Buckling down on torus fractures: has evolving evidence affected practice? B. A. Williams 1 C. A. Alvarado 2 D. C. Montoya-Williams 3 R. C. Matthias 1 L. C. Blakemore 1 Abstract Purpose The purpose of this study was to evaluate the man agement of paediatric torus fractures of the distal forearm in current practice in light of growing evidence supporting a minimalist approach with splint immobilization and limit ed follow-up. We hypothesized that traditional cast-based management has persisted despite alternative evidence. Methods A retrospective review was performed of a consec utive series of paediatric patients diagnosed with torus frac tures 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 propor tion 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 immobiliza tion usage patterns evolved. Results A 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 signicant displacements oc curred in either group. 1 Department of Orthopaedics and Rehabilitation, University of Flori da, Gainesville, Florida, USA 2 University of Florida College of Medicine, Gainesville, Florida, USA 3 Department of Paediatrics, University of Florida, Gainesville, Flori da, USA Correspondence should be sent to B. A. Williams, Department of Orthopaedics and Rehabilitation, Orthopaedics and Sports Medicine Institute, PO Box 112727, Gainesville, Florida 32611, United States. E-mail: email@example.com Conclusion Cast utilization and frequent radiographic fol low-up remain prevalent at our institution in the manage ment 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 III, Therapeutic retrospective cohort study Cite this article: Williams BA, Alvarado CA, Montoya-Williams DC, Matthias RC, Blakemore LC. Buckling down on torus frac tures: has evolving evidence affected practice? JChild Orthop 2018;12:123-128. DOI 10.1302/1863-2548.12.170122 Keywords: Buckle fracture; evidence-based medicine; wrist fracture; closed management Introduction Torus (buckle) fractures of the distal forearm are com mon injuries in children and young adolescents, typically occurring after a fall on an outstretched arm. 1 They are stable due to the thick periosteum present in this patient population and, unlike other paediatric wrist and forearm fractures, the risk of future displacement is minimal. 2 The traditional management of paediatric torus frac tures of the distal forearm has mirrored that of other frac tures in this region, including cast immobilization and serial radiographic and clinical follow-up to assess for displacement until fracture union. However, emerging literature over the last two decades has supported a min imalist approach to managing these injuries. Van Bosse etal 5 described treatment with removable splint applica tion at time of injury, appropriate patient and caregiver counselling, a short (three to four week) period of immo bilization and either self-discontinuation of the splint at home or a single follow-up appointment with clinical examination only. Radiographs become necessary only in the setting of re-injury or continued pain after the treat ment period. Numerous other studies have highlighted safe and efcacious management of these injuries in a similarly minimalist fashion. 2-4,6-9 In addition to pre-fabricated and removable splints, multiple other non-casting alternatives have been found to be equally safe in the management of paediatric torus fractures of the distal forearm. Soft bandage 10 and soft cast, 11,12 neither of which require a physician visit for
124 J Child Orthop 2018;12:123-128 removal, have both been demonstrated to be acceptable treatment options. In the appropriately selected patient, home-based removal of immobilization can further sim plify management and has been demonstrated to have equivalent outcomes to clinic-based reexamination and removal. 7 By eliminating the additional orthopaedic clinic visits for cast removal and radiographic exams, these man agement approaches theoretically minimize the burden to the caregiver and patient while simultaneously reducing treatment cost. 4 Although recent studies have begun to evaluate pro vider opinions regarding minimalist strategies in the treat ment of buckle fractures of the distal forearm and other paediatric orthopaedic injuries, 13,14 to our knowledge, no prior study has examined real world provider uptake and implementation of these practices since the emergence of this literature. The purpose of this study was to evaluate the current management of paediatric torus fractures at a single institution by examining the type and duration of immobilization prescribed, the utilization of radiographs in follow-up, and the number and duration of clinical encounters. We hypothesized that despite the evidence supporting a minimalist approach, the majority of pae diatric patients with torus fractures of the distal forearm in our hospital system would still be managed in a tradi tional fashion. Patients and methods Study design and setting We performed a retrospective review of a consecutive series of paediatric patients diagnosed with a buckle fracture of the distal forearm between May 2011 and November 2014. The selected study period was chosen to coincide with the introduction of the electronic med ical record (EMR) into our institution, which was critical for gathering outcome measures related to time spent receiving care. This study was conducted at a tertiary care academic institution in North Central Florida with an Emergency Department caring for roughly 12 000 chil dren each year.Approvalwas obtained from the University of Florida Institutional Review Board for all study proce dures. Patient management Denitive management of all fractures was determined by the treating clinician as per standard operations for this institution. Treating clinicians consisted of a mixed group of operative and nonoperative providers from a multi-specialty Orthopaedics and Rehabilitation Depart ment. No clinicians involved in the care of the studied population were aware this study would be performed and thus their treatment was based on their own clinical experience and training. The vast majority of immobiliza tion (casts and splints) used was below the elbow, except in a small number of children less than four years old. Casts were all fashioned from breglass, as is the stan dard of care at our centre. The splints referred to in this study included a heterogeneous assortment of both sug ar-tong and breglass slabs applied using cast padding and an ace wrap as well as pre-fabricated Velcro wrist and forearm splints. Patients Eligible subjects were identied through a search of the EMR for individuals matching the following inclusion cri teria: paediatric patient (17 years old and younger) and diagnosis of torus (buckle) fracture of the distal forearm given by the treating provider during our study period. Two independent radiograph evaluations were per formed and compared, one by a radiologist and a second by author BAW, to conrm the diagnosis. Patients with buckle fractures of the distal radius and/or ulna (buckle or styloid fracture) were included. Those with diagnoses by either reviewer discrepant from the clinical record or with concomitant ipsilateral upper extremity fractures affect ing denitive management (e.g. ipsilateral supracondylar humerus fracture) were excluded. Study variables The EMR was reviewed for extraction of the following vari ables: age (continuous), gender (dichotomous), location of each presentation (categorical) and the number of days (continuous) between visits. The number of radiographic exams (continuous) performed over the treatment period was tallied for each injury. Twoand three-view wrist series and two-view forearm series were each counted as a single exam. The treatment at each clinical encounter was recorded as either: splint, cast or no immobilization. Patients managed exclusively in a splint throughout the treatment period were assigned to the splint group (SG), while those casted for any period of time were assigned to the cast group (CG). The total clinical encounter time was the summed difference between the recorded check-in and check-out times (rounded to the nearest quarter of an hour) at each clinical encounter. Each patient chart was reviewed from the date of injury to three months post-in jury to determine if complications or re-injuries occurred and were managed at our institution during this time frame. Our primary outcome was the proportion of patients managed exclusively with splints during the study period. Secondary outcome measures included the rate of compli cations, the duration of follow-up and prescribed immobi lization, and use of follow-up radiographs with each of the treatment strategies.
J Child Orthop 2018;12:123-128 125 Data collection Data collection occurred between January 2015 and June 2016 and was performed by three authors (BAW, CAA and DCM). The primary author determined stan dardized locations for extraction of each recorded variable from the medical record for all reviewers and performed simultaneous reviews of the rst ten records for each reviewer to assure accuracy and consistency of data collection. Data were collected in and managed by Research Electronic Data Capture (REDCap) 15 hosted at our institution. REDCap is a secure, web-based appli cation designed to support data capture for research studies and facilitate seamless data export to common statistical packages. Statistical analysis Statistical analyses were performed using JMP PRO Ver sion 12.0.1 (SAS Institute, Cary, North Carolina). Descrip tive statistics were used to analyze the demographic and treatment-related variables across the entire study cohort. Univariate analyses were performed to evaluate for differ ences between the two treatment approaches (SG versus CG). Given the study was performed over more than a three-year period, we secondarily divided our study period into two epochs to examine whether changes in practice patterns led to differences in management over time. Our study population was divided into two equal sized groups of injuries occurring in the rst and second halves of the study period. The early group received care from 2011 to mid-2013 and the late group received care from mid-2013 to 2014. For all analyses, Students t -tests were used for continuous data (age, duration of prescribed immobiliza tion, duration of follow-up, number of radiographic exams and total clinical encounter time). Data are expressed as means and The chi-squared test was used to analyze group differences in proportions of categorical data (gen der, form of immobilization). A p-value < 0.05 was consid ered to be signicant. Results A total of 300 consecutive records were reviewed and 240 torus fractures of the distal forearm occurring in 236 patients remained after appropriate exclusions (Fig. 1). Five exclusions appeared to be coding errors due to a clearly incorrect diagnosis (e.g. displaced both bone fore arm fracture), while a larger number were excluded due to radiograph review demonstrating injuries more con sistent with greenstick or minimally displaced transverse fractures (both cortices involved). In all, 70 (29.1%) inju ries were referred in after initial management at an outside facility. The duration of clinical visits occurring at outside facilities was not accessible through our EMR, therefore, these injuries were excluded from analyses involving total clinical encounter time. Age at injury was 7.5 years ( 3.5) old. A total of 123 (51.3%) fractures occurred in males. Providers exclusively managed buckle fractures of the distal forearm in a splint in 16 (6.7%) cases. All other injuries (93.3%) were man aged for all or a portion of the treatment period in a cast. Patients were followed in clinic for an average of 28.9 days ( 8.3) and prescribed immobilization (cast or splint) for 35.3 days ( 10.3). Patients underwent 2.3 radiographic exams ( 0.7) and spent 4.9 hours ( 2.2) waiting for, and receiving treatment over their clinical course. Signicant differences existed between SG and CG for a number of our demographic and treatment-related vari ables (Table 1). No signicant differences in management strategy were found with respect to gender or prescribed duration of immobilization. Comparing the early and late care groups, we found no change in the proportion of patients managed in a splint (early 6.7% versus late 6.7%). Additionally, there were no signicant differences in duration of patient fol low-up, duration of prescribed immobilization practices, total radiographs obtained or total duration of clinical care between the two study epochs. Follow-up and complications No radiographic or clinically evident displacement occurred in patients completing follow-up at our institu tion in the CG or SG. A total of 21 (8.8%) patients were lost to follow-up after treatment at our centre, 19 (8.5%) in the CG and two (12.5%) in the SG. In all, 21 (9.4%) Fig. 1 Reasons for subject exclusion. Table 1 Splint group (SG) versus cast group (CG). Signicant differences identied between splint and cast-managed injuries. Signicant variable SG ( SD ) CG ( SD ) p-value Mean age (yrs) 9.4 (3.0) 7.3 (3.5) 0.016 Mean clinical visits (n) 2.1 (0.57) 2.9 (0.69) < 0.001 Mean radiographic exams (n) 1.6 (0.62) 2.3 (0.65) < 0.001 Mean encounter time (hrs)* 3.5 (0.89) 5 (2.2) 0.015 *total encounter time included a subset of injuries with all clinical visits occurring at our institution
126 J Child Orthop 2018;12:123-128 patients in the CG had cast-related problems (e.g. wet or painful cast) requiring an unscheduled clinic visit for cast change or removal while no complications were observed in the SG (Fig. 2). Follow-up and complications In total, 25 (10.4%) patients were lost to follow-up after treatment at our centre, 19 in the CG and six in the SG. In all, 21 cast-related problems (e.g. wet or painful cast) occurred requiring an unscheduled clinic visit for cast change or removal while no splint-related complications were observed (Fig. 2). No radiographic or clinically evi dent displacement occurred in patients completing fol low-up at our institution in either group. Discussion The ndings of our study identied persistent utilization of traditional management strategies throughout the study period without evidence of practice evolution over the three-year time frame. To our knowledge, this is the rst study to examine true provider implementation of the splint approach for distal forearm buckle fractures since emergence of a broad literature base in favour of minimal ist strategies over the last two decades. 2,6,9,10,16-18 In a recent systematic review of randomized-controlled trials comparing treatment of paediatric torus fractures of the distal forearm, Hill et al 16 (2016) found broad support for the use of removable splint over a cast. The benets of splinting have been seen in regards to function, hygiene, cost, convenience and patient and caregiver satisfac tion without increased risk of treatment failure. 2,6,9,10,17,18 Furthermore, although we opted to exclude non-torus fractures of the wrist (i.e. greenstick and transverse) from the current study, a 2010 randomized controlled trial by Boutis et al 19 suggests that these injuries may also be safely managed with a removable device for four weeks. These authors also identied that splints were superior with regards to patient and parental satisfaction. Other non-casting alternatives such as soft bandage 10 and soft cast 11,12 have also demonstrated efcacy and ease of use. Although some studies have suggested a potential down side of non-cast options related to higher pain scores at presentation 9 and longer periods of pain, 18 these ndings have not been consistent across all studies. Most impor tantly, non-cast treatments have not demonstrated any increased risk of fracture displacement or treatment failure across numerous rigorous trials. 16 Our ndings demonstrate that despite this growing evidence base, traditional practices remain prevalent at our institution. The vast majority of paediatric buckle frac tures of the distal forearm at our centre were treated with a cast instead of a splint. Of further concern, the utiliza tion of radiographic and clinical follow-up, the duration of follow-up and the prescribed duration of immobiliza tion were greater than the recent evidence suggests is necessary for safe management. 2,6,9,10,17,18 Additionally, when comparing the early and late groups to evaluate for changes in practice patterns over the study period, we identied no statistically signicant differences in the met rics studied. Together, these results suggest the endur ing tendency to over-treat this injury. We also identied a signicant association with fewer clinical visits, fewer radiographic exams and a shorter total encounter time in injuries managed exclusively in splints. Elimination of unnecessary clinic visits and radiographic exams has great potential to reduce caregiver time lost from work and patient time lost from school. Although the decision to utilize traditional treat ment measures is presumably made with the patients best interest in mind, it is easy to overlook the risks and inconveniences imposed with overtreatment. Traditional measures can increase healthcare spending, introduce unnecessary radiation exposure to the patient, and cre ate additional nancial burden for caregivers due to added travel and time away from work. Most importantly, casting is not benign. Skin complications and burns can occur from ill-tting or mistreated casts and improper cast removal. Additional inconveniences may also arise, such as unscheduled clinic visits for casts that become wet, uncomfortable or too tight. In this study, nearly 10% of injuries managed in a cast had a complication requiring an unscheduled visit (Fig. 2). Finally, cast application is also more time consuming and labour intensive than splint use and requires follow-up for removal. Therefore, this all begs the question: why are many providers continuing to Fig. 2 Complication comparison of cast group (CG) and splint group (SG).
J Child Orthop 2018;12:123-128 127 cast children for these injuries if there exists an equivalent, well-tolerated and evidence-based alternative with fewer complications? The reasons for discrepancy between evidence-based and actual practice are unclear. Dogmatic and long-stand ing practices in medicine are often difcult to change despite strong evidence to the contrary. Some potential barriers to adoption of these new standards of practice include a lack of familiarity with recent literature support ing the minimalist approach, prior provider experiences, patient and caregiver preferences, concerns regarding splint compliance, and inability or lack of condence in accurately identifying fractures appropriate for minimalist treatment. Boutis and colleagues explored the barriers to emergency 14 and paediatric orthopaedic 13 provider utiliza tion of splints in the management of paediatric fractures with low rates of complications. Emergency providers felt constrained by the availability of commercial splinting devices and the support of their orthopaedic colleagues, while both groups expressed concerns about patient compliance and potential complications with removable forms of immobilization. The results of this study, per formed in a health system with a mixed group of both operative and nonoperative paediatric and adult providers caring for these injuries, suggest that further exploration of these barriers is certainly warranted. Quality issues and future directions Based on our ndings, this group of investigators is seek ing to identify and quantify barriers to broader acceptance of minimalist strategies via provider, patient and caregiver survey. Once identied, we plan to deconstruct these barriers in order to facilitate front-line provider (primary care and emergency medicine physicians and orthopae dic residents) education and implement institution-wide changes to the treatment algorithm. These didactic mea sures will also help facilitate improvement in the radio graphic recognition and coding accuracy of these injuries, an issue highlighted by a signicant proportion of patients excluded from our study. Limitations This study was principally limited by the small sample size of patients treated exclusively in a splint and its retrospec tive design. We relied on the accuracy and consistency of the medical record for identication of patients via diagno sis coding and for many of our collected variables. Addi tionally, a substantial number of injuries in this cohort were excluded due to discrepant diagnoses. While it is unclear whether this was due to miscoding or misdiagno sis, it does suggest that appropriate identication of inju ries acceptably managed in splint alone may be a factor limiting implementation of this treatment strategy. Recent work suggests that even among individuals trained in evaluating paediatric musculoskeletal radiographs, overand misdiagnosis of buckle fractures of the distal forearm may be a more widespread issue than most would read ily acknowledge. 20 While our study was not designed to formally address this question, these observations deserve further exploration of strategies for improvement. Finally, the generalizability of our results is uncertain due to the limited number of dedicated paediatric practitioners at our centre during the study period. We recognize that utilization patterns at institutions where providers exclu sively care for paediatric patients may be different. Fur ther multicentre and multi-setting studies are necessary to assess how broadly these treatment patterns extend in our present-day healthcare system. Conclusions Cast utilization and frequent radiographic follow-up remain common at our institution in the management of paedi atric torus fractures despite growing evidence supporting an alternative minimalist strategy. Nearly 10% of casted injuries suffered a complication requiring an unscheduled visit while splint-only management of torus fractures of the distal forearm at our institution was associated with fewer clinical visits, fewer radiographic exams and a shorter total encounter time. Measures to increase implementation of this strategy are likely to decrease treatment-related costs and patient/caregiver inconvenience. Future work will explore barriers to implementation of this management practice with the hope of achieving practice change through pro vider education and institution-wide treatment algorithms. Received 31 July 2017; accepted after revision 05 March 2018. COMPLIANCE WITH ETHICAL STANDARDS FUNDING STATEMENT Research reported in this publication was supported by the University of Florida Clini cal and Translational Science Institute, which is supported in part by the NIH National Center for Advancing Translational Sciences under award number UL1TR001427. The content is solely the responsibility of the authors and does not necessarily represent the ocial views of the National Institutes of Health. OA LICENCE TEXT This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.org/ licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribu tion of the work without further permission provided the original work is attributed. ETHICAL STATEMENT Ethical approval: This study involved a retrospective review of the medical re cord. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research
128 J Child Orthop 2018;12:123-128 committee and with the 1964 Helsinki declaration and its later amendments or com parable ethical standards. Informed consent: Not applicable retrospective review. ICMJE CONFLICT OF INTEREST STATEMENT LCB has received consulting fees from K2M Medical. All other authors declare they have no conict of interest. REFERENCES Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg ;:-. Davidson JS, Brown DJ, Barnes SN, Bruce CE. Simple treatment for torus fractures of the distal radius. J Bone Joint Surg [Br] ;-B:-. Farbman KS, Vinci RJ, Cranley WR, Creevy WR, Bauchner H. The role of serial radiographs in the management of pediatric torus fractures. Arch Pediatr Adolesc Med ;:-. Firmin F, Crouch R. Splinting versus casting of torus fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): a literature review. Int Emerg Nurs ;:-. van Bosse HJP, Patel RJ, Thacker M, Sala DA. Minimalistic approach to treating wrist torus fractures. J Pediatr Orthop ;:-. Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics ;:-. Symons S, Rowsell M, Bhowal B, Dias JJ. Hospital versus home management of children with buckle fractures of the distal radius. A prospective, randomised trial. J Bone Joint Surg [Br] ;-B:-. Neal E. Comparison of splinting and casting in the management of torus fracture. Emerg Nurse ;:-. Williams KG, Smith G, Luhmann SJ, et al. A randomized controlled trial of cast versus splint for distal radial buckle fracture: an evaluation of satisfaction, convenience, and preference. Pediatr Emerg Care ;:-. West S, Andrews J, Bebbington A, Ennis O, Alderman P. Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. J Pediatr Orthop ;:-. Witney-Lagen C, Smith C, Walsh G. Soft cast versus rigid cast for treatment of distal radius buckle fractures in children. Injury ;:-. Khan KS, Gruerty A, Gallagher O, et al. A randomized trial of soft cast for distal radius buckle fractures in children. Acta Orthop Belg ;:-. Boutis K, Howard A, Constantine E, et al. Evidence into practice: pediatric orthopaedic surgeon use of removable splints for common pediatric fractures. J Pediatr Orthop ;:. Boutis K, Howard A, Constantine E, Cuomo A, Narayanan U. Evidence into practice: emergency physician management of common pediatric fractures. Pediatr Emerg Care ;:-. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)--a metadata-driven methodology and workow process for providing translational research informatics support. J Biomed Inform ;:-. Hill CE, Masters JPM, Perry DC. A systematic review of alternative splinting versus complete plaster casts for the management of childhood buckle fractures of the wrist. J Pediatr Orthop B ;:-. Karimi Mobarakeh M, Nemati A, Noktesanj R, Fallahi A, Safari S. Application of removable wrist splint in the management of distal forearm torus fractures. Trauma Mon ;:-. Oakley EA, Ooi KS, Barnett PL. A randomized controlled trial of methodsof immobilizing torus fractures of the distal forearm. Pediatr Emerg Care ;: -. Boutis K, Willan A, Babyn P, Goeree R, Howard A. Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial. CMAJ ;:-. Terreblanche B, Eismann EA, Laor T, Cornwall R, Little K. Overdiagnosis of distal radius buckle fracture in children [Abstract]. Annual Meeting for the American Association for Hand Surgery ().