A One Off Treatment for Distal Radial Greenstick Fractures – Mr Hambridge FRCS & Graham A Neale BCC

Mr Hambridge FRCS – Trauma/Orthopaedic Surgeon, Graham A Neale BCC – Senior Orthopaedic Technician – April 2016

Dorsal buckle, often called greenstick, distal radial fractures are a common presentation in children. One study estimated an incidence of 1% per year, which would give an annual total of over 125,000 in the UK. The commonest treatment for un-displaced isolated stable radial fractures currently is 3 weeks in a rigid cast. The child then requiring a return to fracture clinic for removal of plaster. A remove at home semi-rigid cast which could be made using BeneCast™ Flex has the potential to reduce these visits and hence cost. Is it safe? Keith Willett and co-workers from Oxford studied 317 cases in a randomised trial and found the treatment to be safe. Is it acceptable? Frank Dowling and co-workers in Dublin found that in a study of 117 cases that parents would select a Semi Rigid Cast if given a choice. The greatest advantage is savings both in terms of clinic time and costs. The Oxford paper in 2013 suggested a total cost saving of just over £100 per case. Potentially then a saving to the NHS of £12 million per year. Is everyone suitable? Some parents do not like the idea of removing a cast from their child. Some domestic circumstances mean that concern about premature cast removal may be present. Often concerns can be smoothed over by spending time to reassure parents and having a number to contact in case of concern. So with supporting evidence remove at home casts are a potential treatment.

The Casting Technique in Making this Cast

Casting Article 1

Selection of materials requested for cast.

Casting Article 2

Apply two layers of BeneCast Stockinette

Casting Article 3

Apply felt around hand and thumb and on the Ulnar Styloid

Casting Article 4

Now apply two-layer slab of BeneCast™ Select to cover fracture site.

Casting Article 5

Start applying 5cm BeneFlex Casting Tape distally.

Casting Article 6

Half way through application turn back the first layer of BeneCast Stockinette. Secure with BeneFlex.

Casting Article 7

Once applied turn in the end of Casting and hold down till set. Forming a lip to ease the removal of Cast.

Casting Article 8

On completion of cast turn back BeneCast™ Stockinette and secure with tape.

 

Casting Article - form 3
(Example 1)
We have been using this one off, one visit treatment for Greenstick Distal Radial Fractures at Queens Hospital for approximately two years.

After the patient has attended A/E, has had X-rays to confirm injury and the usual Back Slab applied they will then attend the next Fracture Clinic where we apply the, remove at home cast. The parents are then given Cast Instructions and a supporting letter (see example 1) with a confirmation date to remove cast, including contact numbers for Department should there be any issues or advice required.

For the purpose of this paper I collected request forms for 59 applications.

After completing this Audit, I contacted 10 of these patients to ask the following:

  1. How their child was in the cast?
  2. How easy it was to remove the cast?
  3. How soon their child returned to normal activity?

There were no issues during their time in the cast which was approximately 3 weeks the parents removed the cast with no real issue and the patient was on average back to normal activities within a couple of days or so.

I also asked how they rated this method of treatment on a scale of 1-10 this randomly selected group all rated between 8-10.

They were happy with the treatment, supportive information and backup provided to them if was necessary. Out of the 59 patients collected for this paper none were recorded as presenting to, or contacting the department with any issues or complications.

In casting rooms where the orthopaedic Technicians give a full casting service to A/E, with the support of the Trauma and Orthopaedic department this technique could be a truly one visit, one Cast Protocol for these injuries, greatly reducing Fracture Clinic attendances.

Thank you to Mr Hambridge FRCS – Trauma/Orthopaedic Surgeon &  Graham A Neale BCC – Senior Orthopaedic Technician for allowing us to use this research!