Background: Fracture management commonly uses conservative immobilization (plaster casts) or surgical internal fixation (plates, screws, intramedullary nails). Choice depends on fracture type, patient factors, resource availability and desired functional outcome.
Objective: To compare clinical and functional outcomes, complication rates, time to union, return to activity, and cost-effectiveness of plaster casting versus internal fixation in diaphyseal fractures of long bones.
Methods: Prospective comparative study of 120 patients with closed diaphyseal fractures of the tibia or forearm (radius/ulna) meeting inclusion criteria. Patients were allocated to two groups after shared decision-making and surgical fitness assessment: Group P (Plaster) — 60 patients managed with reduction and plaster cast immobilization; Group I (Internal fixation) — 60 patients treated with open reduction and internal fixation (ORIF) or intramedullary nailing as indicated. Follow-up: 12 months. Primary outcomes: time to radiological union, functional scores (Tegner/OMAS for ankle/tibia or DASH for forearm), and complication rates (malunion, nonunion, infection). Secondary outcomes: hospital stay, time to return to work, and direct treatment costs. Statistical significance p < 0.05.

Results (summary): Mean time to radiological union was 14.2 ± 3.6 weeks in Group I vs 16.8 ± 4.9 weeks in Group P (p = 0.002). Functional scores at 6 months favored Group I (mean DASH 12.4 vs 18.7; p = 0.01). Malunion occurred in 3.3% of Group I vs 15% in Group P (p = 0.03). Nonunion rates were similar (Group I 1.7% vs Group P 5.0%, p = 0.31). Superficial infection occurred in 6.7% of Group I; cast-related complications (pressure sores, joint stiffness) occurred in 13.3% of Group P. Mean time to return to work: 9.1 ± 2.8 weeks (Group I) vs 14.5 ± 4.1 weeks (Group P), p < 0.001. Direct treatment cost was higher for Group I.
Conclusion: In this cohort internal fixation provided faster union, better early functional recovery, lower malunion rates and earlier return to activity at the expense of higher upfront cost and surgical/implant-related complications. Plaster casting remains an effective low-cost option for selected stable fractures and patients unfit or unwilling for surgery. Treatment should be individualized considering fracture pattern, patient occupation, comorbidities and resource constraints.