(From the January 2014 Issue of PediatricsOnline)
Forearm fractures account for about 30 percent of all upper-extremity fractures in kids, with one out of every 100 children suffering this kind of break each year in the U.S. alone. In some cases, after the bone is set, it begins to heal at an angle, a misalignment that can limit range of motion and function.
Traditionally, orthopaedic specialists have repaired this problem, called angulation, with a technique called cast wedging, in which part of the cast is cut out and a wedge is inserted to re-align the fractured bone as it heals. Over the past few decades, however, more specialists have turned to a surgical corrective method, inserting pins or rods to correct angulation.
“We noticed during national meetings and in recent publications that the number of forearm and wrist fractures treated with operative stabilization has increased,” says Walter P. Samora, MD, an orthopaedic surgeon and member of the sports medicine physician team in the Department of Orthopaedics at Nationwide Children’s Hospital. “But cast wedging has been around for a number of years and allows us to safely correct angulation without the risks associated with operative procedures, so we wanted to know whether its outcomes still merit its precedence in our protocol.”
Surgical management is straightforward and typically effective, making it a popular choice for direct correction of angulation, despite the risks associated with incisions and anesthesia. Cast wedging is often considered an art, requiring expert technique and in-depth calculations for angle correction.
Opinions as to the best method differ among experts in the field—even studies published in leading journals offer conflicting statistics. Dr. Samora and a team of clinician researchers in the Department of Orthopaedics at Nationwide Children’s examined outcomes of cast wedging in pediatric patients with forearm fractures.
In this study, Dr. Samora and colleagues reviewed the cases of 2,124 patients who suffered forearm fractures between June 2011 and September 2012. Seventy-nine patients displayed unacceptable alignment within three weeks of injury and received cast wedging, in keeping with hospital protocol. Of the 79 cases, 70 met inclusion criteria of complete radiographic records, open distal radial physis, closed injury and excessive angulation (as determined by review of patient radiographic measurements of the radius and ulna by two orthopedic specialists). The patients ranged in age from 3 to 14, and wedging was performed on fractures with >10 degrees of angulation to >20 degrees, depending on fracture location and patient age.
Sixty-nine of the 70 patients demonstrated significant improvement in radiographic alignment upon follow-up, with nearly all angulations corrected to <5 degrees. Only one patient (1.4 percent) failed to show improvement in angulation of the fracture and required surgical intervention. Three patients reported minor pain or discomfort after wedging, all of which was responsive to over-the-counter pain medication and resolved within two days.
“Cast wedging remains a safe, effective treatment option for physicians seeking to avoid surgical management of pediatric forearm fractures,” says Dr. Samora. “The procedure can be done safely and quickly in the clinic setting without the need for procedural analgesia, with immediate results.”
Samora JB, Klingele KE, Beebe AC, Kean JR, Klamar J, Beran MC, Willis LM, Yin H, Samora WP. Is There Still a Place for Cast Wedging in Pediatric Forearm Fractures? Journal of Pediatric Orthopedics. 2013 Sep 15. [Epub ahead of print]