Soft bandage, splint or cast as the treatment of distal forearm torus fracture in children

Key points

1. 01All 1550 children across 7 RCTs healed their torus fracture within 3-4 weeks regardless of treatment method
2. 02Splint caused slightly more pain than cast in the first week (MD 1.46, CI 0.84-2.08) but led to faster return to sports activities at 3 weeks (RR 1.77) and 4 weeks (RR 1.44)
3. 03Bandage caused only a marginally higher pain score than rigid immobilization on day 1 (MD 0.35, CI 0.04-0.66), a difference below the minimal clinically important threshold, with no difference at later time points
4. 04Complication rates were very low across all treatment groups, with high-certainty evidence of no difference between bandage and rigid immobilization (RD 0.00, CI -0.01 to 0.02)
5. 05Routine follow-up visits are unnecessary since practically all torus fractures heal well within a few weeks

How it was conducted

Design

Systematic review and meta-analysis of randomized controlled trials

Databases searched

PubMed (MEDLINE), Scopus, Web of Science; searched January 2023

Studies included

7 RCTs with 1550 patients

Participants

Children under 18 years with radiologically confirmed distal radius and/or ulna torus fracture; mean age 8.9-9.9 years across studies

Comparisons

(1) removable wrist splint versus cast; (2) soft bandage versus rigid immobilization (splint or cast)

Primary outcomes

Pain (VAS/NRS/Wong-Baker 0-10), clinical healing, and time to return to activities

What they found

• Splint vs cast - pain at 3 days: MD 1.00 (CI 0.06, 1.94); 1 study, 94 patients; moderate-certainty evidence
• Splint vs cast - pain at 1 week: MD 1.46 (CI 0.84, 2.08); 2 studies, 161 patients; moderate-certainty evidence
• Splint vs cast - pain across all time points pooled: MD 0.70 (CI 0.17, 1.23); 3 studies, 213 patients
• Splint vs cast - clinical healing: RR 1.00 (CI 0.98, 1.02); 2 studies, 316 patients; low-certainty evidence; all fractures healed in both groups
• Splint vs cast - return to sports at 3 weeks: RR 1.77 (CI 1.09, 2.88); 1 study, 57 patients; moderate-certainty evidence
• Splint vs cast - return to sports at 4 weeks: RR 1.44 (CI 1.11, 1.82); 1 study, 60 patients; moderate-certainty evidence
• Splint vs cast - problems with immobilization device: RD -0.11 (CI -0.21, -0.01); 1 study, 87 patients; low-certainty evidence (favoring splint)
• Bandage vs rigid immobilization - pain day 1: MD 0.35 (CI 0.04, 0.66); 1 study, 790 patients; moderate-certainty evidence
• Bandage vs rigid immobilization - pain across all time points pooled: MD 0.07 (CI -0.04, 0.19); 2 studies, 963 patients; no evidence of difference
• Bandage vs rigid immobilization - complications: RD 0.00 (CI -0.01, 0.02); 2 studies, 947 patients; high-certainty evidence
• One study reported 1% complication rate in both bandage and rigid immobilization groups (908 patients), with 7/8 reported complications being misdiagnoses

Limitations

• Majority of outcomes were measured in fewer than half of the included studies, and measurement methods varied greatly across studies
• High statistical heterogeneity likely caused by differences in patient populations, follow-up schedules, and outcome measurement tools; meta-regression was not possible due to the low number of studies
• Patient characteristics such as age, sex, and injured side were reported separately for each study group in only about half of the original studies, limiting subgroup analysis
• Results may not generalise to very young children with limited compliance, patients with multiple injuries, metabolic bone diseases, or language barriers

Why it matters

For patients

A child with a buckle fracture can expect full healing within 3-4 weeks whichever treatment is chosen, but a removable splint or soft bandage will likely make everyday activities like bathing easier and allow a faster return to sport compared to a rigid cast.

For clinicians

Soft bandage or removable wrist splint should be considered the first-line treatment for distal forearm torus fractures in children; cast may be reserved for atypically painful cases or as a short initial bridge before transitioning to lighter immobilization.

For readers

This meta-analysis provides moderate-certainty evidence that lighter immobilization options are at least as effective as casting for healing and carry fewer practical drawbacks, supporting a move away from routine casting for this common paediatric fracture.