Less is More: Casting Alone for Overriding Distal Radial Fractures

Source: Crawford SN, Lee LSK, Izuka BH. Closed treatment of overriding distal radius fractures without reduction in children. J Bone Joint Surg. 2012;94A(3):246-252; doi:10.2106/JBJS.K.00163.  See AAP Grand Rounds commentary by Dr. William Hennrikus (subscription required). 

PICO
Question: Among children <11 years old with an overriding distal radius fracture, what is the outcome and cost when the fracture is not reduced?
Question type: Intervention
Study design: Retrospective case series

I had to read between the lines of this study, but I suspect that the senior author, Dr. Izuka, saw a 2003 article suggesting that open reduction wasn't necessary for overriding distal radius fractures and decided to adopt this approach.  He kept track carefully of his patient outcomes, with this study being the result.

A retrospective case series clearly has risk of confounding variables that could be eliminated with a randomized controlled trial design, but the authors were able to secure at least one-year followup for 51 of their 54 patients seen over a five year period.  While there were minor angulations still present by the end of followup, it appears these were clinically insignificant as all patients had normal activities and function.  I'm not certain if a one-year followup period is sufficient to reassure us that the "permanent" outcome is equally good; I'll leave that to the orthpedic surgeons reading the article.  However, the authors calculated cost savings of $3800 to $7700, depending on alternative method used, and included parental satisfaction in their definition of good outcome.  So, the potential benefits of this approach are considerable. 

Kudos to these authors for simply reporting their results and allowing other surgeons to make their own conclusions.  Sometimes study design doesn't need to be complicated to be effective!