Routine Forearm Cast Splitting in Pediatric Patients Following Closed Reduction

Introduction Routine cast splitting following closed reduction of pediatric forearm fractures is commonly performed to accommodate swelling and reduce cast-related complications. However, evidence supporting routine splitting remains conflicting. This study aimed to compare cast-related complications between split and non-split casts and assess the associations of cast splitting, fracture displacement, and gap index with clinical outcomes. Materials and methods A retrospective cohort study was performed of children aged two to 16 years with forearm fractures initially managed with cast immobilization between January 2022 and December 2025. Demographic, clinical, and radiographic data were collected, including cast-splitting status, indication for splitting, fracture displacement, gap index, cast-related complications, and subsequent operative management. The gap index was categorized as ≤0.15 or >0.15. Results were summarized using frequencies and proportions for categorical variables and logistic regression to examine outcomes of interest. Results A total of 146 patients met the inclusion criteria, of whom 42 (28.8%) underwent cast splitting and 104 (71.2%) did not. Of the 42 split casts, 39 (92.9%) were split routinely. Cast-related complications were uncommon. Three patients (2.9%) initially managed without splitting returned for delayed cast splitting, and one patient with a wet cast needed a cast change, while one patient (2.4%) in the split group returned with a broken cast requiring a cast change. No cases of compartment syndrome occurred. Gap index ≤0.15 was not associated with cast-splitting status (p=0.30), and no significant association was identified between the gap index category and cast-related complications. Fifteen patients subsequently required operative management following loss of reduction. Operative management was associated with cast splitting (p=0.033) and initial fracture displacement (p=0.001). Conclusions Cast-related complications were uncommon irrespective of cast-splitting practice. These findings suggest that selective splitting based on clinical assessment and risk factors may be appropriate. Gap index was not associated with cast complications. Cast splitting was associated with subsequent operative management; however, this association should be interpreted cautiously given the retrospective nature of the study and other important variables not assessed in this cohort.