Buckle (or torus) fractures are most commonly seen in the distal radial metaphysis and are a result of compressive forces from an axial load on softer bones in children
X-Ray changes may be subtle with mild cortical bulging on the AP view and angulation on the lateral view may be evident
Buckle fracture of the distal radius and ulna with minimal dorsal angulation
Buckle fractures can be managed in a buckle wrist splint if:
There is dorsal angulation
There is less than 15 degrees angulation
There is no cortical disruption
The fracture involves the distal third of the radius
The ulna does not have a greenstick or a complete fracture (buckle of the ulna is okay)
The buckle wrist splint is kept on day and night for 3 weeks and patients are advised to avoid sport for a further 3 weeks after splint removal. No specific follow up is required for simple dorsal buckle fractures. See Buckle Splint Application and Buckle Fracture Health Facts. If a wrist splint is unavailable, immobilise in a below elbow plaster backslab for 3 weeks.
Buckle fractures that are not suitable for a wrist splint:
Cortical disruption (= greenstick fracture)
Ulna greenstick, complete or styloid fracture
Greater than 15 degrees angulation or obvious clinical deformity – will likely need reduction (refer to Orthopaedic Team urgently)
These fractures should be managed in a below elbow plaster backslab and followed up in Orthopaedic Fracture clinic in 7-10 days. See Outpatient Clinics.
Subtle buckle fracture of distal radius on AP view (arrow) with obvious volar angulation on the lateral view
Disruption of volar cortex (arrow)
The radius usually has a greater degree of injury than does the ulna
The radius can be involved in isolation (never the ulna in isolation – always look for associated radius fracture or radial head dislocation)
When both bones are involved, they often each have a different fracture type, a combination of complete, greenstick, torus (buckle) fractures, or plastic bowing deformity
Minimally displaced and minimally angulated metaphyseal fractures of the radius and ulna are managed in an above elbow plaster backslab (for 6-8 weeks) with Orthopaedic Fracture clinic follow up in 7-10 days. See Outpatient Clinics. These fractures have a tendency to displace or angulate further if not immobilised appropriately.
Fractures with greater than 20 degrees of dorsal angulation, greater than 10 degrees of volar angulation, significant displacement or clinical deformity should be referred urgently to the Orthopaedic Team for reduction.
Transverse fracture of distal radius with 15 degrees of dorsal angulation
Completely displaced fracture of distal radius and ulna
Radial Physeal Fractures
Fractures involving the growth plate are usually Salter-Harris II fractures
Undisplaced Salter-Harris I and V fractures may not be obvious on X-Ray – immobilise in a plaster backslab if there is clinical suspicion (point tenderness and localised swelling of the distal radius)
Salter-Harris I and II fractures rarely affect growth of the limb
Salter-Harris III and IV fractures may cause growth disturbance and should be referred to the Orthopaedic Team. Look for associated ulna injury: fracture of the distal ulna, avulsion of the ulnar styloid or rarely, fracture separation of the ulna epiphysis.
Minimally displaced and minimally angulated Salter-Harris I and II fractures should be immobilised in a below elbow plaster backslab and followed up in Orthopaedic Fracture clinic in 7-10 days. See Outpatient Clinics.
Salter-Harris I and II fractures with greater than 20 degrees angulation or significant displacement and Salter-Harris III and IV fractures should be referred urgently to Orthopaedic Team for possible reduction
Salter-Harris I fracture of distal radius
Undisplaced Salter-Harris II fracture of distal radius
Salter Harris II fracture with dorsal and radial displacement
Suspect scaphoid fractures in older children (> 10 years) who have fallen on outstretched hand with anatomical snuffbox tenderness, pain on longitudinal compression of the thumb and pain on supination against resistance
Scaphoid fractures in adolescents are usually non-displaced fractures of the distal pole
They are not always evident on X-Ray
Displaced scaphoid fractures should be referred immediately to Orthopaedic Surgeon as they may need fixation.
Non-displaced scaphoid fractures are treated in a below elbow plaster backslab with follow up in Orthopaedic Fracture Clinic in 7-10 days.
If there is clinical suspicion without X-Ray changes, immobilise in a buckle splint. If >10 years age, follow up in Orthopaedic Fracture clinic in 7-10 days with a repeat X-Ray. For patients <10 years age, no formal follow up is required (scaphoid fracture extremely unlikely in this age group).
A: Undisplaced distal scaphoid fracture. B: Sclerotic line in follow up X-Ray 2 weeks later.
Galeazzi Fracture Dislocation
A rare fracture of the distal half of the radial shaft with a disrupted distal radio-ulnar joint
Refer immediately to Orthopaedic Surgeon for reduction
Fractures of Distal Radius & Ulna Requiring Urgent Orthopaedic Referral
Significant angulation (>20 degrees dorsal or >10 degrees volar) or significant displacement
Monteggia and Galeazzi fracture dislocations
Salter-Harris III and IV fractures
Referrals and follow-up
Plaster check within 24 hours
All fractures of distal radius and ulna (except simple dorsal buckle fractures) should be followed up in Orthopaedic Fracture clinic in 7-10 days. See Outpatient Clinics.
Mildly angulated dorsal buckle fractures require no specific follow up