Treatment varies from the use of a removable rigid splint, to plaster cast immobilization, to more flexible splints. There is considerable variation in the management of torus fractures. They are very low risk injuries for complications or deformity in the skeletally immature, and these fractures universally heal well. They result from trauma to growing bones and account for 500,000 UK emergency attendances annually. Torus (buckle) fractures of the distal radius are the most common fractures in children, with the bone ‘buckling’, so there is deformation without a break in the cortex. It will not be possible to blind patients and care givers to their allocated treatment. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardian.Ĭite this article: Bone Joint Open 2020 1-6:214–221. The primary outcome is the Wong-Baker FACES pain scale at three days post-randomization. Three and six weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. ResultsĪt day one, three, and seven, data on pain, function, QoL, immobilization, and analgesia will be collected. Each patient will be randomly allocated (1:1, stratified by centre and age group (four to seven years and ≥ eight years) to either a regimen of the offer of a soft bandage and immediate discharge or rigid immobilization and follow-up as per the protocol of the treating centre. Baseline pain as measured by the Wong Baker FACES pain scale, function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb, and quality of life (QoL) assessed with the EuroQol EQ-5D-Y will be collected. MethodsĬhildren aged four to 15-years-old inclusive who have sustained a torus/buckle fracture of the distal radius with/without an injury to the ulna are eligible to take part. This is the protocol for a randomized controlled equivalence trial of ‘the offer of a soft bandage and immediate discharge’ versus ‘rigid immobilization and follow-up as per the protocol of the treating centre’ in the treatment of torus fractures. UK treatment varies widely due to lack of scientific evidence. Most authors agree that where angulation is less than 20 degrees, manipulation for reduction is not required and only symptomatic support is required: this is usually in the form of a removable splint.Torus fractures are the most common childhood fracture, accounting for 500,000 UK emergency attendances per year. Some advocate the reduction of a bowing fracture where angulation exceeds 20 degrees. In isolation, treatment of bowing fractures is debated 2. Treatment and prognosisīowing fractures usually accompany another fracture and in those cases, treatment is determined according to the type and severity of the accompanying injury. In some cases, there may be dislocation of the paired bone, e.g. radius, and this is usually diaphyseal (either greenstick or complete). There is usually an accompanying fracture of a paired bone, e.g. There is no fracture line or visible cortical injury. The bowing tends to be fluid and blend into the normal bone at either end. If the view is in the plane of the bow, the bone may appear completely normal 1. On a plain film, bowing of the bone can be visualized provided that the view is in a different plane to the direction of bowing. Microscopic examination of the bone reveals that there are microfractures along the concave border of the bowed bone, but these are not visible radiographically. If the force is greater than the mechanical strength of the bone, the bone undergoes plastic deformation and when the force is released, the bone remains in its bowed position. This ability to bend occurs because the cortex is thinner in absolute and relative terms compared to adult bones and because of the way the cortex and periosteum bind to each other in the developing skeleton. Pediatric bones have a degree of elasticity and therefore, if the force is low and subsequently released, the bone returns to its normal position and no lasting evidence of that bowing is seen radiographically. When an angulated longitudinal force is applied to a bone, the bone bends. This is often after falling from furniture or climbing equipment, especially monkey bars. Clinical presentationĬhildren present with pain and swelling following a fall, usually on an outstretched hand. However, bowing fractures of all long bones have been described. The radius and ulna are the most commonly affected bones, followed by the fibula. These injuries usually occur in children although adolescents may be affected. However, there have been several case reports of bowing in adult bones. Bowing fractures are almost exclusively found in children.
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