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Only sort of broken
A 9-year old male soccer goalie presented to the emergency department with a complaint of forearm pain following a fall on outstretched arm during practice. Pain was located in the mid-distal radius, proximal to the wrist. There was minimal pain with wrist flexion and extension. No pain with movement of the elbow. There is significant tenderness to palpation in a small area of the mid-distal radius without any tenderness proximal or distal to this area. No deformity of the forearm noted. Bedside ultrasound (Image 1) of the area of tenderness is shown below.
Only sort of broken
Author: Natalie Vera MD, Miguel Agrait MD
Peer-Reviewer and Final Editor: Alex Tomesch, MD, CAQ-SM
A 9-year old male soccer goalie presented to the emergency department with a complaint of forearm pain following a fall on outstretched arm during practice. Pain was located in the mid-distal radius, proximal to the wrist. There was minimal pain with wrist flexion and extension. No pain with movement of the elbow. There is significant tenderness to palpation in a small area of the mid-distal radius without any tenderness proximal or distal to this area. No deformity of the forearm noted. Bedside ultrasound (Image 1) of the area of tenderness is shown below.
Image 1. Patient's forearm ultrasound with radius in long axis. Author’s own image.
Image 2. Opposite, asymptomatic, arm in long axis showing normal bony architecture of the radius. Author's own image.
Which imaging modalities can be used?
X-ray is the traditional diagnostic modality of choice, however, new evidence has shown excellent sensitivity and specificity for the use of ultrasound as the initial diagnostic modality in non-deformed pediatric forearm injuries [2]. The ultrasound probe should be placed lightly over the area of maximal tenderness in long axis to the radius. Normal bony cortex should be visualized proximal and distal to the injury site with the area of maximal tenderness showing cortical irregularity and buckling outward of the cortex diagnostic of a torus fracture as shown below.
Image 3: Longitudinal image of the mid-distal radius showing torus fracture (red circle) and normal bony cortex (blue lines). Author's own images and annotations.
References
[1] Jiang N, Cao ZH, et al. Management of Pediatric Forearm Torus Fractures: A Systematic Review and Meta-Analysis. Pediatr Emerg Care. 2016 Nov;32(11):773-778. doi: 10.1097/PEC.0000000000000579. PMID: 26555307.
[2] Snelling PJ, Jones P, et al. BUCKLED Trial Group. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. N Engl J Med. 2023 Jun 1;388(22):2049-2057. doi: 10.1056/NEJMoa2213883. PMID: 37256975
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