Management of Buckle Fracture of the Distal Radius in a 12-Year-Old
A 12-year-old with a distal radius buckle fracture should be treated with a removable splint for 3 weeks, with no routine orthopedic follow-up or repeat radiographs required. 1, 2
Initial Treatment
- Apply a removable wrist splint (such as a Futura-type splint or soft cast) in the emergency department or clinic at the time of diagnosis 1, 3, 2
- The splint should never obstruct full finger range of motion 4
- Instruct the patient to begin active finger motion exercises immediately to prevent finger stiffness, as finger motion does not adversely affect adequately stabilized buckle fractures 4
Duration of Immobilization
- Wear the removable splint for 3 weeks, after which parents can remove it at home 1, 3, 2, 5
- No cast changes or rigid casting is necessary, as buckle fractures are inherently stable compression injuries of the dorsal cortex 5
Follow-Up Strategy
- No routine orthopedic follow-up is required after providing adequate information at the time of diagnosis 1, 2
- No repeat radiographs are needed, as these stable fractures do not require radiological monitoring 1, 2
- Consider a single follow-up visit with the primary care provider within the first week to confirm the diagnosis and provide anticipatory guidance on return to activities 2, 6
- If PCP follow-up is arranged, 87% of families will adhere to this plan without seeking additional specialty consultation 6
Return to Activities
- Patients should return to usual activities within 4 weeks, with nearly 99% achieving full return to normal function by this timeframe 6
- Provide specific anticipatory guidance to parents about gradual return to activities, as only 47% of PCPs routinely offer this advice 6
- Do not restrict wrist motion indefinitely after the 3-week immobilization period 7, 4
Advantages of Removable Splint Over Rigid Cast
- Allows bathing, showering, and swimming (95% of children in soft casts do so safely) 3
- Avoids the need for plaster saw removal 3
- Reduces parental time off work for follow-up appointments 3
- Comparable comfort (95.7% vs 93.3%) and lower cast change rates (6.8% vs 11.5%) compared to rigid casts 3
- Parents overwhelmingly prefer removable splints when given a choice 3, 5
Critical Pitfalls to Avoid
- Do not use rigid circumferential casts, as current evidence supports removable splints for buckle fractures 1, 3
- Do not confuse buckle fractures with comminuted fractures—the American Academy of Orthopaedic Surgeons explicitly recommends against removable splints for comminuted patterns, but buckle fractures are stable compression injuries that are appropriate for removable splinting 8
- Do not routinely schedule orthopedic follow-up, as this represents unnecessary resource utilization without clinical benefit 1, 2
- Monitor for the rare complication of skin irritation or muscle atrophy (occurs in 14.7% of immobilization cases), though this risk is lower with removable splints 7, 4
Special Consideration for Child Abuse Screening
- While this 12-year-old patient is outside the high-risk age group, be aware that skeletal surveys are not indicated for distal radius buckle fractures in children 12-23 months old with a history consistent with accidental trauma 9
- Skeletal surveys would only be necessary if there were concerns for non-accidental trauma or inconsistent history 9