Evidence-Based Treatment of Wrist Fractures in Children

Comparison

Studies

No of participants

Below elbow cast vs Above elbow cast

Bohm et al. [8]

229

Webb et al. [9]

Neutral vs Pronated vs Suppinated forearm position in above elbow cast

Boyer et al. [7]

109

Percutaneous wire fixation + above elbow cast vs above elbow cast alone

Gibbons et al. [4]

125

McLauchlan et al. [5]

Miller et al. [6]

Assessment of Methodological Quality of Included Trials

Participant allocation was concealed in one trial [8] but not in the two studies utilising quasi randomised methods [4, 9]. In the Miller study [6], nine additional non-randomised patients were included. Blinding of treatment providers and participants was not feasible in the included trial designs. In all of the included studies, assessment of outcomes was un-blinded despite attempts in one study to blind radiographic assessment [8]. The reporting of the baseline characteristics of the patient population was poor with only two studies [4, 5] fully satisfying this criteria. The Boyer trial [7] reported insufficient data to judge study quality in this regard. In two studies [7, 8], provision of comparable care programs was deemed highly likely. Poor reporting of the comparability of care programs in both study arms other than the trial intervention yielded poor quality scores in the remaining studies. All of the included trials provided sufficient information on the inclusion and exclusion criteria defining the study population as well as the interventions being compared. Outcome instruments were adequately described in all included trials. Three trials did not assess function as an outcome measure [4, 7, 8]. Set time points for follow up were defined in all but one study [7] but no study reported outcomes at or beyond 1 year.

Comparison of Treatment Effect in Reported Trials

Below Elbow Versus Above Elbow Cast Immobilisation

Two studies reported outcomes in a total of 229 participants [8, 9]. The differing criteria may have contributed to the moderate statistical heterogeneity (I² = 48.1 %). However, both trials found a trend towards a reduced risk of re-displacement during immobilisation in a below-elbow cast. The analysis is distorted by the absolute numbers of re-manipulations required in each study, four in the Bohm trial [8] and nil in the Webb trial [9], suggesting that the higher re-displacement rate in the above elbow group does not impact on the need for re-manipulation. The below elbow cast group demonstrated significantly fewer limitations and reduced need for help in activities of daily living during cast treatment while the above elbow cast group missed, on average, one extra day of school.

Following cast removal, the above elbow cast group in the Webb study [9] demonstrated significantly reduced elbow range of motion compared with the below elbow group (mean difference 28.7°). Children in the below elbow group regained elbow range of motion 10 days earlier compared with the above elbow group. Comparison of the final elbow range of motion between the two groups did reveal a statistically significant difference. However, the clinical relevance of a three to four degree difference between treatment arms in the context of inter- and intra- observer error in measurements, is of questionable significance.

Most complications were cast related with similar numbers in the two groups having their cast changed or reinforced due to cast weakening or loosening [8]. Five participants requested change from an above elbow to a below elbow cast to reduce discomfort.

Although suggestive of differences in outcome between the two treatments, both studies findings are hampered by methodological limitations. The absence of functional outcomes in the Bohm trial [8] does not yield insight into the function of re-displaced fractures which did not require re-manipulation. This study also demonstrated a significant imbalance in fracture types. The Webb study [9] reported insufficient information on the study population’s baseline characteristics in addition to employing quasi randomised methods. Both studies reported on cast fit [10] which provided some assurance of correct application although failed to describe the position of the forearm in the above elbow cast.

Above Elbow Cast: Forearm Pronated Versus Neutral Versus Supinated

Comparisons in forearm position in above elbow cast were investigated in one study [7] with 109 participants treated for displaced or angulated fractures following reduction under general anaesthesia. Ten children were excluded due to insufficient radiographic assessment. One child in each of the supination and pronation groups required repeat manipulation due to an unacceptable loss of alignment but demonstrated satisfactory outcomes at final follow up. At final follow up, at or beyond 6 weeks, there was no significant difference when comparing the different groups with respect to residual angular deformity (mean 7°). This study demonstrated significant methodological flaws with a quasi-randomised design, varied follow up and an absence of reported population baseline characteristics. These limitations permit very few conclusions regarding which, if any, forearm position is preferable.

Only gold members can continue reading. Log In or Register to continue