
==== Front
Sci Rep
Sci Rep
Scientific Reports
2045-2322
Nature Publishing Group UK London

39251716
71970
10.1038/s41598-024-71970-7
Article
Soft bandage, splint or cast as the treatment of distal forearm torus fracture in children: a systematic review and meta-analysis
Pakarinen Oskari oskari.pakarinen@gmail.com

12
Saarinen Antti J. 3
Ponkilainen Ville T. 3
Uimonen Mikko 3
Helenius Ilkka 45
Kuitunen Ilari 67
1 https://ror.org/040af2s02 grid.7737.4 0000 0004 0410 2071 Faculty of Medicine, University of Helsinki, Helsinki, Finland
2 grid.440346.1 0000 0004 0628 2838 Päijät-Häme Central Hospital, Lahti, Finland
3 grid.513298.4 Department of Surgery, Central Finland Hospital Nova, Jyvaskyla, Finland
4 grid.7737.4 0000 0004 0410 2071 Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
5 https://ror.org/02e8hzf44 grid.15485.3d 0000 0000 9950 5666 Department of Paediatric Orthopaedics, Helsinki University Hospital, New Children’s Hospital, Helsinki, Finland
6 https://ror.org/00cyydd11 grid.9668.1 0000 0001 0726 2490 Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
7 https://ror.org/00fqdfs68 grid.410705.7 0000 0004 0628 207X Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
9 9 2024
9 9 2024
2024
14 2105210 10 2023
2 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
A meta-analysis including all relevant randomized controlled trials was conducted to compare soft bandage, splint and cast as the treatment of torus fracture. PubMed, Scopus, and Web of Science databases were searched in January 2023. Two comparisons were made: (1) splint versus cast, and (2) bandage versus rigid immobilization (i.e. splint or cast). Main outcomes were pain, clinical healing of the fracture and return to activities. Secondary outcomes were adverse events (skin issues, problems with cast/splint/bandage) and patient/parental satisfaction. Seven studies with 1550 patients were included. Splint was associated with higher pain scores at 3 days compared to cast (Mean difference [MD] 1.00, CI 0.06–1.94) and at 1 week (MD 1.46, CI 0.84–2.08, moderate-certainty evidence), but faster return to activities (at 3 weeks RR 1.77, CI 1.09–2.88, at 4 weeks RR 1.44, CI 1.11–1.82, moderate-certainty evidence). All torus fractures heal clinically within 3–4 weeks (low-certainty evidence). Bandage may lead to slightly higher pain score (MD 0.35, CI 0.04–0.66, moderate-certainty evidence) at first day after treatment compared to rigid immobilization, but no evidence of a difference was found in later time points. In conclusion, soft bandage or removable wrist splint seem to be optimal first-line treatment of distal forearm torus fracture.

Keywords

Distal forearm
Torus fracture
Bandage
Splint
Cast
Randomized controlled trial
Meta-analysis
Subject terms

Medical research
Paediatric research
issue-copyright-statement© Springer Nature Limited 2024
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pmcIntroduction

Torus fracture of the forearm is one of the most common fractures in children1,2. Torus fracture, also known as buckle fracture, is an incomplete fracture in which the impact compresses the bony cortex on one side while the other side remains intact, creating a bulging effect. Most of the forearm torus fractures occur in distal radius, but it can also appear in distal ulna. The diagnosis is based on clinical and radiological findings. Torus fractures do not typically have a risk of further angulation and practically all cases undergo bony union and return to normal activity within weeks.

Casting has traditionally been used in the treatment of forearm torus fracture to reduce the pain in the injured wrist. However, cast treatment requires more healthcare staff resources and material costs compared to lighter treatment options such as splint or soft bandage3, which may also be more comfortable options for patients4. In studies published in the last two decades, splint or even a soft bandage seem to lead to equally well results compared to casting with high satisfaction to treatment5,6. Despite the increasing evidence, there is a lack of current comprehensive systematic review and meta-analysis focusing on the treatment of distal forearm torus fractures. The latest analysis is the Cochrane review published in 2018 which included all wrist fractures in children7. The authors concluded that the current evidence based on randomized controlled trials (RCTs) for the treatment of wrist fractures in children is low or very low, but the findings are consistent with the move away from cast immobilization in torus fractures. However, studies are completed after the publication of the latest Cochrane review, including the Forearm Fracture Recovery in Children Evaluation (FORCE) trial that compared bandage to rigid immobilization methods, i.e. splint or cast8.

The aim of this systematic review and meta-analysis was to compare soft bandage, splinting and casting as the treatment of distal forearm torus fracture in children with two comparisons: 1) splint versus cast, and 2) bandage versus rigid immobilization (i.e. splint or cast).

Materials and methods

We reported our findings according to Preferred Reporting Items in Systematic Reviews and Meta-Analysis (PRISMA)9. The PRISMA checklist can be found as supplementary material.

Search strategy

Following databases were searched in January 10th 2023: PubMed (MEDLINE), Scopus, and Web of Science. Following search phrase were used: (torus OR buckle) and fracture. We did not use any filters in the search. There were no limitations regarding the time of publication.

Inclusion and exclusion criteria

We included only original peer-reviewed human studies published in English. All RCTs comparing soft bandage, splint and cast as the treatment of distal forearm torus fractures in children were included. We included studies with children aged from less than 18 years with radiologically confirmed torus fracture of distal radius and/or ulna (later referred as distal forearm). Studies focusing on complete distal forearm fractures on angulated forearm greenstick fractures were excluded. Studies that included both torus fractures and minimally angulated greenstick fractures were included.

Review process

Covidence software was used in the screening and extracting process. Every abstract and full text was screened by two individual authors (A.S., M.U., I.K. or V.P.). Disagreement between the two screening authors was resolved by a third author opinion. Two authors (O.P. and I.K.) performed data extraction independently to reduce the extraction mistakes and the extraction was validated by the other author10. Following information was extracted: authors, year of publication, country where the study was conducted, study period, study design, original inclusion criteria, the definition of intervention group and control group, total number of patients included in the study, number of patients in the intervention and control groups, and outcome measures.

Risk of bias

Cochrane risk of bias tool 2.0 was used to evaluate the quality of included studies, and risk of bias figures were reported accordingly11. Risk of bias figures were generated with robvis shinyapp (https://mcguinlu.shinyapps.io/robvis/).

Intervention and control groups

In the first analysis, the intervention group consisted of patients treated with a removable wrist splint, and the control group consisted of patients treated with cast. In the second analysis, patients treated with soft bandage formed the intervention group and patients treated with either splint or cast formed the control group.

Outcome measures

Main outcome measures were pain (measured with visual analogue scale [VAS] for pain, numeric rating scale [NRS] for pain, Wong-Baker scale for pain, or other appropriate patient-reported outcome measure [PROM]), clinical healing (defined that the fracture is stable and painless in palpation), and time to return to activities. Secondary outcomes were adverse event rates (including skin issues, cast/splint problems requiring re-application, and other complications), and patient and/or parental satisfaction.

Statistical analysis

R statistical software version 4.2.2 were used for the meta-analysis. Data analysis was performed according to Cochrane Handbook of Systematic Reviews Guidelines. The outcome measures were pooled together in meta-analysis using risk ratios (RR) (or risk difference [RD] when the number of outcomes was low) with 95% confidence intervals (CI) for dichotomous outcomes. For continuous variables we used mean difference (MD) with CI. We pooled the validated pain measurements that are scaled comparably from 0 (no pain) to 10 (worst pain): VAS, NRS and Wong-Baker. Other, non-validated pain measurements were reported separately. Forest plots were presented for all pooled outcomes. We chose a random-effects model with Mantel–Haenszel method due to assumed high heterogeneity based on the inclusion criteria and interventions (splinting method, splinting duration, casting method, casting duration). Statistical heterogeneity was also assessed by calculating the inconsistency index statistic I2 for heterogeneity. For outcomes, in which statistical synthesis was not possible due to various reporting of outcomes, we reported the findings according to synthesis without meta-analysis (SWiM) guideline12. The body of evidence for each of the outcomes were assessed by using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework13. In the GRADE analysis, as the studies were designed to show equality or non-inferiority, imprecision was not downgraded based on dichotomous categorization, whether CI included one or not14.

Protocol registration

We registered our protocol in PROSPERO 2023 CRD42023392190 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023392190

Results

Search results and included studies

After screening 1184 abstracts and 28 full-texts, 7 studies with 1550 patients were included for systematic review and meta-analysis3–6,8,15,16 (Fig. 1). Four studies compared splint and cast3–5,16, two studies compared bandage to splint or cast6,8, and in one study all three immobilization methods were compared to each other15. None of the studies compared purely bandage and splint to each other. The treatment period was usually 3 or 4 weeks in all treatment methods (Table 1). Four studies were from UK, two from North America, and one from Iran. Four studies focused on distal radius3,4,6,15, and four studies included also ulnar fractures5,8,16. The number of patients included in the analyses in the original study varied from 39 to 910 (Table 2). The mean age of patients varied from 8.9 to 9.9.Fig. 1 PRISMA flowchart of the study selection process.

Table 1 Characteristics of the included studies.

Study	Country	Study period	Design	Torus fracture diagnosis	Inlusion criteria	Exclusion criteria	Intervention (treatment period)	Control (treatment period)	Main outcomes	Secondary outcomes	
Davidson 2001	UK	6-month period	RCT	Radiograph	Distal radius torus frature	Not defined	Splint (3 weeks)	Short arm cast (3 weeks)	Clinical healing, radiological healing, compliance, costs	Not defined	
Karimi Mobakareh 2013	Iran	7/2010–12/2010	RCT	Radiograph	Distal forearm torus fracture (includes antebrachium and ulnar fractures)	Not defined	Splint (3 weeks)	Short arm cast (3 weeks)	Pain, clinical healing, radiological healing, compliance, skin problems, adverse events, costs	
Perry 2022	UK	1/2019–7/2020	Equivalence RCT	Radiograph	Distal radius torus fracture (includes antebrachium fractures), age 4–15	Injury > 36 h before evaluation, cortical disruption of the radius on radiographs indicating greenstick fracture, additional fractures outside the affected wrist, patient or parent unable to adhere to trial procedures (eg, insufficient English language comprehension, developmental delay, or no internet access)	Bandage (max 3 weeks)	Short arm cast or rigid splint (not defined, depended on the standard practice of the treating centre)	Pain	Functional recovery, absence from school, satisfaction, use of analgesia, adverse events	
Plint 2006	Canada	8/2002–9/2003	RCT	Radiograph	Distal forearm torus fracture (includes antebrachium and ulnar fractures), age 6–15 years	Not defined	Splint (3 weeks)	Short arm cast (3 weeks)	Functional results (ASKp)	Pain, return to normal activity, patient satisfaction, parental satisfaction, adverse events	
Pountos 2010	UK	Not defined	RCT	Radiograph + ultrasound	Distal radius torus fracture or minimally angulated greenstick fracture, age 0–16	Not defined	Bandage or splint (not defined, follow-up visit 4–6 weeks after injury)	Short arm cast (not defined, follow-up visit 4–6 weeks after injury)	Pain, analgesia use, functional results (PDS), deformity, grip strength, range of movement	
West 2005	UK	Not defined	RCT	Not defined (presumably radiograph)	Distal radius torus fracture	Not defined	Bandage (4 weeks)	Short arm cast (4 weeks)	Satisfaction for the treatment, pain, movement, compliance, parental satisfaction, range of movement	
Williams 2013	USA	4/2006–5/2009	RCT	Radiograph	Distal radius torus fracture, age 2–17	Skeletally mature patients, previous distal radius torus fracture, concurrent other fractures except for an ipsilateral ulnar torus fracture, patients with osteogenesis imperfecta or other metabolic bone diseases	Splint (3 weeks)	Short arm cast (3 weeks)	Pain	Patient satisfaction, willingness to have the same treatment in the future, splint removal, treatment concerns	

Table 2 Characteristics of the patients in the included studies.

Study	n of participants in intervention group	n of participants in control group	Mean age in all participants	Mean age in intervention group	Mean age in reference group	Boys % (all participants)	Boys % (intervention group)	Boys % (reference group)	Fracture in radius/ulna/both % (all patients)	Fracture in radius/ulna/both % (intervention group)	Fracture in radius/ulna/both % (control group)	Injury in the right or dominant hand % (all paticipants)	Injury in the right or dominant hand % (intervention group)	Injury in the right or dominant hand % (control group)	
Davidson 2001	116	85	8.9	–	–	53	–	–	–	–	–	41 (right)	–	–	
Karimi Mobakareh 2013	65	77	9.5	–	–	73	–	–	80/1.4/18	–	–	43 (right)	–	–	
Perry 2022	466	442		9.6	9.7		63	58	–	–	–	44 (dominant)	–	–	
Plint 2006	42	45		9.5	9.9		71	60	92/0/8	88/0/12	96/0/4.4	49 (dominant)	52	47	
Pountos 2010	26 + 29	24	9	–	–	59	–	–	–	–	–	–	–	–	
West 2005	18	21	–	–	–	–	–	–	–	–	–	–	–	–	
Williams 2013	43	51		9.5 (median)	9.0 (median)		50	59	–	–	–	35 (right)	31	38	

Risk of bias

Overall, the risk of bias was assessed to be low in four studies and high in three studies (Fig. 2). Most concerns were related to bias arising from the randomization process, bias in the measurement of the outcome and bias in selection of the reported results.Fig. 2 The assessment of the risk of bias.

Splint versus cast

Pain

Three studies including 213 patients assessed pain as outcome measured by previously published pain measurement scale (VAS and NRS)4,5,15. Based on moderate-certainty evidence (downgraded due to risk of bias, Table 3), patients treated with splint may have slightly higher pain score compared to casting at 3 days (1 study; 94 patients; MD 1.00; CI 0.06, 1.94, Fig. 3) and at 1 week (2 studies; 161 patients; in pooled analysis MD 1.46; CI 0.84, 2.08), and when all time points (3 days, 1, 3 and 4–6 weeks) were pooled (3 studies; 213 patients; MD 0.70; CI 0.17, 1.23). At 3 weeks (2 studies; 159 patients; MD 0.35; CI − 0.34, 1.03) and 4–6 weeks (1 study; 52 patients; MD 0.21; CI − 1.07, 1.47) we did not find evidence of a difference between splint or cast.Table 3 Modified summary of findings table and evidence certainty assessed according to the GRADE methodology.

Outcomes	Relative effect (95% CI)	Number of patients (studies)	Certainty of evidence (GRADE)	
Splint versus cast	
 Primary outcomes	
  Pain (VAS/NRS)	MD 0.70 (CI 0.17, 1.23)	213 (3)	Moderate*	
  Clinical healing	RR 1.00 (CI 0.98, 1.02)	316 (2)	Low**	
  Return to normal (sports) activities	At 3 weeks RR 1.77 (CI 1.09, 2.88)

At 4 weeks RR 1.44 (CI 1.11–1.82)

	57 (1)

60 (1)

	Moderate***	
 Secondary outcomes	
  Skin issues	RD 0.00 (CI − 0.01, 0.02)	137 (1)	Very low****	
  Problems with cast/splint/bandage	RD − 0.11 (CI − 0.21, − 0.01)	87 (1)	Low*****	
  Other complications	RD 0.00 (CI − 0.02, 0.02)	112 (2)	Low**	
  Patient/parental satisfaction		323 (3)	Very low******	
Bandage versus rigid	
 Primary outcomes	
  Pain (VAS/Wong-Baker)	MD 0.07 (− 0.04, 0.19)	1020 (2)	Moderate*	
  Clinical healing	–	–		
  Return to normal activities	–	–		
 Secondary outcomes	
  Complications	RD 0.00 (CI − 0.01, 0.02)	947 (2)	High	
  Patient/parental satisfaction		947 (2)	Very low******	
*Downgraded once due to risk of bias.

**Downgraded twice due to risk of bias.

***Downgraded as only one study included.

****Downgraded twice due to risk of bias and further as only one study was included.

*****Downgraded once due to risk of bias and further as only one study was included.

******Statistical synthesis was not possible, downgraded due to major heterogeneity.

Fig. 3 The pooled mean difference in validated pain measurements in patients treated with splint compared to patients treated with cast.

In addition, one study also assessed pain with analog scale, and reported that 41% (28/65) of the patients treated with splint experienced mild to moderate pain in activity compared to 31% (24/77) in patients treated with short arm cast (RR 1.38; CI 0.90, 2.13), and none of the patients reported pain in rest16.

Clinical healing

Two studies including 316 patients assessed clinical healing3,16. Based on low-certainty evidence (downgraded twice due to risk of bias, Table 3), we did not find evidence of a difference in clinical healing between the treatment groups (in pooled analysis RR 1.00; CI 0.98, 1.02; Fig. 4). In both studies, all fractures healed within the study period3,16.Fig. 4 The pooled risk ratio of clinical healing in patients treated with splint compared to patients treated with cast.

Return to activities

One study including 57 patients assessed the time needed to return to activities5. Based on moderate-certainty evidence (downgraded as only one study included, Table 3), patients treated with splint may return to sports activities sooner than patients treated with cast (at 3 week RR 1.77; CI 1.09, 2.88; at 4 week RR 1.49; CI 1.11, 1.82; Fig. 5). In addition, patients treated with wrist splint had less difficulties with bathing/showering at 1, 2 and 3 weeks compared to patients treated with cast5.Fig. 5 The pooled risk ratio of return to sports activities in patients treated with splint compared to patients treated with cast.

Adverse events

Two studies including 224 patients assessed adverse events5,16. Only few complications occurred. Based on low-certainty evidence (downgraded twice due to risk of bias, Table 3), no evidence of a difference in the risk of complications was found between splint and cast (in pooled analysis Risk Difference [RD] 0.00; CI − 0.02, 0.01; Fig. 6). No skin problems were found in either splint or cast groups (1 study; 137 patients; RD 0.00; CI − 0.01, 0.02; very-low certainty evidence; downgraded twice due risk of bias and further as only one study included)16. Based on low-certainty evidence (downgraded as only one study included), the use of splint may lead to fewer problems with immobilization device compared to cast (1 study; 87 patients; RD − 0.11; CI − 0.21, − 0.01)5. No other complications were reported (2 studies; 212 patients; RD 0.00; CI − 0.02, 0.02; low-certainty evidence; downgraded twice due to risk of bias).Fig. 6 The pooled risk difference of adverse events (skin issues, problems with splint or cast, and other complications) in patients treated with splint compared to patients treated with cast.

Patient and parental satisfaction

Three studies including 282 patients measured patient satisfaction4,5,16, and two studies including 140 patients measured parental satisfaction4,5. The certainty of evidence was very low, downgraded due to major heterogeneity in reporting (Table 3), and the studies were judged to be ineligible for statistical synthesis. The outcomes regarding satisfaction are summarized in Table 4. One study with 142 patients reported high convenience for treatment for both splint (89%) and cast (86%)16. One study with 94 patients reported better patient satisfaction and convenience for treatment at 3 weeks in patients treated with splint compared to cast, and also better parent satisfaction4. One study with reported that higher proportion of patients (20/21 vs 5/23, RR 4.38, CI 2.01–9.57) and parents (17/20 vs 12/25, RR 1.77, CI 1.13–2.77) would prefer same treatment in the future in splint group compared to cast group5.Table 4 Patient and parental satisfaction. The results of the intervention groups are presented first.

Study	Patient satisfaction outcome measurement	Patient satisfaction results	Parental satisfaction outcome measurement	Parental satisfaction results	Comments	
Splint versus cast	
 Karimi Mobakareh 2013	Convenience of treatment	89% versus 86%			Difference not statistically tested	
 Plint 2006	Willingness to prefer the same treatment in the future	95% (20/21) versus 22% (5/23)	Willingness to prefer the same treatment in the future	85% (17/20) versus 48% (12/25)	Difference not statistically tested	
 Williams 2013	VAS scale from 0 (worst) to 9 (best) for satisfaction and convenience	Satisfaction: median 9 versus 7 (p = 0.001) at 3 weeks. Convenience: 9 versus 3 at 3 weeks (p < 0.001)	Willingness to prefer the same treatment in the future	85% versus 50% (p = 0.004)	Parental satisfaction percentages estimated from a bar chart	
Bandage versus rigid immobilization	
 Perry 2022	Likert scale from 1 (best) to 7 (worst)	Day 1: Median 2 (IQR 1–2) versus 1 (1–2), p =  < 0.0001; Day 42: 1 (1–2) versus 1 (1–2), p = 0.12			Parents reported results for < 8 years old	
 West 2005	Convenience of treatment	94% (17/18) versus 14% (3/21)	Parental concern	11% (2/18) versus 0% (0/21)	Difference not statistically tested	

Bandage versus rigid immobilization

Pain

Two studies including 1020 patients assessed pain as outcome measured by previously published pain measurement scale (VAS and Wong-Baker scale)8,15. Based on moderate-certainty evidence (downgraded due to risk of bias, Table 3), patients treated with bandage may have slightly higher pain score compared to rigid immobilization at the first day after the start of treatment (1 study; 790 patients; MD 0.35; CI 0.04, 0.66, Fig. 7). At 3 days (1 study; 908 patients; MD 0.07; CI − 0.21, 0.35), 1 week (1 study; 898 patients; MD 0.20; CI − 0.03, 0.43), 3 weeks (1 study; 861 patients; MD − 0.06; CI − 0.24, 0.12), 4–6 weeks (1 study; 55 patients; MD − 0.58; CI − 1.80, 0.64), 6 weeks (1 study; 865 patients; MD 0.03; CI − 0.08, 0.14), and with all time points pooled (2 studies; 963 patients; MD 0.07; CI − 0.04, 0.19) we did not find evidence of a difference in pain scores between bandage and rigid immobilization.Fig. 7 The pooled mean difference in validated pain measurements in patients treated with bandage compared to patients treated with rigid immobilization.

On contrary, in one study 71% (15/21) of patients treated with plaster cast had pain within the first days after the star of the treatment compared to 22% (4/18) of patients treated with bandage (RR 3.21; CI 1.30, 7.95)6.

Clinical healing

Clinical healing, as defined in our methods section, was not assessed in any of the included studies. One study reported no need for surgery of fracture manipulation for any of the 965 patients, and none of the patients were found to have worsened deformity8.

Return to activities

Not assessed in any of the included studies.

Adverse events

Two studies with 947 patients reported adverse events6,8. The complication rate was low. One study with 908 patients reported low 1% complication rate in both bandage and rigid immobilization groups, and 7/8 of the reported complications were misdiagnoses8. One study with 39 patients reported that no skin problems or other adverse events occurred in any of the patients6. Based on this high-certainty evidence (Table 3), no evidence of a difference was found between bandage and rigid immobilization (RD 0.00; CI − 0.01, 0.02; Fig. 8).Fig. 8 The pooled risk difference of adverse events in patients treated with bandage compared to patients treated with rigid immobilization.

Patient and parental satisfaction

Two studies with 947 patients reported patient or parental satisfaction. The certainty of evidence was very low, downgraded due to major heterogeneity in reporting (Table 3), and the studies were judged to be ineligible for statistical synthesis. The outcomes regarding satisfaction are summarized in Table 4. One study with 908 patients reported better satisfaction for rigid immobilization group compared to bandage in the 1st day of the follow-up , but no evidence of a difference was found at 42nd day8. The satisfaction was reported by parents for patients younger than 8 years. One study with 39 patients reported higher proportion of convenience for treatment in bandage group compared to cast group (17/18 vs 3/21, RR 6.61, CI 2.31–18.9). In both groups the proportion of parental concern was low6.

Discussion

In this systematic review and meta-analysis, the use of splint as the treatment of distal forearm torus fracture in children may be associated with more pain during the first week of treatment compared to casting, based on moderate-certainty evidence, but may lead to faster return to activities (moderate-certainty evidence), less problems related to the immobilization device (low-certainty evidence) and equal or better patient satisfaction (very low-certainty evidence). All fractures healed well irrespective of the treatment method (low-certainty evidence). The rate of skin issues and other complications was minimal in both groups (very low-certainty evidence). The use of bandage might be associated with slightly more pain (moderate-certainty evidence) and satisfaction (very low-certainty evidence) within the first day of the treatment compared to the use of rigid immobilization, i.e. splint or cast, but no evidence of a difference was found in later time points. The overall complication rate was very low, and we did not find evidence of a difference in complication rate between bandage and rigid immobilization (high-certainty evidence). We are uncertain if clinical healing or return to activities differ between bandage and rigid immobilization.

In the Cochrane review of wrist fractures of children published in 2018, the authors concluded that the treatment of torus fracture led to full return to normal function and no serious adverse events occurred, irrespective of the treatment method7. The authors recommended to move away from cast treatment. Our results are mostly in line with this Cochrane review, as in our results the use of splint seemed to have advantage over casting in terms of satisfaction and return to activities, and the use of bandage led to similar results compared to rigid immobilization. Regarding the comparison of bandage and rigid immobilization, our analysis had an advantage over the previous meta-analysis because of clearly larger amount of patients and also higher certainty of evidence due to the inclusion of the large FORCE study published in 20228. The main findings in other previous systematic reviews are also mostly in line with our results17–20. However, there are no relevant meta-analyses done after the 2018 Cochrane review to our knowledge. Notably, there are also no original studies that compare purely bandage and splint, even though in the FORCE trial, vast majority of the patients in rigid immobilization group were treated with splint8.

We found that patients treated with splint had more pain compared with cast within the first week, but the difference regarding pain in the comparison of bandage versus rigid immobilization was clearly less than the minimal clinically important difference of VAS and NRS21,22. For patients that are atypically painful after the injury, combination treatment with short period of cast (e.g. 1 week) and then change to bandage/splint after that could be an option. Shared decision-making with patient and/or parents can be utilized regarding the choice of treatment.

Limitations

There was also a large variation in the number and frequency of follow-up visits. Majority of our analyzed outcomes were measured in less than half of the studies, and the specific measurement methods varied greatly. The high statistical heterogeneity was likely caused by the differences in the patient populations and outcome measurements. Due to low number of included studies, we could not perform meta-regression analysis to analyze this further. One study also included minimally displaced greenstick fractures. The heterogeneity of the outcome measures in different studies limited the possibilities to conduct meta-analysis and limits out interpretations. Reported patient characteristics also varied within the studies. Patients’ mean age, sex and side of the injured hand was reported separately for both study groups only in half or less of the original studies (Table 2). The overall mean age was from eight to ten in all studies. Therefore, the results might not be generalized to very young patients who have more limited compliance. The exclusion criteria were defined in only two studies (Table 1). Based on the exclusion criteria, our results cannot be generalized in patients with multiple injuries or fractures, patients with metabolic bone diseases such as osteogenic imperfecta and patients with language barrier.

In conclusion, a splint may not be equally effective in reducing pain as a cast in the first days after distal forearm torus fracture, but may lead to faster return to activities, better satisfaction for treatment and less problems with immobilization device compared to cast. The use of bandage may be associated with slightly more pain and less satisfaction within the first treatment day compared to rigid immobilization with splint or cast but may lead to equally high satisfaction in the later treatment phase and equally low complication rate. Soft bandage or removable wrist splint seem to be optimal first-line treatment of distal forearm torus fracture due to high patient satisfaction, minimal risk of complications and lower costs for healthcare system compared to casting. However, the current evidence is not abundant. Shared decision-making can be utilized regarding the choice of treatment. Since practically all torus fractures heal well within few weeks, routine follow-up is unnecessary.

Supplementary Information

Supplementary Information.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-024-71970-7.

Author contributions

O.P.: Study design, data curation, writing of first draft of the manuscript. V.P.: Statistical analyses. I.H.: Supervision. I.K.: Original idea for the study, study design, data curation, supervision. All authors: Manuscript revision.

Data availability

The data is not publicly available. However, for a reasonable reason it can be requested by e-mail (oskari.pakarinen@tuni.fi).

Competing interests

The authors declare no competing interests.

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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