When an emergency department uses the term “torus fracture”, many parents hear the word fracture and expect a cast, repeat appointments and more X-rays. This injury behaves differently from a complete fracture.
A wrist torus fracture is a compression injury. The cortex of the distal radius buckles slightly without substantially losing stability. That stability allows the type of protection to be chosen according to pain, age and how the child copes with the injured wrist, rather than assuming that there is one correct solution for everyone.
What is a torus fracture?
The alternative name, buckle fracture, describes the mechanism. After a fall onto the hand, the growing bone can compress near the wrist and develop a small cortical bulge.
The wrist is usually tender and mildly swollen but not deformed. The child may avoid using it because it hurts. An X-ray confirms the injury pattern and helps exclude fractures that need a different approach.
It is not a “fake fracture”: the bone has genuinely been injured. It is, however, a stable fracture with a very low risk of displacement when correctly identified.
Diagnosis is the crucial step
Simple treatment is appropriate only when this is truly an isolated distal radius torus fracture.
A minimally displaced complete metaphyseal fracture can look similar, particularly if only one radiographic view is considered. In that situation both cortices are disrupted and stability is not the same. A physeal injury, plastic deformation or an associated ulnar fracture may also alter management.
This is why the word “torus” in a report should be interpreted together with the images and clinical examination. The Royal Children’s Hospital guideline specifically advises checking that both cortices are intact on the anteroposterior and lateral views.
Cast or splint: the choice is not automatic
For a confirmed torus fracture, a cast is not essential to prevent displacement in the way it is for an unstable fracture. That does not mean that using one is necessarily wrong.
NICE recommends against the routine use of a rigid cast for distal radius torus fractures and advises that many children can be discharged after the first assessment without scheduled follow-up, provided the diagnosis is secure and the family receives clear instructions.
In practice, the choice is more individual. I also often use a short cast: some children feel more protected, remain calmer and are not tempted to keep removing a splint. This may be a reasonable option for a younger, very active, anxious or still painful child. It does not mean that a true torus fracture heals better in a cast; it means choosing protection that the individual child can tolerate well.
For other children, a removable splint, removable backslab or bandage is entirely sufficient and makes hygiene easier. The useful question is not which support is universally best, but which is the simplest adequate option for that child without adding unnecessary treatment.
What the FORCE trial found
The FORCE trial recruited 965 children aged 4 to 15 years from 23 UK hospitals. It compared the offer of a soft bandage with immediate discharge against rigid immobilisation and the usual follow-up pathway at the treating centre.
Pain at three days was equivalent. Over the following six weeks there were no differences in function, quality of life, school absence or complications. Complications were uncommon in both groups: 1.0% in the bandage-offer group and 0.6% in the rigid-immobilisation group.
These are average group results. They show that rigid immobilisation is not required for a torus fracture to heal well, but they do not determine which support will make every individual child feel most secure. Comfort, pain, age and the child’s ability to keep the chosen protection in place remain part of the clinical decision.
Analgesic use was slightly higher in the bandage group on day one, but not at later time points. During the first few days a child may still need protection, relative rest and pain relief according to the instructions provided, whichever support is chosen.
The result should not be extended to every wrist fracture. It applies to children with a true distal radius torus fracture, not a complete, displaced or physeal fracture.
Cast, splint, bandage and duration
There is no single international protocol. The Royal Children’s Hospital, for example, uses a removable splint or backslab for about three weeks. The FORCE trial shows that the offer of a simple bandage can produce outcomes equivalent to rigid immobilisation for pain and function.
The evidence helps us avoid automatic choices; it does not require us always to use the lightest support. A cast may feel more reassuring and be easier to respect for some children, while a removable splint may suit others better. In either case the support should fit properly, should not feel tight and should not be altered at home. If it is removable, follow the local instructions about washing, sleep and when it may be taken off.
Some stiffness or hesitation is common for a few days after removal. Movement usually returns with ordinary use. Physiotherapy is not routinely required for an uncomplicated torus fracture.
Are another X-ray and a follow-up appointment needed?
When the diagnosis is secure, the fracture is isolated and recovery follows the expected course, many pathways use neither a follow-up X-ray nor a scheduled orthopaedic appointment.
This does not mean that every painful wrist can be managed without review. Reassessment is appropriate if the original diagnosis is uncertain, pain is not improving, a new deformity appears, the child does not resume using the hand, or another injury is present.
If a follow-up appointment has already been arranged, do not cancel it because of an article. The treating clinician may have information that is not contained in the radiology report.
When should the child be reassessed?
Seek prompt reassessment if:
- pain is increasing rather than settling, or is not controlled by the advice provided;
- the fingers become pale, blue, cold, very swollen or numb;
- the child cannot move the fingers;
- the splint or cast feels too tight, damages the skin, becomes wet or breaks;
- a deformity appears, another injury occurs or the condition worsens;
- after the recommended period, the wrist remains very painful or swollen and the child still avoids using it.
The first four points need particular attention because they may indicate compression or impaired circulation rather than expected early discomfort.
Returning to school and sport
School is often possible once pain is controlled and the wrist can be protected. Activities with a risk of falling or impact should wait until they are safe.
The Royal Children’s Hospital advises avoiding contact sports and rough play for six weeks after injury. This is not an automatic date for every child. Pain, return of movement, the particular sport and the treating team’s instructions all matter. A child who still has pain when loading the wrist or during sport-specific movements is not ready.
Frequently asked questions
Can a torus fracture move out of position?
A true isolated torus fracture is stable and the risk of displacement is very low. If both cortices are disrupted, however, it is not a simple torus fracture and the pathway may change.
Does using a cast mean the fracture is being overtreated?
Not necessarily. A cast is not essential for the stability of a true torus fracture, but it may be chosen for comfort, perceived protection and the child’s peace of mind. The opposite automatic rule should also be avoided: not every child needs a cast, and not every child must use a splint.
Can the splint be removed for washing?
Often yes if it is a removable splint, but follow the instructions provided. A backslab or another support may have different rules.
Does no follow-up X-ray mean the fracture is being neglected?
Not necessarily. For a confirmed torus fracture, several guidelines do not recommend routine repeat radiographs. Reassessment is needed if symptoms do not follow the expected course.
Is physiotherapy needed after the splint?
Usually not. Early stiffness is common and tends to settle with gradual return to normal use. Persistent pain or continued refusal to use the hand should be reviewed.
Sources
[1] National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management, NG38. Recommendations 1.3.3–1.3.4. NICE guideline.
[2] Perry DC, Achten J, Knight R, et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet. 2022;400:39–47. PubMed: 35780790 · DOI.
[3] Perry DC, Achten J, Knight R, et al. Offer of a bandage versus rigid immobilisation in 4- to 15-year-olds with distal radius torus fractures: the FORCE equivalence RCT. Health Technology Assessment. 2022;26(33). PubMed: 35904496 · PMCID: PMC9376802 · DOI.
[4] Royal Children’s Hospital Melbourne. Distal radius and/or ulna metaphyseal fractures — Emergency Department and Fracture care: buckle injury. Clinical guideline · Family information.
Author: Dr Daniele Priano, Specialist in Orthopaedics and Traumatology.
Disclaimer: this article provides general information and does not replace an assessment of the child or the instructions of the clinician who reviewed the X-rays. Management depends on confirmation of the fracture type and the clinical findings.
Related information
For an overview of follow-up and treatment in other distal radius fractures, see Distal radius fractures in children: remodelling, follow-up and indications for reduction.
