Am Fam Physician. 2000;61(4):1158
A torus, or “buckle,” fracture of the distal radius is a common type of fracture in children. The standard treatment for these nondisplaced fractures is casting for three to four weeks. Serial radiographs are often obtained, such as immediately after application of the cast and again a week or so later. To determine whether repeat radiographs are necessary, Farbman and colleagues assessed the utility of follow-up radiographs in 70 children (46 boys and 24 girls) with torus fractures of the distal radius or ulna.
The authors' medical center had no standard protocol for follow-up radiography in patients with torus fractures. Radiographs before and immediately after casting were obtained in the emergency department in 24 of the children.
All but five of the 70 children were subsequently seen in the orthopedic clinic at least four weeks after the injury. Repeat radiographs were obtained as early as two days and as late as seven weeks after the fracture. Follow-up films were obtained twice in 21 children, three times in 12 children and four times in five children. The most common reasons for repeat radiographs were documentation of healing and diagnostic confirmation. The casts remained in place for at least two weeks in all of the children, and casts were removed before the fourth week in 20 children.
The average number of follow-up radiographs was 3.3 studies per patient. At a cost of $119 per study at the authors' institution, this translates to a total cost of $27,251 for radiology services rendered to the 70 patients in the study. The authors cite a study of follow-up radiographs in adults with stable ankle fractures. That study revealed that an average of 4.5 ankle radiographs per patient was obtained, but no radiographs demonstrated a change in fibular alignment in any patient. The authors calculated that as much as $35 million would be saved annually if routine follow-up radiographs were not performed in patients with torus fractures.
To compare protocols for the management of torus fractures at other hospitals, the authors sent a survey to the directors of seven orthopedic surgery residency programs in the New England area. Responses were received from all seven directors. Each said that they did not advise their residents to obtain radiographs after application of a cast in patients with a torus fracture. However, one director noted that the emergency department at the hospital had a standing policy to do so. In response to the question of why repeat films may be obtained, one residency director noted medicolegal reasons, and another mentioned educational purposes, to assess proper placement of a cast.
The authors note that there are no national guidelines that stipulate any medical indications for postcasting radiographs in children with torus fractures, nor does the medical literature support the need for follow-up radiographs one or two weeks after the fracture. Repeat films are recommended to check for displacement after casting only in the presence of dorsal angulation and bicortical fracture or of unicortical fracture through the entire bone to the opposite cortex.
The authors conclude that radiographs after application of a cast for a nondisplaced torus fracture are not required. Clinical examination is appropriate during follow-up, with consideration given to repeat radiographs only at four weeks postfracture to document healing.