Treatment of Acute Buckle Fracture of the Proximal Lateral Tibial Metaphysis
For an acute buckle fracture of the proximal lateral tibial metaphysis, treatment with a removable knee immobilizer for approximately 3-4 weeks is recommended as the optimal approach, offering excellent outcomes with fewer complications compared to casting. 1
Understanding Buckle Fractures
Buckle (torus) fractures are incomplete fractures characterized by compression of one cortex without disruption of the opposite cortex. They are common in children due to the higher elasticity and porosity of immature bone. When occurring in the proximal tibial metaphysis, these fractures are typically stable and have excellent healing potential.
Treatment Algorithm
Initial Assessment
- Confirm diagnosis with appropriate radiographs
- Assess for:
- Fracture displacement (buckle fractures are typically non-displaced)
- Soft tissue injury
- Neurovascular status
- Associated injuries
Primary Treatment
- Immobilization Method: Removable knee immobilizer
- Duration: 25-28 days (approximately 3-4 weeks)
- Follow-up: Typically requires fewer clinic visits (average 2.2 visits) 1
Rationale for Removable Knee Immobilizer
The most recent high-quality evidence demonstrates that removable knee immobilizers provide several advantages over long leg casts for proximal tibial buckle fractures:
- Equal Stability: No patients showed interval fracture displacement during treatment with either immobilization method 1
- Fewer Complications: No skin complications were observed with knee immobilizers, compared to 3.1% in the cast group 1
- Shorter Immobilization: Mean immobilization time was 25.9 days with knee immobilizer versus 27.9 days with long leg cast 1
- Reduced Healthcare Utilization: Fewer clinic visits required (2.2 vs 2.6) 1
Special Considerations
Monitoring
- First follow-up at 1-2 weeks to ensure proper immobilizer use and assess healing
- Final follow-up at 3-4 weeks to confirm healing and discontinue immobilization
Potential Complications
While buckle fractures generally heal well, be aware of:
- Angular Deformity: Historical evidence suggests that proximal tibial metaphyseal fractures can develop genu valgum, particularly with complete or greenstick fractures 2
- Skin Issues: More common with cast immobilization than removable devices 1
Activity Restrictions
- Weight-bearing as tolerated in the immobilizer
- Gradual return to activities after immobilizer removal
- Full return to sports typically 4-6 weeks after injury
Conclusion
Removable knee immobilizers represent the optimal treatment for acute buckle fractures of the proximal lateral tibial metaphysis, providing excellent outcomes with fewer complications and healthcare visits compared to traditional casting approaches. This approach prioritizes both effective fracture healing and patient comfort while minimizing complications.