#390 Use the soft touch for buckle fractures?
CLINICAL QUESTION
Is rigid immobilization needed in buckle fractures?
BOTTOM LINE
Children with buckle fractures treated with a soft bandage, a rigid splint, or a cast all heal with minimal complications and similar functional outcomes and satisfaction at ~4-6 weeks. Pain is similar at all time points though casting results in slight reduction on the first day.
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EVIDENCE
- Results statistically different unless stated.
- Children with buckle fractures, comparing cast, rigid splint, or soft bandage for 3-4 weeks. 2 systematic reviews of Randomized Controlled Trials (RCTs).1,2 Mean age ~10, follow-up 28-42 days.
- Soft bandage with no planned follow-up versus rigid splint with planned follow-up: 1 RCT (965 children).2,3
- Duration of use: Median 7 days (bandage) versus 18 days (splint).
- Pain (0-10, higher=worse, baseline ~5):
- Day 1: 4.3 (bandage) versus 3.9 (splint). Difference not clinically important. Other time points: No difference.
- Use of acetaminophen/ibuprofen day 1: 83% (bandage) versus 78% (splint), number needed to harm (NNH)=20. Other time points: no difference.
- Functional recovery, days of school missed: No difference.
- Change in treatment/Reapplication: 11% (bandage) versus 5% (splint).
- Satisfaction (1-7, lower=better):
- Day 1: 2 (bandage) versus 1(splint).
- Day 42: 1 (both).
- Adverse events: Very low, no analysis done.
- Rigid splint versus cast:
- Pain (5 RCTs, 437 children): 1
- Day of application (0-10 higher=worse): 3 (splint) versus 0 (cast).
- Days 7-21: No difference.1,2
- Change in treatment/Reapplication (4 RCTs, 444 children): ~3% both groups.1
- Physical function at 4 weeks (1 RCT, 65 children): No difference.1
- Satisfaction (different measures used): One study no difference, one favoring splint.1,2
- Adverse events: Few encountered, no difference.1,2
- Pain (5 RCTs, 437 children): 1
- Soft bandage versus cast (additional RCT, 150 children): 4
- Complications, satisfaction: No difference.
- Limitations: All but one study small, blinding of outcome assessment inconsistent.
CONTEXT
- Greenstick fractures (cortex is fractured on one side and buckled on the other) generally require rigid immobilization.5
- NICE (UK) guidelines recommend soft bandage for buckle fractures, but no Canadian guidelines have been published.6,7
- Home management with family physician follow-up as needed results in similar outcomes to scheduled family physician follow-up.8
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#390 Use the soft touch for buckle fractures?
Is rigid immobilization needed in buckle fractures?
Good info
Will implement.
Good to differentiate from greenstick
Good clinical message
Interesting. I don’t work in ER so this could apply to pediatric patients I see in primary care. I would be reassured about managing them, understanding that there is really no superior treatment.
WILL DO
I WILL TRY THE RECOMENDATION
Good to know. Are there any cofounding factors that could affect the effectiveness of the soft bandage?
Good to know that there is no difference in school absence with all three types of approaches
very informative