Primary Care Physician Follow-up
of Distal Radius Buckle Fractures
Eric Koelink, MD,a Suzanne Schuh, MD,b Andrew Howard, MD, MSc,c Jennifer
Stimec, MD,c Lorena Barra, MD,d Kathy Boutis, MD, MScb
OBJECTIVES: Our main objective was to determine the proportion of children referred
abstract
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.
aDivision
of Emergency Medicine, Department of Pediatrics, McMaster University Medical Centre and McMaster
University, Hamilton, Ontario, Canada; bDivision of Emergency Medicine, Department of Pediatrics, cDivision of
Orthopedics, Department of Surgery, and dDepartment of Diagnostic Imaging, The Hospital for Sick Children
and University of Toronto, Toronto, Ontario, Canada
Dr Koelink was involved in the critical development of the research proposal, data collection tools,
and research ethics approval; he oversaw all research operations in patient enrollment, as well
as data collection and entry. Dr Koelink had full access to the data, significantly contributed to the
interpretation of the analyses, and wrote initial drafts of the manuscript. Dr Schuh was primarily
involved in the initial design of the work and development of the research proposal; she also
contributed to interpretation of the results and intellectual input of key study results, and revised
the article critically for important intellectual content. Dr Stimec was involved in the initial design
of the research study and was the content expert in pediatric musculoskeletal radiology; she
independently interpreted the images of all the enrolled cases, contributed to interpretation of
results and intellectual input of key study results, and revised the article critically for important
intellectual content. Dr Howard was primarily involved in the initial design of the study and
development of the research proposal; he also contributed to the interpretation of study results
and revised the article critically for important intellectual content. Dr Barra contributed to the
study methodology and led the logistical operations of patient enrollment; she conducted all
patient follow-up, instituted mechanisms in the study to ensure high follow-up capture, performed
all data entry, and reviewed the manuscript. Dr Boutis is the responsible author and as such has
full access to the data and has final responsibility for the decision to submit for publication. She
PEDIATRICS Volume 137, number 1, January 2016:e20152262
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.
To cite: Koelink E, Schuh S, Howard A, et al. Primary Care
Physician Follow-up of Distal Radius Buckle Fractures.
Pediatrics. 2016;137(1):e20152262
ARTICLE
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
2
participants would receive PCP
follow-up exclusively for this injury.
METHODS
Study Design and Setting
This prospective cohort study was
conducted in an urban university–
affiliated tertiary care children's ED
in Toronto, Canada.
Study Population
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.
Patient Recruitment
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.
Follow-up
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
KOELINK et al
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.
Outcomes
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
PEDIATRICS Volume 137, number 1, January 2016
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.
Data Analyses
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).
RESULTS
Patients
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
3
(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
FIGURE 1
Patient enrollment. aExclusions total >50 because some patients had >1 exclusion criterion.
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
FIGURE 2
Follow-up of children diagnosed with a distal radius buckle fracture in the ED.
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
4
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
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).
KOELINK et al
When asked about their PCPrecommended 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).
DISCUSSION
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
PEDIATRICS Volume 137, number 1, January 2016
FIGURE 3
Injuries misdiagnosed as a distal radius buckle fracture by the ED physician. A, Greenstick fracture
of distal radius. B, Salter-Harris type II fracture of the distal radius.
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
5
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
FIGURE 4
Splint usage reported by parents.
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.
FIGURE 5
Return to activities reported by parents.
6
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
KOELINK et al
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.
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 patientguided 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
ACKNOWLEDGMENTS
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.
ABBREVIATIONS
CONCLUSIONS
The vast majority of children with
distal radius buckle fractures
presented to the PCP for follow-up
CI: confidence interval
ED: emergency department
OR: odds ratio
PCP: primary care provider
lead and provided most input into the intellectual content of the research proposal, developed all data collection forms, performed all the analyses, and had the
most major role in the interpretation of results. She contributed most significantly to the initial drafts and critical revisions of the manuscript and gave final
approval of the submitted version. All authors gave final approval of the submitted version.
DOI: 10.1542/peds.2015-2262
Accepted for publication Sep 28, 2015
Address correspondence to Kathy Boutis, MD, MSc, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
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.
PEDIATRICS Volume 137, number 1, January 2016
7
REFERENCES
1. Landin LA. Epidemiology of children’s
fractures. J Pediatr Orthop B.
1997;6(2):79–83
2. Plint AC, Perry JJ, Correll R, Gaboury
I, Lawton L. A randomized, controlled
trial of removable splinting
versus casting for wrist buckle
fractures in children. Pediatrics.
2006;117(3):691–697
3. Abraham A, Handoll HH, Khan T.
Interventions for treating wrist
fractures in children. Cochrane Syst
Rev. 2008;(2):CD004576
4. Davidson JS, Brown DJ, Barnes SN,
Bruce CE. Simple treatment for torus
fractures of the distal radius. J Bone
Joint Surg Br. 2001;83(8):1173–1175
5. Firmin F, Crouch R. Splinting versus
casting of “torus” fractures to
the distal radius in the paediatric
patient presenting at the emergency
department (ED): a literature review.
Int Emerg Nurs. 2009;17(3):173–178
6. Khan KS, Grufferty A, Gallagher O,
Moore DP, Fogarty E, Dowling F. A
randomized trial of ‘soft cast’ for distal
radius buckle fractures in children.
Acta Orthop Belg. 2007;73(5):594–597
7. West S, Andrews J, Bebbington A,
Ennis O, Alderman P. Buckle fractures
of the distal radius are safely treated
in a soft bandage: a randomized
prospective trial of bandage versus
plaster cast. J Pediatr Orthop.
2005;25(3):322–325
8. Witney-Lagen C, Smith C, Walsh G. Soft
cast versus rigid cast for treatment
of distal radius buckle fractures in
children. Injury. 2013;44(4):508–513
9. Boutis K, Howard A, Constantine
E, Cuomo A, Somji F, Narayanan U.
Evidence into practice: pediatric
orthopaedic surgeon use of removable
splints for common pediatric fractures
J Pediatr Orthop. 2015;35:18–23
10. Ryan LM, DePiero AD, Sadow KB, et
al. Recognition and management
of pediatric fractures by
pediatric residents. Pediatrics.
2004;114(6):1530–1533
11. Taras HL, Nader PR. Ten years of
graduates evaluate a pediatric
residency program. Am J Dis Child.
1990;144(10):1102–1105
8
12. Trainor JL, Krug SE. The training
of pediatric residents in the care
of acutely ill and injured children.
Arch Pediatr Adolesc Med.
2000;154(11):1154–1159
13. Schoenecker J, Bae DS. Fractures of
the distal radius and ulna. In: Flynn JM,
Skaggs DL, Waters PM, eds. Fractures
in Children. Philadelphia, PA: Lippincott
Williams & Wilkins; 2014:349–411
14. Oakley EA, Ooi KS, Barnett PL. A
randomized controlled trial of 2
methods of immobilizing torus
fractures of the distal forearm. Pediatr
Emerg Care. 2008;24(2):65–70
15. Streiner DL, Norman GR. Health
Measurement Scales: A Practical Guide
to Their Development and Use. 2nd ed.
Oxford, UK: Oxford University Press;
1998
16. Boutis K, Willan A, Babyn P, Goeree
R, Howard A. Cast versus splint in
children with minimally angulated
fractures of the distal radius: a
randomized controlled trial. CMAJ.
2010;182:1507–1512
17. Boutis K, Willan AR, Babyn P, Narayanan
UG, Alman B, Schuh S. A randomized,
controlled trial of a removable brace
versus casting in children with lowrisk ankle fractures. Pediatrics.
2007;119(6). Available at: www.
pediatrics.org/cgi/content/full/119/6/
e1256
18. Bjornson CL, Klassen TP, Williamson J,
et al; Pediatric Emergency Research
Canada Network. A randomized trial of
a single dose of oral dexamethasone
for mild croup. N Engl J Med.
2004;351(13):1306–1313
19. Lawton LJ. Fractures of the distal
radius and ulna. In: Letts MR, ed.
Management of Pediatric Fractures.
Philadelphia, PA: Churchill Livingstone
Inc; 1994:345–368
20. Koelink E, Boutis K. Paediatrician
office follow-up of common minor
fractures. Paediatr Child Health.
2014;19(8):407–412
21. Reeder BM, Lyne ED, Patel DR, Cucos
DR. Referral patterns to a pediatric
orthopedic clinic: implications for
education and practice. Pediatrics.
2004;113(3 pt 1):e163–e167
22. Boutis K, Howard A, Constantine E,
Cuomo A, Narayanan U. Evidence
into practice: emergency physician
management of common pediatric
fractures. Pediatr Emerg Care.
2014;30(7):462–468
23. Bae D, Shah A. Follow up buckle
fractures of the distal radius.
Pediatric Orthopedic Society of
North America (Abstract). Chicago,
IL: 2012
24. Farbman KS, Vinci RJ, Cranley
WR, Creevy WR, Bauchner H. The
role of serial radiographs in the
management of pediatric torus
fractures. Arch Pediatr Adolesc Med.
1999;153(9):923–925
25. Wilkins KE. Principles of fracture
remodeling in children. Injury.
2005;36(suppl 1):A3–A11
26. Aitken AP. Further observations
on the fractured distal radial
epiphysis. J Bone Joint Surg.
1935;17:922–927
27. Houshian S, Holst AK, Larsen MS,
Torfing T. Remodeling of Salter-Harris
Type II Epiphyseal Plate Injury of
the Distal Radius. J Pediatr Orthop .
2004;24:472–476
28. Er E, Kara PH, Oyar O, Ünlüer EE.
Overlooked extremity fractures in the
emergency department. Ulus
Travma Acil Cerrahi Derg. 2013;19(1):
25–28
29. Fleisher G, Ludwig S, McSorley M.
Interpretation of pediatric x-ray
films by emergency department
pediatricians. Ann Emerg Med.
1983;12(3):153–158
30. Freed HA, Shields NN. Most frequently
overlooked radiographically apparent
fractures in a teaching hospital
emergency department. Ann Emerg
Med. 1984;13(10):900–904
31. Guly HR. Diagnostic errors in an
accident and emergency department.
Emerg Med J. 2001;18(4):263–269
32. Hallas P, Ellingsen T. Errors in
fracture diagnoses in the emergency
department—characteristics of
patients and diurnal variation. BMC
Emerg Med. 2006;6:4
33. Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou
HJ, Chang CY. Systematic analysis
KOELINK et al
of missed extremity fractures in
emergency radiology. Acta Radiol.
2006;47(7):710–717
34. Espinosa JA, Nolan TW. Reducing
errors made by emergency
physicians in interpreting
PEDIATRICS Volume 137, number 1, January 2016
radiographs: longitudinal study. BMJ.
2000;320(7237):737–740
35. Young NL, Williams JI, Yoshida KK,
Wright JG. Measurement properties
of the activities scale for kids. J Clin
Epidemiol. 2000;53(2):125–137
36. Symons S, Rowsell M, Bhowal B, Dias
JJ. Hospital versus home management
of children with buckle fractures
of the distal radius. A prospective,
randomised trial. J Bone Joint Surg Br.
2001;83(4):556–560
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