What is the appropriate treatment for a minimally displaced acute buckle fracture in a child?

Treatment of Minimal Acute Buckle Fractures in Children

A removable wrist splint for 3 weeks or less, with discharge after a single visit and no routine follow-up or repeat radiographs, is the appropriate treatment for pediatric distal radius buckle fractures.

Recommended Treatment Protocol

Buckle (torus) fractures are inherently stable injuries where the cortex buckles but remains intact. The evidence strongly supports a minimalist approach:

Immobilization Method

• Use a removable wrist splint or soft bandage rather than rigid plaster casting 1, 2, 3
• Rigid casts are unnecessary and increase cost without improving outcomes 4
• A "Futura-type" wrist splint or similar removable device provides adequate immobilization 4

Duration of Immobilization

• 3 weeks or less is sufficient 3, 5
• Some evidence supports even shorter periods given the stability of these fractures 6

Follow-up Strategy

• Single visit for diagnosis confirmation and patient/family education 4, 7
• No routine fracture clinic follow-up required 2, 3, 7
• No repeat radiographs needed 3, 4
• Home removal of the splint by parents after the prescribed period 5

Clinical Reasoning

The shift toward this minimalist approach is supported by:

1. Fracture stability: Buckle fractures are compression injuries with intact cortices that heal reliably without displacement 4, 8

2. Excellent outcomes: Studies demonstrate 100% good results with simple splinting, with no difference compared to rigid casting 4

3. Very low complication risk: The risk of complications is minimal, and all patients in audited cohorts achieved successful outcomes 2, 5

4. Cost-effectiveness and reduced burden: Eliminating unnecessary follow-up visits saves significant time, travel distance, and healthcare resources 2, 5, 7

Current Practice Trends

Recent data shows a dramatic shift in management:

• In 2012, only 29% of pediatric orthopedic surgeons used removable splinting
• By 2020, this increased to 69% 3
• The COVID-19 pandemic accelerated adoption of evidence-based practices, with adherence improving from 11% pre-pandemic to 41% during peak pandemic 1
• Fellowship-trained pediatric orthopedic surgeons demonstrate highest adherence to evidence-based protocols 1

Patient/Family Education

Provide clear verbal and written instructions including:

• Nature of the injury and its stability
• Splint care and home removal instructions
• Expected healing timeline
• Warning signs requiring re-evaluation (though complications are rare)
• Activity modifications during healing

Common Pitfalls to Avoid

1. Over-treatment with rigid casts: Unnecessary and increases morbidity without benefit
2. Routine follow-up appointments: Not evidence-based and wastes resources 7
3. Repeat radiographs: Do not change management in uncomplicated cases 3
4. Concern for misdiagnosis: While this drives some practitioners toward more conservative approaches, proper initial radiographic confirmation is sufficient 3

Distinguishing from Other Fracture Types

This minimalist approach applies specifically to buckle/torus fractures. It does NOT apply to:

• Displaced metaphyseal fractures (may require reduction ± K-wire fixation) 8
• Physeal injuries (require different considerations for growth plate protection) 8
• Greenstick fractures (have cortical disruption and different stability profile)

Accurate initial radiographic diagnosis is essential to identify true buckle fractures and avoid misapplication of this protocol to unstable injury patterns.