Traditional plaster being cast off by modern medicine

~ Doctors around the world are increasing opting for more cutting-edge options

CHICAGO -- The black Velcro bandage strapped on 3-year-old Ben Crotty's left arm looks like a Rollerblader's wrist guard, but it's really a mini medical milestone.

It's today's answer to the cast.

Once almost a childhood rite of passage, plaster or fiberglass casts were the method of choice for fixing broken bones. But now, doctors around the world are increasingly shunning cumbersome casts in favor of more cutting-edge options for both children and adults: splints, special boots, metal plates, rods and screws.

For Ben Crotty's broken wrist, it was a removable splint.

The trend is most common among adults, who often develop swelling and pain and sometimes permanent stiffness. "We often refer to this as 'cast disease.' I say, 'Good riddance!"' said Dr. John Fernandez, an orthopedic surgeon at Rush University Medical Center in Chicago.

Support for the modern technique on children was bolstered by a Canadian study last month in the journal Pediatrics. It showed that in children aged 6 to 15 with wrist fractures like Ben's, those who wore removable splints for three weeks had better physical function during treatment and afterward than those treated with plaster casts.

Cast-related problems

The splinted youngsters also escaped cast-related problems: Four youngsters sought emergency room treatment for wet casts and one for removing a pencil placed under the cast.

As an ER doctor at Chicago's Children's Memorial Hospital, Steve Crotty, Ben's dad, is all too familiar with some of casts' nastier complications.

Casts that aren't waterproof can get moldy, and Crotty said he's "seen maggots crawling out of casts" that children got wet.

So when Ben's doctor offered a splint as an alternative, his dad readily accepted.

'This is nice'

"This is nice because he can take a bath and we just take it off," Crotty said.

Ben broke his wrist in mid-March when he tumbled down the family's stairs.

"I fell down and I hurt myself, and I cried and I cried and I cried," Ben explained.

Some physicians still hesitate to put splints on young children, fearing they will remove them at will.

Ben said he didn't like his splint "because I can't play with two hands," but his mother, Sheeba, said he balked whenever she wanted to remove it because he remembered his doctor's admonition.

Ben's splint was removed for good on April 7, three weeks after his injury.

Advances in splints have revolutionized treatment of wrist fractures in the past few years, Fernandez said.

"Splints now are custom-molded to the body with thermoplastic material allowing a custom fit to immobilize and support without the constriction of the cast," Fernandez said. "These are not the 'off-the-rack' splints you buy at the pharmacy," he said. They're "more like a custom-tailored suit."

For some children, though, casts are still cooler.

Sarah Bond, 11, a suburban Chicago fifth-grader, suffered the same kind of injury as Ben during a recent basketball game and was offered a splint, but she chose a pink fiberglass cast instead.

"It's fun to have a cast because your friends get to sign it," Bond said.

"The cool factor is much bigger in kids, and the look on their faces when you say they don't need a cast is pretty bad," said Dr. Matthew Bueche, a pediatrician at Naperville's Edward Hospital.

Dr. Stuart Hirsch, an orthopedic surgeon in Bridgewater, N.J., says he gets around that disappointment by offering kids a white sock-like device that fits over splints and can be written on with a felt-tipped pen, telling patients to have their friends sign that.

Other cast alternatives include "cast boots," which look and feel like wearing ski boots and are used to treat some foot and ankle fractures. They're removable for bathing and easier to walk in than old-fashioned "walking casts," said Dr. Cynthia LaBella, medical director at the Institute for Sports Medicine at Chicago's Children's Memorial Hospital.

And like splints, they're adjustable. A drawback with casts is that as the confined limb loses muscle mass, the cast loosens and rubs, causing pain and often requiring doctors to replace it. Cast removal, generally with noisy, vibrating medical saws, can be frightening for children.

Adjustable devices can be tightened as needed, LaBella said.

In the past five years or so, better alloy metals and advances in design and technology have made use of pins, rods and special metal plates that "lock" onto bone fragments commonplace in treating adult fractures.

Some of those newer devices require surgery to implant them next to broken bones, but they're far better than casts at realigning bones into a normal position, said Dr. Matthew Jimenez of the Illinois Bone and Joint Institute in Morton Grove.

For some fractures, that means starting to use the injured limb within a few weeks rather than a few months of immobilization in a cast, he said.

These devices are most appropriate for adults, whose bone growth plates have closed, Jimenez said.

But pins and locked plates sometimes are used for school-age children with broken thigh bones who used to be treated with three weeks of traction and then a cast for a month or two, said Dr. John Flynn of The Children's Hospital of Philadelphia. And he said they're occasionally used for older children's forearm or elbow fractures.

Patients and their parents have higher expectations these days and often won't accept "anything short of perfect," said Flynn. "They want a bone to be put back straight."

---

American Academy of Orthopedic Surgeons: http://www.aaos.org