O3261: Selective Cast Valving Following Closed Reduction and Casting for Pediatric Wrist and Forearm Fractures Is Safe

Background: The standard of care for most displaced pediatric wrist and forearm fractures is closed reduction and casting, often under conscious sedation. Cast valving is sometimes employed to accommodate excessive swelling within the confines of a cast; however, routine cast saw use has its own risks. The aim of this study was to evaluate the safety of selective valving practices by evaluating the rate of treatment-related complications following closed reduction and casting at an institution that selectively valves.

Methods: A retrospective review was conducted of pediatric patients ( < 18yo) treated for wrist or forearm fractures requiring closed reduction and casting under conscious sedation at a tertiary care pediatric hospital from 2015-2021 where selective cast valving practices were employed. Patients were excluded if there was loss of follow-up prior to cast removal, open fractures requiring surgical treatment, refracture, underlying medical conditions prohibiting use of a cast, and fractures with associated neurovascular compromise. The use of cast valving was recorded and categorized as no valving, acute valving (performed at time of initial reduction) or subacute valving (performed any time after initial treatment). Treatment-related outcomes were divided into major (hospital readmission, compartment syndrome, neurovascular injury, and cast saw injury), and minor complications (return to emergency department (ED) for cast-related concerns, unplanned clinic visits related to casting, and loss of reduction requiring cast wedging or cast change).

Results: We identified 311 patients meeting study inclusion criteria of whom 296 (95.2%) were treated without valving in the acute or subacute setting. Complications were observed in 26 (8.4%) patients across the cohort, with 30 total complications, including 2 major and 28 minor complications. Major complications included two cast saw injuries ( < 1%), and minor complications included 3 patients requiring cast intervention due to loss of reduction (1%), 6 unplanned office visits (2%), and 19 patients returning to the ED for cast-related concerns (6%). No cases of compartment syndrome or readmission were observed in the treatment cohort. Complications occurred in a higher proportion (p < 0.001) of patients undergoing acute (33%, 2/6) and subacute (77.8%, 7/9) as compared to patients who were not valved (5.8%, 17/295) after ED discharge. Complication occurrence was also associated with number of reduction attempts (p=0.019).

Conclusion: At a single, large institution utilizing selective valving practices, treatment-related complications were infrequent and typically minor. A higher proportion of complications occurred in patients who underwent multiple reduction attempts or cast valving at any point during their care. Cast saw injuries occurred only among those who had been valved. While valving is occasionally necessary in the acute or subacute setting to avoid neurovascular compromise, a selective approach to cast valve use after closed reduction and casting appears safe and does not result in significant risk of hospital readmission or irreversible complication.