A 9-year-old male presents to the Emergency Department (ED) following a fall whilst playing rugby at school earlier that day. He presents with left wrist pain and mild swelling. There are no wounds or breaks to the skin. On examination he is noted to be both swollen and tender over the distal radius. An x-ray is requested which confirms a buckle (or “torus”) fracture.
Buckle and greenstick fractures are frequently found in children who present to the ED following a fall onto an outstretched hand. Children can have severely angulated forearm fractures, which require correction, but greenstick and torus (buckle) fractures with minimal deformity are far more common (Purcell 2010).
- Greenstick fractures (image 1) are an injury caused by an angulation force, with a break in the periosteum on one side of the bone, and a fracture which does not pass fully through to the other side (Purcell 2010).
- Torus (buckle) fractures, shown in image 2, are an axial crush of the bone which shows no gap in the cortex, just a bulge where the impaction has occurred (Purcell 2010).
Image 1 – Greenstick fracture
Image 2 – Buckle (or “torus”) fracture
There is often very little to see in the way of bruising or swelling, but there will be pain, local tenderness, guarding of the limb and a reluctance or inability to use it (Purcell 2010).
Treatment of torus (buckle) fractures can be limited to a futuro splint and there is no requirement for follow up (May 2009 and Sen 2010). This has considerable comfort and cost benefits over plaster cast treatment. In this cohort of patients the use of a splint is reserved for comfort and support, rather than optimal positioning. No clear timelines regarding length of time in immobilisation have been found, although 3 weeks seems to be regarded as the length of time when casts were previously removed (Abraham et al 2008).
Treatment of greenstick fractures will depend on the degree of angulation present and whether the injury is open of closed. Closed reduction and plaster cast application for 6-8 weeks is the most common method of management. This will almost certainly require sedation +/- general anaesthetic and therefore the patient should be referred to orthopaedics for ongoing management.
Fractures are one of the numerous injuries that may represent Non-Accidental Injury (NAI) in children (Wyatt et al 2012). It is extremely important that practitioners pay close attention to the history of injury, whether this changes and if it appears consistent with the fracture sustained. There are a number of fractures (table 1) that should alert the practitioner to the potential of NAI and should therefore be carefully considered and excluded prior to discharge (Wyatt et al 2012).
Table 1 – Consider NAI in the following fractures (Wyatt et al 2012)
|Recurrent attendances or fractures of different ages|
|Spinal and rib fractures|
|Fractures in infants who are not yet independently mobile|
|Long bone fractures in children less than 3-years-old|
|Epiphyseal separation and metaphyseal ‘chip’ fractures of the knee, wrist, ankle or elbow. This type of Salter-Harris type I + II injuries are associated with traction, rotation and shaking.|
The management of these injuries will depend on the clinical and radiological findings. As a general rule, torus (buckle) fractures are safe to be managed in a futuro splint for 3 weeks with no follow up required. Greenstick fractures may require orthopaedic referral for closed reduction and subsequent plaster cast.
As with all paediatric cases, consideration should be made of non-accidental injury.
Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier. Edinburgh.
Purcell, D (2010) Minor injuries. A clinical guide (2nd edition). Churchill Livingstone. London.
May, G (2009) Do buckle fractures of the paediatric wrist require follow-up? Best BETS found at http://bestbets.org/bets/bet.php?id=254 (last accessed 7/1/17).
Sen, N (2010) Splint or cast for buckle fractures of the wrist? Best BETS found at http://www.bestbets.org/bets/bet.php?id=2002 (last accessed 7/1/17).
Abraham, A., Handoll, HHG & Khan, T (2008) Interventions for treating wrist fractures in children (review). The Cochrane Library. Issue 4. Found at http://www.escriber.com/userfiles/ccoch/file/CD004576.pdf (last accessed 7/1/17)
Wyatt, J., Illingworth, R., Graham, C & Hogg, K (2012) Oxford handbook of emergency medicine (4th edition). Oxford University press. Oxford.