In a child with a wrist fracture, what is the recommended type of cast, positioning, duration of immobilization, and follow‑up care?

Pediatric Wrist Fracture Management

Immediate Cast Application and Type

Apply a short arm cast immediately after confirming acceptable fracture alignment on post-reduction radiographs, and mandate active finger motion exercises through complete range of motion starting immediately to prevent finger stiffness. 1

• The American College of Radiology specifically recommends a short arm cast (not long arm) for initial stabilization of pediatric wrist fractures 1
• Post-reduction radiographs must verify acceptable alignment before casting—specifically checking that radial shortening is <3 mm, dorsal tilt is <10°, and intra-articular displacement is minimal 1
• Document complete neurovascular examination including capillary refill (<3 seconds), sensory testing, and motor function before cast application 1

Critical Finger Motion Protocol

The most important aspect of cast management is prescribing immediate and continuous finger motion exercises during the entire immobilization period—finger stiffness after fracture healing is extremely difficult to treat. 1

• Active finger motion through complete range of motion does not adversely affect adequately stabilized fractures 1
• Implement a home exercise program for finger motion during the entire immobilization period 1
• This prevents the common pitfall of finger stiffness, which the American College of Radiology emphasizes as a critical complication to avoid 1

Duration of Immobilization and Follow-Up Schedule

Obtain repeat radiographs at approximately 3 weeks to monitor alignment, and final radiographs at the time of immobilization cessation to confirm healing. 1

• The 3-week interval allows detection of any loss of reduction that may require intervention 1
• Final radiographs at cast removal document adequate healing before discontinuing immobilization 1
• For Salter-Harris type 2 fractures in children, the same principles apply: short arm cast with immediate finger motion exercises and follow-up radiographs at 3 weeks and at immobilization cessation 1

Surgical Indications Requiring Immediate Referral

Refer immediately for operative fixation if articular surface involvement exceeds one-third, palmar displacement of distal fragment is present, or interfragmentary gap is greater than 3 mm. 1

• Post-reduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement are indications for operative fixation rather than casting 1
• These parameters are critical decision points that determine whether casting is appropriate 1

Imaging Protocol

Standard 3-view radiography (posteroanterior, lateral, and 45° semipronated oblique) is mandatory as first-line imaging for all suspected pediatric wrist fractures. 1

• Two-view examinations are inadequate for detecting fractures in wrist joints 2
• If clinical suspicion persists despite negative initial radiographs, proceed directly to MRI or CT without contrast rather than empiric casting 3
• For suspected occult fractures with ability to wait, immobilize appropriately and repeat radiographs at 10-14 days 4

Special Pediatric Considerations

Growth plate injuries are more common in children than ligamentous injuries because the unfused growth plate is less robust than ligamentous complexes. 5

• Salter-Harris classification guides prognosis—higher grades imply increased likelihood of growth disturbance 5
• Distal ulnar physeal separation can occur as a Galeazzi-equivalent fracture in skeletally immature patients 5
• Premature physeal fusion can lead to ulnar-positive variance and chronic wrist pain from ulnar impaction 5, 6

Common Pitfalls to Avoid

• Failure to prescribe finger motion exercises is the most critical error—this leads to finger stiffness that is extremely difficult to treat after fracture healing 1
• Inadequate radiographic views (fewer than 3 views) risk missed diagnosis 3
• Accepting alignment parameters outside the surgical thresholds (>3 mm shortening, >10° dorsal tilt) leads to malunion 1
• Repeating radiographs too early (<10 days) for suspected occult fractures has high risk of missing fractures that are still occult 4