One Brace: One Visit: Treatment of Pediatric Distal Radius Buckle Fractures With a Removable Wrist Brace and No Follow-up Visit

Treatment of proximal tibial buckle fractures: removable knee immobilizer versus long leg cast

The purpose of this study was to compare outcomes and management of patients with buckle fractures of the proximal tibia treated with either a knee immobilizer or a long leg cast (LLC). A retrospective review was performed of pediatric patients with a buckle fracture of the proximal tibia over a 5-year period. Two cohorts were included, those treated with a LLC versus a removable knee immobilizer. Data collected included immobilization type, fracture laterality, length of immobilization, number of clinic visits, fracture displacement, and complications. Differences in complications and management between the cohorts were evaluated. In total, 224 patients met inclusion criteria (58% female, mean age 3.1 years ± 1.7 years). Of these patients, 187 patients (83.5%) were treated with a LLC. No patients in either group were found to have interval fracture displacement during treatment. Seven patients (3.1%) demonstrated skin complications, all in the LLC cohort. Mean length of immobilization was shorter for those treated in a knee immobilizer at 25.9 days versus 27.9 days for the LLC cohort ( P  = 0.024). Total number of clinic visits was also less at 2.2 (SD ± 0.4 days) for the knee immobilizer and 2.6 (SD ± 0.7 days) for the LLC ( P  = 0.001) cohorts. Pediatric patients with proximal tibial buckle fractures can be safely managed with a knee immobilizer. This treatment method is associated with a shorter duration of immobilization and fewer clinic visits without incidence of fracture displacement. In addition, knee immobilizers can lessen skin issues associated with cast immobilization and cast-related office visits. This is a Level III evidence, retrospective comparative study.

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.

Changes in Management at the Postoperative Visit After In-Office Wide Awake Local Anesthetic No Tourniquet Carpal Tunnel Release

PURPOSE

Patients are commonly seen for two postoperative visits following carpal tunnel release (CTR), the first visit being at 1-2 weeks and the second at approximately 6 weeks. Our study aimed to determine if these visits led to changes in postoperative medical management.

METHODS

A retrospective review was conducted of 748 procedures performed in an in-office procedure room under wide awake local anesthetic no tourniquet between August 2020 and December 2022. Charts were reviewed for changes in management related to the patient's CTR. Management changes involving a separate diagnosis or solely an additional follow-up visit were classified as unrelated to postoperative CTR care.

RESULTS

A total of 730 patients returned for follow-up. There were 100 patients (13.7 %) who had a CTR-related change in management at the first postoperative visit. Most management changes at this timepoint were due to superficial surgical site infection. There were 29 patients (4.0 %) who had a CTR-related change in management at their second postoperative visit, most commonly a referral to therapy for stiffness or hypersensitivity.

CONCLUSIONS

While postoperative visits for CTR may have intangible benefits, changes in CTR-related care occur only in 17.7% of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Prescribing braces after forearm fractures does not decrease refracture rate

Refracture is one of the most common complications of pediatric forearm fractures. One way to decrease this risk is to extend immobilization with a brace after the cast has been removed to allow for a range of motion exercises. The purpose of this study was to examine whether prescribing a brace after casting was discontinued decreased the risk of refracture. A retrospective, cohort study was performed at one level I trauma center. Girls under 10 years and boys under 12 years who sustained a forearm fracture from January 2013 to December 2018 were included. Patients with open fractures, fractures that required operative intervention, fractures involving the physis, fracture-dislocations, floating elbows, fractures in children with endocrine abnormalities, and fractures in patients lost to follow-up were excluded. The primary endpoint was a refracture within 6 months of the original injury that extended through the original fracture site. In total 2093 patients met the inclusion criteria. There were 19 refractures (0.9%). There was no statistically significant difference in the refracture rate between the braced (11/1091) and unbraced (8/1002) cohorts (Fisher exact value 0.65 at P  < 0.05). The most common fracture type that went on to refracture was greenstick fractures. This large, retrospective study aimed to examine whether prescribing a brace had any significant effect on the refracture rate. Bracing after the cast is removed may help ease family anxiety and extend the period of immobilization while allowing for hygiene and range of motion, but it does not significantly decrease the rate of refracture.

Trends in Management of Pediatric Distal Radius Buckle Fractures

BACKGROUND

Distal radius buckle fractures (DRBFx) represent nearly half of the pediatric wrist injuries. DRBFx are stable injury patterns that can typically be successfully managed with brief immobilization. The purpose of this study was to evaluate opinions and preferences of pediatric orthopaedic specialists regarding the management of DRBFx.

METHODS

The POSNA Trauma Quality, Safety, and Value Initiative (QSVI) Committee developed a 20-question survey regarding the treatment of DRBFx in children. The survey was sent twice to all active and candidate POSNA members in June 2020 (n=1487). Questions focused on various aspects of treatment, including type and length of immobilization, follow-up, and radiographs and on potential concerns regarding patient/family satisfaction and pain control, medicolegal concerns, misdiagnosis, and mismanagement.

RESULTS

A total of 317 participants completed the survey (response rate=21.3%). In all, 69% of all respondents prefer to use a removable wrist splint, with 76% of those in practice <20 years preferring removable wrist splints compared with 51% of those in practice >20 years (χ 2 =21.7; P <0.01). Overall, 85% of participants utilize shared decision-making in discussing management options with patients and their families. The majority of participants felt that the risk of complications associated with DRBFx was very low, but concern for misdiagnosis and mismanagement have required some respondents to perform closed or open reductions.

CONCLUSIONS

In 2020, the majority of respondents treat DRBFx with removable splints (69%) for 3 or fewer weeks (55%), minimal follow-up (85%), and no reimaging (64%). This marks a dramatic shift from the 2012 POSNA survey when only 29% of respondents used removable splinting for DRBFx.

LEVEL OF EVIDENCE

Level II.

Pediatric Orthopedic Trauma Care During the COVID-19 Pandemic: A Survey of the Pediatric Orthopedic Society of North America

Background: The COVID-19 pandemic has dramatically altered the practice of pediatric orthopedic trauma surgery in both outpatient and inpatient settings. While significant declines in patient volume have been noted, the impact on surgeon decision-making is unclear. Purpose: We sought to investigate changes in pediatric orthopedic trauma care delivery as a result of COVID-19 and determine their implications for future orthopedic practice. Methods: An electronic survey was distributed to all members (N = 1515) of the Pediatric Orthopedic Society of North America (POSNA) in March to April 2021; only members who provided care for pediatric orthopedic trauma patients were asked to complete it. The survey included questions on hospital trauma call, inpatient care, outpatient clinic practice, and 3 unique fracture case scenarios. Results: A total of 147 pediatric orthopedic surgeons completed the survey, for a 9.7% response rate, with 134 (91%) taking trauma call at a hospital as part of their practice. Respondents reported significant differences across institutions regarding COVID-19 testing, hospital rounding, and employee COVID-19 screening. Changes in outpatient fracture management were observed, including a decreased number of follow-up visits for nondisplaced clavicle fractures, distal radius buckle fractures, and toddler's fractures. Of respondents who changed their fracture follow-up schedules due to COVID-19, over 75% indicated that they would continue these outpatient treatment schedules after the pandemic. Conclusions: This survey found changes in pediatric orthopedic trauma care as a result of the COVID-19 pandemic. The use of telemedicine and abbreviated follow-up practices for common fracture types are likely to persist following the resolution of the COVID-19 pandemic.

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.

Impact of Cost Information on Parental Decision Making: A Randomized Clinical Trial Evaluating Cast Versus Splint Selection for Pediatric Distal Radius Buckle Fractures

BACKGROUND

Price transparency purports to help patients make high-value health care decisions, however, there is little data to support this. The pediatric distal radius buckle fracture (DRBF) has 2 equally efficacious but not equally priced treatment options (cast and splint), serving as an excellent potential model for studying price transparency. This study uses the DRBF model to assess the impact of up-front cost information on a family's treatment decisions when presented with clinically equivalent treatment options for a low-risk injury.

METHODS

Participants age 4 to 14 presenting with an acute DRBF to a hospital-based pediatric orthopaedic clinic were recruited for this randomized controlled trial. Participants were randomized into cost-informed or cost-blind cohorts. All families received standardized information about the injury and treatment options. Cost-informed families received additional cost information. Both groups were allowed to freely choose a treatment. Families were surveyed regarding their decision factors. Cost-blinded families were subsequently presented with the cost information and could change their decision. Independent samples t tests and χ2 tests were utilized to evaluate differences.

RESULTS

A total of 127 patients were enrolled (53% cost-informed, 47% cost-blind). The 2 groups did not significantly differ in demographics. Immobilization selection did not differ between groups, with 48% of the cost-informed families selecting the more expensive option (casting), compared with 47% of the cost-blind families. Cost was the least influential factor in the decision-making process according to participant survey, influencing only 9% of families. Only one family changed their decision after receiving cost information, from a splint to a cast.

CONCLUSION

Families appear to be cost-insensitive when making medical treatment decisions for low-risk injuries for their child. Price transparency alone may not help families arrive at a decision to pursue high-value treatment in low-risk orthopaedic injuries.

LEVEL OF EVIDENCE

Level I.

Management of Gartland Type 1 Supracondylar Fractures: A Systematic Review

PURPOSE

Gartland Type 1 supracondylar humerus fractures are stable, non-displaced injuries treated with non-operative management. This systematic review was performed to gather evidence on the optimal form of immobilization to treat these fractures.

METHODS

The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic search was performed in November 2020. Articles were eligible if they included children less than 18 years old, with non-displaced supracondylar fractures, treated non-operatively. Randomized trials, quasi-experimental trials, and prospective cohort studies were included. Outcomes of interest included fracture displacement, pain control, time to return to normal activities, return of range of motion (ROM), child/parent satisfaction, adverse events, and cost. Risk of bias was assessed using the Newcastle-Ottawa scale, Rob-2, and the ROBINS tools.

RESULTS

After duplicate records were removed, 525 records were evaluated with 9 studies meeting the inclusion criteria and 5 reporting clinical outcomes. The studies were heterogenous, in intervention and outcomes, and all at moderate risk of bias. Within the available evidence there were no cases of fracture displacement. Two small studies suggested that cuff and collar treatment provided inadequate pain control and delay in return to normal activities, compared to posterior splints. Two randomized control trials (RCTs) suggested that soft fiberglass casts reduced appointment time and increased parent satisfaction, compared to traditional casts. No studies directly compared posterior splints to circumferential casts.

CONCLUSION

There is insufficient high-quality evidence to determine the optimal conservative treatment for patients with Gartland type 1 supracondylar fractures. Level of Evidence Level II systematic review of Level II studies.

SYSTEMATIC REVIEW REGISTRATION

[PROSPERO], identifier [CRD42020144616].

Pediatric radius torus fractures in x-rays-how computer vision could render lateral projections obsolete

It is an indisputable dogma in extremity radiography to acquire x-ray studies in at least two complementary projections, which is also true for distal radius fractures in children. However, there is cautious hope that computer vision could enable breaking with this tradition in minor injuries, clinically lacking malalignment. We trained three different state-of-the-art convolutional neural networks (CNNs) on a dataset of 2,474 images: 1,237 images were posteroanterior (PA) pediatric wrist radiographs containing isolated distal radius torus fractures, and 1,237 images were normal controls without fractures. The task was to classify images into fractured and non-fractured. In total, 200 previously unseen images (100 per class) served as test set. CNN predictions reached area under the curves (AUCs) up to 98% [95% confidence interval (CI) 96.6%-99.5%], consistently exceeding human expert ratings (mean AUC 93.5%, 95% CI 89.9%-97.2%). Following training on larger data sets CNNs might be able to effectively rule out the presence of a distal radius fracture, enabling to consider foregoing the yet inevitable lateral projection in children. Built into the radiography workflow, such an algorithm could contribute to radiation hygiene and patient comfort.

Management of "torus" or "buckle" fractures of the distal radius: a systematic review

BACKGROUND

Torus fractures, also known as buckle fractures, of the distal radius are a very common reason for presentation to emergency departments. Traditional approaches to their management involved immobilisation in a circumferential cast but the evidence now supports the use of removable splints with or without radiological and clinical follow-up. Unfortunately current practice conflicts with the evidence base and there is no guideline which highlights all the evidence as one clear, concise management protocol.

METHODS

An online review of Pubmed, EMBASE, Biomed, and the Cochrane library using keyword searches combining "radius", "torus", "buckle" and "fracture" was performed. All prospective, retrospective or randomised trials involving the management of distal radius torus fractures in patients aged 0-18 years were included. Our outcomes focused on 5 aspects of patient care: immobilisation method and duration, clinical follow-up, radiological follow-up and the use of diagnostic ultrasound.

RESULTS

The initial search identified 143 papers which following application of the inclusion and exclusion criteria 21 articles were deemed eligible. A Cochrane review and 8 systematic reviews were also identified and manually searched for missed articles and this yielded a further 3 articles.

CONCLUSIONS

Current research indicates that torus fractures should be managed with a removable splint supplied in A&E and worn for 3 weeks. There is no need for fracture clinic follow-up or repeat radiological imaging once patients are given adequate information at the time of diagnosis. This would represent both an economical and resource saving for patients, parents and the health service.

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

STUDY OBJECTIVE

In patients with a distal radius buckle fracture, we determine whether home removal of a splint and physician follow-up as needed (home management) is noninferior to primary care physician follow-up in 1 to 2 weeks with respect to functional recovery. We also compare groups with respect to health care and patient-level costs.

METHODS

This was a noninferiority randomized controlled trial conducted at a tertiary care children's hospital. Eligible patients were randomized to home management versus primary care physician follow-up and received telephone contact at 3 and 6 weeks after the index ED visit. Functional recovery was measured with the Activities Scale for Kids-performance, and participants reported wrist-injury-related health care interventions and expenses. The primary outcome was a comparison of the performance score between groups at 3 weeks.

RESULTS

We enrolled 149 patients with mean age 9.5 years (SD 2.7 years), and 81 (54.4%) were male patients. Of the 133 patients (89.3%) with completed 3-week follow-up, the mean Activities Scale for Kids-performance score was 95.4% in the home management group (n=66) and 95.9% in the primary care physician follow-up group (n=67) (mean difference -0.4%; lower bound of the 95% confidence interval -2.4%). There was a mean costs savings of -$100.10 (95% confidence interval -$130.0 to -$70.20) in health care and -$28.2 (95% confidence interval -$49.6 to -$7.0) in patient costs in the home management versus primary care physician follow-up group.

CONCLUSION

In patients with distal radius buckle fractures, home management is at least as good as primary care physician follow-up with respect to functional recovery. Implementation of the home management strategy also demonstrated significant cost savings.

The single visit treatment of pediatric distal radius buckle fractures-A center's experience with the treatment algorithm

INTRODUCTION

This descriptive study aims to review and evaluate the implementation of a single visit treatment protocol for pediatric distal radius buckle fractures at our center - its success, learning points and limitations. It hopes to raise awareness of the efficacy of the protocol and its benefits to promote its utilization.

METHODS

Following a pilot study, the protocol was implemented from 1 March 2017. A retrospective review of clinical records over 2 years since implementation for patients with a new-visit diagnosis of "distal radius buckle fracture" was conducted. Data collected included age at time of injury, gender, side of injury, whether the patient was enrolled into the protocol, number of clinic visits, and number of radiographic examination(s) performed. Each record was reviewed up to 3 months post-injury to check for any complications or return visits. Costs of specific treatment interventions were also obtained from the hospital's finance department.

RESULTS

286 patients with buckle fractures of the distal radius eligible for enrolment into the single visit treatment protocol were identified. Of these, 202 patients (70.6%) were enrolled and managed with the protocol, while 84 patients (29.4%) were treated with conventional management. Of the 202 protocol-managed patients, all fractures healed without complications. Only 4 patients returned for additional clinic visits. Another 4 patients had additional X-rays taken on top of their initial injury film. A breakdown of expenses for treatment also showed cost savings of USD 110.67 and USD 320.80 for residents and non-residents respectively for single visit treatment.

CONCLUSION

Single visit treatment of pediatric distal radius buckle fractures is recommended and supported by evidence, with advantages of convenience, cost reduction, and being less labor intensive.

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.