What is the appropriate management for a buckle (torus) fracture in a 2‑year‑old child?

Management of Buckle Fracture in a 2-Year-Old

A buckle (torus) fracture in a 2-year-old should be treated with a soft bandage or removable splint for 3 weeks, followed by immediate discharge without routine follow-up or repeat radiography.

Treatment Approach

Immobilization Method

• Use a soft bandage or removable splint rather than rigid casting 1, 2
• The FORCE trial demonstrated equivalence in pain and function between bandage and rigid immobilization, with no difference in complications (1.0% vs 0.6%) 1
• Duration: 3 weeks of immobilization 3

Follow-Up Protocol

• No routine fracture clinic follow-up required 3, 4
• No repeat radiographs needed once diagnosis is confirmed 3
• Provide adequate written information to parents at time of diagnosis

Key Clinical Considerations

Important caveat for this age group: While buckle fractures generally have low specificity for abuse 5, you must assess for concerning features:

• Evaluate the injury history carefully - buckle fractures result from axial compression loading 5
• In a 2-year-old (12-23 months), buckle fractures of the radius/ulna are among the few fracture types where skeletal survey is not automatically indicated if there is a clear accidental history 6
• However, skeletal survey IS necessary if 6:
  • No history of trauma is provided
  • History is inconsistent with mechanism
  • Attributed to abuse or being hit by an object
  • Child is non-ambulatory (less likely at age 2, but assess developmental status)

Clinical Reasoning

The evidence strongly supports minimal intervention for these inherently stable fractures 1, 2, 3. Torus fractures have excellent healing capacity and extremely low complication rates regardless of immobilization method. The FORCE trial (965 children, 2022) provides the highest-quality evidence showing:

• Pain equivalence at 3 days (difference -0.10,95% CI -0.37 to 0.17) 1
• No difference in functional recovery or quality of life over 6 weeks 2
• Significant cost reduction with bandage approach 2
• Only marginally higher analgesia use on day 1 with bandage (83% vs 78%) 1

Common Pitfalls to Avoid

1. Over-treatment with rigid casting - This increases cost without improving outcomes 2, 7
2. Unnecessary follow-up appointments - These consume resources without clinical benefit 3, 4
3. Repeat radiographs - Not indicated for confirmed torus fractures 3
4. Missing abuse red flags - While torus fractures have low abuse specificity, always assess history consistency and consider skeletal survey if concerning features present 6, 5

Parent Education Points

Provide clear written instructions including:

• Expected healing time (3 weeks)
• When to remove bandage/splint
• Normal activity progression
• Red flags requiring return (severe pain, neurovascular compromise)
• Reassurance that these fractures heal reliably without complications