Episode notes
In this episode of Ortho Appraised, Dr Rajabifard appraises "Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study)" published in The Lancet. The clinical question: in children with a badly displaced distal radius fracture, is a cast alone — no manipulation — as good as surgical reduction? The findings support offering a cast first for most children.
📄 Citation: Perry DC, Zimmermann A, Achten J, et al. 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. Lancet. 2026;407:1538–48. DOI: https://doi.org/10.1016/S0140-6736(26)00409-5
Key Takeaways:
* Well-conducted multicentre non-inferiority RCT — 750 children across 49 UK hospitals, with modern mixed-model missing-data handling.
* Function at 3 months only trivially favoured surgery (ITT −1.64; per-protocol −2.07 on PROMIS), and the arms were level by 6 months.
* Formally, non-inferiority of casting was "not demonstrated" against the −2.5 margin — but the difference is clinically negligible.
* Practice implication: a cast without manipulation is a reasonable first-line choice for most, sparing anaesthetic and theatre time.
* Outcomes are parent-reported and, unavoidably, unmasked; the completely off-ended subgroup is where casting is least certain.
🔗 Full paper: https://doi.org/10.1016/S0140-6736(26)00409-5
Keywords: paediatric distal radius fracture, CRAFFT trial, cast versus surgery, children's wrist fracture, non-inferiority RCT.
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