Buckle or Torus Fracture

The bones of growing children exhibit unique characteristics. These characteristics, combined with the unique mechanisms of injury seen in children, result in fracture patterns that differ significantly from those that are common in adults. When axial loads are applied, particularly to long bones in children, compressive forces may result in buckling of the bone without disruption of the periosteum. These fractures are called buckle or torus fractures and are considered generally stable, requiring only immobilization.

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Overview

Definition

A buckle, or torus, fracture is a fracture that primarily affects growing metaphyseal bone secondary to a compression load, in which the bone buckles or compresses.

Epidemiology

  • Common fracture in children
  • Peak incidence: ages 7–12
  • Most commonly seen in long bones
  • Buckle fractures of distal radius make up 27% of pediatric fractures.
  • 50% of pediatric wrist fractures are buckle fractures.

Pathophysiology

  • Unique features of pediatric bone:
    • During growth, consists of calcified cartilage
    • Periosteum is more active, thick, and resistant.
    • More compliant
  • Buckle fracture caused by axial/compressive forces:
    • Fall on outstretched hand (FOOSH)
    • Jumping down from high places
  • Disrupted cortices on concave side appear as a bulge or prominence, generally with little angulation.
Buckle fracture

Buckle (torus) fracture:
Caused primarily by an axial load, a buckle fracture is a common injury seen primarily in the pediatric population. The fracture features disrupted cortices but intact periosteum, appearing as a bulge or prominence, generally with little angulation.

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Clinical Presentation and Diagnosis

The clinical presentation of pediatric patients with buckle fractures is similar to patients with other pediatric fractures.

History

  • Mechanism of action is consistent (forces axially applied).
  • Patient presents with pain after trauma, with decreased range of motion.

Physical exam

  • Point tenderness over presumed fracture site
  • Presence of swelling 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 findings may be subtle: Buckling of 1 or both sides of bone may be visible.
  • Imaging of joint above and below injured bone is recommended to rule out other associated injuries.

Management

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

  • Pain relief and splinting/immobilization are the mainstays of treatment.
  • Generally nondisplaced or minimally displaced 
  • Heal when immobilized in appropriate cast or splint for 3–4 weeks
Splinting options for forearm

Splinting options for forearm:
In many patients, pediatric fractures of the forearm will heal with simple splinting.

Image by Lecturio.

Clinical Relevance

Additional important pediatric skeletal injuries:

  • Greenstick fracture: partial-thickness fracture that involves complete break of cortex and periosteum on only 1 side of the bone. Termed “greenstick,” as the fracture 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 or angulation deformities, and often should be referred for orthopedic follow-up.
  • Supracondylar fracture: complete fracture affecting the distal humerus after falling on an outstretched hand (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: Apophysis is a secondary ossification center found in non-weight-bearing segments of bones and is the site of ligament or tendon insertion. Acute apophyseal avulsion fracture 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 control, but may require surgical repair if fragment of avulsed bone is large with significant displacement. 

References

  1. Rennie L, Court-Brown CM, Mok JY, Beattie TF. The epidemiology of fractures in children. Injury. 2007 Aug;38(8):913-22. doi: 10.1016/j.injury.2007.01.036. Epub 2007 Jul 12. PMID: 17628559.
  2. Symons S, Rowsell M, Bhowal B, Dias JJ. Hospital versus home management of children with buckle fractures of the distal radius. A prospective, randomised trial. J Bone Joint Surg Br. 2001 May;83(4):556-60. doi: 10.1302/0301-620x.83b4.11211. PMID: 11380131.
  3. Love JC, Symes SA. Understanding rib fracture patterns: incomplete and buckle fractures. J Forensic Sci. 2004 Nov;49(6):1153-8. PMID: 15568684.

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