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What level of immobilisation is necessary for treatment of torus (buckle) fractures of the distal radius in children?

BMJ 2021; 372 doi: (Published 07 January 2021) Cite this as: BMJ 2021;372:m4862

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Re: What level of immobilisation is necessary for treatment of torus (buckle) fractures of the distal radius in children?

Dear Editor

The authors are to be congratulated on highlighting the unnecessary use of casts for buckle/torus fractures. A splint that can be taken off at home is certainly sufficient, and removes the requirement for a follow-up visit to hospital. However, adequate instructions (written) for the parents are essential. Access to fracture clinic, if required, should also be ensured, as the authors have stated.

In our 2002 case-series (1) the only dissatisfied parents were just one family who returned to fracture clinic by mistake, and were then understandably frustrated to find that there had been no need to attend.

Where protocols encourage a "buckle pathway" from A&E it is certainly wise that the radiographs are appropriately reviewed. The distinction between a torus fracture and a greenstick one, which requires more support, is sometimes missed by less experienced clinicians. Regular audit of "buckle pathways" is recommended and helps ensure: compliance with the process; parent satisfaction and staff education.

However, is further formal research on this subject really required? The 10 trials listed in this review paper all - without exception - report that casts and follow-up are not needed. NICE Guidance is clear already.

"..studies from the US and Australia...high rates of cast immobilisation, out-patient follow-up and repeated radiographic assessment..." do not mean that "It is therefore unclear whether children with a torus fracture....require a cast...". Comparisons with the expensive and wasteful practice in these health economies, based on a fee-for-service, is just a distraction.

There are many aspects of orthopaedic trauma care where research endeavour is required. SCIENCEStudy and CRAFFTStudy are good examples. Since time and money for research are both limited, I would respectfully suggest that Torus fractures can be safely and efficiently managed on the basis of existing evidence and guidelines. The FORCE study is superfluous and probably costly.

Follow-up not required!

1 M C Solan, R Rees, K Daly. Current management of torus fractures of the distal radius. Injury.2002 Jul;33(6):503-5. doi: 10.1016/s0020-1383(01)00198-x. PMID: 12098547 DOI: 10.1016/s0020-1383(01)00198-x

Competing interests: No competing interests

20 January 2021
Matthew C Solan
Royal Surrey Hospital, Egerton Road, Guildford, Surrey UK GU2 7XX