Torus Fracture

A torus fracture is a stable, incomplete compression fracture of the metaphysis in a child, in which the cortex bulges outward with a raised rim, without a break through the bone.

• It is the commonest fracture of the distal radius in children aged 5 to 10 years, typically after a fall on an outstretched hand.
• Children's metaphyseal bone is porous and compresses rather than breaking completely.
• The fracture is stable and heals in 3 to 4 weeks.
• It can also occur in the distal ulna, tibia, fibula, humerus and femur.

Findings are mild and easily missed.

• Wrist pain and mild swelling after a fall, with localised tenderness over the distal radius.
• The child often continues to use the hand with reduced grip.
• No obvious deformity, normal circulation and sensation.
• Pain at the extremes of wrist movement and forearm rotation.
• Differential diagnosis: greenstick fracture, complete distal radius fracture, scaphoid fracture, growth plate injury, wrist sprain, osteomyelitis and non-accidental injury.
• Complications: rare; displacement or conversion to a complete fracture, stiffness and cast-related skin problems.

Diagnosis is by X-ray.

• Anteroposterior and lateral wrist views: a smooth buckling or bulge of the cortex, with no cortical break and no or minimal angulation. The fracture may be subtle on one view only.
• Check for a second fracture (ulna, scaphoid) and for growth plate involvement.
• Ultrasound can confirm the fracture where available and avoids radiation.
• Consider non-accidental injury if the history is inconsistent or other injuries exist.

Short simple immobilisation is sufficient.

• Supportive: analgesia, elevation and ice for the first 48 hours.
• Pharmacological: paracetamol 15 mg/kg every 6 hours (maximum 1 g per dose) and ibuprofen 5 to 10 mg/kg every 8 hours after food.
• Procedures: removable wrist splint or soft bandage for 3 weeks. A below-elbow cast for 3 to 4 weeks if the child cannot manage a splint or has marked pain. No reduction is needed.
• Special groups: fractures with angulation or associated injuries need orthopaedic review.
• Red flags: angulation, cortical break, deformity, nerve symptoms, pain out of proportion, open wound and suspected abuse.
• Follow-up: return to normal activity when pain-free, usually at 3 to 4 weeks, and avoid contact sport for about 6 weeks. Review if pain continues beyond 3 weeks.