Torus fracture

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A Torus fracture, also known as a buckle fracture is the most common fracture 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] As the bulge is only on one side of the bone, this injury can be classified as an incomplete fracture. The compressive force is provided by the trabeculae and is longitudinal to the axis of the long bone, meaning that the fracture itself is orthogonal to that axis. [3] The word "torus" originates from the Latin word "protuberance." [4]

Contents

A radiograph image of a torus (buckle) fracture Buckle Fracture.jpg
A radiograph image of a torus (buckle) fracture
Simplified diagram of a buckle fracture Buckle fracture of the Radius.svg
Simplified diagram of a buckle fracture

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.[ citation needed ]

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 by performing a radiograph. The diagnosis of a torus fracture is made from both anterior/posterior and lateral projections.[ citation needed ] The typical features include:

Treatment

There is no established 'standard' treatment for buckle fractures. However, in 2022 the largest and highest quality treatment study was published about this injury in the Lancet medical journal - called the FORCE Study [9] (see infographic in images). The study was conducted throughout the UK in 21 emergency departments. This study fairly allocated children (through randomisation) to either splint and routine follow-up, or a bandage and no follow-up. 965 children were in this study, which showed equivalent results for pain scores, function and complications between the treatments. This offered clinicians, parents and young people reassurance that this fracture will heal well, without complications and immobilisation and follow-up is almost always not needed.

Furthermore, a national guideline from the UK National Institute for Health and Care Excellence (NICE), which was published before the FORCE study, identified that all treatments appeared safe and recommended either a removable splint or a bandage, without the need for a follow-up. [10]

Other studies have also shown that, with removable splints that can be taken off at home, without the need for outpatient clinics, parental satisfaction of nearly 100% is achieved. [11]

The FORCE Study Results Summary Force-Infographic-v7-4.pdf
The FORCE Study Results Summary

The FORCE study also published a package of dissemination materials (i.e. cartoons/ leaflets/ treatment pathways) for parents, children and clinicians to best implement the results in clinical practice - available here.

Related Research Articles

The forearm is the region of the upper limb between the elbow and the wrist. The term forearm is used in anatomy to distinguish it from the arm, a word which is used to describe the entire appendage of the upper limb, but which in anatomy, technically, means only the region of the upper arm, whereas the lower "arm" is called the forearm. It is homologous to the region of the leg that lies between the knee and the ankle joints, the crus.

<span class="mw-page-title-main">Colles' fracture</span> Medical condition

A Colles' fracture is a type of fracture of the distal forearm in which the broken end of the radius is bent backwards. Symptoms may include pain, swelling, deformity, and bruising. Complications may include damage to the median nerve.

<span class="mw-page-title-main">Bone fracture</span> Physical damage to the continuity of a bone

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

<span class="mw-page-title-main">Distal radius fracture</span> Fracture of the radius bone near the wrist

A distal radius fracture, also known as wrist fracture, is a break of the part of the radius bone which is close to the wrist. Symptoms include pain, bruising, and rapid-onset swelling. The ulna bone may also be broken.

<span class="mw-page-title-main">Greenstick fracture</span> Medical condition

A greenstick fracture is a fracture in a young, soft bone in which the bone bends and breaks. Greenstick fractures occur most often during infancy and childhood when bones are soft. The name is by analogy with green wood which similarly breaks on the outside when bent.

<span class="mw-page-title-main">Boxer's fracture</span> Break of the 5th metacarpal bones of the hand near the knuckle

A boxer's fracture is the break of the 5th metacarpal bones of the hand near the knuckle. Occasionally it is used to refer to fractures of the 4th metacarpal as well. Symptoms include pain and a depressed knuckle.

<span class="mw-page-title-main">Pulled elbow</span> Medical condition

A pulled elbow, also known as nursemaid's elbow or a radial head subluxation, is when the ligament that wraps around the radial head slips off. Often a child will hold their arm against their body with the elbow slightly bent. They will not move the arm as this results in pain. Touching the arm, without moving the elbow, is usually not painful.

A traction splint most commonly refers to a splinting device that uses straps attaching over the pelvis or hip as an anchor, a metal rod(s) to mimic normal bone stability and limb length, and a mechanical device to apply traction to the limb.

<span class="mw-page-title-main">Mallet finger</span> Type of fracture

A mallet finger, also known as hammer finger or PLF finger or Hannan finger, is an extensor tendon injury at the farthest away finger joint. This results in the inability to extend the finger tip without pushing it. There is generally pain and bruising at the back side of the farthest away finger joint.

<span class="mw-page-title-main">Madelung's deformity</span> Medical condition

Madelung's deformity is usually characterized by malformed wrists and wrist bones and is often associated with Léri-Weill dyschondrosteosis. It can be bilateral or just in the one wrist. It has only been recognized within the past hundred years. Named after Otto Wilhelm Madelung (1846–1926), a German surgeon, who described it in detail, it was noted by others. Guillaume Dupuytren mentioned it in 1834, Auguste Nélaton in 1847, and Joseph-François Malgaigne in 1855.

<span class="mw-page-title-main">Ulnar styloid process</span> Bony prominence at the wrist

The styloid process of the ulna is a bony prominence found at distal end of the ulna in the forearm.

<span class="mw-page-title-main">Triangular fibrocartilage</span> Anatomical feature in the wrist

The triangular fibrocartilage complex (TFCC) is formed by the triangular fibrocartilage discus (TFC), the radioulnar ligaments (RULs) and the ulnocarpal ligaments (UCLs).

<span class="mw-page-title-main">Scaphoid fracture</span> Fracture of the scaphoid bone in the wrist

A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include nonunion of the fracture, avascular necrosis of the proximal part of the bone, and arthritis.

<span class="mw-page-title-main">Barton's fracture</span> Medical condition

A Barton's fracture is a type of wrist injury where there is a broken bone associated with a dislocated bone in the wrist, typically occurring after falling on top of a bent wrist. It is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint.

A child bone fracture or a pediatric fracture is a medical condition in which a bone of a child is cracked or broken. About 15% of all injuries in children are fracture injuries. Bone fractures in children are different from adult bone fractures because a child's bones are still growing. Also, more consideration needs to be taken when a child fractures a bone since it will affect the child in his or her growth.

The Essex-Lopresti fracture is a fracture of the radial head of the forearm with concomitant dislocation of the distal radio-ulnar joint along with disruption of the thin interosseous membrane which holds them together. The injury is named after Peter Essex-Lopresti who described it in 1951.

<span class="mw-page-title-main">Ulna fracture</span> Medical condition

An ulna fracture is a break in the ulna bone, one of the two bones in the forearm. It is often associated with a fracture of the other forearm bone, the radius.

<span class="mw-page-title-main">Wrist osteoarthritis</span> Medical condition

Wrist osteoarthritis is a group of mechanical abnormalities resulting in joint destruction, which can occur in the wrist. These abnormalities include degeneration of cartilage and hypertrophic bone changes, which can lead to pain, swelling and loss of function. Osteoarthritis of the wrist is one of the most common conditions seen by hand surgeons.

<span class="mw-page-title-main">Lister's tubercle</span>

Lister's tubercle or dorsal tubercle of radius is a bony prominence located at the distal end of the radius. It is palpable on the dorsum of the wrist.

<span class="mw-page-title-main">Medial epicondyle fracture of the humerus</span>

A medial epicondyle fracture is an avulsion injury to the medial epicondyle of the humerus; the prominence of bone on the inside of the elbow. Medial epicondyle fractures account for 10% elbow fractures in children. 25% of injuries are associated with a dislocation of the elbow.

References

  1. Naranje, SM; Erali, RA; Warner WC, Jr; Sawyer, JR; Kelly, DM (June 2016). "Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States". Journal of Pediatric Orthopedics. 36 (4): e45-8. doi:10.1097/BPO.0000000000000595. PMID   26177059. S2CID   36351361.
  2. Della-Giustina, K; Della-Giustina, DA (November 1999). "Emergency department evaluation and treatment of pediatric orthopedic injuries". Emergency Medicine Clinics of North America. 17 (4): 895–922, vii. doi:10.1016/s0733-8627(05)70103-6. PMID   10584108.
  3. Sharp, JW; Edwards, RM (August 2019). "Core curriculum illustration: pediatric buckle fracture of the distal radius". Emergency Radiology. 26 (4): 483–484. doi:10.1007/s10140-017-1524-4. PMID   28593329. S2CID   3984890.
  4. Wheeless, Clifford R.; Nunley, James A.; Urbaniak, James R. (2016). Wheeless' Textbook of Orthopaedics. Data Trace Internet Publishing, LLC.
  5. Randsborg, PH; Sivertsen, EA (October 2009). "Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures". Acta Orthopaedica. 80 (5): 585–9. doi: 10.3109/17453670903316850 . PMC   2823323 . PMID   19916694.
  6. van Bosse, HJ; Patel, RJ; Thacker, M; Sala, DA (July 2005). "Minimalistic approach to treating wrist torus fractures". Journal of Pediatric Orthopedics. 25 (4): 495–500. doi:10.1097/01.bpo.0000161098.38716.9b. PMID   15958903. S2CID   33574847.
  7. Firmin, F; Crouch, R (July 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): 173–8. doi:10.1016/j.ienj.2009.03.006. PMID   19577205.
  8. Patrice Eiff, M.; L. Hatch, Robert (2003). "Boning up on common pediatric fractures". Contemporary Pediatrics.
  9. Perry, Daniel C.; Achten, Juul; Knight, Ruth; Appelbe, Duncan; Dutton, Susan J.; Dritsaki, Melina; Mason, James M.; Roland, Damian T.; Messahel, Shrouk; Widnall, James; Costa, Matthew L.; Ahmad, Rahail; Alcock, Anastasia; Appelboam, Andrew; Armour, Lisa (2022-07-02). "Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK". The Lancet. 400 (10345): 39–47. doi: 10.1016/S0140-6736(22)01015-7 . ISSN   0140-6736. PMID   35780790.
  10. Nice.org.uk. 2020. Overview | Fractures (Non-Complex): Assessment And Management | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng38 [Accessed 21 December 2020].
  11. Solan, MC; Rees, R; Daly, K (July 2002). "Current management of torus fractures of the distal radius". Injury. 33 (6): 503–5. doi:10.1016/s0020-1383(01)00198-x. PMID   12098547.