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Reference:  Perry DC, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet April 2026.

Date: May 8, 2026

Dr. Andrew Tagg

Guest Skeptic:  Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles.

Case: A healthy 7-year-old boy presents to the emergency department (ED) with obvious deformity of the wrist after a fall from playground equipment. X-rays show a severely displaced distal radius fracture, with an associated ulnar fracture. The child is neurovascularly intact. But the wrist looks dramatic. It’s quite bent. The child gazes at his arm, a mix of fear and intrigue. You consult the friendly orthopedics specialist who greets the family and recommends reduction under sedation because “it looks too crooked to leave alone.” You recall that in younger children, some fractures can remodel quite well on their own. The child’s father asks you whether you think the boy really needs a procedure to re-align the bones, or if he can just be placed in a cast.

 Background:

Distal radius fractures are among the most common fractures in childhood, and severely displaced injuries create one of those classic tensions between what looks bad on an X-ray and what matters to patients over time.

Traditional teaching has favored reduction, often under sedation or general anesthesia, to restore anatomy and avoid concerns about deformity, loss of motion, or unhappy families. But pediatric bone is not adult bone. Younger children have substantial remodeling potential, especially near active growth plates, and prior observational studies suggested that even very displaced distal radial fractures can straighten out over time with good function.

Many clinicians still feel uneasy leaving these fractures unreduced. The visual deformity can be alarming. Families may equate straight bones with proper healing. Procedural reduction also comes with costs and potential harms: anesthesia, sedation, procedural pain, wound complications, etc.

Clinical Question: In children aged 4 to 10 years with severely displaced distal radial fractures, is non-surgical casting non-inferior to surgical reduction for functional recovery?

Reference:  Perry DC, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet April 2026.

  • Population: Children aged 4 to 10 years from 49 UK hospitals with severely displaced distal radial fractures, either metaphyseal or Salter-Harris II, with or without an associated ulnar fracture.
    • Exclusion: Injury >7 days, complex wrist fractures that were open or extending into the joint, additional fractured bones elsewhere, inability to adhere to trial procedures or follow up.
  • Intervention: Non-surgical casting without purposeful manipulation, without sedation or general anesthesia.
  • Comparison: Surgical reduction under general anesthesia or conscious sedation, with fixation permitted at the surgeon’s discretion.
  • Outcome:
    • Primary Outcome: Patient Report Outcomes Measurement System (PROMIS) Upper Extremity Score for Children at 3 months.
    • Secondary Outcomes: Pain, health-related quality of life, cosmesis, complications, refracture, unplanned surgery, school absence, parental satisfaction, and cost-effectiveness.
  • Trial: Pragmatic, multicenter, randomized, controlled non-inferiority trial with economic evaluation

Authors’ Conclusions: “The CRAFFT trial 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.”

Quality Checklist for Randomized Clinical Trials:

  1. The study population included or focused on those in the emergency department. Yes
  2. The patients were adequately randomized. Yes
  3. The randomization process was concealed. Yes
  4. The patients were analyzed in the groups to which they were randomized. Yes
  5. The study patients were recruited consecutively (i.e. no selection bias). Unsure
  6. The patients in both groups were similar with respect to prognostic factors. Yes
  7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
  8. All groups were treated equally except for the intervention. Unsure
  9. Follow-up was complete (i.e. at least 80% for both groups). Yes
  10. All patient-important outcomes were considered. Yes
  11. The treatment effect was large enough and precise enough to be clinically significant. Yes,
  12. Who funded the study? Funded by the National Institute for Health and Care Research Health Technology Assessment programme and supported by the NIHR Oxford Biomedical Research Centre.
  13. Financial conflicts of interest. One author declared paid lectures for Smith & Nephew and Arthrex; all other authors declared no competing interests.

Results: The trial enrolled 750 children, with 375 randomized to non-surgical casting and 375 to surgical reduction. The median age was 7.9 (IQR 6.5-9.5) years, with 456 (61%) being male. 44% had completely off-ended or displaced fractures.

Key Results: In children aged 4 to 10 with severely displaced distal radius fractures, surgery provided a small early functional advantage, but the difference was not clinically meaningful and disappeared in later months. Non-surgical casting was less expensive and had fewer early complications.

Primary Outcome: PROMIS Upper Extremity score was:

  • 44.9 in the non-surgical group vs 46.6 in the surgical group
  • Adjusted mean difference was minus 1.64 points [95% CI -2.84 to -0.44], favouring surgery.

This confidence interval crossed the prespecified conservative non-inferiority margin of 2.5. Non-surgical casting did not meet formal non-inferiority for the full cohort.

Secondary Outcomes:

There are several secondary outcomes from this study (check out the paper for more detail). Secondary outcomes mostly told a small early advantage, little long-term difference story.

First, in the pre-specified subgroup with completely off-ended fractures, non-surgical casting was non-inferiority. Keep in mind this threshold was a bit wider with a margin of minus 5 points.

When they looked at PROMIS scores over time, there was really no functional difference between groups by 6 and 12 months.

Surgical patients had more early complications, including pressure injury, wound infection, scarring, and nerve irritation.

Cosmesis slightly favored surgery early on, but the gap narrowed over time

Non-surgical casting saved about £1665 per patient and had a 100% probability of being cost-effective at standard UK willingness-to-pay thresholds.

Statistical vs Clinical Significance

This was a non-inferiority trial, but whether something is ‘non-inferior’ depends entirely on where you draw the line. The margin was –2.5 PROMIS points, and the result was minus 1.64 with the 95% confidence interval barely crossing the prespecified margin at -2.84. So technically, it failed non-inferiority.

It’s important to keep in mind that, because they had incorporated patient and public involvement across many aspects of the trial, they knew that families said a 5-point difference mattered. They chose a bit more conservative margin of -2.5.

This is one of those trials where the statistics say, ‘maybe not’… but the patients say, ‘we don’t care.’

And we care about the POOs, those patient-oriented outcomes, more.

Lack of Masking (and why it matters here)

One thing worth pausing on is the lack of masking. In this trial, neither clinicians nor families were masked to the treatment, and the primary outcome was a parent-reported function measure using PROMIS. That combination matters because it opens the door to expectation bias, which is a form of observer bias.

If your child has gone to theatre, had an anaesthetic, and the bone has been “put back in place,” it’s very natural to feel that something definitive has been done. It feels like proper treatment. On the other hand, if the arm has been put in a cast and left looking a bit bent, that can feel like something has been left unfinished even if it’s entirely appropriate.

When we see a small early functional advantage for surgery, it’s worth asking how much of that is true benefit, and how much might be shaped by perception. Because if you’ve just watched your child go through a procedure, you might understandably feel like they’re doing better, regardless of what’s happening at the level of bone healing.

There’s a lot of additional information in the supplemental section, but one part includes parental satisfaction scores, and there were really no big differences between the two groups.

Selection Bias / Equipoise Problem

Another interesting aspect is who made it into the trial. Of the 1,227 children who were eligible, only 750 were randomized. Many families declined to participate, and a notable proportion of clinicians felt there wasn’t enough equipoise to even offer enrollment.

Some of these exclusions based on clinician equipoise seem warranted like concern for neurovascular compromise. When it came to the families who declined consent, most of them declined because they had a preferred treatment…which more preferring surgical reduction.

This means the study population isn’t a perfect reflection of everyone we see in practice. Instead, it’s a group made up of families and clinicians who were already relatively comfortable with uncertainty and willing to accept that maybe we don’t need to “fix” something that looks quite dramatic.

The hardest patients to randomize are often the ones we feel strongest about, and they’re the ones who end up missing from the data.

While the results are reassuring, they also hint at a challenge. If there was hesitation to enroll these patients in a controlled trial, adopting a cast-first approach in everyday practice, where the X-ray looks alarming, and the room is full of anxious energy, may be even harder than the numbers alone suggest.

Crossovers

This trial embraces a bit of real-world messiness. There were crossovers in both directions. Around 10% of children assigned to surgery didn’t undergo it, and about 7% in the casting group crossed over to a procedure.

The authors analyzed the results using an intention-to-treat approach, which is the right approach. It preserves the benefits of randomization. But it also means that any true differences between the groups may be a bit diluted, because some patients didn’t receive the treatment they were assigned.

The authors also performed a per-protocol analysis, which is shown in Supplementary Table 7. The 95% confidence interval for the difference between the two groups did cross the prespecified -2.5 threshold but not the -5 threshold set by families.

The crossovers do make the findings feel more like real life. Even in a tightly run trial, some of these kids didn’t stay in their lane, and that’s exactly what happens at 2 am in the emergency department, when plans change, parents hesitate, or clinicians reconsider.

In that sense, the crossovers don’t weaken the study so much as make it more believable. They reflect the uncertainty, negotiation, and fluid decision-making that define everyday practice, and strengthen the generalizability of the results.

The Outcome They Didn’t Measure

One of the more quietly radical choices in this trial is what the authors didn’t focus on. They didn’t center the outcomes around radiographic alignment. There’s no primary endpoint for how straight the bone looks on an X-ray. Instead, they focused on what matters most to patients and families: function, pain, quality of life, and, to some extent, appearance.

That’s a subtle but important shift. In orthopaedics, we’re often drawn to what we can measure and see: angles, alignment, and the perfect position on imaging. But this study asks us to step back and consider whether that visual perfection translates into meaningful benefit.

Because when you look at the results, the function is the same by 6 to 12 months. Cosmetic differences narrow over time. And no child needed corrective surgery. So, it raises a slightly uncomfortable question: are we sometimes treating the X-ray rather than the child?

And perhaps that’s the most interesting takeaway of all.

Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: The authors’ conclusion is fair and more nuanced than a simple “negative” or “positive” trial framing. They acknowledge that non-surgical casting did not meet formal non-inferiority at 3 months, but they also emphasize that the difference was small, transient, and probably not meaningful enough to justify the cost and harms of surgery for most children. That seems like a reasonable interpretation of the data.

SGEM Bottom Line: For most children aged 4 to 10 years with severely displaced distal radial fractures, especially many completely off-ended fractures, a cast-first strategy appears to be a reasonable alternative. Surgical reduction may offer a small short-term advantage, but that benefit may not be clinically important enough for families.

Case Resolution: I think this is one of those classic paediatric cases where the X-ray looks terrifying… but the child is going to do just fine.

You discuss the evidence with the family. Their child is 7 years old, has a severely displaced distal radius fracture, but is neurovascularly intact with no threatened skin or other urgent indication for reduction.

You explain that while the x-ray looks dramatic, younger children have excellent remodeling potential. Surgery may make the wrist look straighter sooner and offer a very small short-term functional edge, but it also brings sedation or anesthesia, possible wire or wound complications, scarring, and higher cost.

In most similar children, a cast-first approach results in recovery that looks very similar by 6 to 12 months. The family chooses non-surgical casting with close follow-up.

Clinical Application:

This is the kind of paper that can shift both ED and orthopedic conversations. It does not mean every displaced wrist fracture should be left alone. Children with neurovascular compromise, threatened skin, open injury, older age, or fracture patterns outside the study still need individualized care. But for a large group of younger children with dramatic distal radial fractures, this trial provides clinicians with evidence to support a less invasive option.

The main practical challenge will not be biology. It will be culture. Many clinicians and parents have difficulty accepting a bent wrist that is expected to remodel. Using this paper well means reframing success away from immediate radiographic straightness and toward long-term function, avoiding harm, and shared decision-making.

We have some hope for the shifting culture. Another type of orthopedic injury we encounter in kids is proximal humerus fractures. These often look impressive on X-ray. But turns out, these types of fractures are usually treated non-operatively with a coaptation splint with a great prognosis.

What do I tell the patient? 

The bone looks quite bent right now, and I understand why that is alarming. The good news is that in children this age, these fractures often straighten out very well as they heal and grow. A procedure to put the bones back in alignment may make it look better sooner, but in studies like this one the long-term function was very similar. Going through with procedural sedation or surgery can potentially add more anesthesia, more complications, and more cost. Since blood flow and nerves in your child’s arm are okay, starting with a cast is a very reasonable option, and we will follow closely to make sure healing goes the way we expect.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.