O2160: Comparison of "soft" versus "hard" casting in the pediatric acute fracture management

Background: In order to reduce in person visits during the early COVID pandemic, the use of ‘soft’ casting tape for acute fractures increased in our clinic as it allows for at-home cast removal. The practice remained after pandemic restrictions were lifted as there was value in the ability to remove casts without a cast saw for certain populations. The purpose of this study is to compare outcomes and complications resulting from the use of ‘soft’ casting to a matched cohort of patients who received a ‘hard’ cast for acute fracture care.

Methods: Retrospective chart review was performed in patients 0-17 years with acute fractures at a pediatric outpatient orthopedic practice. They were treated using soft (semi-rigid fiberglass) or hard cast (traditional fiberglass) without reduction between March 2017-2023. Patients were matched 1:1 using propensity scores based on age, sex, fracture and provider type. Average overall associated cost inclusive of professional fees, x-rays and cast materials for each encounter, were obtained for cost comparison. Comparison of outcomes and complications between the two groups was conducted using non-inferiority testing using a one-sided t-test.

Results: One hundred forty-three patients with soft casting were matched to 143 patients with a hard cast (Table1, Table 2). Hard cast patients healed at a mean of 25 days (95% CI, 23-26 days) and soft cast patients at mean of 21 days (95% CI, 20-23 days).

Eight patients experienced a complication in the hard cast group for an incidence of 5.5% (95% CI, 2.6-10.9%). One patient experienced malunion, while the other seven experienced cast saw injuries, none requiring intervention. One patient in the soft cast group experienced a skin complication for an incidence of 0.7% (95% CI, 0.04-4.3%). The patient transitioned from a soft cast to hard cast and additionally suffered a cast saw injury that did not require any intervention.

Four patients experienced loss of alignment in the hard cast group (2.7% (95% CI, 0.9-7.3%)). No patients in the soft cast group experienced loss of alignment (0% (95% CI, 0-2.0%)). Patients who were treated with soft cast had lower average number of visits per patient (2.5 vs 3.1) and a 17% reduction in average total cost per patient compared to hard cast. Non-inferiority testing concluded that soft casts were non-inferior to hard casts, with respect to time to healing, complication incidence and loss of alignment (p < 0.001).

Conclusion: Soft casting was utilized as non-inferior alternative to acute fracture immobilization with regards to time to healing, loss of alignment and complication incidence. It can be applied to children safely and without care compromise in stable fractures which eliminates cast saw use and its associated issues.