What do they mean when they tell us “less aggressive” care is best for an arm fracture in children? Our son ended up in the emergency department over the weekend for a broken arm that was treated less aggressively (according to the physician’s assistant we talked with). They put the forearm in a cast on the basis of a single X-ray. Then we started hearing our friends tell horror stories of other children who got a cast but really needed surgery. Did we miss something important here for our child?



Current trends in treatment and evidence-based recommendations for management of upper extremity fractures in children support a “less aggressive” approach. Less aggressive is defined as fewer diagnostic tests, less medicine, no surgery (or slower time to surgery) with less invasive surgical procedures. Splinting or casts for short periods of time under the care of a generalist (rather than a surgical specialist) may be all that’s needed in most cases.

These recommendations come from a study done at the Division of Orthopaedic Surgery in Cincinnati Children’s Hospital. Using information presented at annual meetings of two orthopedic groups, they summarized current trends in treatment and evidence-based recommendations for management of these injuries. Abstracts on the treatment of pediatric upper extremity fractures were reviewed from the Pediatric Orthopaedic Society of North America (POSNA) and the American Academy of Orthopaedic Surgeons (AAOS). The time period selected was from 1993 through 2012 (20 years).

Papers, posters, and abstracts were included with evidence from all Levels (I through IV). Level I and II were prospective, randomized controlled trials (RCT). Level III were case-control studies and retrospective comparative studies. Level IV was only case series.

Two pediatric orthopedic surgeons with special skill and training in the treatment of pediatric upper extremity fractures rated the treatment recommendations made in each publication as: 1) more aggressive, 2) less aggressive, or 3) neutral.

More aggressive meant there were more diagnostic studies performed, more medications prescribed, surgery more often than conservative (nonoperative care), and faster time to surgery. Other criteria for a classification of more aggressive included treatment by a specialist and more invasive surgery (open incision, use of pins and plates).

The majority of comparative studies and case series recommended conservative (less aggressive) care for upper extremity fractures in children.