Removable splintage versus below‐elbow cast for buckle or minimally displaced fracture in children
Patient or population: children with stable wrist fracture, predominantly buckle (torus) fracturesa Settings: hospital clinic Intervention: Removable splintb for 2 to 6 weeks Comparison: Below‐elbow cast for 2 to 6 weeks
Outcomes	Illustrative comparative risks* (95% CI)		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Below‐elbow cast	Removable splint
Pain VAS (0 to 10; worst pain) during device use (4 ‐ 6 weeks follow‐up)	The mean score in the study control group was 2.92	The mean score in the intervention group was 0.20 higher (1.10 lower to 1.50 higher)	‐	50 children (1 study)	⊕⊝⊝⊝ very lowc	A 0.2 difference is minute and clinically unimportant. Overall, 5 trials provided data on pain, using different measures and timings. The 2 trials (161 children) reporting pain at 1 week found higher median pain scores in the splint group but neither of the differences between the 2 groups reached statistical significance; moreover, the difference in 1 trial was also unlikely to be clinically important. Most children in these 2 trials had no or very little pain by the end of 2 or 3 weeks immobilisation
Discomfort during use of device	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported
Participant satisfaction: child and/or parent preference for same device in future (3 to 6 weeks follow‐up)	See comment	See comment	Not estimable	178 children (2 studies)	See comment	Results (1 indicating no difference, 1 favouring the splint) not pooled: clinically (e.g. different types of splint) and statistically heterogeneous (I2 = 83%)d
Time to return to former activities	See comment	See comment	Not estimable	‐	See comment	This outcome was not reportede
Skin problems (rash) (3 weeks follow‐up)	See comment	See comment	Not estimable	‐	See comment	1 study reported 11 cases of rash (17% of 64) in the splint group but none in the cast group (73 children). Conversely it reported 5 cases of oedema (7% of 73) in the cast group. The severity of both complications was not stated and the trial also made a contradictory statement that there were no adverse events or skin problems
Serious adverse events: refracture (6 months follow‐up)	See comment	See comment	Not estimable	87 children (1 study)	See comment	This study reported there had been no refractures
Health‐related quality of life Modified Activities Scale for Kids ‐ performance version (0 to 100; best function; no disability) (4 weeks follow‐up)	See comment. The median score in the study control group was 99.11 (IQR 96.42 to 100.00)	See comment. The median score in the intervention group was 99.04 (IQR 95.29 to 100.00)	‐	65 children (1 study)	⊕⊝⊝⊝ very lowf	This outcome assesses physical function rather than quality of life but has been used as a basis for cost‐effectiveness analysis in Boutis 2010. The data for the final scores are shown here for illustrative purposes; with no evidence of a clinically important difference between the two groups (MCID set at 15 in the study for sample size calculation).
Cast changes & number of outpatient visits (3 to 6 weeks follow‐up)	See comment	See comment	Not estimable	‐	See comment	Data for this outcome, which serves primarily as an indication of health care resource utilisation, were not available.
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; VAS: visual analogue scale
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.