Torus Fractures Research Articles

Comparison of splinting and casting in the management of torus fracture

Torus, or buckle, fractures are unique to, and common in, children, but their treatment varies by hospital protocol and practitioners' preference. This article reviews the literature on managing torus fractures with a splint and with plaster of Paris, and concludes that splinting is more cost effective, more likely to ensure quick return to normal function, and is preferred by parents. There is no conclusive evidence, however, that it is less painful.

Radius Distal Torus Fracture with Lunatum Pathology at Childhood; Lunatum Fracture? Lunatum Partitum?

Radius Distal Torus Fracture with Lunatum Pathology at Childhood; Lunatum Fracture? Lunatum Partitum?

Swim cast versus traditional cast in pediatric distal radius fractures: A prospective randomized controlled trial

Non-displaced distal radius fractures in children are traditionally treated in a forearm cast. However, a traditional cast does not tolerate getting wet, with skin lesions and bad smell as result. A Swim cast, which has the ability to dry quickly, is an airy cast that is applied using the MOKcast technique. We hypothesize that Swim casts contribute to higher patient satisfaction scores than traditional casts, without any adverse effects on fracture healing or skin condition. A prospective, randomized, single-center, blinded study was conducted to compare traditional and Swim cast treatment in children aged 5-15 years with greenstick or torus fractures of the distal radius. Primary endpoint was the patient and parent satisfaction, as determined by a questionnaire. Secondary endpoints were radiographic and clinical bone healing and cast-related skin conditions. A total of 68 patients, divided into two treatment groups (traditional case and Swim cast; n = 34 per group). Baseline characteristics were similar between the groups. The overall satisfaction score (0-10) reported by the patients was 8.6 in the Swim cast group versus 7.5 in the traditional cast group (p < 0.002); the overall satisfaction score reported by the parents was 8.3 and 7.7, respectively (p < 0.02). There was no difference in radiographic or clinical healing between groups, and skin conditions also did not differ significantly between groups. In our patient group, treatment of non-displaced, pediatric, distal radius fractures by Swim cast yielded better patient satisfaction results compared to treatment with the traditional, cotton-lined cast, without adverse effects on fracture healing or skin condition.

Posttraumatic Cortical Defect of Femur

Posttraumatic cortical defect of bone is a rare entity which occurs in a maturing skeleton following green stick or torus fracture. Most of the cases are asymptomatic and they are detected incidentally on radiograph. These lesions usually require no treatment. However, the appearance of these lesions can mimic various pathological conditions affecting bone. Knowledge about this entity is important as it avoids unnecessary investigations. We present this case as the occurrence of this entity in femur is very rare and the child was symptomatic.

Application of Removable Wrist Splint in the Management of Distal Forearm Torus Fractures

BackgroundThere is considerable variation in the treatment of distal forearm torus fractures (DFTF), from soft bandaging to cast immobilization.ObjectivesThe present study aimed to show the result of removable wrist splint (RWS) in the treatment of these fractures.Materials and MethodsOne hundred forty two children aged less than 17 years old with DFTF were studied prospectively. These patients were randomly treated either by a short arm cast (SAC) or a RWS for three weeks. Finally the treatment results of the two groups were compared.ResultsThere were no significant differences regarding degree of pain, compliance or complications between RWS and SAC groups. Resource savings can be made with this approach also patients’ and parents’ satisfaction can be increased without compromising patients' care.ConclusionsRWS can be considered as an easy and acceptable treatment modality with very low costs and complications in the management of DFTF.

Post-traumatic cortical defect: Presentation of a case

Post-traumatic cortical defect appears 3 months after greenstick or torus fractures in children. This entity is asymptomatic and usually located just proximal to the fracture site. The most frequently affected bone is the distal radius. The pathogenesis of this lesion remains unclear but it seems to be caused by an intramedullary fat and blood accumulation beneath a intact periostium. Its diagnosis is based on CT and MR images and no treatment is needed, because its resolution is the rule. There are only 25 cases reported in English literature, we present another one after an epiphisiolysis in the distal radius.

Distal Radius Fractures

To discuss the evidence base behind treatment of pediatric distal radius fractures. We identified randomized controlled trials addressing the treatment of children with torus fractures, minimally displaced fractures, and displaced fractures of the distal radius. Torus fractures and minimally displaced fracture is treated by removable splints instead of circumferential casts with improved secondary outcomes for the patient and family and with equal position at healing. Case immobilization versus immediate pinning was studied in 2 small randomized trials of displaced fractures. Long-term outcomes were equivalent, despite more loss of reduction in the cast groups and more pin complications in the pin groups. Unbiased evalution of empirical patient outcomes using randomized trials has proven feasible for distal radius fractures and should continue to inform and guide our practice in the future.

Defecto cortical postraumático. A propósito de un caso

Post-traumatic cortical defect appears 3 months after greenstick or torus fractures in children. This entity is asymptomatic and usually located just proximal to the fracture site. The most frequently affected bone is the distal radius. The pathogenesis of this lesion remains unclear but it seems to be caused by an intramedullary fat and blood accumulation beneath a intact periostium. Its diagnosis is based on CT and MR images and no treatment is needed, because its resolution is the rule. There are only 25 cases reported in English literature, we present another one after an epiphisiolysis in the distal radius.

Paediatric forearm fractures in the west of Scotland

Forearm fractures are common paediatric injuries. This study aimed to describe the epidemiology and treatment of paediatric forearm fractures in the urban population of Glasgow. We reviewed all forearm fractures treated by the orthopaedic service in Yorkhill Children's Hospital in 2008 up to the age of 13 years. Data were gathered from case-notes and radiographs using the prospective orthopaedic database to identify patients with forearm fractures. The age, sex, side and type of fracture, the timing and mechanism of the injury and treatment were documented for the 439 fractures. Census data were used to derive absolute age-specific incidences. Distinction was made between torus and other types of fractures. Torus fractures require no specific orthopaedic treatment and were segregated out. For the remaining 314 fractures, the age and sex distribution, seasonal variation of fractures and treatments for each type of fracture were examined. The incidence of forearm fractures in our population is 411 fractures per 100,000 population per year and 294 fractures per 100,000 population per year for non-torus fractures. An increased number of fractures occurred between May and August. A fall from less than 1 m was the most common mechanism of injury. Sporting injuries were the second most common. This study identifies some features which are in agreement with studies from elsewhere in Britain. However, there are also interesting differences, such as the Glasgow peak incidence for forearm fractures being at age eight, with a marked decline by 12 years. Furthermore, our findings have been extended to consideration of type of intervention and likelihood of successful treatment.

Treatment of torus fractures in the forearm in children using bandage therapy

In a torus fracture, there is an intact cortex at the side of the fracture which gives more intrinsic stability than in greenstick fractures, where one side of the cortex is disrupted. Two previously done studies compared soft bandage therapy (BT) with cast therapy in the treatment of torus forearm fractures in children and showed this is safe and does not cause any complications. The aim of our study was to validate these studies by treating all patients presenting to emergency department with a torus fracture with BT and investigate whether any complications occur. At a single-center from January 2009 to June 2009, all patients with an impacted greenstick fracture of the distal radius and/or ulna without exception were treated using BT. Primary endpoint was secondary angulation; secondary endpoint was pain on Visual Analog Score. Seven patients were misdiagnosed as torus fractures but were actually greenstick fractures and had to be excluded. A total of 49 patients with a torus fracture were included in statistical analysis. No fracture displacement was seen. Four patients needed an additional nonsteroidal antiinflammatory drug or an antalgic plaster cast. The overall Visual Analog Score of the patients was lower than in previous studies. Soft BT is safe in all children without risk of further angulation and with a pain score equal to cast therapy. Important is that misdiagnosis of the torus fracture at initial presentation should be minimized.

Tibial torus and toddler's fractures misdiagnosed as transient synovitis: a case series

IntroductionThe high incidence of transient synovitis in early childhood makes it the first suspected pathology in a limping child. Trauma, which has long been regarded as a causative factor for transient synovitis, may be underestimated in a non-cooperative toddler.After excluding most serious conditions, such as septic arthritis, a speculative diagnosis of transient synovitis can be made, and this can easily mask a subtle musculoskeletal injury.Case presentationsWe report the cases of three Caucasian patients (two boys, aged 20-months- and three-years-old, and one girl, aged two-years-old), with tibial torus and toddler's fractures which were late-diagnosed due to an initial misdiagnosis of transient synovitis of the hip.ConclusionIn a non-cooperative child musculoskeletal trauma can be mistaken as a simple causative factor for transient synovitis of the hip and this can easily prevent further investigation for a possible subtle musculoskeletal injury of the lower extremities.Our experience with the presented cases suggests the need to be more vigilant in the differential diagnosis of transient synovitis in young children.

Distal Radius Fractures: Cast or Splint?

Distal Radius Fractures: Cast or Splint?

Diagnosis and treatment of greenstick and torus fractures of the distal radius in children: A prospective randomised single blind study

The management and the diagnostic modalities used in cases of undisplaced greenstick and torus fractures of the distal radius in children vary between different treatment centres. The aim of this study was twofold: firstly, to analyse the sensitivity of X-rays versus ultrasound to diagnose these fractures; secondly, to compare three available treatment options (plaster cast, Futuro splints, and double Tubigrip) in terms of pain, analgesia requirements, grip strength, deformity, stiffness and interference with a child's activities of daily living. We prospectively included 79 patients suffering from undisplaced greenstick and torus fractures of the distal radius. Patients were randomized (single blindly) to the studied treatment groups. In terms of diagnosis, the ultrasound was found to be more sensitive than X-rays for diagnosing these fractures. Our results also showed that Tubigrip was superior in terms of interference with a child's ADLs, stiffness and grip strength. However, there was no difference in the levels of pain, analgesia required, and deformity. These results support the idea that ultrasound is an effective and sensitive tool for detecting undisplaced greenstick and torus fractures of the distal radius in children. Treating these fractures with functional nonrigid devices (Tubigrip) results in improved function without increased discomfort or deformity.

Splinting versus casting of “torus” fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): A literature review

To compare outcomes regarding splinting versus casting of paediatric torus fractures in the ED with the aim of establishing the preferred treatment. Evidence was collated using electronic databases; Pubmed, Ovid, Medline and Cochrane library. Search terms included [torus fractures; buckle fractures; splinting distal radius fractures; paediatric wrist fractures; paediatric forearm fractures/injuries; cast versus splint]. Searches identified papers published between 1984 and June 2008. The review demonstrated that children with removable splints preferred them to casts, in terms of improved physical functioning and lower pain scores reported after initial injury than those with casts. Children demonstrated this by using their wrists in the first week after injury to shower and bathe more easily. The cast group reported unscheduled visits to ED due to problems with the cast, such as discomfort or re-application of the cast from getting it wet. Using a splint will have considerable economic implications, money was found to be saved in terms of time and resource management. Radiographs taken at 4 weeks in both the cast and splint group confirmed that all fractures healed without significant change in alignment, suggesting that neither clinical nor radiographic follow-up is necessary for injury. Torus splints in all the studies were consistently better than plaster immobilisation in terms of clinical outcome, patient preference and cost, with the exceptions of young children or children with special needs who can easily remove the device. Splinting torus fractures may reduce cost, time and resource management if used instead of casting in the ED.

Benign self-limiting cystic lesion after lower end radius fracture in a child

Post-traumatic cystic lesion is usually found adjacent to a healing torus fracture. It is typically asymptomatic and appears just proximal to the fracture line within the area of subperiosteal new bone formation. We report one such cyst in a 7 year old boy, with a brief review of literature to highlight the occurrence of such benign self limiting cystic lesions of lower end radius fracture.

Are frequent radiographs necessary in the management of closed forearm fractures in children?

A prospective pooled case series was used to assess the value of frequent radiographic examinations during treatment of closed forearm fractures in children from major university pediatric medical centers in Israel and China. The sample consisted of 202 consecutive children (mean age 7 years; range 3-12 years) with closed forearm fractures treated nonoperatively. Children with open, growth-plate fractures or fractures associated with dislocation of the nearby joint (i.e., monteggia fractures) were excluded. In 28 children who had torus fractures, radiographic examination was performed at the time of cast removal, 3 weeks after the start of treatment. In 63 children who had stable fractures that did not require reduction (undisplaced or minimally displaced, complete or greenstick), radiographic examination was performed 1 week after the start of treatment and again at cast removal 4-6 weeks later. In the remaining 111 children with complete, displaced, or greenstick fractures (all with angulation of more than 15 degrees ) who underwent closed reduction, an additional X-ray was taken 2 weeks after cast placement. All children (except those with torus fractures) were followed clinically, without further radiographic examination, for 3 months after cast removal. Radiographs at cast removal showed good union in all stable fractures, indicating that additional X-rays on cast removal would have had no added value. In the children with unstable fractures, only 9 showed redisplacement with angulation of more than 15 degrees on repeated X-rays during the first 2 weeks after cast placement. All 9 underwent successful re-reduction. On clinical evaluation 3 months after cast removal, all patients in the sample had full range of elbow and forearm motion. Repeated fracture did not occur in any of the patients. On the basis of these results, radiographs are recommended 2 weeks after cast placement for greenstick or complete fractures. At the time of cast removal, if clinical examination does not show signs of nonunion or malalignment, no radiographic examination is necessary.

A Randomized Controlled Trial of 2 Methods of Immobilizing Torus Fractures of the Distal Forearm

Immobilization of torus fractures of the distal forearm, for 1 to 4 weeks in a slab, cast, or splint, produces good radiological and functional outcomes. This study assesses the pain associated with 2 forms of immobilization used for these injuries. A randomized controlled trial comparing fiberglass volar slab and encircling plaster-of-paris cast was conducted at a children's hospital emergency department. Patients presenting with torus fractures of the distal forearm were enrolled and reviewed after 2 weeks of immobilization. A daily questionnaire was used during immobilization to assess pain, satisfaction, and activity state of the child. Adequate data were available for 42 participants in each group. Immobilization in a volar slab was associated with the following: increased duration of pain, with a median of 6.0 days (interquartile range [IQR] 2.0-11.0) versus 3.0 days (2.0-5.0) P = 0.009, and an increased time to resumption of normal activity at 2 weeks 67% versus 95%, P = 0.001. Average daily pain severity was similar in the 2 groups (35 mm on visual analogue scale [VAS] for the cast group vs. 39 mm for the slab group), P = 0.48. Stratified analysis showed pain on enrollment of greater than 50 mm on VAS, which was a strong association for longer duration of pain in both groups, P < 0.001. Use of a slab may increase the duration of pain, especially in patients who had more severe pain at presentation.

Very young and elderly patients are less likely to receive narcotic prescriptions for clavicle fractures

There has been increased interest in the management of pain in the emergency department (ED) in the last decade partly as a result of increased emphasis by the Joint Commission on Accreditation of Healthcare Organizations. Prior studies have looked into analgesia based on age groups and have concluded that there are differences in how physicians treat patients based on age [2,4]. These studies may be limited because they compared a multitude of painful conditions with variable severities among age groups. For example, a torus fracture in a child may be less painful than a Colles fracture in an adult. In addition, although there are pieces of evidence indicating that patients receive inadequate pain medication while in the ED [1-7,9], only few studies have evaluated ED physician narcotic prescribing patterns at the time of patient discharge [2,4,9,10]. We had access to a large patient database that included discharge prescriptions written by ED physicians. This enabled us to isolate a single painful condition and examine the discharge prescriptions written as a function of age. We used clavicle fractures to test for analgesia use because the pain severity associated with these may be more uniform

Transverse Divergent Dislocation of the Elbow With Ipsilateral Distal Radius Fracture in a Child

We report a rare case of an irreducible transverse divergent dislocation of the elbow with an ipsilateral distal radius torus fracture and a fracture of the coronoid process in a 9-year-old male. Closed reduction of the elbow was attempted, but the humeroulnar joint remained dislocated. At surgery, the avulsed anterior band of the medial collateral ligament complex of the elbow was found to be interposed between the medial condyle of the humerus and the olecranon. The dislocation was reduced after relieving the ligament entrapment, which was then repaired. The unstable proximal radioulnar joint was fixed with a Kirschner wire. Two years after surgery, the patient had a painless left elbow with full range of motion and no instability. He was able to use his upper extremity for all activities in his daily life and had returned to sports. No radiographic abnormalities were found at this follow-up, particularly premature epiphyseal closure of the radial head. Closed reduction has been successful in a majority of reported cases of transverse divergent dislocation of the elbow, yet the presence of an incomplete reduction of the ulnohumeral joint should alert the physician to the possible interposition of soft tissues or bony fragments necessitating an open reduction.

MRT zur Beurteilung von Begleitverletzungen distaler Unterarmbrüche im Wachstumsalter

The study was made to evaluate the role of MR imaging in pediatric distal forearm fractures by comparison with the findings of plain radiographs and MRI. 38 patients (27 boys and 11 girls, mean age of 12 years, range 7 to 15 years) with radiographically open distal radius and ulna growth plates requiring first aid for a fracture of the distal third of the forearm, were included in this study. The fractures were diagnosed on plain radiographs and conservative treatment was performed. In 35 patients MR imaging was performed within 3 weeks after the accident and in 3 patients MRI was performed after 6 to 9 weeks because of persistent wrist pain. Fifteen Salter/Harris II injuries of the radius and 1 of the ulna, 1 torus fracture of the radius and 2 of the ulna, 12 greenstick fractures of the radius and 3 of the ulna, 10 complete displaced radius fractures and 15 ulnar styloid fractures were found on plain radiographs. Twelve patients had evidence of associated triangular fibrocartilage complex (TFCC) lesions in MRI, there was no statistical correlation between TFCC lesions and fracture types, fracture dislocations or patients age (p > 0.5). One patient had an avulsion of the radioscaphocapitate ligament from the radius accompanying a greenstick fracture of the distal radius. 19 bone bruises and two radiographically occult fractures were identified. In 2 patients, a bone marrow oedema was seen in the radial epiphysis immediately adjacent to the germinal zone of the growth plate. In these patients premature physeal arrest occurred. MRI plays an important role in the evaluation of acute pediatric wrist injuries. It allows a better evaluation of osseous lesions than plain radiographs. In our study, a tear of the triangular fibrocartilage complex accompanied distal radius fractures in 32 % of patients. Simultaneous rupture of the TFCC insertion in the fovea ulnaris and ulnar styloid fracture lead to destabilisation of the distal radioulnar joint (DRUJ).