Unplanned Return Visits to the Emergency Department Following Circumferential Cast Applications for Pediatric Forearm Fractures

INTRODUCTION: To quantify the incidence of and identify predictors for unplanned first-week return visits (1wRV) to the emergency department (ED) after circumferential casting (CC) application for pediatric forearm fractures. MATERIALS AND METHODS: Retrospective, single-center study of patients aged 0 to 18 years with radius and/or ulna fractures. The primary outcome was unplanned ED revisit within 7 days (1wRV). Analyses included demographic variables, and fracture type, location, reduction versus casting in situ, and cast length. Multivariable logistic regression was used to identify predictors of 1wRV. RESULTS: A total of 4661 cases were reviewed, with detailed analysis of 551 patients treated with CC in 2022. Among these, 67 (12.2%) experienced a 1wRV, most commonly due to pain (92.5%), with 95.5% requiring cast modification. Revisit rates varied by fracture location: distal radius and ulna (23.8%), midshaft radius and ulna (15.7%), distal radius (8.5%), and other fractures (5.5%; P=0.007), and were higher following reduction versus in-situ casting (16.1% vs. 4.3%; P<0.001; OR 3.265), peaking at 27.1% for reduced distal radius and ulna fractures. No compartment syndrome occurred, and 98.4% of patients completed nonoperative treatment successfully. CONCLUSIONS: Rates of 1wRV ranged from 0 to 27.1%, depending on fracture pattern and the need for reduction, and constituted the most common adverse event associated with CC. These granular findings underscore the need for a more individualized approach to immobilization and may inform the development of tailored, evidence-based nonoperative protocols for pediatric forearm fractures. LEVEL OF EVIDENCE: Level.