Intended for healthcare professionals

Rapid response to:

Practice Uncertainties

What level of immobilisation is necessary for treatment of torus (buckle) fractures of the distal radius in children?

BMJ 2021; 372 doi: (Published 07 January 2021) Cite this as: BMJ 2021;372:m4862

Rapid Response:

Re: What level of immobilisation is necessary for treatment of torus (buckle) fractures of the distal radius in children?

Dear Editor

The authors have highlighted that the appropriate management of torus fractures following the NICE pathways depends on clinicians being proficient in distinguishing torus fractures from other wrist injuries. We agree with their recommendation that early radiological review of suspected torus fractures is performed by a senior clinician.

In our 2018 review (1) of diagnostic accuracy of paediatric wrist fractures by ED staff, we found that ED clinicians were able to identify the present of wrist fracture in 93% of cases. However, these fractures were only correctly classified in 67% of cases, with 12% of cases incorrectly classified as a different type of wrist fracture. In 14% of cases the presence of a fracture was identified but the no fracture type was included in the initial assessment, which may indicate a lack of confidence in distinguishing between wrist injuries. We did not perform further analysis based on the grade of the ED clinician performing the initial radiological assessment, but experience suggests that the majority of these inaccurate assessments were performed by junior ED team members.

Early radiological review by a senior clinician may not be achievable in all departments and at all times. As such, we recommend that junior ED clinicians receive dedicated teaching on this topic to increase their confidence in differentiating between torus fractures and other wrist injuries.

1 Hedges WP, Irwin GJ. 2020. Do emergency department staff accurately diagnose buckle and greenstick fractures? [Online poster]. European Society of Paediatric Radiology, Marseilles. Available from:

Competing interests: No competing interests

22 January 2021
William P Hedges
Paediatric Radiology Fellow
Greg J Irwin, Consultant Paediatric Radiologist, Royal Hospital for Children, Glasgow
Birmingham Children's Hospital
Radiology Department, Steelhouse Ln, Birmingham B4 6NH