In response to changing clinical practice in other centres, Dr Richard Jackman, an Emergency Physician, and Dr Arvind Puri, an Orthopaedic Surgeon, have introduced a new buckle fracture pathway for our region.
C – Clinical practice
Current clinical practice is moving towards using lighter removable splints to immobilise minor bony injuries rather than plaster of paris casts e.g- Cam boots in 5th metatarsal fractures or minor avulsion fractures of the malleoli. Splints are easier to use and do not require follow up or replacement/ removal by a specialist tech. They are lighter and are likely to cause less morbidity from pressure areas, general discomfort or compartment syndrome.
H – How/where/why?
In children who sustain buckle fractures the bony cortex is deformed rather than broken. These fractures heal well and are relatively stable requiring less restrictive immobilisation.
A – Affecting who?
Any clinician working in the ED.
N – New or old?
Splinting is an ancient method of providing analgesia and immobilisation to help healing in bony injury. New lighter more comfortable splints allow a movement away from plaster of paris or fibreglass casts as a method of splinting.
G – Good or bad?
Removable splints allow more movement at the fracture site and more possibility for a fracture to slip and heal in a deformed manner or for non-union to occur. These risks are minimal in minor fractures and so the benefits of patient comfort, reduced plaster associated morbidity and reduced resource demand on fracture clinics, plaster techs etc., become significant.
E – Evidence
There is a reasonable sized body of recent evidence supporting the use of removable splints in the treatment of radial buckle fractures, some are listed below.
1. A Randomized, Controlled Trial of Removable Splinting Versus Casting for Wrist Buckle Fractures in Children. Plint A, PEDIATRICS Volume 117, Number 3, March 2006.
2. Common Pediatric Fractures Treated With Minimal Intervention. Boutis K
Pediatr Emer Care 2010;26: 152-162.
3. Interventions for treating wrist fractures in children. Abraham A
Handoll HHG, Khan T, The Cochrane Library 2009, Issue 3.