Splint or cast for buckle fractures of the wrist

Date First Published:
April 11, 2010
Last Updated:
July 6, 2010
Report by:
Nandini Sen, SpR in Emergency Medicine (Wythenshawe)
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/tor exp Radius/ or radius.mp. or exp Forearm/ or forearm.mp. or metaphyseal.mp.tor 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/t
Limit to (english language and humans and "all child (0 to 18 years)")t1394
Search Details:
Medline, Cinahl, Embase
Cochrane database
google scholar
unpublished trial from clinical trials registry
Outcome:
25 papers
11 papers directly relevant to question.
5 were reviews.
6 papers of which 1 is unpublished.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Treatment of Impacted Greenstick Fractures in Children using Bandage or Cast Therapy: A Prospective Randomised Trial. Kropman R.H.J., Bemelman M, Feb-10 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
Buckle Fractures of the Distal Radius Are Safely Treated in a Soft Bandage. West S, Andrews J, Bebbington A, Ennis O, Alderman P. 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
A Randomised, Controlled Trial of removable Splinting versus Casting for Wrist Buckle Fractures in Children. Plint AC, Perry J.P, Correll R, Gaboury I, Lawton L. 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
Paediatric Buckle fractures: Should we just splint and go? Plint, A.C, Perry J.P, Tsang J.LY. 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)
Pilot Randomised Controlled Trial at Hertfordshire Hospitlas NHS Trust. Distal Forearm Fractures- do they need a splint? Ziouani. Jacobs M. Unpublished pilot. 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
Minimalistic Approach to Treating Wrist Torus Fractures. van Bosse HJP, Patel RJ, Thacker M, Sala DA. 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.
Simple treatment for torus fractures of the distal wrist. Davidson J.S. UK, 2001 Cost-benefit analysis

N=201
 PRCT Complications No difference in clinical and radiological outcome for splints or casts.<br><br>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
Author Commentary:
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.
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.
  2. West S, Andrews J, Bebbington A, Ennis O, Alderman P. . Buckle Fractures of the Distal Radius Are Safely Treated in a Soft Bandage.
  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.
  4. Plint, A.C, Perry J.P, Tsang J.LY.. Paediatric Buckle fractures: Should we just splint and go?
  5. Ziouani. Jacobs M. Unpublished pilot.. Pilot Randomised Controlled Trial at Hertfordshire Hospitlas NHS Trust. Distal Forearm Fractures- do they need a splint?
  6. van Bosse HJP, Patel RJ, Thacker M, Sala DA. . Minimalistic Approach to Treating Wrist Torus Fractures.
  7. Davidson J.S. . Simple treatment for torus fractures of the distal wrist.