Rockwood Children CH8

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CHAPTER 8 • Fractures of the Distal Radius and Ulna

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B

Figure 8-25.  Anteroposterior ( A ) and lateral ( B ) radiographs of a distal radius torus fracture.

Splint Immobilization of Torus Fractures By definition, torus fractures are compression fractures of the distal radial metaphysis and are therefore inherently stable (Fig. 8-25). There is typically minimal cortical disruption or displacement. As a result, treatment should consist of pro- tected immobilization to prevent further injury and relieve pain. Multiple studies have compared the effectiveness and cost of casting, splinting, and simple soft bandage applica- tion in the treatment of torus fractures. As expected, there is little difference in outcome of the various immobilization techniques. 2,21,102,147,163,173,182,207 Davidson et al. 43 randomized 201 children with torus fractures to plaster cast or removable wrist splint immobili- zation for 3 weeks. All patients went on to successful healing without complications or need for follow-up clinical visits or radiographs. Similarly, Plint et al. 161 reported the results of a prospective randomized clinical trial in which 87 children were treated with either short-arm casts or removable splints for 3 weeks. Not only were there no differences in healing or pain, but also early wrist function was considerably better in the splinted patients. West et al. 209 even challenged the need for splinting in their clinical study randomizing 39 patients to either plaster casts or soft bandages. Again, fracture healing was universal and uneventful, and patients treated with soft ban- dages had better early wrist motion. Given the reliable healing seen with torus fracture healing, Symons et al. 186 performed a randomized trial of 87 patients treated with plaster splints to either hospital follow-up or home removal. No difference was seen in clinical results, and patient/ families preferred home splint removal. A similar study by Khan et al. 115 confirmed these findings. No differences in outcomes

were seen in 117 patients treated with either rigid cast removal in fracture clinic versus soft cast removal at home, and families preferred home removal of their immobilization. A meta-analysis of torus and minimally displaced fractures treated by removable splints instead of circumferential casts was found to have improved secondary outcomes for the patient and family and with equal position at healing. 11 SCAMPs (Stan- dardized Clinical Assessment and Management Plans) work from Boston Children’s Hospital has indicated that reduction in casting and postinjury radiographs, coupled with phone call follow-up visits, have lessened direct and indirect costs, radi- ation and cast saw injury risk significantly, with no change or improved outcome for torus fractures. 130,131 Therefore, simple splinting is sufficient, and once the patient is comfortable, range-of-motion exercises and nontrau- matic activities may begin. Fracture healing usually occurs in 3 to 4 weeks. 2,10 Simple torus fractures heal without long-term sequelae or complications.

Cast Immobilization of Nondisplaced or Minimally Displaced Distal Radial Metaphyseal and Physeal Fractures

Nondisplaced fractures are treated with cast immobilization until appropriate bony healing and pain resolution have been achieved. 47,52,175 Although these fractures are radiographically well aligned at the time of presentation, fracture stability is dif- ficult to assess and a risk of late displacement exists (Fig. 8-26). Serial radiographs are obtained in the first 2 to 3 weeks pos- treduction to confirm maintenance of acceptable radiographic alignment. In general, most fractures will heal within 4 to 6 weeks.