ORIGINAL ARTICLE
Risk Factors for Redisplacement of Pediatric Distal
Forearm and Distal Radius Fractures
Alexander Geoffrey McQuinn, BMBS, B.Phys and Ruurd Lukas Jaarsma, MD, PhD, FRACS
Background: Fractures of the distal forearm and distal radius
represent the most common types of fracture in the pediatric
population, with the majority treated by closed reduction and
cast. Redisplacement has been known to occur in up to 39% of
cases. There have been numerous risk factors and radiologic
indices put forward as methods of predicting redisplacement,
but this topic remains a matter of debate. This retrospective
study aims to further assess the significance of the many factors
in redisplacement after treatment with closed reduction.
Methods: This retrospective study included 155 children with
distal radius and forearm fractures. Age, sex, location of frac-
ture, angulation, displacement, an associated ulna fracture,
obliquity of fracture, and accuracy of reduction were measured
for assessment as potential risk factors. In addition, the cast
index, padding index, Canterbury index, second metacarpal-
radius index, gap index, and 3-point index were measured on
postreduction radiographs.
Results: Redisplacement occurred in 33 of the 155 cases (21.3%).
Initial displacement and accuracy of the reduction were identi-
fied as significant risk factors for redisplacement. Initial dis-
placement of >50% (of the radius width) was significantly
associated with redisplacement (odds ratio of 5.4). Failure to
achieve anatomic reduction was significantly higher in the re-
displacement group (odds ratio 3.9). The only radiologic index
that differed significantly between groups was the cast index,
with more patients without redisplacement meeting the cut-off
value (60% vs. 32%, P = 0.010).
Discussion: Initial displacement of >50% and inability to ach-
ieve anatomic reduction are major risk factors for redisplace-
ment. Given its effectiveness and ease of clinical application, the
cast index remains the most useful measure of cast molding.
Level of Evidence: Level II—Retrospective prognostic study.
Key Words: fracture, forearm, distal radius, closed reduction,
redisplacement
(J Pediatr Orthop 2012;32:687–692)
From the Department of Orthopaedic Surgery, Flinders Medical Centre,
Bedford Park, SA, Australia.
No internal/external funding received for this project from any source.
None of the authors received financial support for this study.
The authors declare no conflict of interest.
Reprints: Alexander Geoffrey McQuinn, BMBS, B.Phys, Department of
Orthopaedic Surgery, Flinders Medical Centre, Flinders Drive,
Bedford Park, SA 5042, Australia. E-mail: alexmcq@gmail.com.
Copyright r 2012 by Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 32, Number 7, October/November 2012
F ractures of the forearm and distal radius represent the
most common type of fracture in the pediatric pop-
ulation.1,2 The mechanism of injury is that of a direct fall
in the majority of cases.2,3 Fractures in the pediatric
population differ from those in adults, due to the ability
for increased bone remodeling while the physes remain
open.2,3 Closed reduction in a molded cast has tradi-
tionally been the primary form of treatment.3–5 In some
reports, although, the incidence of redisplacement has
been found to be as high as 39%.6 Although some au-
thors have advocated the use of operative methods of
fixation such as percutaneous pinning in cases of severe
angulation or displacement,7,8 other reports have shown
similar cost and complication rates between closed re-
duction and percutaneous pinning.6
The risk factors associated with fracture redis-
placement have been reported on previously; however,
there is no clear consensus on which factors are the most
important in predicting treatment failure. Risk factors
have been grouped into fracture, surgeon, and patient
factors,1 with many of the fracture-related and surgeon-
related factors being objectively measurable. Some of the
factors that have previously been related to risk of re-
displacement are complete initial displacement,8,9 quality
of reduction,4,9,10 obliquity of fracture,9 and use of con-
scious sedation or hematoma block without general an-
esthesia.8 A variety of measures of the quality of plaster
molding and position have been described, including the
cast index,11 padding index,12 Canterbury index,12 second
metacarpal-radius angle,13 gap index,14 and 3-point in-
dex.9 These various radiologic indices have been put
forward as a method of predicting treatment failure, al-
though evidence to show a single index as a standalone
predictive measure is lacking.1
This retrospective study of pediatric distal forearm and
distal radius fractures aims to further assess the significance
of the many fracture-related and surgeon-related factors in
redisplacement after treatment with closed reduction.
METHODS
This study was performed retrospectively using data
obtained from the hospitals surgical and specialty services
database. Children aged 15 and below who had sustained
a fracture of the distal radius or forearm, treated with
closed reduction under general anesthesia, were included.
After closed reduction, the majority of patients were
immobilized in an above elbow cast. The data collected
www.pedorthopaedics.com | 687
McQuinn and Jaarsma
represent a 24-month period from March 2008 to March
2010. None of the included cases had associated neuro-
vascular injuries. Intra-articular fractures, open fractures,
and fractures associated with another fracture on the
ipsilateral side were excluded.
Radiographs taken at initial presentation were an-
alyzed for various measurements such as location of
fracture, angulation, displacement (defined as transla-
tional displacement of distal fragment relative to prox-
imal fragment), associated ulna fracture, and obliquity of
fracture. The obliquity of the fracture was measured by
taking the maximum fracture angle on either ante-
roposterior or lateral projections (ie, a true transverse
fracture would have an obliquity angle of 0 degree).
The quality of initial reduction was classified as
anatomic, good, or fair. This method has been used pre-
viously by Alemdaroglu et al9 and describes initial re-
duction as anatomic (complete anatomic fracture
reduction with no translation or angulation), good (< 10
degrees of dorsal angulation or r2 mm of translation), or
fair (less than a good reduction, with translation of be-
tween 2 and 5 mm or angulation of between 10 and 20
degrees or any radial deviation of <5 degrees or a com-
bination of 5 to 10 degrees of dorsal angulation and
r2 mm of translation). At the time of closed reduction,
the radiographs taken after cast application were used for
measurement of the various radiologic indices.
The indices measures were cast index,11 padding
index,12 Canterbury index,12 second metacarpal-radius
angle,13 gap index,14 and 3-point index.9 The formulae
used for measurement of these indices are summarized
and depicted in Table 1 and Figure 1, respectively. As
TABLE 1. Radiologic Indices Formulae, Descriptions, and
Cut-off Values
Description
Cast index Inner diameter of cast on lateral (at
fracture site)/inner diameter of cast on
AP (at fracture site)
Padding index Dorsal gap on lateral (at fracture site)/
maximum interosseus space on AP
Canterbury index Cast index+padding index
Second Angle created by bisection of the long
metacarpal- axis of the second metacarpal and long
radius index axis of the radius on AP radiographs
Gap index [(Radial fracture-site gap+ulnar
fracture-site gap)/inner diameter of cast
in AP plane]+[(dorsal fracture-site
gap+volar fracture-site gap)/inner
diameter of cast in lateral plane]
Three-point index [(Distal radial gap+ulnar fracture-site
gap+proximal radial gap)/contact
between fracture fragments in
transverse projection]+[(distal dorsal
gap+volar fracture-site gap+proximal
dorsal gap)/contact between fracture
fragments in sagittal projection]
*All indices except the second metacarpal radius angles are ratios and there-
fore do not have units applied to them.
AP indicates anteroposterior.
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J Pediatr Orthop  Volume 32, Number 7, October/November 2012
some of these indices have been validated for use in only
specified fracture locations, fractures outsides of these
parameters were not included for analysis (eg, the 3-point
index has been validated for distal 1/3 radius fractures but
not epiphyseal or middle 1/3 fractures9).
The follow-up films were then reviewed for assess-
ment of angulation and displacement. Redisplacement
was defined as >10 degrees angulation or >50% dis-
placement on follow-up imaging.5,9,13,14 Operative re-
cords were used to identify follow-up treatment in these
patients, and in the cases of further intervention, the na-
ture of this was recorded. To be included in the study,
patients must have had follow-up radiographs at least
once in the period 5 to 10 days after reduction. All of the
data were collected by a single investigator (A.G.M.).
For statistical analysis, the sample is described using
mean and standard deviation for continuous variables
and percentages for categorical variables. The Mann-
Whitney U test and w2 tests were used to evaluate differ-
ences between the groups. Data collection was entered
into a Microsoft Excel spreadsheet (Microsoft; Redmond,
Washington, DC). SPSS version 17.0 (SPSS; Chicago, IL)
was used to run the statistical queries.
RESULTS
There were 175 patients who met the above in-
clusion criteria. Twenty of these patients were excluded,
as there was insufficient imaging or follow-up data
available, with a final sample size of 155 patients. Re-
displacement occurred in 33 of the 155 cases (21.3%). Of
these, 3 had remanipulation under anesthesia, 6 had
percutaneous pinning with Kirschner wires, 4 had an in-
tramedullary titanium elastic nail (TENS nail) inserted,
and 1 had plate and screw fixation. Nineteen patients had
no acute intervention but were monitored clinically and
Cut-off radiologically for further redisplacement. There was no
Values* further displacement found in these cases on follow-up
0.8 imaging, and the subanatomic position was left for
natural remodeling.
The descriptive statistics of the sample are shown
0.3
in Tables 2 and 3. There was no difference between the
1.1 group with redisplacement and the group with no redis-
> 01 placement with regard to age, sex, presence of associated
ulna fracture, fracture location, fracture angulation, or
obliquity of fracture. The only significant difference be-
0.15
tween the groups regarding initial parameters was the
level of initial displacement. The group with redisplace-
ment had significantly higher levels of initial displacement
than the group with no redisplacement (P < 0.001).
0.8
Further analysis of these data showed that the proportion
of cases with >50% initial displacement in the redis-
placement group was more double that of the no redis-
placement group (23/33 or 70% vs. 36/122 or 30%), with
an odds ratio of 5.4 (95% confidence interval [CI], 2.4-
12.5; P < 0.001). In addition, the accuracy of reduction
was significantly better in the group with no redisplace-
ment (P < 0.001). This remained statistically significant
after correction for the differences in displacement
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J Pediatr Orthop  Volume 32, Number 7, October/November 2012 Pediatric Distal Forearm and Radius Fractures

A B C

a a
b b

D E

a e
d h
a b e b
d f
f
c

c g

FIGURE 1. Radiographic indices used to assess quality of cast application after closed reduction. A, Cast index: a/b. B, Padding
index: a/b. C, Second metacarpal-radius angle (this image depicts an angle >0 degree). D, Gap index: [(a+b)/c]+[(d+e)/f].
E, Three-point index: [(a+b+c)/d]+[(e+f+g)/h].

between groups (P = 0.028). Overall, 60% of this group differences in displacement (ie, analysis of only those
had anatomic reduction compared with only 27% in the patients with >50% displacement, thereby eliminating
redisplacement group. The odds ratio for nonanatomic the difference between groups), this remained statistically
reduction as a risk factor is 3.9 (95% CI, 1.7-8.9; significant (P = 0.040). The Canterbury index was also
P = 0.001), which was also statistically significant. significantly higher in the redisplacement group (P =
Data related to the various radiologic index for- 0.012); however, this finding lost statistical significance
mulae are shown in Table 4. The cast index was sig- after correction for differences in displacement (P =
nificantly higher in the redisplacement group than the 0.59), and there was no difference in the proportion of
no redisplacement group (0.83 ± 0.07 vs. 0.78 ± 0.09, cases meeting the cut-off. For all other indices, there was
P = 0.010), with the proportion of cases meeting the no significant difference between the 2 groups.
cut-off being significantly lower. After correction for the
DISCUSSION
TABLE 2. Comparison of Potential Risk Factors (Independent The results of our study show that the degree of
Variables) Between Groups initial displacement and quality of reduction are sig-
No Redisplacement Redisplacement nificant factors with regard to risk of redisplacement of
(n = 122) (n = 33) P fractures in this population. These findings have been
Age 9.23 (± 2.8) 9.55 (± 3.0) 0.55 shown in previous studies7,8,9,15; however, our study
Angulation (degree) 25.0 (± 11.9) 27.9 (± 14.1) 0.44 showed that it is not only fractures with complete initial
on lateral displacement that are at significant risk of redisplacement.
Angulation (degree) 9.18 (± 8.5) 12.0 (± 8.9) 0.42 Fractures with >50% displacement (defined as <50%
on AP
Obliquity of # line 13.4 (± 11.6) 14.7 (± 13.1) 0.55
bony apposition between proximal and distal fracture
(degree) fragments on the radius) were shown to be more prone to
redisplacement. This finding, in conjunction with a pre-
Values are shown as mean (standard deviation).
P values obtained using Mann-Whitney U test. vious study that showed similar outcomes,15 suggests that
all fractures with >50% displacement should be treated

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McQuinn and Jaarsma J Pediatr Orthop  Volume 32, Number 7, October/November 2012

TABLE 3. Comparison of Potential Risk Factors (Categorical TABLE 4. Radiologic Indices Data
Variables) Between Groups No
No Redisplacement Redisplacement Redisplacement Redisplacement P
(n = 122) (n = 33) P Cast index 0.78 (0.09) 0.83 (0.07) 0.001
Sex, male 85 (69.7) 23 (69.7) 0.99 63/105 (60.0) 9/28 (32.1) 0.010
Associated 60 (49.2) 21 (63.6) 0.20 Padding index 0.17 (0.10) 0.18 (0.09) 0.424
ulna # 97/105 (92.4) 25/28 (89.3) 0.699
Fracture location (on radius) Canterbury index 0.95 (0.15) 1.01 (0.12) 0.550
Middle 1/3 19 (15.6) 2 (6.1) 0.37 91/105 (86.7) 23/28 (82.1) 0.012
Distal 1/3 86 (70.5) 26 (78.8) Second metacarpal-radius 1.8 (4.8) 1.6 (6.7) 0.659
Epiphyseal* 17 (13.9) 5 (15.1) angle (degree)
Initial displacement 71/103 (68.9) 23/31 (74.2)
0%-25% 56 (45.9) 8 (24.2) < 0.001 Gap index 0.14 (0.04) 0.13 (0.04) 0.081
26%-50% 30 (24.6) 2 (6.1) 74/86 (86.0) 24/26 (92.3) 0.515
51%-75% 16 (13.1) 8 (24.2) Three-point index 0.91 (0.21) 1.01 (0.40) 0.382
76%-100% 11 (9.0) 7 (21.2) 33/86 (38.4) 10/26 (38.4) 1.000
> 100% 9 (7.4) 8 (24.2)
The values on the top line are represented as mean (standard deviation); the
Reduction accuracy
bottom value is the number of cases with a satisfactory index/total number of cases
Anatomic 73 (59.8) 9 (27.2) < 0.001 (percentage of total cases for that group).
Good 48 (39.3) 15 (45.5) Values of indices are ratios, except for the second metacarpal-radius angle,
Fair 2 (1.6) 9 (27.2) which is measured in degrees.
Values are shown as total number of cases (percentage of group).
P values obtained using w2 test.
*Epiphyseal fractures include fractures with physeal involvement, as described
by Salter and Harris.18 In this sample, all of the fractures were Salter-Harris
reduction in theatre with associated brief hospital stay
type II injuries. would cost a minimum $500 to $1000, which is a sig-
nificant figure.
The results from the radiologic indices data were
as high risk for redisplacement. Given this, any fracture mixed, and the cast index was the only index that was
with >50% displacement should be followed up closely significantly worse in the redisplacement group. This was
in the initial postreduction period, and repeat closed re- the first index devised for this purpose, and there are
duction or percutaneous pinning should be considered if multiple studies that have shown that it is a predictor of
redisplacement occurs (an example of the latter is shown treatment failure.11,12,17 The key components to adequate
in Fig. 2). In cases of complete initial displacement, per- fracture fixation are proper molding, thin and uniform
cutaneous pinning after closed reduction should be con- padding, and 3-point fixation.12 It has been theorized that
sidered, as this has been shown to reduce the risk of the cast index is able to assess the quality of some of these
redisplacement.7,8 components, in particular plaster molding, as the ratio of
Anatomic reduction accuracy has previously been plaster diameter in lateral and anteroposterior planes
shown to be a significant factor in treatment failure.4,9,10 certainly differs between a correctly and poorly molded
The results from our study show this once again. Given plaster. The cut-off figure for this index has been sup-
the importance of this factor in achieving a satisfactory ported by validation studies,12 and this gives an ob-
outcome, the development of minimum acceptable reduc- jectively measurable quantification of adequate cast
tion standards may be beneficial to aid in the prevention of molding.
redisplacement. If there were guidelines regarding the The other indices have evidence to support their use,
maximum amount of displacement and angulation that but in this study they were not found to differ between the
is considered acceptable (which may vary depending on redisplacement group and the group with no redisplace-
patient demographics such as age), this would guide the ment. Of these, the index that seems theoretically to be
clinician further in their decision-making process. If closed most sound is the 3-point index, which uses the principle
reduction did not achieve these minimum acceptable of 3-point fixation. Alemdaroglu et al9 found it to be a
standards, then proceeding to percutaneous pinning could good measure for predicting displacement in their pro-
be recommended to avoid redisplacement. spective study. In their study, all patients were placed in
The need to avoid redisplacement is further em- below elbow casts after closed reduction, and this differs
phasized when the medical, social, and financial re- from our study where the practice at our institution is for
percussions are considered. Medically, a repeat procedure the arm to generally be placed in an above elbow cast.
would entail the administration of another anesthetic that Alemdaroglu et al9 also stated that short-arm (below
could contribute to morbidity and complications. The elbow) casts are more dependent on 3-point fixation, and
emotional effect of a repeat procedure and hospital stay this may have contributed to the lack of significant results
on the young patient and their family is difficult to for the 3-point index in our study. A different issue entirely
quantify but should not be ignored. In addition, the is the clinical applicability of the index. The complexity of
financial cost to patient, family, and institution must be the 3-point index calculation makes its use in the clinical
considered. On the basis of local experience and other setting less realistic than in the research setting. In terms of
quoted sources,16 it is estimated that a repeat fracture ease of clinical application, the cast index and also the

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J Pediatr Orthop  Volume 32, Number 7, October/November 2012 Pediatric Distal Forearm and Radius Fractures

FIGURE 2. Example of redisplacement after closed reduction. A, Initial prereduction radiograph. B, In a cast after closed re-
duction. C, Dorsal redisplacement found on review of 7-days postreduction. D, Subsequent fixation using percutaneous pinning
with Kirschner wires.

second metacarpal radius angle are the 2 indices most
clinicians would find most useful.
There are some limitations to our study, of which
the retrospective study design is probably the most im-
portant. The follow-up intervals were similar in all
patients in our study, as part of the inclusion criteria
required follow-up to occur at least once in the 5- to
10-day postreduction period. The patients excluded due
to inadequate data were not negligible in number, but this
was unavoidable, as meaningful interpretation of the data
requires the full availability of initial, postreduction, and
follow-up films. The only difference between groups was
with regard to degree of fracture displacement. This is a
positive finding in that it supports the theory that initial
displacement is a risk factor for redisplacement; however,
it must also be considered as a possible factor in any other
differences found between groups after treatment. To
counter this difference, statistical analyses for treatment
parameters were corrected for this difference, with the
statistical significance of our main findings unaffected.
Another important factor to consider is that because
of the nature of the study, long-term follow-up of all
patients was not able to be achieved. This raises the issues
of whether there were further cases of fracture redisplace-
ment at a later stage than the follow-up period and also
regarding the outcomes of the redisplaced fractures that
were managed without acute intervention (ie, patients
managed with close observation for further displacement).
The majority of patients were actually followed up to
6-weeks postreduction; hence, in these cases, it could be
said that the fracture had united and displacement was
very unlikely to occur after this time. However, given the
incomplete and variable data available over this longer
follow-up period, these statistics were not included. It
could therefore be viewed that this study is limited to that
of an assessment of risk factors for early redisplacement.
Given the lack of long-term follow-up, the authors are not
able to comment further on the long-term radiologic and
functional outcomes of the 19 patients that were managed
with observation alone; however, it should be noted that
all these patients showed no worsening of displacement on
available follow-up films. These cases could therefore be
viewed as a subset of borderline cases that met the strict
criteria for redisplacement in this study but were judged by

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McQuinn and Jaarsma J Pediatr Orthop
the clinician to be within an acceptable range to allow for
management with close observation, with the view that
bony remodeling would occur.
Epiphyseal injuries were included for the initial
analysis of risk factors. This differs from the approach of a
number of previous studies in this area. There are nu-
merous arguments for their inclusion. The first is that they
are common injuries, forming up to 18% of bone injuries
in this population.18 Another reason is that the vast ma-
jority of these injuries and treated by closed reduction,
essentially dealt with in the same manner as metaphyseal
fractures.19,20 The major difference in terms of follow-up
with these injuries is regarding the risk of premature
growth plate closure, although in Salter-Harris type II in-
juries of this region (the classification subtype to which all
the epiphyseal injuries in our study belonged), the in-
cidence of this has been shown to be extremely low.21,22 In
any case, this complication is monitored for and identified
at a later timeframe than the period of follow-up for re-
displacement.21 Further analysis of the data showed that
the results of this study were not altered in any meaningful
way by the inclusion of these cases. Where the use of ra-
diologic indices has not been validated in this subgroup of
fractures, these patients were excluded from analysis.
In conclusion, this study found that initial fracture
displacement of >50% and inability to achieve anatomic
reduction were the most important risk factors for re-
displacement after closed reduction. In addition, the cast
index differed significantly betweens group with redis-
placement and with no redisplacement. Given it is a
simple and practical measure of cast molding, its use in
clinical practice should be encouraged.
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