What is a Buckle injury?

Buckle Injury: Definition and Management

A buckle injury, also known as a torus fracture, is a compression fracture where bone trabeculae are compressed and the cortex bulges outward, most commonly occurring in the distal radius of children. 1, 2

Characteristics of Buckle Fractures

• Buckle fractures are inherently stable injuries with low risk for displacement, making them amenable to various treatment options 3
• They typically occur when compressive forces cause axial loading along the length of the bone 1
• These fractures may present as either a classical bulging of the cortex (unilateral or bilateral) or as subtle cortical angulation along one side of the bone 2
• Buckle fractures are extremely common in pediatric patients, particularly in the distal radius 4, 5

Mechanism of Injury

• Buckle fractures result from compression from axial loading along the length of the bone 1
• Common mechanisms include:
  • Falls from standing or running (most common) 4
  • Falls from bicycles 4
  • Trampoline accidents 4
  • Short falls (from heights between 6 inches and 4 feet) 1

Diagnosis

• Diagnosis is primarily radiographic, with characteristic appearance of compressed trabeculae and cortical bulging 2
• Some buckle fractures may be subtle and easily missed, particularly those showing only cortical angulation without classical buckling 2
• In certain cases, diagnostic ultrasound may be considered as an alternative imaging modality 5

Treatment Approaches

• Removable splints are the preferred treatment method for buckle fractures of the distal radius, worn for approximately 3 weeks 5, 4
• Compared to traditional rigid casts, splints offer:
  • Higher levels of patient and parent satisfaction 3
  • Greater convenience 3
  • Better patient preference 3
  • Ability to bathe, shower, or swim while wearing the splint 4
• Rigid casting is an alternative treatment option but offers no clinical advantage over splinting 6
• Soft casts can also be effectively used, with parents removing them at home after the treatment period 4

Follow-up Recommendations

• Current evidence suggests that once adequately diagnosed and properly splinted, buckle fractures do not require routine follow-up visits or repeat radiological imaging 5
• This approach reduces healthcare resource utilization while maintaining excellent clinical outcomes 6, 5

Clinical Considerations in Pediatric Patients

• In children under 12 months with fractures, including buckle fractures, clinicians should consider the possibility of non-accidental injury 1
• For children 9-11 months old with distal radius/ulna buckle fractures with a reported fall while cruising or walking, skeletal survey may not be necessary 1
• For children 12-23 months old with distal radius/ulna buckle fractures, skeletal survey is generally considered inappropriate 1

Outcomes

• Buckle fractures generally have excellent outcomes with appropriate management 4
• Patient satisfaction rates exceed 95% with both soft cast and rigid cast treatment approaches 4
• No re-fractures are typically observed following treatment of buckle fractures 4
• Pain is generally well-controlled with either splinting or casting approaches 3