Splint, Bandage or Cast for the Buckle Fracture
A buckle fracture heals with any treatment, so an unneeded cast and clinic visits cost the child comfort, bathing and school days, while a missed greenstick fracture can angulate in a splint.
Key terminology
- Buckle (torus) fracture
- This incomplete fracture crushes one cortex so it bulges, while the opposite cortex stays intact. It is stable and most common in the distal radius.
- Greenstick fracture
- This incomplete fracture breaks through one cortex while the opposite cortex bends. It is potentially unstable and can angulate further during treatment.
- Angulation
- This tilt between the fracture fragments is usually measured on the lateral radiograph. Angulation that increases over time marks an unstable fracture.
- Equivalence trial
- This trial tests whether two treatments differ by less than a prespecified margin. A result that stays inside the equivalence margin means the treatments perform the same for practical purposes.
- Wong-Baker FACES scale
- This pain scale asks a child to point to one of six faces, from no hurt to hurts worst. It scores pain from 0 to 10 and suits young children.
- Removable splint
- This prefabricated wrist brace holds the wrist still and comes off for bathing. It replaces a plaster or fiberglass cast for stable fractures.
Takeaways
- A buckle fracture is a stable crush of one cortex with the opposite cortex intact. The buckle (torus) fracture of the distal radius is the most common fracture in children and makes up nearly half of pediatric wrist injuries. Cochrane separates it from greenstick and other usually displaced fractures because the buckle pattern is stable. (Perry et al, Lancet 2022;400:39-47, PMID 35780790; Lindsay et al, J Pediatr Orthop 2022;42:367-371, PMID 35551146; Handoll et al, Cochrane Database Syst Rev 2018;12:CD012470, PMID 30566764).
- A greenstick fracture breaks through a cortex and can keep drifting after it is immobilized. In 305 pediatric distal radius fractures, buckle fracture angulation did not change importantly during treatment. Greenstick fractures displaced 5° on average and kept displacing after the first 2 weeks. Complete fractures displaced 9° on average and were highly unstable. (Randsborg & Sivertsen, Acta Orthop 2009;80:585-589, PMID 19916694).
- A soft bandage with discharge from the ED works as well as rigid immobilization for a buckle fracture. This equivalence trial randomized 965 children aged 4 to 15 at 23 UK hospitals. Pain at 3 days on the Wong-Baker FACES scale was 3.21 vs 3.14, an adjusted difference of -0.10 (95% CI -0.37 to 0.17) against a margin of 1.0. Function did not differ over 6 weeks, and complications were 1.0% vs 0.6%. (Perry et al, Lancet 2022;400:39-47, PMID 35780790; Perry et al, Health Technol Assess 2022;26(33):1-78, PMID 35904496).
- A removable splint gives better early function than a cast for a buckle fracture. In an RCT of 87 children aged 6 to 15, the removable splint group had better Activities Scales for Kids scores at day 14 and less difficulty bathing throughout. Pain did not differ between groups. There were no refractures. (Plint et al, Pediatrics 2006;117:691-697, PMID 16510648).
- Buckle fractures do not need routine repeat radiographs or fracture clinic follow-up. In 305 pediatric distal radius fractures, only 1 of 311 follow-up visits led to an active intervention. In a separate torus cohort, serial follow-up radiographs did not change management. (Randsborg & Sivertsen, Acta Orthop 2009;80:585-589, PMID 19916694; Farbman et al, Arch Pediatr Adolesc Med 1999;153:923-925, PMID 10482206).
- Minimal treatment is safe only when the fracture is correctly called a buckle. Cochrane limits its reassurance to correctly diagnosed buckle fractures. At one children's hospital, radiology reports told buckle fractures apart from potentially unstable ones in only 23% of a small baseline sample. Accuracy rose to 90% after education, a template and a 1 cm measurement rule. (Handoll et al, Cochrane Database Syst Rev 2018;12:CD012470, PMID 30566764; Ruess et al, Pediatr Qual Saf 2022;7:e547, PMID 35919219).
- Every trial of splint or bandage vs cast points the same way, although all were unblinded. A review of 8 RCTs found splinting superior for function, cost and convenience without worse pain or complications. Cochrane found full return to function with no serious adverse events whatever the treatment. Cochrane rated the evidence low or very low quality due to lack of blinding. (Hill et al, J Pediatr Orthop B 2016;25:183-190, PMID 26523533; Handoll et al, Cochrane Database Syst Rev 2018;12:CD012470, PMID 30566764).
- Practice is shifting toward splints, and many clinicians and families still prefer a cast. POSNA members preferring a removable splint rose from 29% in 2012 to 69% in 2020 (76% of those in practice under 20 years vs 51% over 20 years). Families in the UK bandage trial had a strong preexisting preference for rigid immobilization. (Lindsay et al, J Pediatr Orthop 2022;42:367-371, PMID 35551146; Perry et al, Health Technol Assess 2022;26(33):1-78, PMID 35904496).