Today's News

Friday, March 2, 2001

Routine cast changes for children unnecessary

Pediatric distal forearm fractures account for nearly half of all pediatric fractures. Most orthopaedists perform routine cast changes when treating distal forearm fractures in children, investigators observed Thursday in scientific paper 132. However, they say "our results suggest that a routine cast change may be unnecessary since we observed no loss of motion utilizing a single above-elbow cast until complete healing.

"Routine cast changes increase treatment costs. We believe that cast changes should be limited to patients who have lost an initial reduction or who have a damaged, nonrepairable cast."

The initial part of the study surveyed local pediatric orthopaedists regarding their management of uncomplicated distal forearm fractures in children. Nineteen of the 20 survey respondents routinely performed a cast change, even if the fracture had not displaced and the cast did not require repair. Of these 19 respondents, 16 changed to a below-elbow cast. The most common reason cited for this cast change was "to prevent elbow stiffness" (50 percent) followed by "to allow better function" (31.3 percent).

In the second part of the study, the investigators prospectively followed 93 children with these fractures to clinical and radiographic union. Ninety patients were treated in a single above-elbow cast until union. A cast change was required for three patients due to a loss of reduction or a poorly fitting cast. Elbow range of motion was recorded at cast removal and at each follow-up visit. None of the children in the cohort had limitation to flexion or extension at the elbow, nor pronation or supination in the forearm, at latest follow-up.

In addition to the clinical arm of this study, the annual costs of pediatric forearm fracture care were investigated. Purchasing departments at both a public and a private hospital were interviewed to determine the costs of materials associated with cast changes. Human resources departments at these institutions were similarly used to help determine the hours and salaries that must be invested in fracture care.

The average estimated cost of labor and materials used for a cast technician to remove a long arm cast and apply a short arm cast, using plaster materials, was $16.14. These costs would be considerably greater if the physician provides the labor or if synthetic cast materials is used. In an era of cost containment, routinely switching from a long arm cast to a short arm cast to allow a brief period of patient convenience is probably not economically justified, especially since elbow stiffness was not found to be a problem in one group of children.

John P. Kelly, MD, and Lewis E. Zionts, MD, both of Keck School of Medicine, University of Southern California, Los Angeles, Calif. are the investigators. Dr. Zionts also is director of the pediatric orthopaedic service at Women's and Children's Hospital, Los Angeles County/USC Medical Center.

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Last modified 20/February/2001 by IS