1. Evidence-Based Minimal Intervention
Strategies for Common Pediatric
Fractures
Kathy Boutis, BSc, MD, FRCPC, MSc
Staff Emergency Physician and Associate Scientist
Associate Professor, University of Toronto
This webinar should not be reproduced without permission

2. Learning Objectives
At the end of this session, you will be able to...
1. Manage the most common pediatric fractures with
symptom-based (‘minimal’) intervention strategies
2. Explain the science behind these management choices

3. Pediatric Fractures
Pediatric fractures are very common
•
–
10-25% of all injuries
Children have unique and exceptional healing abilities
•
–
–
Callous - malunion and non union are very rare
Remodelling - children’s bones straighten as they grow
Landin LA 1997

4. callous formation

5. Three weeks after injury...
25 degrees angulated

6. One year later...
remodelling to perfect anatomic alignment

7. Pediatric Fractures - Management
•
Because of these unique healing properties, clinicians
have questioned the need for rigid immobilization for
weeks in some common pediatric fractures
•
Evidence has compared standard of care (casting) to a
more symptom based strategy for the most common,
minor pediatric fractures

8. Pediatric Fractures - Management
•
We will discuss evidence based management of the
following fractures…
1.
2.
3.
Mid-shaft clavicle fractures
Distal radius buckle fractures
Minor distal fibular fractures (isolated fibular Salter-Harris
I, II, avulsion)

9. Mid-shaft Clavicle Fracture

10. Mid-Shaft Clavicle - Evidence
Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD
J OrthopTrauma 2005;19:504-7
Treatment of acute mid-shaft clavicle fractures:
systematic review of 2144 fractures: EvidenceBased Orthopaedic Trauma Working Group
Level II Evidence

11. Mid-Shaft Clavicle - Management
• Arm sling is preferred over a figure-of-eight dressing
– sling greater comfort
– same outcomes
• Immobilization for 1-2 weeks / major pain subsides
• Follow up with range of motion exercises
• Return to sports at least 6 weeks after the injury

12. Distal Radius Buckle Fracture

13. Many faces of the buckle fracture
A
B
C

14. Distal Radius Buckle - Evidence
1. Abraham et al. Cochrane Review. 2008.
2. Khan KS et al. Acta Orthop Belg 2007;73:594-7.
3. Oakley E et al. Pediatric Emergency Care 2008;24:65-70.
4. Plint A et al. Pediatrics. 2006;117(3):691-7.
5. Stoffelen D et al. The Journal of Trauma. 1998;44:503-5.
6. West S et al. J Pediatr Orthop 2005;25:322-5.
Level I Evidence

15. Distal Radius Buckle - Management
• No indication for orthopaedic consultation
• Five randomized controlled trials - removable splint
compared to a short arm cast has similar functional
outcomes, higher patient satisfaction
– none of the trials reported re-fracture

16. Distal Radius Buckle - Management
• Removal of splint safely done at home/pediatrician’s
office and preferred by caregivers
• Duration of immobilization and return to sports as
guided by the patient’s symptoms

17. Minor Distal Fibular Fractures
Avulsion of distal fibula
Salter-Harris I of distal fibula
Avulsion of distal fibula
Salter-Harris II of distal fibula

18. Minor Distal Fibular Fractures Evidence
Gleeson et al. Journal of Bone and Joint Surgery. 1996.
Boutis K et al. Pediatrics. 2007.
Barnet P et al. Pediatric Emergency Care 2012.
Level I Evidence – all randomized control trials

19. Cast versus Sprain-like Management
• Largest RCT of minor distal fibular fractures –
BKWC (50)
vs Brace (54)
• Removable brace superior to cast with respect to
– Recovery of physical function
– Patient and parental preferences
– Cost-effectiveness

20. Minor Distal Fibular Fractures Management
• No emergency consultation of orthopedics required
• Removable posterior slab, brace, tensor are
preferred treatment choices
• Duration of immobilization and return to sports
guided by patient’s symptoms
• Follow up with primary care physician at one week

21. Summary
• Evidence supports that mid-shaft clavicle fractures,
buckle fractures of distal radius, and isolated distal
fibular fractures can be managed with a focus on
symptomatic care