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What is your diagnosis?

The most likely diagnosis is a buckle or torus fracture of the radius. 

• Pearl: This is a fracture pattern almost exclusively seen in children under the ages of 10-12. 

What is the mechanism of injury?

This is a common injury mechanism in children with immature bones. It is a result of compressive forces or axial loads acting on immature "spongy" bone resulting in a bulging out of the cortex and periosteum. 

• Pearl: The most common site for this injury is the radial metaphysis, usually as a result of falling on an outstretched hand. 

What physical exam findings are expected?

There will be significant tenderness to palpation in the affected area of the radius with minimal to no tenderness elsewhere. There should be no pain with elbow or wrist movement and it is unusual to have significant gross deformity evident on examination. Evaluating for injuries to the elbow and/or wrist is crucial as the presence of an additional injury would significantly alter treatment plan. 

Which imaging modalities can be used?

X-ray is the traditional diagnostic modality of choice, however, new evidence has shown excellent sensitivity and specificity for the use of ultrasound as the initial diagnostic modality in non-deformed pediatric forearm injuries [2]. The ultrasound probe should be placed lightly over the area of maximal tenderness in long axis to the radius. Normal bony cortex should be visualized proximal and distal to the injury site with the area of maximal tenderness showing cortical irregularity and buckling outward of the cortex diagnostic of a torus fracture as shown below.

Image 3: Longitudinal image of the mid-distal radius showing torus fracture (red circle) and normal bony cortex (blue lines). Author's own images and annotations.

What is the management in the ED?

Recently, there has been a trend towards less aggressive management of these injuries due to their excellent healing. Velcro wrist splints are superior to splinting or casting and there is generally no need for evaluation by orthopedics. Usual follow up will be with the patient's pediatrician [1]. 

When do you consult orthopedics?

Orthopedics should generally not be consulted in the ED for torus fractures. If a patient with a torus fracture has pain beyond 2-3 weeks, additional testing and evaluation by orthopedics can be obtained at that time on an outpatient basis.