Home Management Versus Primary Care Physician Follow-up of Patients With Distal Radius Buckle Fractures: A Randomized Controlled Trial

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.

Robert Jones bandage versus cast in the treatment of distal radius fracture in children: A randomized controlled trial

PURPOSE

The present study aimed to treat fractures of the distal end of the radius in children with Robert Jones (RJ) bandage. The objective was to compare this treatment modality with the cast regarding the frequency of the complication occurrence, child comfortability, and family satisfaction.

METHODS

The study was a randomized controlled non-inferiority clinical trial including children with recent (less than 5 days) fractures at the distal end of the radius OTA/AO 23-A2, which is usually treated conservatively. Those with open fractures, pathological fracture, severely displaced fracture that needs reduction or multiple injuries were excluded. The participants were divided randomly into 2 groups according to the treatment modalities. Group 1 was treated by plaster of Paris cast (control group), and Group 2 by modified RJ bandage (trial group). The difference between 2 groups was found by the Chi-squared test. The difference was considered statistically significant when the p value was less than 0.05.

RESULTS

There were 150 children (aged 2 - 12 years, any gender) included in the study, 75 in each group. The complications occured in 5 (3.3%) cases only, pressure sores in 3 cases treated by the cast and fracture displacement in 2 cases treated by RJ bandage. There was no statistically significant difference in the rate of complication occurrence between both modalities of treatment (p = 0.649). Children treated with RJ bandages were more comfortable than those treated with the cast (97.3% vs. 73.3%, p < 0.001) with a statistically significant difference between them. Contrary to that, the families were more satisfied with the cast than RJ bandage (88.0% vs. 81.3%), but without a statistically significant difference (p = 0.257).

CONCLUSION

RJ bandage is a non-inferior alternative to the cast for the treatment of fractures at the distal end of the radius that can be treated conservatively in children.

Patient and parent satisfaction with soft cast immobilization and a single visit for buckle fractures

Introduction

Compression fractures of the distal radius (known as buckle or torus fractures) should be managed with non-rigid immobilization and a single visit as per the NICE guidelines. A recent national survey demonstrated ongoing reluctance to incorporate this treatment strategy in Ireland, with more than 70% of institutions still managing these fractures with the traditional method (rigid cast immobilization and fracture clinic follow up). In this study we assessed whether this could be attributed to parent or carer preference.

Methods

All paediatric patients from January 2021 to August 2022 in a single centre with buckle fractures of the distal radius were included in this study. A 10-question survey was created to assess whether the care giver and patient was satisfied with the information supplied, method of stabilization, single point of contact, and self-removal of the soft cast. A maximum of 5 points could be given to each score with a maximum of 50 for the overall satisfaction of care.

Results

A total of 82 surveys were completed via the post or telephonically. The two lowest average scores were 3.77 (SD ± 1.20) and 3.95 (SD ± 1.24), which indicated that patients would have no issues organising a follow up appointment and difficulty with cast removal respectively. Three other questions scored slightly better with 4.12 (SD ± 1.02), 4.17 (SD ± 1.04) and 4.22 (SD ± 1.05) which demonstrated some dissatisfaction with the cast condition at time of removal, difficulty with returning to school directly after removal and a desire to have another follow up appointment respectively. The highest average score was for adequacy of information provided at the time of treatment, 4.58 (SD ± 0.67). Furthermore, high scores were also given to the questions regarding confidence in the stability provided by the soft cast and the modality of treatment provided.

Conclusion

This study highlighted that one of the limiting factors to implementing the non-rigid immobilization and single visit protocol for buckle fractures as recommended by NICE is likely due to parental wariness and frequent dissatisfaction. This was mostly attributed to soft cast immobilization as patients experienced similar complications as found with rigid immobilization. The authors would rather suggest splint or soft bandage immobilization as this would likely improve patient/parent satisfaction with single visit treatment. With regards to further research, a follow up study can be performed focussing on the physician's preferences with regards to buckle fracture treatment protocol. And to determine what factors from the physician's perspective contributes to the reluctance in implementing the NICE guidelines protocol.

2021 Update on Pediatric Overuse

This update on pediatric medical overuse identifies and provides concise summaries of 10 impactful articles related to pediatric medical overuse from the years 2019 to 2020.

Financial balance of home nursing care providers in the Czech Republic

BACKGROUND

To enable people to live in old age in their own homes often requires specialised home care services. Despite the high importance of these services, the finance of home nursing care (HNC) is still under-investigated in many countries. The aim of this paper was to describe the finance of HNC in the Czech Republic.

METHODS

Balancing of revenues and costs was done using structured questionnaires from the closed accounting year 2018 as a monthly average. Nonparametric Kruskal-Wallis and Wilcoxon signed ranks tests were used to test hypotheses.

RESULTS

Data from 62 providers were analysed. The data included information from a total of 2297 patients and 995 employees. The average of total costs were € 17,591.7 (95% CI 14,175.3 - 21,008.1) and average of total revenues were € 17,276.5 (95% CI 13,923.5 - 20,629.5). The average cost per a patient was € 516.0 (95% CI 465.9-566.1) and the average revenues were € 500.1 (95% CI 457.0-543.3).

CONCLUSIONS

The overall financial balance of HNC providers seems to be balanced in the Czech Republic. Nevertheless, insurance, although it should, did not cover all the costs. Micro- providers tended to be cheaper regarding the hours worked by nurses.

Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED): a protocol for an open-label non-inferiority diagnostic randomised controlled trial

BACKGROUND

Children frequently present to the emergency department (ED) with forearm injuries and often have x-rays to determine if there is a fracture. Bedside ultrasound, also known as point-of-care ultrasound (POCUS), is an alternative diagnostic test used to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Prospective studies have demonstrated high agreement between POCUS and x-ray findings. However, whether the initial imaging modality affects the patient's medium-term physical function is unknown.

METHODS

This is a multicentre, open-label, non-inferiority randomised controlled trial conducted in Australian EDs. Recruitment will continue until 112 children with distal forearm injuries (including 48 buckle fractures) per trial arm have achieved the primary outcome measure. Patients aged 5-15 years presenting with an isolated, acute, clinically non-angulated, distal forearm injury with suspected fracture will have their initial diagnostic approach randomised to either POCUS, performed by a credentialled practitioner, or x-ray imaging. If a cortical breach fracture is identified on POCUS, the patient will receive x-rays and have usual care. If a buckle fracture is identified, the patient will have their forearm placed in a splint and be discharged home. Patients will be followed up at 1, 4 and 8 weeks. The primary outcome is upper limb physical function at 4 weeks, as determined by the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Secondary outcomes include healthcare costs, satisfaction, pain, complications, rates of imaging, ED length of stay and diagnostic accuracy.

DISCUSSION

If POCUS is non-inferior to x-ray in terms of patient's medium-term physical function, it may have an effect on overall health care resource use, including the number of x-ray performed and earlier ED discharge. Although prospective studies have confirmed the accuracy of POCUS, this will be the first RCT to assess non-inferiority of functional outcomes of POCUS to diagnose non-angulated paediatric distal forearm injuries, compared to x-ray. POCUS may be of particular importance in settings where access to x-ray imaging can be limited either during or after-hours, as it can aid the triaging and management of patients.

TRIAL REGISTRATION

Prospectively registered with the ANZCTR on 29 May 2020 ( ACTRN12620000637943 ).