Anatomy Review

Medical knowledge data
Part of Pediatric Distal Forearm Fractures

Buckle (Torus) Fracture of Pediatric Female Left Distal Radius

This module allows traditional bone setters, pre-hospital providers, clinical officers, nurses, nurse practitioners, and medical officers to become confident and competent in performing point-of-care ultrasound diagnostic imaging to rule out the presence of a pediatric distal forearm fracture and distinguish between buckle (torus) fractures and cortical break fractures to make appropriate referrals as part of the management of closed pediatric (< 16 years of age) distal forearm fractures in regions without access to X-ray imaging and orthopedic specialist coverage.[1][2][3][4][5][6][7][8][9]

Anatomy Review

Learning Objectives

  1. Identify the dorsal, volar (palmar), radial and ulnar surfaces of the forearm
  2. Identify the proximal and distal regions of the forearm
  3. Identify the radius and ulna bones of the forearm
  4. Identify the diaphysis (shaft), metaphysis, physis (growth plate) and epiphysis of the long bones of the juvenile forearm
  5. Identify the tension and compression cortex of the radius and ulna for buckle (torus) and incomplete (greenstick) fractures
  6. Describe the differences between the pediatric distal forearm fracture subtypes, including; buckle (torus), incomplete (greenstick), complete and physeal (Salter-Harris) fractures
  7. Recognize no fracture, buckle (torus) fracture, cortical breach fracture of the pediatric distal forearm, and other fractures of the forearm

Surface Anatomy of the Forearm

Surface Anatomy of the Forearm
# Surface Reference Image
1 Dorsal
2 Volar (Palmar)
3 Radial
4 Ulnar
5 Proximal and Distal

Long Bone Anatomy

Long Bone Anatomy
# Anatomic Structure Description Reference Image
1 Diaphysis Body (shaft) of bone
2 Metaphysis Flared part of bone shaft
3 Physis Growth plate made of cartilage; also known as epiphyseal plate
4 Epiphysis End of bone

Classification of Pediatric Distal Forearm Fractures

Classification of Children's Fractures
# Fracture Type Description Reference Image Prognosis
1 No Fracture Cortices are unbent and unbroken
Excellent
2 Buckle (Torus) Fracture Compression cortex and tension cortex are bent but unbroken[10][11][12]
Stable[12]
3 Incomplete (Greenstick) Fracture Compression cortex is bent and tension cortex is broken [10][12]
Unstable[12]
4 Complete Fracture Both cortices are broken[12]
Highly unstable[12]
5 Physeal (Salter-Harris) Fracture Fracture of the growth plate (physis)[12]
Might lead to growth disturbances (rare)[12]

Pediatric Forearm Fracture Subtypes

Fracture Subtype Reference Image
1A Buckle (torus) fracture of distal radius
1B Buckle (torus) fracture of the distal radius and ulna
2 Incomplete (greenstick) fracture of distal radius
3A Complete fracture of the distal radius
3B Complete fracture of the distal radius and ulna
4 Proximal radius fracture[13]

Physeal (Salter-Harris) Fractures

Physeal (Salter-Harris) Fractures
Fracture SubType Fracture Description[14][15] Reference Illustration[16]
Salter-Harris Type I Fracture across growth plate and does not involve bone
Salter-Harris Type II Fracture across growth plate and through metaphysis
Salter-Harris Type III Fracture across growth plate and through epiphysis
Salter-Harris Type IV Fracture through metaphysis, growth plate, and epiphysis
Salter-Harris Type V Compression fracture of growth plate

Pediatric Distal Forearm Fracture Categories

# Fracture Category Fracture Types
1 No Fracture
  • No Fracture
2 Buckle (Torus) Fracture
  • Buckle Fracture of the Distal Radius
  • Buckle Fracture of the Distal Radius and Ulna
3 Cortical Break Fracture
  • Incomplete (Greenstick) Fracture of the Distal Radius
  • Incomplete (Greenstick) Fracture of the Distal Radius and Ulna
  • Complete Fracture of the Distal Radius
  • Complete Fracture of the Distal Radius and Ulna
  • Salter-Harris Type I
  • Salter-Harris Type II
  • Salter-Harris Type III
  • Salter-Harris Type IV
  • Salter-Harris Type V

Supplemental Learning Topics

(Optional) After completion of the module, the learner may wish to learn more about the following topics:

Acknowledgements

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.

References

  1. ↑ Onyemaechi NO, Itanyi IU, Ossai PO, Ezeanolue EE. Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters. Hum Resour Health. 2020 Mar 20;18(1):24. doi: 10.1186/s12960-020-00468-w. PMID: 32197617; PMCID: PMC7085192.
  2. ↑ Heiner JD, McArthur TJ. The ultrasound identification of simulated long bone fractures by prehospital providers. Wilderness Environ Med. 2010 Jun;21(2):137-40. doi: 10.1016/j.wem.2009.12.028. Epub 2009 Dec 22. PMID: 20591377.
  3. ↑ Heiner JD, Baker BL, McArthur TJ. The ultrasound detection of simulated long bone fractures by U.S. Army Special Forces Medics. J Spec Oper Med. 2010 Spring;10(2):7-10. PMID: 20936597.
  4. ↑ Heiner JD, Proffitt AM, McArthur TJ. The ability of emergency nurses to detect simulated long bone fractures with portable ultrasound. Int Emerg Nurs. 2011 Jul;19(3):120-4. doi: 10.1016/j.ienj.2010.08.004. Epub 2010 Sep 25. PMID: 21665155.
  5. ↑ Snelling PJ, Jones P, Keijzers G, Bade D, Herd DW, Ware RS. Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study. Emerg Med J. 2021 Feb;38(2):139-145. doi: 10.1136/emermed-2020-209689. Epub 2020 Sep 8. PMID: 32900856.
  6. ↑ Snelling PJ, Jones P, Moore M, Gimpel P, Rogers R, Liew K, Ware RS, Keijzers G. Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound. Australas J Ultrasound Med. 2022 Mar 7;25(2):66-73. doi: 10.1002/ajum.12291. PMID: 35722050; PMCID: PMC9201201.
  7. ↑ Heiner JD, McArthur TJ. A simulation model for the ultrasound diagnosis of long-bone fractures. Simul Healthc. 2009 Winter;4(4):228-31. doi: 10.1097/SIH.0b013e3181b1a8d0. PMID: 19915442.
  8. ↑ Snelling PJ, Keijzers G, Byrnes J, Bade D, George S, Moore M, Jones P, Davison M, Roan R, Ware RS. Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED): a protocol for an open-label non-inferiority diagnostic randomised controlled trial. Trials. 2021 Apr 14;22(1):282. doi: 10.1186/s13063-021-05239-z. PMID: 33853650; PMCID: PMC8048294.
  9. ↑ Snelling PJ. A low-cost ultrasound model for simulation of paediatric distal forearm fractures. Australas J Ultrasound Med. 2018 Feb 25;21(2):70-74. doi: 10.1002/ajum.12083. PMID: 34760505; PMCID: PMC8409885.
  10. ↑ 10.0 10.1 https://surgeryreference.aofoundation.org/orthopedic-trauma/pediatric-trauma/further-reading/principles-of-nonoperative-treatment-of-childrens-fractures#fracture-patterns
  11. ↑ Light TR, Ogden DA, Ogden JA: The anatomy of metaphyseal torus fractures. Clin Orthop Relat Res 1984, 103-111.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Randsborg PH, Sivertsen EA. Classification of distal radius fractures in children: good inter- and intraobserver reliability, which improves with clinical experience. BMC Musculoskelet Disord. 2012 Jan 23;13:6. doi: 10.1186/1471-2474-13-6. PMID: 22269925; PMCID: PMC3331853.
  13. ↑ Dietzel M, Scherer S, Esser M, Kirschner HJ, Fuchs J, Lieber J. Fractures of the proximal radius in children: management and results of 100 consecutive cases. Arch Orthop Trauma Surg. 2022 Aug;142(8):1903-1910. doi: 10.1007/s00402-021-03917-w. Epub 2021 May 11. PMID: 33974141; PMCID: PMC9296417.
  14. ↑ Levine RH, Foris LA, Nezwek TA, et al. Salter Harris Fractures. [Updated 2022 Apr 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430688/
  15. ↑ https://radiopaedia.org/articles/salter-harris-classification?lang=us
  16. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9233428/figure/F1/
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