I have had a long and circuitous relationship with the radius. When I was 9 years old, I slipped on the wet grass of our front yard in an attempt to make a highlight-reel baseball catch and landed awkwardly on my left arm. After I continued to complain for a day and a half, my mother took me to see our pediatrician, Dr. Blum. After feeling up and down my forearm and asking me to squeeze his fingers, he pronounced me well.
A week and a half later, when I was still favoring what is my dominant arm, we returned to Dr. Blum. Apparently still unimpressed with my physical exam, he begrudgingly ordered an x-ray. Hurrah! I had a fracture! But then he announced that we would treat it with a splint and an ace wrap. Come on! Everyone knows that if you break a bone you get a cast. From then on he was Dr. Bum to me.
Dr. William G. Wilkoff
For the next 2 weeks, I was forbidden to play sports, meanwhile losing serious credibility points with my peers who suspected that I was a wimp and had fabricated the whole story. And of course, does anyone go around asking their friends to sign his ace wrap ... really? It took me years of overcompensation to regain even a hint of preteen machismo.
During my last year of medical school, I leapt at the opportunity to take an elective in pediatric orthopedics. It was great! With coaching from the residents, I learned when to suspect a buckle fracture of the radius, identify it on x-ray, and best of all, how to apply a cast.
When I finally entered practice here in Brunswick, we were seriously short of specialists, including orthopedists. When it was discovered that I knew how to apply a forearm cast, the orthopedists encouraged me to treat my own patients with simple forearm fractures. They were more than busy enough with really exciting stuff.
As an artist at heart, the chance to mold in plaster and plastic was a special treat. I took great pride in my creations, and making a beautiful crafted cast was sometimes the high point of my day. No splints or wimpy ace wraps for my patients!
Parents loved the one-stop shopping. History, exam, x-ray, casting, and out the door in less than an hour. Because I was the only primary care physician in town who was casting fractures, I occasionally had to remind the emergency room physicians to send me my patients with buckle fractures instead of knee-jerking a referral to an orthopedist.
But then about 10 years ago, some party-pooping orthopedists from who-knows-where looked at a very large series of pediatric patients with buckle fractures of the radius and discovered that those patients treated with splints had at least as good results as those who had been casted. And ... the patients and parents preferred the splints. I had to admit that maybe Dr. Blum wasn’t such a bum after all. Sadly, I had to respond to the evidence by giving up my hobby except when a child’s temperament or past history of injury suggested that he or she might benefit from the extra protection a cast could afford.
A recent study from Toronto published in Pediatrics, “Primary Care Physician Follow-up of Distal Radius Buckle Fractures,” by Koelink et al., makes me wonder whether a splint and ace wrap may even be overtreatment (Pediatrics. 2016 Jan;137[1]:11-9. doi: 10.1542/peds.2015-2262). In this review of 200 pediatric patients with distal radius buckle fractures, the investigators found that regardless of whether the primary care physician discussed how long to use the splint or when to return to activity, more than two-thirds of the patients wore their splints less than 3 weeks. Despite what the authors considered suboptimal primary care physician guidance, 99% of the patients returned to usual activities within 4 weeks.
My mother and Dr. Blum were on the right track from the beginning. They just needed to ignore my complaints a few days longer.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”