta-analysis failed to generate robust conclusions and hence has provoked additional RCTs to answer this question. Since the updated meta-analysis, four additional recent RCTs [16][17][18][19] with larger sample sizes have been published.…”