Do buckle fractures of the paediatric wrist require follow-up?

Date First Published:
October 5, 2004
Last Updated:
November 24, 2009
Report by:
Gabby May, Specialist Trainee in Emergency Medicine, (Stepping Hill Hospital, Stockport, UK and East Lancashire Hospitals )
Search checked by:
Alan Grayson, Stepping Hill Hospital, Stockport, UK and East Lancashire Hospitals
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.
Search Details:
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"





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):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Interventions for treating wrist fractures in children. Abraham A, Handoll HHG, Khan T, 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<br><br>Heterogeneity of studies<br><br>
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
The role of serial radiographs in the management of paediatric torus fractures. Farbman KS, 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<br><br>Variation in number of and timing of x rays<br><br>No baseline characteristics given<br><br>Conclusion states need for one follow-up study but with no evidence for this
Simple treatment for torus fractures of the distal radius. Davidson JS, et al. UK, 2000 Prospective randomised trial. <br><br>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<br><br>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<br><br>Poor method of randomisation<br><br>Short follow-up
Cost analysis Cost of treatment with POP—£116.98, with splint—£65.75
A randomised trial of Khan SK, 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)
A randomised, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Plint AC, 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<br><br>Researchers could not be blinded (certain questions on the ASKp made this impossible)<br><br>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)<br><br>POP 89.29 (82.33–95.64) (95% CI)<br><br>p = 0.041<br><br>100% full recovery at 28/7<br><br>No refracture at 6/12 follow-up (34/42 splint, 41/45 POP)
Current management of torus fractures of the distal radius. Solan MC, 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<br><br>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
Hospital versus home management of children with buckle fractures of the distal radius. A prospective randomised trial. Symons S, et al. UK, 2001 154 Children with distal radius buckle fractures identified September 1997 to May 1998. 101 Referred to the study, 14 excluded<br><br>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<br><br>Follow-up at 6/52, questionnaire, examination and repeat x ray<br><br>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<br><br>No blinding of x ray reviewer<br><br>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<br><br>Follow-up x ray in 19/42 control and 14/38 home patients at 6/52 showed healed fractures with no increase in deformity<br><br>Patients who did not attend at 6/52 showed no differences in recovery<br><br>Preference for future therapy favoured home therapy in the home group c/w further hospital treatment in the control group, p<0.001
Minimalistic approach to treating wrist torus fractures. Van Bosse HJP, 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<br><br>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)<br><br>Large loss to follow-up (6))<br><br>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)<br><br>21 Available initial and follow-up lateral x rays, mean difference 1.7° (p<0.03)<br><br>Follow-up x ray on all 33 patients had healed fractures
Buckle fractures of the distal radius are safely treated in a soft bandage. West S, 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<br><br>Bandage group seen weekly, POP group seen at 4/52 for removal<br><br>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<br><br>Difference in follow-up strategy between the two groups<br><br>No long-term follow-up<br><br>Poor method of randomisation<br><br>Small numbers, no sample size calculations
Patient/parent satisfaction 100% of patients in the bandage group had removed it by week 2<br><br>Convenience bandage versus POP, 94% versus 14%<br><br>Parental concern: bandage versus POP, 11.1% versus 0%
Author Commentary:
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:<br><br>Removable braces support healing as much as casts and promote earlier functional recovery in children with distal buckle wrist fractures" (Howes, BestBET, updated 2008) <br><br>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.

<br><br>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.
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.
  2. Farbman KS, et al.. The role of serial radiographs in the management of paediatric torus fractures.
  3. Davidson JS, et al.. Simple treatment for torus fractures of the distal radius.
  4. Khan SK, et al.. A randomised trial of
  5. Plint AC, et al.. A randomised, controlled trial of removable splinting versus casting for wrist buckle fractures in children.
  6. Solan MC, et al.. Current management of torus fractures of the distal radius.
  7. Symons S, et al.. Hospital versus home management of children with buckle fractures of the distal radius. A prospective randomised trial.
  8. Van Bosse HJP, et al.. Minimalistic approach to treating wrist torus fractures.
  9. West S, et al. . Buckle fractures of the distal radius are safely treated in a soft bandage.