Numerous studies have shown simple buckle fractures do well with removable splints or soft bandages. Simple dorsal buckle fractures are stable injuries that require treatment for comfort and protection. Simple dorsal buckle fractures can be subtle on the lateral view-but the fracture line does not extend to the volar cortex and there is no angulation (the planes of the proximal and distal fragments are parallel/anatomic). The volar aspect of the distal radius impacts the ground, and the force results in the commonly seen buckle fracture on the opposite compressed dorsal aspect of the distal radius. The child falls on the outstretched hand. They are caused by a compression-type force applied to relatively soft, immature bone. Simple dorsal buckle fractures of the distal radius are very common. Recognition requires astute radiographic interpretation. 1 Subtle radiologic abnormalities result in significantly different ED management. Rather, the challenge lies in recognizing the subtle fractures that may shift, identifying the direction they may shift, and ensuring proper ED immobilization and follow-up.Ībout 10 percent of injuries diagnosed by emergency physicians as simple buckle fractures of the distal radius are subtle examples of more complex injuries. The ED challenge in managing pediatric distal radius fractures lies not so much with the common simple dorsal buckle fracture since it does not require specific immobilization or with the significantly angulated fracture that clearly needs reduction.
As in three of the above cases, recognizing the instability of some fractures can be quite subtle. However, unstable fractures are not always so obvious. Those cases are more impressive, and it is more intuitive that those fractures have a tendency to shift back to their pre-reduction position and should be molded in the opposite direction to prevent that possible shift. Some kids with distal radius fractures need a reduction (not covered in this article). Unstable fractures have a tendency to shift. A simple dorsal buckle fracture of the distal radius is a good example (as in Case 2). They need comfort and protection while healing. Stable fractures will not shift with activities of daily living. Distal radius fractures are the most common.įractures can be stable or unstable. If you see kids in your emergency department, then you’re managing pediatric fractures. Make sure you see the X-rays, not just the report! Don’t solely rely on the radiologist’s report.Volar buckle fractures are less common, more difficult for emergency physicians to appreciate, and more likely to be mismanaged these should be molded in extension.For these fractures, the distal fragment tends to shift dorsally the fractures should be molded in flexion. If the dorsal buckle fracture extends to the volar side or if the distal fragment is dorsally angulated, then it is not a simple dorsal buckle fracture. Transverse fractures (also called complete or bicortical fractures) can be subtle on X-ray.Simple dorsal buckle fractures are stable.The Clinical Pearls: Pediatric Distal Radius Fractures Optimal ED management requires us to recognize the subtle differences between these pediatric distal radius fractures. However, two of the cases should be molded in flexion the third case, in extension. For the other three cases, they require well-molded immobilization in the emergency department. Of the above four cases, the radiology report for each may read, “buckle fracture of the distal radius.” One case is a simple buckle fracture, and it tends to be overtreated in the emergency department. What is your diagnosis, emergency department treatment, and follow-up plan for each? Each is mildly swollen and tender at the distal radius, closed, neurovascularly intact, and without scaphoid (or other carpal) tenderness. Here are X-rays of four pediatric patients with isolated wrist injuries after a fall. Tips for Diagnosing Occult Fractures in the Emergency DepartmentĮxplore This Issue ACEP Now: Vol 36 – No 10 – October 2017 The Cases.Pearls from Emergency Medicine Literature on Pulmonary Problems, Bleeding, Evaluating Pediatric Injuries, and More.Tips for Catching Commonly Missed Ankle Injuries.
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