The Hidden Costs of Long vs. Short Leg Casting in Pediatric Fracture Care

Introduction Long leg casting (LLC) and short leg casting (SLC) are common treatments for pediatric lower-extremity fractures, yet little is known about their psychosocial and socioeconomic impact. This cross-sectional survey study quantified and compared the biopsychosocial burden of LLC and SLC on pediatric patients and caregivers using validated outcome measures and qualitative analysis. Methods A cross-sectional observational study was performed among pediatric patients (2-18 years) who presented for lower-extremity cast removal from 2022-2025. Patient-guardian dyads completed age-appropriate Pediatric Quality of Life Inventory (PedsQL) and Revised Impact on Family Scale (rIOFS) questionnaires and provided open-ended responses regarding disruptions and mobility-related challenges. Demographic and clinical information were collected, and multivariate linear regression controlling for age was performed to account for baseline differences between groups. Results A total of 136 patient-guardian dyads were enrolled, including 68 SLC patients and 68 LLC patients. After controlling for age, patients treated with SLC reported PedsQL scores 11.4 points higher than those treated with LLC (66.7± 14.3 vs. 56.6±16.3, p<0.001). Caregiver burden, measured by rIOFS, did not significantly differ between cast lengths (p=0.138). Patients restricted to complete non-weight-bearing (NWB) reported PedsQL scores 17.0 points lower than patients permitted any degree of weight-bearing (58.0±14.8 vs. 73.1±15.0, p<0.001), while caregivers reported greater burden, reflected by lower rIOFS scores (44.3±8.6 vs. 48.9±7.2, p=0.002). Cast length was not associated with any difference in missed school or caregiver workdays after controlling for age. However, NWB status was associated with 4.8 additional missed school days (p=0.026) and 1.7 additional caregiver workdays missed (p=0.004). Qualitative analysis revealed families struggled with transportation, obtaining medical equipment, physical strain, and social isolation. Conclusion LLC was associated with worse patient-reported quality of life compared with SLC, and complete non-weight-bearing restrictions were associated with worse patient quality of life, increased caregiver burden, and greater educational and occupational disruption. When clinically feasible, treatment strategies that promote mobility and permit weight-bearing may help mitigate the psychosocial and socioeconomic burdens of pediatric lower-extremity casting. Level of Evidence III, Cross-Sectional Observational Survey Study Key Concepts · Beyond clinical outcomes, lower extremity casting imposes psychosocial, physical, and logistical burdens on pediatric patients and their families. · Long leg casting was associated with significantly lower patient-reported quality of life than short leg casting, even after adjustment for age. · Complete non-weight-bearing restrictions were associated with worse patient quality of life, greater caregiver burden, and increased missed school and caregiver workdays compared to any degree of permitted weight-bearing. · Caregiver burden was associated with weight-bearing restrictions but not cast length, highlighting the importance of mobility during treatment. · When clinically appropriate, treatment strategies that maximize safe weight-bearing and mobility may reduce the psychosocial and socioeconomic burden of pediatric lower-extremity casting.