SGEM#510: Take this Broken Radius and just Cast It.

Reference:  Perry DC, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet April 2026. Date: May 8, 2026 Dr. Andrew Tagg Guest Skeptic:  Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles. Case: A healthy 7-year-old boy presents to the emergency department (ED) with obvious deformity of the wrist after a fall from playground equipment. X-rays show a severely displaced distal radius fracture, with an associated ulnar fracture. The child is neurovascularly intact. But the wrist looks dramatic. It’s quite bent. The child gazes at his arm, a mix of fear and intrigue. You consult the friendly orthopedics specialist who greets the family and recommends reduction under sedation because “it looks too crooked to leave alone.” You recall that in younger children, some fractures can remodel quite well on their own. The child’s father asks you whether you think the boy really needs a procedure to re-align the bones, or if he can just be placed in a cast.  Background: Distal radius fractures are among the most common fractures in childhood, and severely displaced injuries create one of those classic tensions between what looks bad on an X-ray and what matters to patients over time. Traditional teaching has favored reduction, often under sedation or general anesthesia, to restore anatomy and avoid concerns about deformity, loss of motion, or unhappy families. But pediatric bone is not adult bone. Younger children have substantial remodeling potential, especially near active growth plates, and prior observational studies suggested that even very displaced distal radial fractures can straighten out over time with good function. Many clinicians still feel uneasy leaving these fractures unreduced. The visual deformity can be alarming. Families may equate straight bones with proper healing. Procedural reduction also comes with costs and potential harms: anesthesia, sedation, procedural pain, wound complications, etc. Clinical Question: In children aged 4 to 10 years with severely displaced distal radial fractures, is non-surgical casting non-inferior to surgical reduction for functional recovery? Reference:  Perry DC, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet April 2026. Population: Children aged 4 to 10 years from 49 UK hospitals with severely displaced distal radial fractures, either metaphyseal or Salter-Harris II, with or without an associated ulnar fracture. Exclusion: Injury >7 days, complex wrist fractures that were open or extending into the joint, additional fractured bones elsewhere, inability to adhere to trial procedures or follow up. Intervention: Non-surgical casting without purposeful manipulation, without sedation or general anesthesia. Comparison: Surgical reduction under general anesthesia or conscious sedation, with fixation permitted at the surgeon's discretion. Outcome: Primary Outcome: Patient Report Outcomes Measurement System (PROMIS) Upper Extremity Score for Children at 3 months. Secondary Outcomes: Pain, health-related quality of life, cosmesis, complications, refracture, unplanned surgery, school absence, parental satisfaction, and cost-effectiveness. Trial: Pragmatic, multicenter, randomized, controlled non-inferiority trial with economic evaluation Authors’ Conclusions: “The CRAFFT trial did not demonstrate non-inferiority of non-surgical casting at 3 months against a conservative margin; however, the observed difference in favour of surgical reduction was small, below thresholds that families considered meaningful, and did not persist beyond early recovery. Surgical reduction was associated with higher costs, early procedural complications, and only a modest improvement in cosmetic appearance, supporting consideration of a cast-first strategy for most children.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at leas