Below-Elbow Versus Initial Above-Elbow Casting for Distal Radius Fractures

Below-Elbow Versus Initial Above-Elbow Casting After Closed Reduction of Distal Radius Fractures: 12-Week Isokinetic and 5-Year Functional Outcomes of a Prospective Randomized Trial

The goal of this clinical trial was to compare two casting strategies for adults with a broken wrist, also called a distal radius fracture. The study included people whose treating team had determined that treatment without surgery was appropriate. Their fracture was first put back into position without surgery.

The main questions were:

• Does starting treatment with a below-elbow cast or an above-elbow cast affect how well the fracture stays in position?
• Does cast length affect early elbow or shoulder pain and stiffness?
• Does it affect grip strength, arm and wrist muscle recovery, wrist function, or long-term disability?

Researchers compared a below-elbow cast used from the start with an above-elbow cast used for the first 2 weeks and then changed to a below-elbow cast.

Participants:

• were randomly assigned to one of the two casting strategies
• wore a cast for 4 weeks, followed by a splint and rehabilitation
• had x-rays and clinical assessments during the first 12 weeks
• were scheduled for bilateral grip-strength and machine-based muscle-strength testing at cast removal and at 12 weeks
• were invited to complete a clinical and functional follow-up assessment at approximately 5 years

Study Overview

• Status: Completed
• Conditions: Distal Radius Fracture
• Intervention / Treatment: Procedure: Below-Elbow Cast Immobilization; Procedure: Initial Above-Elbow Cast Followed by Below-Elbow Cast

Detailed Description

Distal radius fractures that are suitable for nonsurgical care are commonly treated with closed reduction and cast immobilization. Whether the elbow should be immobilized during the early treatment period remains uncertain. Above-elbow casting may restrict forearm rotation and theoretically improve fracture stability, but it may also cause elbow and shoulder discomfort or stiffness. Below-elbow casting preserves elbow movement and may reduce this treatment burden.

This was a single-center, prospective, randomized, parallel-group clinical trial involving adults aged 18 to 70 years with eligible AO/OTA distal radius fractures. After the treating team established that nonsurgical treatment was indicated, participants underwent closed reduction and were assigned by web-based block randomization to one of two cast-immobilization strategies. Randomization therefore occurred after the indication for nonsurgical treatment had been established, not after nonsurgical treatment had been completed.

Participants assigned to the below-elbow casting group received a below-elbow cast immediately after reduction. Participants assigned to the initial above-elbow casting group received an above-elbow cast immediately after reduction. At 2 weeks, the above-elbow cast was converted to a below-elbow cast. Cast immobilization ended at 4 weeks in both groups, followed by wrist splinting and rehabilitation.

At the initial injury assessment on Day 1, grip-strength testing and Cybex isokinetic testing were performed only on the uninjured contralateral upper extremity. Bilateral grip-strength and Cybex assessments were performed at cast removal, 4 weeks after closed reduction, and again at 12 weeks. Cybex measurements included raw peak torque, peak torque normalized to body weight, raw work per repetition, work per repetition normalized to body weight, and range of motion during elbow flexion and extension, wrist flexion and extension, and forearm supination and pronation. Side-to-side deficits were derived from the bilateral assessments at 4 and 12 weeks.

Radiographic follow-up included measurement of radial inclination, radial height, ulnar variance, and volar tilt immediately after reduction, at 4 weeks, and at 12 weeks. Maintenance of reduction was evaluated as within-participant change in these radiographic parameters through 12 weeks. Early clinical outcomes included elbow or shoulder pain and stiffness at cast removal, grip-strength recovery, and patient-reported wrist and upper-extremity function. Complications, additional treatment, and conversion to surgery were monitored through the 12-week follow-up period.

Patient-reported outcomes included the Patient-Rated Wrist and Hand Evaluation and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire. These measures were assessed during early follow-up and again at approximately 5 years. The long-term assessment also included treatment satisfaction. The 5-year assessment was limited to clinical and functional outcomes; Cybex isokinetic testing was not repeated at 5 years.

• Study Type: Interventional
• Enrollment (Actual): 93
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Istanbul, Turkey (Türkiye), 34093
    • Istanbul University, Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age 18 to 70 years
• Closed distal radius fracture for which the treating team determined that nonsurgical treatment with closed reduction and cast immobilization was appropriate
• AO/OTA distal radius fracture classified as 2R3A2, 2R3A3, 2R3B2, 2R3B3, 2R3C1, 2R3C2, or 2R3C3

Exclusion Criteria:

• AO/OTA distal radius fracture classified as 2R3A1 or 2R3B1
• Open distal radius fracture
• History of an allergic reaction to cast material
• Previous surgery involving the wrist or elbow
• Distal radius fracture judged to require operative treatment at the initial evaluation

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Below-Elbow Cast; After nonoperative treatment was determined to be appropriate and closed reduction was completed, participants received a below-elbow cast. Cast immobilization continued for 4 weeks, after which the cast was removed and splinting and rehabilitation were started.	Procedure: Below-Elbow Cast Immobilization; A below-elbow cast was applied following closed reduction of the distal radius fracture. The cast was maintained until 4 weeks after reduction and was then removed. Splinting and rehabilitation followed cast removal.; Other Names: Short-Arm Cast Immobilization
Active Comparator: Initial Above-Elbow Cast; After nonoperative treatment was determined to be appropriate and closed reduction was completed, participants received an above-elbow cast. At 2 weeks, the cast was converted to a below-elbow cast. All cast immobilization ended at 4 weeks, followed by splinting and rehabilitation.	Procedure: Initial Above-Elbow Cast Followed by Below-Elbow Cast; An above-elbow cast was applied following closed reduction of the distal radius fracture. At 2 weeks, the above-elbow cast was converted to a below-elbow cast. All cast immobilization ended at 4 weeks after reduction, followed by splinting and rehabilitation.; Other Names: Initial Long-Arm Cast Followed by Short-Arm Cast

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Isokinetic Peak Torque Normalized to Body Weight at 12 Weeks	Peak torque measured by bilateral Cybex isokinetic dynamometry was normalized to body weight and expressed as a percentage for elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded separately for the affected and unaffected upper extremities. Higher values indicate greater strength relative to body weight.	12 weeks after closed reduction

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Raw Isokinetic Peak Torque at Cast Removal	Bilateral Cybex isokinetic dynamometry measured raw peak torque during elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded separately for the affected and unaffected upper extremities in newton-meters. Higher values indicate greater maximal isokinetic strength.	At cast removal, 4 weeks after closed reduction
Raw Isokinetic Peak Torque at 12 Weeks	Bilateral Cybex isokinetic dynamometry measured raw peak torque during elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded separately for the affected and unaffected upper extremities in newton-meters. Higher values indicate greater maximal isokinetic strength.	12 weeks after closed reduction
Isokinetic Peak Torque Normalized to Body Weight at Cast Removal	Peak torque measured by bilateral Cybex isokinetic dynamometry was normalized to body weight and expressed as a percentage for elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded separately for the affected and unaffected upper extremities. Higher values indicate greater strength relative to body weight.	At cast removal, 4 weeks after closed reduction
Raw Isokinetic Work per Repetition at Cast Removal	Bilateral Cybex isokinetic dynamometry measured raw work per repetition during elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded separately for the affected and unaffected upper extremities in newton-meters. Higher values indicate greater work performed per repetition.	At cast removal, 4 weeks after closed reduction
Isokinetic Work per Repetition Normalized to Body Weight at Cast Removal	Work per repetition measured by bilateral Cybex isokinetic dynamometry was normalized to body weight and expressed as a percentage for elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded separately for the affected and unaffected upper extremities. Higher values indicate greater work capacity relative to body weight.	At cast removal, 4 weeks after closed reduction
Isokinetic Range of Motion at Cast Removal	Bilateral range-of-motion values were recorded in degrees during Cybex testing for elbow flexion and extension, wrist flexion and extension, and forearm supination and pronation. Values were recorded separately for the affected and unaffected upper extremities. Positive or negative values could be recorded according to the directional convention of the dynamometer.	At cast removal, 4 weeks after closed reduction
Affected-to-Unaffected Isokinetic Deficit at Cast Removal	Affected-to-unaffected side deficits were calculated separately for raw peak torque, peak torque normalized to body weight, raw work per repetition, work per repetition normalized to body weight, and range of motion across the tested movements. Deficits were expressed as percentages relative to the unaffected side. Higher positive values indicate a greater deficit of the affected side; 0% indicates no side-to-side difference.	At cast removal, 4 weeks after closed reduction
Bilateral Grip Strength at Cast Removal	Grip strength was measured in kilograms using a hand dynamometer. Three trials were recorded separately for the affected and unaffected hands. Higher values indicate greater grip strength.	At cast removal, 4 weeks after closed reduction
Raw Isokinetic Work per Repetition at 12 Weeks	Bilateral Cybex isokinetic dynamometry measured raw work per repetition during elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded separately for the affected and unaffected upper extremities in newton-meters. Higher values indicate greater work performed per repetition.	12 weeks after closed reduction
Isokinetic Work per Repetition Normalized to Body Weight at 12 Weeks	Work per repetition measured by bilateral Cybex isokinetic dynamometry was normalized to body weight and expressed as a percentage for elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded separately for the affected and unaffected upper extremities. Higher values indicate greater work capacity relative to body weight.	12 weeks after closed reduction
Isokinetic Range of Motion at 12 Weeks	Bilateral range-of-motion values were recorded in degrees during Cybex testing for elbow flexion and extension, wrist flexion and extension, and forearm supination and pronation. Values were recorded separately for the affected and unaffected upper extremities. Positive or negative values could be recorded according to the directional convention of the dynamometer.	12 weeks after closed reduction
Affected-to-Unaffected Isokinetic Deficit at 12 Weeks	Affected-to-unaffected side deficits were calculated separately for raw peak torque, peak torque normalized to body weight, raw work per repetition, work per repetition normalized to body weight, and range of motion across the tested movements. Deficits were expressed as percentages relative to the unaffected side. Higher positive values indicate a greater deficit of the affected side; 0% indicates no side-to-side difference.	12 weeks after closed reduction
Bilateral Grip Strength at 12 Weeks	Grip strength was measured in kilograms using a hand dynamometer. Three trials were recorded separately for the affected and unaffected hands. Higher values indicate greater grip strength.	12 weeks after closed reduction
Change in Affected-Hand Grip Strength From 4 to 12 Weeks	Grip strength of the affected hand was measured in kilograms using a hand dynamometer at 4 and 12 weeks. The analysis value at each assessment was derived from the recorded grip-strength trials. Change was calculated as the 12-week value minus the 4-week value. Positive values indicate improvement in affected-hand grip strength.	4 and 12 weeks after closed reduction
Change in Radial Inclination From Post-Reduction to 12 Weeks	Radial inclination was measured in degrees on anteroposterior wrist radiographs immediately after closed reduction and at 12 weeks. Change was calculated as the 12-week value minus the immediate post-reduction value. A negative change indicates loss of radial inclination.	Immediately after closed reduction and 12 weeks after closed reduction
Change in Radial Height From Post-Reduction to 12 Weeks	Radial height was measured in millimeters on anteroposterior wrist radiographs immediately after closed reduction and at 12 weeks. Change was calculated as the 12-week value minus the immediate post-reduction value. A negative change indicates loss of radial height.	Immediately after closed reduction and 12 weeks after closed reduction
Change in Ulnar Variance From Post-Reduction to 12 Weeks	Ulnar variance was measured in millimeters on anteroposterior wrist radiographs immediately after closed reduction and at 12 weeks. Change was calculated as the 12-week value minus the immediate post-reduction value. A positive change indicates increased positive ulnar variance.	Immediately after closed reduction and 12 weeks after closed reduction
Change in Volar Tilt From Post-Reduction to 12 Weeks	Volar tilt was measured in degrees on lateral wrist radiographs immediately after closed reduction and at 12 weeks. Change was calculated as the 12-week value minus the immediate post-reduction value. A negative change indicates loss of volar tilt or progression toward dorsal tilt.	Immediately after closed reduction and 12 weeks after closed reduction
Elbow or Shoulder Pain and Stiffness at Cast Removal	Participants rated elbow or shoulder pain and stiffness using a numeric scale from 0 to 10. A score of 0 indicates no elbow or shoulder pain or stiffness. Higher scores indicate greater symptom severity.	At cast removal, 4 weeks after closed reduction
Patient-Rated Wrist and Hand Evaluation Total Score at 4 Weeks	The Patient-Rated Wrist and Hand Evaluation is a 15-item participant-reported questionnaire assessing wrist and hand pain and disability. The total score ranges from 0 to 100, with higher scores indicating greater pain and disability.	At cast removal, 4 weeks after closed reduction
Patient-Rated Wrist and Hand Evaluation Total Score at 12 Weeks	The Patient-Rated Wrist and Hand Evaluation is a 15-item participant-reported questionnaire assessing wrist and hand pain and disability. The total score ranges from 0 to 100, with higher scores indicating greater pain and disability.	12 weeks after closed reduction
Quick Disabilities of the Arm, Shoulder and Hand Total Score at 4 Weeks	The 11-item Quick Disabilities of the Arm, Shoulder and Hand questionnaire assesses upper-extremity symptoms and disability. The total score ranges from 0 to 100, with higher scores indicating greater disability.	At cast removal, 4 weeks after closed reduction
Quick Disabilities of the Arm, Shoulder and Hand Total Score at 12 Weeks	The 11-item Quick Disabilities of the Arm, Shoulder and Hand questionnaire assesses upper-extremity symptoms and disability. The total score ranges from 0 to 100, with higher scores indicating greater disability.	12 weeks after closed reduction
Number of Participants With Complications or Additional Treatment Through 12 Weeks	Number of participants with at least one cast-related or fracture-related complication, repeat reduction, conversion to surgery, unplanned change in immobilization, or other additional treatment during the first 12 weeks after closed reduction.	From closed reduction through 12 weeks after closed reduction
Patient-Rated Wrist and Hand Evaluation Total Score at 5 Years	The Patient-Rated Wrist and Hand Evaluation is a 15-item participant-reported questionnaire assessing wrist and hand pain and disability. The total score ranges from 0 to 100, with higher scores indicating greater pain and disability.	5 years after closed reduction
Quick Disabilities of the Arm, Shoulder and Hand Total Score at 5 Years	The 11-item Quick Disabilities of the Arm, Shoulder and Hand questionnaire assesses upper-extremity symptoms and disability. The total score ranges from 0 to 100, with higher scores indicating greater disability.	5 years after closed reduction
Treatment Satisfaction Score at 5 Years	Participants rated their satisfaction with the assigned casting treatment on a scale from 0 to 5. Higher scores indicate greater treatment satisfaction.	5 years after closed reduction

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Contralateral Raw Isokinetic Peak Torque at the Initial Injury Assessment	Cybex isokinetic dynamometry measured raw peak torque of the uninjured contralateral upper extremity during elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded in newton-meters. Higher values indicate greater maximal isokinetic strength.	At the initial injury assessment (Day 1)
Contralateral Isokinetic Peak Torque Normalized to Body Weight at the Initial Injury Assessment	Peak torque of the uninjured contralateral upper extremity was measured using Cybex isokinetic dynamometry, normalized to body weight, and expressed as a percentage for elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Higher values indicate greater strength relative to body weight.	At the initial injury assessment (Day 1)
Contralateral Raw Isokinetic Work per Repetition at the Initial Injury Assessment	Cybex isokinetic dynamometry measured raw work per repetition of the uninjured contralateral upper extremity during elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Values were recorded in newton-meters. Higher values indicate greater work performed per repetition.	At the initial injury assessment (Day 1)
Contralateral Isokinetic Work per Repetition Normalized to Body Weight at the Initial Injury Assessment	Work per repetition of the uninjured contralateral upper extremity was measured using Cybex isokinetic dynamometry, normalized to body weight, and expressed as a percentage for elbow flexion, elbow extension, wrist flexion, wrist extension, forearm supination, and forearm pronation. Higher values indicate greater work capacity relative to body weight.	At the initial injury assessment (Day 1)
Contralateral Isokinetic Range of Motion at the Initial Injury Assessment	Range-of-motion values of the uninjured contralateral upper extremity were recorded in degrees during Cybex testing for elbow flexion and extension, wrist flexion and extension, and forearm supination and pronation. Positive or negative values could be recorded according to the directional convention of the dynamometer.	At the initial injury assessment (Day 1)
Contralateral Grip Strength at the Initial Injury Assessment	Grip strength of the uninjured contralateral hand was measured in kilograms using a hand dynamometer. Three grip-strength trials were recorded. Higher values indicate greater grip strength.	At the initial injury assessment (Day 1)

Collaborators and Investigators

• Sponsor: Istanbul University
• Investigators: Principal Investigator: Alper Ş. Kendirci, M.D., Istanbul University

Publications and helpful links

General Publications

• Chaudhry YP, Morway GR, Papadelis EA, Doerr NA, Graf KW, Mashru RP, Dolch HJ. Comparison of Short-Arm Immobilization and Long-Arm Immobilization in Conservatively Managed Distal Radius Fractures: A Meta-Analysis and Systematic Review. Cureus. 2024 Mar 8;16(3):e55813. doi: 10.7759/cureus.55813. eCollection 2024 Mar.
• Okamura A, de Moraes VY, Neto JR, Tamaoki MJ, Faloppa F, Belloti JC. No benefit for elbow blocking on conservative treatment of distal radius fractures: A 6-month randomized controlled trial. PLoS One. 2021 Jun 10;16(6):e0252667. doi: 10.1371/journal.pone.0252667. eCollection 2021.
• Caruso G, Tonon F, Gildone A, Andreotti M, Altavilla R, Valentini A, Valpiani G, Massari L. Below-elbow or above-elbow cast for conservative treatment of extra-articular distal radius fractures with dorsal displacement: a prospective randomized trial. J Orthop Surg Res. 2019 Dec 30;14(1):477. doi: 10.1186/s13018-019-1530-1.
• Dib G, Maluta T, Cengarle M, Bernasconi A, Marconato G, Corain M, Magnan B. Short arm cast is as effective as long arm cast in maintaining distal radius fracture reduction: Results of the SLA-VER noninferiority trial. World J Orthop. 2022 Sep 18;13(9):802-811. doi: 10.5312/wjo.v13.i9.802. eCollection 2022 Sep 18.
• Park MJ, Kim JP, Lee HI, Lim TK, Jung HS, Lee JS. Is a short arm cast appropriate for stable distal radius fractures in patients older than 55 years? A randomized prospective multicentre study. J Hand Surg Eur Vol. 2017 Jun;42(5):487-492. doi: 10.1177/1753193417690464. Epub 2017 Mar 1.

Study record dates

Study Major Dates

• Study Start (Actual): July 2, 2020
• Primary Completion (Actual): June 20, 2022
• Study Completion (Actual): June 14, 2026

Study Registration Dates

• First Submitted: July 11, 2026
• First Submitted That Met QC Criteria: July 11, 2026
• First Posted (Actual): July 15, 2026

Study Record Updates

• Last Update Posted (Actual): July 15, 2026
• Last Update Submitted That Met QC Criteria: July 11, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Grip strength; Isokinetic dynamometry; Cast immobilization; Wrist fracture; Closed reduction; Below-elbow cast; Initial above-elbow cast; Short-arm cast; Long-arm cast; Nonoperative treatment; Reduction loss; Five-year follow-up
• Additional Relevant MeSH Terms: Wounds and Injuries; Fractures, Bone; Arm Injuries; Wrist Injuries; Wrist Fractures
• Other Study ID Numbers: 2020/882

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: There is no plan to share de-identified individual participant data with other researchers. No prospective IPD-sharing framework, repository, or data-access process was established for this single-center study. Participant-level data will therefore not be made available for secondary research; study findings will be reported in aggregate form.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No