• 
• 

Three Part Question

[In a child with a buckle fracture of the distal radius +/or ulna] is [follow up in fracture clinic with repeat XR] necessary [to ensure fracture healing in a satisfactory position and functional recovery]?

Clinical Scenario

A 6-year-old child presents to the ED with a painful wrist following a fall. His x ray shows a buckle fracture of the distal radius. You apply a removable brace as you have recently read a 2008 BestBET that suggests that it will support healing as much as a full cast. Your next question is whether he really needs fracture clinic follow-up with repeat x ray(s) or whether this type of fracture will always heal with no risk of loss of position or residual functional deficit.

Search Strategy

Medline 1950–June Week 2 2009.
exp radius fracture$/OR wrist fracture$.mp. OR radius fracture$.mp. OR radial fracture$.mp. OR (torus adj5 fracture$).mp. OR (buckle adj5 fracture$).mp. OR exp ulna fracture$/OR (forearm adj 5 fracture$).mp. OR exp fracture$, closed/exp *Wrist/pa, ab, su, ra OR exp *Forearm/ab, su, ra, pa. AND exp child$/OR child$.mp. OR paediatric$.mp. OR exp pediatrics/OR pediatric$.mp. OR exp child, preschool/OR exp infant OR exp adolescent/OR infant$.mp. Or adolescent$.mp. OR toddler$.mp. AND complications.mp. OR prognosis.mp. OR exp prognosis/OR outcome.mp. OR recovery.mp. OR exp treatment outcome$/OR exp recovery of function/

Cochrane Database 2009 – "buckle" "radius" "fractures"

Google – "buckle" "radius" "fractures"

Search Outcome

Medline—1067 articles found, seven relevant articles

Cochrane—one review article

Google scholar—one extra relevant article found

Nine articles were critically appraised

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Abraham et al, 2008, UK (Cochrane review)	4 Randomised/quasi-randomised trials of children with buckle fractures—comparison of removable splint versus POP (Davidson, Plint, West, Symons)	2a	Any worsening deformity	No short-term deformity was found in all four trials	Few and some poorer quality studies included Heterogeneity of studies
			Functional recovery	No refracture at 6/52 in one (Plint)
			Patient/parent satisfaction	Conclusion: Limited evidence for removable splint but? best type of splintage. Further research is needed
Farbman et al, USA, 1999	70 Children with buckle fractures of the wrist who attended an urban tertiary care fracture clinic between February 1995 and 1997	Two-part retrospective notes review—level 4. Expert opinion level 5 on need for follow-up	Number of, and timing of, follow up x ray	Of 65 patients followed up for 4/52, all had recorded adequate healing either clinically, on x ray, or both	Varying length of follow-up Variation in number of and timing of x rays No baseline characteristics given Conclusion states need for one follow-up study but with no evidence for this
Davidson et al, UK, 2000	Prospective randomised trial. 201 Children 2–15 years with buckle fracture of the distal radius over 6/12 at fracture clinic were (quasi) randomised to full Colles’ type cast or futura splint Loss to follow-up—four POP and 18 splint leaving 81 POP and 98 splint. Two excluded, one did not consent, one had a greenstick fracture	2b	Clinical and radiological recovery at 3/52	In both groups all fractures were united clinically and on x ray with no loss of position	High loss to follow-up Poor method of randomisation Short follow-up
			Cost analysis	Cost of treatment with POP—£116.98, with splint—£65.75
Khan et al, Ireland, 2007,	131 Children aged 2–12 years with buckle fractures randomised to hard (BE full POP) or soft (Cellacast) casts between July and October 2004 (at fracture clinic). Three excluded Randomisation dependent on month of attendance Cast removal at 3/52. telephone follow-up at 4–5/52	2b Prospective randomised trial	Parental satisfaction scale 1–10	117 Questionnaires completed—69 soft cast, 48 rigid cast	Parent satisfaction score not validated
			Complications	100% Recovery of function both groups at follow-up
			Future choice of treatment	Complication rate 10.4% rigid cast, 1.4% soft cast (p = 0.035)
Plint et al, 2006, Canada	113 Children (6–15 years) with distal radius +/or ulna buckle fracture from 08/02 to 09/03 Block randomised to BE POP or removable plaster splint. Cast removal at 3/52 Excluded 2nd fracture of same limb, bilateral fractures, metabolic bone disease, language barrier, home outwith catchment area	2b PRCT	Primary—ASKp at 14 days	87 Included in final analysis—42 splint, 45 POP (losses: 15 splint, 11 POP)	High loss to follow-up/withdrawal AND No intention to treat analysis Researchers could not be blinded (certain questions on the ASKp made this impossible) Tertiary PED
			Secondary (multiple)- ASKp at 7, 20 and 28 days, patient and parent satisfaction at 28 days, refracture at 6/12	ASKp at day 14—splint 93.77 (87.26–99.15) POP 89.29 (82.33–95.64) (95% CI) p = 0.041 100% full recovery at 28/7 No refracture at 6/12 follow-up (34/42 splint, 41/45 POP)
Solan et al, UK, 2001	41 Patients with buckle fracture distal radius age 12 years were consecutively enrolled at 1st fracture clinic and treated with Dynacast Prelude backslab. Written and verbal instructions (also sent to GP). Telephone follow-up was at 4/52	Prospective cohort level 4	Need for prolonged follow-up?	100% Satisfaction with treatment and outcome	Individual determination of length of time to remain in POP No info on demographics/exclusions given
			Satisfaction with one-stop service	10% Required further medical advice BUT for a rash, loose POP, POP that fell off, and one mistaken reattendance at fracture clinic
			Complications	No complaints of pain or lack of functional recovery
Symons et al, UK, 2001	154 Children with distal radius buckle fractures identified September 1997 to May 1998. 101 Referred to the study, 14 excluded 87 Remaining patients randomised by computer generated random number sheet to home (40) or hospital (control) (47) group. Removeable backslab applied with removal at 3/52, home versus hospital Follow-up at 6/52, questionnaire, examination and repeat x ray Excluded—pathological fracture, previous injury to that wrist, lack of parental consent or understanding	2b	Parent satisfaction (VAS) Preference for future treatment ROM at 6/52	95% of the home and 89% of the control group reviewed at 6/52. 33% of control group had problems with treatment c/w 13% of the home group. p = 0.06. (no re-attendances required)	No sample size calculations so study may not be powered to detect differences No blinding of x ray reviewer No blinding at 6/52 review
			x Ray evidence of healing and lack of change in fracture position	100% of patients in both groups back to all normal activities and no difference in ROM Follow-up x ray in 19/42 control and 14/38 home patients at 6/52 showed healed fractures with no increase in deformity Patients who did not attend at 6/52 showed no differences in recovery Preference for future therapy favoured home therapy in the home group c/w further hospital treatment in the control group, p<0.001
Van Bosse et al, USA, 2005	Retrospective review May 2001 to October 2004. 33 Children aged 1–13 years at fracture clinic with unilateral torus fracture who were treated in a removable volar forearm slab. Instruction for use of the splint was given to all patients Patients were reviewed at a mean of 4.3 weeks (3–8) for repeat x ray (reporter blinded) and questionnaire	2b	Difference in ROM at 4/52	Splint used for mean 2.8 weeks	Large number of original sample excluded (9) Large loss to follow-up (6)) One of outcome measures was change in angulation of fracture but only 21/33 had both sets of x rays available for review
			Patient/parent satisfaction	All patients had full ROM and had gone back to full activity at 4 weeks
			Change in angulation of fracture on re-x ray	21 Available initial and follow-up AP x ray, no significant difference in angulation (p = 0.79) 21 Available initial and follow-up lateral x rays, mean difference 1.7° (p<0.03) Follow-up x ray on all 33 patients had healed fractures
West et al, UK, 2005	39 Children with buckle fracture of the wrist. Randomised by sealed envelope picked by their parent to bandage or POP on day of diagnosis Bandage group seen weekly, POP group seen at 4/52 for removal 3 Patients (one dropped out from the bandage group, and two failed to return at 1/52) excluded to leave final 39	2b	Difference in ROM at 4/52	Median ROM at 4/52 bandage versus splint, 162° versus 126° (p<0.001)	Unvalidated scales Difference in follow-up strategy between the two groups No long-term follow-up Poor method of randomisation Small numbers, no sample size calculations
			Patient/parent satisfaction	100% of patients in the bandage group had removed it by week 2 Convenience bandage versus POP, 94% versus 14% Parental concern: bandage versus POP, 11.1% versus 0%

Comment(s)

This paper set out to study the need for repeat x ray and follow-up in the fracture clinic for buckle fractures or whether one could simply discharge the patient from the ED with advice/and appropriate splinting:

Removable braces support healing as much as casts and promote earlier functional recovery in children with distal buckle wrist fractures" (Howes, BestBET, updated 2008)

With no good quality papers looking at the benefit of repeat x ray and follow-up, I have included studies comparing different treatment modalities that use functional recovery as an outcome measure. These studies are variable in quality, number of patients, type of splint and length of follow-up. They also use different measures as a marker of recovery, be it clinical examination, x ray, patient satisfaction scales, or parent satisfaction. Despite this heterogeneous mix of studies and with no definite conclusion on the type of splint to use, although with enough evidence to conclude that a removable splint can be used in place of a plaster of Paris, there is one definitive point that is present in all these studies. That is that buckle fractures will heal regardless of what treatment you give. In none of the studies was there lack of recovery, ongoing pain, loss of position, need for orthopaedic intervention, or in the one study with longer follow-up, refracture at 6/12. Indeed, these studies do confirm the benign nature of the injury.

With this in mind, it would appear that as long as a patient is treated in any form of immobilisation that can be removed at home, then repeat x rays or follow-up are not required as the fracture will heal with no risk of loss of position. This would be beneficial both to the patient (no need to miss school for the child, and no loss of earnings from time off work for the parent) and the hospital with less expense for x rays and shorter waiting times in the fracture clinic.

Editor Comment

AP, anteroposterior; ASKp, Activities Scale for Kids performance; BE, below elbow; c/w, compared with; GP, general practitioner; PED, paediatric emergency department; POP, plaster of Paris; PRCT, prospective randomised, controlled trial; ROM, range of movement; VAS, visual analogue scale.

Clinical Bottom Line

A child diagnosed with a buckle fracture of the wrist can be safely discharged from the ED in a removable splint with no follow-up from the orthopaedic department. They should be given appropriate verbal and written advice regarding the benign nature of the injury, appropriate pain relief and removal of the splint as pain allows. They should be invited to return at any time if they have concerns.

References

1. Abraham A, Handoll HHG, Khan T, et al. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev 2008;(2):CD004576. doi: 10.1002/14651858. CD004576.pub2.
2. Farbman KS, et al. The role of serial radiographs in the management of paediatric torus fractures. Arch Pediatr Adolesc Med 1999;153:923–5.
3. Davidson JS, et al. Simple treatment for torus fractures of the distal radius. J Bone Joint Surg (Br) 2001;83-B:1173–5.
4. Khan SK, et al. A randomised trial of Acta Orthopaed Belg 2007;73:594–7.
5. Plint AC, et al. A randomised, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics 2006;117:691–7.
6. Solan MC, et al. Current management of torus fractures of the distal radius. Injury, Intl J Care Injured 2002;33:503–5.
7. Symons S, et al. Hospital versus home management of children with buckle fractures of the distal radius. A prospective randomised trial. J Bone Joint Surg (Br) 2001;83-B:556–60.
8. Van Bosse HJP, et al. Minimalistic approach to treating wrist torus fractures. J Pediatr Orthopaed 2005;25:495–500.
9. West S, et al. Buckle fractures of the distal radius are safely treated in a soft bandage. J Pediatr Orthopaed 2005;25:322–5.