Medically Clear: Buckle Fractures Don't Need a Splint, and, Yes, the Evidence Supports That : Emergency Medicine News

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Medically Clear

Medically Clear

Buckle Fractures Don't Need a Splint, and, Yes, the Evidence Supports That

Vinson, David MD; Ballard, Dustin MD

Emergency Medicine News 45(1):p 4, January 2023. | DOI: 10.1097/01.EEM.0000911884.15641.0a
    buckle fractures, x-ray, splint, evidence-based medicine

    It is a Monday morning in early September, and the emergency department Rule of Threes has made an encore appearance. The first three patients of the day are kids with bike accidents: a 17-year-old whose e-bike tire popped and dropped her to the ground, knee first; a 12-year-old whose e-bike skidded out and resulted in a radial head fracture; and an 11-year-old who went over the handlebars of his new (normal) bike. The x-rays for the third patient reveal the classic buckle sign of the distal radius.

    The tech peers over the doctor's shoulder. “Sugar tong?” he asks. “Maybe,” the doctor hedges. “Let's see how sore he is; there may be another option.” “Really?” the tech asks. “Do you read The Lancet?” the doctor responds. “Maybe a splint isn't necessary.”

    The Evidence

    Treating pediatric distal radius torus fractures has actually been studied extensively. One review identified 10 randomized trials (of about 700 kids) with similar outcomes, whatever the treatment—plaster cast, removable splint, or bandage. (Cochrane Database Syst Rev. 2018;12[12]:CD012470; And now, the large, high-quality pragmatic FORCE trial from the United Kingdom undergirds the Cochrane findings. (Lancet. 2022;400[10345]:39;

    The FORCE investigators randomized 965 kids aged 4-15 presenting to 23 EDs with an acute torus fracture of the distal radius. Patients with any concomitant ipsilateral ulna fracture were permitted in the study. One group of children was randomized to receive an offer of a gauze roller bandage (or equivalent), which was applied in the ED from the mid-forearm to the metacarpophalangeal joints (in 94%). The rest of this group (6%) opted to apply the gauze roll at home. Whether to wear the bandage and for how long were up to the family. They were advised not to wear it longer than three weeks. Patients could return to activity as tolerated. No follow-up was provided. This gauze group was essentially a no immobilization/no follow-up arm (pun intended).

    The second group was randomized to rigid immobilization, the type depending on local ED practice. Most received a removable, prefabricated wrist splint (95%). Some received a plaster splint molded in the ED (5%). Follow-up was also in step with the treating facility's usual practice. Duration of treatment varied by group. Median gauze use was seven days (IQR: 4-16), and median splint use was 18 days (IQR: 14-21).

    The two groups were similar on all baseline metrics and complications were rare, minor, and equal between groups. No child required reduction or surgery. The primary outcome was pain score at three days measured with the Wong-Baker FACES Pain Rating Scale (kudos to Donna Wong and Connie Baker for designing and validating this highly useful pediatric pain scale). Pain scores were equivalent at three days and throughout the six-week study in both groups, even when stratified by age: 4-7 years and 8-15 years.

    Multiple secondary outcomes, including functional scores, quality of life, and school absences, were also similar between groups. Parental satisfaction was similar between groups, except on day one when parents whose children received immobilization were more satisfied than their gauze group counterparts.

    A treatment crossover phenomenon was seen, however—11 percent of the bandage-offer group switched to rigid immobilization within the first 21 days post-injury—perhaps because of parental or provider perception that this treatment was the standard of care.

    The study was accompanied by a supportive editorial, in which the authors described the buckle fracture as the “common cold of pediatric fractures,” an analogy intended to highlight the benign, self-resolving nature of the fracture and that treatment is really symptom mitigation. The editorial concluded that the FORCE investigation demonstrated that “in most children with this type of fracture, any form of rigid immobilisation is unnecessary; therefore, clinicians who prescribe circumferential casts for these injuries cannot justify continuing this practice, especially given that this practice often also results in needless reimaging and repeat health-care visits.” (Lancet. 2022;400[10345]:4.)

    The Verdict

    It is not clear who was more unnerved by our patient's injury, which occurred on his first ride to school on his new e-bike—the boy himself or his dad. The child is quite reluctant to supinate and pronate the arm and holds it as still as a statute of plaster. The doctor can see where this is going, but nonetheless attempts to offer the easier, sleeker, and most time-efficient treatment.

    In this particular scenario, however, the physical and psychological discomfort is too great to transition into common cold-like therapy.

    “Yes, sugar tong for this guy,” the doctor said, not wanting to FORCE the issue of a novel, less aggressive approach, “although he may not need the splint for more than a couple days.”

    Dr. Vinsonis an emergency physician at Kaiser Permanente Sacramento Medical Center, a chair of the KP CREST (Clinical Research on Emergency Services and Treatment) Network, and an adjunct investigator at the Kaiser Permanente Division of Research ( Dr. Ballardis an emergency physician at San Rafael Kaiser, a past chair of the KP CREST Network, and the medical director for Marin County Emergency Medical Services. Read their past articles at

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    • medmalinsights11:37:17 PMI learned this from my 12-year-old&#160;son. He had a buckle fracture, and we splinted it. His pain was gone in two&#160;days. Five days later, he lifted his end of a sailing dinghy off the roof of our car&#160;with no splint and no pain.&#160;<br>