Treatment of Buckle Fracture in an 8-Year-Old Female
A removable splint for 3 weeks is the recommended treatment, with no need for follow-up radiographs or multiple clinic visits. 1
Immobilization Strategy
Use a removable wrist splint rather than a rigid cast for this stable compression injury. 1, 2 The evidence strongly supports this approach:
- Removable splints provide superior physical functioning compared to rigid casts, with children demonstrating significantly better Activities Scales for Kids performance scores at 14 days post-injury. 2
- Splinted children experience less difficulty with bathing and daily activities throughout the entire treatment period. 2
- Pain levels are equivalent between splinting and casting, so there is no therapeutic advantage to rigid immobilization. 2
- Parent and patient satisfaction is significantly higher with removable splints, with parents in both treatment groups preferring soft/removable options when given a choice (p < 0.01). 3, 4
Duration and Instructions
- Immobilize for exactly 3 weeks, then discontinue the splint. 1
- The splint must never obstruct full finger range of motion, and patients should begin active finger motion exercises immediately to prevent stiffness. 1
- Return to usual activities within 4 weeks of injury, with no need to restrict wrist motion indefinitely after the 3-week period. 1
Follow-Up Requirements
No orthopedic follow-up visits or repeat radiographs are necessary for uncomplicated buckle fractures. 1, 5 The evidence demonstrates:
- In a cohort of 309 pediatric buckle fractures, no subjects had fracture displacement identified on follow-up radiographs. 5
- Of children who received traditional follow-up, 67% had multiple visits and 46% had multiple radiographs performed—all without clinical benefit. 5
- No refractures occurred in children treated with removable splints in randomized trials. 2, 3, 4
Critical Pitfalls to Avoid
Do not use rigid circumferential casts for this injury. 1, 5 Emergency department casting poses more risk than benefit:
- 11% of children in rigid casts develop cast complications requiring cast changes. 5
- The most frequent complication is getting the cast wet, necessitating replacement. 3
- Rigid casts require clinic visits for removal with a plaster saw, causing unnecessary anxiety and healthcare utilization. 3, 4
Do not order routine follow-up radiographs or multiple clinic visits, as buckle fractures are inherently stable with low risk for displacement. 6, 5
Special Consideration for This Age Group
At 8 years old, this patient is well beyond the age range where non-accidental trauma screening would be routine. 7 However, if the history is inconsistent with the injury mechanism or there are other concerning features, consider skeletal survey. 7 The American Academy of Pediatrics guidelines indicate:
- Skeletal survey is inappropriate for children 12-23 months old with distal radius/ulna buckle fractures with a consistent fall history. 7
- For children 9-11 months with buckle fractures from falls while cruising or walking, skeletal survey is not necessary. 7
- This 8-year-old is far outside these concerning age ranges, so proceed with standard treatment unless red flags exist. 7
Cost-Effectiveness and Practical Advantages
Removable splint treatment is cost-effective and reduces healthcare system burden. 8
- Parents can remove the splint at home after 3 weeks, eliminating the need for a cast removal appointment. 3, 4
- 94.9% of children in soft casts successfully bathed, showered, or swam during treatment without complications. 3
- Only one patient in soft cast groups experienced problems compared to five in rigid cast groups (p = 0.035). 4