Is a cast or a Donjoy (orthopedic) brace best for a 6-year-old with a buckle fracture of the radius and ulna with mild angulation?

Management of Buckle Fractures in a 6-Year-Old Child

A removable splint or brace (such as a Donjoy brace) is the preferred treatment option over a cast for a 6-year-old with a buckle fracture of the radius and ulna with mild angulation, as it provides better physical functioning while maintaining adequate immobilization. 1

Treatment Rationale

Buckle (torus) fractures are incomplete compression fractures without cortical disruption that are common in children 2. The evidence strongly supports using less restrictive immobilization methods for these stable fractures:

• Children treated with removable splinting demonstrate significantly better physical functioning and less difficulty with daily activities compared to those treated with casts 1
• Removable splints allow for easier hygiene, bathing, and overall comfort while providing adequate immobilization 3
• Current research indicates buckle fractures should be managed with a removable splint worn for approximately 3 weeks 4

Treatment Algorithm

1. Initial Assessment

   • Confirm diagnosis with standard radiographs (anteroposterior and lateral views) 5
   • Verify mild angulation (less than 10 degrees) and stable fracture pattern 5

2. Immobilization Options

   • First choice: Removable splint/brace (Donjoy)

     • Provides adequate immobilization
     • Allows for better physical functioning 1
     • Enables bathing and hygiene maintenance 1, 6
     • Can be removed by parents after treatment period (typically 3 weeks) 4

   • Alternative: Short-arm cast

     • Consider only if compliance with removable splint is a concern
     • Results in more limited physical functioning 1
     • Requires professional removal after 3 weeks 6

3. Follow-up

   • For removable splint/brace: Limited follow-up needed
   • Provide clear instructions to parents about duration of use (3 weeks) 4
   • No need for routine radiological follow-up for uncomplicated buckle fractures 4

Key Advantages of Removable Splint/Brace

• Better Activities Scale for Kids performance (ASKp) scores at 14 days post-injury 1
• Less difficulty with bathing throughout the treatment period 1
• No significant difference in pain compared to casting 1
• High parental satisfaction (97.4% for soft/removable options vs. 95.2% for rigid casts) 6
• No increased risk of refracture compared to casting 1, 6

Important Considerations

• Ensure proper fit of the removable splint/brace to maintain adequate immobilization
• Provide clear instructions to parents about when and how to remove the splint for hygiene purposes
• Instruct on signs that would warrant reassessment (increasing pain, swelling, or change in alignment)
• The brace should be worn consistently except during bathing for the recommended duration

Common Pitfalls to Avoid

• Overtreatment with rigid casting when a removable option would provide better functional outcomes
• Unnecessary follow-up appointments and radiographs for stable buckle fractures
• Inadequate parent education about proper use of the removable splint/brace
• Failure to recognize that buckle fractures are inherently stable injuries with excellent healing potential

The evidence clearly demonstrates that removable splints or braces offer superior functional outcomes while maintaining adequate immobilization for pediatric buckle fractures, making them the preferred choice over traditional casting for this 6-year-old patient.