Lancet
Casting over surgery? Trial challenges standard care for pediatric wrist fractures
Clinical takeaway: For most children aged 4–10 years with severely displaced distal radial fractures, a cast-first approach is reasonable—offering comparable long-term function with fewer complications and lower costs.
Distal radius fractures are among the most common pediatric injuries, yet many children still undergo surgery despite limited evidence of long-term benefit. This trial could shift practice toward less invasive care.
In the multicenter CRAFFT randomized trial of 750 children (median age 7.9 years), non-surgical casting didn’t meet strict non-inferiority criteria vs. surgical reduction at 3 months, but differences in function were small and not clinically meaningful. Mean PROMIS* upper-extremity scores were 44.9 with casting vs. 46.6 with surgery (adjusted difference –1.64; 95% confidence interval, –2.84 to –0.44).
Importantly, outcomes converged over time. By 6 months and 12 months, there was no significant difference in functional recovery between groups, with nearly identical scores at 1 year (50.5 vs. 50.6).
Complications were more common with surgery, including wound infections (n=6), scarring (n=5), and nerve irritation (n=1), while refracture rates were low overall (13 cases total).
Economic analysis showed a substantial advantage for casting, with mean cost savings of £1665 per patient and a 100% probability of cost-effectiveness at standard UK thresholds, despite a very small short-term reduction in quality-adjusted life-years (–0.023).
Among children with completely displaced (“off-ended”) fractures, casting met a broader non-inferiority margin, reinforcing its applicability even in severe cases.
As the authors note, “the observed difference was small… and did not persist beyond early recovery,” supporting a shift away from routine surgery.
Overall, these findings suggest that avoiding surgery in most children can reduce harms and costs without compromising recovery.
*PROMIS, Patient Report Outcomes Measurement System.
Source: Perry DC, et al. (2026, April 18). Lancet. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation