Evidence-Based Minimal Intervention

Strategies for Common Pediatric

Fractures

Kathy Boutis, BSc, MD, FRCPC, MSc

Staff Emergency Physician and Associate Scientist

Associate Professor, University of Toronto

This webinar should not be reproduced without permission

At the end of this session, you will be able to...

1. Manage the most common pediatric fractures with

symptom-based (‘minimal’) intervention strategies

2. Explain the science behind these management choices

Learning Objectives

Pediatric Fractures

• Pediatric fractures are very common – 10-25% of all injuries

• Children have unique and exceptional healing abilities

– Callous - malunion and non union are very rare

– Remodelling - children’s bones straighten as they grow

Landin LA 1997

callous formation

Three weeks after injury... 25 degrees angulated

One year later... remodelling to perfect anatomic alignment

Pediatric Fractures - Management

• Because of these unique healing properties, clinicians

have questioned the need for rigid immobilization for

weeks in some common pediatric fractures

• Evidence has compared standard of care (casting) to a

more symptom based strategy for the most common,

minor pediatric fractures

Pediatric Fractures - Management

• We will discuss evidence based management of the

following fractures…

1. Mid-shaft clavicle fractures

2. Distal radius buckle fractures

3. Minor distal fibular fractures (isolated fibular Salter-Harris

I, II, avulsion)

Mid-shaft Clavicle Fracture

Mid-Shaft Clavicle - Evidence

Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD

J OrthopTrauma 2005;19:504-7

Treatment of acute mid-shaft clavicle fractures:

systematic review of 2144 fractures: Evidence-

Based Orthopaedic Trauma Working Group

Level II Evidence

Mid-Shaft Clavicle - Management

• Arm sling is preferred over a figure-of-eight dressing

– sling greater comfort

– same outcomes

• Immobilization for 1-2 weeks / major pain subsides

• Follow up with range of motion exercises

• Return to sports at least 6 weeks after the injury

Distal Radius Buckle Fracture

Many faces of the buckle fracture A B C

Distal Radius Buckle - Evidence

1. Abraham et al. Cochrane Review. 2008.

2. Khan KS et al. Acta Orthop Belg 2007;73:594-7.

3. Oakley E et al. Pediatric Emergency Care 2008;24:65-70.

4. Plint A et al. Pediatrics. 2006;117(3):691-7.

5. Stoffelen D et al. The Journal of Trauma. 1998;44:503-5.

6. West S et al. J Pediatr Orthop 2005;25:322-5.

Level I Evidence

Distal Radius Buckle - Management

• No indication for orthopaedic consultation

• Five randomized controlled trials - removable splint

compared to a short arm cast has similar functional

outcomes, higher patient satisfaction

– none of the trials reported re-fracture

Distal Radius Buckle - Management

• Removal of splint safely done at home/pediatrician’s

office and preferred by caregivers

• Duration of immobilization and return to sports as

guided by the patient’s symptoms

Avulsion of distal fibula Avulsion of distal fibula

Salter-Harris I of distal fibula Salter-Harris II of distal fibula

Minor Distal Fibular Fractures

Minor Distal Fibular Fractures -

Evidence Gleeson et al. Journal of Bone and Joint Surgery. 1996.

Boutis K et al. Pediatrics. 2007.

Barnet P et al. Pediatric Emergency Care 2012.

Level I Evidence – all randomized control trials

• Largest RCT of minor distal fibular fractures –

BKWC (50) vs Brace (54)

• Removable brace superior to cast with respect to

– Recovery of physical function

– Patient and parental preferences

– Cost-effectiveness

Cast versus Sprain-like Management

Minor Distal Fibular Fractures -

Management

• No emergency consultation of orthopedics required

• Removable posterior slab, brace, tensor are

preferred treatment choices

• Duration of immobilization and return to sports

guided by patient’s symptoms

• Follow up with primary care physician at one week

Summary

• Evidence supports that mid-shaft clavicle fractures,

buckle fractures of distal radius, and isolated distal

fibular fractures can be managed with a focus on

symptomatic care