Buckling down on torus fractures: Has evolving evidence affected practice?

Abstract

PurposeThe purpose of this study was to evaluate the management of paediatric torus fractures of the distal forearm in current practice in light of growing evidence supporting a ‘minimalist’ approach with splint immobilization and limited follow-up. We hypothesized that ‘traditional’ cast-based management has persisted despite alternative evidence.MethodsA retrospective review was performed of a consecutive series of paediatric patients diagnosed with torus fractures of the distal forearm between 2011 and 2014. Records were reviewed to abstract the type of immobilization (splint versus cast) prescribed at each visit, number of radiographic exams, duration of immobilization, number of clinical visits and complications. The primary outcome was the proportion of patients exclusively managed in splints. Injuries were grouped based on treatment into a cast group (CG) and a splint group (SG) for statistical analyses. Additionally, injuries were grouped by epoch of time to determine if immobilization usage patterns evolved.ResultsA total of 240 forty injuries met criteria for inclusion. Of these, 16 (6.7%) were exclusively splinted (SG). Relative to the CG, the SG had fewer clinical visits (p < 0.001), fewer radiographic exams (p < 0.001) and a shorter total encounter time (p = 0.015). No change in immobilization use occurred over the study period. In all, 21 (9.4%) of the CG experienced complications. No clinically significant displacements occurred in either group.ConclusionCast utilization and frequent radiographic follow-up remain prevalent at our institution in the management of paediatric torus fractures. Splint-only management was associated with fewer clinical visits, fewer radiographic exams and a shorter total encounter time.Level of Evidence Level IIITherapeutic retrospective cohort study

How useful are virtual fracture clinics?

“…Many studies have demonstrated that a minimalist approach to managing these fractures, has shown improved function, reduced return time to school along with reduced cost and medical time. 60 , 61 Recent research has guided the use of soft casts or splints rather than rigid casts, 62 and this has been advocated by the most recent National Institute for Health and Care Excellence (NICE) guidelines for the management of torus fractures. 63 A recent retrospective study also demonstrated increased efficiency and cost reduction in managing these injuries in a VFC setting.…”

Trauma in Children during Lockdown for SARS-CoV-2 Pandemic. A Brief Report

“…In this way, we are conducting a study about the efficacy of treating children with torus distal radius fractures with an easy-to-use 3D-printed splint in place of the classic plaster cast usually moulded by an orthopaedic specialist and a dedicated nurse. Results collected to date showed faster treatment in the emergency room, improved childhood activities during recovery and high satisfaction for parents and children without any complication or delay in the healing process as seen for splints in previous studies [23,24]. As we can easily expect new epidemic waves in the near future, changing medical care modalities for minor trauma in children (at the moment, the least vaccinated population) could improve our attempts to limit the spread of the virus.…”

Trends in Management of Pediatric Distal Radius Buckle Fractures

“…19 Despite these guidelines, there is evidence that there is still a high rate of utilization of casting, frequent follow-up, and serial radiographs, all of which can be potentially harmful to patients. 15,20 Our study demonstrated that while an increasing proportion of orthopaedic providers are managing DRBFx with removable wrist splints and limited follow-up, there remain a substantial number of pediatric orthopaedic surgeons who continue to prefer more aggressive measures. The rationale behind this discrepancy remains unclear.…”

“…POSNA guidelines similarly recommend a removable wrist splint with limited follow-up 19. Despite these guidelines, there is evidence that there is still a high rate of utilization of casting, frequent follow-up, and serial radiographs, all of which can be potentially harmful to patients 15,20…”