Buckle fractures are injuries that occur to either the radius, ulna or both usually due to a fall in young children. Buckle fractures are NOT what most people think of when they think of a fracture or broken bone. The fracture does not go through the entire bone. Because of this, buckle fractures are very stable fractures, so we do not have to worry about them moving out of alignment. They also heal more quickly than a typical fracture. Show
Bones are like pipes in that the strongest portion of the bone is around the sides (called the cortex or cortices for plural). In a buckle fracture, one or two cortices are compressed during the fall resulting in very slight bending on one side, but the other side of the bone is not injured. As such, the bone is NOT broken into two pieces. Arrows point to the buckle in the cortex. Notice that there is not a fracture line extending across the bone. How are Buckle Fractures Treated?Because buckle fractures are not complete fractures, they are very stable fractures and heal quickly. A cast is not usually necessary, and we typically treat these with a removable Velcro® wrist brace. The brace can be removed for bathing but should otherwise be worn at all times while the patient has pain. As the pain improves, the brace may be removed for sleeping and even swimming. It should be worn at all other times for a total of 3 to 4 weeks. At 3 to 4 weeks, the parent can give the child’s wrist a firm squeeze. If the patient does not have pain at that point, he or she may quit using the brace and resume normal activities. What is the Long-Term Outcome?Buckle fractures do not involve the growth plate, so there are no complications with a difference in the lengths of the forearms or with deformity. Buckle fractures do not put a patient at higher risk for another fracture in the future. Buckle injury: Compression injury failure of bone resulting in the cortex bulging outwards (unilateral or bilateral). Also known as a torus injury. Although there is a disruption to the cortical bone, the integrity of the bone is minimally compromised, resulting in different patient management from other fractures See fracture education module for more information Anteroposterior (AP) view Lateral view Complete: A fracture that extends through both cortices. Most complete metaphyseal fractures involve both the radius and ulna. The radius is commonly a complete fracture. The ulna may have a complete fracture, greenstick fracture, or a plastic deformity AP view Lateral view 3. How common are they and how do they occur?Metaphyseal fractures have a peak incidence during the adolescent growth spurt (girls aged 11-12 years, boys 12-13 years) due to weakening through the metaphysis with rapid growth. Up to 13% incidence of other arm injuries (hand, forearm, elbow) occur on the same side. The most common mechanism of injury is a fall on an outstretched hand. Extension of the wrist at the time of injury causes the distal fragment to be displaced dorsally (posteriorly). Volar (anterior) displacement of the distal fragment is usually the result of a fall on a flexed wrist. These injuries can occur in conjunction with more proximal forearm fractures, such as Monteggia fracture-dislocations, supracondylar humeral fractures and hand fractures. 4. What do they look like - clinically?There is usually pain and tenderness directly over the fracture site, and limited range of motion in the wrist and hand. Deformity depends on the degree of fracture displacement. Buckle injuries present with no or minimal deformity. Buckle injuries are often misdiagnosed as a wrist sprain. An x-ray of the wrist should be ordered to clarify the diagnosis. 5. What radiological investigations should be ordered?A 'wrist x-ray' request will provide AP and lateral views of the distal forearm and wrist. If the injury is to the mid forearm or the pain is poorly localised, a 'forearm x-ray' should be ordered. Avoid ordering 'x-ray arm' as it is better to have images focused to the region of local tenderness. If there are any elbow joint symptoms, an 'elbow x-ray' should be ordered as some fractures around the elbow can be difficult to detect. 6. What do they look like on x-ray?Buckle injuryFigure 1: Lateral and AP x-ray of a five year old who sustained a buckle injury of the distal radius.Buckle injuries are often subtle radiographically.They are best viewed on the lateral x-ray. Bilateral or unicortical cortical bulging can occur. ! Minimally displaced complete metaphyseal fractures can be mistaken for buckle injuries (Figure 2). These fractures are potentially unstable and need to be managed in a well moulded cast. Figure 2: Six year old with complete metaphyseal fracture. On the lateral view, there is a minimally displaced radial metaphysis, which could be mistaken for a buckle fracture. However on the AP view, it shows that both cortices are broken (i.e. it is a complete fracture). |