Torus fracture

Torus fractures, also known as buckle (FIBBIA) fractures, are incomplete fractures of the shaft of a
long bone that is characterised by bulging of the cortex. They result from trabecular
compression from an axial loading force along the long axis of the bone. They are usually seen in
children, frequently involving the distal radial metaphysis.

Terminology

Strictly speaking, a torus fracture refers to a circumferential buckle fracture 7. However, the terms
are often used interchangeably.

Epidemiology

These type of fractures are more common in children, especially aged 5-10 years, due to the
elasticity of their bones.

Pathology

Cortical buckle fractures occur when there is axial loading of a long bone. This most commonly
occurs at the distal radius or tibia following a fall on an outstretched arm; the force is transmitted
from carpus to the distal radius and the point of least resistance fractures, usually the dorsal
cortex of the distal radius.

Radiographic features

Plain radiograph

- distinct fracture lines are not seen

- subtle deformity or buckle of the cortex may be evident
- in some cases, angulation is the only diagnostic clue

Treatment and prognosis

They are self-limiting and typically do not require operative intervention, although a manipulation
may be required if the angulation is severe. Sometimes a cast may be applied, but often a splint is
all that is required with a period of rest and immobilisation.

History and etymology

The term torus is derived from the Latin word tori which means protuberance. A torus is the
convex portion of the upper part of the base of a Greek column (figure 1), and resembles the
appearance of the cortical buckling seen in the "column" of bone which has been fractured in the
pattern discussed in this article.
 Radiographs demonstrate a distal
radial torus fracture
 Buckle fracture of the distal radius and ulna.

Vedi il BULGING DELLA CORTICALE! La corteccia

è deformata!

The torus fracture that results in buckling (deformazione) of the cortex on

the concave side of the bend and an intact convex surface
Greenstick fractures are incomplete fractures of long bones and are usually seen in young
children, more commonly less than 10 years of age. They are commonly mid-diaphyseal, affecting
the forearm and lower leg. They are distinct from torus fractures.

Pathology

Mechanism

Greenstick fractures occur when the force applied to a bone results in bending of the bone such that
the structural integrity of the convex surface is overcome. The fact that the integrity of the cortex
has been overcome results in fracture of the convex surface. However, the bending force applied
does not break the bone completely and the concave surface of the bent bone remains intact.

This can occur following an angulated longitudinal force applied down the bone (e.g. an indirect
trauma following a fall on an outstretched arm), or after a force applied perpendicular to the bone
(e.g. a direct blow).

This fracture is very different, and much less common, than the torus fracture that results in
buckling of the cortex on the concave side of the bend and an intact convex surface.

Radiographic features

Plain radiograph

 usually mid-diaphyseal
 occur in tandem with angulation
 incomplete fracture, with cortical breech of only one side of the
bone
History and etymology

The fracture resembles the break that results when a supple green branch of a tree is bent and breaks
incompletely.

Differential diagnosis

 torus fracture: much more common, metaphyseal and results in buckling of the cortex
 bowing fracture: the bone is bowed, but there is no discernible fracture
 salter-Harris fractures
Incomplete fracture of the distal radius with cortical break of the convex surface - a greenstick fracture.
Greenstick fracture of the mid to distal radial and ulnar diaphyses.

A typical greenstick fracture is observed here, with mild to moderate radial angulation of the fracture sites
and incomplete fracture on the concave (radial) aspect of the fractures. This is a common fracture pattern
in children due to the pliable nature of the bone. This fracture is in contrast to a torus fracture, which is also
commonly seen in pediatric patients.
Bowing fractures are incomplete fractures of tubular long bones in paediatric patients (especially
the radius and ulna) that often require no intervention and heal with remodelling.

Epidemiology

Bowing fractures are almost exclusively found in children. However, there have been several case
reports of bowing in adult bones. These injuries usually occur in children although adolescents may
be affected.

The radius and ulna are the most commonly affected bones, followed by the fibula. However,
bowing fractures of all long bones have been described.

Clinical presentation

Children present with pain and swelling following a fall, usually on an outstretched hand. This is
often after falling from furniture or climbing equipment, especially monkey bars.

Pathology

When an angulated longitudinal force is applied to a bone, the bone bends. Paediatric 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.

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.

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.

Microscopic examination of the bone reveals that there are microfractures along the concave border
of the bowed bone, but these are not visible radiographically.

Radiographic features

Plain film

On a plain film, bowing of the bone can be visualised provided that the view is in a different plane
to the direction of bowing. If the view is in the plane of the bow, the bone may appear completely
normal 1. The bowing tends to be fluid and blend into the normal bone at either end.

There is no fracture line or visible cortical injury.

There is usually an accompanying fracture of a paired bone, e.g. radius, and this is usually
diaphyseal (either greenstick or complete). In some cases, there may be dislocation of the paired
bone, e.g. radial head dislocation.

Treatment and prognosis

Bowing fractures usually accompany another fracture and in those cases, treatment is determined
according to the type and severity of the accompanying injury.
In isolation, treatment of bowing fractures is debated 2. Some advocate the reduction of a bowing
fracture where angulation exceeds 20 degrees. 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.
 Bowing fractures are rarely as obvious as this
example. The are usually found in conjunction with a
transverse or greenstick fracture of a paired bone. The
most common example is a radial greenstick fracture
and ulnar bowing fracture.

On the AP view, the radius and ulna appear normal. However,

on the lateral view, there is bowing of both bones in a volar direction. There is no visible fracture
after close inspection of the convex surface. Appearances are of bowing fractures of the radius
and ulna.
Physeal fractures (also called Salter-Harris fractures) are important childhood fractures that
involve the physeal plate. They are relatively common and important to differentiate from other
injuries because the involvement of the physis (growth plate) may cause premature closure
resulting in limb shortening and abnormal growth.

Useful mnemonics for remembering the Salter-Harris classification system are:

 SALTR
 SMACK

Fortunately, this is also the order of prognosis (from best to worse)

Mnemonics

SALTR

 S: slipped (type I)
 A: above (type II)
 L: lower (type III)
 T: through or transverse or together (type IV)
 R: ruined or rammed (type V)

SMACK

 S: slipped (type I)
 M: metaphyseal (type II)
 A: articular-epiphyseal (type III)
 C: complete-metaphysis and epiphysis (type IV)
 K: krushed! (type V)