Torus Fractures Research Articles

Soft bandage, splint or cast as the treatment of distal forearm torus fracture in children: a systematic review and meta-analysis

A meta-analysis including all relevant randomized controlled trials was conducted to compare soft bandage, splint and cast as the treatment of torus fracture. PubMed, Scopus, and Web of Science databases were searched in January 2023. Two comparisons were made: (1) splint versus cast, and (2) bandage versus rigid immobilization (i.e. splint or cast). Main outcomes were pain, clinical healing of the fracture and return to activities. Secondary outcomes were adverse events (skin issues, problems with cast/splint/bandage) and patient/parental satisfaction. Seven studies with 1550 patients were included. Splint was associated with higher pain scores at 3 days compared to cast (Mean difference [MD] 1.00, CI 0.06–1.94) and at 1 week (MD 1.46, CI 0.84–2.08, moderate-certainty evidence), but faster return to activities (at 3 weeks RR 1.77, CI 1.09–2.88, at 4 weeks RR 1.44, CI 1.11–1.82, moderate-certainty evidence). All torus fractures heal clinically within 3–4 weeks (low-certainty evidence). Bandage may lead to slightly higher pain score (MD 0.35, CI 0.04–0.66, moderate-certainty evidence) at first day after treatment compared to rigid immobilization, but no evidence of a difference was found in later time points. In conclusion, soft bandage or removable wrist splint seem to be optimal first-line treatment of distal forearm torus fracture.

Physeal and metaphyseal fractures of the distal radius in pediatric patients

Background: This article aims to summarize the available information and present treatment recommendations. The scope of this discussion is limited to physeal and metaphyseal fractures of the pediatric distal radius.Current Concepts: Pediatric distal radial fractures are common among children and adolescents. The mechanism of injury is usually a fall on an outstretched hand, and fractures typically occur during sports-related activities. Children with distal radial fractures initially present with pain, swelling, and distal forearm deformities. Plain radiographs are essential for evaluating the fracture type and degree of displacement. Complete wrist, forearm, and elbow views should also be assessed, especially for high-energy injuries, to identify ipsilateral fractures. Fractures typically involve the distal radial metaphysis or physis. Metaphyseal fractures are classified as torus, buckle, and bicortical fractures. Most displaced Salter-Harris types I and II and non-displaced metaphyseal fractures can be treated with closed reduction and casting. Operative treatment is recommended if irreducibility or soft-tissue neurovascular compromise is suspected. Operative options include closed reduction, percutaneous pinning, or open reduction, followed by pin or plate fixation. Malunion, nonunion, physeal arrest, ulnocarpal impaction, and nerve injury are possible complications of distal radial fractures in pediatric patients.Discussion and Conclusion: Metaphyseal and physeal fractures of the distal radius are common in children. Most cases are best treated with closed reduction and cast immobilization. Clinicians should be aware of delayed complications and understand how to manage them to ensure successful long-term outcomes.

Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures.

The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius. A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective, as well as a broader societal point of view. Health resources and quality of life (the youth version of the EuroQol five-dimension questionnaire (EQ-5D-Y)) data were collected, as part of the Forearm Recovery in Children Evaluation (FORCE) multicentre randomized controlled trial over a six-week period, using trial case report forms and patient-completed questionnaires. Costs and health gains (quality-adjusted life years (QALYs)) were estimated for the two trial treatment groups. Regression was used to estimate the probability of the new treatment being cost-effective at a range of 'willingness-to-pay' thresholds, which reflect a range of costs per QALY at which governments are typically prepared to reimburse for treatment. The offer of a soft bandage significantly reduced cost per patient (saving £12.55 (95% confidence interval (CI) -£5.30 to £19.80)) while QALYs were similar (QALY difference between groups: 0.0013 (95% CI -0.0004 to 0.003)). The high probability (95%) that offering a bandage is a cost-effective option was consistent when examining the data in a range of sensitivity analyses. In addition to the known clinical equivalence, this study found that the offer of a bandage reduced cost compared with rigid immobilization among children with a torus fracture of the distal radius. While the cost saving was small for each patient, the high frequency of these injuries indicates a significant saving across the healthcare system.

Infographic: Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures.

Infographic: Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures.

Torus fractures - diagnosis and management.

Torus fractures are a common paediatric injury involving the distal radius. Patients typically present following a fall onto the outstretched hand, with wrist pain as their primary complaint. The principal investigation of choice is a plain radiograph of the wrist joint. These fractures should be managed with a soft-bandage and immediate discharge approach and do not require specialist follow-up. Clinicians have historically had differing views regarding optimal management of torus fractures. It is therefore important for hospital clinicians to uniformly understand the most up-to-date management of this condition. This review provides an overview of the epidemiology, anatomy, diagnosis and management, with an aim to improve outcomes.

Is soft bandaging comparable with rigid immobilization of torus fractures of the wrist in the pediatric population?

Is soft bandaging comparable with rigid immobilization of torus fractures of the wrist in the pediatric population?

Direct discharge for children with a greenstick or torus fracture of the wrist is a non-inferior satisfactory solution to traditional treatment.

Direct Discharge protocols (DD) can alleviate strain on healthcare systems by reducing routine outpatient follow-up. These protocols include low-complex musculoskeletal injuries, such as isolated greenstick fractures or torus fractures of the wrist in children. While there is consensus on the effectiveness of DD, there is a lack of injury-specific powered studies. This study compares treatment satisfaction between DD and traditional treatment in children with a greenstick fracture or torus fractures of the wrist. Children with isolated torus or greenstick fractures of the distal radius or ulna were eligible for inclusion before (pre-DD cohort) and after (DD cohort) the implementation of DD in four hospitals. Traditionally, patients receive a (soft) cast and minimally one routine outpatient follow-up appointment. With DD, patients are discharged directly from the ED after receiving a brace and information, summarized in a smartphone app and a helpline for questions during recovery. The primary outcome was patient or proxy treatment satisfaction (0 to 10), and a power analysis was performed to assess non-inferiority. Secondary outcomes included complications, functional outcomes measured in Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE), primary healthcare utilisation, and secondary healthcare utilisation (follow-up appointments and imaging). In total, 274 consecutive children were included to analyse the primary endpoint. Of these, 160 (58%) were male with a median age of 11years (IQR 8 to 12). Pre-DD and DD treatment satisfaction did not vary statistically significantly for greenstick fractures (p = 0.09) and torus fractures (p = 0.93). No complications were observed. PROMIS UE showed no statistically significant differences before and after implementation of direct discharge protocol for torus (p = 0.99) or greenstick (p = 0.45) fractures. Secondary healthcare utilisation regarding follow-up was significantly lower in the DD-torus cohort compared to the pre-DD torus cohort, with a mean difference (MD) of -1.00 follow-up appointments (95% Confidence Interval (CI) -0.92 to -1.13). Similar results were found in the pre DD-greenstick cohort compared to the pre-DD-greenstick cohort (MD): -1.17 follow-up appointments, 95% CI -1.09 to -1.26). Direct Discharge is non-inferior to traditional treatment in terms of treatment satisfaction for paediatric patients with greenstick or torus fractures of the wrist compared to children treated with rigid immobilisation and routine follow-up. Furthermore, the results demonstrate no complications, comparable functional outcomes, and a statistically significant reduction of secondary healthcare utilisation, making DD a good solution to cope with strained resources for children with an isolated greenstick fracture or torus fracture of the wrist.

Does Immobilization of Distal Radius Torus Fractures Affect Treatment Outcome?

The aim of this study is to compare the clinical results of splint, short arm circular plaster, and soft bandage immobilization methods applied in the treatment of wrist torus fractures in a single center. Patients treated for torus fractures at a tertiary trauma hospital between January 2018 and January 2022 were analyzed retrospectively. According to the physician's preference, a splint, short arm circular plaster, or soft bandage was applied to each patient. The treatment modalities, the number of hospital admissions during the treatment, the number of radiological imaging procedures used during the treatment, immobilization time, and the follow-up periods of the patients were checked and noted on the hospital data processing system. Six hundred ten patients were included in the study. It was determined that 351 patients were treated with a short arm splint, 155 with a short arm circular cast, and 104 with soft bandaging. The number of radiological imaging procedures, the number of hospital admissions during the treatment, the duration of the pain complaint, and the complication rate of the patients treated with splint were significantly lower than the groups treated with short arm circular plaster and soft bandage (P < 0.001). It was observed that patients who were immobilized with a short arm splint required less follow-up time and fewer imaging procedures and hospital admissions and experienced earlier pain relief and lower complication rates. We think that the use of short arm splints in the treatment of torus fractures is sufficient, safe, and advantageous.

A Simulation Model for the Handheld Ultrasound Diagnosis of Pediatric Forearm Fractures.

Handheld ultrasound (HHU) devices have gained prominence in emergency care settings and post-graduate training, but their application in the diagnosis of pediatric fractures remains under-explored. The aim of this study is to evaluate the effectiveness and accuracy of an HHU device for diagnosing pediatric forearm fractures using a simulation model. The materials for the basic pediatric fracture model include turkey bones soaked in white vinegar to make them pliable, food-grade gelatine, and plastic containers. Ultrasound analysis of the models was done with an HHU device, Sonosite İViz US (FUJIFILM Sonosite, Inc.; Bothell, Washington USA). Four different fracture patterns (transverse fracture, oblique fracture, greenstick fracture, and a torus fracture) and one model without fracture were used in this study. Twenty-six Emergency Medicine residents sonographically evaluated different bone models in order to define the presence and absence of fracture and the fracture subtype. The participants' ability to obtain adequate images and the time taken to create and recognize the images were evaluated and recorded. After the sonographic examination, the residents were also asked for their opinion on the model as a teaching tool. All participants (100%) recognized the normal bone model and the fracture, regardless of the fracture type. The consistency analysis between the practitioners indicated a substantial agreement (weighted kappa value of 0.707). The duration to identify the target pathology in fracture models was significantly longer for the greenstick fracture (78.57 [SD = 30.45] seconds) model compared to other models. The majority of participants (92.3%) agreed that the model used would be a useful teaching tool for learning ultrasound diagnosis of pediatric forearm fractures. All participants successfully identified both the normal bone model and the presence of fractures, irrespective of the fracture type. Significantly, the identification of the greenstick fracture took longer compared to other fracture types. Moreover, the majority of participants acknowledged the model's utility as a teaching tool for learning ultrasound diagnosis of pediatric forearm fractures.

93 Managing paediatric torus fractures at the Royal London Hospital: A Clinical Audit and Cost Analysis

Abstract Aim Torus fractures are extremely common, accounting for up to 25% of all paediatric-related visits to the emergency department (ED). This audit aims to assess the adherence of the Royal London Hospital (RLH) to the NG38 NICE guidelines. These guidelines state that patients should not be given a rigid cast and should be discharged, advising carers a follow-up is not required. Method We analysed and retrospectively collected data from a cohort of paediatric patients with torus fractures who presented at the RLH between September 2021 and December 2021. In total 59 patients were included in the audit. Recommendations were later presented at the paediatric orthopaedic meeting of the RLH. Results From the cohort, 22% of patients were given inappropriate treatment including rigid casts with or without manipulation, with an average time in cast of 3.8 weeks. 18.6% of all the patients were followed-up in clinic, including 54.5% of the patients who received a rigid cast during discharge from the ED (the rest returned only for cast removal). 63.6% of the patients who returned for follow-up had a repeat X-Ray performed. Conclusions Overall, 18 out of 59 (30.5%) cases were not managed according to NICE guidelines (received inappropriate treatment, had a clinic follow-up with a clinician or was referred for &amp;gt;1 X-Ray). This incurred an inappropriate cumulative cost of almost 2000£ only during a 4-month period from one hospital. This audit aims to educate ED staff and update local protocols. A re-audit is going to follow to assess the impact of these recommendations.

OVERVIEW OF PAEDIATRIC BONE AND JOINT : A SYSTEMATIC REVIEW

Mercer Rang well observed, "Children are not young adults." Children and adults have different skeleton physiology and morphology. Depending on bone growth and remodelling, skeletal conditions should be treated differently. Because bone growth and modelling differ. Children's bones are more flexible than those of adults, so they can move more before they break. People often use the word "plastic deformation" to describe a condition in which the bone changes shape but does not break. Sometimes, the bone might just bend, causing a type of break called a torus fracture. Adults don't have these patterns because their bones are much less flexible and resistant to bending at angles than those of a growing skeleton. When two bones touch, they make a joint. Groups of joints can be made based on how they look or how they work. Functional classification is based on how much movement is allowed, while histological classification is based on the type of connective tissue that makes up most of the body. The mesoderm gives rise to joints, which are made up of bones and connective tissue. Bones can form either directly or indirectly through endochondral ossification or intramembranous ossification. The blood supply and nerve supply to each joint follow different rhythms.

Accuracy and Reliability of Cortical Buckling or Bulging: A Reliable Indicator of Ultrasound in Diagnosing Buckle or Torus Fracture of Long Bones in Children

Accuracy and Reliability of Cortical Buckling or Bulging: A Reliable Indicator of Ultrasound in Diagnosing Buckle or Torus Fracture of Long Bones in Children

Is it possible to reduce treatment costs in distal radius torus fractures?

Aim: The aim of the study was to evaluate the effect of parental information on the number of radiological examinations, the number of orthopedics outpatient visits, the duration of early orthopedic outpatient admission, the fracture recovery scores of reduction, and the cost of treatment of torus fractures in children in in the emergency service.Material and Method: A total of 85 patients having stable torus fractures, aged between 0-16 years have been included to the longituidinal study during the period of first of April 1, 2020 and first of September, 2022. A total of 44 patients whose parents are not informed were evaluated in the emergency department and were transfered to the Orthopedics polyclinic (No Information group- No-INF), whereas 41 patients were evaluated by the Orthopedist in the emergency department and their parents were informed directly (Information group- INF). The groupd were compared in terms of the duration of the first admission to the orthopedic polyclinic, the number of applications to the orthopedic polyclinic, the number of radiological examinations performed, whether reduction has been performed, fracture healing scores and current treatment costs and correlation was analyzed. Results: The MAYO Wrist Score (p=0.80), age (p=0.712), gender (p=0.815), and complications (p=0.482) did not differ significantly between the No-INF and INF groups. Patients in the INF group whose parents have been directly informed in the emergency department had lower orthopedic polyclinic application rates (p&amp;lt;0.001), longer delay for the first orthopedic polyclinic admission (p&amp;lt;0.001) and a lower probability and/or less number of X-Ray evaluation(p&amp;lt;0.001). Correlation between the variables such as Patient’s Modified MAYO Wrist Scores, the number of orthopedic polyclinic visits, the first orthopedic polyclinic admission time, the reduction procedure and the number of X-Rays was not ststistically significant (p&amp;gt;0.05). Findings show that additional tests and procedures such as radiography has increased the costs of 6-41% in the present study. Conclusion: It can be concluded that adequate information in the emergency services for parents of children with stable torus fractures might provide a reduction in treatment costs due to lower orthopaedic polyclinic admission and reduced radiographic examination. Wrist MAYO scores have not been affected application of reduction, radiographic evaluation, polyclinic admission and time.

Evidence-Based Management of Pediatric Distal Radius Buckle Fractures

Distal radius fractures are the most common fracture in children younger than 16 years. A common pattern of distal radius fractures is the buckle or torus fracture. Traditional treatment of these injuries involved casting with serial x-ray imaging to evaluate for proper healing and maintained alignment. Studies of these injury patterns, however, suggest that these fractures are inherently stable and have a very low incidence of displacement. These studies posit that torus fractures can be treated definitively in a removable brace that can be discontinued by the patient's caregiver without the need for follow-up examinations or imaging. A review of pertinent literature from the past 5 years concluded that, in pediatric patients with acute radial torus fractures, clinical outcomes were equivalent between patients treated with removable braces and no scheduled follow-up and those treated with hard casting and repeat clinical evaluation. Implementation of this evidence-based treatment can significantly improve patient care by reducing unneeded follow-ups and imaging while minimizing the cost of treatment and missed school/work days by patients and their caregivers.

Patient and parent satisfaction with soft cast immobilization and a single visit for buckle fractures

IntroductionCompression fractures of the distal radius (known as buckle or torus fractures) should be managed with non-rigid immobilization and a single visit as per the NICE guidelines. A recent national survey demonstrated ongoing reluctance to incorporate this treatment strategy in Ireland, with more than 70% of institutions still managing these fractures with the traditional method (rigid cast immobilization and fracture clinic follow up). In this study we assessed whether this could be attributed to parent or carer preference. MethodsAll paediatric patients from January 2021 to August 2022 in a single centre with buckle fractures of the distal radius were included in this study. A 10-question survey was created to assess whether the care giver and patient was satisfied with the information supplied, method of stabilization, single point of contact, and self-removal of the soft cast. A maximum of 5 points could be given to each score with a maximum of 50 for the overall satisfaction of care. ResultsA total of 82 surveys were completed via the post or telephonically. The two lowest average scores were 3.77 (SD ± 1.20) and 3.95 (SD ± 1.24), which indicated that patients would have no issues organising a follow up appointment and difficulty with cast removal respectively. Three other questions scored slightly better with 4.12 (SD ± 1.02), 4.17 (SD ± 1.04) and 4.22 (SD ± 1.05) which demonstrated some dissatisfaction with the cast condition at time of removal, difficulty with returning to school directly after removal and a desire to have another follow up appointment respectively. The highest average score was for adequacy of information provided at the time of treatment, 4.58 (SD ± 0.67). Furthermore, high scores were also given to the questions regarding confidence in the stability provided by the soft cast and the modality of treatment provided. ConclusionThis study highlighted that one of the limiting factors to implementing the non-rigid immobilization and single visit protocol for buckle fractures as recommended by NICE is likely due to parental wariness and frequent dissatisfaction. This was mostly attributed to soft cast immobilization as patients experienced similar complications as found with rigid immobilization. The authors would rather suggest splint or soft bandage immobilization as this would likely improve patient/parent satisfaction with single visit treatment. With regards to further research, a follow up study can be performed focussing on the physician's preferences with regards to buckle fracture treatment protocol. And to determine what factors from the physician's perspective contributes to the reluctance in implementing the NICE guidelines protocol.

Pediatric radius torus fractures in x-rays-how computer vision could render lateral projections obsolete.

It is an indisputable dogma in extremity radiography to acquire x-ray studies in at least two complementary projections, which is also true for distal radius fractures in children. However, there is cautious hope that computer vision could enable breaking with this tradition in minor injuries, clinically lacking malalignment. We trained three different state-of-the-art convolutional neural networks (CNNs) on a dataset of 2,474 images: 1,237 images were posteroanterior (PA) pediatric wrist radiographs containing isolated distal radius torus fractures, and 1,237 images were normal controls without fractures. The task was to classify images into fractured and non-fractured. In total, 200 previously unseen images (100 per class) served as test set. CNN predictions reached area under the curves (AUCs) up to 98% [95% confidence interval (CI) 96.6%-99.5%], consistently exceeding human expert ratings (mean AUC 93.5%, 95% CI 89.9%-97.2%). Following training on larger data sets CNNs might be able to effectively rule out the presence of a distal radius fracture, enabling to consider foregoing the yet inevitable lateral projection in children. Built into the radiography workflow, such an algorithm could contribute to radiation hygiene and patient comfort.

Prevalence of inadequate vitamin D level and its predictors in children presenting with torus fractures.

Review of the published articles does not show any study done to see if children with torus fracture are with Vitamin D deficiency. The aim of this study was to determine association of inadequacy of Vitamin D level with torus fracture and its predictors in children in Karachi Pakistan. Patient underage of 13years came with torus fracture were included in study, and managed non-operatively with below elbow cast. Proforma was made which includes demographic data (age, gender, nutritional status) and exposure to sunlight, dietary habits, kind to apparel and type of accommodation they were living at. All participants underwent measurement of serum vitamin D level. Out of 558 children presented with limb fractures in emergency department, 190 (34.05%) had torus fracture, with mean age of 6.0 ± 4.2years. 93 (48.94%) in pre-school group, 59 (31.05%) in school and 38 (20%) were breast-fed. On nutritional status, malnourished were 72 (37.89%), out of which 32 (44.44%) had first-degree malnutrition. On vitamin D level status only 52 (27.36%) participants had Vitamin D within normal range while 86 (45.26%) were found Vitamin D deficient. We found that vitamin D level is directly related to nutritional status, duration of sun exposure maternal vitamin d levels and not significantly related to age, gender, type of accommodation and different fabric types. In this study torus fracture in children is significantly associated with Vitamin D deficiency, with common predictors including nutritional status, maternal Vitamin D level for lactating mothers and duration of exposure of sunlight. Vitamin D supplementation in children can prevent a significant number of fractures via national programs for food fortification and increase the awareness of general population on the importance of sunlight exposure and intake of food rich in Vitamin D.

Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK

The most common fractures in children are torus (buckle) fractures of the wrist. Controversy exists over treatment, which ranges from splint immobilisation and discharge to cast immobilisation, follow-up, and repeat imaging. This study compared pain and function in affected children offered a soft bandage and immediate discharge with those receiving rigid immobilisation and follow-up as per treating centre protocol. In this randomised controlled equivalence trial we included 965 children (aged 4-15 years) with a distal radius torus fracture from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using bespoke web-based randomisation software. Treating clinicians, participants, and their families could not be masked to treatment allocation. Exclusion criteria included multiple injuries, diagnosis at more than 36 h after injury, and inability to complete follow-up. The primary outcome was pain at 3-days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. We performed a modified intention-to-treat and per protocol analysis. The trial was registered with ISRCTN registry, ISRCTN13955395. Between Jan 16, 2019, and July 13, 2020, 965 children were randomly allocated to a group, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 379 (39%) were girls and 586 (61%) were boys. Primary outcome data was collected for 908 (94%) of participants, all of whom were included in the modified intention-to-treat analysis. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group versus 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was -0·10 (95% CI -0·37 to 0·17) and-0·06 (95% CI -0·34 to 0·21) in the per-protocol population. This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up. UK National Institute for Health and Care Research.

Torus fractures of the distal radius: time to focus on symptomatic management

The torus (buckle) fracture of the distal radius is one of the most common fractures in children. This fracture is inherently stable and carries an excellent prognosis,1 and several studies have supported the use of a removable splint primarily for symptom relief and discretionary follow-up.2–5 In The Lancet, Daniel Perry and colleagues6 report the results of a pragmatic randomised trial that was designed to challenge the need for any immobilisation. At 23 emergency departments across the UK, 965 children (379 [39%] female and 586 [61%] male) from age 4 years to 15 years with a torus fracture of the distal radius, were randomly assigned to either an offer of a bandage and no scheduled follow-up (n=489) or rigid immobilisation (cast or splint; n=476) with follow-up as per the standard practice of the treating centre.

Does digital, multimedia information increase recruitment and retention in a children’s wrist fracture treatment trial, and what do people think of it? A randomised controlled Study Within A Trial (SWAT)

ObjectivesTo evaluate digital, multimedia information (MMI) for its effects on trial recruitment, retention, decisions about participation and acceptability by patients, compared with printed information.DesignStudy Within A Trial using random cluster...