Torus Fracture of
Childhood—3yo
Female Exemplar
{

3 yo female reading with mother on floor at
foot of bed. Child crawls onto the bed, loses
balance, begins to fall face first onto floor, but
braces fall by extending hands forward,
hyperextending left wrist. Mother partially
caught child by hips. This kind of fall is
common to toddler/preschool torus fracture
of the distal radius and is usually not
significant for abuse. Torus complicated with
other fractures of the distal radius are
common to school-age bracing trauma. Pure
torus is known as “Toddler’s Fracture.”
Trauma History—Key to accurate Dx of Torus Fracture

3 yo female, otherwise well, inconsolable for
1 hour since trauma event described by
mother (inconsolability uncommon for
preschoolers). Child guarding and not using
left arm. Palpation reveals exquisite distal
radial pain, very minor inflammation, ROM
elicits severe pain response. Child can point
with one finger to greatest area of pain—
distal head of radius. Deformity, crepitus,
loss of ROM uncommon for simple torus.
Exemplar Physical

Child is referred to X-Ray urgently after
administration of ibuprofen for pain
management on route. X-Ray study reveals
torus fracture of the distal radius consistent
with trauma narration and clinical findings.
Child is plaster casted with anticipated 3-6
week casting time and pain is managed with
ibuprofen 5mg/kg/dose q8 PRN for pain and
inflammation. Anticipated re-imaging at
uncasting to confirm reunion and growth.
Exemplar Management

The study sample consisted of a total of 202
consecutive children with closed fractures of the ulna,
radius, or both who were nonoperatively treated. All 28
children with torus fractures treated by 3 weeks in a
plaster cast showed good union on the radiographs
performed at cast removal. No further follow-up was
performed. This study was conducted to determine
whether fewer radiographs than the current norm can
be safely performed in children with forearm fractures,
without compromising outcome. We found that in all
the children with torus fractures, cast immobilization
was successful, with no displacement and no
complications, so that the inclusion of additional
radiographs during management or after cast removal
would have had no added benefit.
Are frequent radiographs necessary in the management of closed
forearm fractures in children?
-- Journal of Child Orthopedics June 2008

Immobilization of torus fractures of the distal
forearm, for 1 to 4 weeks in a slab, cast, or
splint, produces good radiological and
functional outcomes. This study assesses the
pain associated with 2 forms of immobilization
used for these injuries. A randomized
controlled trial comparing fiberglass volar slab
and encircling plaster-of-paris cast was
conducted at a children's hospital emergency
department. Use of a slab may increase the
duration of pain, especially in patients who had
more severe pain at presentation.
A randomized controlled trial of 2 methods of immobilizing
torus fractures of the distal forearm.
--Pediatric Emergency Care February 2008

Multiple fractures were more common in cases of
abuse. Once major trauma was excluded, rib
fractures had the highest probability for abuse (0.71,
95% confidence interval 0.42 to 0.91). The probability
of abuse given a humeral fracture lay between 0.48
(0.06 to 0.94) and 0.54 (0.20 to 0.88). When infants
and toddlers present with a fracture in the absence
of a confirmed cause, physical abuse should be
considered as a potential cause. No fracture, on its
own, can distinguish an abusive from a non-abusive
cause. During the assessment of individual
fractures, the site, fracture type, and developmental
stage of the child can help to determine the
likelihood of abuse
Patterns of skeletal fractures in child abuse: systematic
review –BMJ October 2008

The importance of pediatric-client specific urgent
and emergency care is clear in the guidelines for
pediatric trauma. Recognition of the unique needs of
the ill and/or injured children served by a hospital,
including children with special health care needs;
the commitment to better meeting those needs
through adoption of these guidelines; and the
ongoing commitment to evaluating care quality and
safety and maintaining pediatric emergency care
competencies should provide a strong foundation
for pediatric emergency and all-hazard disaster
readiness.
Joint Policy Statement—Guidelines for Care of Children in the
Emergency Department
--PEDIATRICS October 1, 2009

Management of the exemplar case followed
guidelines and best practices for identification,
casting, pain management, and referral
(pediatric urgent care) as currently understood
by the research. Additionally, parent narrative
and injury type agreed, and this, with the
addition of research indicating distal radial
torus fracture to be a infrequent abuse fracture,
rules out abuse according to guidelines for
pediatric trauma.
Critique of Exemplar Case Care
Bochang, C.,Katz, K., Weigl, D., Jie, Y.,Zhigang, W. and Bar-On., E. (2008)
Are frequent radiographs necessary in the management of closed forearm
fractures in children? Journal of Child Orthopedics. 2008 June; 2(3): 217–220.
Published online 2008 April 26. doi: 10.1007/s11832-008-0101-5
Joint Policy Statement—Guidelines for Care of Children in the Emergency
Department. (2009) PEDIATRICS Vol. 124 No. 4 October 1 pp. 1233 -1243
doi: 10.1542/peds.2009-1807 Nationwide Children’s Hospital.
.
References