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Home Specialties Orthopedics Common Orthopedic Injuries in Kids -- Is a Cast a Must?

Common Orthopedic Injuries in Kids — Is a Cast a Must?

Pediatric fractures are common. Physician Assistants and Nurse Practitioners often face the decision of immobilizing the fracture with a cast or splint. While the use of a cast is taught as standard practice, there is evidence that splinting can be as effective with fewer side effects. 

Here’s another option for treating pediatric fractures that results in improved healing with fewer complications.

Why Pediatric Fractures May Be Deemed “Low-Risk”
Two characteristics of pediatric skeletal composition allow you to deem a fracture as “low-risk”, as compared to similar fractures in adults [1]:

  1. The periosteum in a child is thicker than in an adult and can provide additional stability to the fracture site
  2. Children’s bones remodel much more quickly than bones in adults, especially the closer the fracture is to the physes 

Because of these characteristics, some pediatric fractures and misalignment of bones can be more easily dealt with than in the adult patient.

Use of Splints in Specific Types of Pediatric Fractures
Some low-risk pediatric fractures lend themselves to treatment with a splint versus a cast.[2]

Wrist buckle (distal radius/ulna) fractures — The standard treatment for this common fracture is a short arm cast for two to four weeks. A study shows that children treated with splints for this fracture had more mobility, no significant increase in pain, and a slightly better outcome.[2]

Low-risk ankle (distal fibula) fractures — Children treated with a splint or lace-up brace returned to their baseline of function sooner than those treated with a short leg cast. The cost of treatment was less due to fewer repeat visits to the clinic or emergency room for adjustments (more on this later). 

Slightly angulated transverse and greenstick distal radius fractures — Treatment of these fractures with a splint resulted in less deformity at the fracture site than those treated with a short arm cast. Splinted patients also experienced slightly better range of motion after treatment.

Increased Complications and Expense with Casts
The standard practice of using casts comes with a number of potential complications that make the use of splints a compelling option. [3] The child with a cast may return to the clinic or emergency room after casting for a number of reasons:

  1. The cast has become wet and is breaking down
  2. Specific patient activity has damaged the cast
  3. The cast is too tight or has become too loose to be effective
  4. Shifting of the cast is causing new pain or discomfort

Proper application of a cast can reduce the number of return visits. However, the child’s activity level and compliance with the care of the cast may still require subsequent visits for further adjustment or even the application of a new cast.

Proper Splint Application to Further Reduce Complications
As with any treatment technique, the improper use of splints can result in poor healing and patient satisfaction. Staff applying the splints should be well trained as to the proper use of splints and how to reduce patient returns. 

The use of splints should not be seen as a quicker form of treatment. Sufficient time to apply the splint needs to be allotted to get the best outcome.

A number of issues can contribute to the improper application of a splint. These include:[4]

  1. Incorrect positioning of the splint
  2. Improper placement of elastic bandages on the skin (too tight or loose)
  3. Incorrect splint length for the type of fracture

Skin and soft-tissue damage is a risk with improper splinting. The most common issue is excessive edema from incorrect placement of the splint or bandage. Other risks are direct abrasions to the skin due to improper padding of the edges of a splint or uneven lacing of a lace-up splint.

Cast or Splint: The Decision Process
There is no general rule as to when to use a cast or splint. The PA or NP needs to be familiar with the various pediatric fractures and which treatment technique is most appropriate for each.[5Severely displaced fractures and compound fractures continue to require full circumferential casting as a definitive treatment. But low-risk pediatric fractures offer the additional treatment option of a splint.

Beyond the type and severity of the fracture, the child’s age, activity level, and parental support need to be factored into the treatment decision. You may well choose to use a cast if there is any question about the patient’s or parents’ ability to comply with the care and management of the splinted fracture. The restrictions in mobility afforded by a cast may be just what that patient needs to ensure a good outcome.

Last updated on 9/25/19.

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