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Children’s Radius Acute Fracture Fixation Trial. A multi-centre prospective randomized non- inferiority trial of surgical reduction versus non-surgical casting for displaced distal radius fractures in children.

Background 

The UK is more interventional than many countries, including the USA, in the treatment of distal radius fractures in children. The standard treatment in the UK is to surgically correct these injuries, whilst other countries often follow a non-operative approach. There is evidence to suggest that these fractures will heal well and completely correct themselves without surgery in children under 11 years old, even if bones are initially displaced, however the quality of evidence is poor. The British Society of Children's Orthopaedic Surgery recently prioritised this as one of their most important research question. There is a clear and pressing need to inform patients about the benefits or otherwise of surgical reduction versus non-operative casting, and a need to inform commissioners regarding the costs of the different treatments to the NHS and society.

We propose a multi-centre prospective randomized non-inferiority trial of surgical reduction versus non-surgical casting for severely displaced off-ended distal radius fractures (metaphyseal or Salter Harris) in children aged 4 to 10 years inclusive. We will use well-established networks of children's orthopaedic and emergency doctors engaged in research. The primary outcome is the Patient Reported Outcomes Measurement Information System Upper Extremity Score for Children (PROMIS UE).

The proposed project is a two-phased study. An internal pilot will confirm the expected rate of recruitment to this large trial, and will take place at 15 centres over 9 months. The pilot will determine the number of eligible and recruited patients in centres, optimise electronic data collection procedures and enable qualitative work to enhance study procedures. The pilot will seek to recruit 125 patients, and has clear stop/go criteria.

The main trial will recruit from at least 35 UK centres. With consent, a research associate will collect baseline demographic data, PROMIS UE, Wong Baker Faces Pain Score, and health-related quality of life using EQ-5DY.

A randomisation sequence, with stratification factors including centre, fracture type (completely versus incompletely off-ended), fracture location and age group (4-6 years, 7-10 years) will be produced by the trial statistician. Each patient will be randomly allocated (1:1) to interventions.


Follow-up will occur at 4-6 weeks during routine follow-up, and thereafter electronically (by email or text message) or by telephone. Outcomes will be collected at 6 weeks, 3 months (Primary outcome time-point), 6 months and 12 months. Electronic follow-up will be administered centrally. Parents will also be asked to complete a treatment satisfaction VAS, a cosmesis VAS and a resource use questionnaire following treatment for the fracture at 3, 6 months and 12 months. Complications will also be collected, including the persistence of deformity identified from routinely collected radiographs.

An embedded qualitative study will occur throughout the trial to inform the development of trial materials, to understand the child and parent's experience of injury, treatment, recovery and reflections on taking part in the trial, and to understand the experience and barriers of the use of interventions amongst staff.
Patients will then enter long-term follow-up where a minimal dataset will be requested annually until 3- years post-randomisation, when remodelling of fractures is complete. Complications or further surgery will also be collected throughout.

SUMMARY 

The most common bone for a child to break is their wrist. Most need just a plaster cast, but some need surgery to reset the bones before they go in a plaster cast . These operations are really common but doctors are unsure whether they are really necessary in younger children. Research suggests in children up to 11 years old even when the bones break and then move so they overlap, the wrist will heal well and will grow back to a normal shape over a few months. The risk of not resetting the bones is that they do not fully return to normal (may appear bent) and normal activities will be a bit harder to do, or get better so slowly that it causes the family concern. The risk of resetting the bones with surgery is that the child will need an anaesthetic, may get scars and be at risk of infection. Parents and children want to know if surgery is really necessary, or whether a plaster cast without resetting the bones will be as good by allowing the wrist to heal naturally.

Oxford Trauma

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