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Myths in Emergency Medicine: Bent Out of Shape Buckle Fractures

May, Natalie MBCHB, MPHE

doi: 10.1097/01.EEM.0000520590.11707.92
Myths in Emergency Medicine

Dr. Mayis a specialist in pediatric emergency medicine in the UK and a registrar in prehospital emergency medicine in Sydney, Australia. She writes regularly for Follow her on Twitter @_NMay, and read her past articles at



Buckle (or torus) fractures are probably the most common bony injury I see in the pediatric emergency department. These injuries are unique to children whose growing bones are softer than adults. A buckle fracture is seen on radiograph as an incomplete fracture with bulging of the cortex on one side of the injury. This fracture is usually caused by axial loading, such as a fall onto an outstretched arm. (Radiopaedia; Clinical diagnosis can be difficult because patients are often tender only at the exact buckle site, which is why I have quite a low threshold for getting x-rays in this group.

The term buckle fracture is often used interchangeably with greenstick fracture, but that has a different etiology and is incorrect. Greenstick fractures are diagnosed when there is cortical breach on the convex bony surface (there may be a corresponding bulge on the concave surface of the bone). (Radiopaedia; The greenstick fracture is typically more painful because of the greater degree of cortical disruption.

Treating these injuries varies considerably. Chaudhry, et al., described as recently as 2014 managing 166 patients whose immobilization varied from below-elbow casts to removable splints. (Online J Clin Audits 2014;6[2].) This certainly reflects the variation in practice I have seen.

Our initial response to fracture management as emergency physicians is immobilization in plaster, but the kicker for undisplaced or minimally displaced (position within 10-20 degrees) buckle fractures is that it probably isn't necessary nor is it what patients want. Studies published in the past 16 years have been suggesting that removable brace splints like the Futuro or Velcro splint are well tolerated by patients and show no loss of initial position. (Emerg Med J 2008;25[4]:222.)

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Treating the Pain

Williams, et al., addressed satisfaction, convenience, and preference in their randomized controlled trial of these patients, finding all were improved by using a splint over a cast with an insignificantly higher pain score in the splint group. (Pediatr Emerg Care 2013;29[5]:555.) This is an important practice point; not all patients tolerate splints well, and we must accept this. I tend to offer the splint as first-line treatment with explanation of the advantages of being able to remove it, but I also make clear that if pain in the splint becomes a problem, returning to the ED for conversion to a cast is always an option. Loss of position doesn't really happen in these patients, so the primary purpose of immobilization of any sort is analgesia.

Hill, et al. (J Pediatr Orthop B 2016;25[2]:183), and Jiang, et al. (Pediatr Emerg Care 2016;32[11]:773), summarized the evidence in their systematic reviews of eight randomized controlled trials on the topic, finding splinting superior in terms of cost, convenience, and function with no significant difference in pain or complication rates.

One study suggested that the same evidence can be extrapolated to minimally or undisplaced greenstick fractures, but this remains controversial and in need of a good quality randomized controlled trial. (Curr Opin Pediatr 2017;29[1]:46.)

Here's what might really blow your mind. The evidence suggests we might not even need to provide hospital follow-up for these patients. The risks of nonunion and malunion just don't exist. A review by May and Grayson suggested that formal follow-up did not alter outcomes (presumably other than cost). (Emerg Med J 2009;26[11]:819.) The quality of evidence drew some criticism (Emerg Med J 2010;27[5]:413), but subsequent work by Crowder, et al., evaluated a no follow-up approach with provision of written discharge information, and found a reduction in revisits to the ED. (Arch Dis Childhood 2014;99[Suppl 1]:A15.) Knight, et al., instigated a similar practice change and found no revisits and measurable cost savings to the health care institution. (Arch Dis Childhood 2015;100[Suppl 3]:A229.) Koelink, et al., treated patients with splint and referral to their primary care provider rather than hospital-based follow-up, and found that primary care follow-up was sufficient for 82.7 percent, with 98.8 percent of them reporting a return to normal activities within four weeks. (Pediatrics 2016;137[1]; doi: 10.1542/peds.2015-2262.)

Managing undisplaced or minimally displaced fractures in a removable splint improves quality of life for our patients, especially with splints permitting removal overnight and for showering or bathing. If you've ever spent a significant amount of time in plaster, you know the novelty soon wears off. Splinting also saves money by avoiding unnecessary clinic follow-up. The proviso to this is that we must provide clear advice about healing time.

So discharge the next buckle fracture patient to his primary care practitioner (or to the virtual fracture clinic [BMJ Open 2014;4[6]:e005282]) with a removable splint to be worn for six weeks and clear advice on expected healing time, and then pat yourself on the back for providing better care.

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