Soft bandages in buckle fracture treatment

Clinical question

Is rigid immobilization needed in buckle fractures?

Bottom line

Children with buckle fractures treated with a soft bandage, a rigid splint, or a cast heal with minimal complications and similar function and satisfaction at about 4 to 6 weeks. Pain is similar at all time points although casting results in a slight reduction on the first day.

Evidence

Results are statistically different unless stated. In 2 systematic reviews of randomized controlled trials (RCTs)^1,2 of children with buckle fractures that compared casts, rigid splints, or soft bandages for 3 to 4 weeks, mean age was about 10 years and follow-up time was 28 to 42 days.

• In 1 RCT (N=965)^2,3 of soft bandages with no planned follow-up versus rigid splints with planned follow-up:

  • -Median use was 7 days (bandage) versus 18 days (splint).

  • -On a pain scale of 0 to 10, higher being worse, baseline score was about 5. On day 1, pain scores were 4.3 (bandage) versus 3.9 (splint); difference not clinically important and no difference at other time points. Use of acetaminophen or ibuprofen on day 1: 83% (bandage) versus 78% (splint); number needed to harm=20. No difference at other time points.

  • -There were no differences in functional recovery and days of school missed.

  • -Changes in treatment or reapplication were 11% (bandage) versus 5% (splint).

  • -On a satisfaction scale of 1 to 7 (lower is better), scores on day 1 were 2 (bandage) versus 1 (splint); the score for both on day 42 was 1.

  • -Adverse event rate was very low; no analysis was done.

• Rigid splint versus cast:

  • -Pain (5 RCTs, N=437)¹ on the day of application (scale of 0 to 10; higher is worse) was 3 (splint) versus 0 (cast); on days 7 to 21 there was no difference.^1,2

  • -Change in treatment or reapplication (4 RCTs, N=444) was about 3% in both groups.¹

  • -No difference in physical function at 4 weeks (1 RCT, N=65).¹

  • -Satisfaction (different measures used): 1 study had no difference and 1 favoured splints.^1,2

  • -Adverse events: Few encountered, no difference.^1,2

• Soft bandage versus cast (additional RCT, N=150)⁴: No difference in complications or satisfaction.

• Limitations: All but 1 study were small and the blinding of the outcome assessment was inconsistent.

Context

• Greenstick fractures (cortex fractured on 1 side and buckled on the other) usually need rigid immobilization.⁵

• National Institute for Health and Care Excellence guidelines recommend soft bandages for buckle fractures, but no Canadian guidelines have been published.^6,7

• Home management with family physician follow-up as needed results in similar outcomes to scheduled family physician follow-up.⁸

Implementation

Soft bandages (stretchy gauze or elastic bandage) or removeable splints are applied in the acute care setting. Soft bandages are used for isolated buckle fractures in the distal one-third of the radius (with or without ulna fracture) where the cortex is fully intact. Parents should be advised—via handout or website referral⁹—about the fracture and that bandages can be removed for bathing and when pain is gone. If pain returns, the bandage or splint is replaced for another week. Activities with swinging or high risk of falls should be avoided for about 6 weeks.