BACKGROUND: Distal radius fractures (DRFs) are a common challenge in orthopaedic trauma care, yet for those fractures that are treated nonoperatively, strong evidence to guide cast treatment is still lacking. AIM: To compare the efficacy of below elbow cast (BEC) and above elbow cast (AEC) in maintaining reduction of manipulated DRFs. METHODS: We conducted a prospective, monocentric, randomized, parallel-group, open label, blinded, noninferiority trial comparing the efficacy of BEC and AEC in the nonoperative treatment of DRFs. Two hundred and eighty patients > 18 years of age diagnosed with DRFs were successfully randomized and included for analysis over a 3-year period. Noninferiority thresholds were defined as a 2 mm difference for radial length (RL), a 3degree difference for radial inclination (RI), and volar tilt (VT). The trial is registered at ClinicalTrials.gov (NCT03468023). RESULTS: One hundred and forty-three patients were treated with BEC, and 137 were treated with AEC. The mean time of immobilization was 33 d. The mean loss of RL, RI, and VT was 1.59 mm, 2.83 degree, and 4.11 degree for BEC and 1.63 mm, 2.54 degree, and 3.52 degree for AEC, respectively. The end treatment differences between BEC and AEC in RL, RI, and VT loss were respectively 0.04 mm (95%CI -0.36 to 0.44), -0.29degree (95% CI -1.03 to 0.45), and 0.59degree (95% CI -1.39 to 2.57), and they were all below the prefixed noninferiority thresholds. The rate of loss of reduction was similar. CONCLUSION: BEC performs as well as AEC in maintaining the reduction of a manipulated DRF. Being more comfortable to patients, BEC may be preferable for nonoperative treatment of DRFs.

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