1. No category

Interventions for treating wrist fractures in children (Review)
Abraham A, Handoll HHG, Khan T
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 4
http://www.thecochranelibrary.com
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 1 Non-attendance
at follow-up clinic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.2. Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 2 Non-union.
Analysis 1.3. Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 3 Non-adherence
(non-compliance). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.1. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 1
Moderate or severe difficulty levels for different activities at 28 days. . . . . . . . . . . . . . . .
Analysis 2.2. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 2
Moderate or severe levels of difficulty for bathing/showering.
. . . . . . . . . . . . . . . . .
Analysis 2.3. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 3
Unable to return to regular sporting or physical play activities. . . . . . . . . . . . . . . . . .
Analysis 2.4. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 4
Unable to return to regular sporting or physical play activities at 28 days: worst/best case scenarios. . . . .
Analysis 2.5. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 5
Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.6. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures, Outcome 6
Would prefer not to have the same treatment (splint or cast) in future. . . . . . . . . . . . . . .
Analysis 3.1. Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures, Outcome 1
Uncomfortable splintage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.2. Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures, Outcome 2
Pain while wearing splintage. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.3. Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures, Outcome 3
Found splintage inconvenient. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.4. Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures, Outcome 4
Adverse effects (e.g. skin problems). . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.1. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 1
Swelling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.2. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 2
Tenderness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.3. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 3
Avoidance of some hobbies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.4. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 4
Deformity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.5. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 5 Parents
reported problems with care of fracture. . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.6. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 6 Parents
would not choose the same treatment again. . . . . . . . . . . . . . . . . . . . . . . .
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Analysis 4.7. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures, Outcome 7 Nonadherence (non-compliance). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.1. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 1 Fracture
redisplacement and rereduction. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.2. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 2 Limitations
in activities of daily living during cast use. . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.3. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 3 Days off
school. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.4. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 4 Range of
movement (differences between injured and contralateral side) (degrees). . . . . . . . . . . . . .
Analysis 5.5. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 5 Time to
regain range of motion (days). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.6. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome 6
Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.1. Comparison 6 Above-elbow cast (forearm pronated versus neutral versus supinated) for displaced fractures,
Outcome 1 Second reduction for unacceptable loss of alignment. . . . . . . . . . . . . . . . .
Analysis 7.1. Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced
fractures, Outcome 1 Fracture redisplacement and rereduction. . . . . . . . . . . . . . . . . .
Analysis 7.2. Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced
fractures, Outcome 2 Complications. . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.3. Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced
fractures, Outcome 3 Anatomical deformity at 3 months. . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
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[Intervention Review]
Interventions for treating wrist fractures in children
Alwyn Abraham1 , Helen HG Handoll2 , Tahir Khan3
1 Department of Paediatric Orthopaedics, Leicester Royal Infirmary, Leicester, UK. 2 Centre for Rehabilitation Sciences (CRS), Research
Institute for Health Sciences and Social Care, University of Teesside, Middlesborough, UK. 3 Department of Paediatric Orthopaedics,
Booth Hall Children’s Hospital, Manchester, UK
Contact address: Alwyn Abraham, Department of Paediatric Orthopaedics, Leicester Royal Infirmary, Wd 14, Infirmary Square,
Leicester, LE1 5WW, UK. [email protected]. [email protected].
Editorial group: Cochrane Bone, Joint and Muscle Trauma Group.
Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.
Review content assessed as up-to-date: 18 February 2008.
Citation: Abraham A, Handoll HHG, Khan T. Interventions for treating wrist fractures in children. Cochrane Database of Systematic
Reviews 2008, Issue 2. Art. No.: CD004576. DOI: 10.1002/14651858.CD004576.pub2.
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Approximately a third of all fractures in children occur at the wrist, usually from falling onto an outstretched hand.
Objectives
We aimed to evaluate removable splintage versus plaster casts (requiring removal by a specialist) for undisplaced compression (buckle)
fractures; cast length and position; and the role of surgical fixation for displaced wrist fractures in children.
Search strategy
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2007), the Cochrane Central Register
of Controlled Trials (The Cochrane Library 2007, Issue 4), MEDLINE (from 1966), EMBASE (from 1988), CINAHL (from 1982)
and reference lists of articles. Date of last search October 2007.
Selection criteria
Any randomised or quasi-randomised controlled trials comparing types and position of casts and the use of surgical fixation for distal
radius fractures in children.
Data collection and analysis
Two authors performed trial selection. All three authors independently assessed methodological quality and extracted data.
Main results
The 10 included trials, involving 827 children, were of variable quality.
Four trials compared removable splintage versus the traditional below-elbow cast in children with buckle fractures. There was no shortterm deformity recorded in all four trials and, in one trial, no refracture at six months. The Futura splint was cheaper to use; a removable
plaster splint was less restrictive to wear enabling more children to bathe and participate in other activities, and the option preferred
by children and parents; the soft bandage was more comfortable, convenient and less painful to wear; home-removable plaster casts
removed by parents did not result in significant differences in outcome but were strongly favoured by parents.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Two trials found below-elbow versus above-elbow casts did not increase redisplacement of reduced fractures or cast-related complications,
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 but one of these found no
advantage in function at three months.
Authors’ conclusions
Limited evidence supports the use of removable splintage for buckle fractures and challenges the traditional use of above-elbow casts
after reduction of displaced fractures. Although percutaneous wire fixation prevents redisplacement, the effects on longer term outcomes
including function are not established.
Further research is warranted on the optimum approach, including splintage, for buckle fractures; and on the use of below-elbow casts
and indications for surgery for displaced wrist fractures in children.
PLAIN LANGUAGE SUMMARY
Interventions for treating wrist fractures in children
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 belowelbow 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 aboveelbow 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.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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BACKGROUND
Putting out an outstretched hand to break a fall is a common protective reflex in humans. The upper limb therefore bears the brunt
of the axial force in such an event and is at risk of fracture along
its length if the force exceeds the strength of the bony skeleton.
In children this is most likely to occur at the wrist (the fracture
occurring in the distal third of one or both of the two forearm
bones: the radius and ulna).
The epidemiology of fracture in children has been reported in
detail by Worlock 1986. The most common mechanism in their
study was a fall in or around the house. Fractures of the distal
radius and ulna were the most common fractures and accounted
for 35.8% of all fractures in this age group. The annual incidence
of these ’wrist’ fractures was estimated to be 16 per 1000 children
in the UK.
Fractures of the distal radius have been divided into six categories
by Herring 2002: buckle, greenstick, metaphyseal, distal radial
physeal injuries, distal ulnar physeal injuries and Galeazzi fractures. Buckle or ’torus’ fractures are incomplete fractures which
appear on X-ray examination to involve compression of only part
of the circumference of the cortex of the bone. They are stable
injuries and require no more than minimal splintage to alleviate
pain and discomfort. Greenstick fractures are somewhat similar,
but involve complete disruption of a segment of cortex with associated plastic deformation of the remaining cortex at that level,
which may result in significant deformity. If the amount of deforming force transcends the resistance of both cortices a complete
(bicortical) metaphyseal fracture occurs. These are often displaced
in all planes creating a deformity that requires reduction and immobilisation.
In growing children, a growth plate (physis) is present at the lower
end of each forearm bone. Somewhat commoner in older children, fractures close to the physis of the lower end of the radius account for about 20% of childhood wrist fractures (Herring 2002;
Worlock 1986). If displaced, these fractures also require reduction
and immobilisation.
Fractures of the distal ulna epiphysis and Galeazzi fractures, where
there is fracture of the distal radius with disruption of the distal
radio-ulnar joint, are rare in children. Neither of these fracture
types are considered further in this review.
• what constitutes a degree of fracture displacement and
angulation likely to be compensated by remodelling with growth
over time;
• what are the indications for fracture stabilisation with wires
or other invasive methods compared with plaster casting alone;
• what position should the arm be kept in during
immobilisation in a cast;
• and whether the cast should immobilise the wrist alone
(below-elbow or short-arm casting) or both the wrist and the
elbow (above-elbow or long-arm casting).
Various research studies have been conducted that aim to inform
practice. A recent randomised controlled trial suggests that wire
fixation should form part of the treatment in the immobilisation
of displaced metaphyseal (region near the end of the bone) fractures (McLauchlan 2002a). This has been especially advocated for
displaced distal shaft and metaphyseal fractures in which the ulna
is either intact or has undergone plastic deformation (Gibbons
1994a). Traditionally, an above-elbow cast in supination (forearm
is positioned so that the palm of hand faces upwards) has been
the accepted form of immobilisation following a displaced distal radial fracture. In a randomised controlled trial, Boyer 2002a
examined whether there was a difference in the residual angular
deformity at the fracture site, at the time of union between aboveelbow casts where the arm was in supination, pronation (palm
faces downwards) or in neutral. In a large retrospective study of
761 distal radial fractures treated with below-elbow casts, Chess
1994a reported a 10% rate of significant loss of fracture alignment
during immobilisation, these cases correlating well with the quality of moulding of the applied cast.
In summary, distal radius fractures are common throughout childhood from first walking through to adolescence. The anatomical
site of the injury influences the degree of deformity accepted and
the form of immobilisation traditionally practiced. Controversial
areas of management such as the use of wire stabilisation, position
of immobilisation and below-elbow casts form the focus of this
review
OBJECTIVES
The management of buckle fractures of the distal radius is relatively
uncontroversial, involving splintage for symptomatic relief from
pain. Some authors have advocated removable wrist supports, with
discontinuation of splintage at the parents’ discretion (Symons
2001).
We aimed to evaluate the evidence from randomised controlled
trials comparing the relative effects (benefits and harms) of different methods of managing fractures of the distal radius in children.
The controversial issues in the management of displaced distal
radius fracture in children are:
1. buckle fractures of the distal radius with removable splints or
bandages versus plaster casts;
We aimed to examine the effects (primarily in terms of function,
redisplacement and residual deformity) of treating:
2. displaced fractures with below-elbow versus above-elbow casts;
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
3
3. displaced fractures with above-elbow casts positioned in supination, pronation or neutral;
4. displaced fractures with wire fixation versus plaster cast.
We planned to study the outcomes in different age groups and
for different fracture types (for instance, radial fractures with or
without ulna fracture).
• Secondary treatment including surgery
• Pain and discomfort
• Patient (child) satisfaction and adherence (compliance);
parent satisfaction and adherence
• Resource use and other costs
Search methods for identification of studies
METHODS
Criteria for considering studies for this review
Types of studies
Any randomised or quasi-randomised (for example, allocation by
date of birth or alternation) controlled trials which compared types
of immobilisation, position of immobilisation and the use of wire
fixation for distal radius fractures in children.
Types of participants
Babies, infants, children or adolescents who have had a distal radius
fracture diagnosed radiographically, with or without ulna fracture.
We searched the Cochrane Bone, Joint and Muscle Trauma Group
Specialised Register (to October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 4),
MEDLINE (1966 to October week 1 2007), EMBASE (1988 to
2007 week 40), CINAHL (1982 to October week 1 2007) and
reference lists of articles. We also contacted researchers in the field.
One author (HH) checked her database on wrist fractures. No
language restrictions were applied.
In MEDLINE (OVID WEB) a subject-specific strategy was combined with the optimal Cochrane trial search strategy (Higgins
2006) and modified for use in other databases (see Appendix 1 for
MEDLINE; Appendix 2 for The Cochrane Library; Appendix 3
for EMBASE and Appendix 4 for CINAHL).
Results of a separate search for ongoing and recently completed
trials of the Current Controlled Trials register at www.controlledtrials.com (accessed December 2007) were provided by one of the
referees of the review.
Types of interventions
Any treatment involving the use of splints or casts. These could
be of different materials (e.g. plaster of Paris or fibreglass) and
could be incomplete such as the typical plaster backslab, which just
covers the back of the wrist and forearm and allows for swelling
of the arm to subside, or complete or full casts that encircle the
whole arm. The casts could either include the elbow (above-elbow
casts) or stop before the elbow (below-elbow or forearm casts).
Above-elbow casts could hold the position of the forearm in either
pronation, supination or neutral. Surgical fixation, such as wire
fixation, was included. Also included was the duration of cast
immobilisation and the setting for removal of casts.
Types of outcome measures
These included the following.
• Redisplacement and residual deformity
• Function including activities of daily living and
impairments such as loss of forearm rotation and wrist range of
motion
• Complications from treatment including pin site infection,
nerve or tendon injuries, loss of elbow range of movement
Data collection and analysis
Selection of studies
The initial searches were carried out by one of the authors (AA)
and updated by a second author (HH); both were assisted by
the Cochrane Bone, Joint and Muscle Trauma Group’s editorial
base. Pairs of review authors (AA and KT; AA and HH) assessed
potentially eligible trials for inclusion and any disagreement was
resolved through discussion. Titles of journals, names of authors
or supporting institutions were not masked at any stage. Study
selection was reviewed by the third author (HH).
Data extraction and management
All three authors independently performed data extraction, two
using a pre-piloted form. Any disagreement was resolved through
discussion.
Assessment of methodological quality of included studies
All three authors independently assessed the methodological quality of included studies using modified version of the Cochrane
Bone, Joint and Muscle Trauma Group’s quality assessment tool
(see Table 1). Disagreement was resolved by discussion.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Table 1. Quality assessment tool
Items
Coding
A. Was the assigned treatment adequately 2 = method did not allow disclosure of asconcealed prior to allocation?
signment.
1 = small but possible chance of disclosure
of assignment or unclear.
0 = quasi-randomised or open list or tables.
Notes
Cochrane code:
Clearly Yes = A
Not sure = B
Clearly No = C
B. Were the outcomes of participants who 2 = withdrawals well described and acwithdrew described and included in the counted for in analysis.
analysis (intention to treat)?
1 = withdrawals described and analysis not
possible.
0 = no mention, inadequate mention, or
obvious differences and no adjustment.
C. Were the outcome assessors blinded to 2 = effective action taken to blind assessors.
treatment status?
1 = small or moderate chance of unblinding
of assessors, or some blinding of outcomes
attempted.
0 = not mentioned or not possible.
D. Were important baseline characteristics 2 = good comparability of groups, or conreported and comparable?
founding adjusted for in analysis.
1 = confounding small, mentioned but not
adjusted for, or comparability reported in
text without confirmatory data.
0 = large potential for confounding, or not
discussed.
The principal confounders were considered
to be age, time since injury, previous wrist
injury, presence of other wrist and forearm injuries, hand dominance and type of
sporting activity.
E. Were the participants blind to assign- 2 = effective action taken to blind particiment status after allocation?
pants.
1 = small or moderate chance of unblinding
of participants.
0 = not possible, or not mentioned (unless
double-blind), or possible but not done.
F. Were the treatment providers blind to 2 = effective action taken to blind treatment
assignment status?
providers.
1 = small or moderate chance of unblinding
of treatment providers.
0 = not possible, or not mentioned (unless
double-blind), or possible but not done.
G. Were care programmes, other than the 2 = care programmes clearly identical.
trial options, identical?
1 = clear but trivial differences, or some
evidence of comparability.
0 = not mentioned or clear and important
differences in care programmes.
Interventions for treating wrist fractures in children (Review)
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Table 1. Quality assessment tool
(Continued)
H. Were the inclusion and exclusion crite- 2 = clearly defined (including whether priria for entry clearly defined?
mary or secondary dislocation).
1 = inadequately defined.
0 = not defined.
I. Were the interventions clearly defined?
2 = clearly defined interventions are applied
with a standardised protocol.
1 = clearly defined interventions are applied
but the application protocol is not standardised.
0 = intervention or application protocol are
poorly or not defined.
J. Were the outcome measures used clearly 2 = clearly defined.
defined?
1 = inadequately defined.
0 = not defined.
K. Were the outcome measures/diagnostic 2 = optimal.
tests used in outcome assessment appropri- 1 = adequate.
ate?
0 = not defined or adequate.
L. Was the surveillance active and of clini- 2 = active surveillance and appropriate ducally appropriate duration?
ration (1 year or more).
1 = active surveillance, but inadequate duration.
0 = surveillance not active or not defined.
Data analysis
Relative risks (RR) and 95% confidence intervals (95% CI) were
calculated for dichotomous outcomes, and mean differences (MD)
with 95% confidence intervals were calculated for continuous outcomes. Results of comparable trials were pooled using the fixed-effect model and 95% confidence intervals. Heterogeneity between
comparable trials was tested using a standard chi-squared test and
considered statistically significant at P < 0.1. We also considered
the I² statistic (Higgins 2003). Where there was significant heterogeneity, we checked the results using the random-effects model
and presented these where appropriate.
Should data become available in future updates, we plan separate
outcome analyses of a) patients with first injury compared with
those with recurrent injuries, b) older children approaching skeletal maturity and juveniles (under 10 years of age) and c) patients
with distal radius fracture only and those with a distal ulna fracture
as well. To test whether subgroups are statistically significantly different from one another, we propose to test the interaction using
the technique outlined by Altman and Bland (Altman 2003).
RESULTS
Description of studies
Sensitivity and subgroup analyses
Lack of data precluded our prespecified sensitivity and subgroup
analyses. We investigated loss to follow up in a minimal way, using
worst and best case analyses, for one trial (Plint 2006).
See: Characteristics of included studies; Characteristics of excluded
studies; Characteristics of ongoing studies.
Of 25 eligible studies, 10 studies were included, nine were excluded, two are ongoing and four await assessment. Further de-
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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tails of the included studies can be found in the ’Characteristics
of included studies’.
Included studies
Settings
Five studies were from centres in the UK (Davidson 2001; Gibbons
1994; McLauchlan 2002; Symons 2001; West 2005), three from
the USA (Boyer 2002; Miller 2005; Webb 2006) and two from
Canada (Bohm 2006; Plint 2006). All were carried out in the
acute care setting with six from dedicated children’s acute hospitals
(Boyer 2002; Davidson 2001; McLauchlan 2002; Miller 2005;
Plint 2006; Webb 2006).
Participants
The 10 trials included a total of 827 children, the majority of
whom were male. The percentage of male children ranged from
53% (Davidson 2001) to 91% (Miller 2005); no data on gender
were provided for West 2005. West 2005 did not provide a summary statistic for age but most participants were between 5 and
10 years of age. The mean age ranged from 8 to 10 years in the
other trials, except for Miller 2005 in which the minimum age
for inclusion was 10 and the mean was 12 years. The youngest
recorded child was two years old (Davidson 2001) and the oldest
was 16 years (Webb 2006).
The 10 included studies specified the site of interest as fractures
of the distal radial metaphysis. Davidson 2001 and West 2005 defined buckle fractures of the distal radius as failure of bone in compression at the metaphyseal-diaphyseal junction. In Plint 2006, a
buckle fracture was defined as compression of the bony cortex with
the opposite cortex intact. Symons 2001 did not define their use of
the term ’buckle fracture’ but stated that these were stable injuries
that did not displace. Three studies (Gibbons 1994; McLauchlan
2002; Miller 2005) specified inclusion criteria for defining their
population of displaced fractures while three did not (Bohm 2006;
Boyer 2002; Webb 2006). Gibbons 1994 stipulated that the ulna
needed to be intact, whereas children with ulna fracture in addition to that of the distal radius were explicitly included in Bohm
2006, Boyer 2002 and McLauchlan 2002. While Bohm 2006 and
Plint 2006 would also have included isolated ulnar fractures, there
were none in these trial populations.
Comparisons
The 10 included trials have been grouped according to the comparisons addressed by each trial. Four comparisons pertain to interventions for treating buckle fractures and three for displaced
fractures.
Futura splint versus below-elbow plaster cast for buckle fractures
One study (Davidson 2001) compared the use of Futura splints
versus traditional below-elbow plaster cast for buckle fractures in
201 children.
Removable plaster splint versus below-elbow plaster cast for buckle
fractures
One study (Plint 2006) compared the use of removable plaster
splints, worn for comfort, versus traditional below-elbow plaster
cast for buckle fractures in 87 children. (However, 113 were randomised; the largest group of excluded children was 16 with greenstick fractures.)
Soft bandage versus below-elbow cast (plaster then polymer) for buckle
fractures
One study (West 2005) compared the use of soft bandaging versus
below-elbow plaster cast followed by a “polymer” cast for buckle
fractures in 42 children.
Home versus hospital-clinic removal of plaster backslab for buckle
fractures
One study of 87 children with buckle fractures (Symons 2001)
compared removal of a plaster backslab by parents at home versus
removal in the hospital clinic by clinicians.
Below-elbow versus above-elbow plaster cast after reduction of displaced fractures
Two studies (Bohm 2006; Webb 2006) compared below-elbow
(short) versus above-elbow (long) plaster casts applied after reduction of displaced fractures in 229 children.
Above-elbow cast (forearm pronated versus neutral versus supinated)
after reduction of displaced fractures
One study (Boyer 2002) assessed the effect of the forearm position
(pronated versus neutral versus supinated) held by an above-elbow
cast in 109 children with displaced (or angulated) fractures reduced
under general anaesthesia.
Percutaneous wire fixation and above-elbow cast versus above-elbow
cast alone after reduction of displaced fractures
Three studies (Gibbons 1994; McLauchlan 2002; Miller 2005)
compared percutaneous wire fixation and above-elbow cast immobilisation versus above-elbow cast immobilisation alone after
reduction of displaced fractures in 125 children.
Excluded studies
Nine studies were excluded (see the ’Characteristics of excluded
studies’ for details).
Ongoing studies
Two trials (Colaris 2008a; Colaris 2008b) are ongoing (see the
’Characteristics of ongoing studies’ for details).
Studies awaiting assessment
Of the four trials in this category, one (Yousef 2006) is reported
only as a conference abstract, one (Hammacher 2006) has been
submitted for publication and two (Hudson 2004; Ziouani 2007)
are completed but not yet written up.
Risk of bias in included studies
Table 2 gives the results of the methodological assessment of the
included trials using the tool presented in Table 1. Some general
comments are given below.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
7
Table 2. Quality assessment results for individual trials
Study ID
Items A to D grades
Items E to H grades
Items I to L grades
Item A: Allocation concealment
Item B: Intention-to-treat analysis
Item C: Outcome assessor blinding
Item D: Comparable baseline characteristics
Item E: Participant blinding
Item F: Treatment provider blinding
Item G: Identical care programmes
Item H: Clearly defined inclusion
criteria
Item I: Well defined interventions
Item J: Well defined outcome measures
Item K: Optimal outcome measures
Item L: Active and sufficiently long
(at least 1 year) follow up
Bohm 2006
Item A: 2 (“blinded”; sealed envelopes)
Item B: 0 (treatment allocations of
post-randomisation exclusions not
given)
Item C: 0 (attempted blinding of
radiographs did not work)
Item D: 0 (insufficient information;
some imbalance in involvement of
ulna)
Item E: 0 (no)
Item F: 0 (no)
Item G: 2 (very likely)
Item H: 2 (yes, although some retrospective application)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 1 (no functional assessment)
Item L: 1 (18 weeks follow up)
Boyer 2002
Item A: 0 (quasi-randomised - by
date of birth)
Item B: 0 (treatment allocations of
post-randomisation exclusions not
given)
Item C: 0 (not done)
Item D: 0 (no data)
Item E: 0 (no)
Item F: 0 (no)
Item G: 2 (yes)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 1 (no functional assessment)
Item L: 0 (variable follow up: 6-8
weeks)
Davidson 2001
Item A: 0 (quasi-randomised - by
date of attendance)
Item B: 2 (full account of participant flow)
Item C: 0 (not done)
Item D: 0 (no information)
Item E: 0 (no)
Item F: 0 (no)
Item G: 2 (yes)
Item H: 2 (although broad)
Item I: 2 (yes)
Item J: 1 (insufficient description)
Item K: 1 (no functional assessment)
Item L: 1 (3 weeks follow up)
Gibbons 1994
Item A: 0 (quasi-randomised - by
surgeon allocated to child)
Item B: 0 (participant flow could be
inferred but not stated)
Item C: 0 (not done)
Item D: 2 (yes)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (aftercare not specified)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 1 (no functional assessment)
Item L: 1 (6 months follow up)
McLaughlan 2002
Item A: 1 (sealed envelopes but no
indication of safeguards)
Item B: 2 (definitely, and reported
intention-to-treat analysis
Item C: 0 (although independent
physiotherapist at 3 months)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (slight differences in timing of clinical review)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (3 months follow up)
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
8
Table 2. Quality assessment results for individual trials
(Continued)
Item D: 2 (yes)
Miller 2005
Item A: 0 (compromised by the
addition of 9 non-randomised patients)
Item B: 0 (no, inclusion of non-randomised patients)
Item C: 0 (not done)
Item D: 0 (no; imbalances in dorsal
angulation and shortening)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (aftercare not specified)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (6 months follow up; for
whole population)
Plint 2006
Item A: 2 ( web-based randomisation, then sealed opaque envelopes
sequentially opened by research assistant)
Item B: 1 (participant flow but baseline characteristics and results not
given for whole group)
Item C: 0 (not done)
Item D: 1 (balanced for those included in analyses, but no data for
whole group)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (possible discrepancy on
timing of treatment)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (6 months follow up)
Symons 2001
Item A: 1 (computer generated random number sheet)
Item B: 1 (probably but baseline
data not available for all randomised
patients)
Item C: 0 (not done)
Item D: 1 (balanced for those included in analyses, but no data for
whole group)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (insufficient information;
differences in explanations to parents?)
Item H: 2 (yes)
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (6 weeks follow up)
Webb 2006
Item A: 0 (quasi-randomised based
on odd and even medical record
numbers)
Item B: 1 (participant flow but baseline data not available for all randomised patients)
Item C: 0 (not done)
Item D: 1 (balanced for those included in analyses, but no data for
whole group)
Item E: 0 (no)
Item I: 2 (yes)
Item F: 0 (no)
Item J: 2 (yes)
Item G: 1 (potential for difference Item K: 2 (yes)
in reduction methods)
Item L: 1 (8 months follow up)
Item H: 2 (yes)
West 2005
Item A: 2 (presealed envelopes selected by parent)
Item B: 2 (yes)
Item C: 0 (not done)
Item D: 0 (insufficient information)
Item E: 0 (no)
Item F: 0 (no)
Item G: 1 (differences in timing of
clinical review)
Item H: 2 (yes)
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Item I: 2 (yes)
Item J: 2 (yes)
Item K: 2 (yes)
Item L: 1 (4 weeks follow up)
9
Allocation concealment (item A)
Allocation was concealed in three trials (Bohm 2006; Plint 2006;
West 2005) but not in the four studies using quasi-randomised
methods (West 2005; Davidson 2001; Gibbons 1994; Webb
2006), nor in Miller 2005 where an additional nine non-randomised patients were included. Insufficient detail was available to
determine whether allocation was concealed in the two remaining
studies.
Intention-to-treat analysis (item B)
We considered there were sufficient details of participant flow with
a high likelihood of a correct analysis being performed in three
trials (Davidson 2001; McLauchlan 2002; West 2005). The failure
to give the numbers randomised to each group or baseline data for
all recruited patients were the main reasons for a low score for this
item in the other trials. Intention-to-treat analysis was definitely
not carried out in Miller 2005 because of the inclusion of nonrandomised patients.
Assessor blinding (item C)
Blinding of radiographic assessment was attempted in Bohm 2006
but apparently did not succeed. No other studies described assessor
blinding.
Baseline characteristics (item D)
Only two trials (Gibbons 1994; McLauchlan 2002) fully satisfied
the criteria for this item. Most trials failed to provide baseline
characteristics for all randomised patients. As well as insufficient
information, there was an imbalance in the numbers with ulna
fracture in Bohm 2006. The imbalances in radiological parameters
in Miller 2005 probably reflected the inclusion of non-randomised
patients. Two trials (Boyer 2002; Davidson 2001) failed to provide
any data to judge this item.
Participant and treatment provider blinding (items E and F)
Blinding of patients and care providers is generally not feasible in
these interventions, and was not done.
Care programme comparability (item G)
Provision of comparable care programmes other than the trial interventions was highly likely in three trials (Bohm 2006; Boyer
2002; Davidson 2001). Lack of information or the potential for
minor variation in care (see Table 2) were the reasons for a lower
score in the other trials.
Inclusion criteria (item H)
All the included trials provided sufficient trial inclusion and exclusion criteria to define their study populations.
Trial interventions (item I)
All the included trials provided sufficient details of the interventions under comparison.
Outcome assessment (items J, K and L)
Except for Davidson 2001, the trials adequately described their
outcome measurement (item J). Four trials (Bohm 2006; Boyer
2002; Davidson 2001; Gibbons 1994) were marked down for item
K because they did not include any assessment of function. Aside
from Boyer 2002, all trials clearly had active follow up at set times
but none followed up all patients for one year or more (item L).
Effects of interventions
Futura splint versus below-elbow plaster cast for buckle fractures
One study (Davidson 2001) compared the use of Futura splints
versus traditional below-elbow plaster cast for buckle fractures in
201 children. Significantly more children in the splint group did
not attend the three weeks follow-up clinic, possibly because a
clinic visit was not necessary to remove the splint (see Analysis
01.01: relative risk (RR) 3.30, 95% confidence interval (CI) 1.16
to 9.39). Adherence (compliance) was good in both groups among
those that attended the clinic, with the exception of two young
children who tried to remove their splints shortly after application
(see Analysis 01.02). A further child allocated a splint was given a
cast on the request of her parents. All fractures united clinically and
radiologically without loss of position. Davidson 2001 estimated
the cost of treatment including materials, plaster technician’s time
and attendance at clinic was £116.98 for the plaster cast compared
with £65.75 for the Futura splint (these probably reflect costs in
2000).
Removable plaster splint versus below-elbow plaster cast for
buckle fractures
One study (Plint 2006) compared the use of removable plaster
splints, worn for comfort, versus traditional below-elbow plaster
cast for buckle fractures in 87 children. Physical function, assessed
using the Activities Scale for Kids performance tool (Young 2000;
range 0 to 100: severe disability to no disability), was significantly
better in the splint group at 14 days (median scores: 93.77 versus
89.29; P = 0.04) but not by 28 days when the median scores were
over 99 in both groups, indicating that physical function was nor-
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
10
mal. By 28 days post-injury there was also no difference between
the two groups in the numbers of children who had moderate
or severe problems in performing various activities (see Analysis
02.01). However, in the preceding follow-up times, significantly
fewer children in the splint group had difficulties bathing or showering (see Analysis 02.02). Significantly more children in the splint
group were able to return to regular sporting or physical activities
at 20 days and 28 days (see Analysis 02.03). The numbers of children reporting these outcomes were often markedly fewer than
those entered into the trial. Analysis 02.04, which presents worst
and best case analyses for the 28 day data for physical activities,
shows that the result in Analysis 02.03 is not robust. There was
no difference in pain scores at any time interval, and no child had
wrist pain by 28 days. There were no problems encountered with
the plaster splints, which were worn at least some part of each day
for 13.7 days on average; continuous use declined rapidly over
three weeks. Five problems with casts occurred in the paster cast
group: four because of wet casts and one resulting from a pencil inserted under the cast (see Analysis 02.05). There was no refracture found at six months, either by contacting the parents or
by checking hospital records. Of those questioned, significantly
more children and their parents of both groups indicated that they
would prefer a removable splint in future should they sustain the
same injury (see Analysis 02.06).
Soft bandage versus below-elbow cast (plaster then polymer)
for buckle fractures
One study (West 2005) compared the use of soft bandaging versus
below-elbow casts (plaster then polymer) for buckle fractures in 42
children. Significantly more children in the bandage group found
the splintage comfortable (see Analysis 03.01: RR 0.01, 95% CI
0.01 to 0.68), convenient to wear (see Analysis 03.03: RR 0.06,
95% CI 0.01 to 0.44), and they experienced less pain during use
(see Analysis 03.02: RR 0.31, 95% CI 0.13 to 0.77). Pain was also
for shorter duration in the bandage group. There were no adverse
effects. The majority of children (83%) in the bandage group had
removed their bandage by one week, and all had by two weeks.
Parents of one child assigned to wear a bandage requested a change
to a cast at one week. All children in the cast group retained their
casts until they were removed at a clinic after four weeks. Early
bandage removal allowed early mobilisation of the wrist and the
range of movement (extension/flexion) was significantly greater
in the bandage group at four weeks (median values: 162 degrees
versus 126 degrees; reported P < 0.0001). Trial recruitment was
reported as being hampered by parental perception that a plaster
cast was needed, but of those included in the trial only two parents
in the bandage group indicated their worry on entering the trial.
Home versus hospital-clinic removal of plaster backslab for
buckle fractures
One study of 87 children with buckle fractures (Symons 2001)
compared removal of a plaster backslab by parents at home versus
removal in a hospital clinic by clinicians.
At six weeks there was no significant difference between the two
groups in the incidence of residual swelling (see Analysis 04.01),
tenderness (see Analysis 04.02) or avoidance of hobbies (see Analysis 04.03); and no child had difficulties with writing or activities
of daily living. No deformity was reported at six weeks in either
group, although this was confirmed radiologically in only 33 children. Although fewer parents in the home-removal group reported
difficulties with the care of their child’s fracture this did not reach
statistical significance (see Analysis 04.05: RR 0.42, 95% CI 0.17
to 1.06). Parents in the hospital group complained about waiting
times (N = 10), having to take time off work (N = 5), transport
difficulties (N = 3) and hospital parking (N = 2). Significantly
more parents in the hospital group indicated that they would not
opt for the same treatment again (see Analysis 04.06: RR 0.07,
95% CI 0.01 to 0.47). There were three cases of non-adherence to
treatment (see Analysis 04.07). In the home-removal group, one
child removed their backslab prematurely (before three weeks),
and one parent delayed removal of the backslab until six weeks.
One parent in the hospital group successfully removed their child’s
backslab at home to avoid loss of earnings.
Below-elbow versus above-elbow cast after reduction of displaced fractures
Two studies (Bohm 2006; Webb 2006) compared below-elbow
versus above-elbow plaster casts applied after reduction of displaced fractures in 229 children. Though based on different criteria, which may have contributed to the moderate statistical heterogeneity (I² = 48.1%), both trials found a trend to less loss of
reduction or redisplacement during immobilisation in a belowelbow cast (see Analysis 05.01: RR 0.60, 95% CI 0.36 to 1.00,
fixed-effect model; RR 0.54, 95% CI 0.20 to 1.47, random-effects model). However, only four fractures were remanipulated in
Bohm 2006 while none were in Webb 2006. There were significantly fewer limitations in various activities of daily living during
cast immobilisation in children allocated below-elbow casts (see
Analysis 05.02). Overall, significantly fewer children wearing below-elbow casts reported needing help with activities of daily living (see Analysis 05.02: RR 0.10, 95% CI 0.03 to 0.31). Children
in the above-elbow cast group missed on average one extra day of
school (see Analysis 05.03).
Upon cast removal, the above-elbow cast group of Webb 2006
had significantly reduced elbow motion compared with the belowelbow group (see Analysis 04.04: mean difference -28.70 degrees,
95% -32.84 to -24.56 degrees). Although the final wrist and elbow
mobility deficits were statistically significantly less in the belowelbow group of Webb 2006, the clinical significance of a four and
three degree difference is uncertain (see Analysis 05.04). Children
in the below-elbow group regained range of motion 10 days earlier
than those in the above-elbow group (see Analysis 05.05).
Aside from one child who had three weeks of physical therapy
to regain shoulder mobility, the only reported complications were
cast related (see Analysis 05.06). Similar numbers in the two groups
of Bohm 2006 had cast reinforcement or cast changes due to
’breakdown’ or loosening. One below-elbow cast fell off and was
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
11
changed to an above-elbow cast, and there were five requests for a
change to a below-elbow cast from an above-elbow cast to reduce
discomfort.
Above-elbow cast (forearm pronated versus neutral versus
supinated) after reduction of displaced fractures
One study (Boyer 2002) assessed the effect of the forearm position
(pronated versus neutral versus supinated) held by an above-elbow
cast in 109 children with displaced (or angulated) fractures reduced
under general anaesthesia. Ten children were excluded from the
analyses because of insufficient X-rays. Boyer 2002 reported there
was no significant effect (P > 0.05) on angular deformity at final
follow up of six weeks or over (overall mean = 7 degrees); separate
data for angular deformity were not available. Two children (one in
the supination group and one in the pronation group) required a
second reduction (timing not reported) due to an unacceptable loss
of alignment (see Analysis 06.01); both had a satisfactory outcome
at final follow up.
Percutaneous wire fixation and above-elbow cast versus aboveelbow cast alone after reduction of displaced fractures
Three studies (Gibbons 1994; McLauchlan 2002; Miller 2005)
compared percutaneous wire fixation and above-elbow cast immobilisation versus above-elbow cast immobilisation alone after
reduction of displaced fractures in 125 children. With the exception of one person in the wire-fixation group of McLauchlan 2002
with wire migration, all fracture redisplacement occurred in the
cast alone group (see Analysis 07.01: RR 0.06, 95% CI 0.02 to
0.24). All redisplaced fractures were remanipulated in Gibbons
1994. Of the seven treated in McLauchlan 2002, four had surgery
as did one of the six children receiving a secondary procedure for
loss of position in Miller 2005. Individual complications other
than redisplacement were not significantly different between the
two groups (see Analysis 07.02). There were significantly fewer
unscheduled secondary procedures in the wire-fixation group (see
Analysis 07.02: RR 0.26, 95% CI 0.12 to 0.56, fixed-effect model).
However, these results were heterogeneous (I² = 49.5%) and these
results were only marginally significant when using the randomeffects model (RR 0.28, 95% CI 0.08 to 1.02). Moreover, overall
there were more secondary procedures in the wire-fixation group
because the wire was routinely removed after three or four weeks.
McLauchlan 2002 reported one person in the cast group had a
successful outcome after a corrective osteotomy at six months (after the last follow-up time for the trial).
In McLauchlan 2002, five children out of 56 reviewed at three
months complained of minor pain after strenuous activity. None
had any functional deficit and there were only small and clinically
insignificant differences between the two groups in grip strength
(22 Kg versus 21 Kg) and range of motion outcomes. Miller 2005
reported no limitations in motion, strength alterations, pain or
activity restrictions at follow up. McLauchlan 2002 found residual
coronal deformity (see Analysis 07.03: mean difference -3.00, 95%
CI -5.46 to -0.51) and sagittal deformity (mean difference -5.10,
95% CI -9.74 to -0.46) were less at three months in the wirefixation group. In Miller 2005 there was no cosmetic deformity
at long-term follow up (mean 2.8 years) and all fractures in 25
children had healed and remodelled to anatomic alignment.
Miller 2005 estimated the cost of treating a patient with percutaneous pinning was less that cast alone when the further procedures
due to complications were included (US $3347 versus $3831).
Subgroup analyses
Our plans to study the outcomes in different age groups and for
different fracture types were prevented by the lack of data.
DISCUSSION
Limitations of the review and review evidence
Our search culminated in the inclusion of 10 trials, involving 827
children. Four other trials are pending assessment, all of which
are unpublished, and two are ongoing. Four of these trials were
located by an editor during editorial review and another one subsequently. This supported our previous supposition that it was
plausible that we had missed some studies, especially unpublished
ones. This is likely to remain the case. However, some trials may
never be published and we have found that some registered trials
have not taken place. In all, there are surprisingly few trials and
few children given the very large numbers of children sustaining
wrist fractures in all regions of the world. The trial populations
are also restricted to North America and the UK. Nonetheless, the
trial populations are generally representative as are the questions
examined by these trials, which address generally accepted areas
of treatment controversy (see ’Background’). The potential of the
included trials to give definitive answers and thus guide practice is
hampered by the small sample sizes available for each of the seven
comparisons evaluated so far and the lack of data for pooling.
Methodological limitations, such as the use of quasi-randomised
methods and failure to conduct intention-to-treat analysis, could
also invalidate trial findings.
The review addresses three key areas: the management of buckle
fractures; the type of casting used after reduction of displaced fractures; and the use of percutaneous wire fixation for after reduction
of displaced fractures.
Management of buckle fractures
The four trials examining the management of buckle fractures examined whether conventional below-elbow plaster cast immobilisation is really necessary. Since these commonplace fractures are
usually stable, splintage is mainly for pain relief, comfort and support. Therefore the conventional approach might constitute overtreatment and the disadvantages of plaster casts could be avoided.
The evidence from the four trials leant support to this argument.
Although a quasi-randomised trial with only short-term follow-up,
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
12
Davidson 2001 provided some evidence that Futura splints, which
allowed independent removal, did not adversely affect anatomical
outcome and cost less than plaster cast immobilisation. Plint 2006
demonstrated better early functioning and fewer problems with
activities, including bathing, in children fitted with a removable
plaster splint. Furthermore, Plint 2006 found there were no refractures in either group at six months. More children were lost to follow up in the splint group in both Davidson 2001 and Plint 2006,
but Plint 2006 argued that they would have returned if something
had been wrong. West 2005 compared plaster cast immobilisation
for four weeks to a soft bandage and found that most bandages
had been removed by two weeks and, as a likely consequence, wrist
mobility was significantly greater in the bandage group. Children
found the soft bandage was less uncomfortable, more convenient
and less painful than a plaster cast and no adverse effects were
reported for either group at four weeks follow up. Symons 2001
found the home removal of a pre-prepared backslab did not affect
swelling, tenderness, deformity or activities of daily living at six
weeks. Parents favoured home removal and the dissatisfaction in
the hospital group was compounded by waiting times, having to
take time off work and other practical considerations. Absolute
assurance of the safety and longer term clinical benefits is not provided in these trials. Yet with appropriate attention to diagnosis,
allowances made for exceptional cases for whom a cast seems warranted and availability of follow up to allay any concerns, it does
appear that easily removable and soft splints are less restrictive and
uncomfortable than cast immobilisation, enable more activities
and are more desirable to patients with buckle fractures and their
parents. It is not possible to identify which removable splint is best
or whether a soft bandage would do just as well.
Bohm 2006 or Webb 2006. The one trial (Boyer 2002) investigating this was seriously flawed (e.g. it was quasi-randomised and had
intention-to-treat problems), provided very limited outcome data
and, in all, does not provide any reliable evidence to determine
which, if any, arm position is preferable.
All three trials reported on cast fit, which here provided some
assurance of correctly applied casts (Chess 1994a).
Use of percutaneous wires for stabilisation
Strategies to maintain reduction and minimise post-injury deformity have been advocated with a view to maximising forearm and
wrist function. This is particularly relevant in children approaching skeletal maturity, in whom remodelling potential is reduced.
The most commonly advocated strategy is wire fixation. The three
trials (Gibbons 1994; McLauchlan 2002; Miller 2005) testing
wire fixation consistently found surgery reduced fracture redisplacement and secondary procedures. This was especially marked
in Gibbons 1994, where the distal ulna was intact in all cases. It
should be noted, however, that routine wire removal was not considered a secondary procedure. Amongst other biases, major selection bias cannot be ruled out for Gibbons 1994 or Miller 2005
(see Table 2). McLauchlan 2002 inadequately reported long-term
results but found that no child had any functional deficit at three
months, although there was less deformity in the wire-fixation
group. Miller 2005 gave some assurance of eventual restoration to
anatomic alignment in generally older children (mean age 12 years
at trial entry), which was independent of their treatment group.
AUTHORS’ CONCLUSIONS
Type of cast used after reduction of displaced fractures
Traditionally, displaced distal radius fractures have been immobilised in above-elbow casts. These are believed to reduce the risk
of displacement by blocking forearm rotation. Some surgeons have
further emphasised the benefits of positioning the forearm in either
supination or pronation to further minimise the effects of deforming muscle forces across the fracture. Two small trials (Bohm 2006;
West 2005) found a potential trend to less reduction or redisplacement in the below-elbow group but the treatment consequence of
this in terms of remanipulation was not significant. Bohm 2006
failed to report on function. Webb 2006 found children allocated
the below-elbow cast required less help with activities during cast
use and had better elbow mobility after cast removal. The two cast
groups did not differ in their cast-related complication rates. Both
trials were compromised; the use of quasi-randomised methods in
Webb 2006 is particularly disappointing. Additionally, there was
an imbalance in fracture types in Bohm 2006. Webb 2006 provided insufficient information on baseline characteristics.
Arm position in the above-elbow cast was not described in the
Implications for practice
The limited evidence available from randomised controlled trials
supports the use of removable splintage or supports for buckle
fractures with the option of clinical review rather than plaster cast
for three weeks requiring a return for removal and assessment.
However, the best type of splintage is not established.
For children whose displaced fractures have been reduced, there is
some preliminary evidence suggesting that below-elbow casts do
not increase, and may in fact reduce, the risk of redisplacement
compared with above-elbow casts. Furthermore, below-elbow casts
allow earlier return to activities, avoid elbow stiffness and are more
comfortable. If shorter casts are better then the need to consider
supinated, neutral or pronated positions of the forearm in aboveelbow immobilisation is redundant. Surgical fixation of reduced
fractures using percutaneous wiring maintains the reduction more
effectively than above-elbow casts. The limited data available indicated no advantage in function at three months. There was insufficient evidence to determine the best treatment for the different
types of displaced fracture, including radial fractures where the
ulna is intact.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
13
Implications for research
It is prudent to wait on the results of currently unpublished trials on buckle fractures (Hudson 2004; Ziouani 2007) to check
whether there remains a need for further randomised trials comparing removable splintage or supports versus plaster cast immobilisation. There is however scope for randomised comparisons
to establish the best methods of splinting or supporting buckle
fractures. Patient and parental acceptability of less intrusive and
restrictive treatment for buckle fractures is predictable and so in
choosing and conducting future research the emphasis should be
on obtaining reliable evidence to assure safety and cost effectiveness (health service and societal costs), especially given the large
numbers of children incurring these injuries.
Further research, involving good quality randomised trials that also
consider longer term outcome and cost effectiveness, is needed to
establish whether below-elbow casts are sufficient after the reduction of displaced fractures; measures are required to ensure that
the types of fractures, including whether the ulna is intact, are
balanced in each arm of the study. The same applies for research
to determine when surgery is needed.
ACKNOWLEDGEMENTS
We thank Lesley Gillespie for developing the subject-specific
search strategy. We thank the following for helpful comments at
editorial and external review of the protocol and/or review: Joanne
Elliott, Lindsey Elstub, Andrew Furlong, Lesley Gillespie, Alastair
Murray, Ben Vandemeer and Janet Wale. Special thanks are due to
Lesley Gillespie for her suggestions for rephrasing and her identification of additional trials.
REFERENCES
References to studies included in this review
Bohm 2006 {published data only}
Bohm ER, Bubbar V, Hing KY, Dzus A. Above and below-theelbow plaster casts for distal forearm fractures in children. A
randomized controlled trial. Journal of Bone & Joint Surgery American Volume 2006;88(1):1–8.
Boyer 2002 {published data only}
Boyer BA, Overton B, Schrader W, Riley P, Fleissner P. Position of
immobilization for pediatric forearm fractures. Journal of Pediatric
Orthopedics 2002;22(2):185–7.
Davidson 2001 {published data only}
Davidson JS, Brown DJ, Barnes SN, Bruce CE. Simple treatment
for torus fractures of the distal radius. Journal of Bone & Joint
Surgery - British Volume 2001;83(8):1173–5.
Gibbons 1994 {published data only}
∗
Gibbons CL, Woods DA, Pailthorpe C, Carr AJ, Worlock P. The
management of isolated distal radius fractures in children. Journal
of Pediatric Orthopedics 1994;14(2):207–10.
Gibbons CL, Woods DA, Pailthorpe C, Carr AJ, Worlock P. The
management of isolated distal radius fractures in children [abstract].
Journal of Bone & Joint Surgery - British Volume 1994;76(Suppl 1):
38.
McLauchlan 2002 {published data only}
McLauchlan GJ, Cowan B, Annan IH, Macnicol MF, Robb JE. A
randomised trial of treatment of completely displaced distal radial
fractures in children [abstract]. Journal of Bone and Joint Surgery British Volume 2000;82(Suppl 1):63.
∗
McLauchlan GJ, Cowan B, Annan IH, Robb JE. Management of
completely displaced metaphyseal fractures of the distal radius in
children. A prospective, randomised controlled trial. Journal of
Bone & Joint Surgery - British Volume 2002;84(3):413–7.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
14
Miller 2005 {published data only}
Miller B, Waters PM, Taylor B. A prospective, randomized study of
displaced pediatric metaphyseal distal radius fracture: cast
immobilization versus percutaneous pin fixation [abstract].
American Academy of Orthopaedic Surgeons 67th Annual
Meeting. 2000 Mar 15-19;Orlando (FL). http://www.aaos.org/
wordhtml/anmt2000/sciprog/054.htm (accessed 30 March 2001).
∗
Miller BS, Taylor B, Widmann RF, Bae DS, Snyder BD, Waters
PM. Cast immobilization versus percutaneous pin fixation of
displaced distal radius fractures in children: a prospective,
randomized study. Journal of Pediatric Orthopedics 2005;25(4):
490–4.
Plint 2006 {published data only}
Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. A randomized,
controlled trial of removable splinting versus casting for wrist
buckle fractures in children. Pediatrics 2006;117(3):691–7.
Symons 2001 {published data only}
Mehlman CT. Home removal of a backslab 3 weeks after buckle
fracture of the distal radius was as safe as removal at a fracture clinic.
Journal of Bone & Joint Surgery - American Volume 2002;84(5):883.
∗
Symons S, Rowsell M, Bhowal B, Dias JJ. Hospital versus home
management of children with buckle fractures of the distal radius.
A prospective, randomised trial. Journal of Bone & Joint Surgery British Volume 2001;83(4):556–60.
Webb 2006 {published data only}
Webb GR, Galpin RD, Armstrong DG. Comparison of short and
long arm plaster casts for displaced fractures in the distal third of
the forearm in children. Journal of Bone & Joint Surgery - American
Volume 2006;88(1):9–17.
West 2005 {published data only}
West S, Andrews J, Bebbington A, Ennis O, Alderman P. Buckle
fractures of the distal radius are safely treated in a soft bandage: a
randomized prospective trial of bandage versus plaster cast. Journal
of Pediatric Orthopedics 2005;25(3):322–5.
References to studies excluded from this review
wire stabilisation versus manipulation and plaster. National
Research Register 2007; Vol. 3.
Clarke N. personal communication 10 September 2007.
∗
Clarke N. A randomised controlled trial comparing Kirschner
wire stabilisation versus MUA plaster treatment for displaced radial
fractures. National Research Register 2006; Vol. 4.
Davidson 2002 {published data only}
Davidson AJ, Eyres RL, Cole WG. A comparison of prilocaine and
lidocaine for intravenous regional anaesthesia for forearm fracture
reduction in children. Paediatric Anaesthesia 2002;12(2):146–50.
Duncan 1999 {unpublished data only}
Duncan R. personal communication 03 October 2007.
∗
Duncan RD. Pinning or plaster for the unstable wrist fracture in
children?. National Research Register 2006; Vol. 4.
Gregory 1996 {published data only}
Gregory PR, Sullivan JA. Nitrous oxide compared with intravenous
regional anesthesia in pediatric forearm fracture manipulation.
Journal of Pediatric Orthopedics 1996;16(2):187–91.
Hargreaves 2004 {published data only}
Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract
infection rates: a randomized controlled trial between percutaneous
and buried wires. Journal of Hand Surgery - British Volume 2004;29
(4):374–6.
Pierce 1997 {published data only}
Pierce MC, Fuchs S. Evaluation of ketorolac in children with
forearm fractures. Academic Emergency Medicine 1997;4(1):22–6.
References to studies awaiting assessment
Hammacher 2006 {unpublished data only}
∗
Hammacher ER. Treatment of greenstick forearm fractures in
children using bandages or cast therapy. Controlled Clinical Trials:
http://controlled-trials.com/mrct/trial/231125 (accessed 17 January
2008).
Kropman R. personal communication 21 January 2008.
Bratt 1996 {published data only}
Bratt HD, Eyres RL, Cole WG. Randomized double-blind trial of
low- and moderate-dose lidocaine regional anesthesia for forearm
fractures in childhood. Journal of Pediatric Orthopedics 1996;16(5):
660–3.
Hudson 2004 {unpublished data only}
Guly H. personal communication 18 January 2008.
∗
Hudson 2004. Forearm buckle fracture treatment study.
Controlled Clinical Trials: http://controlled-trials.com/mrct/trial/
230245 (accessed 17 January 2008).
Chang 1999 {published data only}
Chang E, Daly J, Hawkins A, McGirr J, Fielding K, Hemmings L,
et al.An evaluation of the nurse practitioner role in a major rural
emergency department. Journal of Advanced Nursing 1999;30(1):
260–8.
Yousef 2006 {unpublished data only}
Yousef A, Al-Jafari N, Horton T. Soft cast versus plaster of paris
treatment of greenstick forearm fractures in children [abstract].
Journal of Bone and Joint Surgery - British Volume 2006;88(Suppl 2):
278.
Chess 1994 {published data only}
Chess DG, Hyndman JC, Leahey JL, Brown DC, SInclair AM.
Short arm plaster cast for distal pediatric forearm fractures. Journal
of Pediatric Orthopedics 1994;14(2):211–3.
Clarke 2006 {unpublished data only}
Bell M. personal communication 04 September 2007.
Bell M. EPOS Randomised controlled trial of management of distal
radial fractures: A randomised controlled trial comparing Kirschner
Ziouani 2007 {unpublished data only}
∗
Jacobs M. Distal forearm torus fractures - do they need a splint?.
Controlled Clinical Trials: http://www.controlled-trials.com/
ISRCTN34857372 (accessed 17 January 2008).
Ziouani S. personal communication 22 January 2008.
References to ongoing studies
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
15
Colaris 2008a {unpublished data only}
Colaris J. personal communication January 21 2008.
∗
Colaris J. Dislocated stable distal both-bone forearm fractures in
children. Clinicaltrials.gov: http://clinicaltrials.gov/ct2/show/
NCT00397852 (accessed 22 January 2008).
Colaris 2008b {unpublished data only}
Colaris J. personal communication January 21 2008.
∗
Colaris J. Dislocated unstable distal both-bone forearm fractures
in children. Clinicaltrials.gov: http://clinicaltrials.gov/ct2/show/
NCT00398268 (accessed 22 January 2008).
Additional references
Altman 2003
Altman DG, Bland JM. Interaction revisited: the difference
between two estimates. BMJ 2003;326(7382):219.
Boyer 2002a
Boyer BA, Overton B, Schrader W, Riley P, Fleissner P. Position of
immobilization for pediatric forearm fractures. Journal of Pediatric
Orthopedics 2002;22(2):185–7. [MEDLINE: MEDLINE&#160;
21846604; : CN–00378135]
Chess 1994a
Chess DG, Hyndman JC, Leahey JL, Brown DC, Sinclair AM.
Short arm plaster cast for distal pediatric forearm fractures. Journal
of Pediatric Orthopedics 1994;14(2):211–3. [MEDLINE:
94245921]
Gibbons 1994a
Gibbons CL, Woods DA, Pailthorpe C, Carr AJ, Worlock P. The
management of isolated distal radius fractures in children. Journal
of Pediatric Orthopedics 1994;14(2):207–10. [MEDLINE:
MEDLINE&#160;94245920; : CN–00101451]
Herring 2002
Herring JA, Tachdjian MO. Upper extremity injuries. In: Herring
JA editor(s). Tachdjian’s Pediatric Orthopaedics. 3rd Edition. Vol. 3,
London: Saunders, 2002:2233–41.
Higgins 2003
Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring
inconsistency in meta-analyses. BMJ 2003;327:557–60.
Higgins 2006
Higgins JPT, Green S, editors. Highly sensitive search strategies for
identifying reports of randomized controlled trials in MEDLINE.
Cochrane Handbook for Systematic Reviews of Interventions 4.2.6
[updated September 2006]; Appendix 5b. www.cochrane.org/
resources/handbook/hbook.htm (accessed 01 May 2007).
McLauchlan 2002a
McLauchlan GJ, Cowan B, Annan IH, Robb JE. Management of
completely displaced metaphyseal fractures of the distal radius in
children. A prospective, randomised controlled trial. Journal of
Bone & Joint Surgery - British Volume 2002;84(3):413–7.
[MEDLINE: MEDLINE&#160;21997179; : CN–00380028]
Worlock 1986
Worlock P, Stower M. Fracture patterns in Nottingham children.
Journal of Pediatric Orthopedics 1986;6(6):656–60.
Young 2000
Young NL, Williams JI, Yoshida KK, Wright JG. Measurement
properties of the Activities Scale for Kids. Journal of Clinical
Epidemiology 2000;53(2):125–37.
∗
Indicates the major publication for the study
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
16
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Bohm 2006
Methods
Randomised trial: use of sealed envelopes (claimed blinded randomisation)
Participants
Royal University Hospital, Saskatoon, Saskatchewan. Canada
117 children with closed fracture of the distal third of the forearm (radial or radial and ulnar; no isolated
distal ulnar fractures) that required reduction.
Exclusion: open fracture or Salter Harris type III and IV fractures
Sex: 61 male (60% of 102)
Age: mean 8.6 years
Assigned: ? (below-elbow) / ? (above-elbow)
Post exclusion (see Notes): 56 / 46
Analysed: 56 / 46 (at 18 weeks follow up) (see Notes)
Interventions
Closed reduction under conscious sedation in Emergency department (within 4 hours of presentation) or
general anaesthesia in operating theatre (within 24 hours).
1. Below-elbow plaster cast (3-point moulding)
2. Above-elbow cast. Once hard, the below-elbow cast was extended to above the elbow.
Follow-up visit to fracture clinic every week for 3 weeks. Cast removal at clinic at 6 weeks. Hospital
discharge with a sling and analgesia.
Outcomes
Length of follow up: 18 weeks
Redisplacement and remanipulation
Angular deformity (radial and ulnar)
Complications: reinforced or changed cast, cast split because of swelling, compartment syndrome (none)
Conversion to other cast (adherence)
Notes
Fifteen patients were excluded after enrolment: nine didn’t require fracture reduction, two had wrong cast
applied, two were of the wrong age, one had wrong fracture type, and one had surgery.
Radiographs were inadequate for two participants (1 versus 1).
Cast fit (a confounding factor) was assessed by calculating a ’cast index’: there was no difference reported
between the two groups.
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
Yes
A - Adequate
Boyer 2002
Methods
Quasi-randomised trial: according to date of birth
Participants
Children’s Hospital in Akron, Ohio, USA
109 children with displaced (or angulated) fractures of the distal third of forearm (distal radius or radius
and ulna) requiring closed reduction (based on judgement of attending physician).
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
17
Boyer 2002
(Continued)
Exclusion: closed metaphyses
Sex: 71 male (65%)
Age: mean 8.7 years
Fracture: 59 “displaced”; 40 “angulated”
Assigned: ? (supinated) / ? (pronated) / ? (neutral)
Analysed: 35 / 26 / 38 (at minimum 6 weeks follow up ) (see Notes)
Interventions
All participants had a closed reduction under general anaesthesia. A below-elbow plaster cast was then
applied. After confirmation of the reduction with fluoroscopy, fibreglass casting material was used to
complete an above-elbow cast. The forearm was positioned in one of three positions:
1. Supinated forearm position
2. Pronated forearm position
3. Neutral forearm position
Routine clinical and radiographic follow up; first check at 1 week. Duration of splintage was not stated
but assumed to be at fracture union (6 to 8 weeks).
Outcomes
Length of follow up: minimum 6 weeks (6-8 weeks)
Clinical and radiological union (no report)
Residual fracture angulation (mean 7 degrees overall)
Secondary reduction (for unacceptable loss of alignment)
Notes
Ten children were excluded from the analyses because of insufficient X-rays.
Cast fit (a confounding factor) was assessed by calculating a ’cast index’: there was no difference reported
between the three groups.
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
No
C - Inadequate
Davidson 2001
Methods
Quasi-randomised trial: allocation based on day of attendance at fracture clinic
Participants
Children’s Hospital in Liverpool, UK
201 children with buckle (“torus”) fractures of the distal radius.
Exclusion: none stated
Sex: 107 male (53%)
Age: mean 8.9 years, range 2 to 15 years
Assigned: 116 (splint)/ 85 (cast)
Analysed: 98 / 81 (at 3 weeks follow up) (see Notes)
Interventions
After initial diagnosis at A&E, fractures were immobilised by a metal splint held in place by a crepe
bandage. Trial interventions were provided upon attending the fracture clinic, usually the next day.
1. Futura splint sized and fitted by doctor or nurse
2. Below-elbow plaster cast applied by plaster cast technician
Splints or casts were removed after 3 weeks.
Interventions for treating wrist fractures in children (Review)
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18
Davidson 2001
(Continued)
Outcomes
Length of follow up: 3 weeks
Clinical and radiological union (all healed)
Loss of position (none)
Adherence
Non-attendance at clinic
Costs
Notes
Two participants were excluded from follow up: one because parents requested child was given a cast
rather than a splint and the other (group not stated) who was discovered at follow up to have a greenstick
fracture.
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
No
C - Inadequate
Gibbons 1994
Methods
Quasi-randomised: child received the preferred treatment used by the consultant surgeon who was responsible for care
Participants
John Radcliffe Hospital, Oxford, UK
23 children with isolated distal radius fracture with an intact ulna. Indications for manipulation: > 15
degrees angulation for children under 10 years or > 10 degrees angulation if age > 10 years.
Exclusion: patients aged 15 years or over.
Sex: 15 male (65%)
Age: mean 9 years, range 5 to 14 years
Assigned: 12 (wire) / 11 (cast only)
Analysed: 12 / 11 (6 months: numbers assumed)
Interventions
Manual reduction under general anaesthesia.
1. Percutaneous (stab incision) Kirschner wire inserted from the radial styloid. Use of fluoroscopy. Aboveelbow plaster cast. Wire removed under sedation or general anaesthesia after 3 weeks, then below-elbow
cast applied for a further week
2. Above-elbow plaster cast.
Outcomes
Length of follow up: 6 months
Loss of reduction and remanipulation
Non-union (none)
Hypertrophic scar
Superficial radial nerve damage (none)
Early physeal closure (none)
Notes
Baseline characteristics similar for the two groups except for pre-reduction dorsal angulation: mean 26.4
degrees versus 13.4 degrees. Completely displaced fractures: 8 in each group.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
19
Gibbons 1994
(Continued)
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
No
C - Inadequate
McLauchlan 2002
Methods
Randomised trial: use of sealed envelopes, opened after closed reduction.
Participants
Royal Hospital for Sick Children, Edinburgh, UK
68 with completely displaced metaphyseal fractures of the distal radius, with of without ulnar fracture
Exclusion: physeal injuries
Sex: 42 male (62%)
Age: mean 7.9 years, range 4 to 14 years
Assigned: 35 (wire) / 33 (cast only)
Analysed: 34 / 31 (radiological review); 56 for clinical review (3 months) (see Notes)
Interventions
Reduction under general anaesthesia within 18 hours of admission, checked with image intensifier.
1. Single percutaneous Kirschner wire introduced across the fracture to the radial side of Lister’s tubercule.
Then above-elbow cast (probably plaster). Review at 3 weeks when wire removed and cast changed.
2. Above-elbow cast (probably plaster). Weekly radiological review for 3 weeks.
Casts removed between 4 and 6 weeks after injury depending on age of child.
Outcomes
Length of follow up: 3 months
Loss of position and secondary procedure
Wire migration
Grip strength
Residual pain
Range of motion (flexion, extension, radial and ulnar deviation, supination, pronation)
Prominant scarring
Pain requiring early wire removal
Angular deformity
Notes
Intact ulna: 3 versus 5.
Paper did not provide the numbers of participants in the two groups available for clinical review.
Corrective osteotomy was performed at 6 months in one participant of the cast only group.
Small discrepancies between abstract and full reports of the trial.
Seven children who parents refused consent for trial inclusion were treated conservatively.
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
Unclear
B - Unclear
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
20
Miller 2005
Methods
Randomised by sealed envelopes for consenting participants (25). A further 9 patients enrolled and treated
according to surgeon’s preference (see Notes)
Participants
Children’s Hospital, Boston, MA, USA
34 children with displaced metaphyseal fractures of the distal radius. Aged 10 years or over. Angulation
> 30 degrees or complete fracture displacement.
Exclusion: open fracture, history of injury or surgery of the affected wrist, fractures requiring open
reduction, swelling or neurovascular compromise precluding circumferential cast immobilisation. Skeletal
maturity.
Sex: male 31 (91%)
Age: mean 12.4 years, range 10 to 14 years
Assigned: 16 (wire) / 18 (cast only)
Analysed: ? / ? (25 followed up at mean 2.8 years)
Interventions
Closed reduction under general anaesthesia with fluoroscopic guidance.
1. Percutaneous wire fixation. Small incision made over radial styloid. Wire directly proximally and
ulnarly across fracture site engaging in opposite cortex. Optional second wire inserted through small dorsal
incision. Then above-elbow cast. Wires removed at 4 weeks.
2. Above-elbow cast.
Above-elbow cast comprised plaster cast overwrapped with fibreglass casting material. All patients had
above-elbow cast for 4 weeks and then a further 2 weeks in a below-elbow cast.
Outcomes
Length of follow up: 6 months (average 10.5 weeks); also long-term follow up mean 2.8 years (numbers
in each group not stated).
Overall complications
Loss of reduction and secondary procedures
Nerve hyperesthesia
Tendon (extensor carpi ulnaris) irritation
Wire migration
Pin-site (wire-site) infection
Failed closed reduction
Non-union (none)
Permanent nerve damage (none)
Compartment syndrome (none)
No long-term pain or limitations in range of motion, strength, or activities noted. No neurovascular
compromise, growth arrest or deformity.
Notes
Separate data were not provided for the 9 children treated according to the surgeon’s preference. Discrepancies between the two groups in initial dorsal angulation and shortening may have reflected some bias
in the surgeon preference group.
A retrospective cost analysis was based on charges for operating room, anaesthesia services, orthopaedic
surgery, office visits, radiology, plaster cast services.
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
No
C - Inadequate
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
21
Plint 2006
Methods
Randomised trial: initial use of web-based computer generated allocation with a block size of 4. Changed
due to web access problems to sealed opaque envelopes sequentially opened by a research assistant.
Participants
Children’s Hospital of Eastern Ontario, Ottawa, Canada
113 children with buckle fractures of the distal radius or ulna confirmed by a radiologist. (No child had
an isolated distal ulna fracture.) Age 6 to 15 years.
Exclusion: another fracture of the same limb, bilateral wrist fractures, pathological fracture, language
barrier, lived outside hospital catchment area.
Sex: male 57 (66% of 87)
Age: mean 9.7 years
Assigned: 57 (splint) / 56 (cast)
Analysed: 42 / 45 (at 4 weeks follow up) (see Notes)
Interventions
All treated within 7 days of injury.
(1) Removable plaster splint: individually fitted plaster splint attached with a wrap (tensor bandage).
Verbal and written instructions to wear splint for comfort only; to remove as desired; and to discontinue
when desired.
(2) Below-elbow plaster cast. Written and verbal instructions (e.g. avoid getting cast wet). Cast removed
at 3 weeks.
All children instructed to avoid contact sports until follow-up clinic.
Outcomes
Length of follow up: 4 weeks; also long-term follow up at 6 months for refracture.
ASKp (Activities Scales for Kids performance) scores
Pain (visual analogue scale)
Problems with various activities (printing or writing; drawing; feeding; grooming; bathing or showering)
Problems with casts
Length of immobilisation and usage
Report to clinic with a problem
Treatment preference
Refracture
Notes
Sixteen children (7 versus 9) were excluded post-randomisation because they did not have buckle fractures
(all had greenstick fractures); one child in the splint group was too young and four in the same group
withdrew their participation. Five children (2 versus 3) were lost to follow up.
Pre-study power calculation to detect 80% chance of a 15 point difference in the ASKp score.
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
Yes
A - Adequate
Symons 2001
Methods
Randomised trial: use of computer generated random-number sheet
Participants
Leicester University Hospital, Leicester, UK
87 children with buckle fractures of the distal radius
Interventions for treating wrist fractures in children (Review)
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22
Symons 2001
(Continued)
Exclusion: pathological fractures, previous problems with wrist, bicortical fractures, unwilling to enter
study, parents not available, unable to understand study, not in local catchment area.
Sex: male 47 (59% of 80)
Age: mean 9.2 years
Assigned: 40 (home)/47 (hospital)
Analysed: 38 / 42 (at 6 weeks follow up) (see Notes)
Interventions
After initial diagnosis at A&E, referral was made to the study team on the same day. After randomisation,
both groups were treated with a below-elbow plaster backslab.
1. Home group: backslab removed by parents at 3 weeks. The backslab was cut and rewrapped to avoid
the need for scissors during removal at home. Parents were given an explanation and assured of access to
the fracture clinic if required.
2. Hospital group: return to clinic at 3 weeks for removal of backslab by nursing staff and for medical
review.
Outcomes
Length of follow up: 6 weeks
Swelling
Tenderness
Deformity (none)
Writing and activities of daily living
Ability to partake in hobbies
Range of movement (wrist and forearm)
Problems with care
Complaints
Adherence
Satisfaction with treatment
Notes
All 7 children not attending the 6 weeks follow-up examination were reported to have “no difference in
outcome from those who came for review”
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
Unclear
B - Unclear
Webb 2006
Methods
Quasi-randomised: allocation based on odd and even medical record numbers
Participants
Women and Children’s Hospital, Buffalo, New York, USA
127 children with displaced fractures of the distal forearm
Exclusion: age under 4 years old, open or pathological fracture, closed physes, non consent, refracture
along pre-existing fracture lines
Sex: 85 male (75% of 113)
Age: 9.8 years, range 4 to 16 years
Assigned: 63 (below-elbow) / 64 (above-elbow)
Analysed:53 / 60 (at 7.7 months follow up) (see Notes)
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
23
Webb 2006
(Continued)
Interventions
Fracture was reduced (manual or fingertraps methods) under analgesia and sedation at Emergency department.
1. Below-elbow plaster cast
2. Above-elbow plaster cast; the below-elbow cast was extended to above the elbow.
Strict elevation for first 24 to 48 hours. First follow-up visit at 7-10 days. At 4 weeks, cast were removed if
healed. Otherwise, casts left in place but above-elbow casts were cut down to below-elbow casts. Clinical
examination at 8-10 weeks and physical; therapy if restricted mobility
Outcomes
Length of follow up: mean 7.7 months (3.5 to 11 months)
Lost reduction in cast
Rereduction (none)
Radiological outcome (displacement, angulation, deviation)
Wrist and elbow motion
Time to regain range of motion
Days missed school
Activities of daily living during cast use
Complications: refracture (none), restricted shoulder motion
Notes
Of 10 children in the below-elbow cast group who were not included in the analyses, seven were lost to
follow up and three were excluded because of surgery. Of four children in the above-elbow cast group not
included in the analyses, three were lost to follow up and one was excluded because of surgery.
Cast fit (a confounding factor) was assessed by calculating a ’cast index’: there was no difference reported
between the two groups.
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
No
C - Inadequate
West 2005
Methods
Randomised trial: presealed envelopes selected by parent
Participants
Royal Gwent Hospital, Newport, UK
42 children with buckle fractures of the distal radius
Exclusion: not stated
Sex: not stated
Age: < 5 years = 1; 5-10 years = 26; > 10 years = 12 (of 40)
Assigned: 21 (bandage)/ 21 (cast)
Analysed: 18 / 21 (at 4 weeks follow up) (see Notes)
Interventions
Recruited on the day of presentation to A&E. After randomisation, treatment started on the same day.
1. Bandage: orthopaedic wool and cotton crepe held by tape. Patient assessed at weekly intervals up to 4
weeks
2. Cast: below-elbow plaster backslab applied for 1 week and then changed to full below-elbow polymer
(probably fibreglass) cast for further 3 weeks. Seen at 4 weeks for cast removal.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
24
West 2005
(Continued)
Outcomes
Length of follow up: 4 weeks
Comfort
Pain (in bandage/cast)
Range of movement (flexion/extension)
Adherence (all bandages were removed at home by end of week 2) Convenience
Parental concern (regarding trial)
Adverse effects or skin problems (none)
Notes
One participant allocated bandage was withdrawn from follow up because parents requested the child was
given a cast at first appointment at fracture clinic. Two other participants in the bandage group failed to
return for follow up; their parents reported these had no problems.
Risk of bias
Item
Authors’ judgement
Description
Allocation concealment?
Yes
A - Adequate
A&E: Accident and Emergency Department
K-wire: Kirschner wire
MUA: manipulation under anaesthesia
ROM: range of motion
Characteristics of excluded studies [ordered by study ID]
Bratt 1996
Randomised trial of low- versus moderate-dose lidocaine regional anaesthesia for forearm fractures in children.
Excluded as it is an anaesthesia trial.
Chang 1999
Randomised trial of nurse practitioners versus medical officers for wound management and treatment of blunt
limb trauma. Excluded as it is not specific for distal radius fractures in children.
Chess 1994
Retrospective series of below-elbow plaster cast treatment of 761 distal one-third paediatric forearm fractures with
an independent retrospective radiographic review.
Clarke 2006
Recruitment into the original and second stage of a randomised trial comparing Kirschner-wire fixation versus
plaster cast in children under 12 years of age was reported to have been difficult with insufficient numbers.
Davidson 2002
Blinded randomised study, comparing prilocaine and lidocaine for intravenous regional anaesthesia for forearm
fracture reduction in children. Excluded as it is an anaesthesia trial.
Duncan 1999
This randomised trial was not started after an initial pilot study completed in 1999 found no differences between
pins and plaster for unstable wrist fractures in children.
Gregory 1996
A randomised trial of intravenous regional anaesthesia compared with nitrous oxide gas in children with forearm
fractures requiring manipulation. Excluded as it is an anaesthesia trial.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
25
(Continued)
Hargreaves 2004
Randomised trial compared the results of burying the wire ends under the skin to leaving them above the surface
in children and adults with isolated distal radial fractures. Excluded because separate data for children were not
available.
Pierce 1997
Randomised, double-blind trial evaluating ketorolac for pain relief and an opioid-sparing effect in children with
forearm fractures requiring reduction. Excluded as it is an anaesthesia trial.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
26
Characteristics of ongoing studies [ordered by study ID]
Colaris 2008a
Trial name or title
Dislocated stable distal both-bone forearm fractures in children
Methods
Participants
Aim: 110 children with stable dislocated distal both-bone forearm fracture.
Inclusion Criteria:
both-bone forearm fracture
distal
dislocated
stable after reposition
age < 16 years
Exclusion Criteria:
fracture older than 1 week
no informed consent
refracture
open fracture (Gustillo 2 and 3)
both fractures of type torus
Interventions
K-wire fixation versus no K-wire fixation of the fracture after a stable reposition
Outcomes
Follow up: 6 months
number of re-dislocations, re-operations, consolidation and dislocation on X-ray, function of both arms,
complaints in daily living and complications.
Starting date
January 2006
Contact information
Dr Joost Colaris
Juliana Children’s Hospital, Den Haag, Zuid Holland, Netherlands
Tel: +31642220265
Email: [email protected]
Notes
Colaris 2008b
Trial name or title
Dislocated unstable distal both-bone forearm fractures in children
Methods
Participants
Aim: 60 children with unstable dislocated distal both-bone forearm fracture.
Inclusion Criteria:
both-bone forearm fracture
distal
dislocated
unstable after reposition
age < 16 years
Exclusion Criteria:
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
27
Colaris 2008b
(Continued)
fracture older than 1 week
no informed consent
refracture
open fracture (Gustillo 2 and 3)
both fractures of type torus
Interventions
K-wire fixation versus no K-wire fixation of the fracture after an unstable reposition
Outcomes
Follow up: 6 months
number of re-dislocations, re-operations, consolidation and dislocation on X-ray, function of both arms,
complaints in daily living and complications.
Starting date
January 2006
Contact information
Dr Joost Colaris
Juliana Children’s Hospital, Den Haag, Zuid Holland, Netherlands
Tel: +31642220265
Email: [email protected]
Notes
K-wire: Kirschner wire
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
28
DATA AND ANALYSES
Comparison 1. Futura splint versus below-elbow plaster cast for buckle fractures
Outcome or subgroup title
1 Non-attendance at follow-up
clinic
2 Non-union
3 Non-adherence (noncompliance)
No. of
studies
No. of
participants
Statistical method
Effect size
1
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
Totals not selected
Comparison 2. Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome or subgroup title
1 Moderate or severe difficulty
levels for different activities at
28 days
1.1 Difficulty with printing,
writing
1.2 Difficulty with drawing
1.3 Difficulty with feeding
1.4 Difficulty with grooming
1.5 Difficulty with bathing/
showering
2 Moderate or severe levels
of difficulty for bathing/
showering
2.1 Difficulty at 7 days
2.2 Difficulty at 14 days
2.3 Difficulty at 20 days
2.4 Difficulty at 28 days
3 Unable to return to regular
sporting or physical play
activities
3.1 At 20 days
3.2 At 28 days
4 Unable to return to regular
sporting or physical play
activities at 28 days: worst/best
case scenarios
4.1 Worst case for splint group
4.2 Best case for splint group
5 Complications
No. of
studies
No. of
participants
Statistical method
Effect size
1
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
1
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
1
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Not estimable
Not estimable
Not estimable
1
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
1
1
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Not estimable
Not estimable
Not estimable
Totals not selected
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Not estimable
Totals not selected
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Not estimable
Totals not selected
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
29
5.1 Problems with cast
5.2 Refracture
6 Would prefer not to have the
same treatment (splint or cast)
in future
6.1 Patient preference
6.2 Parent preference
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Not estimable
Totals not selected
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Not estimable
Comparison 3. Soft bandage versus below-elbow plaster then polymer cast for buckle fractures
Outcome or subgroup title
1 Uncomfortable splintage
2 Pain while wearing splintage
3 Found splintage inconvenient
4 Adverse effects (e.g. skin
problems)
No. of
studies
No. of
participants
1
1
1
1
Statistical method
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Effect size
Totals not selected
Totals not selected
Totals not selected
Totals not selected
Comparison 4. Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome or subgroup title
1 Swelling
2 Tenderness
3 Avoidance of some hobbies
4 Deformity
5 Parents reported problems with
care of fracture
6 Parents would not choose the
same treatment again
7 Non-adherence (noncompliance)
No. of
studies
No. of
participants
Statistical method
Effect size
1
1
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
Totals not selected
Totals not selected
Totals not selected
Totals not selected
1
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
1
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
30
Comparison 5. Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome or subgroup title
1 Fracture redisplacement and
rereduction
1.1 Redisplaced fracture
1.2 Reangulation greater
than 15 degrees or > 30%
redisplacement
1.3 Remanipulation
2 Limitations in activities of daily
living during cast use
2.1 Needed help dressing
2.2 Unable to shower
2.3 Needed help using toilet
2.4 Needed help eating
2.5 Needed help at school
2.6 Unable to write
2.7 Patient reported help
required because of difficulties
with activities of daily living
3 Days off school
4 Range of movement (differences
between injured and
contralateral side) (degrees)
4.1 Difference at cast removal
in arcs of wrist motion
4.2 Final difference in arcs of
wrist motion
4.3 Difference at cast removal
in arcs of elbow motion
4.4 Final difference in arcs of
elbow motion
5 Time to regain range of motion
(days)
6 Complications
6.1 Refracture
6.2 Compartment syndrome
6.3 Cast split for swelling
6.4 Cast reinforced for
’breakdown’
6.5 Cast changed for
loosening or breakdown
6.6 Change of cast type (for
comfort or other problems)
6.7 Physical therapy required
to regain shoulder range of
movement
No. of
studies
No. of
participants
2
Statistical method
Effect size
Risk Ratio (M-H, Fixed, 95% CI)
Subtotals only
2
1
213
113
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
0.60 [0.36, 1.00]
0.16 [0.01, 3.05]
2
1
213
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
0.41 [0.04, 3.78]
Totals not selected
1
1
1
1
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Not estimable
Not estimable
Not estimable
Not estimable
Not estimable
Not estimable
1
1
Mean Difference (IV, Fixed, 95% CI)
Mean Difference (IV, Fixed, 95% CI)
Totals not selected
Totals not selected
1
Mean Difference (IV, Fixed, 95% CI)
Not estimable
1
Mean Difference (IV, Fixed, 95% CI)
Not estimable
1
Mean Difference (IV, Fixed, 95% CI)
Not estimable
1
Mean Difference (IV, Fixed, 95% CI)
Not estimable
1
Mean Difference (IV, Fixed, 95% CI)
Totals not selected
2
1
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
Not estimable
Not estimable
Not estimable
Not estimable
1
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
1
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
1
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
31
Comparison 6. Above-elbow cast (forearm pronated versus neutral versus supinated) for displaced fractures
Outcome or subgroup title
1 Second reduction for
unacceptable loss of alignment
1.1 Pronation versus
supination
1.2 Neutral position versus
supination
1.3 Pronation versus neutral
position
Comparison 7.
fractures
No. of
studies
No. of
participants
Statistical method
Effect size
1
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
1
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
1
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
1
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced
Outcome or subgroup title
1 Fracture redisplacement and
rereduction
1.1 Redisplaced fracture
1.2 Remanipulation (and
secondary procedure for loss of
position)
2 Complications
2.1 Failed reduction
2.2 Compartment syndrome
2.3 Pin site infection
2.4 Pin migration (wires
removed)
2.5 Pain resulting from wire
2.6 Nerve damage or irritation
2.7 Tendon irritation
2.8 Non-union
2.9 Malunion
2.10 Prominent scar at K-wire
insertion site
2.11 Early physeal closure
2.12 Secondary procedures
(early wire removal, cast
adjustment, rereduction, open
reduction)
3 Anatomical deformity at 3
months
3.1 Coronal angular deformity
(degrees)
No. of
studies
No. of
participants
3
Statistical method
Effect size
Risk Ratio (M-H, Fixed, 95% CI)
Subtotals only
3
3
125
125
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
0.06 [0.02, 0.24]
0.06 [0.01, 0.30]
3
1
1
1
2
34
34
34
102
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Subtotals only
0.37 [0.02, 8.55]
Not estimable
5.59 [0.29, 108.38]
4.15 [0.49, 35.21]
1
2
1
2
2
1
68
57
34
57
57
23
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
2.83 [0.12, 67.19]
1.13 [0.08, 16.55]
3.35 [0.15, 76.93]
Not estimable
Not estimable
2.77 [0.12, 61.65]
2
3
57
125
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Not estimable
0.26 [0.12, 0.56]
1
Mean Difference (IV, Fixed, 95% CI)
Totals not selected
1
Mean Difference (IV, Fixed, 95% CI)
Not estimable
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
32
3.2 Sagittal angular deformity
(degrees)
1
Mean Difference (IV, Fixed, 95% CI)
Not estimable
Analysis 1.1. Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 1
Non-attendance at follow-up clinic.
Review:
Interventions for treating wrist fractures in children
Comparison: 1 Futura splint versus below-elbow plaster cast for buckle fractures
Outcome: 1 Non-attendance at follow-up clinic
Study or subgroup
Davidson 2001
Futura splint
Plaster cast
n/N
n/N
18/116
4/85
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
3.30 [ 1.16, 9.39 ]
0.1 0.2
0.5
1
Favours splint
2
5
10
Favours cast
Analysis 1.2. Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 2
Non-union.
Review:
Interventions for treating wrist fractures in children
Comparison: 1 Futura splint versus below-elbow plaster cast for buckle fractures
Outcome: 2 Non-union
Study or subgroup
Davidson 2001
Futura splint
Plaster cast
n/N
n/N
0/98
0/81
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
0.0 [ 0.0, 0.0 ]
0.1 0.2
0.5
Favours splint
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
2
5
10
Favours cast
33
Analysis 1.3. Comparison 1 Futura splint versus below-elbow plaster cast for buckle fractures, Outcome 3
Non-adherence (non-compliance).
Review:
Interventions for treating wrist fractures in children
Comparison: 1 Futura splint versus below-elbow plaster cast for buckle fractures
Outcome: 3 Non-adherence (non-compliance)
Study or subgroup
Davidson 2001
Futura splint
Plaster cast
n/N
n/N
2/98
0/81
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
4.14 [ 0.20, 85.05 ]
0.01
0.1
1
Favours splint
10
100
Favours cast
Analysis 2.1. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures,
Outcome 1 Moderate or severe difficulty levels for different activities at 28 days.
Review:
Interventions for treating wrist fractures in children
Comparison: 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome: 1 Moderate or severe difficulty levels for different activities at 28 days
Study or subgroup
Removable splint
Cast
n/N
n/N
Risk Ratio
0/26
1/34
0.43 [ 0.02, 10.19 ]
0/26
1/34
0.43 [ 0.02, 10.19 ]
0/26
0/34
0.0 [ 0.0, 0.0 ]
1/26
2/34
0.65 [ 0.06, 6.83 ]
1/26
2/34
0.65 [ 0.06, 6.83 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Difficulty with printing, writing
Plint 2006
2 Difficulty with drawing
Plint 2006
3 Difficulty with feeding
Plint 2006
4 Difficulty with grooming
Plint 2006
5 Difficulty with bathing/showering
Plint 2006
0.001 0.01 0.1
Favours splint
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10 100 1000
Favours cast
34
Analysis 2.2. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures,
Outcome 2 Moderate or severe levels of difficulty for bathing/showering.
Review:
Interventions for treating wrist fractures in children
Comparison: 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome: 2 Moderate or severe levels of difficulty for bathing/showering
Study or subgroup
Removable splint
Cast
n/N
n/N
Risk Ratio
Risk Ratio
8/32
26/40
0.38 [ 0.20, 0.73 ]
4/30
23/41
0.24 [ 0.09, 0.62 ]
1/25
13/32
0.10 [ 0.01, 0.70 ]
1/26
2/34
0.65 [ 0.06, 6.83 ]
M-H,Fixed,95% CI
M-H,Fixed,95% CI
1 Difficulty at 7 days
Plint 2006
2 Difficulty at 14 days
Plint 2006
3 Difficulty at 20 days
Plint 2006
4 Difficulty at 28 days
Plint 2006
0.01
0.1
1
Favours splint
10
100
Favours cast
Analysis 2.3. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures,
Outcome 3 Unable to return to regular sporting or physical play activities.
Review:
Interventions for treating wrist fractures in children
Comparison: 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome: 3 Unable to return to regular sporting or physical play activities
Study or subgroup
Removable splint
Cast
n/N
n/N
Risk Ratio
7/25
19/32
0.47 [ 0.24, 0.94 ]
1/26
11/34
0.12 [ 0.02, 0.86 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 At 20 days
Plint 2006
2 At 28 days
Plint 2006
0.001 0.01 0.1
Favours splint
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10 100 1000
Favours cast
35
Analysis 2.4. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures,
Outcome 4 Unable to return to regular sporting or physical play activities at 28 days: worst/best case scenarios.
Review:
Interventions for treating wrist fractures in children
Comparison: 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome: 4 Unable to return to regular sporting or physical play activities at 28 days: worst/best case scenarios
Study or subgroup
Removable splint
Cast
n/N
n/N
Risk Ratio
17/42
11/45
1.66 [ 0.88, 3.11 ]
1/42
22/45
0.05 [ 0.01, 0.35 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Worst case for splint group
Plint 2006
2 Best case for splint group
Plint 2006
0.001 0.01 0.1
1
Favours splint
10 100 1000
Favours cast
Analysis 2.5. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures,
Outcome 5 Complications.
Review:
Interventions for treating wrist fractures in children
Comparison: 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome: 5 Complications
Study or subgroup
Removable splint
Cast
n/N
n/N
Risk Ratio
0/42
5/45
0.10 [ 0.01, 1.71 ]
0/34
0/41
0.0 [ 0.0, 0.0 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Problems with cast
Plint 2006
2 Refracture
Plint 2006
0.001 0.01 0.1
Favours splint
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10 100 1000
Favours cast
36
Analysis 2.6. Comparison 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures,
Outcome 6 Would prefer not to have the same treatment (splint or cast) in future.
Review:
Interventions for treating wrist fractures in children
Comparison: 2 Removable plaster splint versus below-elbow plaster cast for buckle fractures
Outcome: 6 Would prefer not to have the same treatment (splint or cast) in future
Study or subgroup
Removable splint
Cast
n/N
n/N
Risk Ratio
Risk Ratio
1/21
18/23
0.06 [ 0.01, 0.42 ]
3/20
12/25
0.31 [ 0.10, 0.96 ]
M-H,Fixed,95% CI
M-H,Fixed,95% CI
1 Patient preference
Plint 2006
2 Parent preference
Plint 2006
0.001 0.01 0.1
1
Favours splint
10 100 1000
Favours cast
Analysis 3.1. Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle
fractures, Outcome 1 Uncomfortable splintage.
Review:
Interventions for treating wrist fractures in children
Comparison: 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures
Outcome: 1 Uncomfortable splintage
Study or subgroup
West 2005
Bandage
Cast
n/N
n/N
1/18
12/21
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
0.10 [ 0.01, 0.68 ]
0.01
0.1
Favours bandage
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10
100
Favours cast
37
Analysis 3.2. Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle
fractures, Outcome 2 Pain while wearing splintage.
Review:
Interventions for treating wrist fractures in children
Comparison: 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures
Outcome: 2 Pain while wearing splintage
Study or subgroup
West 2005
Bandage
Cast
n/N
n/N
4/18
15/21
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
0.31 [ 0.13, 0.77 ]
0.1 0.2
0.5
1
Favours bandage
2
5
10
Favours cast
Analysis 3.3. Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle
fractures, Outcome 3 Found splintage inconvenient.
Review:
Interventions for treating wrist fractures in children
Comparison: 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures
Outcome: 3 Found splintage inconvenient
Study or subgroup
West 2005
Bandage
Cast
n/N
n/N
1/18
18/21
Risk Ratio
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
0.06 [ 0.01, 0.44 ]
0.001 0.01 0.1
Favours bandage
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10 100 1000
Favours cast
38
Analysis 3.4. Comparison 3 Soft bandage versus below-elbow plaster then polymer cast for buckle
fractures, Outcome 4 Adverse effects (e.g. skin problems).
Review:
Interventions for treating wrist fractures in children
Comparison: 3 Soft bandage versus below-elbow plaster then polymer cast for buckle fractures
Outcome: 4 Adverse effects (e.g. skin problems)
Study or subgroup
West 2005
Bandage
Cast
n/N
n/N
0/18
0/21
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
0.0 [ 0.0, 0.0 ]
0.1 0.2
0.5
1
Favours bandage
2
5
10
Favours cast
Analysis 4.1. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures,
Outcome 1 Swelling.
Review:
Interventions for treating wrist fractures in children
Comparison: 4 Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome: 1 Swelling
Study or subgroup
Symons 2001
Home removal
Hospital removal
n/N
n/N
1/38
0/42
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
3.31 [ 0.14, 78.84 ]
0.01
0.1
Favours home
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10
100
Favours hospital
39
Analysis 4.2. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures,
Outcome 2 Tenderness.
Review:
Interventions for treating wrist fractures in children
Comparison: 4 Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome: 2 Tenderness
Study or subgroup
Home removal
Hospital removal
n/N
n/N
3/38
3/42
Symons 2001
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
1.11 [ 0.24, 5.15 ]
0.1 0.2
0.5
1
Favours home
2
5
10
Favours hospital
Analysis 4.3. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures,
Outcome 3 Avoidance of some hobbies.
Review:
Interventions for treating wrist fractures in children
Comparison: 4 Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome: 3 Avoidance of some hobbies
Study or subgroup
Symons 2001
Home removal
Hospital removal
n/N
n/N
3/38
7/42
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
0.47 [ 0.13, 1.70 ]
0.1 0.2
0.5
Favours home
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
2
5
10
Favours hospital
40
Analysis 4.4. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures,
Outcome 4 Deformity.
Review:
Interventions for treating wrist fractures in children
Comparison: 4 Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome: 4 Deformity
Study or subgroup
Symons 2001
Home removal
Hospital removal
n/N
n/N
0/38
0/42
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
0.0 [ 0.0, 0.0 ]
0.01
0.1
1
Favours home
10
100
Favours hospital
Analysis 4.5. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures,
Outcome 5 Parents reported problems with care of fracture.
Review:
Interventions for treating wrist fractures in children
Comparison: 4 Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome: 5 Parents reported problems with care of fracture
Study or subgroup
Symons 2001
Home removal
Hospital removal
n/N
n/N
5/40
14/47
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
0.42 [ 0.17, 1.06 ]
0.1 0.2
0.5
Favours home
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
2
5
10
Favours hospital
41
Analysis 4.6. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures,
Outcome 6 Parents would not choose the same treatment again.
Review:
Interventions for treating wrist fractures in children
Comparison: 4 Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome: 6 Parents would not choose the same treatment again
Study or subgroup
Symons 2001
Home removal
Hospital removal
n/N
n/N
1/38
17/42
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
0.07 [ 0.01, 0.47 ]
0.001 0.01 0.1
1
Favours home
10 100 1000
Favours hospital
Analysis 4.7. Comparison 4 Home versus hospital clinic removal of plaster backslab for buckle fractures,
Outcome 7 Non-adherence (non-compliance).
Review:
Interventions for treating wrist fractures in children
Comparison: 4 Home versus hospital clinic removal of plaster backslab for buckle fractures
Outcome: 7 Non-adherence (non-compliance)
Study or subgroup
Symons 2001
Home removal
Hospital removal
n/N
n/N
2/40
1/47
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
2.35 [ 0.22, 24.97 ]
0.01
0.1
Favours home
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10
100
Favours hospital
42
Analysis 5.1. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome
1 Fracture redisplacement and rereduction.
Review:
Interventions for treating wrist fractures in children
Comparison: 5 Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome: 1 Fracture redisplacement and rereduction
Study or subgroup
Below-elbow
Above-elbow
n/N
n/N
Risk Ratio
Bohm 2006
14/45
23/55
0.74 [ 0.44, 1.27 ]
Webb 2006
2/53
9/60
0.25 [ 0.06, 1.11 ]
98
115
0.60 [ 0.36, 1.00 ]
0/53
3/60
0.16 [ 0.01, 3.05 ]
53
60
0.16 [ 0.01, 3.05 ]
Bohm 2006
1/45
3/55
0.41 [ 0.04, 3.78 ]
Webb 2006
0/53
0/60
0.0 [ 0.0, 0.0 ]
98
115
0.41 [ 0.04, 3.78 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Redisplaced fracture
Subtotal (95% CI)
Total events: 16 (Below-elbow), 32 (Above-elbow)
Heterogeneity: Chi2 = 1.93, df = 1 (P = 0.17); I2 =48%
Test for overall effect: Z = 1.97 (P = 0.049)
2 Reangulation greater than 15 degrees or > 30% redisplacement
Webb 2006
Subtotal (95% CI)
Total events: 0 (Below-elbow), 3 (Above-elbow)
Heterogeneity: not applicable
Test for overall effect: Z = 1.22 (P = 0.22)
3 Remanipulation
Subtotal (95% CI)
Total events: 1 (Below-elbow), 3 (Above-elbow)
Heterogeneity: Chi2 = 0.00, df = 0 (P<0.00001); I2 =100%
Test for overall effect: Z = 0.79 (P = 0.43)
0.001 0.01 0.1
Favours below-elbow
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10 100 1000
Favours above-elbow
43
Analysis 5.2. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome
2 Limitations in activities of daily living during cast use.
Review:
Interventions for treating wrist fractures in children
Comparison: 5 Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome: 2 Limitations in activities of daily living during cast use
Study or subgroup
Below-elbow
Above-elbow
n/N
n/N
Risk Ratio
Risk Ratio
6/48
48/58
0.15 [ 0.07, 0.32 ]
6/45
36/54
0.20 [ 0.09, 0.43 ]
2/47
23/35
0.06 [ 0.02, 0.26 ]
4/45
14/44
0.28 [ 0.10, 0.78 ]
7/35
26/40
0.31 [ 0.15, 0.62 ]
5/23
31/40
0.28 [ 0.13, 0.62 ]
M-H,Fixed,95% CI
M-H,Fixed,95% CI
1 Needed help dressing
Webb 2006
2 Unable to shower
Webb 2006
3 Needed help using toilet
Webb 2006
4 Needed help eating
Webb 2006
5 Needed help at school
Webb 2006
6 Unable to write
Webb 2006
7 Patient reported help required because of difficulties with activities of daily living
Webb 2006
3/49
35/58
0.10 [ 0.03, 0.31 ]
0.01
0.1
1
10
Favours below-elbow
100
Favours above-elbow
Analysis 5.3. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome
3 Days off school.
Review:
Interventions for treating wrist fractures in children
Comparison: 5 Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome: 3 Days off school
Study or subgroup
Webb 2006
Below-elbow
Above-elbow
Mean Difference
N
Mean(SD)
N
Mean(SD)
53
0.56 (0.89)
60
1.6 (1.3)
IV,Fixed,95% CI
-1.04 [ -1.45, -0.63 ]
-4
-2
Favours below-elbow
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Mean Difference
IV,Fixed,95% CI
0
2
4
Favours above-elbow
44
Analysis 5.4. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome
4 Range of movement (differences between injured and contralateral side) (degrees).
Review:
Interventions for treating wrist fractures in children
Comparison: 5 Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome: 4 Range of movement (differences between injured and contralateral side) (degrees)
Study or subgroup
Below-elbow
N
Above-elbow
Mean(SD)
Mean Difference
Mean Difference
N
Mean(SD)
IV,Fixed,95% CI
IV,Fixed,95% CI
47.1 (19.3)
60
53.6 (22.6)
-6.50 [ -14.23, 1.23 ]
6.3 (8.6)
60
10.7 (14.8)
-4.40 [ -8.80, 0.00 ]
1.1 (3.6)
60
29.8 (15.9)
-28.70 [ -32.84, -24.56 ]
0.4 (1.8)
60
3.1 (5.9)
-2.70 [ -4.27, -1.13 ]
1 Difference at cast removal in arcs of wrist motion
Webb 2006
53
2 Final difference in arcs of wrist motion
Webb 2006
53
3 Difference at cast removal in arcs of elbow motion
Webb 2006
53
4 Final difference in arcs of elbow motion
Webb 2006
53
-100
-50
0
Favours below-elbow
50
100
Favours above-elbow
Analysis 5.5. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome
5 Time to regain range of motion (days).
Review:
Interventions for treating wrist fractures in children
Comparison: 5 Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome: 5 Time to regain range of motion (days)
Study or subgroup
Webb 2006
Below-elbow
Above-elbow
Mean Difference
N
Mean(SD)
N
Mean(SD)
53
7.3 (5.1)
60
17.3 (8.4)
IV,Fixed,95% CI
-10.00 [ -12.53, -7.47 ]
-100
-50
Favours below-elbow
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Mean Difference
IV,Fixed,95% CI
0
50
100
Favours above-elbow
45
Analysis 5.6. Comparison 5 Below-elbow versus above-elbow plaster casts for displaced fractures, Outcome
6 Complications.
Review:
Interventions for treating wrist fractures in children
Comparison: 5 Below-elbow versus above-elbow plaster casts for displaced fractures
Outcome: 6 Complications
Study or subgroup
Below-elbow
Above-elbow
n/N
n/N
Risk Ratio
Risk Ratio
0/53
0/60
0.0 [ 0.0, 0.0 ]
0/46
0/56
0.0 [ 0.0, 0.0 ]
3/46
3/56
1.22 [ 0.26, 5.75 ]
4/46
11/56
0.44 [ 0.15, 1.30 ]
10/46
4/56
3.04 [ 1.02, 9.07 ]
5/56
0.24 [ 0.03, 2.01 ]
1/60
0.38 [ 0.02, 9.05 ]
M-H,Fixed,95% CI
M-H,Fixed,95% CI
1 Refracture
Webb 2006
2 Compartment syndrome
Bohm 2006
3 Cast split for swelling
Bohm 2006
4 Cast reinforced for ’breakdown’
Bohm 2006
5 Cast changed for loosening or breakdown
Bohm 2006
6 Change of cast type (for comfort or other problems)
Bohm 2006
1/46
7 Physical therapy required to regain shoulder range of movement
Webb 2006
0/53
0.01
0.1
Favours below-elbow
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10
100
Favours above-elbow
46
Analysis 6.1. Comparison 6 Above-elbow cast (forearm pronated versus neutral versus supinated) for
displaced fractures, Outcome 1 Second reduction for unacceptable loss of alignment.
Review:
Interventions for treating wrist fractures in children
Comparison: 6 Above-elbow cast (forearm pronated versus neutral versus supinated) for displaced fractures
Outcome: 1 Second reduction for unacceptable loss of alignment
Study or subgroup
Position A
Position B
n/N
n/N
Risk Ratio
1/26
1/35
1.35 [ 0.09, 20.54 ]
0/38
1/35
0.31 [ 0.01, 7.31 ]
1/26
0/38
4.33 [ 0.18, 102.42 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Pronation versus supination
Boyer 2002
2 Neutral position versus supination
Boyer 2002
3 Pronation versus neutral position
Boyer 2002
0.001 0.01 0.1
Favours position A
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
10 100 1000
Favours position B
47
Analysis 7.1. Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone
for displaced fractures, Outcome 1 Fracture redisplacement and rereduction.
Review:
Interventions for treating wrist fractures in children
Comparison: 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced fractures
Outcome: 1 Fracture redisplacement and rereduction
Study or subgroup
Wire + cast
Plaster cast alone
n/N
n/N
Risk Ratio
Weight
Gibbons 1994
0/12
10/11
33.7 %
0.04 [ 0.00, 0.67 ]
McLauchlan 2002
1/35
14/33
44.5 %
0.07 [ 0.01, 0.48 ]
Miller 2005
0/16
7/18
21.9 %
0.07 [ 0.00, 1.21 ]
63
62
100.0 %
0.06 [ 0.02, 0.24 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Redisplaced fracture
Subtotal (95% CI)
Total events: 1 (Wire + cast), 31 (Plaster cast alone)
Heterogeneity: Chi2 = 0.08, df = 2 (P = 0.96); I2 =0.0%
Test for overall effect: Z = 3.97 (P = 0.000073)
2 Remanipulation (and secondary procedure for loss of position)
Gibbons 1994
0/12
10/11
44.1 %
0.04 [ 0.00, 0.67 ]
McLauchlan 2002
0/35
7/33
31.1 %
0.06 [ 0.00, 1.06 ]
Miller 2005
0/16
6/18
24.8 %
0.09 [ 0.01, 1.42 ]
63
62
100.0 %
0.06 [ 0.01, 0.30 ]
Subtotal (95% CI)
Total events: 0 (Wire + cast), 23 (Plaster cast alone)
Heterogeneity: Chi2 = 0.11, df = 2 (P = 0.94); I2 =0.0%
Test for overall effect: Z = 3.45 (P = 0.00056)
0.001 0.01 0.1
Favours wire + cast
1
10 100 1000
Favours cast alone
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
48
Analysis 7.2. Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone
for displaced fractures, Outcome 2 Complications.
Review:
Interventions for treating wrist fractures in children
Comparison: 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced fractures
Outcome: 2 Complications
Study or subgroup
Wire + cast
Plaster cast alone
n/N
n/N
Risk Ratio
0/16
1/18
0.37 [ 0.02, 8.55 ]
16
18
0.37 [ 0.02, 8.55 ]
0/16
0/18
0.0 [ 0.0, 0.0 ]
16
18
0.0 [ 0.0, 0.0 ]
2/16
0/18
5.59 [ 0.29, 108.38 ]
16
18
5.59 [ 0.29, 108.38 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Failed reduction
Miller 2005
Subtotal (95% CI)
Total events: 0 (Wire + cast), 1 (Plaster cast alone)
Heterogeneity: not applicable
Test for overall effect: Z = 0.62 (P = 0.54)
2 Compartment syndrome
Miller 2005
Subtotal (95% CI)
Total events: 0 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
3 Pin site infection
Miller 2005
Subtotal (95% CI)
Total events: 2 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: not applicable
Test for overall effect: Z = 1.14 (P = 0.26)
4 Pin migration (wires removed)
McLauchlan 2002
1/35
0/33
2.83 [ 0.12, 67.19 ]
Miller 2005
2/16
0/18
5.59 [ 0.29, 108.38 ]
51
51
4.15 [ 0.49, 35.21 ]
Subtotal (95% CI)
Total events: 3 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: Chi2 = 0.09, df = 1 (P = 0.76); I2 =0.0%
Test for overall effect: Z = 1.31 (P = 0.19)
5 Pain resulting from wire
McLauchlan 2002
1/35
0/33
2.83 [ 0.12, 67.19 ]
Subtotal (95% CI)
35
33
2.83 [ 0.12, 67.19 ]
0/11
0.0 [ 0.0, 0.0 ]
Total events: 1 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: not applicable
Test for overall effect: Z = 0.64 (P = 0.52)
6 Nerve damage or irritation
Gibbons 1994
0/12
0.001 0.01 0.1
Favours wire + cast
1
10 100 1000
Favours cast alone
(Continued . . . )
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
49
(. . .
Study or subgroup
Wire + cast
Miller 2005
Subtotal (95% CI)
Plaster cast alone
Risk Ratio
M-H,Fixed,95% CI
Continued)
Risk Ratio
n/N
n/N
1/16
1/18
1.13 [ 0.08, 16.55 ]
M-H,Fixed,95% CI
28
29
1.13 [ 0.08, 16.55 ]
1/16
0/18
3.35 [ 0.15, 76.93 ]
16
18
3.35 [ 0.15, 76.93 ]
Total events: 1 (Wire + cast), 1 (Plaster cast alone)
Heterogeneity: Chi2 = 0.0, df = 0 (P = 1.00); I2 =0.0%
Test for overall effect: Z = 0.09 (P = 0.93)
7 Tendon irritation
Miller 2005
Subtotal (95% CI)
Total events: 1 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: not applicable
Test for overall effect: Z = 0.76 (P = 0.45)
8 Non-union
Gibbons 1994
0/12
0/11
0.0 [ 0.0, 0.0 ]
Miller 2005
0/16
0/18
0.0 [ 0.0, 0.0 ]
28
29
0.0 [ 0.0, 0.0 ]
Subtotal (95% CI)
Total events: 0 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: Chi2 = 0.0, df = 0 (P<0.00001); I2 =0.0%
Test for overall effect: Z = 0.0 (P < 0.00001)
9 Malunion
Gibbons 1994
0/12
0/11
0.0 [ 0.0, 0.0 ]
Miller 2005
0/16
0/18
0.0 [ 0.0, 0.0 ]
28
29
0.0 [ 0.0, 0.0 ]
1/12
0/11
2.77 [ 0.12, 61.65 ]
12
11
2.77 [ 0.12, 61.65 ]
Subtotal (95% CI)
Total events: 0 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: Chi2 = 0.0, df = 0 (P<0.00001); I2 =0.0%
Test for overall effect: Z = 0.0 (P < 0.00001)
10 Prominent scar at K-wire insertion site
Gibbons 1994
Subtotal (95% CI)
Total events: 1 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: not applicable
Test for overall effect: Z = 0.64 (P = 0.52)
11 Early physeal closure
Gibbons 1994
0/12
0/11
0.0 [ 0.0, 0.0 ]
Miller 2005
0/16
0/18
0.0 [ 0.0, 0.0 ]
28
29
0.0 [ 0.0, 0.0 ]
Subtotal (95% CI)
Total events: 0 (Wire + cast), 0 (Plaster cast alone)
Heterogeneity: Chi2 = 0.0, df = 0 (P<0.00001); I2 =0.0%
Test for overall effect: Z = 0.0 (P < 0.00001)
12 Secondary procedures (early wire removal, cast adjustment, rereduction, open reduction)
Gibbons 1994
0/12
10/11
0.04 [ 0.00, 0.67 ]
0.001 0.01 0.1
Favours wire + cast
1
10 100 1000
Favours cast alone
(Continued . . . )
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
50
(. . .
Study or subgroup
Wire + cast
Plaster cast alone
Risk Ratio
n/N
n/N
McLauchlan 2002
2/35
7/33
0.27 [ 0.06, 1.20 ]
Miller 2005
4/16
8/18
0.56 [ 0.21, 1.52 ]
63
62
0.26 [ 0.12, 0.56 ]
Subtotal (95% CI)
M-H,Fixed,95% CI
Continued)
Risk Ratio
M-H,Fixed,95% CI
Total events: 6 (Wire + cast), 25 (Plaster cast alone)
Heterogeneity: Chi2 = 3.96, df = 2 (P = 0.14); I2 =50%
Test for overall effect: Z = 3.42 (P = 0.00062)
0.001 0.01 0.1
Favours wire + cast
1
10 100 1000
Favours cast alone
Analysis 7.3. Comparison 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone
for displaced fractures, Outcome 3 Anatomical deformity at 3 months.
Review:
Interventions for treating wrist fractures in children
Comparison: 7 Percutaneous wire fixation and above-elbow cast versus above-elbow cast alone for displaced fractures
Outcome: 3 Anatomical deformity at 3 months
Study or subgroup
Wire + cast
N
Plaster cast alone
Mean Difference
Mean Difference
Mean(SD)
N
Mean(SD)
IV,Fixed,95% CI
IV,Fixed,95% CI
1.6 (3.4)
31
4.6 (6.3)
-3.00 [ -5.49, -0.51 ]
2.7 (7.3)
31
7.8 (11.2)
-5.10 [ -9.74, -0.46 ]
1 Coronal angular deformity (degrees)
McLauchlan 2002
34
2 Sagittal angular deformity (degrees)
McLauchlan 2002
34
-10
-5
Favours wire + cast
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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5
10
Favours cast alone
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APPENDICES
Appendix 1. Search strategy for MEDLINE (OVID-WEB)
1. Ulna Fractures/ or Radius Fractures/
2. (distal or metaphys$ or epiphys$ or torus or wrist).tw.
3. and/1-2
4. Wrist Injuries/ or Forearm Injuries/
5. fracture$.tw.
6. and/4-5
7. (ulna$1 or radius or radial or forearm$1 or wrist$1).tw.
8. and/2,5,7
9. or/3,6,8
10. exp Pediatrics/
11. Infant, Newborn/
12. Infant/
13. exp Child/
14. Adolescent/ not exp Adult/
15. (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw.
16. or/10-15
17. and/9,16
Appendix 2. Search strategy for The Cochrane Library (CD version)
#1 MeSH descriptor Ulna Fractures explode all trees
#2 MeSH descriptor Radius Fractures explode all trees
#3 (#1 or #2)
#4 ((distal in Record Title or metaphys* in Record Title or epiphys* in Record Title or torus in Record Title or wrist in Record Title)
or (distal in Abstract or metaphys* in Abstract or epiphys* in Abstract or torus in Abstract or wrist in Abstract))
#5 (#3 and #4)
#6 MeSH descriptor Wrist Injuries explode all trees
#7 MeSH descriptor Forearm Injuries explode all trees
#8 (fracture* in Record Title or fracture* in Abstract)
#9 (#6 or #7)
#10 (#8 and #9)
#11 ( (ulna* in Record Title or radius in Record Title or radial in Record Title or forearm* in Record Title or wrist* in Record Title)
or (ulna* in Abstract or radius in Abstract or radial in Abstract or forearm* in Abstract or wrist* in Abstract) )
#12 (#4 and #8 and #11)
#13 (#3 or #10 or #12)
#14 MeSH descriptor Pediatrics explode all trees
#15 MeSH descriptor Infant explode all trees
#16 MeSH descriptor Child explode all trees
#17 MeSH descriptor Adolescent explode all trees
#18 MeSH descriptor Adult explode all trees
#19 (#17 and not #18)
#20 (#14 or #15 or #16 or #19)
#21 ((paediatr* in Record Title or pediatr* in Record Title or neonate* in Record Title or bab* in Record Title or infant* in Record Title
or child* in Record Title or teenage* in Record Title or adolescen* in Record Title) or (paediatr* in Abstract or pediatr* in Abstract or
neonate* in Abstract or bab* in Abstract or infant* in Abstract or child* in Abstract or teenage* in Abstract or adolescen* in Abstract))
#22 (#20 or #21)
#23 (#13 and #22)
Interventions for treating wrist fractures in children (Review)
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Appendix 3. Search strategy for EMBASE
1. Radius Fracture/ or Ulna Fracture/
2. (distal or metaphys$ or epiphys$ or torus or wrist).tw.
3. and/1-2
4. Wrist Injury/
5. fracture$.tw.
6. and/4-5
7. (ulna$1 or radius or radial or forearm$1 or wrist$1).tw.
8. and/2,5,7
9. or/3,6,8
10. exp Pediatrics/
11. Newborn/
12. Infant/
13. exp Child/
14. Adolescent/ not Adult/
15. (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw.
16. or/10-15
17. and/9,16
18. exp Randomized Controlled trial/
19. exp Double Blind Procedure/
20. exp Single Blind Procedure/
21. exp Crossover Procedure/
22. Controlled Study/
23. or/18-22
24. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.
25. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
26. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
27. (cross?over$ or (cross adj1 over$)).tw.
28. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or
group$)).tw.
29. or/24-28
30. or/23,29
31. limit 30 to human
32. and/17,31
Appendix 4. Search strategy for CINAHL
1. Ulna Fractures/ or Radius Fractures/
2. (distal or metaphys$ or epiphys$ or torus or wrist).tw.
3. and/1-2
4. exp Wrist Injuries/ or Forearm Injuries/
5. fracture$.tw.
6. and/4-5
7. (ulna$1 or radius or radial or forearm$1 or wrist$1).tw.
8. and/2,5,7
9. or/3,6,8
10. exp Pediatrics/
11. Infant, Newborn/
12. Infant/
13. exp Child/
14. Adolescence/ not exp Adult/
15. (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw.
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16. or/10-15
17. and/9,16
18. exp Clinical Trials/
19. exp Evaluation Research/
20. exp Comparative Studies/
21. exp Crossover Design/
22. clinical trial.pt.
23. or/18-22
24. ((clinical or controlled or comparative or placebo or prospective or randomi#ed) adj3 (trial or study)).tw.
25. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
26. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
27. (cross?over$ or (cross adj1 over$)).tw.
28. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or
group$)).tw.
29. or/24-28
30. or/23,29
31. and/17,30
WHAT’S NEW
Last assessed as up-to-date: 18 February 2008.
8 May 2008
Amended
Converted to new review format.
HISTORY
Protocol first published: Issue 1, 2004
Review first published: Issue 2, 2008
CONTRIBUTIONS OF AUTHORS
AA initiated the review, researched the background, drafted and completed the review protocol, checked abstracts, selected trial reports
for inclusion, reviewed selected papers, entered data into RevMan, performed statistical analysis, and completed the first draft of the
review.
HH substantively revised the results sections and analyses of the draft review in RevMan after performing independent quality
assessement and data collection of the included trials. She updated the search and contacted trialists of registered trials.
TK performed independent study selection, and quality assessment and data collection for the trials included in the first draft of the
review. He provided feedback on various drafts of the review.
AA is the guarantor for the review.
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
• University of Teesside, Middlesbrough, UK.
• University Hospitals of Leicester, UK.
• Central Manchester and Manchester Children’s University Hospitals NHS Trust, UK.
External sources
• No sources of support supplied
NOTES
At editorial review, one referee noted the publication of another trial on buckle fractures, the citation of which was only available in
MEDLINE after the date of last search for the review. The following trial will be considered in the first update: Khan KS, Grufferty
A, Gallagher O, Moore DP, Fogarty E, Dowling F. A randomized trial of ’soft cast’ for distal radius buckle fractures in children. Acta
Orthopaedica Belgica 2007; 73(5):594-7.
INDEX TERMS
Medical Subject Headings (MeSH)
Bandages; Casts, Surgical; Fracture Fixation [instrumentation; ∗ methods]; Radius Fractures [∗ therapy]; Randomized Controlled Trials
as Topic; Splints; Wrist Injuries [∗ therapy]
MeSH check words
Child; Female; Humans; Male
Interventions for treating wrist fractures in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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