Above- or below-elbow casts for distal third forearm fractures in children? A meta-analysis of the literature

Fractures of the distal third forearm are common fractures in childhood. Most of these fractures can be treated non-operatively by means of closed reduction and immobilization. The purpose of this meta-analysis is to investigate whether above- or below-elbow cast should be considered the first-choice for conservative treatment. A search was performed in multiple databases to identify all the studies comparing above- and below-elbow cast for the treatment of distal third forearm fractures in children. All RCT's or CCT's were assessed for eligibility. Quality was assessed by the Cochrane Musculoskeletal Injuries Group assessment. Data were pooled using RevMan 5.0 Three trials involving a total of 300 participants were included. A total of 142 fractures were treated with a below-elbow cast (BEC) versus 158 with an above-elbow cast (AEC). Loss of reduction was encountered in 17 and 36 cases, respectively [odds ratio 0.44 (0.22-0.87)]. For combined radius and ulna fractures 15 of 97 in the BEC group and 34 out of 122 in the AEC group showed loss of reduction [odds ratio 0.55 (0.26-1.15)]. Children treated with BEC missed less school days [mean difference 1.12 (-1.52 to -0.59)], and encountered less difficulties in daily living [odds ratio 112.41 (6.58-1920.77)]. Due to heterogeneity, the trials are not fully compared. Based on the presented meta-analysis, we conclude that BEC is not inferior to AEC so that this is a valid treatment option for distal third forearm fractures.