Buckle Fracture

Buckle fracture (torus fracture) is a stable, incomplete compression fracture of the metaphysis of a long bone in a child, in which the cortex buckles without breaking through.

• It is the commonest fracture of the distal radius in childhood, usually after a fall on an outstretched hand.
• The porous metaphyseal bone compresses and bulges rather than fracturing completely.
• The fracture is stable, heals quickly and rarely needs reduction.
• Ages 5 to 10 years are most affected.

Mild to moderate wrist pain after a fall.

• Wrist pain and swelling, with tenderness over the distal radius.
• Child often keeps using the hand with a reduced grip.
• No deformity, no angulation, and normal neurovascular status.
• Reduced range of movement or pain on wrist movement or forearm rotation.
• Differential diagnosis: greenstick fracture, complete distal radius fracture, scaphoid fracture, growth plate injury, soft tissue sprain, osteomyelitis and non-accidental injury.
• Complications: very few; rarely displacement or progression to a complete fracture, and skin problems from the cast.

Diagnosis is by X-ray.

• Anteroposterior and lateral X-rays of the wrist and forearm: a buckling or bulge of the cortex of the distal radius (and sometimes ulna), with no cortical break.
• Assess for angulation and for a second fracture (scaphoid, ulna).
• Ultrasound can confirm the diagnosis where available.
• Consider non-accidental injury if the mechanism is inconsistent or other injuries exist.

Simple immobilisation is usually enough.

• Supportive: analgesia, elevation and ice.
• Pharmacological: paracetamol 15 mg/kg every 6 hours and ibuprofen 5 to 10 mg/kg every 8 hours.
• Procedures: removable wrist splint or soft bandage for 3 weeks (as effective as a cast). A below-elbow cast for 3 to 4 weeks if the child cannot manage a splint. No reduction is needed. Repeat X-ray is usually unnecessary.
• Special groups: unstable patterns, angulated fractures and associated injuries need specialist review.
• Red flags: marked angulation, cortical break (greenstick), deformity, nerve injury, pain out of proportion, open wound, and suspected abuse.
• Follow-up: advise on return to activities when pain-free, usually 3 to 6 weeks, and avoidance of contact sport for about 6 weeks. Review if pain persists beyond 3 weeks.