Treatment of Pediatric Buckle Fractures
Pediatric buckle fractures should be treated with removable splinting rather than circumferential casting, as splinting provides superior physical functioning, greater patient and family satisfaction, and fewer complications without any risk of fracture displacement. 1, 2
Primary Treatment Approach
Immobilization Method
Use a removable splint (prefabricated wrist splint or knee immobilizer depending on location) as first-line treatment for buckle fractures, as this approach demonstrates better outcomes across multiple quality metrics 1, 2
If posterior splinting is chosen over removable splints, the American Academy of Orthopaedic Surgeons recommends posterior splint (back-slab) over collar and cuff immobilization for better pain control during the first two weeks 3
Avoid circumferential casting in the emergency department, as it poses more risk than benefit with an 11% complication rate and no demonstrated advantage in fracture stability 4
Evidence Supporting Splinting Over Casting
The evidence strongly favors splinting based on:
Physical functioning: Children treated with removable splints have significantly better Activities Scale for Kids (ASKp) scores at 14 days post-injury compared to those in casts 1
Activities of daily living: Splinted children experience less difficulty with bathing throughout the entire treatment period 1
Patient satisfaction: Splinting demonstrates higher levels of satisfaction, preference, and convenience on 10-point visual analog scales compared to casting 2
Pain: No significant differences in pain exist between splinting and casting groups 1, 2
Safety: Zero cases of fracture displacement have been documented in multiple studies of splinted buckle fractures 1, 4
Complications: Casting is associated with skin complications (3.1% in one study), while splinting avoids these issues 4, 5
Duration of Immobilization
Immobilize for approximately 3-4 weeks total, though the optimal duration lacks high-quality evidence 1, 4
Removable knee immobilizers for proximal tibial buckle fractures require shorter immobilization (mean 25.9 days) compared to long leg casts (27.9 days) 5
The American Academy of Orthopaedic Surgeons acknowledges insufficient evidence for specific recommendations on optimal timing for removal of immobilization 3
Follow-Up Strategy
Minimize Unnecessary Follow-Up
Orthopedic follow-up visits and repeat radiographs have minimal utility for buckle fractures, as no fracture displacement occurs during healing 4
In one study, 67% of patients had multiple orthopedic visits and 46% had multiple radiographs performed, yet zero cases showed fracture displacement 4
Consider primary care follow-up rather than orthopedic specialty follow-up as a reasonable management strategy 4
Clinic Visits
Removable splinting reduces total clinic visits (mean 2.2 visits) compared to casting (mean 2.6 visits) 5
The American Academy of Orthopaedic Surgeons does not provide specific guidance on optimal follow-up timing, highlighting a gap in evidence 3
Location-Specific Considerations
Distal Radius/Ulna Buckle Fractures
These are the most common buckle fractures and respond well to removable wrist splinting 1, 2
In children 9-11 months old with distal radius/ulna buckle fractures from a reported fall while cruising or walking, skeletal survey is not necessary 6
In children 12-23 months old with distal radius/ulna buckle fractures, skeletal survey is judged inappropriate 6
Proximal Tibial Buckle Fractures
Use a removable knee immobilizer rather than long leg cast for proximal tibial buckle fractures 5
This approach results in shorter immobilization duration, fewer clinic visits, and no fracture displacement 5
Common Pitfalls to Avoid
Overtreatment Barriers
Family preferences and compliance concerns are the most commonly cited barriers (59.1% and 54.5% respectively) to implementing minimalist splinting approaches, despite strong evidence supporting this strategy 7
Many providers (56.5%) still prefer casting despite 77% being aware of literature supporting minimalist strategies 7
Address family concerns proactively by explaining that buckle fractures are inherently stable with zero documented cases of displacement in splinted patients 1, 4
Unnecessary Interventions
Avoid routine orthopedic referrals when primary care follow-up is sufficient 4
Avoid repeat radiographs unless clinical concern for new injury arises 4
Avoid emergency department circumferential casting given the 11% complication rate without added benefit 4
Physical Therapy and Activity Restrictions
The American Academy of Orthopaedic Surgeons does not provide specific recommendations on the need for supervised physical or occupational therapy or optimal timing for unrestricted activity 3
Based on functional outcome data, children in splints demonstrate better physical functioning throughout treatment, suggesting earlier return to activities may be appropriate 1