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Buckle (Torus) Fracture of Pediatric Female Left Distal Radius

This module allows traditional bone setters, pre-hospital providers, clinical officers, nurses, nurse practitioners, and medical officers to become confident and competent in performing point-of-care ultrasound diagnostic imaging to rule out the presence of a pediatric distal forearm fracture and distinguish between buckle (torus) fractures and cortical break fractures to make appropriate referrals as part of the management of closed pediatric (< 16 years of age) distal forearm fractures in regions without access to X-ray imaging and orthopedic specialist coverage.[1][2][3][4][5][6][7][8][9]

Anatomy Review[edit | edit source]

Learning Objectives[edit | edit source]

  1. Identify the dorsal, volar (palmar), radial and ulnar surfaces of the forearm
  2. Identify the proximal and distal regions of the forearm
  3. Identify the radius and ulna bones of the forearm
  4. Identify the diaphysis (shaft), metaphysis, physis (growth plate) and epiphysis of the long bones of the juvenile forearm
  5. Identify the tension and compression cortex of the radius and ulna for buckle (torus) and incomplete (greenstick) fractures
  6. Describe the differences between the pediatric distal forearm fracture subtypes, including; buckle (torus), incomplete (greenstick), complete and physeal (Salter-Harris) fractures
  7. Recognize no fracture, buckle (torus) fracture, cortical breach fracture of the pediatric distal forearm, and other fractures of the forearm

Surface Anatomy of the Forearm[edit | edit source]

Surface Anatomy of the Forearm
# Surface Reference Image
1 Dorsal
Normal Left Forearm of 10 y.o. Female - Dorsal View.png
2 Volar (Palmar)
Normal Left Forearm of 10 y.o. Female - Volar View.png
3 Radial
Normal Left Forearm of 10 y.o. Female - Radial View.png
4 Ulnar
Normal Left Forearm of 10 y.o. Female - Ulnar View.png
5 Proximal and Distal
File:Normal Left Forearm of 10 y.o. Female - Proximal Distal v2.0.png

Long Bone Anatomy[edit | edit source]

Long Bone Anatomy
# Anatomic Structure Description Reference Image
1 Diaphysis Body (shaft) of bone
Normal Left Forearm of 10 y.o. Female - Diaphysis v2.0.png
2 Metaphysis Flared part of bone shaft
Normal Left Forearm of 10 y.o. Female - Metaphysis v2.0.png
3 Physis Growth plate made of cartilage; also known as epiphyseal plate
Normal Left Forearm of 10 y.o. Female - Physis v2.0.png
4 Epiphysis End of bone
Normal Left Forearm of 10 y.o. Female - Epiphysis v2.0.png

Classification of Pediatric Distal Forearm Fractures[edit | edit source]

Classification of Children's Fractures
# Fracture Type Description Reference Image Prognosis
1 No Fracture Cortices are unbent and unbroken
Normal Left Forearm of 10 y.o. Female - Radial View.png
 Excellent
2 Buckle (Torus) Fracture Compression cortex and tension cortex are bent but unbroken[10][11][12]
Buckle Fracture Left Distal Radius - Radial View.png
 Stable[12]
3 Incomplete (Greenstick) Fracture Compression cortex is bent and tension cortex is broken [10][12]
Greenstick Fracture Left Distal Radius - Radial View v3.0.png
 Unstable[12]
4 Complete Fracture Both cortices are broken[12]
Complete Fracture Left Distal Radius - Radial View.png
 Highly unstable[12]
5 Physeal (Salter-Harris) Fracture Fracture of the growth plate (physis)[12]
Salter-Harris Type II Fracture of Left Forearm of 10 y.o. Female v4.0.png
 Might lead to growth disturbances (rare)[12]

Pediatric Forearm Fracture Subtypes[edit | edit source]

Fracture Subtype Reference Image
1A Buckle (torus) fracture of distal radius
Buckle Fracture Left Distal Radius - Radial View.png
1B Buckle (torus) fracture of the distal radius and ulna
Buckle Fracture Left Distal Radius and Ulna - Dorsal View.png
2 Incomplete (greenstick) fracture of distal radius
Greenstick Fracture Left Distal Radius - Radial View v3.0.png
3A Complete fracture of the distal radius
Complete Fracture Left Distal Radius - Radial View.png
3B Complete fracture of the distal radius and ulna
Complete Fracture Left Distal Radius and Ulna - Volar View.png
4 Proximal radius fracture[13]
Left Proximal Radius Fracture - Volar View v2.0.png

Physeal (Salter-Harris) Fractures[edit | edit source]

Physeal (Salter-Harris) Fractures
Fracture SubType Fracture Description[14][15] Reference Illustration[16]
Salter-Harris Type I Fracture across growth plate and does not involve bone
Salter-Harris Type I Fracture of Left Forearm of 10 y.o. Female v4.0.png
Salter-Harris Type II Fracture across growth plate and through metaphysis
Salter-Harris Type II Fracture of Left Forearm of 10 y.o. Female v4.0.png
Salter-Harris Type III Fracture across growth plate and through epiphysis
Salter-Harris Type III Fracture of Left Forearm of 10 y.o. Female v4.0.png
Salter-Harris Type IV Fracture through metaphysis, growth plate, and epiphysis
Salter-Harris Type IV Fracture of Left Forearm of 10 y.o. Female v4.0.png
Salter-Harris Type V Compression fracture of growth plate
Salter-Harris Type V Fracture of Left Forearm of 10 y.o. Female v4.0.png

Pediatric Distal Forearm Fracture Categories[edit | edit source]

# Fracture Category Fracture Types
1 No Fracture
  • No Fracture
2 Buckle (Torus) Fracture
  • Buckle Fracture of the Distal Radius
  • Buckle Fracture of the Distal Radius and Ulna
3 Cortical Break Fracture
  • Incomplete (Greenstick) Fracture of the Distal Radius
  • Incomplete (Greenstick) Fracture of the Distal Radius and Ulna
  • Complete Fracture of the Distal Radius
  • Complete Fracture of the Distal Radius and Ulna
  • Salter-Harris Type I
  • Salter-Harris Type II
  • Salter-Harris Type III
  • Salter-Harris Type IV
  • Salter-Harris Type V

Supplemental Learning Topics[edit | edit source]

(Optional) After completion of the module, the learner may wish to learn more about the following topics:

Acknowledgements[edit | edit source]

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.

References[edit | edit source]

  1. ↑ Onyemaechi NO, Itanyi IU, Ossai PO, Ezeanolue EE. Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters. Hum Resour Health. 2020 Mar 20;18(1):24. doi: 10.1186/s12960-020-00468-w. PMID: 32197617; PMCID: PMC7085192.
  2. ↑ Heiner JD, McArthur TJ. The ultrasound identification of simulated long bone fractures by prehospital providers. Wilderness Environ Med. 2010 Jun;21(2):137-40. doi: 10.1016/j.wem.2009.12.028. Epub 2009 Dec 22. PMID: 20591377.
  3. ↑ Heiner JD, Baker BL, McArthur TJ. The ultrasound detection of simulated long bone fractures by U.S. Army Special Forces Medics. J Spec Oper Med. 2010 Spring;10(2):7-10. PMID: 20936597.
  4. ↑ Heiner JD, Proffitt AM, McArthur TJ. The ability of emergency nurses to detect simulated long bone fractures with portable ultrasound. Int Emerg Nurs. 2011 Jul;19(3):120-4. doi: 10.1016/j.ienj.2010.08.004. Epub 2010 Sep 25. PMID: 21665155.
  5. ↑ Snelling PJ, Jones P, Keijzers G, Bade D, Herd DW, Ware RS. Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study. Emerg Med J. 2021 Feb;38(2):139-145. doi: 10.1136/emermed-2020-209689. Epub 2020 Sep 8. PMID: 32900856.
  6. ↑ Snelling PJ, Jones P, Moore M, Gimpel P, Rogers R, Liew K, Ware RS, Keijzers G. Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound. Australas J Ultrasound Med. 2022 Mar 7;25(2):66-73. doi: 10.1002/ajum.12291. PMID: 35722050; PMCID: PMC9201201.
  7. ↑ Heiner JD, McArthur TJ. A simulation model for the ultrasound diagnosis of long-bone fractures. Simul Healthc. 2009 Winter;4(4):228-31. doi: 10.1097/SIH.0b013e3181b1a8d0. PMID: 19915442.
  8. ↑ Snelling PJ, Keijzers G, Byrnes J, Bade D, George S, Moore M, Jones P, Davison M, Roan R, Ware RS. Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED): a protocol for an open-label non-inferiority diagnostic randomised controlled trial. Trials. 2021 Apr 14;22(1):282. doi: 10.1186/s13063-021-05239-z. PMID: 33853650; PMCID: PMC8048294.
  9. ↑ Snelling PJ. A low-cost ultrasound model for simulation of paediatric distal forearm fractures. Australas J Ultrasound Med. 2018 Feb 25;21(2):70-74. doi: 10.1002/ajum.12083. PMID: 34760505; PMCID: PMC8409885.
  10. ↑ 10.0 10.1 https://surgeryreference.aofoundation.org/orthopedic-trauma/pediatric-trauma/further-reading/principles-of-nonoperative-treatment-of-childrens-fractures#fracture-patterns
  11. ↑ Light TR, Ogden DA, Ogden JA: The anatomy of metaphyseal torus fractures. Clin Orthop Relat Res 1984, 103-111.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Randsborg PH, Sivertsen EA. Classification of distal radius fractures in children: good inter- and intraobserver reliability, which improves with clinical experience. BMC Musculoskelet Disord. 2012 Jan 23;13:6. doi: 10.1186/1471-2474-13-6. PMID: 22269925; PMCID: PMC3331853.
  13. ↑ Dietzel M, Scherer S, Esser M, Kirschner HJ, Fuchs J, Lieber J. Fractures of the proximal radius in children: management and results of 100 consecutive cases. Arch Orthop Trauma Surg. 2022 Aug;142(8):1903-1910. doi: 10.1007/s00402-021-03917-w. Epub 2021 May 11. PMID: 33974141; PMCID: PMC9296417.
  14. ↑ Levine RH, Foris LA, Nezwek TA, et al. Salter Harris Fractures. [Updated 2022 Apr 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430688/
  15. ↑ https://radiopaedia.org/articles/salter-harris-classification?lang=us
  16. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9233428/figure/F1/
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Part of Pediatric Distal Forearm Fractures
Keywords orthopedic surgery, surgical training, pediatric distal forearm fracture, buckle fracture, torus fracture, greenstick fracture, complete fracture, non-displaced fracture, fracture care, fracture sonography, point-of-care ultrasound, portable ultrasound, handheld ultrasound, 3d printing, artificial bones, splinting
SDG SDG03 Good health and well-being
Authors Medical Makers
License CC-BY-SA-4.0
Organizations Medical Makers
Language English (en)
Related 0 subpages, 4 pages link here
Impact 247 page views
Created November 7, 2022 by Medical Makers
Modified February 28, 2024 by Felipe Schenone
Cite as Medical Makers (2022–2024). "Pediatric Distal Forearm Fractures/Anatomy Review". Appropedia. Retrieved April 23, 2024.
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