Boring Question | Does this pediatric patient require a hard cast ?

It is a typical day in Fast Track, and you have a 8 year old who fell off their skateboard with a distal radius fracture that is commonly referred to as a “Buckle fracture” (AKA torus fracture). The child is very upset and concerned about having their arm splinted / casted given that they plan on spending a lot of time in a swimming pool this summer. You wonder, does this patient require an unremovable splint in the ED?

Fortunately, for your patient, the literature is on their side. In one study of 87 patients (age 6 to 15 years) with distal radius and/or ulna buckle fractures treatment with a short arm cast for 3 weeks (45 patients) was compared with a removable splint (42 patients). Scoring via the Activities Scale for Kids [1] at days 14 and 20 suggested better physical functioning and less difficulty with activities in the removable splint group [2]. A second study on buckle fractures allocated 18 pediatric patients to a removable bandage [ie, an ACE wrap] and 21 to plaster cast. Results strongly favored the removable bandage with excellent range of motion in the first week and no reported adverse effects [3]. A third study evaluated 66 adult patients with minimally displaced distal radial fractures that were randomly assigned to either a plaster cast or removable splint. Cast satisfaction, cast problems and the functional assessment score at 6 weeks all favored the removable splint [4].

Many of you may be wondering about patient compliance and potential complications. Well, in a meta-analysis [5] encompassing 455 participants, there were no refractures reported during the healing period regardless of degree of immobilization, with improved function, patient acceptance, and caregiver satisfaction with the use of removable splints.

In fact, the same can be said for Salter Harris Class I & II ankle fractures. In a study of 54 children treated with a removable ankle brace vs 50 casted children, 81% of those in a removable ankle brace were back at baseline activities in 4 weeks compared to just 60% of those casted [6]. A second study of 40 patients with Lauge-Hansen supination-eversion, stage II ankle fractures compared a removable air stirrup splint to casting; this study demostrated a significant improvement in early patient comfort, post-fracture swelling, range of ankle motion at union, and time to full rehabilitation with the removable splint [7]. In a third study that looked at splinting vs casting of 62 pediatric sprained ankles, absenteeism and the parents’ absenteeism were higher in the casted group [8].

After explaining to the parents that non-displaced buckle fractures heal quite well on their own, that refractures are rare, and that functionality is regained sooner with a removable splint, you proceed to place a removable Velcro wrist splint, recommend rest, ice, elevation, NSAIDs, and primary care follow up in 1-2 weeks. The patient proceeds to do well without complications, and is swimming without sequelae in a matter of weeks.

References

Activities Scale for Kids. Website. Available at: http://www.activitiesscaleforkids.com/
Plint, A. C., Perry, J. J., Correll, R., Gaboury, I., & Lawton, L. (2006). A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children.Pediatrics, 117(3), 691-697.
West, S., Andrews, J., Bebbington, A., Ennis, O., & Alderman, P. (2005). Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. Journal of Pediatric Orthopaedics, 25(3), 322-325.
O’connor, D., Mullett, H., Doyle, M., Mofidi, A., Kutty, S., & O’SULLIVAN, M. (2003). Minimally displaced Colles’ fractures: a prospective randomized trial of treatment with a wrist splint or a plaster cast. Journal of Hand Surgery (British and European Volume), 28(1), 50-53.
Kennedy, S. A., Slobogean, G. P., & Mulpuri, K. (2010). Does degree of immobilization influence refracture rate in the forearm buckle fracture?.Journal of Pediatric Orthopaedics B, 19(1), 77-81.
Boutis, K., Willan, A. R., Babyn, P., Narayanan, U. G., Alman, B., & Schuh, S. (2007). A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics, 119(6), e1256-e1263.
Stuart, P. R., Brumby, C., & Smith, S. R. (1989). Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fractures. Injury, 20(6), 323-326.
Launay, F., Barrau, K., Simeoni, M. C., Jouve, J. L., Bollini, G., & Auquier, P. (2008). [Ankle injury without fracture in children: cast immobilization versus symptomatic treatment. Impact on absenteeism and quality of life]. Archives de pediatrie: organe officiel de la Societe francaise de pediatrie, 15(12), 1749-1755.

Reviewing with the Staff | Damian Roland

In all aspects of medicine translating evidence into practice is a slow process. Paediatric Emergency Medicine is no exception. In this short review the evidence for using splints rather than casts is presented. A Cochrane review six years ago highlighted their potential benefit however only slowly are children’s emergency departments using this approach to improve the patient experience and reduce costs.

The challenge here, ignoring the inherent face validity, is the balance between improved patient experience, for which there is good evidence, and potential negative outcomes. The authors don’t describe the quality of the papers that are reviewed: what were the biases, and were they sponsored by splint manufacturers for instance.

This conundrum is a persistent research challenge – but our hospital for one (Leicester Royal Infirmary, UK) has been using splints for buckle fractures for some time. 🙂