OBJECTIVES: Our main objective was to determine the proportion of children referred to a primary care provider (PCP) for follow-up of a distal radius buckle fracture who subsequently did not deviate from this reassessment strategy.
METHODS: This prospective cohort study was conducted at a tertiary care pediatric emergency department (ED). Eligible children were aged 2 to 17 years with a distal radius buckle fracture treated with a removable splint and referred to the PCP for reassessment. We telephoned families 28 days after their ED visit. The primary outcome was the proportion who received PCP follow-up exclusively. We also measured the proportion who received PCP anticipatory guidance and those children who reported returning to usual activities “always” by 4 weeks.
RESULTS: We enrolled 200 children, and 180 (90.0%) received telephone follow-up. Of these, 157 (87.2% [95% confidence interval: 82.3 to 92.1]) received PCP follow-up exclusively. Specifically, 11 (6.1%) families opted out of physician follow-up, 5 (2.8%) self-referred to an ED, and the PCP requested specialty consultation in 7 (3.9%) cases. Of the 164 with a PCP visit, 77 (47.0%) parents received anticipatory guidance on return to activities for their child, and 162 (98.8%) reported return to usual activities within 4 weeks.
CONCLUSIONS: The vast majority of children with distal radius buckle fractures presented to the PCP for follow-up and did not receive additional orthopedic surgeon or ED consultations. Despite a suboptimal rate of PCP advice on return to activities, almost all parents reported full return to usual activities within 4 weeks.
- CI —
- confidence interval
- ED —
- emergency department
- OR —
- odds ratio
- PCP —
- primary care provider
What's Known On This Subject:
Distal radius buckle fractures have an excellent prognosis. They are often managed by orthopedic surgeons, but primary care providers (PCPs) may also be able to reassess these low-risk injuries. Currently, no data are available on PCP follow-up of this injury.
What This Study Adds:
The majority of children with distal radius buckle fractures presented to the PCP for follow-up and received no additional orthopedic or emergency department consultation. Almost all parents reported a full return to usual activities within 4 weeks for their child.
A buckle fracture of the distal radius is the most common type of fracture in childhood and represents ∼20% of all pediatric fractures.1 Despite their high frequency, these fractures represent very stable injuries with excellent prognosis.2 As a result, extensive evidence recommends their treatment with a removable wrist splint, rather than the traditional use of casting.2–8 After the initial diagnosis and treatment, most of these fractures are managed by orthopedic surgeons.9 Given that intervention by an orthopedic specialist is rarely required for these fractures, it may also be appropriate to have these low-risk injuries followed up by the primary care provider (PCP).
However, some studies suggest there may be knowledge deficits in the management of this injury by PCPs because education in musculoskeletal injuries is often lacking in family practice and pediatrics residency training.10–12 Thus, PCP follow-up may result in unwarranted referrals to orthopedic surgeons or emergency departments (EDs), as well as inappropriate anticipatory guidance for this injury regarding duration of splint use or readiness for return to activities. Because 90% of these injuries are currently managed by orthopedic surgeons,9 and there are no studies demonstrating whether PCP follow-up is adequate for this common injury, it is important to examine the management outcomes of children with distal radius buckle fractures referred to the PCP for follow-up before implementing this strategy as a practice standard.
The main objective of the present study was to determine the proportion of children referred to a PCP for follow-up of a distal radius buckle fracture who subsequently received PCP follow-up and were not referred to an orthopedic surgeon or ED physician. Based on the excellent prognosis of this fracture,2 we hypothesized that ∼90% of participants would receive PCP follow-up exclusively for this injury.
Study Design and Setting
This prospective cohort study was conducted in an urban university–affiliated tertiary care children's ED in Toronto, Canada.
A convenience sample of children aged 2 to 17 years diagnosed with a distal radius buckle fracture13 were enrolled and referred to the PCP for follow-up. Children were also eligible if the distal radius buckle fracture was associated with a distal ulnar buckle/styloid fracture.2,14 Patients were excluded if image review resulted in a different diagnosis. Other exclusion criteria involved patients at risk for pathologic fractures, multiple injuries, developmental delay affecting assessment, history of fracture in the same forearm within 3 months, and those who could not complete follow-up due to lack of telephone access or an insurmountable language barrier. The study was approved by the Hospital for Sick Children Research Ethics Board.
Research assistants present from 8:30 to 2:30 daily screened the ED electronic tracking system to identify children presenting with wrist injuries. In cases confirmed as having a distal radius buckle fracture and meeting eligibility criteria, the research assistant obtained informed consent and assent where applicable. Research assistants completed a study data collection sheet to capture demographic information, management, and type of PCP (family physician, pediatrician, or none). A PCP is the physician identified by the family who regularly sees the child for well-child and sick visits.
At discharge, parents were provided with an information handout that discussed the diagnosis and recommended PCP follow-up in 2 weeks. At the study institution, follow-up of distal radius buckle fractures by the PCP is the standard of care, and thus these injuries are not routinely referred to an orthopedic surgeon. Upon implementation of this practice standard, there was no education outreach to the PCPs, and the management outcomes of this practice have never been examined.
All study radiographs were reviewed by a pediatric radiologist specializing in musculoskeletal injuries within 72 hours. Discordant interpretations from the ED interpretation and respective changes in management were reported to the family. All enrolled families were contacted by telephone at day 28 after the ED visit to allow adequate time for contact with the PCP. This time frame also allowed adequate recall of events by parents.15 For those with continued symptoms, weekly telephone calls were made after day 28 until patients reached full recovery. We chose telephone contact (versus in-person contact) to maximize compliance with follow-up2,16 and to remove the impact that a hospital visit may have on PCP and/or other physicians’ visits. Other rigorously designed studies support the use of parental recall via telephone follow-up with respect to reports on physician visits within the time frame used in this study.,17,18
Families were asked about the following details related to the index fracture: clinical status, pain (never, occasionally, often, or always) and return to usual activities (always, most of the time, some of the time, not very often, or never); type (if any) of physician follow-up; parent management of splint usage and return to activities; and physician visits and diagnostic imaging taken after the ED visit, with respective changes in diagnosis/treatment. Families were also asked about their satisfaction with PCP follow-up and PCP-recommended time frames for splint usage and return to usual activities.
The primary study outcome was the proportion of participants referred to the PCP for follow-up of a distal radius buckle fracture who, after ED discharge, received PCP follow-up and did not have visits to other physicians for this injury (ie, exclusive PCP follow-up). This outcome is clinically relevant as a measure of physician ability and willingness to manage the injury without additional specialty consultation, and it also measures the feasibility of this follow-up strategy for parents. Although follow-up of this fracture was not routinely accepted at the study institution's orthopedic clinic, follow-up of distal radius buckle fractures are routinely accepted into several other orthopedic clinics in the study region; thus, PCPs do have the option of referring these children to fracture clinics at a different hospital.
As secondary outcomes, we also reported the frequency of each type of deviation from exclusive PCP follow-up. To explore PCP management of these injuries, the following factors were examined: (1) mean number of physician visits; (2) proportion of children who received repeat radiographs at the PCP visit; (3) comparison of physician-recommended timelines on splint usage and return to activities versus those applied by the parents; and (4) variables that may be independently associated with lack of anticipatory guidance on return to activity provided at the PCP visit (pediatrician versus family physician; age ≤5 years versus >5 years; radius and ulna fractures versus isolated radius fracture). We also examined the proportion of children with a poor or prolonged recovery, defined as pain/limitation of activity >6 weeks13,19 and re-injury that leads to re-fracture. To establish the convenience and satisfaction with PCP follow-up, the mean distance of a PCP clinic from the family home versus the mean distance of the hospital from the family home was determined. We also determined the proportion of families who reported being “very satisfied/satisfied” with PCP follow-up for this injury as measured by using a 5-point categorical scale.
Based on PCP knowledge of managing these injuries,7,10,20,21 we estimated that 90% of participants would receive follow-up with the PCP exclusively. Therefore, assuming a primary outcome proportion of 0.90 and a 95% confidence interval (CI) precision of ±0.05 yields a minimum number of 158 patients (PASS, 2011; NCSS, LLC, Kaysville, UT).
Descriptive statistics were used to summarize responses. Proportions were compared by using a χ2 test. Logistic regression was used to determine the association between variables and the binary outcome of anticipatory guidance on return to activities given in follow-up or the lack thereof. All variables were entered into a full (ie, saturated) multivariable logistic regression model. Odds of anticipatory guidance for a given variable were reported with respective 95% CIs. All analyses were completed by using SPSS version 20 (IBM SPSS Statistics, IBM Corporation, Armonk, NY).
During the study period, 297 children were diagnosed with a distal radius buckle fracture, 247 met enrollment criteria in the ED, and 223 (90.3%) consented to participate (Fig 1). There were no significant differences in the mean age (P = .34) or gender (P = .12) of children who consented to participate versus those who declined. Upon image review, 23 (10.3%) of the 223 enrolled children were found to have ED physician diagnostic errors.
Of the remaining 200 enrolled children, 109 (54.5%) were male, and the mean ± SD age was 8.4 ± 3.4 years. Specifically, 33 (16.5%) were aged 2 to 4 years, 65 (32.5%) were aged 5 to 7 years, 63 (31.5%) were aged 8 to 10 years, 25 (12.5%) were aged 11 to 12 years, and 14 (7.0%) were aged ≥14 years. There were 183 (91.5%) patients who demonstrated skeletal immaturity (open physes) on radiographs. In this cohort, 191 (95.5%) identified a regular PCP; 110 (55.0%) used a pediatrician. A total of 66 (33.0%) participants had buckle fractures of the ulna as well as the distal radius. Telephone follow-up was successful in 180 (90.0%) of the 200 enrolled children.
Orthopedic Referral, ED Visits, and No Physician Follow-up
Of the 180 children with distal radius buckle fractures who received the study telephone follow-up, 157 (87.2% [95% CI: 82.3 to 92.1]) received exclusive PCP follow-up (Fig 2). Specifically, 11 (6.1%) families opted out of any physician follow-up due to a reported lack of need; 5 (2.8%) self-referred to an ED for a second opinion; and the PCP referred 7 (3.9%) children for further ED care (3 for a broken splint) or orthopedic consultation (4 for a second opinion). None of the families who received a second opinion by the ED or an orthopedic surgeon were given a different diagnosis or management. If we assume that all 20 patients lost to follow-up either did not receive a PCP visit or received orthopedic/ED consultation, the proportion of those who received exclusive PCP follow-up would be 157 of 200 (78.5% [95% CI: 72.3 to 83.6]).
Of the 23 patients with ED physician diagnostic errors, 7 children had no fractures and were advised that splinting and follow-up were no longer required. The remaining 16 injuries represented subtle examples of more complex fractures. Fourteen of these were greenstick fractures of the distal radius metaphysis (2 minimally displaced at ≤15 degrees; 12 nondisplaced) that were managed with a removable splint for the duration of therapy. There were also 2 cases of minimally displaced Salter-Harris type II fractures of the distal radius that were immobilized with a cast and healed to anatomic alignment by 6 months. Figure 3 presents the ED radiographs of the children with the highest degree of displacement. In this subset of 16 cases, there was no further displacement on follow-up radiographs, and parents reported a full return to baseline activities by 4 weeks.
Resource Use of PCP Visits
Of the 164 patients with distal radius buckle fractures with PCP follow-up, 123 (75.0%) visited their PCP once after the index ED visit, 35 (21.3%) visited twice, and 6 (3.7%) were seen 3 times. In addition, 126 (76.8%) children followed up with their PCP at 2 to 3 weeks after the ED visit, 15 (9.1%) were seen within 1 week, and 23 (14.0%) were seen in 4 to 5 weeks due to scheduling issues. Seven (4.3%) patients had repeat wrist radiographs ordered by the PCP.
Splint Use and Return to Activities
Parents reported <3 weeks of splint usage in 112 (68.3%) of 154 cases (Fig 4). According to parental report, duration of splint use was not discussed by the PCP with 77 (47.0%) parents. However, the reported frequency of splint usage in the group that did not receive specific physician advice on this topic was not significantly different from that reported by parents who did receive specific PCP advice on duration of splint use (P = .72). In contrast, the proportion of parents who opted for splint use for ≤3 weeks was 72.9% versus 54.0% of physicians who recommended this time frame to parents (P < .0001).
When asked about their PCP-recommended time to return to normal activities, 87 (53.1%) families stated lack of specific advice about this issue (Fig 5). There were no differences in reported return to activities in patients who received physician advice versus those who did not (P = .79). Family physicians versus pediatricians were more likely to provide activity anticipatory guidance on return to activities (odds ratio [OR]: 2.1 [95% CI: 1.1 to 4.1]). However, young age (≤5 years versus >5 years) and fracture of both radius and ulna were not likely to provide guidance (OR: 1.0 [95% CI: 0.4 to 2.4]; OR: 1.1 [95% CI: 0.5 to 2.2], respectively). Of the 75 families who received PCP anticipatory guidance advice, 59 (78.7%) opted for return to activities in <3 to 4 weeks versus 38.3% of the PCPs who reportedly recommended this time frame (P < .0001).
Clinical Recovery and Parental Satisfaction
In the 164 children with distal radius buckle fractures and PCP follow-up, 162 (98.8%) reported recovery to usual activities within 4 weeks; 2 patients had occasional pain until 6 weeks after injury. Parental satisfaction was reported as follows: 117 (71.3%), very satisfied; 39 (23.8%), satisfied; 5 (3.1%), neither satisfied/unsatisfied; 2 (1.3%), unsatisfied; and 1 (0.6%), very unsatisfied. The mean distance from a patient's home to the PCP was 7.8 ± 9.6 km, and the respective distance to the treatment hospital's orthopedic clinic was 12.7 ± 14.5 km, a mean difference of 4.9 km (95% CI: –7.2 to –2.6).
This study showed that the majority of children with distal radius buckle fractures were followed up exclusively by the PCP. Despite the suboptimal rate of PCP anticipatory guidance on splint use and return to activities, parents reported a full return to usual activities within 4 weeks, which represents an expected time frame for this injury.2
Considerable practice variation exists in the care of distal radius buckle fractures after the index ED visit. Approximately 99% of pediatric orthopedic respondents in a US-based survey reported these fractures to be at “very low/low risk” for future complications, but 90% still recommended an orthopedic reassessment of this fracture.9 In Canada, ∼50% of patients with these injuries are referred from the ED to the PCP for follow-up.22 The present study's findings support the premise that PCP care represents a safe and feasible follow-up option for this low-risk fracture. Despite previous reports that parents may prefer care by orthopedic surgeons,20 our study found that parents reported a high degree of satisfaction with PCP follow-up, and PCP offices were significantly closer to patients’ homes. Importantly, most of the patients who saw a PCP only required 1 visit, and very few had repeat imaging. This finding contrasts with the practice in some orthopedic clinics in which several visits and repeat radiographs seem to be common,23,24 leading to increased health care costs, loss of patient and provider time, and exposure to potentially unnecessary radiation.23
Approximately 10% of injuries diagnosed by the ED physician as distal radius buckle fractures were subtle examples of more complex injuries. Other studies have found a similar frequency and type of misdiagnosis by ED physicians when considering this injury.2,7 Nevertheless, healing of these more complex injuries is excellent because the distal radius has one of the highest capacities for remodeling.25 An intervention by an orthopedic surgeon is rarely required,25–27 and these fractures can generally be safely treated by using a splint. However, these injuries may require longer immobilization and different anticipatory guidance.13 Because diagnostic errors in radiograph interpretation by the ED physician can result in a change in management,28–33 we recommend a robust quality assurance system for ED physician image interpretation34 to ensure errors are recognized and acted on.
Only approximately one-half of participating parents reported receiving PCP recommendations with respect to 2 key elements of anticipatory guidance: duration of splint usage and return to normal activities. This relatively low rate of PCP advice may be related to the limited PCP expertise in this area. A recent survey of pediatricians across Canada and the United States found that ∼45% of respondents reported perceived knowledge deficits in anticipatory guidance of minor common pediatric fractures.20 Although ∼70% of these respondents supported PCP office management of this injury, they anticipated benefit from further related education. Interestingly, most parents removed the splint and returned their children to activities by 3 to 4 weeks, regardless of the PCP advice on this matter. The latter finding is consistent with the data reported by Plint et al,2 in which families were advised to use the splint as needed, and ∼95% were no longer using it by 4 weeks. Given the excellent prognosis of this injury, lack of reported complications, and the conservative physician guidance compared with choices influenced by patient symptoms, PCPs would likely benefit from further related education while assuming primary responsibility of follow-up of these injuries.
This study has limitations. There was no orthopedic surgeon comparator group, limiting comparisons of PCP versus orthopedic surgeon follow-up outcomes. Nevertheless, our study has value in demonstrating the feasibility of PCP follow-up without the need for further specialty consultation for this injury. Our outcomes were susceptible to the accuracy of parental recall and were not corroborated with physician records; functional recovery in particular was subject to parental interpretation and not validated by a scale35 or health care professional. Our results may not be generalizable to areas in which many patients lack a PCP. However, ∼5% of our patients opted out of any follow-up care due to reported lack of need, a finding also present in other studies examining this population.2,7 Although there is 1 study supporting no physician follow-up of distal radius buckle fractures,36 future research examining this strategy may be warranted. Our reported rate of misdiagnosis may differ from other ED settings with different levels of expertise in pediatric musculoskeletal image interpretation.
The vast majority of children with distal radius buckle fractures presented to the PCP for follow-up and received no additional orthopedic surgeon or ED consultation. Many parents did not receive PCP anticipatory guidance on splint use and return to activities. Furthermore, when PCPs did provide this guidance, their timelines were more conservative than patient-guided choices. The latter 2 findings suggest that PCPs may benefit from further education in this area, which echoes the desire for more education on office management of minor pediatric fractures previously reported by PCPs.20
The authors acknowledge the Pediatric Research Academic Initiative at SickKids Emergency (PRAISE). This research would not have been possible without the superb efforts of the program manager, Johanna Crudden, and the participating PRAISE research assistants.
- Accepted September 28, 2015.
- Address correspondence to Kathy Boutis, MD, MSc, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: The Hospital for Sick Children funded the research support received via the Pediatric Research Academic Initiative at SickKids Emergency (PRAISE) program.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2016 by the American Academy of Pediatrics