Background and aim
Wrist fractures are the most common bone injury in children. Most are buckle (or torus) fractures, where the bone surface bulges out. These minor fractures heal well. They are often treated with a wrist splint or a below-elbow plaster cast.
More serious fractures are where the bone breaks, generally resulting in displacement of the bone parts. Usually the bone is manipulated back into place ('reduction'), followed by cast immobilisation, often with an above-elbow cast including the elbow. When considered, surgery generally involves placing wires through the skin and into the bone (percutaneous wiring).
We aimed to assess the best-quality evidence for different treatments of wrist fractures in children.
Results of the search
We searched medical databases up to May 2018 and included 30 studies with 2930 children. Studies included more male children and reported mean ages between eight and 10 years. We summarise the results from five key comparisons.
Key results
Six studies compared a removable splint with a below-elbow cast for buckle fractures. One study found there may be little or no difference between the two devices in physical function at four weeks. Few children needed a change or reapplication of either splint or cast (4 studies). There were no refractures. We are uncertain whether there is any difference in pain during device use. There was insufficient evidence to evaluate time to return to former activities (recovery time), minor complications, and child or parent satisfaction. Two studies found lower healthcare costs for splints.
Four studies compared a soft or elasticated bandage with a below-elbow cast for buckle fractures. We are uncertain if there is less disability at four weeks after bandaging. Few children changed device or needed extended immobilisation (3 studies). There were no serious adverse events. There was insufficient evidence to evaluate recovery time, wrist pain, minor complications, and satisfaction. Children found the bandage more convenient (1 study).
Two studies (mainly buckle fractures) compared cast removal at home by parents versus at the hospital fracture clinic by clinicians (a cast saw was not required for home removal). All had recovered function at four weeks (1 study). There were few treatment changes and no serious adverse effects. Recovery time and number of children with minor complications were not reported. There may be no difference in pain at four weeks (1 study). There may be greater parental satisfaction for cast removal at home (1 study). One study found lower healthcare costs for home removal.
Four studies compared below-elbow versus above-elbow casts in usually displaced fractures. We are uncertain if children are less dependent on help when using below-elbow casts. We are uncertain if there is a difference between the two casts in physical function at six months (1 study). We are uncertain about the finding that all children with above-elbow casts needed another fracture reduction. There were no serious adverse events. Recovery time and minor complications were not reported. There may be little difference in needing physiotherapy for stiffness. Pain at one week may be less for below-elbow casts (1 study). One study found lower healthcare costs for below-elbow casts.
Five studies compared percutaneous wiring and above-elbow cast immobilisation versus above-elbow cast immobilisation alone after closed reduction of displaced fractures. Short-term physical function was not reported. There may be no between-group difference in function at six months (1 study). We are uncertain whether surgery reduces the risk of treatment failure, defined as early or difficult removal of wires, and remanipulation for loss in position. We are uncertain whether there are fewer serious adverse events with surgery. Recovery time, wrist pain, and satisfaction were not reported. There may be less need for physiotherapy after surgery. One USA study found treatment costs were similar.
Quality of the evidence
All 30 studies had weaknesses that could affect the reliability of their results. We considered the evidence for all outcomes to be low or very low quality.
Conclusion
There is not enough evidence to determine the best ways of treating different types of wrist fractures in children. However, the review findings are consistent with the move away from cast immobilisation for buckle fractures.
Where available, the quality of the RCT-based evidence on interventions for treating wrist fractures in children is low or very low. However, there is reassuring evidence of a full return to previous function with no serious adverse events, including refracture, for correctly-diagnosed buckle fractures, whatever the treatment used. The review findings are consistent with the move away from cast immobilisation for these injuries. High-quality evidence is needed to address key treatment uncertainties; notably, some priority topics are already being tested in ongoing multicentre trials, such as FORCE.
Wrist fractures, involving the distal radius, are the most common fractures in children. Most are buckle fractures, which are stable fractures, unlike greenstick and other usually displaced fractures. There is considerable variation in practice, such as the extent of immobilisation for buckle fractures and use of surgery for seriously displaced fractures.
To assess the effects (benefits and harms) of interventions for common distal radius fractures in children, including skeletally immature adolescents.
We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, trial registries and reference lists to May 2018.
We included randomised controlled trials (RCTs) and quasi-RCTs comparing interventions for treating distal radius fractures in children. We sought data on physical function, treatment failure, adverse events, time to return to normal activities (recovery time), wrist pain, and child (and parent) satisfaction.
At least two review authors independently performed study screening and selection, 'Risk of bias' assessment and data extraction. We pooled data where appropriate and used GRADE for assessing the quality of evidence for each outcome.
Of the 30 included studies, 21 were RCTs, seven were quasi-RCTs and two did not describe their randomisation method. Overall, 2930 children were recruited. Typically, trials included more male children and reported mean ages between 8 and 10 years. Eight studies recruited buckle fractures, five recruited buckle and other stable fractures, three recruited minimally displaced fractures and 14 recruited displaced fractures, typically requiring closed reduction, typically requiring closed reduction. All studies were at high risk of bias, mainly reflecting lack of blinding. The studies made 14 comparisons. Below we consider five prespecified comparisons:
Removable splint versus below-elbow cast for predominantly buckle fractures (6 studies, 695 children)
One study (66 children) reported similar Modified Activities Scale for Kids - Performance scores (0 to 100; no disability) at four weeks (median scores: splint 99.04; cast 99.11); low-quality evidence. Thirteen children needed a change or reapplication of device (splint 5/225; cast 8/219; 4 studies); very low-quality evidence. One study (87 children) reported no refractures at six months. One study (50 children) found no between-group difference in pain during treatment; very low-quality evidence. Evidence was absent (recovery time), insufficient (children with minor complications) or contradictory (child or parent satisfaction). Two studies estimated lower healthcare costs for removable splints.
Soft or elasticated bandage versus below-elbow cast for buckle or similar fractures (4 studies, 273 children)
One study (53 children) reported more children had no or only limited disability at four weeks in the bandage group; very low-quality evidence. Eight children changed device or extended immobilisation for delayed union (bandage 5/90; cast 3/91; 3 studies); very low-quality evidence. Two studies (139 children) reported no serious adverse events at four weeks. Evidence was absent, insufficient or contradictory for recovery time, wrist pain, children with minor complications, and child and parent satisfaction. More bandage-group participants found their treatment convenient (39 children).
Removal of casts at home by parents versus at the hospital fracture clinic by clinicians (2 studies, 404 children, mainly buckle fractures)
One study (233 children) found full restoration of physical function at four weeks; low-quality evidence. There were five treatment changes (home 4/197; hospital 1/200; 2 studies; very low-quality evidence). One study found no serious adverse effects at six months (288 children). Recovery time and number of children with minor complications were not reported. There was no evidence of a difference in pain at four weeks (233 children); low-quality evidence. One study (80 children) found greater parental satisfaction in the home group; low-quality evidence. One UK study found lower healthcare costs for home removal.
Below-elbow versus above-elbow casts for displaced or unstable both-bone fractures (4 studies, 399 children)
Short-term physical function data were unavailable but very low-quality evidence indicated less dependency when using below-elbow casts. One study (66 children with minimally displaced both-bone fractures) found little difference in ABILHAND-Kids scores (0 to 42; no problems) (mean scores: below-elbow 40.7; above-elbow 41.8); very low-quality evidence. Overall treatment failure data are unavailable, but nine of the 11 remanipulations or secondary reductions (366 children, 4 studies) were in the above-elbow group; very low-quality evidence. There was no refracture or compartment syndrome at six months (215 children; 2 studies). Recovery time and overall numbers of children with minor complications were not reported. There was little difference in requiring physiotherapy for stiffness (179 children, 2 studies); very low-quality evidence. One study (85 children) found less pain at one week for below-elbow casts; low-quality evidence. One study found treatment with an above-elbow cast cost three times more in Nepal.
Surgical fixation with percutaneous wiring and cast immobilisation versus cast immobilisation alone after closed reduction of displaced fractures (5 studies, 323 children)
Where reported, above-elbow casts were used. Short-term functional outcome data were unavailable. One study (123 children) reported similar ABILHAND-Kids scores indicating normal physical function at six months (mean scores: surgery 41.9; cast only 41.4); low-quality evidence. There were fewer treatment failures, defined as early or problematic removal of wires or remanipulation for early loss in position, after surgery (surgery 20/124; cast only 41/129; 4 studies; very low-quality evidence). Similarly, there were fewer serious advents after surgery (surgery 28/124; cast only 43/129; 4 studies; very low-quality evidence). Recovery time, wrist pain, and satisfaction were not reported. There was lower referral for physiotherapy for stiffness after surgery (1 study); very low-quality evidence. One USA study found similar treatment costs in both groups.