Introduction. Displaced distal radius fractures in children have been treated in above elbow plaster casts since the last century. Cast index has been calculated previously, which is a measure of the sagittal cast width divided by the coronal cast width measurement at the fracture site. This indicates how well the cast was moulded to the contours of the forearm. We retrospectively analysed the cast index in post manipulation radiographs to evaluate its relevance in redisplacement or reangulation of distal forearm fractures. Study Design. Consecutive radiographic analysis. Materials and methods. 156 consecutive paediatric patients (114M : 42F), with a mean age of 9.8 years (range 2-15 years), presenting with forearm fractures were studied. All patients were manipulated in OR and a moulded above elbow cast was applied. The cast index was measured on immediate post manipulation radiographs. Results. Displacement of the fracture within the original plaster cast occurred in 30 patients (19%), 22/114 males; 8/42 females. The cast index in the 30 patients requiring a second procedure (mean 0.92, SD=0.08) was significantly more than the cast index (mean 0.77, SD=0.07) in the others (p< .001). Discussion. A high cast index in post manipulation radiographs indicates increased risk of re-displacement of the fracture and these patients should be kept under close review. Conclusion. Cast index is a valuable tool to assess the quality of moulding of the cast following closed manipulation of distal radius fractures in children. The maximum acceptable cast index should be 0.82

We present an objective method for predicting the redisplacement of paediatric forearm and wrist fractures. Novel radiographic measurements were defined and their value assessed for clinical decision making. In Phase I of the study we defined the cast index and padding index and correlated these measurements with the incidence of fracture redisplacement. Phase II assessed these indices for their value in clinical decision making. Cast Index (a/b) is the ratio of cast width in lateral view (a) and the width of the cast in AP view (b). Padding Index (x/y) isthe ratio of padding thickness in the plane of maximum deformity correction (x) and the greatest interosseous distance (y) in AP view. The sum of cast index and padding index was defined as the Canterbury Index. In Phase I, 142 children's radiographs were analysed and a statistically significant difference was identified between redisplacement and initial complete off-ending of the bones, cast index > 0.8 and padding index of > 0.3. There was no significant association with age, fracture location, seniority of surgeon or angulation. In Phase II, radiographs of 5 randomly selected cases were presented to 40 surgeons (20 consultants & 20 registrars). Following an eyeball assessment they were asked to measure the cast index and padding index (after instruction). With eyeballing the consultants predicted 33% and registrars 25% of the cases that redisplaced. After learning to measure the indices the accuracy increased to 72% for consultants and 81% for registrars (p<0.001). We conclude that the cast index, padding index and Canterbury Index are validated tools to assess plaster cast quality and can be used to predict redisplacement of paediatric forearm fractures after manipulation. They can easily be taught to orthopaedic surgeons and are more accurate than eyeballing radiographs in the clinical setting. Redisplacement can be predicted if cast index > 0.8, padding index > 0.3 and Canterbury Index > 1.1

Distal radius fractures (DRFs) are common injuries that represent 17% of all adult upper extremity fractures. Some fractures deemed appropriate for nonsurgical management following closed reduction and casting exhibit delayed secondary displacement (greater than two weeks from injury) and require late surgical intervention. This can lead to delayed rehabilitation and functional outcomes. This study aimed to determine which demographic and radiographic features can be used to predict delayed fracture displacement. This is a multicentre retrospective case-control study using radiographs extracted from our Analytics Data Integration, Measurement and Reporting (DIMR) database, using diagnostic and therapeutic codes. Skeletally mature patients aged 18 years of age or older with an isolated DRF treated with surgical intervention between two and four weeks from initial injury, with two or more follow-up visits prior to surgical intervention, were included. Exclusion criteria were patients with multiple injuries, surgical treatment with fewer than two clinical assessments prior to surgical treatment, or surgical treatment within two weeks of injury. The proportion of patients with delayed fracture displacement requiring surgical treatment will be reported as a percentage of all identified DRFs within the study period. A multivariable conditional logistic regression analysis was used to assess case-control comparisons, in order to determine the parameters that are mostly likely to predict delayed fracture displacement leading to surgical management. Intra- and inter-rater reliability for each radiographic parameter will also be calculated. A total of 84 age- and sex-matched pairs were identified (n=168) over a 5-year period, with 87% being female and a mean age of 48.9 (SD=14.5) years. Variables assessed in the model included pre-reduction and post-reduction radial height, radial inclination, radial tilt, volar cortical displacement, injury classification, intra-articular step or gap, ulnar variance, radiocarpal alignment, and cast index, as well as the difference between pre- and post-reduction parameters. Decreased pre-reduction radial inclination (Odds Ratio [OR] = 0.54; Confidence Interval [CI] = 0.43 – 0.64) and increased pre-reduction volar cortical displacement (OR = 1.31; CI = 1.10 – 1.60) were significant predictors of delayed fracture displacement beyond a minimum of 2-week follow-up. Similarly, an increased difference between pre-reduction and immediate post reduction radial height (OR = 1.67; CI = 1.31 – 2.18) and ulnar variance (OR = 1.48; CI = 1.24 – 1.81) were also significant predictors of delayed fracture displacement. Cast immobilization is not without risks and delayed surgical treatment can result in a prolong recovery. Therefore, if reliable and reproducible radiographic parameters can be identified that predict delayed fracture displacement, this information will aid in earlier identification of patients with DRFs at risk of late displacement. This could lead to earlier, appropriate surgical management, rehabilitation, and return to work and function

Background and Aims:. Forearm fractures are common in the paediatric population and most are treated in a moulded plaster of Paris (POP) cast. It is our concern that many casts applied by our registrars are sub-optimal and that we need to improve our training process. The aim of our study was to review the adequacy of forearm cast application in paediatric patients at our institution and to identify if there is a need for a more formal training program with regard to plaster cast application. Methods:. A retrospective review of control x-rays of forearm fractures treated at our institution was undertaken. X-rays that were reviewed were done as part of the routine treatment protocol. X-ray measurements to assess POP application were the cast index and the gap index. A cast index of > 0.81 and Gap index of > 0.15 were regarded as an indication of poor cast application. Results:. Adequate control X-rays of twenty eight patients with a forearm fracture were available. The average patient age range was 5–12 years. There were thirteen distal metaphyseal fractures, nine diaphyseal fractures and six Salter-Harris type fractures. Of the 28 patients, 20 patients had a poor cast index and 17 patients had poor gap index. In 12 patients both the gap and the cast index were unacceptable. Conclusion:. Our study suggests that paediatric forearm plaster cast application by registrars at our institution is inadequate. This indicates a need for a strategy to improve the training in plaster cast application amongst our registrars

Introduction. To investigate if the gap index measured in the follow-up X-rays predicts the reduction of swelling in the plaster cast thereby increasing the risk of re-displacement of fracture treated by manipulation alone. Materials/Methods. We selected for this study a cohort of children who presented with a traumatic displaced fracture of distal radius at the junction of metaphysis and diaphysis who were treated with manipulation alone. This cohort was chosen because of the high risk of re-displacement following closed manipulation of this unstable fracture and to maintain uniformity of the fracture type. Cast index and Gap index was measured in the intra-operative radiograph and at two-weeks to note the change in these indices. Gap index which is measured by summing radial and ulnar translation/inner diameter of cast in the AP X-ray and similar translation on the lateral x-ray/inner diameter of cast, with a measure of <0.15 considered to be a satisfactory cast. Results. Forty-one children with a mean age of 9 years (mode-8, range 4–15 yrs) admitted between Jan 2008 and Feb 2010 with the above described fracture and were treated with manipulation alone were included in this study. Serial radiographs show a gradual loss of reduction in 34 (83%) children and 17 (41%) of these children required re-manipulation. As the plaster cast was not changed the cast index remained same while the gap index increased in the follow-up x-rays as the swelling subsided. In those children whose reduction remained satisfactory, the initial gap index was 0.14 which changed to 0.18 (n=7, p>0.05) while in children in whom the fracture lost reduction, the initial gap index was 0.18 and changed to 0.25 (n=34, p=0.0092) at two weeks. Conclusion. Gap index can easily be calculated on follow-up radiographs and can be used to assess the adequacy of plaster cast. From this study we can conclude that it is effective in assessing the adequacy of plaster cast as the swelling subsides

Aim. Up to 34% of fractures of the distal radius in children can ‘re-displace’ early after reduction. Main risk factors are initial displacement (bayonet apposition, > 50% translation, and > 30°angulation), isolated distal radius fracture, associated ulna fracture at the same level, inadequate initial closed reduction and poor casting technique. This study was to identify the rate of ‘re-displacement’ following first successful reduction in distal radius fractures. We also assessed the risk factors associated with initial injury and compared the efficacy of the available indices to assess the quality of casting. Materials & Methods. We performed a case note based radiographic analysis of 90 distal radius fractures treated at our centre from 2005 to 2008. A cohort of 18 patients with re-displacement was compared with 72 patients with maintenance of reduction. Radiological indices were calculated to assess the quality of casting technique. The patient and fracture demographics were compared between the two groups. Statistical analysis was carried out using ANOVA, Fisher's Exact Test and multiple logistic regression analysis. Results. The rate of ‘re-displacement’ in our study was 20 %. A desirable cast index of < 0.7 was achieved in 4 out of 55 cases treated with cast alone. A significant difference (p< 0.008) was observed in the Three Point Index, the degree of comminution (< 0.01) and the quality of the initial reduction (< 0.003). Conclusion. We recommend careful identification of high risk factors and appropriate stabilisation for potentially unstable fractures at first treatment. The magnitude of initial deformity, the comminution, and the amount of remaining skeletal growth must all be considered in the decision making process. Further training to improve the quality of casting technique cannot be over-emphasised. Trainees should be trained to calculate the Three Point Index before accepting the reduction after casting to prevent late displacement and second anaesthesia

Introduction and aims. Cast immobilisation of paediatric forearm fractures has traditionally used plaster of Paris. Recently, synthetic casting materials have been used. There have been no studies comparing the efficacy of these two materials. The aim of this study is to investigate whether one material is superior for paediatric forearm fracture management. Methods. A single-centre prospective randomised trial of patients presenting to the Women's and Children's Hospital with acute fractures of the radius and/or ulna was undertaken. Patients were enrolled into the study on presentation to the Emergency Department and randomised by sealed envelope into either a fiberglass or plaster of Paris group. Patients then proceeded to a standardised method of closed reduction and cast immobilisation. Clinical follow-up occurred at one and six weeks post-immobilisation. A patient satisfaction questionnaire was completed following cast removal at six weeks. All clinical complications were recorded and cast indexes were calculated. Results. Initially 50 patients were recruited to the study, with equal randomisation. There were no significant differences between the patient demographics of the two groups. The results from this sample indicated an increase in clinical complications involving the plaster of Paris casting group. These complications included soft areas of plaster requiring revision, loss of reduction with some requiring re-manipulation and a high rate of cast spliting due to material swelling. The fractures that loss reduction had increased cast indices. Fibreglass casts were also preferred by patient and their families, with many observational comments regarding the light-weight and durable nature of the material. Conclusions. Cast immobilisation of paediatric forearm fractures is a common orthopaedic treatment. There is currently no evidence regarding the best material for casting. This study suggests that both clinical outcomes and patient satisfaction are superior with fiberglass casts, we are continuing this study to enable greater power with our results