Journal Article

Immobilisation of torus fractures of the wrist in children

2022

Overview

A ‘torus’ (Greek for ‘bulge’ often seen at the base of Greek columns) fracture, or a ‘buckle’ fracture of the wrist, is one of the most common minor injuries seen in a Paediatric Emergency Department. Many centres will recommend cast immobilisation, discharge, follow-up, and repeat imaging. Is that the best way? Perry DC et al [Lancet 2022; 400: 39–47. DOI:https://doi.org/10.1016/S0140-6736(22)01015-7] and the PERUKI research network have published a beautifully pragmatic, properly powered, randomised, open, equivalence study which compared pain and function in children with a distal radial torus fracture offered a soft bandage and immediate discharge and no follow-up with those receiving a more traditional management of rigid immobilisation and follow-up. They recruited 965 children (aged 4–15 years) presenting with a distal radius torus fracture (with or without associated ulnar fracture) from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using a web-based randomisation software. Treating clinicians, participants, and their families could not be blinded to treatment allocation. Exclusion criteria included multiple injuries, greenstick fractures, diagnosis at more than 36 hours after injury, and inability to complete follow-up. The primary outcome was pain at 3 days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. Secondary outcomes that were proxy reported for participants younger than 8 years and self-reported by participants aged 8 years and older were: functional recovery using Patient Report Outcomes Measurement System (PROMIS Bank version 2.0) Upper Extremity Score for Children Computer Adaptive Test, which was collected at baseline, 3, and 7 days, and 3 and 6 weeks and health-related quality of life using the EuroQol 3-level EQ-5DY (EQ-5DY-3L), which is a child-friendly version of the EQ-5D-3L. During the eighteen months recruitment period, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 586 (61%) were boys. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group vs 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was –0·10 (95% CI –0·37 to 0·17) and–0·06 (95% CI –0·34 to 0·21) in the per-protocol population. Essentially, this trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up. There were no safety concerns. So, it appears that this form of de-escalation the treatment of children with a torus fracture of the distal radius is appropriate. These results will be incorporated into the next updated UK National Institute for Health and Care Excellence guideline with an aim to rationalise the overuse of healthcare resources. This is another example of how a well-organised research network delivers a simple answer to a simple question. Congratulations to the researchers for such a well-constructed study.

• Publisher: BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health,BMJ Publishing Group LTD
• Subject: Adaptive Testing / Children / Fractures / Immobilization / Injuries / Miscellanea / Pain / Pediatrics / Quality of life / Rating Scales / Recovery of function / Wrist