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.