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How Important is Cast Application to the Successful Management of Paediatric Distal Radius Fractures
Robert W. Jordan, MBChB, MRCS; Gurdip Chahal, K. Srinivas; Gunaratnam Shyamalan
Trauma & Orthopaedic, Birmingham Heartlands Hospital, Birmingham, United Kingdom

Introduction: Distal radial fractures are among the commonest skeletal injuries in childhood. For displaced fractures, closed reduction and cast immobilisation has been the mainstay of treatment in this population but high rates of redisplacement have been reported. Risk factors include initial displacement, imperfect reduction and the cast quality. The success of cast application has been measured using both cast and gap index. The aim of this study was to establish whether the cast or gap index are more successful at predicting the risk of redisplacement following manipulation for displaced paediatric distal radius fractures.

Methods: A retrospective analysis was carried out between September 2010 and April 2013 of all children under the age of 16 years old who underwent manipulation under anaesthesia for a distal third radius fracture at our centre. Open fractures, cases with associated dislocations and epiphyseal injuries were excluded from the study. Demographic data was collected from electronic records. Pre-operative radiographs were reviewed and initial severity of displacement graded according to Mani et al. Intra-operative radiographs were scrutinised to assess the success of closed reduction. The first post-operative radiograph was analysed with both the cast index and gap index measured. Clinic records and post-operative radiographs were reviewed to identify any redisplacement as described by Alemdaroglu et al.

Results: During the study period 107 patients underwent closed manipulation of their distal radial fractures. There were 63 boys (69.9%) and the mean age of 9.3 years (range 2 to 15). Mean duration of follow up was 32 days (range 15-70 days). 26 patients (19.7%) suffered a radiographic redisplacement although only 6 underwent further surgery. The redisplacement group had a significantly higher gap index (0.41 versus 0.27) than those with good radiographic outcomes. Although the cast index was higher in those suffering a radiographic redisplacement (0.84 versus 0.78) this did not reach statistical significance. Additional risk factors associated with a significant risk of redisplacement were initial grade of fracture displacement and a successful reduction intra-operatively.

Conclusion: The displacement of the initial injury, success of reduction and quality of cast are key factors in a successful outcome. Although both the cast and gap index are importance, the results from this study demonstrate the gap index to be more accurate in predicting risk of redisplacement. Therefore the authors endorse its use as an assessment of casting technique and one factor to consider when predicting redisplacement risk.

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