Buckle or Torus Fracture

Overview

Definition

A buckle, or torus, fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures is a fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures that primarily affects growing metaphyseal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types secondary to a compression Compression Blunt Chest Trauma load, in which the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types buckles or compresses.

Epidemiology

• Common fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures in children
• Peak incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: ages 7–12
• Most commonly seen in long bones Long bones Length greater than width. Bones: Structure and Types
• Buckle fractures of distal radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy make up 27% of pediatric fractures.
• 50% of pediatric wrist fractures are buckle fractures.

Pathophysiology

• Unique features of pediatric bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types:
  • During growth, consists of calcified cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology
  • Periosteum Periosteum Thin outer membrane that surrounds a bone. It contains connective tissue, capillaries, nerves, and a number of cell types. Bones: Structure and Types is more active, thick, and resistant.
  • More compliant
• Buckle fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures caused by axial Axial Computed Tomography (CT)/compressive forces:
  • Fall on outstretched hand Fall On Outstretched Hand Distal Radius Fractures (FOOSH)
  • Jumping down from high places
• Disrupted cortices on concave side appear as a bulge or prominence, generally with little angulation.

Clinical Presentation and Diagnosis

The clinical presentation of pediatric patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with buckle fractures is similar to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with other pediatric fractures.

History

• Mechanism of action is consistent (forces axially applied).
• Patient presents with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways after trauma, with decreased range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs.

Physical exam

• Point tenderness Point Tenderness Chronic Apophyseal Injury over presumed fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures site
• Presence of swelling Swelling Inflammation and bruising depends on time since injury. 
• Detailed neurologic exam is essential.

Imaging

• Radiographs needed to diagnose buckle fractures:
  • At last 2 views should be obtained (orthogonal).
  • Fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures findings may be subtle: Buckling of 1 or both sides of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types may be visible.
• Imaging of joint above and below injured bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types is recommended to rule out other associated injuries.

Management

The majority of buckle fractures are stable and treated with immobilization Immobilization Delirium.

• Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways relief and splinting/ immobilization Immobilization Delirium are the mainstays of treatment.
• Generally nondisplaced or minimally displaced 
• Heal when immobilized in appropriate cast or splint for 3–4 weeks

Clinical Relevance

Additional important pediatric skeletal injuries:

• Greenstick fracture Greenstick fracture The bones of growing children exhibit unique characteristics, which, combined with the unique mechanisms of injury seen in children, result in fracture patterns differing significantly from those common in adults. The greenstick fracture is an incomplete fracture usually seen in long bones. Greenstick Fracture: partial-thickness fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures that involves complete break of cortex and periosteum Periosteum Thin outer membrane that surrounds a bone. It contains connective tissue, capillaries, nerves, and a number of cell types. Bones: Structure and Types on only 1 side of the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types. Termed “greenstick,” as the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures resembles the break in a live, “green” twig, where 1 side of the stick remains intact. High risk for refracture and should be completely immobilized. Rarely requires reduction, but should be managed cautiously to prevent malunion Malunion Hip Fractures or angulation deformities, and often should be referred for orthopedic follow-up.
• Supracondylar fracture Supracondylar fracture Supracondylar fractures are the most common elbow fractures in the pediatric population. The most common mechanism of injury involves a fall on an outstretched hand, resulting in a fracture of the distal humerus. Patients frequently present with pain, visible deformity, and limited range of motion of the injured elbow. Supracondylar Fracture: complete fracture Complete Fracture Overview of Bone Fractures affecting the distal humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy after falling on an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy (FOOSH). Commonly fractures of the elbow in children. Requires immediate orthopedic consultation, as many cases are associated with neurovascular injury and require surgical intervention. 
• Apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures: Apophysis is a secondary ossification center Secondary ossification center Development of the Limbs found in non-weight-bearing segments of bones and is the site of ligament or tendon insertion. Acute apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures occurs when a portion of apophysis is pulled off by ligament, usually secondary to explosive movements and eccentric muscular contractions. Primarily treated conservatively, with rest and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways control, but may require surgical repair if fragment of avulsed bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types is large with significant displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms.