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Report by: Gabby May, Specialist Trainee in Emergency Medicine
Checked by: Alan Grayson, Specialist Trainee in Emergency Medicine
Institution: Stepping Hill Hospital, Stockport, UK and East Lancashire Hospitals
A short-cut review was carried out to determine if paediatric buckle fractures of the wrist need routine follow-up. A total of 1067 papers was found using the reported search, of which nine represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are shown in table 1. The clinical bottom line is that a child diagnosed with a buckle fracture of the wrist can be safely discharged from the emergency department (ED) in a removable splint with no follow-up from the orthopaedic department.
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
Comments
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.
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.
Footnotes
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Provenance and Peer review Commissioned; not externally peer reviewed.