1. { Torus Fracture of Childhood—3yo Female Exemplar

2.  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.  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

4.  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

5.  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

6.  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

7.  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

8.  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 -- Joint Policy Statement—Guidelines for Care of Children in the Emergency Department -- PEDIATRICS October 1, 2009

9.  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

10. References