{
  "abstract": "There were no randomised controlled studies examining the management of a very common injury in children: the wrist fractures. The observational case series described the well-known feature of children’s fractures, that they have an amazing ability to remodel marked deformities of the wrist as the children grew. The usual practice was, however, surgery. There was a classic absence of evidence to inform management guidelines. The Children’s Radius Acute Fracture Fixation Trial (CRAFFT) trial is the first large multicentre randomised study addressing this absence of evidence. It is another great example of research networks, such as the Paediatric Emergency Medicine Research in the UK and Ireland (PERUKI), working with other specialties to deliver powered studies to answer common uncertainties. Perry et al, on behalf of PERUKI (Lancet 2026 online 8 April 2026 https://doi.org/10.1016/S0140-6736(26)00409-5), have challenged this usual surgical intervention practice of distal wrist fracture management treated by closed reduction. This was a lovely pragmatic open study of 750 children; 456 (61%) participants were male with a median age of 7.9 years (IQR 6.5–9.5). There were 329 (44%) of the 750 participants who had completely off-ended fractures. They were randomly assigned to two groups: 375 were treated with non-surgical casting and 375 had standard surgical reduction as per usual practice. The trial was non-inferior in design and recruited participants from 49 trauma centres across the UK, providing a great (generalisable) mixture of secondary or tertiary care hospitals. Non-surgical care involved immobilisation of the fracture in a plaster cast without general anaesthesia or sedation and without purposeful manipulation of the fracture position. The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Score for Children is a score of function, and the non-inferiority margin was set conservatively at –2.5 points for the main trial population. These data were collected from 640 (85%) participants. At 3 months postrandomisation, the mean PROMIS Upper Extremity score was 44.9 (SD 8.7) in the non-surgical casting group and 46.6 (SD 8.8) in the surgical reduction group (adjusted mean difference –1.64 (95% CI –2.84 to –0.44)), with the CI favouring surgical reduction but extending beyond the prespecified non-inferiority margin of –2.5 points. Most complications within 8 weeks occurred in the surgical reduction group, including pressure damage (n=2), wound infections (n=6), scarring (n=5) and nerve irritation (n=1). Thus, the study did not demonstrate non-inferiority of non-surgical casting at 3 months against a conservative margin; however, the observed difference in favour of surgical reduction was small, below thresholds that families considered meaningful, and did not persist beyond early recovery. Surgical reduction was associated with higher costs, early procedural complications and only a modest improvement in cosmetic appearance, supporting consideration of a cast-first strategy for most children. The cost and complications data are compelling; at 1 year, cosmesis was similar in both groups. The study had a qualitative component, which highlighted the discomfort among the clinicians with the simple casting option. The Archivist is sure this will change practice, but it may need more evidence and more time.",
  "authors": [
    {
      "affiliations": [],
      "name": "BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health"
    }
  ],
  "title": "CRAFFT study: wrist fractures in children",
  "uid": "f12e7dd8-0cc8-571a-ac6f-6146f843ee91"
}