SGEM#372: Use the FORCE for Buckle Wrist Fractures in Children

Date: July 22nd, 2022 Reference: Perry et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. The Lancet 2022 Guest Skeptic: Dr. Tessa Davis is a Paediatric Emergency Consultant at the Royal London Hospital, Senior Lecturer at Queen Mary University of London, Co-founder of Don’t Forget The Bubbles (DFTB). Tessa also has a weekly newsletter with tips to help you level up your use of everyday technology and to optimise your writing and to reach the audience you want. Case: Jack is nine years old, and he presents to emergency department (ED) with an arm injury. Today he was running at school, and he fell over onto his outstretched arm. His right arm is neurovascularly intact, with no swelling or deformity. He has bony tenderness at the distal radius. The X-ray shows a buckle fracture of his right distal radius. Background: We covered buckle fractures way back in Season#1 of the SGEM on SGEM#19. In that episode from ten years ago we made the distinction between a buckle fracture and greenstick fractures. Buckle fractures (also called torus fractures) are defined as a compression of the bony cortex on one side with the opposite cortex remains intact. In contrast, a greenstick fractures the opposite cortex is not intact. Buckles of the distal radius are the most common fracture seen in children and very commonly present to the ED [1-2]. Despite being a common injury they are often managed differently. Some clinicians apply casts, some a splint, some have orthopedic follow up, some have no follow up [3]. This practice variation is not new. A survey done almost 20 years ago in Canada demonstrated the variability of managing buckle fractures by Pediatric orthopedic surgeons and pediatric emergency physicians [4]. An RCT published 12 years ago reported that a soft bandage wrapping treatment for four weeks was not statistically different for discomfort, function or fracture displacement compared a below elbow back slab cast for one week followed by circumferential cast for three weeks despite some more pain in the first week with the soft bandage [5]. Yet here we are ten years later doing an SGEM episode on whether it is ok to put a soft bandage on these pediatric patients with a distal radius buckle fracture. It is a great example of how knowledge translation can take years or even decades for clinically relevant information to reach the patients’ bedside due to leaks in the EM knowledge translation pipeline [6-7]. Clinical Question: What is the appropriate management of torus fractures in children? Reference: Perry et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. The Lancet 2022 Population: Children between 4 and 15 years of age with a distal radius torus fracture that had been confirmed by x-ray. Exclusions: Other fractures, although a concomitant ulnar fracture did not lead to exclusion. Injury over 36 hours old, any cortical disruption seen on x-ray, and any reasons that meant follow-up would not be possible, such as a language barrier, lack of internet access or developmental delay. Intervention: Rigid immobiisation Comparison: Tensor (crepe) bandage Outcome: Primary Outcome: Pain on day three measured using the Wong-Baker FACES Pain Rating Scale [8]. Participants also recorded their pain score on day one, seven and weeks three and six. Secondary Outcomes: Measured a variety of other outcomes at the same time points, unless otherwise specified: Functional recovery using the PROMIS (Patient Report Outcomes Measurement System)Upper Extremity Score – a patient or parent-reported measure of physical function of the upper limbs. Health-related quality of life outcomes, using a EuroQol EQ-5DYa standardised questionnaire, suitable for children, which asks about quality of life,