Immobilization for Distal Radius Fracture in a 3-Year-Old
For a 3-year-old with a distal radius fracture, apply an above-elbow cast (or splint initially) with the wrist in slight flexion and gentle ulnar deviation, ensuring a well-molded three-point mold with a cast index <0.8. 1
Type of Immobilization
- An above-elbow cast is the standard treatment for distal radius fractures in young children, chosen in 84% of cases by experienced surgeons 2
- For minimally displaced buckle fractures specifically, a removable splint is an acceptable alternative per AAOS guidelines, but this applies primarily to stable, non-displaced injuries 3
- At 3 years of age with significant growth potential remaining, cast immobilization is preferred over surgical intervention for most fracture patterns 4, 5
Critical Casting Technique
- The cast must have excellent three-point molding with a cast index less than 0.8 at the fracture site to prevent loss of reduction 1
- Position the wrist in gentle flexion and slight ulnar deviation (avoid excessive "cotton-loader" position which can compress the carpal tunnel) 6
- Use minimal cast padding to achieve optimal cast index—waterproof padding is not recommended as it prevents adequate molding 6
- The cast must never obstruct full finger range of motion 1
Reduction Considerations for a 3-Year-Old
- In children under 9 years of age, up to 15 degrees of angulation, complete displacement (bayonet apposition), and 45 degrees of malrotation are acceptable 4
- For completely displaced fractures, recent evidence shows that cast immobilization in bayonet position (without reduction) yields excellent outcomes in children under 10 years, avoiding the risks of anesthesia and surgery 5
- However, most surgeons (83%) still prefer to reduce overriding fractures, typically under general anesthesia 2
When Reduction IS Required
If post-reduction imaging shows any of the following, surgical fixation should be considered rather than cast alone:
Duration and Follow-Up
- Immobilize for 4-6 weeks (4 weeks is most common, though healing typically occurs around 6 weeks) 2, 4
- Obtain radiographs at 1 week post-reduction to detect early loss of reduction 1, 6
- Continue radiographic monitoring at 3 weeks and at cast removal 3, 1
Essential Management Points
- Initiate active finger motion exercises immediately—finger motion does not adversely affect adequately stabilized fractures and prevents stiffness 3, 1
- Monitor for median nerve compression, particularly in the thumb, index, and long fingers 6
- Consider bivalving the cast at time of application and overwrapping after a few days when acute swelling improves 6
- Screen radiographically at 6-12 months for growth arrest, which occurs in 4-5% of cases (more common with reduction) 6, 7