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The BUCKLED trial



Should we use ultrasound to diagnose distal forearm fractures in children and adolescents?

Distal forearm fractures are common in children and adolescents, but the best method for diagnosing them is still debatable. X-ray (radiography) is the standard imaging technique used in emergency departments. However, ultrasound is gaining popularity due to its portability, affordability, and lack of ionising radiation. To determine the effectiveness of ultrasound, a recent study compared its diagnostic capabilities to radiography for distal forearm fractures in children and adolescents, with the primary outcome of functional recovery of the arm.

Snelling PJ, Jones P, Bade D, Bindra R, Byrnes J, Davison M, George S, Moore M, Keijzers G, Ware RS; BUCKLED Trial Group. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. N Engl J Med. 2023 Jun 1;388(22):2049-2057. doi: 10.1056/NEJMoa2213883. PMID: 37256975.

How did we perform the BUCKLED study?

The BUCKLED RCT was an open-label, multicentre, non-inferiority, randomized trial conducted across four hospitals in Australia. The trial enrolled 270 participants, aged 5 to 15 years, who presented to the emergency department with an isolated distal forearm injury. Participants were randomly assigned to receive either ultrasound or X-ray as the initial diagnostic imaging method.

Ultrasound was performed by a trained clinician – an emergency physician, nurse practitioner or physiotherapist.  If the participant had a buckle fracture or no fracture, they could be discharged immediately.  If they had a cortical break, they went on to have x-ray imaging and routine follow-up in the fracture clinic. The primary outcome was the physical function of the affected arm at four weeks using the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) score, with higher scores indicating better function.

What were the results of the study?

The study found that ultrasound was non-inferior to radiography in terms of the physical function of the arm at four weeks. The mean PROMIS scores at four weeks in the ultrasonography group were similar to those in the radiography group, with a mean difference of only 0.1 points. The confidence interval was within the noninferiority margin of -5 points, indicating that ultrasound was as effective as X-ray for diagnosing forearm fractures.

Additional Findings

No clinically important fractures were missed using ultrasound or x-ray. The emergency department length of stay was reduced by an average of 15 minutes per participant in the ultrasound group. There was also a 2/3 reduction in the number of X-rays required if ultrasound was used first.

The bottom line

Ultrasound is a reliable alternative to X-ray for diagnosing distal forearm fractures in children and adolescents.

Ultrasound can be used safely and effectively within the current emergency department system. 

Further research is needed to explore its usefulness in settings with
limited access to X-rays.


  • Peter Snelling is a general paediatrician, emergency physician, and sonologist who is passionate about exploring how point-of-care ultrasound can improve the patient journey and is the founder of the SOnography iNnovation And Research (SONAR) group ( In his spare time he enjoys caravanning in the Australian outback with his wife and 5 kids.

  • Ben Lawton is a paediatric emergency physician interested in education, retrieval medicine and simulation. Lives in Brisbane where he enjoys falling off his mountain bike and being outsmarted by his pre-teen children. @paedsem | + Ben Lawton | Ben's DFTB posts


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