Distal radius fractures are among the most common skeletal injuries in children. Representing up to one fifth of all pediatric fractures, the annual incidence has been estimated to be 1 in 100.1–4 It has been speculated that the frequency of pediatric distal radius fractures may be rising due to a host of epidemiological factors, including diminished bone density, increased body mass indices, higher risk activities, and younger age at the time of initial sports participation.5–8
Treatment of distal radius fractures in children remains challenging, due to their relative frequency, as well as inherent issues of skeletal growth and fracture remodeling, diversity of nonoperative and surgical techniques, and variable patient, family, and provider expectations. These challenges are further compounded by increasing pressure to provide high quality yet cost-effective care. Given these considerations, orthopaedic surgeons should be aware of the highest quality published information guiding distal radius fracture care. The purpose of this review is to discuss the evidence-based treatment of pediatric distal radius fractures and highlight the challenges of both obtaining and applying high levels of evidence to clinical practice.
Torus, or “buckle,” fractures refer to “incomplete” fractures of the distal radial metaphysis resulting from compressive loads. These injuries are inherently stable, with little risk of late displacement or long-term impairment. Despite the simple definition, there is great variability in how these injuries are managed. A careful review of the literature, however, reveals several level 1 prospective, randomized trials that may guide torus fracture treatment.
Davidson et al9 randomized 201 patients to either plaster casts or removable wrist splints for 3 weeks. All patients went on to successful healing without complications or need for follow-up clinical visits or radiographs. Plint et al10 similarly randomized 87 children to either short-arm casts or removable splints for 3 weeks. Not only were there no differences in healing or pain, but also early wrist function was considerably better in the splinted patients. West et al11 even questioned the need for splinting, randomizing 39 patients to either plaster casts or soft bandages. Again, fracture healing was universal, and patients treated with soft bandages had better early wrist motion.
Symons et al12 performed a randomized trial of 87 patients treated with plaster splints to either hospital follow-up or home removal. No difference was seen in clinical results, and patient/families preferred home splint removal. These findings were corroborated by Khan et al,13 who randomized 117 patients to either soft cast removal at home versus rigid cast removal in fracture clinic. No differences were seen in outcomes, and families again preferred home soft cast removal.
In summary, torus fractures are inherently stable injuries that do not require rigid cast immobilization or extended clinical follow-up. Equal anatomic and functional results are seen with simple splint immobilization and home removal.
MINIMALLY DISPLACED FRACTURES
Given the remodeling potential of younger patients with distal radius fractures, it is widely taught that up to 20 to 30 degrees of sagittal plane angulation will remodel with continued skeletal growth. Applying these principles, Boutis et al14 randomized 96 patients between the ages of 5 and 12 years with distal radius fractures and <15 degrees of angulation to either cast or splint immobilization. At 6 weeks after injury, no differences were seen in fracture displacement, and functional outcomes according to the Activity Scale for Kids did not significantly differ. Indeed, patients and families were more satisfied and preferred splinting over cast immobilization. This level 1 study supports the concept that minimally displaced fractures may be successfully treated with splinting in younger patients.
DISPLACED FRACTURES REQUIRING REDUCTION
Patients who present with displaced distal radius fractures and unacceptable alignment benefit from initial attempts at closed reduction. However, there continues to be variability in the type of immobilization used after fracture manipulation. Bohm et al15 randomized 102 children with displaced distal radius fractures to either above-elbow or below-elbow casts after closed reduction. There was no difference in loss of reduction rates or the need for remanipulation between groups. Webb et al16 similarly randomized 113 patients to above-elbow or below-elbow casts after closed reduction of displaced distal radius fractures. Again, no difference was seen in loss of reduction between groups, and the authors noted that the quality of the cast mold—as measured by the cast index—was more important than cast length in maintenance of reduction.
Although short-arm and long-arm casts may be equally effective, there is nonetheless a risk of redisplacement requiring intervention after initial closed reduction in approximately 20% to 30% of patients.17–20 Given the risk of late displacement, some have questioned whether all displaced distal radius fractures should be stabilized acutely with percutaneous pin fixation.21 McLauchlan et al18 randomized 68 children to either closed reduction or cast immobilization versus immediate pin fixation. Loss of reduction was seen in 21% and 0% of patients treated with casting versus pinning, respectively. However, there was 6% rate of pin-related complications, and clinical function 3 months after injury did not significantly differ between groups. Miller et al19 similarly randomized 34 patients to either cast immobilization or percutaneous pinning after closed reduction. All patients were over 10 years of age and had either complete displacement or >30 degrees of initial angulation. Among the casting group, 39% required remanipulation for loss of reduction. Among the pinning group, there was a 38% pin-related complication rate. Overall clinical results and cost of treatment was similar between groups. On the basis of these level 1 studies, although immediate reduction and pin fixation of displaced distal radius fractures will reduce loss of reduction rates, the rate of pin-related complications is noteworthy and longer-term outcomes equivalent. Providers should take into account both the advantages and disadvantages of immediate pin fixation when considering treatment.
APPLICATION OF EVIDENCE IN PRACTICE
Evidence-based medicine should inform practice but should not dictate it. There is ample room for legitimate variability in treatment of distal radius fractures given the limited body of randomized trials we have to work with. The membership of Pediatric Orthopaedic Society of North America clearly demonstrated by a show of hands (Montreal 2011) that the treatments we apply for distal radius fractures differ. We do not all treat fractures the same way, and we do not all follow the trial recommendations as published above. This is as it should be, the number of trials is small and the trials available do not answer all of the important questions in clinical practice. In contrast, as evidence advances we need to know whether it might be incorporated into practice.
Some trials will be very influential in changing practice, most will have a very limited effect. Evidence-based medicine rests atop established techniques of pediatric fracture treatment, which have served patients and surgeons well for generations. Many, if not most, improvements pediatric fracture care were made, taught, reported, and adopted, before wide application of evidence-based medicine. An orthopaedic textbook still provides much more information about fracture care than does a single randomized trial.
The 2009 version of the Rockwood and Wilkins Paediatric fracture textbook differed from the 2006 in incorporating the results of randomized trials, and treatment recommendations were changed. In 2006, a short-arm cast was recommended for buckle fractures, and in 2009, the recommendation was for either a short-arm cast or a splint. In 2006, a long-arm cast was recommended for displaced fractures after reduction, and in 2009, a long-arm cast continued to be recommended, although the textbook stated that 2 randomized controlled trials15,16 have “challenged traditional teaching” in recommending a short-arm cast. Rockwood and Wilkins recommendations reflect both the conservatism in the profession and the breadth of standard of care. A newer orthopaedic textbook, Evidence-based Orthopaedics22 bases recommendations on the best available clinical evidence and therefore suggests splinting for buckle fractures and short-arm casts only after reduction of displaced fractures.
Surgeons practice as they were trained and adapt their practice at varying rates based on information in textbooks, updates, and published trials. Published trials take years to get into textbooks. If a new trial were to answer an important clinical question in a way that should change practice rapidly, then waiting for it to show up in a textbook is not the best way of moving evidence into practice.
The process between the publication of a trial and its application in practice is called knowledge translation. Straus offers the definition that knowledge translation is “the method for closing the gaps between knowledge and practice.” These gaps can be large. For example, large numbers of US patients who would benefit from statin drugs or osteoporosis medicine never receive them, and conversely, antibiotics for upper respiratory infections in children are routinely overused when audits of actual practice are compared with best evidence.23 Large numbers of randomized trials exist on each of these medical examples, and well-performed systematic reviews and meta-analyses regularly summarize such evidence for clinical use. This still does not provide information in time for practice. It takes clinicians an average of 2 minutes to find the clinical “bottom line” in a Cochrane review,23 and furthermore most such reviews have been found to contain insufficient information regarding the treatment and in particular the complications to be immediately applicable in clinical practice.23 Further barriers to the application of evidence in practice include availability of equipment, standard practice of care teams, expectations of patients, and local financial incentives or disincentives to practice in a particular way. In fact, over 250 distinct barriers to practice change have been described and catalogued.23
There is some tension between the realities of daily clinical practice and the ideal world of evidence-based medicine. Some randomized trials have been criticized for answering the questions best suited to the methodology, rather than the questions most important to clinicians. Systematic reviews have been criticized for emphasizing the validity of information, without considering its applicability. These criticisms are often valid, particularly in fields such as pediatric orthopaedics where the culture of evidence-based medicine is still young.
We do have level 1 evidence for some questions about this common fracture, as summarized above. However, trials remain small in size and few in number even for one of the most common fractures that we treat. Clinical outcomes of conscientious treatment of distal radius fractures are good with a variety of approaches to management. A common theme across all of the trials is that simpler treatments seem to be equally effective compared with more intensive ones.
The knowledge base regarding even this common and “straightforward” fracture is still quite limited—leaving ample room for practice variation now and ample questions for future trials. Unbiased evaluation of empirical patient outcomes through randomized trials has proven feasible for distal radius fractures and should continue to inform and guide our practice in the future.
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