Above-Elbow Casts With the Wrist and Hand Free vs. Standard Above-Elbow Casts With the Wrist and Hand Included in the Treatment of Supracondylar Humerus Fractures in Children: A Randomized Prospective Study.

BACKGROUND: Supracondylar humerus fractures are the most common elbow fractures in the pediatric population. Despite evolving management concepts, there is limited evidence comparing different cast types for immobilization following operative management. This study compared above-elbow casts that leave the wrist and hand free (experimental group) versus standard above-elbow casts that include the wrist and hand for the postoperative treatment of supracondylar humerus fractures in children. METHODS: In this randomized prospective study, 255 patients aged 3-10 years with isolated, operatively treated (Gartland Type II and III) supracondylar humerus fractures were randomized, following closed reduction and percutaneous pinning, to receive either a postoperative cast that did not include the wrist or hand (n = 124) or a postoperative cast that included the wrist and hand (n = 131). The primary outcome was the Quick Disability of Arm, Shoulder, and Hand (QuickDASH) questionnaire score. Secondary outcomes included range of motion (ROM), dexterity, pain, radiographic carrying angle, and functional results at 3-4 weeks, 9 weeks, and 1-year post-treatment. RESULTS: The experimental group demonstrated lower QuickDASH scores at 3-4 weeks (26.0 vs. 36.0, P < .0001). At 9 weeks, the experimental group showed slightly higher QuickDASH scores (5.6 vs. 4.1, P = .2). Dexterity was higher in the experimental group at 3-4 weeks measured by the peg-board test (P < .0001). Range of motion measurements at 9 weeks revealed better elbow extension and similar values in elbow flexion, forearm rotation, wrist motion, radiographic carrying angle, and pain scores between groups. CONCLUSIONS: Above-elbow casts, leaving the wrist and hand free, demonstrated non-inferiority compared to standard casts including the hand for treating pediatric supracondylar humerus fractures. Although early (3-4 week) QuickDASH scores were statistically lower in the wrist and hand free group, this difference did not exceed the minimal clinically important difference, and long-term results were comparable between groups. The wrist and hand free group completed in-cast dexterity testing more quickly at 3-4 weeks. Importantly, leaving the wrist and hand free permits direct assessment of the radial pulse and hand perfusion. Wrist and hand free casting is a viable alternative that maintains appropriate fracture immobilization. KEY CONCEPTS: (1)Above-elbow casts with the wrist and hand free demonstrate non-inferior functional outcomes compared to above-elbow casts with the hand and wrist included for the postoperative treatment of pediatric supracondylar humerus fractures.(2)Patients treated with the wrist and hand free showed significantly better early functional scores (QuickDASH) and superior dexterity at 3-4 weeks compared to the wrist and hand included patients.(3)Range of motion, pain scores, and radiographic carrying angles were comparable between groups at 9 weeks and 1 year, confirming that wrist and hand free casting does not compromise fracture healing or alignment.(4)Above-elbow casting with the wrist and hand free offers practical clinical advantages, including easier postoperative vascular assessment of the hand and improved patient hygiene during the immobilization period.(5)This is the first prospective randomized study (n = 255) to directly compare hand inclusion versus exclusion in cast immobilization following operative fixation of supracondylar humerus fractures in children. LEVEL OF EVIDENCE: 2 (Randomized controlled trial).