Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
John F. Sarwark, MD*,
Children's Memorial Hospital, Chicago, Illinois
When treating children for the most common of pediatric fractures—fracture of the distal forearm—orthopedic surgeons are, of course, interested in doing what is best for these children and their families; however, until now, the "best management strategy" has not been evidence based1-5. We note in this issue of The Journal, not one, but two randomized, controlled, prospective trials to assess various methods of cast immobilization for displaced pediatric fractures of the distal forearm. Thanks to Bohm et al. and Webb et al., we now have a reasonable answer: a below-the-elbow cast is as effective in maintaining acceptable fracture reduction of pediatric forearm fractures as an above-the-elbow cast, with similar complication rates. The age limits for this recommendation are four years to twelve years for the Bohm study and older than four years for the Webb study. The level of evidence for both studies is high—Level 1.
Why is management of this fracture worthy of study? The two groups answer that a long arm cast is notably more limiting to children, causing more school days lost, more help required to dress, and more problems with writing in school. Also, they note that this fracture is very frequent and that there is no clear consensus (until now) regarding treatment strategies.
The studies are well organized and executed. The primary outcome measure in the Bohm study was reangulation of the fracture in the cast and the need for remanipulation. Interestingly, the authors noted that surgeons were reluctant to remanipulate fractures even when the fractures met their criteria for remanipulation, thus underscoring the importance of subjectivity on the part of the surgeon and the realities of a busy fracture clinic in the decision-making process. Another interesting observation is that a combined radial and ulnar fracture was more likely to meet the criteria for remanipulation. The authors note that a weakness of the study is that it had a slightly unequal distribution of patients in the two groups, with fifty-six children in the above-the-elbow group and forty-six children in the below-the-elbow group, although this did not affect the statistical outcome.
In the second paper, Webb et al. emphasize the importance of the cast index—the desired amount of volar-dorsal molding, with an ideal cast index described as 0.7. Lost reduction was associated with poor cast-molding in both groups, and, interestingly, more patients in the long arm cast group lost reduction for this reason. Also of interest, displaced fractures maintained reduction as well as did partially displaced fractures of the radius and ulna after casting. The authors note that a weakness of the study was the loss of ten patients to follow-up, although this did not affect the statistical outcome or power of the study.
I believe that the information provided by these two studies can be used with confidence. In the words of Bohm et al.: "Below-the-elbow casts perform as well as above-the-elbow casts in maintaining reduction of fractures in the distal third of the forearm in children, and the complication rates are similar."
*The author did not receive grants or outside funding in support of their research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
References
1. Chess DG, Hyndman JC, Leahey JL, Brown DC, Sinclair AM. Short arm plaster cast for distal pediatric forearm fractures. J Pediatr Orthop. 1994;14:211-3.
2. Gibbons CL, Woods DA, Pailthorpe C, Carr AJ, Worlock P. The management of isolated distal radius fractures in children. J Pediatr Orthop. 1994;14:207-10.
3. Jones K, Weiner DS. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop. 1999;19:811-5.
4. Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;6:146-56.
5. Roy DR. Completely displaced distal radius fractures with intact ulnas in children. Orthopedics. 1989;12:1089-92.
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