Pediatric Torus Fracture of the Distal Radius: Splint Recommendation
A removable splint is the recommended treatment for pediatric torus (buckle) fractures of the distal radius, worn for 3 weeks without the need for routine follow-up or repeat radiographs. 1, 2
Treatment Algorithm
Initial Management
- Apply a removable splint in the emergency department and discharge the patient immediately 1, 2
- The American Academy of Orthopaedic Surgeons (AAOS) specifically recommends removable splints as appropriate for minimally displaced distal radius fractures 1
- Duration of immobilization should be 3 weeks 1, 2
Active Motion Protocol
- Instruct patients to perform active finger motion exercises immediately following diagnosis 1
- Finger motion does not adversely affect adequately stabilized distal radius fractures and is critical to prevent stiffness, which is one of the most functionally disabling complications 3, 1
- Early wrist motion is not routinely necessary following stable fracture fixation 3, 1
Follow-Up Requirements
- No routine clinical or radiological follow-up is necessary when adequate information is provided at diagnosis 2
- If follow-up is performed, radiographic evaluation at approximately 3 weeks and at immobilization removal can confirm adequate healing 1
Evidence Supporting Removable Splints
The highest quality recent evidence strongly supports this approach:
- A 2022 randomized controlled equivalence trial (FORCE trial) involving 965 children demonstrated that pain was equivalent at 3 days between bandage and rigid immobilization groups (adjusted difference -0.10,95% CI -0.37 to 0.17) 4
- There were no differences in functional recovery, quality of life, or school absence at any point during 6-week follow-up 4, 5
- Complication rates were extremely low and equivalent: 1.0% in the bandage group versus 0.6% in the rigid immobilization group 5
- All fractures healed without significant change in alignment regardless of immobilization method 6
Clinical and Economic Benefits
- Removable splints significantly reduce treatment costs and have high probability of cost-effectiveness 5
- Children with removable splints demonstrate improved physical functioning, can shower and bathe more easily, and report lower pain scores 6
- The cast group had more unscheduled ED visits due to cast-related problems (discomfort, getting wet) 6
- This approach represents both an economical and resource saving for patients, parents, and the health service 2
Common Pitfalls to Avoid
- Do not routinely order follow-up radiographs - they are unnecessary when adequate information is provided at diagnosis 2
- Do not use rigid casting - evidence shows no benefit over removable splints for torus fractures 4, 5, 6
- Monitor for skin irritation or muscle atrophy, which occur in approximately 14.7% of immobilization cases 1
- Consider rigid immobilization only for very young children or those with special needs who may easily remove the device 6
When Alternative Treatment Is Needed
If radiographs show any of the following, surgical management may be indicated instead of conservative splinting 1:
- Significant displacement >3mm
- Dorsal tilt >10°
- Intra-articular involvement