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Three Part Question

In [paediatric buckle wrist fractures] is [a futura splint or other removable supportive device as good as plaster cast immobilisation] for [functional recovery without increasing complications?]

Clinical Scenario

You wonder why some hospitals splint buckle fractures and others plaster them. Is there any need to plaster these fractures?
Only 1 study for futura splints (currently a 2nd trial in recruitment stage in Washinton USA).
So looked for papers that compared plaster cast with alternatives including wool and crepe and tubigrip, 1 trial comparing splint with no treatment at all.

Search Strategy

exp Radius Fractures/ or torus.mp. or buckle.mp. or exp Ulna Fractures/ or exp Ulna/ or ulna.mp. or wrist.mp. or exp Wrist/ or exp Radius/ or radius.mp. or exp Forearm/ or forearm.mp. or metaphyseal.mp. or metaphyseal fracture.mp. or Greenstick fracture.mp.) AND (splint.mp. or exp Splints/ or Futura.mp. or Plaster.mp. or exp Fracture Fixation/ or exp Immobilization/ or immobilisation.mp. or brace.mp. or exp Braces/
Limit to (english language and humans and "all child (0 to 18 years)") 1394
Medline, Cinahl, Embase
Cochrane database
google scholar
unpublished trial from clinical trials registry

Search Outcome

25 papers
11 papers directly relevant to question.
5 were reviews.
6 papers of which 1 is unpublished.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kropman R.H.J., Bemelman M, Feb 2010 Netherlands	92 children age 4-13 years with buckle fracture Compared wool and crepe (changed to tubigrip at 1 week) with plaster cast	PRCT	Pain VAS	Increased pain in bandage group compared to plaster at wk 1.	Excluded patients -not intention to treat analysis -interpretation bias
			Comfort	itching 219 cast 140 bandage P<0.001
			ROM wrist	26 +/-19mm bandage 20+/-16mm plaster
			Refracture	No refracture at 4 weeks
West et al, 2005, Wales	Wool & Crepe v Plaster cast N=39	PRCT	Pain	W&C 22% Cast 71%	-Small sample size. -Not intention to treat. -Treatment bias -Assessment bias
			ROM at 4 weeks	W&C 162o Cast 126o
Plint et al, 2006, USA	Plaster Splint v Backslab N=113 randomised 87 analysed	PRCT	ASKp (activity scale for Kids- Daily physical function)	Significant difference in ASKp scores at day 14 for splint. No diff at day 7 or 20.	Study Strengths -Prospective -longer term follow up (6 months) Significant no.s not included or lost to follow up
			Refracture	No refracture at 6 months
Plint et al, 2004, Canada	309 buckle fractures. 13% (40) had been in a plaster splint	Retrospective cohort 2000-2001	Fracture displacement	All 40 splinted had no fracture displacement	Weaknesses -retrospective -Assumption that those lost to F/U were unlikely to have had complications
			Complications	32 unplanned ED visits with cast related problems (30 for cast and 2 for splint)
Ziouani and Jacobs 2007 UK (unpublished)	Children <17yr Torus fracture distal wrist randomized after Xray diagnosis into 2 groups Splint v no treatment	RCT	Difference in pain levels at weeks1 and 4. Time to return to normal use of affected limb with & without splint	No difference	Pilot Lost data
van Bosse et al, 2005, USA	buckle # 1-13yr Removable plaster splint N=48	Retrospective review 2001-2004	1o outcome: angulation onInitial and F/U Xrays.	Statistical diff between initial & F/U lateral Xray -1.7o (p=0.03) “not clinically significant”	Bias -no control group - Small no.s with large loss to F/U.
			Complications	2 had slight pain despite 3 weeks of splintage but had resumed all normal activities.
Davidson JS, UK, 2001	Cost-benefit analysis N=201	PRCT	Complications	No difference in clinical and radiological outcome for splints or casts. Saving per patient £51.23 if futura splint used rather than cast	No clear outcome measure -Quasi-randomized. -No sample size estimates. -no outcome measure -Loss to F/U -No statistical analysis of data

Comment(s)

No good trials but all trials have no refracture complications. No evidence to suggest that futura splint is inferior to plaster cast immobilisation it is superior in terms of patient satisfaction. Wool and crepe/bandage/ no treatment no evidence.

Clinical Bottom Line

Safe to treat buckle fracture in a futura splint so long as there is a system in place to prevent misdiagnosis of other fractures.

References

1. Kropman R.H.J., Bemelman M, Treatment of Impacted Greenstick Fractures in Children using Bandage or Cast Therapy: A Prospective Randomised Trial. J.Trauma 2010;68:425-428 425-428.
2. West S, Andrews J, Bebbington A, Ennis O, Alderman P. Buckle Fractures of the Distal Radius Are Safely Treated in a Soft Bandage. J Paediatric Orthop 2005;25:322-325
3. Plint AC, Perry J.P, Correll R, Gaboury I, Lawton L. A Randomised, Controlled Trial of removable Splinting versus Casting for Wrist Buckle Fractures in Children. Paediatrics 2006;691-697.
4. Plint, A.C, Perry J.P, Tsang J.LY. Paediatric Buckle fractures: Should we just splint and go? Can J Emerg Med 2004;6(6):397-401.
5. Ziouani. Jacobs M. Unpublished pilot. Pilot Randomised Controlled Trial at Hertfordshire Hospitlas NHS Trust. Distal Forearm Fractures- do they need a splint? http://www.controlled-trials.com/ (accessed 24 June 2010) ISRCTN34857372
6. van Bosse HJP, Patel RJ, Thacker M, Sala DA. Minimalistic Approach to Treating Wrist Torus Fractures. J Pediatric Orthop 2005;25:495-500.
7. Davidson J.S. Simple treatment for torus fractures of the distal wrist. The Journal of Bone and Joint surgery (Br) 2001;Vol 83-B, issue 8, 1173-1175.