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Three Part Question

In [a child with a buckle fracture of the distal radius] does [immobilisation in a plaster cast or symptomatic bracing] offer better [pain relief and functional recovery]?

Clinical Scenario

A seven year old girl presents having fallen onto her out-stretched hand. X-ray shows a typical buckle fracture of the distal radius, minimally displaced. The department protocol stipulates immobilisation in a full below-elbow cast for 4 weeks with regular fracture clinic follow-up but you remember that in your last job the orthopaedic surgeons preferred removable splints and symptomatic treatment, with no follow-up. You wonder if your current department is behind the times, or if your previous department was recklessly negligent!

Search Strategy

Medline to November Week 2 2007and EMBASE 1980 to 2008 Week 01 via the Ovid interface
The Cochrane Library Issue 4 2007
child.mp OR children.mp or exp child/ OR pediatric$.mp OR exp pediatrics/ OR paediatric.mp] AND [exp casts, surgical/ OR plaster$.mp OR cast$.mp OR brace$.mp OR exp braces/ OR splint$.mp OR exp splints/] AND exp fractures, closed/ OR exp ulna fractures/ OR exp radius fractures/ OR buckle.mp OR torus.mp OR exp wrist injuries/ OR wrist fractur$.mp OR exp forearm injuries/ OR exp forearm/ OR forearm.mp] LIMIT to human and English Language.
Cochrane: (buckle fracture):ti,ab,kw

Search Outcome

1448 papers were identified. Review of the abstracts excluded the majority as being irrelevant to the question. 3 papers were identified as relevant and of sufficient quality, 1 of which was the update of another. The 2 remaining papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Davidson et al 2001 UK	179 children aged 2 – 15 with torus fractures of the distal radius, Futura splint (98) vs plaster cast (81)	PRCT	Descriptive	All fractures united clinically with no loss of position	Randomised by day of attendance. Results narrative
Plint et al, 2006, Canada	87 children aged 6 – 15 years with distal radius buckle fractures. Removable splint (42) vs cast (45)	PRCT	Activities Scale for Kids performance (ASKp) at 14 days	93.77 vs 89.29 (p=0.041)

Comment(s)

Authors describe the non-union of buckle fractures as occurring "almost never" - therefore the main outcomes investigated were cost, comfort, and parental satisfaction.

Clinical Bottom Line

Removable braces support healing as much as casts and promote earlier functional recovery in children with distal buckle wrist fractures

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Davidson JS, Brown DJ, Barnes SN, Bruce CE Simple treatment for torus fractures of the distal radius Journal of Bone & Joint Surgery 83(8):1173-5, 2001 Nov
2. Plint AC, Perry AA, Correll R et al. A Randomized Controlled Trial of Splinting versus Casting for Wrist Buckle Fractures in Children. Pediatr 2006;117:691-7.