Differentiating stable buckle fractures from other distal radius fractures: the 1-cm rule

Volar Distal Radius Buckle Fractures: Is Bracing and Home Management Safe?

BACKGROUND

A removable brace with home management is widely accepted treatment for distal radius buckle fractures, which most commonly involve the dorsal cortex.

PURPOSE

The purpose of this study is to determine if a removable brace and home management treatment is safe for volar distal radius buckle fractures.

MATERIALS AND METHODS

Isolated distal radius buckle fractures in children (3-16 years) diagnosed at an acute care visit (April 1, 2019 to May 31, 2022) were identified. Final diagnosis was confirmed using strict criteria including cortical buckling without cortical breach or physeal involvement. Cortical buckling was categorized as either dorsal or volar. Demographic data, mechanism of injury, treatment, and any complications were recorded and analyzed.

RESULTS

Three hundred thirty-three fractures were either dorsal (254, 76%) or volar (79, 24%) buckle fractures. Mean age (SD) for volar fractures (9.3 [2.2 years]; range, 4-14 years) was significantly higher than for dorsal fractures (8.5 (3.0 years); range, 3-15 years; P = 0.012). More girls had volar fractures (48 [60%], P = 0.006). Most fractures occurred after a standing-height fall. Two hundred forty-four (96%) dorsal and 76 (96%) volar fractures were initially treated with a removable brace. Two hundred fourteen (84%) dorsal and 66 (84%) volar fractures had orthopedic follow-up. Brace treatment continued for 167 (167/204, 82%) dorsal and 56 (56/63, 89%) volar fractures. Treatment changed from initial brace to cast for 37 (37/204, 18%) dorsal fractures and 7 (7/63, 11%) volar fractures, influenced by caregiver preference and/or sport participation requirements. Only 1 (1/79, 1%) patient with a volar fracture returned for an additional visit for persistent pain.

CONCLUSIONS

When diagnosis of volar buckle fracture is made using the same strict criteria used for dorsal buckle fractures, removable brace and home management treatment is safe. Shared decision making with caregivers may alter buckle fracture treatment.

Point-of-Care Ultrasound Fracture-Physis Distance Association with Salter-Harris II Fractures of the Distal Radius in Children: The "POCUS 1-cm Rule"

Salter-Harris II fractures of the distal radius can result in serious complications. The aim of this study was to measure the fracture-physis distance using point-of-care ultrasound (POCUS) to determine whether a certain distance is associated with Salter-Harris II fractures, compared with other fracture types, in a cohort of children with X-ray-identified distal radius fractures. Participants were from a parent diagnostic study conducted in an Australian tertiary pediatric emergency department, which prospectively evaluated the diagnosis of pediatric distal forearm fractures using POCUS compared against X-ray. Nurse practitioners, who underwent 2 h of training, administered a six-view POCUS protocol in clinically non-angulated pediatric forearm injuries prior to X-ray. This was a secondary analysis of data from the parent study. The 122 participants with X-ray-identified distal radius fractures from the parent study had their POCUS images interpreted by two emergency physician sonologists, who measured the fracture-physis distance. The median and maximum fracture-physis distances for Salter-Harris II fractures (n = 19) were 8.00 and 9.85 mm, whereas minimum and median distances for incomplete fractures (n = 22) were 10.20 and 15.98 mm, and those for complete fractures (n = 9) were 10.85 and 12.85 mm. Buckle fracture (n = 72) distances ranged from 4.35 to 26.55 mm, with a median of 13.65 mm. In children diagnosed with a distal radius fracture on X-ray, a fracture-physis distance cutoff of 1 cm differentiated Salter-Harris II fractures from other cortical breach fracture types, but not buckle fractures. Although this exploratory study suggests the "POCUS 1-cm rule" could be used as a secondary sign to augment the diagnosis of Salter-Harris II distal radius fractures using POCUS, further research is required to validate this measurement prospectively.

Improving Diagnostic Accuracy for Distinguishing Buckle Fractures From Other Distal Radius Fractures in Children

Introduction:

Accurately distinguishing between stable and unstable isolated distal radius fractures (DRF) in children allows for appropriate fracture-specific treatment. Although fractures with cortical disruption, displacement, or angulation are unstable, distinguishing stable buckle fractures (BF) from more subtle potentially unstable DRF is challenging. Our quality improvement project aimed to improve radiology reporting accuracy for these subtle fractures from 23% to 90% in a large tertiary pediatric hospital.

Methods:

Exams with a reported isolated distal radius fracture during baseline (January–March 2016) and intervention (April 2016–June 2019) were reviewed for accuracy. We introduced 3 types of interventions: radiologist education (self-directed learning modules and individual feedback), a new standardized report template, and a measurement tool (“The 1 cm Rule”). In addition, a statistical process control chart tracked accuracy data to study process changes over time.

Results:

During the baseline and intervention period, 22 and 480 radiographs, respectively, had either a stable BF or a potentially unstable isolated DRF. Each intervention type created a centerline shift. Overall, reporting accuracy increased from 23% to 90%. Most reports (95%, 639/676) used the template and standard terminology for reporting DRF.

Conclusions:

Radiology reporting diagnostic accuracy for distinguishing between stable BF and potentially unstable DRF in children increased to 90% through education, standardized reporting, and a measurement tool to enhance radiologist performance. Our institution plans to expand fracture-specific treatment practices with improved radiology reporting accuracy, including bracing and home management of stable BF diagnosed during an acute care visit.

Uniquely pediatric upper extremity injuries

The pediatric population is prone to unique upper extremity injuries that are not typically seen in adults. The normal dynamic maturation pattern of ossification centers and open physis can potentially confuse radiologists who are not familiar with the pediatric patients. In this review article, we discuss the normal anatomy and commonly encountered acute and chronic upper extremity injuries such as supracondylar distal humeral fracture and osteochondritis dissecans, in pediatric patients. Diagnosing the correct type of fracture (e.g., buckle vs Salter-Harris) is important for proper management of the injury. With an increasing number of adolescents participating in competitive sports, specific sports related injuries such as little league shoulder, gymnast wrist, and medial epicondyle apophysitis, are also discussed in this review. We examine late complications of injuries, such as physeal bar formation and fishtail deformity of the distal humerus.

Describing pediatric fractures in the era of ICD-10

Childhood fractures are extremely common. The recent trend is to direct certain fracture care from orthopedic specialists to primary care clinicians. However, to confirm an appropriate level of treatment, the initial diagnosis must be accurate, the description precise, and the communication between those caring for the child consistent. This review illustrates descriptors used at one institution that are based on terminology consensually created between radiologists and orthopedic surgeons for common pediatric fracture types and their displacement, and that satisfy the expanded and detailed International Statistical Classification of Diseases and Related Health Problems (ICD)-10 requirements for successful coding.