Anterior/posterior (A/P) and lateral wrist or forearm radiographs, if not already available Evaluate for true buckle versus incomplete fracture o o

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1 BUCKLE FRACTURE SUMMARY CLINICAL MANAGEMENT Preventin f swelling and pain Ice Elevatin Oral ver-the-cunter (OTC) pain medicatin Mnitr effectiveness f pain cntrl measures CLINICAL ASSESSMENT Assess fr vascular injury and neurlgical deficit Assessment f pain using strategies apprpriate t the age/develpment level f the patient Obtain true anterir/psterir (A/P) and lateral wrist r frearm radigraphs, if nt already available Assessment fr ther injuries IMAGING Anterir/psterir (A/P) and lateral wrist r frearm radigraphs, if nt already available Evaluate fr true buckle versus incmplete fracture Buckling f ne crtex with ppsite crtex (tensin side) intact N measurable angulatin present IMMOBILIZATION Placement f shrt vlar r drsal splint depending n lcatin f fracture buckling fr supprt and prtectin r placement f sugar tng splint if patient is in significant pain Placement f remvable Velcr splint, if available, may be definitive treatment. Splint shuld be wrn during the daytime fr 3 t 4 weeks. May wean ut f splint at night as tlerated. A shrt-arm cast with semi-rigid casting tape fr yunger children (with whm cmpliance in a splint is questinable) is apprpriate and avids use f a cast saw fr remval Patients experiencing significant pain may be treated in a shrt arm cast fr 3 t 4 weeks If the patient is minimally tender, there is evidence supprting treatment in a sft bandage nly Fr questins regarding the best curse f treatment, please call Orthpedics at FOLLOW-UP If patient was nt casted and is pain-free with full range f mtin after 4 t 5 weeks, the patient shuld fllw-up n an as-needed basis If a cast has been placed, the patient shuld return t the prvider that placed the cast in the timeframe recmmended by the prvider Page 1 f 6

2 TABLE OF CONTENTS Algrithm - N/A Summary Target Ppulatin Backgrund Definitins - N/A Initial Evaluatin - N/A Clinical Management Telephne Triage Labratry Studies Imaging Therapeutics Immbilizatin Parent Caregiver Educatin References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria Patients with a cmpressin fracture f the distal radius and/r ulna with buckling f ne crtex (ppsite crtex {tensin side} intact with n measurable angulatin) Exclusin Criteria N cmpressin fracture f the distal radius and/r ulna with buckling f ne crtex CLINICAL MANAGEMENT Preventin f swelling and pain Ice Elevatin Oral ver-the-cunter (OTC) pain medicatin Mnitr effectiveness f pain cntrl measures TELEPHONE TRIAGE Fractures f the distal radius and/r ulna shuld be seen by the PCP r Orthpedic Clinic within 5 t 7 days t cnfirm fracture type and prvide apprpriate management Advise parent r caregiver t cntinue with ice, elevatin and ral pain medicatins Prvide parent r caregiver educatin regarding reasns t seek ED treatments, including neurvascular cmprmise and pain cntrl CLINICAL ASSESSMENT Assess fr vascular injury and neurlgical deficit Page 2 f 6

3 Assessment f pain using strategies apprpriate t the age/develpment level f the patient Obtain true anterir/psterir (A/P) and lateral wrist r frearm radigraphs, if nt already available Assessment fr ther injuries IMAGING Anterir/psterir (A/P) and lateral wrist r frearm radigraphs, if nt already available Evaluate fr true buckle versus incmplete fracture Buckling f ne crtex with ppsite crtex (tensin side) intact 1 N measurable angulatin present THERAPEUTICS Pain cntrl Use OTC pain medicatins (ibuprfen r acetaminphen) as recmmended by manufacturer s labeling IMMOBILIZATION 3-5 Placement f shrt vlar r drsal splint depending n lcatin f fracture buckling fr supprt and prtectin r placement f sugar tng splint if patient is in significant pain Placement f remvable Velcr splint, if available, may be definitive treatment. Splint shuld be wrn during the daytime fr 3 t 4 weeks. May wean ut f splint at night as tlerated. A shrt-arm cast with semi-rigid casting tape fr yunger children (with whm cmpliance in a splint is questinable) is apprpriate and avids use f a cast saw fr remval Patients experiencing significant pain may be treated in a shrt arm cast fr 3 t 4 weeks If the patient is minimally tender, there is evidence supprting treatment in a sft bandage nly Fr questins regarding the best curse f treatment, please call Orthpedics at PATIENT CAREGIVER EDUCATION The Patient/caregiver shuld be given instructin regarding: Hw t evaluate neurvascular status Apprpriate pain cntrl measures Return precautins Splint/cast care FOLLOW-UP If patient was nt casted and is pain-free with full range f mtin after 4 t 5 weeks, the patient shuld fllw-up n an as-needed basis If a cast has been placed, the patient shuld return t the prvider that placed the cast in the timeframe recmmended by the prvider Page 3 f 6

4 REFERENCES 1. Randsbrg PH, Sivertsen EA. Classificatin f distal radius fractures in children: gd inter- and intrabserver reliability, which imprves with clinical experience. BMC Musculskelet Disrd 2012;13:6. 2. Kennedy SA, Slbgean GP, Mulpuri K. Des degree f immbilizatin influence refracture rate in the frearm buckle fracture? J Pediatr Orthp B 2010;19: Plint AC, Perry JJ, Crrell R, Gabury I, Lawtn L. A randmized, cntrlled trial f remvable splinting versus casting fr wrist buckle fractures in children. Pediatrics 2006;117: West S, Andrews J, Bebbingtn A, Ennis O, Alderman P. Buckle fractures f the distal radius are safely treated in a sft bandage: a randmized prspective trial f bandage versus plaster cast. J Pediatr Orthp 2005;25: Williams KG, Smith G, Luhmann SJ, Ma J, Gunn JD, 3rd, Luhmann JD. A randmized cntrlled trial f cast versus splint fr distal radial buckle fracture: an evaluatin f satisfactin, cnvenience, and preference. Pediatr Emerg Care 2013;29: Randsbrg PH, Sivertsen EA. Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures. Acta Orthp 2009;80: Page 4 f 6

5 CLINICAL IMPROVEMENT TEAM MEMBERS Mark Ericksn, MD Orthpedics Brian Khuth, PA Orthpedics Susan Graham, PA Orthpedics Denise Pickard, RN, MSN Clinical Care Guideline Crdinatr APPROVED BY Clinical Care Guideline and Measures Review Cmmittee Nt frmulated at time f apprval Medicatin Safety Cmmittee Nt applicable Antimicrbial Stewardship Cmmittee Nt applicable Pharmacy & Therapeutics Cmmittee Nt applicable Clinical Care Guidelines/Quality MANUAL/DEPARTMENT ORIGINATION DATE January 5, 2015 LAST DATE OF REVIEW OR REVISION February 8, 2016 APPROVED BY Daniel Hyman, MD, MMM, Chief Quality Officer, Children s Hspital Clrad REVIEW/REVISION SCHEDULE Scheduled fr full review n February 8, 2020 Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 5 f 6

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