It’s Time to Cast Away Plaster of Paris and Splint Stable Distal Radius Fractures: A Review of the Literature
Distal radius fractures account for up to 15% of all bony injuries sustained by adults, and are responsible for approximately 20% of all emergency department presentations (Meena et al., 2014).
In older adults (>65 years old), this injury is most prevalent in women and commonly attributed to a low-energy trauma, such as a fall from a standing position onto an outstretched hand (Meena et al., 2014). Conversely, among younger adults, the injury is most prevalent in males and associated with high-energy trauma such as a fall from a great height, or a motor vehicle accident (Meena et al., 2014).
Optimizing Recovery: Principles and Timelines for Distal Radius Fracture Immobilization
Fracture management principles dictate a fracture must first be reduced to re-establish acceptable anatomical positioning; then, immobilised to maintain and hold that reduction (Meena et al, 2014). Whilst many distal radius fractures require surgical intervention and subsequent fixation to achieve an acceptable reduction, research has found stable and minimally displaced fractures (defined as having a palmar tilt loss <10°, radial shortening ≤2mm and intra-articular step < 2mm) can safely be managed conservatively with good outcomes (Kashmiri et al., 2016).
It is generally accepted that distal radius fractures should be protected from excessive forces for a period of 6-8 weeks (Herman et al., 2010). Whilst bone healing continues for an extensive period of time, upwards of many months, by 6-8 weeks the fracture has clinically united and can begin to tolerate progressive loading (Slutsky & Osterman, 2009).
Revolutionizing Immobilisation: Exploring Alternatives to Plaster of Paris Casting
Currently, there are two main methods of immobilisation: Plaster of Paris (POP) casting, and thermoplastic splinting. POP casting is the most common method utilised in emergency departments or General Practitioner offices, as the material is cheap, relatively easy to apply, and research has found it to be effective in maintaining reduction.
However, there are numerous downsides to this method, particularly arising from POP casting being circumferential and unable to be removed, including: inability to perform skin care or commence scar management, an increased risk of skin break-down and development of pressure areas, risk of the POP becoming too loose (which increases the risk of loss of reduction) or too tight (which places patient at risk of compartment syndrome) due to changes in levels of oedema.
In addition, POP must remain dry and will deteriorate when wet, and negatively impacts a patient’s ability to perform their normal daily living activities, such as showering and performing regular hand hygiene.
Breaking the Mold: Advantages of Thermoplastic Splinting Over Traditional Casting
In contrast, thermoplastic splinting is custom made from a light weight material and can be removed as required, is easily adjustable, waterproof, and easy to clean. A study conducted by Kashmiri et al (2016) demonstrated thermoplastic splints to be clearly favoured by patients for comfort and convenience with performing various activities of daily living. A common fear of immobilising a fracture with a non-circumferential, removable splint is that common complications seen with fracture healing- such as delayed union, non-union, and malunion, are more likely to occur (Mavcic & Antolic, 2012). However, these concerns are unfounded, as research shows no deterioration in radiological outcomes or increased risk of non-union or malunion when used with adults with stable distal radius fractures (either stabilised surgically, or anatomically stable), when compared to those immobilised with circumferential POP (Kashmiri et al., 2016; O’Connor et al., 2003). Furthermore, there is research to indicate thermoplastic splinting allows for a faster return to normal function (O’Connor et al., 2003).
Redefining Rehabilitation: How Early Mobilisation Transforms Fracture Recovery
Perhaps the most notable and significant difference between these methods of immobilisation is in the rehabilitation process. It is significantly delayed with circumferential POP casting until its removal at approximately six weeks.
In contrast, a removable thermoplastic splint allows for immediate skin care and commencement of active range of movement, and other rehabilitation strategies, as soon as it is safe and clinically appropriate.
These methods differ drastically in regards to the amount of therapy sessions required by the patient: those able to commence early mobilisation needed an average of only 6.57 sessions, versus 17 sessions when mobilisation was delayed (Ikpeze et al., 2016). When comparing early commencement of range of movement with late range of movement, research has found statistically significant differences in favour of early commencement with regards to increased patient compliance to rehabilitation, faster return to normal function, superior grip strength, and improved wrist range of movement (Handoll, Madhok, & Howe, 2003).
A similar result was found with the use of splints to allow for early wrist range of movement with distal radius fractures which have been internally fixated to stabilise- seeing an improved range of movement and grip strength up to 6 months post-surgery, when compared to patients completely immobilised until 5 weeks (Quadlbauer et al., 2016).
Early range of movement may even aid with secondary bone healing, in which healing is thought to be enhanced by micro-motion and controlled mechanical stress (Marsell & Einhorn, 2011).
Final thoughts on Casts and Splints for Distal Radius Fractures
Immobilising distal radius fractures with POP is an outdated method, used for ease of application and to save expense. When used appropriately, thermoplastic splints are far superior to traditional casting due to a number of factors: improved patient satisfaction and comfort, greater level of function regained in a shorter period of time, and fewer therapy sessions required.
Greater awareness among health professionals is needed regarding the numerous benefits of thermoplastic splinting, so that patients can make informed decisions about their own care and have access to additional options.
Currently, health professional management of distal radius fractures is not patient-centred, with only an estimated 10% of patients following fracture being referred to specialist clinics for early rehabilitation (Ikpeze et al., 2016). This needs to change for the betterment of patients; it is time to cast away POP in favour of all the associated benefits of thermoplastic splinting.
Reference List
- Handoll, H. H., & Madhok, R. (2003). Conservative interventions for treating distal radial fractures in adults. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd000314
- Ikpeze, T. C., Smith, H. C., Lee, D. J., & Elfar, J. C. (2016). Distal radius fracture outcomes and rehabilitation. Geriatric orthopaedic surgery & rehabilitation, 7(4), 202-205. doi: doi.org/10.1177/2151458516669202
- Kashmiri, N. (2018). Management of Undisplaced and Minimally Displaced Colles’ Fracture with Thermoplastic Splint Versus Conventional Colles Casting. Journal of Rawalpindi Medical College, 20(4), 275-277. Retrieved from http://journalrmc.com/index.php/JRMC/article/view/140
- Marsell, R., & Einhorn, T. A. (2011). The biology of fracture healing. Injury, 42(6), 551-555. doi: 10.1016/j.injury.2011.03.031
- Mavčič, B., & Antolič, V. (2012). Optimal mechanical environment of the healing bone fracture/osteotomy. International Orthopaedics, 36(4), 689-695. doi:10.1007/s00264-012-1487-8
- Meena, S., Sharma, P., Sambharia, A. K., & Dawar, A. (2014). Fractures of distal radius: an overview. Journal of family medicine and primary care, 3(4), 325-332. doi:10.4103/2249-4863.148101
- O’Connor, D., Mullett, H., Doyle, M., Mofidi, A., Kutty, S., & O’Sullivan, M. (2003). Minimally displaced Colles’ fractures: A prospective randomized trial of treatment with a wrist splint or a plaster cast. Journal of Hand Surgery, 28(1), 50-53. doi:10.1054/jhsb.2002.0864
- Quadlbauer, S., Pezzei, C., Jurkowitsch, J., Keuchel, T., Beer, T., Hausner, T., & Leixnering, M. (2016). Early wrist mobilization after distal radius fractures stabilized by volar locking plate. Journal of wrist surgery, 6(2), 102-112. doi:10.1055/s-0036-1587317
- Slutsky, D. J., & Osterman, A. L. (2009). Rehabilitation after distal radius fractures. In Fractures and Injuries of the Distal Radius and Carpus: The Cutting Edge (pp. 47-50). St. Louis, MO: Elsevier Health Sciences.
