Clinical Question: Are casts below the elbow as effective as casts that extend above the elbow for children with fractured forearms?

Setting: Outpatient (specialty)

Study Design: Randomized controlled trial (single-blinded)

Allocation: Concealed

Synopsis: A total of 102 children between four and 12 years of age with an uncomplicated fracture of the forearm were randomly assigned (concealed allocation) to be casted above or below the elbow. When fractures needed reduction, it was performed under anesthesia. Children with open fractures or Salter-Harris fractures were not eligible because these generally are treated surgically. A consensus set of criteria for acceptable reduction was developed before starting the study, as were criteria for remanipulation in cases where there was a loss of reduction.

The children were evaluated weekly for three weeks and again six weeks after the injury, and the casts were removed at six weeks. After removal of the cast, all children had follow-up radiography to assess adequacy of reduction. The assessment of reduction was not entirely blinded. In children with casts above the elbow, 42 percent had inadequate reduction compared with 31 percent of those with casts below the elbow (P = .27). Four children had to have the fractures remanipulated, suggesting that the treating physicians had a higher tolerance for angulation than did the study criteria. Casts above the elbow were more likely to require reinforcement, whereas casts below the elbow were more likely to require changing because of wear or looseness.

Bottom Line: Children with uncomplicated forearm fractures have comparable outcomes whether the cast is placed below or extends above the elbow. (Level of Evidence: 2b)