What Is the Best Treatment for Wrist Fractures?

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Chapter 25 What Is the Best Treatment for Wrist Fractures?

Pediatric wrist fractures may be classified based on the level of injury and the degree of soft-tissue damage (Table 25-1). The level of injury may be physeal or metaphyseal. Physeal injuries may be further subdivided into Salter–Harris type I and II injuries. The literature demonstrates that the majority of physeal injuries at the wrist are Salter–Harris type II.¹ Metaphyseal fractures may be subdivided into torus (buckle fractures), greenstick, and complete fractures. Complete fractures may be angulated, translated, or completely displaced with shortening. Most wrist fractures in the pediatric age group are closed injuries. Open fractures, which indicate a greater degree of soft-tissue damage, may increase the risk for complications including loss of reduction, infection, and growth arrest.

TABLE 25-1 Classification of Pediatric Wrist Fractures

Physeal fractures

Salter–Harris type 1

Salter–Harris type 2

Metaphyseal fractures

Complete displacement

Open fractures

An extensive review of recent English-speaking orthopedic literature from 1997–2007 was undertaken to identify areas of uncertainty and to determine the best evidence available to justify the current treatment of wrist fractures in the pediatric age group. This search identified five articles that reach evidence level I or II (Journal of Bone and Joint Surgery combined volumes [JBJS] Levels of Evidence for Primary Research Question).^2,³ Three of these five articles concern management of torus fractures of the distal radius.⁴^–⁶ Eleven more articles reached levels of evidence III and IV.

Torus Fractures

By definition, torus fractures are incomplete fractures with a failure of the cortex on the compression side of the bone. The convex (or tension side) cortex remains intact. These are stable injuries, and five articles support a minimalist approach to management of these injuries.⁴^–⁹

Three randomized clinical trials addressed the subject of torus fractures. Davidson and colleagues ⁴ randomized 201 patients to treatment with a cast versus a removable “Futura-type” wrist splint for 3 weeks with no difference in outcome as measured by a mail-in questionnaire. Plint and coauthors⁵ found similar results using a validated outcome tool—the Activities Scales for Kids performance version (ASKp). This study reported better functioning in the splint group, with less interference with bathing. Symons and coworkers⁶ reviewed 87 patients treated with splints to assess home management versus standard hospital follow-up. Forty patients who had their splints removed at home were compared with 47 patients treated by removal of the cast in the orthopedic clinic. Results were similar between the groups, but both groups, if given the choice, would prefer removal of the splint at home. Several authors believe there is no evidence that further follow-up is needed after splint removal.^4,⁶

Several articles report cost savings with these minor injuries, because of fewer clinic and physician visits, fewer radiographs, and a reduction in family’s time lost from school and work.^4,⁶^–⁸

In summary, this evidence-based literature demonstrates that buckle fractures of the distal radius can be managed with application of a splint in the emergency ward, followed by one orthopedic clinic visit to confirm the diagnosis. Support of the injured limb with a removable splint should continue for approximately 3 weeks, followed by removal of the splint in the home setting and initiation of self-administered range-of-motion exercises. Parental education in the emergency department and clinic, with a written description of expected course of management, results in uniformly good outcomes and high levels of patient satisfaction.