Immobilization in a Schede Cast as a Treatment Option for Distal Forearm Fractures in Children and Adolescents

Findings on efficacy and safety

Distal forearm fractures are the commonest factures in children and adolescents. Fractures with acceptable displacement are treated non-surgically, while those displaced beyond acceptable limits must be reduced. Additional Kirschner-wire fixation may be required for instability, but this involves additional clinical resources and may be associated with certain risks. No fixation, on the other hand, carries the risk of secondary displacement which can result in loss of function or require subsequent interventions. A non-surgical treatment alternative is to immobilize the forearm fracture in the Schede position (Figure a), named after the German surgeon Franz Schede who developed this form of treatment in the first half of the last century. The fracture can be retained in correct axial alignment and stabilized in the emergency room, either as an initially non-displaced fracture or after reduction by continuous longitudinal traction at the fracture fragments, using ligamentotaxis and applying forced flexion and ulnar abduction of the wrist. This contributes towards preventing secondary displacement (1). There are reports of complications arising in adults, such as iatrogenic carpal tunnel syndrome, which is why the Schede position is viewed skeptically and occasionally considered obsolete. The aim of the present feasibility study was to examine the tolerability and clinical course involving children with distal forearm fractures treated in a Schede cast.

Figure

Examples illustrating Schede therapy

Methods

A retrospective multicenter analysis was conducted at four German clinics (members of the Pediatric Section of the German Society of Trauma Surgeons from Dresden, Hamburg and Tübingen) over a period of 13 years. The study included all patients up to and including the age of 17 years who had undergone immobilization in the Schede position after sustaining an extension fracture of the distal forearm. Demographic parameters, disturbances of peripheral circulation, sensory and motor function, as well as complications were recorded using the hospital information systems. The position of flexion of the cast was determined based on available studies (2): Figure b shows the central axis of the radius in relation to the axis of a representative metacarpal. In addition, lateral X-rays were also used to check for secondary displacement – both after cast application and after consolidation of the fracture. Data analysis was performed with SPSS Statistics Premium 29.0.2 (IBM Corp., Armonk, NY, USA). Mean values, standard deviations, and confidence intervals were determined. Pearson correlations and odds ratios were also calculated. All p-values were based on adjusted multiple linear regression analyses.

Results

The study included a total of 713 patients with an average age of 9.59 (± 3.12) years, of which 68.7% were male. The left arm (57.2%) was predominantly involved. Many cases occurred as a result of sports injuries (48.2%). Metaphyseal radius fractures were most commonly documented (62.7%), followed by Salter-Harris type II (30.7%), diametaphyseal (4.6%), and Salter-Harris type I fractures (1.8%). A concomitant fracture of the ulna was found in 380 cases (53%). Displacement was reduced on average by 11.7° to 5.5° (± 5.1°). Average duration of immobilization was 34 (± 10) days, and the time to return to sports was 54 (± 18) days.

Secondary displacement was evident in 21 cases (2.9%; 95% confidence interval [2.2; 4.5]) at the time of the scheduled follow-up to check for displacement after one week, resulting in a change of therapeutic procedure. During the present study, the angle of flexion of the cast was found to differ between cases with secondary displacement and the other cases (42.9° [37.1°; 48.9°] versus 52.6° [51.5°; 53.6°]; odds ratio [OR] 0.95 [0.92; 9.81]), with secondary displacement being greater in the group with a smaller angle of flexion (4.7° ± 5.9° [2.1°; 8.2°] versus 0.5° ± 4.9° [0.1°; 0.9°]; OR 1.19 [1.08; 1.3]). Furthermore, patients with secondary displacement were on average older (10.86 [9.61; 12.11] years versus 9.55 [9.31; 9.79] years; OR 1.15 [0.99; 1.33]). Tingling paresthesia was the only complication evident in 2.2% [1.3; 3.5] of cases. The majority of these cases was nonspecific (n = 9), while the rest involved the dermatomes of the median (n = 4), ulnar (n = 2), and radial nerves (n = 1). The symptoms resolved in all patients within the space of a week, either spontaneously or after applying simple measures such as analgesia, local cooling, and adjustment of the cast. This particularly affected older children and boys. Development of the symptoms was unrelated to the degree of flexion (Table).

Table

Analysis of the prevalence of “tingling paresthesia” as a complication of Schede cast management of distal forearm fractures

Discussion

Given their favorable bone healing potential, the majority of forearm fractures in children and adolescents can be treated by cast immobilization alone, with or without reduction. Our article analyzes immobilization in a Schede cast in children and adolescents. Although we did not see the complications reported in the literature for adults, statistically speaking, they cannot be entirely ruled out, given their occurrence of up to 0.5% of cases. The high rates of secondary displacement of 7 to 39 % (3) during the treatment of distal forearm fractures in children and adolescents reported elsewhere were also not reflected in our study. However, adequate wrist flexion of at least 45° appears to be required when using a Schede cast to reduce the risk of secondary displacement, as Kralj et al. have previously demonstrated for Salter-Harris type I and II fractures (4). Treatment by immobilization in the Schede position is therefore a conservative form of treatment for distal forearm fractures in children and adolescents with a low complication rate that can be carried out on an outpatient basis. Surgery was rendered superfluous in many cases. However, more multicenter observational studies as well as randomized controlled trials are required to raise the level of evidence.

Kristofer Wintges, Jurek Schultz, Till Rausch, Benjamin Schoof, Meltem Sahin, Laura Altmeier, Josephine Hertel, Michael Esser, Boy Bohn, Guido Fitze, Justus Lieber, Dirk Sommerfeldt, Simon Scherer

Department of Pediatric Surgery at the University Hospital Hamburg-Eppendorf (Wintges, Schoof, Sahin, Sommerfeldt)

Conflict of interest statement
SS received financial support from the “Help for Sick Children” Foundation.

The other authors declare that there are no conflicts of interest.

Manuscript received on 28 January 2025, revised version accepted on 8 May 08 2025

Translated from the original German by Dr. Grahame Larkin

Cite this as:
Wintges K, Schultz J, Rausch T, Schoof B, Sahin M, Altmeier L, Hertel J, Esser M, Bohn B, Fitze G, Lieber J, Sommerfeldt D, Scherer S: Immobilization in a Schede cast as a treatment option for distal forearm fractures in children and adolescents: Findings on efficacy and safety. Dtsch Arztebl Int 2025; 122: 360–1. DOI: 10.3238/arztebl.m2025.0084

References

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3. Malviya A, Tsintzas D, Mahawar K, Bache CE, Glithero PR: Gap index: a good predictor of failure of plaster cast in distal third radius fractures. J Pediatr Orthop Part B 2007; 16: 48–52

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