Pediatric distal forearm fractures (DFF) are very common and accounts for 25-30% of all
fractures in children.(1,2) Up to half of all pediatric DFF are displaced to an extent
where surgery has been the preferred treatment option.(3) However, surgery does come with
a cost.
The most common treatment of displaced pediatric DFF has long been closed reduction with
or without pin fixation (or in rare cases plate and screw fixation) under general
anesthesia, followed by immobilization in a cast.(4) Pin-related complications vary from
4-23%, depending on what is reported as complications,(5-11) and up to 40% has been
reported when including re-displacements.(12) The insertion of a metal wire or plate also
requires subsequent procedures to remove these implants again.
Numerous small cohort studies and case series have found pin fixation advantageous in
achieving anatomic reduction and avoiding re-displacement.(5-11) However, whether
anatomic reduction and stabilization is important regarding the patient-reported
functional outcome has not been investigated since most studies use only radiographic or
objective measures (e.g. range of motion). In addition, children's bones, and in
particular the metaphysis and epiphysis, have a unique ability to heal and remodel
throughout the growth period until puberty.(13) Almost 20 years ago, Do et al. (14)
stated that "the tremendous capacity of distal metaphyseal radius fractures to heal and
remodel makes this one of the most rewarding fractures to treat non-operatively. [...]".
In accordance with Do et al., other studies indicate that displaced DFF fractures in
prepubertal children might heal without manipulation, and that most displaced fractures
will remodel within a year or two to almost anatomical position with no functional
impairment.(14-17) Although most surgeons are aware that children's bones have this
remodeling potential, they still find it challenging to deal with the uncertainty of
whether the bone will actually remodel to an acceptable position. Furthermore, surgeons
might have difficulties with how families will react to the waiting time until the
misaligned arm looks normal again.
If non-surgical treatment of displaced pediatric DFF were more common, the costs
associated with surgery could be minimized. Unfortunately, there is limited evidence to
guide the decision to operate or not. The available studies are typically small,
retrospective cohort studies or case series of low quality with no predefined follow-up
or outcome measures. To our knowledge, there are no published randomized controlled
trials (RCTs) comparing non-surgical treatment with surgical treatment, and no studies
report outcomes from the patient's perspective.
The aim of this trial is to investigate the patient-reported functional outcome after
non-surgical treatment of displaced DFF in children aged 4-10 years. Our hypothesis is,
that casting without manipulation is non-inferior to surgical treatment.
