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Overdiagnosis of Distal Radius Buckle Fracture in Children
Bernardus Terreblanche, BS; Emily A. Eismann, MS; Tal Laor, MD; Roger Cornwall, MD; Kevin J. Little, MD
Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH

Introduction: Distal radius buckle fractures are incomplete compression fractures of the distal radius metadiaphysis that commonly occur in children. These fractures can be treated with a splint or cast and their management continues to transition from specialty care to the primary care setting. This study hypothesizes that children who have complete fractures with cortical and/or physeal disruption are frequently misdiagnosed as having buckle fractures.
Materials & Methods: Hospital records were searched to identify children under age 18 years diagnosed with a distal radius fracture from January 1, 2013 to June 30, 2013. Exclusion criteria were: 1) substantial joint/bone deformity, 2) previous wrist surgery, 3) systemic disease, 4) multiple trauma, and 5) infection. Three blinded raters experienced in the interpretation of pediatric musculoskeletal radiographs, independently reviewed wrist or forearm radiographs to assess whether or not the distal radius fracture was a buckle fracture. A buckle fracture was diagnosed if there was buckling of the cortex on both the AP and lateral views without any cortical disruption, indicative of complete fracture, or without radiolucency to the physis, indicative of a Salter-Harris II fracture. Diagnostic accuracy was determined by comparing the diagnosis made by the radiologist and treating clinician to the gold stanadard diagnosis made by the reviewers.
Results: 585 patients (ages 0.9-17.9 mean 8.83.7 years; 309 boys, 276 girls) with unilateral distal radius fractures met inclusion criteria. In cases of discrepancy between all 3 reviewing physicians, a consensus was obtained and used as the gold standard. The radiologist showed a sensitivity of 81% (115) for the 142 buckle fractures, a specificity of 79% (351) for the 443 non-buckle fractures, and a positive predictive value of 56% for diagnosing buckle fractures (207 diagnosed, 115 accurate). The treating clinician had a sensitivity of 87% (124), a specificity of 76% (338), and a positive predictive value of 54% (229 diagnosed, 124 accurate).
Conclusions: Fractures with cortical buckling but also with evidence of cortical disruption or physeal injury were frequently mistaken for benign buckle fractures in children. These non-buckle fractures are at risk for substantial complications, such as displacement and subsequent malunion. Salter-Harris II fractures are at risk for growth arrest and deformity. Careful attention must be taken for the proper diagnosis of buckle fractures in children. The establishment of rigid diagnostic criteria and subsequent education of those interpreting radiographs may help to limit misdiagnosis, incomplete follow-up, and possible adverse outcomes.

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