14. Summary of NICE 2016 guideline on torus fractures of the distal radius.

Comparison	Rigid cast versus removable splint	Rigid cast versus soft cast	Rigid cast versus bandage
Included trials	Karimi 2013; Oakley 2008; Plint 2006; Williams 2013	Used Khan 2007; labelled an RCT	West 2005
Trials excluded but included in our review	Davidson 2001: no relevant outcomes (used for cost analysis) Pountos 2010: included greenstick with no subgrouping by fracture type	‐	Pountos 2010: included greenstick with no subgrouping by fracture type
Outcomes with GRADE rating (L = low; VL = very low)	Pain on activity (VL; favoured cast) Found treatment convenient (L; no difference) Skin problems (L: favoured cast) Oedema (VL; favoured removable splint) Would use treatment again (VL; favoured removable splint)* Resumed normal activities at 2 weeks (L; favoured cast) Required re‐immobilisation at 2 weeks (VL; no difference) Adverse events: refractures (L; no difference (0 events)) * data from 3 trials	Parental problems with casts (VL; no difference) Would use treatment again (L; favoured soft cast) Cast complications at 3 weeks (VL; favoured soft‐cast)	Pain at 4 weeks (L; favoured bandage) Pain 2 or more days at 4 weeks (L; favoured bandage) Discomfort during treatment (L; favoured bandage) Found treatment convenient (L; favoured bandage)
Trade‐off between clinical benefits and harms	Rigid casts had a relative benefit in terms of pain, a return to normal activities, and the adverse events of skin problems. However, this was partially offset by a relative harm for rigid casts in terms of the proportion who would choose to continue the therapy in future, and the adverse event of oedema. Overall, however, the benefits of rigid casts over removable splints were deemed to outweigh the harms	There were no benefits of using rigid casts over soft casts, and thus the relative harms for rigid casts (parents not wishing to choose that treatment in future and cast complications) were unopposed. Overall, then, soft casts were deemed preferable to rigid casts	There were no benefits of using rigid casts over bandaging, and thus the relative harms for rigid casts (parents not wishing to choose that treatment in future, pain, and inconvenience) were unopposed. Overall, then, bandaging was deemed preferable to rigid casts
Comments	See: Appendix 2 Where data for the NICE outcomes were available, we gave very low GRADE ratings: Pain and Patient experience (would use same treatment in future)	Khan 2007 was referred to as an RCT in the guideline but excluded from our review as the 2 groups are not concurrent: essentially it is a before‐and‐after cohort comparison)	See: Appendix 4 Where data for the NICE outcomes were available, we gave very low GRADE ratings: Pain, Discomfort and Patient experience (treatment was convenient)
Recommentations for practice	Do not use a rigid cast for torus fractures of the distal radius. Discharge children with torus fractures after first assessment and advise parents and carers that further review is not usually needed
Key research recommendation	What is the clinical effectiveness and cost effectiveness of no treatment for torus fractures of the distal radius in children compared with soft splints, removable splints or bandages?