Management of pediatric distal radius fractures – A systematic review and meta-analysis

BACKGROUND: Pediatric distal radius fractures are the most common fractures in children. Management of displaced injuries remains controversial because remodeling capacity varies with skeletal maturity, fracture stability, and fracture subtype. Metaphyseal and physeal fractures differ biologically: metaphyseal injuries are primarily threatened by redisplacement, whereas physeal injuries carry risks of growth disturbance and iatrogenic physeal injury. An evidence-based, maturity- and stability-guided framework is required. METHODS: A PRISMA-compliant systematic review and Meta-analysis was performed using PubMed, Embase, Scopus, Web of Science, and the Cochrane Library (inception-2025). Randomized controlled trials and comparative observational studies of pediatric distal radius fractures (0-18 years) treated with cast or splint immobilization, with or without percutaneous Kirschner-wire fixation, were included. Primary outcomes were redisplacement and secondary intervention for metaphyseal fractures; growth disturbance and physeal complications were evaluated separately for physeal injuries. Secondary outcomes included union, functional recovery, complications, and casting quality. RESULTS: Forty-five studies (5,340 patients) were included qualitatively; twelve comparative studies (4 RCTs, 8 observational; 1,455 patients) were analyzed quantitatively (853 cast alone; 602 cast + K-wire). In predominantly metaphyseal fractures, redisplacement occurred in 20-35% after casting versus 0-5% after K-wire fixation (pooled OR 0.10), with reduced secondary intervention (OR 0.15). Union approached 100% and long-term functional outcomes were equivalent. In children with substantial remaining growth, including those <11 years with completely displaced metaphyseal fractures, casting without reduction achieved reliable union and remodeling. For physeal injuries, restoration of physeal alignment and longitudinal growth surveillance were prioritized. Cast length and removable splints demonstrated comparable stability when molding was adequate; casting quality indices were variably predictive. CONCLUSIONS: Outcomes are excellent when treatment aligns with fracture biology and skeletal maturity. Metaphyseal and physeal injuries require distinct considerations. Nonoperative care - including acceptance of bayonet apposition in young children - is appropriate for many metaphyseal fractures, while K-wire fixation should be selectively reserved for unstable patterns. LEVEL OF EVIDENCE: Level II (Systematic review and meta-analysis of Level I-III studies).