Below- vs above-elbow cast for distal radius fractures: is elbow immobilization really effective for reduction maintenance?

Predictors of limited forearm rotation following conservative treatment of distal radius fractures: a retrospective comparative study

BACKGROUND

Limitations in forearm rotation resulting from distal radius fracture are often neglected in clinical practice. We aimed to explore possible influencing factors of forearm rotation limitation following conservative treatment of these fractures.

METHODS

A series of patients with distal radius fractures who underwent conservative treatment in the Third Hospital of Hebei Medical University were retrospectively enrolled. Basic patient information and data on post-reduction imaging parameters and specific treatment strategies were collected. Ranges of forearm pronation and supination motion were recorded at 6-month and 12-month follow-ups. Univariate and multivariate logistic regression analyses were used to identify factors associated with forearm rotation limitation.

RESULTS

A total of 118 enrolled patients, 49 patients (41.5%) had limited forearm rotation function at the 6-month follow-up. Analysis of the fracture and cast fixation characteristics revealed that involvement of the sigmoid notch (odds ratio [OR], 7.010; 95% confidence interval [CI], 1.572-31.249), immobilization > 6 weeks (OR, 2.524; 95% CI, 1.044-6.099), and pronation fixation (OR, 1.797; 95% CI, 1.082-2.985) were associated with limited forearm rotation. Among patients with sigmoid notch fractures, there were no significant differences in forearm pronation or supination motion between the 6-month and 12-month follow-ups. At the 12-month follow-up, there was less supination function in patients with > 6 weeks of immobilization than in those with < 6 weeks of immobilization (P = 0.012), with no significant difference in pronation function (P = 0.131). At the 6-month follow-up, the degree of forearm supination was significantly lower in the fixed pronation position than in the neutral (P = 0.001) or supination (P < 0.001) positions, with no significant differences in the degree of forearm pronation among the three groups (P = 0.166). At the 12-month follow-up, no significant differences in pronation (P = 0.257) or supination (P = 0.164) were found among the three groups.

CONCLUSIONS

Sigmoid notch involvement, immobilization > 6 weeks, and pronation fixation were influencing factors of post-fracture limitation in forearm rotation. The effects of these factors on pronation and supination were not completely consistent and exhibited varying duration.

Short arm splints for wrist stabilization: A mechanical material test and cadaveric radiography study

Purpose

Documentation of the wrist stabilizing effect and mechanical properties of common splinting materials is warranted to support evidence-based condition-specific recommendations for wrist immobilization. The objectives of this study were to assess the wrist stabilizing properties of volar and dorsal short-arm splints made of four different materials and evaluate the mechanical properties of the splinting materials.

Methods

Dorsal and volar short arm splints made of plaster of Paris (PoP) (eight layers), Woodcast (2 mm, rigid vented), X-lite (classic, two layers) or a 3D-printed material (polypropylene) were sequentially mounted on 10 cadaveric arm specimens and fixed in a radiolucent fixture. This enabled the evaluation of maximum wrist flexion and extension relative under an orthogonal load of 42 N via radiographic images. In addition, a three-point bending test was performed on ten sheet duplicates of each of the four splinting materials.

Results

When applied as a volar splint, PoP had the highest capability to resist wrist flexion and extension. However, when applied as a dorsal splint, Woodcast exhibited a lower wrist flexion and a similar wrist extension. The 3D-printed splints-both volar and dorsal-showed the highest mean wrist flexion and extension. The mechanical properties of the Woodcast, X-lite and 3D-printed splinting materials were very similar. PoP exhibited distinct properties with a stiffness of 146 (95% confidence interval [CI]: 120-173) N/mm and a deflection at F max of 0.6 (95% CI: 0.5-0.7) mm compared to ≤7.7 (95% CI: 7.4-7.9) N/mm and ≥20 (95% CI: 18-22) mm for the other materials.

Conclusion

PoP displayed better wrist stabilizing properties and material stiffness than Woodcast, X-lite and 3D-printed polypropylene. When considering wrist stabilizing properties, PoP may still prove to be the preferred choice for wrist immobilization.

Level of Evidence

Not applicable.

The Effect Immobilization Mechanisms Have on Radiographic Outcomes and Complication Rates in the Conservative Treatment of Distal Radius Fractures: A Systematic Review

Distal radius fractures (DRFs) are among the most common fractures in the United States. Despite their high incidence, there is no consensus on the optimal type of cast or splint to treat these fractures. The purpose of this systematic review is to evaluate the available literature pertaining to the outcomes for different constructs used to conservatively treat DRFs. A literature search of PubMed, Medline, and Embase was conducted to identify research comparing the outcomes of various immobilization mechanisms. In particular, endpoints included complications (eg, loss of reduction, pain), radiographic outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. A total of 1655 articles were identified during the literature search, and 22 ultimately fulfilled inclusion criteria. These 22 studies included 1826 conservatively treated DRFs. The different immobilization mechanisms were divided into 8 groupings: above-elbow casts, above-elbow splints, below-elbow casts, below-elbow splints, gutter or spica casts, gutter or spica splints, dorsal-volar splints, and dorsal splints. Qualitative review of the studies determined that below-elbow constructs result in equal or better functional and radiologic outcomes when compared with above-elbow constructs. Meta-analysis demonstrated that a statistically significant difference (P = .04) existed in the incidence of loss of reduction between the immobilization constructs, although post hoc analysis did not detect significant differences between 2 particular constructs.

Short arm cast is as effective as long arm cast in maintaining distal radius fracture reduction: Results of the SLA-VER noninferiority trial

BACKGROUND

Distal radius fractures (DRFs) are a common challenge in orthopaedic trauma care, yet for those fractures that are treated nonoperatively, strong evidence to guide cast treatment is still lacking.

AIM

To compare the efficacy of below elbow cast (BEC) and above elbow cast (AEC) in maintaining reduction of manipulated DRFs.

METHODS

We conducted a prospective, monocentric, randomized, parallel-group, open label, blinded, noninferiority trial comparing the efficacy of BEC and AEC in the nonoperative treatment of DRFs. Two hundred and eighty patients > 18 years of age diagnosed with DRFs were successfully randomized and included for analysis over a 3-year period. Noninferiority thresholds were defined as a 2 mm difference for radial length (RL), a 3° difference for radial inclination (RI), and volar tilt (VT). The trial is registered at Clinicaltrials.gov (NCT03468023).

RESULTS

One hundred and forty-three patients were treated with BEC, and 137 were treated with AEC. The mean time of immobilization was 33 d. The mean loss of RL, RI, and VT was 1.59 mm, 2.83°, and 4.11° for BEC and 1.63 mm, 2.54°, and 3.52° for AEC, respectively. The end treatment differences between BEC and AEC in RL, RI, and VT loss were respectively 0.04 mm (95%CI: -0.36-0.44), -0.29° (95%CI: -1.03-0.45), and 0.59° (95%CI: -1.39-2.57), and they were all below the prefixed noninferiority thresholds. The rate of loss of reduction was similar.

CONCLUSION

BEC performs as well as AEC in maintaining the reduction of a manipulated DRF. Being more comfortable to patients, BEC may be preferable for nonoperative treatment of DRFs.

BET 1: should Colles' fractures be splinted in a long or short arm cast?

A short-cut review of the available medical literature was carried out to establish whether elbow immobilisation is required after closed reduction of a distal radial fracture. After abstract review, six papers were found to answer this clinical question using the detailed search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that elbow immobilisation is not required.

Below- or above-elbow immobilization in conservative treatment of distal radius fractures: a systematic review and meta-analysis

INTRODUCTION

There is no consensus regarding the range of immobilization in the conservative treatment of distal radius fractures (DRFs). Therefore, this systematic review and meta-analysis aimed to compare the clinical outcome of patients with DRFs treated conservatively with below- or above-elbow immobilization.

MATERIALS AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, two independent reviewers searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform in April 2020; a subsequent update search was conducted in April 2021. We identified all randomised controlled trials comparing two immobilization methods in DRFs. The primary outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) or QuickDASH questionnaire scores in the short- and long-term (≤ and >six weeks, respectively) follow-up as well as the treatment failure rate. The secondary outcome measures were radiographic outcome, patient-rated wrist evaluation (PRWE) score, pain score and adverse events. Risk of bias was evaluated using the Cochrane Risk of Bias tool version 2. We used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence.

RESULTS

The initial search revealed 1,775 records, and ten studies with 909 participants in total were included. There was no significant difference in DASH score in the short-term follow-up (4.99 lower, 95% confidence interval (CI): 10.45 lower to 0.46 higher; very low certainty) and treatment failure (risk ratio: 0.91, 95% CI: 0.59 to 1.40; low certainty). A clinically irrelevant but significant mean difference (0.83 lower, 95%CI: 1.64 lower to 0.03 lower; low certainty) was found in the DASH score in favour of below-elbow immobilization in the long-term follow-up. The overall risk of bias in DASH scores was high based on the measurement bias. Furthermore, there was no significant difference in secondary outcome measures.

CONCLUSION

This meta-analysis did not demonstrate clinically meaningful difference between below- and above-elbow immobilization in terms of DASH score both in the short- and long-term follow-ups. However, overall certainty of evidence was considered very low, based on the very serious risk of bias, inconsistency and imprecision. Hence, there is a need for further higher quality research.

TRIAL REGISTRATION NUMBER

UMIN000040134 (4/14/2020).

Ultrasound-Guided Distal Forearm Fracture Reduction by Pediatric Emergency Physicians: A Single Center Retrospective Study

INTRODUCTION

Fracture reduction under point-of-care ultrasound (POCUS) guidance facilitates measurement of residual angulation or displacement that may not be apparent on examination. Point-of-care ultrasound is without patient or staff exposure to ionizing radiation and enlists no additional staffing resources or patient transfer.

METHODS

We conducted a chart review of all children who underwent reduction of a distal forearm fracture in the pediatric emergency department over a 2-year period, from September 2018 to September 2020. We compared length of stay (LOS) with that for orthopedist-performed distal forearm reductions during the study period. We allowed a 6-week lag period to ensure no missed rereduction before analyzing the data. After reduction, children were instructed to follow up with an orthopedist within 1 week. Children with loss of reduction on orthopedic follow-up are referred back through our emergency department for operative reduction.

RESULTS

A total of 74 children with 75 distal forearm fractures were identified. Average LOS was 179 minutes for the pediatric emergency medicine physician reductions and 215 minutes for the orthopedist reductions (P < 0.001). Ninety-six percent of reductions were completed with POCUS assistance, and 61% had less than 5 degrees of angulation on postreduction radiography. Only 2.7% of children underwent rereduction.

CONCLUSIONS

Distal forearm fracture reductions by a pediatric emergency medicine physician under POCUS guidance have a high rate of excellent alignment, low rate of failed reduction, and significantly shorter LOS (P < 0.001) than reductions performed by orthopedists.

No benefit for elbow blocking on conservative treatment of distal radius fractures: A 6-month randomized controlled trial

Purpose

For displaced distal radius fracture, this trial aimed to compare an above-elbow (AE) and below-elbow (BE) cast at the end of a 24-week follow-up using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as a primary outcome.

Methods

This is a clinical trial with parallel groups (1:1) and a blinded evaluator. There are two non-surgical interventions: AE and BE. A total of 128 adult patients with acute (up to 7 days) displaced distal radius fracture of type A2-3, C1-3 by the AO classification were included. The follow-up was 24 weeks. The primary outcome was the DASH questionnaire at 24 weeks. Secondary outcomes were the maintenance of reduction by the evaluation of radiographic parameters, pain measured by VAS, PRWE, objective functional evaluation and rate of adverse effects.

Results

The difference between the two groups in the DASH score at 24 weeks was not significant, with the mean (95% CI) DASH score being AE: 9.44 (2.70 to 16.17) vs. BE: 9.88 (3.19 to 16.57) (p = 0.895). The above-elbow group had a significantly greater worsening of the mean DASH score from baseline to 2 weeks (p < 0.001). No statistically significant differences were found between the 2 groups in any of the other follow-up assessments. Objective functional evaluation, PRWE, radiographical measures and rates of reduction loss were similar between groups. Above-elbow casting resulted in more adverse effects (mostly shoulder pain; 19 events vs. 9 events); RR = 0.39 (0.19–0.94); p = 0.033 at the end of six-month follow-up.

Conclusions

This study did not demonstrate a difference between above-elbow and below-elbow cast in terms of DASH outcome at 6 months in non-surgical treatment of deviated distal radius fractures. However, below-elbow casting is less debilitating during the treatment period, has comparable performance in maintaining the reduction, and is related to fewer minor adverse effects than above-elbow casting.

How to Treat Distal Radius Fractures: Right Patient, Right Care, Right Time, and Right Cost

Operative intervention for distal radius fractures is typically reserved for patients with displaced fractures that may result in bothersome compromises in function, although patient-specific factors (age, activity level, and preference) are considered. Operative intervention is associated with earlier improvement in function but exposes the patient to the risk of anesthesia and surgery. Although surgery is associated with an initial increase in cost of care, the benefits of earlier return to activity may offset these increases. Efforts to contain cost through implant selection, use of ambulatory surgical centers, and judicious referrals for postoperative therapy can aid surgeons in delivering high-value care.

Short and long-arm fiberglass cast immobilization for displaced distal forearm fractures in children: a randomized controlled trial

Purpose

The aim of this study was to investigate whether short-arm fiberglass cast (SAC) immobilization provides fracture stabilization comparable to that of long-arm cast (LAC) treatment of displaced distal forearm fractures after closed reduction in paediatric patients.

Methods

A prospective, randomized, controlled trial of children aged four to 16 years (mean 9.9 years) was designed with a sample of 120 children, whose size was set a priori, with 60 treated with SAC and 60 with LAC. The primary outcome was fracture stability and rate of loss of reduction. The secondary outcome analysis evaluated duration of analgesic therapy, restriction in activities of daily life, and the duration until patients regained normal range of motion in the elbow.

Results

No statistically significant differences were found between the two groups in loss of reduction or duration of analgesic therapy. In contrast, the duration until normal range of motion in the elbow was regained was significantly longer in the LAC group (median 4.5 days, P < 0.001). Restriction in activities of daily life did not differ significantly between the two groups except for the item “help needed with showering in the first days after trauma” (SAC 60%, LAC 87%, P = 0.001).

Conclusion

Fracture immobilization with short-arm fiberglass cast in reduced distal forearm fractures is not inferior to long-arm casts in children four years and older, excluding completely displaced fractures. Furthermore, short-arm casting reduces the need for assistance during showering.

Trial registration

NCT03297047, September 29, 2017

Below-elbow or above-elbow cast for conservative treatment of extra-articular distal radius fractures with dorsal displacement: a prospective randomized trial

Background

Distal radial fractures are common traumatic injuries, but their management remains controversial also in case of conservative treatment regarding the type of immobilisation. Hence, we conducted a two-arm, parallel-group, prospective randomised trial to compare the capacity of long casts (above-elbow) and short casts (below-elbow) to maintain the reduction of extra-articular distal radius fractures with dorsal displacement (AO/OTA classification: 2R3A2.2).

Methods

Seventy-four eligible patients with AO/OTA 2R3A2.2 fractures treated with closed reduction and cast immobilisation were randomised to the long cast group (n°= 37) or to the short cast group (n°= 37). Baseline radiological parameters, radial inclination (RI), radial height (RH), ulnar variance (UV) and palmar tilt (PT) were taken, and compared with clinical (DASH, Mayo Wrist and Mayo Elbow) and radiological scores taken at 7–10 days, 4 weeks and 12 weeks. Furthermore, to evaluate correlations between radiological parameters and functional outcomes, patients were divided into two groups according to whether or not their radiological parameters at Follow-ups 2 and 3 were acceptable, i.e. within the range 11–12 mm for RH, 16°–28° for RI, − 4–+ 2 mm for UV and 0°–22° for PT.

Results

Patient demographic and baseline radiological parameters were similar between groups. At follow-up, there were no statistically significant differences between the two types of cast in terms of RI, RH, UV or PT, or Mayo wrist or DASH scores. Short cast group patients displayed better Mayo elbow score at follow-up 2 (4 weeks), but this difference was no longer statistically significant at follow-up 3 (12 weeks). No statistically significant differences in clinical outcomes were found between patients who presented acceptable radiographic parameters at follow-up and those who did not.

Conclusion

As there were no significant differences between short casts and long casts in terms of fracture reduction maintenance or clinical outcomes, short casts are an effective method of post-reduction immobilisation in AO/OTA 2R3A2.2 fracture of the radius. Radiological parameters outside the range conventionally considered acceptable do not preclude a satisfactory clinical outcome.

Trial registration

ClinicalTrials.gov PRS, NCT04062110. Registred 20 August 2019.

SLA-VER: study protocol description and preliminar results of the first italian RCT on conservative treatment of distal radial fractures

INTRODUCTION

There is no consensus on which is the best way to maintain initial reduction of a distal radius fractures (DRFs). The aim of this study is to test the hypothesis that below elbow cast (BEC) is equivalent to above elbow cast (AEC) in maintaining initial reduction of DRFs. This paper will report on midterm results.

METHODS

SLA-VER is a prospective, monocentric, randomized, parallel-group, open label, blinded endpoint evaluation non-inferiority trial (PROBE design) comparing the efficacy of AECs and BECs in DRFs conservative treatment in terms of loss of radial height (RH), radial inclination (RI) and volar tilt (VT) during cast immobilization (average 35 days) of 353 consecutive DRFs. Non-inferiority thresholds are 2 mm for radial height, 3Åã for radial inclination and 3Åã for volar tilt. Study population will be 353 patients, randomized into 2 groups (AEC vs BEC). One-hundred patients have completed the study so far.

RESULTS

Patients in BEC group lost 1,75 mm of RH, 2,9Åã of RI and 4,5Åã of VT over the course of cast immobilization. Patients in AEC group lost 1,71 mm of RH, 2,2Åã of RI and 4,8Åã of VT. Raw differences between average loss of RH, RI, VT during treatment between study groups were respectively 0,04 mm, 0,7Åã and 0,3Åã. Logistic and ANCOVA models have been used to correct for confouding variables.

CONCLUSIONS

Difference of loss of RH, RI and VT between the two groups are all below the non inferiority thresholds. Cast type does not seem to affect maintenance of reduction in conservatively managed DRFs.