Closed Reduction and Casting

Indications

Melone Classification of Distal Radial Fractures, radiograph of a displaced distal radius fracture
Radiograph of a displaced distal radius fracture. Image by Curtishand, Wikimedia Commons, Public domain.
  • Displaced fractures that are stable once reduced
  • Most paediatric forearm and distal radius fractures
  • Temporary splintage before fixation
  • Paediatric fractures tolerate more angulation due to remodelling, more so near the physis and in the plane of joint motion
  • Rotational deformity does not remodel

Position

  • Position for gravity assisted traction where possible
  • Analgesia with haematoma block, Bier block or procedural sedation
  • Image intensifier to confirm reduction

Operative Steps

  1. Apply traction to disimpact
  2. Recreate then reverse the mechanism of injury
  3. Use the intact soft tissue hinge to hold reduction
  4. Three point moulding (Charnley)
  5. Immobilise the joint above and below for shaft fractures
  6. Pad bony prominences, split or use a backslab if swelling is expected
  7. Check films in two planes
  8. Cast index under about 0.8 indicates a good mould in forearm casts
  9. Avoid excess wrist flexion (Cotton Loder position)
  10. Convert to fixation if reduction is lost or unstable

Postoperative Care

  • Elevation and neurovascular observations
  • Repeat X-ray at about 1 week for unstable patterns
  • Written cast care advice
  • Return if pain worsens, fingers swell or colour changes
  • Typical cast duration of 4 to 6 weeks for wrist fractures

Complications

  • Compartment syndrome and tight cast
  • Pressure areas
  • Loss of reduction
  • Joint stiffness and CRPS
  • Cast saw burns
  • Malunion
  • Joint stiffness, worse in older patients

Related Pages

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.