Rebaked Morsel: Pediatric Buckle and Greenstick Forearm Fractures

Trauma season is at hand and like all other pediatric emergency departments in the country, we find our ED breaking (pun intended) at the seams with orthopedic injuries. We see all different flavors of upper extremity injuries. Yes, we’re talking about your clavicular, proximal humeral, supracondylar, lateral condylar, scaphoid and metacarpal fractures. Pediatric patients have unique bony anatomy and physiology compared to the skeletally mature. Today, we want to focus on a couple of our good friends, buckle and greenstick forearm fractures. Let’s take some time to refresh ourselves on the injury pattern and some updates to management and follow up. 

Pediatric Buckle and Greenstick Forearm Fractures: Basics

• The junction of the metaphysis and diaphysis in pediatric long bones is an area of biomechanical transition (Light, 1984)
  • Thin metaphyseal cortex meets the thick cortex of the diaphysis
  • Or in Emergency Medicine terms, “Thick bone meet thin bone.”
• This area of transition is ripe for fracture (Light, 1984)
  • Fracture of only part of the cortex leads to plastic deformity and buckling, giving us the torus (buckle) fracture 
  • Fracture and plastic deformity of one side of the cortex give us the greenstick fracture.

Buckle Fractures: Evolving literature

• Multiple prospective studies have been performed using single posterior slabs, splints, braces and soft bulky bandages (Davidson, 2001. West, 2005. Plint, 2006. Oakley, 2008)
  • These all seem equivalent to casts in several outcome measures
• Another study showed greater parent satisfaction in physician-directed splint removal without formal follow up in clinic (Symons, 2001)
• Finally, there is evidence that formal clinical follow up and repeat radiographs are not needed for buckle fractures (Davidson, 2001)

Buckle Fractures: “New Best Practice“

• A 2018 study incorporated all 3 of the above under one umbrella (Kuba, 2018)
  • Patients (1-19 yrs. old) with pure buckle fracture of the distal radius, ulna or both were:
    • treated with a removable wrist brace, 
    • parents given specific activity restrictions and directions on removal of splint. 
    • No formal follow up was scheduled
• Outcomes were:  effectiveness, parental satisfaction, and economic benefits 
  • The majority of children wore their braces as directed (94%)There was no re-fractureAll parents were happy with the treatment (100%) and felt comfortable removing the brace (100%).  
  • The minority of parents would have wanted clinic follow up (6%) and reimaging (14%).
    • 67% and 77% of parents and children would have had to miss work and school respectively if asked to follow up
• So, it is reasonable to consider removable splints or even soft bulky dressings for distal radius or ulnar buckle fractures and discharge without having to arrange follow up with orthopedics
  • The caveat is that we should probably conform to our regional and institutional standards and ensure that our orthopedics colleagues are on board 

Greenstick Fractures: Removable splints

• One prior RCT (Boutis, 2010) compared splints versus short arm casts in kids 5-12 yrs  old, who came to ED with minimally angulated (<15 degrees) greenstick or transverse fractures of the wrist
  • There was little difference between the two groups in daily activities, ROM, grip strength, and pain scores
  • Mean fracture angulations did not differ significantly between the groups at 4 weeks
  • Kids and parents preferred the splint
  • These kids should still follow up +/- repeat imaging 

Moral of the Morsel

• Buckle fractures of the distal radius and ulna can be splinted with removable splint or a soft bulky dressing and do not require clinical follow up or repeat imaging.
• Minimally angulated greenstick and transverse radial/ulnar fractures can be placed in a removable wrist splint with normal follow up and imaging.
• Casts stink …. literally … and they can be used to bludgeon siblings. Perhaps the removable wrist splint has several advantages for the entire family.
• As always, when in doubt, ask an orthopod.

References:

1. Boutis K, Willan A, Babyn P, Goeree R, Howard A. Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial. CMAJ. 2010 Oct 5;182(14):CMAJ 2010. DOI:10.1503/cmaj.100119. 
2. Light TR, Ogden DA, Ogden JA. The anatomy of metaphyseal torus fractures. Clin Orthop Relat Res. 1984 Sep;(108):103-111. 
3. Kuba MH, Izuka BH. One Brace: One Visit: Treatment of Pediatric Distal Radius Buckle Fractures With a Removable Wrist Brace and No Follow-up Visit. J Pediatr Orthop. 2018;Volume 00(00):DOI:10.1097/BPO.0000000000001169. 
4. Davidson JS, Brown DJ, Barnes SN, et al. Simple treatment for torus fractures of the distal radius. J Bone Joint Surg Br. 2001;83:1173-5. 
5. Oakley EA, Ooi KS, Barnett PLJ. A randomized controlled trial of 2 methods of immobilizing torus fractures of the distal forearm. Pediatr Emerg Care. 2008;24:65–70. 
6. Plint AC. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117:691–697. 
7. West S, Andrews J, Bebbington A, et al. Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. J Pediatr Orthop. 2005;25:322–325. 
8. Symons S, Rowsell M, Bhowal B, et al. Hospital versus home management of children with buckle fractures of the distal radius. A prospective, randomised trial. J Bone Joint Surg Br. 2001;83:556–560.