In this section
See also: Distal radius and / or ulna metaphyseal fractures - Fracture clinics
Below-elbow fibreglass/plaster backslab or removable wrist splint for 3 weeks
Check that both cortices are intact on the anteroposterior (AP) and lateral x-ray.
Provide parent with buckle injury fact sheet.
No follow-up by GP or fracture clinic is required.
No follow-up x-ray is needed
Complete - undisplaced or minimally displaced fractures
Refer to acceptable angulations
Below-elbow cast for 6 weeks
Fracture clinic within 7 days with x-ray
Complete - displaced fractures
Closed reduction with immobilisation in below-elbow cast for 6 weeks
For young children, above-elbow casts may be applied
Distal radius metaphyseal fractures can be classified according to:
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
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
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.
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.
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.
Figure 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).
Figure 3: AP and lateral x-ray of 15 year old with complete metaphyseal fracture of radius and ulna. Most metaphyseal fractures displace posteriorly.
As a rule of thumb, if the deformity is clinically visible, reduction may be indicated.
Acceptable angulations are dependent on the age of the child. Table 1 shows the acceptable angulations for distal radius metaphyseal fractures. Fractures angulated more than these values usually need to be reduced. Angulation in the coronal plane (as seen on AP x-ray) is less tolerated as it does not remodel as well as angulation in the sagittal plane (as seen on the lateral x-ray).
X-rays should be taken post-reduction. Angles should be within the same parameters for acceptable angulation.
Table 1: Acceptable angulations for distal radius metaphyseal fractures.
* As girls mature earlier, acceptable angulations may be less.
Bayonet apposition is acceptable in children up to age of six as long as angulation alignment parameters are acceptable. For children aged 6-10 years, if the fracture is still in bayonet position after reduction, ask the orthopaedic on call service to review the post-reduction x-rays to check if the position is acceptable. Children aged 11 years and above need to have apposition at the fracture site.
Figure 4: Bayonet apposition refers to a fracture in which the two bone fragments are aligned side-by-side rather than in end-to-end contact.
Indications for prompt consultation include:
Treatment options depend on the fracture type, age of patient (years of remaining growth) and the amount of displacement (Table 2).
Table 2: ED management of metaphyseal distal radius fracture.
Type of reduction
Immobilisation method & duration
No reduction required
This fracture is suitable for a local anaesthetic, manipulation and plaster (LAMP)or procedural sedation in the ED, provided that there are appropriate resources and accredited personnel at your health service
Below elbow plaster cast for 6 weeks. For young children, above-elbow casts may be applied
Fractures where the distal fragment is angulated dorsally should have a cast with three point moulding with slight wrist flexion
Fractures where the distal fragment is angulated volarly should have casting with three point moulding with slight wrist extension
Distal metaphyseal fractures of the radius have very good remodelling potential because of the proximity to the growth plate. There is a very low risk of growth arrest.
For complete metaphyseal displaced fractures and fractures involving both the radius and ulna, the need for close follow-up should be emphasised due to the risk of loss of reduction.
The main early complication is loss of reduction. One in ten (10%) will lose position and will need a re-reduction. Contributing factors are poor cast technique and residual angulation/displacement after the initial reduction. Loss of position and the opportunity for re-reduction can only happen with appropriately timed follow-up.
Another complication is compartment syndrome due to restriction by cast.
See fracture clinics for other potential complications.
Bae D. Pediatric distal radius and forearm fractures. J Hand Surgery 2008; 33: 1911-23.
Bohm ER, Bubbar V, Yong Hing K, Dzus A. Above and below the elbow plaster casts for distal forearm fractures in children: A randomized controlled trial. J Bone Joint Surg Am 2006; 88: 1-8.
Crawford SN, Lee LSK, Izuka SH. Closed treatment of overriding distal radial fractures without reduction in children. J Bone Joint Surg Am 2012; 94: 246-52.
Herring JA. Upper extremity injuries. In Tachdjian's Pediatric Orthopedics, 4th Ed. Saunders, Philadelphia 2008. p.2536-68.
Kennedy SA, Slobogean GP, Mulpuri K. Does degree of immobilization influence refracture rate in the forearm buckle fracture? J Pediat Ortho B 2010; 19(1): 77-81.
Rang M, Stearns P, Chambers H. Radius and ulna. In Rang's Children's Fractures, 3rd Ed. Rang M, Pring ME, Wenger DR (Eds). Lippincott Williams & Wilkins, Philadelphia 2005. p.135-50.
Stutz C, Mencio G. Fractures of the distal radius and ulna: metaphyseal and physeal injuries. J Pediat Ortho 2010; 30: S85-9.
Waters PM, Bae DS. Fractures of the distal radius and ulna. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.292-346.
Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children.J Bone Joint Surg Am 2006, 88(1): 9-17.