Treatment of Pediatric Radius Buckle Fractures
Treat pediatric radius buckle fractures with a removable splint for 3 weeks, followed by primary care physician follow-up without routine orthopedic consultation or repeat radiographs. 1
Recommended Immobilization Approach
- Use a removable splint rather than a rigid cast for nondisplaced buckle fractures of the distal radius, as recommended by the American Academy of Orthopaedic Surgeons 1
- Removable splinting provides superior physical functioning compared to casting, with children experiencing less difficulty with daily activities, particularly bathing 2
- The duration of immobilization should be 3 weeks, with radiographic assessment at approximately 3 weeks and at the time of immobilization removal to confirm adequate healing 1, 3
Evidence Supporting Removable Splinting
The shift toward removable splinting represents a dramatic change in practice patterns. In 2020,69% of pediatric orthopedic surgeons preferred removable splints compared to only 29% in 2012, with younger practitioners (in practice <20 years) showing even higher adoption rates at 76% 4. This change is supported by randomized controlled trial data demonstrating better physical functioning at 14 days post-injury in splinted children, with no refractures in either group 2.
Soft casts can be safely removed by parents at home after 3 weeks, eliminating the need for a clinic visit for cast removal 5. Parents overwhelmingly prefer this approach, citing the ability to bathe, avoidance of the plaster saw, and reduced time off work 5.
Follow-Up Protocol
- Primary care physician follow-up is appropriate for the vast majority of buckle fractures, with 87.2% of children successfully managed without orthopedic consultation or emergency department revisits 6
- Obtain radiographs at 3 weeks to assess healing, though some practitioners now forgo repeat imaging entirely (64% perform no reimaging) given the extremely low complication rate 4
- No routine orthopedic referral is necessary for uncomplicated buckle fractures 6
Immediate Post-Diagnosis Care
- Initiate active finger motion exercises immediately following diagnosis to prevent stiffness, which is one of the most functionally disabling complications of distal radius fractures 1
- Finger motion does not adversely affect adequately stabilized fractures in terms of reduction or healing 1
- Early wrist motion is not routinely necessary following stable fracture management 1
When Surgical Management Is Indicated
Consider surgical fixation only if the fracture demonstrates any of the following radiographic parameters 1:
- Radial shortening >3 mm
- Dorsal tilt >10°
- Intra-articular displacement
These criteria apply to displaced fractures, not typical buckle fractures which are by definition stable compression injuries.
Common Pitfalls to Avoid
- Do not use rigid casting for simple buckle fractures—this provides no clinical benefit and significantly impairs daily activities like bathing 2, 5
- Do not routinely refer to orthopedics for uncomplicated buckle fractures, as primary care management is safe and effective 6
- Immobilization-related complications (skin irritation, muscle atrophy) occur in only 14.7% of cases and are generally minor 1
- Provide anticipatory guidance to families about return to activities, as only 47% of primary care physicians currently do this, despite 98.8% of children returning to usual activities within 4 weeks 6
- The risk of refracture with appropriate splinting is essentially zero 2, 5
Shared Decision-Making
85% of pediatric orthopedic surgeons utilize shared decision-making when discussing management options with families 4. Present the option of removable splinting as the evidence-based standard while acknowledging that traditional casting remains an alternative if families have specific concerns about compliance.