Cast OFF-2: 1 week of plaster cast immobilization for non-reduced distal radius fractures-a study protocol for an implementation study

Cast-OFF 2: One Week Versus 3-5 Weeks of Plaster Cast Immobilization for Non- or Minimally Displaced Distal Radius Fractures-A Stepped Wedge Cluster Randomized Controlled Trial

OBJECTIVES

Implementation of 1 week of cast immobilization followed by gradually increasing wrist mobilization for non- or minimally displaced distal radius fracture (DRF) and comparison of the functional outcomes and pain scores with the usual care (3-5 weeks of cast immobilization).

METHODS

DESIGN

A randomized stepped wedge cluster design, prospective cohort.

SETTING

Academic and peripheral hospitals in levels 1, 2, and 3 trauma centers.

PATIENT SELECTION CRITERIA

All patients between 18 and 85 years old with an isolated non- or minimally and nonreduced DRF were eligible for inclusion. Participating hospitals were randomized to transition from usual care (3-5 weeks of cast immobilization) to 1 week of cast immobilization, following the stepped wedge design.

OUTCOME MEASURES AND COMPARISONS

Patient characteristics, secondary dislocation, surgical treatment, visual analog scale, Patient Rated Wrist Evaluation (PRWE), Patient Reported Outcomes Measurement Information System Pain Interference, Pain Catastrophizing Scale 4, and patient satisfaction were compared between control and intervention group at weeks 1, 3-5, 6, months 3, 6, and 12. A difference around 11 points on the PRWE scale was considered clinically significant.

RESULTS

Four hundred two patients were included (control n = 197 vs. intervention n = 205, 267/135, female/male). There were no differences in age (53.7 ± 18.6 vs. 53.3 ± 19.5, P = 0.27), sex (66% vs. 67% female, P = 0.44), dominant hand fractured (44% vs. 53%, P = 0.39), and type of fracture (39% vs. 41% extra-articular, P = 0.44). After 6 weeks, the PRWE score showed no clinically significant differences (-4.5 [confidence interval -12.9 to 4.02], P = 0.30). No significant differences were observed for function, pain scores, and patient satisfaction between groups (all P > 0.05). Furthermore, there was no significant difference in secondary dislocation rate (control 1.5% vs. intervention 1.0%, P = 0.32) and operation rate (control 1.5% vs. 1.5% intervention, P = 0.92).

CONCLUSIONS

This study compared 1 week of cast immobilization followed by gradually increasing wrist mobilization to the usual care of 3-5 weeks for nonreduced DRF. No clinically significant differences in function, pain scores, patient satisfaction, secondary dislocation, and operations were observed. Therefore, 1 week of plaster immobilization can be safely recommended for the non- or minimally displaced and nonreduced DRF treatment.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Cast immobilization duration for distal radius fractures, a systematic review

PURPOSE

The optimal duration of immobilization for the conservative treatment of non- or minimally displaced and displaced distal radius fractures remains under debate. This research aims to review studies of these treatments to add evidence regarding the optimal immobilization period.

METHODS

A comprehensive database search was conducted. Studies investigating and comparing short (< 3 weeks) versus long (> 3 weeks) immobilizations for the conservative treatment of distal radius fractures were included. The studies were evaluated for radiological and functional outcomes, including pain, grip strength, and range of motion. Two reviewers independently reviewed all studies and performed the data extraction.

RESULTS

The initial database search identified 11.981 studies, of which 16 (involving 1.118 patients) were ultimately included. Patient-reported outcome measurements, grip strength, range of motion, and radiological outcomes were often better after shorter immobilization treatments. Radiological outcomes were better with longer immobilization in two studies and shorter immobilization in one study. Fourteen studies concluded that early mobilization is preferred, while the remaining two studies observed better outcomes with longer immobilization. The data were unsuitable for meta-analysis due to their heterogeneous nature.

CONCLUSION

Shorter immobilization for conservatively treated distal radius fractures often yield equal or better outcomes than longer immobilizations. The immobilization for non- or minimally displaced distal radius fractures could therefore be shortened to 3 weeks or less. Displaced and reduced distal radius fractures cannot be immobilized shorter than 4 weeks due to the risk of complications. Future research with homogeneous groups could elucidate the optimal duration of immobilization.

The past, present and future of the conservative treatment of distal radius fractures

The distal radius fracture is a common fracture with a prevalence of 17% on the emergency departments. The conservative treatment of distal radius fractures usually consists of three to six weeks of plaster immobilization. Several studies show that one week of plaster immobilization is safe for non- or minimally displaced distal radius fractures that do not need reduction. A shorter period of immobilization may lead to a better functional outcome, faster reintegration and participation in daily activities. Due to upcoming innovations such as three-dimensional printed splints for distal radius fractures, a patient specific splint can be produced which may offer more comfort. Furthermore, these three-dimensional printed splints are expected to be more environmental friendly in comparison with traditional plaster casts.