Fig. 1 Two points of inflection (left) demonstrate a clear buckle fracture vs. one point of inflection (right) which is not a stable buckle fracture and requires cast immobilization rather than a Velcro splint.
Courtesy of Cincinnati Children’s Hospital


Published 1/1/2018

Quality Initiative Results in Practice Changes, Cost Savings

Study results encourage bracing of forearm buckle fractures
A quality improvement project aimed at increasing the use of removable braces instead of casting to treat distal radius buckle fractures (DRBFs) at two pediatric centers changed minds and resulted in significant savings, according to a report presented at the 2017 annual meeting of the American Society for Surgery of the Hand.

Presenter Julie Balch Samora, MD, PhD, said she and her fellow researchers saw a “dramatic shift and remarkable savings” in the response by practitioners to the initiative to encourage consideration of bracing for DRBFs. At baseline, 34.8 percent of providers used bracing for most patients; by the end of the study, more than 80 percent were using them.

The investigators applied their intervention in two large Ohio pediatric hospitals (Nationwide Children’s in Columbus and Cincinnati Children’s in Cincinnati) with high orthopaedic volume. Their “SMART” (Specific, Measurable, Actionable, Relevant, Time-bound) Aim was to increase the percentage of patients with DRBFs treated with a removable wrist brace from a 34.8 percent to 80 percent. They also wanted “to improve the application of evidence-based medicine into our clinics, and thereby decrease costs and increase patient satisfaction while maintaining appropriate outcomes.”

The research team identified five key drivers of success for the SMART Aim:

  1. appropriate treatment by provider based on evidence-based algorithm
  2. appropriate diagnosis of buckle fracture by radiology
  3. diagnosis made by appropriate imaging (wrist radiograph)
  4. consistent coding of diagnosis
  5. education of providers

The investigators established the following diagnostic criteria to identify a DRBF on radiographic images of the wrist:

  1. an intact cortex on all views
  2. no visible fracture lines extending toward the physis on any view
  3. two or three inflection points in the cortex on either anteroposterior or lateral view, whichever best represents the fracture
  4. correlation between the images and the point of tenderness on exam

From this foundation, and using a working set of diagnostic criteria for a buckle fracture—cortex remains continuous on all views; two inflection points; no radiolucency with physis (Fig. 1)—the researchers created a care algorithm (Fig. 2). Operational definitions to track the primary outcome measure (brace utilization for treatment of DRBFs), as well as balance measures (correct diagnosis of buckle fracture by provider, correct application of the algorithm for “true” buckle fractures only) and process measures (number of radiographic series obtained at each clinic visit, number of follow-up visits, correct diagnosis applied, average charges for patients pre- and post-intervention) were created.

To ensure that diagnostic criteria were being applied correctly, one member of the study team at each institution independently reviewed all imaging for patients coded with a distal radius fracture seen in clinic. Reviewers were blinded to the provider, the provider’s diagnosis, and the radiology provider’s diagnosis.

The interventions
After baseline data were collected, members of the quality improvement (QI) team at each institution introduced the project to providers and staff. The short presentation covered the project background, evidence-based support for the project, the operational definition of a buckle fracture, and the project’s SMART Aim.

At both institutions, researchers reviewed performance, sought feedback, analyzed results, and made changes to the algorithm on a regular basis. They informed providers of their individual and group compliance rates during staff meetings. “We regularly elicited public comments regarding impediments to implementation of the algorithm at staff meetings,” said Dr. Samora.

Low-compliance providers were contacted privately by a QI team member to assess their specific concerns and impediments in applying the algorithm. These providers and their staff also received additional education on the algorithm and on correct identification of buckle fractures, along with evidence from the medical literature, as needed. The feedback to providers was crucial for success. Brace utilization improved among these providers as soon as they compared their practices to their colleagues (Fig. 3).

Researchers calculated a baseline bracing rate of 34.8 percent for the two hospitals in the 3-month period prior to project implementation, based on a 20.5 percent usage rate for hospital A and a 55 percent rate for hospital B.

In both hospitals, “increasing compliance was immediately evident,” once the project was introduced. Within 9 months of the project’s initiation, researchers were able to confirm that the shift in treatment habits was due to the intervention (Fig. 4, A and B). The study covered 18 providers and 385 DRBF cases. At the end of the study period, the combined compliance with brace treatment was 84 percent (322/385), with 15 of 18 providers (83 percent) using braces for a majority of patients (defined as more than 67 percent) (Fig. 5).

Just one surgeon continued to cast all patients, “despite numerous attempts to educate and influence change in that practitioner’s practice,” the authors noted. In the other cases when casts were used, parent preference was cited as the most common reason.

Several benefits
The change in practice resulted in a significant decrease in the number of radiographs obtained at the two institutions. Financial savings were noted as well; charges for brace treatment averaged $630 less per patient than casting, with an estimated medical-cost savings of $205,000.

“Multiple studies have demonstrated good outcomes, equivalent healing, and improved satisfaction with brace treatment compared with cast treatment for distal radius buckle fractures. However, clinical practice certainly lags behind this evidence,” said Dr. Samora. She noted that a recent survey by the Pediatric Orthopaedic Society of North America (POSNA) found that less than a third of members treated DRBF with bracing.

Asked if the results yielded any surprises, Dr. Samora replied, “The dogmatic refusal by one provider to change practice was surprising. But on the flip side, the absolute open acceptance by all other providers of a completely new treatment regimen after years of practicing otherwise was incredible.”

Future work in this area should seek “to ensure that providers know the exact definition and diagnosis of a buckle fracture. If Velcro braces are applied in an urgent care or emergency department setting [without a visit to an orthopaedic specialist],” Dr. Samora said, “the principal concern would be inappropriate application of a Velcro splint for an unstable fracture.”

Overall, she said, the project “demonstrates how it is possible to implement evidence into practice with a good team, thorough education, streamlined procedures, and continued practice evaluation, and maintain good outcomes.” Implementation of the findings “should improve patient satisfaction, minimize radiation exposure, and decrease healthcare costs.”

From her practice at Nationwide Children’s Hospital, Dr. Samora was eager to note the value she perceived in conducting this study jointly with another pediatric center. “One of the most rewarding aspects of this quality improvement project was the collaboration with Cincinnati Children’s,” she said. “I really enjoyed working with my colleagues there, and I believe that by working with another large institution, the impact of our effort was greater.”

Dr. Samora’s coauthors of  “Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures” are Kevin Little, MD; Jenna Godfrey, MD; Roger Cornwall, MD; Preston Carr; and Kevin Dolan.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at

Bottom Line

  • Despite evidence of the efficacy of and patient preference for removable brace treatment for DRBF, only 29 percent of responding POSNA members said they manage the injury with a brace, underscoring the need for a treatment intervention.
  • This study reported on an evidence-based quality improvement initiative that aimed to increase the use of bracing at two pediatric orthopaedic centers.
  • After the intervention was implemented, the use of bracing for DRBF increased from a combined baseline of 34.8 percent to 86 percent.
  • The intervention also resulted in reductions in the number of radiographs taken and decreased costs to both the medical facilities and the families.