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Torus (buckle) Fractures
Fractures of the wrist account for a third of all childhood fractures, with 1 in every 100 children presenting either a torus or a greenstick fracture.
Torus fractures are compression failures of the bone and are the most common fractures in children.[1] It is a common occurrence following a fall, as the wrist absorbs most of the impact and compresses the bony cortex on one side and remains intact on the other, creating a bulging effect.[2] For this reason, it is often referred to as an 'incomplete fracture' as the break is only on the one side. The compressive force is provided by the trabeculae and is longitudinal to the axis of the long bone[3]. The word "torus" originates from the Latin word "protuberance."[4]
Signs and Symptoms
Torus fractures are low risk and may cause acute pain. As the bone buckles (or crushes), instead of breaking, they are a stable injury as there is no displacement of the bone.[5] This mechanism is analogous to the crumple zones in cars. As with other fractures, the site of fracture may be tender to touch and cause a sharp pain if pressure is exerted on the injured area.
Risk Factors
Physical activities or sports such as bike riding or climbing increase the associated risk for buckle fractures in the potential event of a collision or fall. As aforementioned, the most common buckle fracture is of the distal radius in the forearm, which typically originates from a Fall Onto an Outstretched Hand (FOOSH)[6]. Such orthopaedic injuries are distinctive in children as their bones are softer and in a dynamic state of bone growth and development, with a higher collagen to bone ratio so incomplete fractures such as the buckle fracture are a more common occurrence.[7]
Diagnosis
Buckle fracturs can be identified using a radiograph image. Diagnosis of a torus fracture should be possible in both anterior/posterior and lateral projections. Some observations in the presence of a buckle fracture include:
- Small fracture lines may be present
- The buckling of cortical bone, which may appear as a small bulge or protuberance in the radius or ulna.
- The bone may have a slight angulation.[8].
Treatment
There is no established 'standard' treatment for buckle fractures but methods vary from soft bandages to removable splints to stricter immobilisation methods such as casting, with some countries advocating that subsequent 'follow-up' appointments, are not necessary after initial discharge. Traditionally, treatment methods have paralleled that of other fractures of the same class with full cast immobilisation for 2-4 weeks being the customary form of treatment[9], with regular follow-ups until fracture union.
However, this convention is being challenged by emerging evidence and literature that is encouraging a 'minimalist' approach in the management of buckle fractures, involving the use of removable splints, in contrast to the casting. Indeed, the former proves to be more cost-effective and in some cases, improve overall physical functioning of the affected area.[10] The splint is also convenient to remove so eliminates the need to revisit the hospital for the removal of a cast, so this treatment may invoke stronger patient preference. Studies have shown that, with removable methods at home, without the necessity of a follow-up appointment, parental satisfaction of nearly 100% is achieved.[11]
However, questions have also been raised if any treatment at all is necessary. At present, research is being conducted by the FORCE Trial, a randomised controlled trial, in paediatric buckle fractures of the distal radius which aims to assess and compare the effectiveness of soft bandages to removable splints.[12]
References
- ^ Naranje, S. M., Erali, R. A., Warner, W. C., Sawyer, J. R., & Kelly, D. M. (2016). Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States. Journal of Pediatric Orthopaedics, 36(4), e45–e48. doi:10.1097
- ^ Della-Giustina, D.A., Della-Giustina, K., 1999. Orthopaedic injuries: emergency department evaluation and treatment of pediatric orthopaedic injuries. Emergency Medicine Clinics of North America 17 (4)
- ^ Sharp, J. W., & Edwards, R. M. (2017). Core curriculum illustration: pediatric buckle fracture of the distal radius. Emergency Radiology. doi:10.1007
- ^ Wheeless, C.R., 2007. Wheeless Textbook of Orthopaedics. Duke Orthopaedics, North Carolina.
- ^ Randsborg P, Sivertsen E (2009) Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures. Acta Orthop 80(5):585–589. doi:10.3109/ 17453670903316850
- ^ van Bosse, H.J.P., Patel, R.J., Thacker, M., Sala, D.A., 2005. Minimalistic approach to treating wrist torus fractures. Journal of Orthopaedics 25 (4), 495–500.
- ^ Firmin, F., & Crouch, R. (2009). Splinting versus casting of “torus” fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): A literature review. International Emergency Nursing, 17(3), 173–178. doi:10.1016
- ^ Eiff, M.P., Hatch, R.L., 2003. Boning up on common pediatric fractures. Contemporary Pediatrics 20.
- ^ Wilkins K, Upper Extremity. In: Rockwood C, Wilkins K, Beaty J, editors. Fractures in Children. 4th ed. New York: Raven, 1996 p. 483
- ^ Plint, A.C., Perry, J.J., Correll, R., Gaboury, I., Lawton, L., 2006. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics 117 (3), 691–697.
- ^ Solan, M. ., Rees, R., & Daly, K. (2002). Current management of torus fractures of the distal radius. Injury, 33(6), 503–505. doi:10.1016
- ^ "FORCE (Forearm Fracture Recovery in Children Evaluation)". NDORMS. Retrieved 19th December 2020.
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