Anteroposterior radiograph of the right wrist of an 8-year-old boy shows a bicortical distal radius fracture
Lateral radiograph of the patient
An 8-year-old boy presents with right wrist pain after an injury 5 days earlier. He was playing soccer with his older brothers when he caught a ball off the hand. He had immediate pain and was unable to continue playing. His parents took him to an urgent care facility the next day, where anteroposterior and lateral radiographs showed distal radius fracture.
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Forearm fractures are the most common pediatric fracture, and most of the fractures occur at the distal radius. The porous metaphyseal bone in the pediatric population is prone to compression injury with minimal cortical disruption.
Stable unicortical metaphyseal fractures proximal to the physis are referred to as buckle or torus fractures. Pediatric distal radius fractures are stable when there is unicortical involvement but can be unstable or prone to displacement when there is bicortical involvement. A bicortical fracture line seen on anteroposterior and lateral radiographs represents a fracture that is more severe than a stable unicortical buckle fracture.
To help guide treatment, it is therefore critical to recognize whether the tension side of a metaphyseal fracture is intact. This patient presents with a distal radius fracture with bicortical involvement. Initial treatment with a removable splint would result in an unacceptably high risk for fracture displacement. A short arm cast can be wiggled off by a noncompliant child and fails to restrict forearm rotation. An initial long arm cast offers the best protection for fractures prone to displacement.
A long arm cast for 2 to 3 weeks, or until cortical bridging is seen on radiograph, is commonly used for bicortical distal radius fractures. Patients can then be transitioned to a short arm cast for an additional 2 to 3 weeks once cortical bridging is seen. Most distal radius fractures take 4 to 6 weeks to heal, depending on the patient’s age.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Waters PM, Mih AD. Fractures of the distal radius and ulna. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
- Wheeless CR III. Torus Fracture/Platic Deformation. Wheeless’ Textbook of Orthopaedics. http://www.wheelessonline.com/ortho/torus_fracture_platic_deformation. Updated January 4, 2013. Accessed January 9, 2017.