Buckle Fractures in Children

Column Author: Caroline Tougas, MD, MACM |   Pediatric Orthopedic Surgery | Clinical Assistant Professor Orthopedic Surgery - UMKC School of Medicine

Colleen Moreland, DO | Pediatric Orthopedic Surgery Fellow   

Column Editor: Amita Amonker, MD, FAAP | Pediatrics | Pediatric Hospitalist | Division Billing Liaison, Division of Pediatric Hospital Medicine | Physician Advisor, Care Management and Utilization Review | Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine | Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Background

Pediatric buckle fractures are a common injury pattern, estimated to occur in about 1 in 25 children and usually occurring about the wrist.² A buckle fracture may also be referred to as a torus fracture, so named because it is an incomplete injury to the outer layer of bone which creates a bulge or protuberance, “torus” in Latin. The porosity and relative flexibility of the juvenile skeleton lends itself to this unique fracture pattern in children. The most common location for a buckle fracture is the distal radius at the wrist; however, these injuries may also occur about the distal tibia near the ankle, or any other bone subject to axial loading.

Diagnosis

A distal radius buckle fracture occurs predominantly after a fall on an outstretched hand. The child may complain of wrist pain and be reluctant to use the affected extremity immediately after injury. Swelling or ecchymosis may also be present. It is important to examine the entire extremity to identify any other areas of tenderness including all fingers, the elbow and the shoulder. The child with a distal radius buckle fracture may be point tender to the wrist, but with proper wrist support the elbow and the shoulder should demonstrate normal, painless motion in an isolated wrist injury. Similarly, if the buckle fracture occurs about the leg, the child may be reluctant to bear weight on the affected extremity immediately after injury, but the toes, ankle, knee and hip should be examined to rule out concomitant pathology.

Once the history and physical examination support a buckle fracture diagnosis, radiographs are used to confirm the diagnosis. A minimum of two views (AP and lateral) are required to assess the injury pattern. An isolated buckle fracture will include a buckling or bulging defect on one side of the bone that does not affect the entire cortex, nor does it extend to the opposite cortex. Radiographs should be assessed for any angulation or to determine if the fracture goes through one or both cortices. In either of these instances, orthopedic surgical consultation is recommended.

The differential diagnosis for buckle fracture includes incomplete or greenstick fracture, plastic deformation, Salter-Harris fractures to the growth plate, and any underlying physiologic process that makes a child more susceptible to fractures, including osteogenesis imperfecta. In all circumstances, an injured child should be assessed for mechanism of injury and other associated injuries. The treating provider should maintain an index of suspicion for non-accidental injury if a buckle fracture occurs in a non-ambulatory child.

Treatment

The treatment of an isolated buckle fracture is a brief period of splinting for soft tissue rest. The majority of the cortex remains unaffected in a buckle fracture, preserving the inherent stability of the bone. Many studies have reviewed clinical outcomes of isolated distal radius buckle fractures and determined that placement in a prefabricated removable wrist brace is adequate for recovery without requiring orthopedic consultation, surgical intervention or repeat radiographs.³ The removable wrist brace is recommended to be worn continuously for two to three weeks and the child is held from participating in contact sports for an additional four to six weeks. In the event of a distal tibia buckle fracture, the child may be placed in a walking boot and allowed to bear weight as tolerated. A similar timeline for recovery is recommended. High-risk or high-impact activities should be avoided for up to two months depending on patient age, degree of fracture displacement and activities in question.

Outcomes

Due to their inherent stability, buckle fractures are associated with excellent outcomes. They do not require long-term follow-up or repeat radiographs. The rare complication after a buckle fracture usually relates to casting such as stiffness or skin blisters, hence the push toward removable splints, braces or semi-rigid casts. Children with buckles fractures can be safely discharged from care after their first visit with appropriate instructions to caregivers about the child’s condition and recovery and the management of the removable orthoses.⁵

Home management after the index visit with a removable immobilization and follow-up telephone contact has shown outcomes equivalent to long-term follow-up and repeat radiographs, as well as increased patient and parent satisfaction and decreased costs to the family and system.⁶

Figure 1: AP + LATERAL of the RIGHT wrist demonstrating a buckle fracture of the distal radius and ulna (arrows)

Figure 2: Photo of a 6-year-old girl wearing a removable wrist brace.

References: 

1. Asokan A, Kheir N. Pediatric torus buckle fracture. In:  StatPearls Publishing; 2023. Updated August 3, 2022. https://www.ncbi.nlm.nih.gov/books/NBK560634/
2. Naranje SM, Erali RA, Warner WC Jr, Sawyer JR, Kelly DM. Epidemiology of pediatric fractures presenting to emergency departments in the United States. J Pediatr Orthop. 2016;36(4):e45-e48.
3. Williams KG, Smith G, Luhmann SJ, Mao J, Gunn JD, Luhmann JD. A randomized controlled trial of cast versus splint for distal radial buckle fracture: an evaluation of satisfaction, convenience, and preference.Pediatr Emerg Care. 2013;29(5):555-559.
4. Solan MC, Rees R, Daly K. Current management of torus fractures of the distal radius.Injury. 2002;33(6):503-505.
5. Riera-Álvarez L, Pons-Villanueva J. Do wrist buckle fractures in children need follow-up? Buckle fractures’ follow-up.J Pediatr Orthop B. 2019;28(6):553-554.
6. 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;83(4):556-560.