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Is There Still a Place for Cast Wedging in Pediatric Forearm Fractures?

Samora, Julie Balch MD, PhD, MPH*,†; Klingele, Kevin E. MD*,†; Beebe, Allan C. MD*,†; Kean, John R. MD*,†; Klamar, Jan MD*,†; Beran, Matthew C. MD*,†; Willis, Leisel M. BSc, CCRC*; Yin, Han PhD, MS*; Samora, Walter P. MD*,†

Journal of Pediatric Orthopaedics: April/May 2014 - Volume 34 - Issue 3 - p 246–252
doi: 10.1097/BPO.0000000000000091

Background: Forearm fractures are common skeletal injuries in childhood and can usually be treated nonoperatively with closed reduction and casting. Trends toward increasing operative treatment of these fractures have emerged. We aim to demonstrate the safety and efficacy of cast wedging for treatment of pediatric forearm fractures.

Methods: We performed a prospective chart review of patients with forearm fractures, including distal radius (DR) fractures, treated with cast wedging at a single large pediatric hospital from June 2011 to September 2012. Inclusion criteria specified open distal radial physis, closed injury, loss of acceptable reduction, and availability of clinical and radiographic data from injury to cast removal. Exclusion criteria included pathologic fractures, neurovascular injury, fracture dislocations, open fractures, and closed DR physis. Reductions were performed and patients followed according to standard protocol at our institution, including placement into long-arm casts, initial follow-up visit within 5 to 10 days postinjury, and weekly visits for 2 weeks thereafter. If alignment were deemed unacceptable within 3 weeks of injury, cast wedging was utilized. Radiographic measurements of alignment included both radius and ulna on the injury film, postreduction, prewedge, postwedge, and final films. Radiographic technique was standardized, with repeatability testing demonstrating a precision of ±2 degrees.

Results: Over 15 months, our hospital treated 2124 forearm or DR fractures with closed reduction and casting. There were 60 fractures treated either with percutaneous fixation (36) or open treatment (24). A total of 79 forearm or DR fractures were treated with cast wedging secondary to loss of reduction, of which 70 patients had complete clinical and radiographic data. Average age was 8.4 years (range, 3 to 14 y), with 25 females and 45 males. Significant improvement in angulation for both-bone forearm fracture from prewedge to final films was seen in 69 children, with no major complications. One patient failed wedging and required surgical reduction and fixation.

Conclusions: Cast wedging is a simple, safe, noninvasive, and effective method for treatment of excessive angulation in pediatric forearm fractures.

Level of Evidence: Level IV.

*Nationwide Children’s Hospital

Department of Orthopaedics, The Ohio State University, Columbus, OH

None of the authors received financial support for this study.

The authors declare no conflict of interest.

Reprints: Walter P. Samora, MD, Nationwide Children’s Hospital, 700 Children’s Drive, Room 2630, Columbus, OH 43205. E-mail:

© 2014 by Lippincott Williams & Wilkins