TOP 27 - Reducing Casting of Distal Radius Buckle Fractures in the Pediatric Emergency Department

Publication Number: 4730.TOP 27

Natalia Rimareva, Albert Einstein College of Medicine, Jersey City, NJ, United States; Jana Romm, Albert Einstein College of Medicine, White Plains, NY, United States; James Meltzer, Albert Einstein College of Medicine, Bronx, NY, United States

Background: Distal radius buckle fractures are among the most common orthopedic injuries in children. National guidelines indicate that these fractures can be safely managed with removable splints rather than rigid casts. Splints offer multiple advantages, including improved comfort for children, ease of hygiene, and reduced environmental impact compared to plaster casts. Despite strong evidence supporting splint use, casting remains a frequent practice in many emergency departments (EDs). This performance improvement (PI) project aimed to align our hospital's practice with evidence-based standards to minimize unnecessary casting.

Objective: To reduce the proportion of children with distal radius buckle fractures treated with casts in the pediatric ED from 44% to 10% between November 2024 and October 2025.

Design/Methods: In the year preceding the PI project, 44% of children with buckle fractures were treated with casts at our institution. We conducted a PI study between November 2024 and October 2025 at two urban academic pediatric EDs in the Bronx, New York, using Plan-Do-Study-Act (PDSA) cycles.
A multidisciplinary team, including pediatric emergency medicine clinicians, nursing staff, a pediatric orthopedic surgeon, and a quality improvement officer, collaborated to define project aims, metrics, and interventions.
Key interventions included: 1. Targeted education for ED clinicians, pediatric and orthopedic residents on current evidence-based practices; 2. Implementation of standardized EMR documentation templates for clinician notes and discharge instructions; 3. Ensuring consistent availability of pediatric-sized splints; 4. Establishment of a data-tracking system to monitor treatment choices, repeat ED visits, follow-up and complication rates.
The primary outcome was the rate of splint versus cast application. The secondary outcome was the number of repeat radiographs. The process measure tracked clinician use of standardized documentation, and the balancing measure assessed whether splinting unintentionally reduced orthopedic follow-up rates. For our equity lens, we compared rates of casting between younger and older children.

Primary and Secondary Outcomes.


Percent of Patients with Appropriate Documentation.


Orthopedic Follow-up Rates.