One hundred eighty children aged 4 to 12 undergoing first-time cast removal were randomized to receive either standard care with noise-canceling earmuffs (n=90) or immersive virtual reality with noise-canceling headphones (n=90). The primary outcome was sympathetic response measured by heart rate (HR) before, during, and after the procedure. Secondary outcomes included child-reported and caregiver-reported pain (FACES and VAS scores), and anxiety (VAS scores), as well as caregiver satisfaction. Outcomes were assessed immediately before and after the procedure. Overall, the results of the study revealed no significant differences in sympathetic response or pain scores between groups. However, VR significantly reduced self-reported and caregiver-reported anxiety during cast removal. These findings suggest that while VR may not impact physiological stress or pain in this context, it could be effective in lowering perceived anxiety.