Delayed treatment does not adversely affect clinical outcome. Our study objective was to compare clinical outcomes of buckle fractures treated acutely on the same day of injury with outcomes of those treated subacutely. The 2 groups did not differ in extent or angulation of fracture at presentation. We found no difference in outcomes between the groups; all fractures healed without complication. We observed no difference in final angulation of fracture on follow-up imaging. Though our institution routinely obtains follow-up films, it is worth mentioning that the utility of repeat films in pediatric buckle fractures with minimal initial angulation has been debated.5 These data suggest that subacute treatment of a buckle fracture is a safe and reasonable option.
Non-ED treatment substantially reduces cost. One goal of efficient health care delivery is to decrease the cost and burden of care without increasing long-term morbidity and disability. Evidence suggests that families may prefer less acute management options that allow greater convenience and flexibility, provided that clinical outcomes are not compromised.8 In the case of pediatric buckle fractures, higher costs (for both the patient and the hospital) and longer wait times related to ED care may be avoided by counseling patients on the option of subacute care. Our study found that referring patients directly to the orthopedic clinic, even if this results in a delay in definitive management, leads to a reduction in health care burden without a change in clinical outcome.
Children with buckle fractures are frequently (46.6%) taken to their PCP for initial care. Many pediatricians and family physicians—especially the increasing number of physicians who have completed additional fellowship training in sports medicine—may prefer to manage buckle fractures within their practices. Many other PCPs may be practicing in communities lacking local orthopedic expertise. The results of this study provide reassurance regarding the positive outcome of buckle fractures. Furthermore, managing buckle fractures in the primary care setting may be even more cost effective than referring patients to a specialty orthopedic clinic—but additional research on this point is needed.
We do not advocate delayed imaging or treatment of suspected fractures. However, once a diagnosis of buckle fracture is confirmed radiographically, our data show that subacute treatment yields significant cost and time savings without affecting final clinical outcome.
Study limitations
This study is limited by its retrospective data collection in 1 pediatric tertiary care hospital. As current clinical practice is to treat all buckle fractures once identified, very few patients with known injury were specifically treated in a subacute fashion. We defined the subacute care group as patients who were treated >1 day from the time of injury. Because initial splinting did not occur in this group, we expect that the observed results would be similar, and no worse, compared with buckle fracture care directed by a subacute treatment algorithm.
This study examined only patients with a diagnosis of isolated buckle fracture. Non-buckle stable fractures were excluded a priori from our patient population. Although it is possible that most stable fractures (eg, nondisplaced transverse fractures, Salter-Harris I injuries) could be managed subacutely, we addressed only isolated buckle fractures.
Because of the universally positive outcomes in these cases, most of our patients had no orthopedic follow-up beyond 1 month. We are not able to comment on whether any longer-term abnormalities in function occurred. This question could be addressed through a prospective trial requiring reevaluation of each patient at a set endpoint of the study.
Although buckle fractures are inherently stable and do not present a significant risk of displacement with delayed treatment, they are nevertheless painful fractures that can be a cause of considerable anxiety for both patient and family. The goal of the physician, beyond ensuring the best medical outcome, extends to provide emotional support to the patient and family. Pain control and reassurance are therefore central to the discussion of fracture management, and are most likely the driving factor for a patient to seek urgent care. A key limitation of this study was the inability to determine differences in pain control between acute and subacute treatment. As mentioned above, a prospective study would enable the issue of pain control to be better addressed.