Bowing fracture
Bowing fractures are incomplete fractures of tubular long bones in pediatric patients (especially the radius and ulna) that often require no intervention and heal with remodeling.
On this page:
Epidemiology
Bowing fractures are almost exclusively found in children. However, there have been several case reports of bowing in adult bones. These injuries usually occur in children although adolescents may be affected.
The radius and ulna are the most commonly affected bones, followed by the fibula. However, bowing fractures of all long bones have been described.
Clinical presentation
Children present with pain and swelling following a fall, usually on an outstretched hand. This is often after falling from furniture or climbing equipment, especially monkey bars.
Pathology
When an angulated longitudinal force is applied to a bone, the bone bends. Pediatric bones have a degree of elasticity and therefore, if the force is low and subsequently released, the bone returns to its normal position and no lasting evidence of that bowing is seen radiographically.
This ability to bend occurs because the cortex is thinner in absolute and relative terms compared to adult bones and because of the way the cortex and periosteum bind to each other in the developing skeleton.
If the force is greater than the mechanical strength of the bone, the bone undergoes plastic deformation and when the force is released, the bone remains in its bowed position.
Microscopic examination of the bone reveals that there are microfractures along the concave border of the bowed bone, but these are not visible radiographically.
Radiographic features
Plain radiograph
On a plain film, bowing of the bone can be visualized provided that the view is in a different plane to the direction of bowing. If the view is in the plane of the bow, the bone may appear completely normal 1. The bowing tends to be fluid and blend into the normal bone at either end.
There is no fracture line or visible cortical injury.
There is usually an accompanying fracture of a paired bone, e.g. radius, and this is usually diaphyseal (either greenstick or complete). In some cases, there may be dislocation of the paired bone, e.g. radial head dislocation.
Treatment and prognosis
Bowing fractures usually accompany another fracture and in those cases, treatment is determined according to the type and severity of the accompanying injury.
In isolation, treatment of bowing fractures is debated 2. Some advocate the reduction of a bowing fracture where angulation exceeds 20 degrees. Most authors agree that where angulation is less than 20 degrees, manipulation for reduction is not required and only symptomatic support is required: this is usually in the form of a removable splint.
Differential diagnosis
- greenstick fracture: accompanying bowing, there is a visible fracture
- buckle fracture: there is cortical irregularity
- physiological bowing
- stress fracture: there is a periosteal reaction
Related Radiopaedia articles
Fractures
-
fracture
- terminology
- fracture location
- diaphyseal fracture
- metaphyseal fracture
- physeal fracture
- epiphyseal fracture
- fracture types
- avulsion fracture
- articular surface injuries
- complete fracture
- incomplete fracture
- infraction
- compound fracture
- pathological fracture
- stress fracture
- fracture displacement
- fracture location
- fracture healing
- skull fractures
-
facial fractures
- fractures involving a single facial buttress
- alveolar process fractures
- frontal sinus fracture
- isolated zygomatic arch fractures
- mandibular fracture
- nasal bone fracture
- orbital blow-out fracture
- paranasal sinus fractures
- complex fractures
- dental fractures
- fractures involving a single facial buttress
-
spinal fractures
- classification (AO Spine classification systems)
-
cervical spine fracture classification systems
- AO classification of upper cervical injuries
- AO classification of subaxial injuries
- Anderson and D'Alonzo classification (odontoid fracture)
- Levine and Edwards classification (hangman fracture)
- Roy-Camille classification (odontoid process fracture )
- Allen and Ferguson classification (subaxial spine injuries)
- subaxial cervical spine injury classification (SLIC)
- thoracolumbar spinal fracture classification systems
- three column concept of spinal fractures (Denis classification)
- classification of sacral fractures
-
cervical spine fracture classification systems
- spinal fractures by region
- spinal fracture types
- classification (AO Spine classification systems)
- rib fractures
- sternal fractures
-
upper limb fractures
- classification
- Rockwood classification (acromioclavicular joint injury)
- AO classification (clavicle fracture)
- Neer classification (clavicle fracture)
- Neer classification (proximal humeral fracture)
- AO classification (proximal humeral fracture)
- AO/OTA classification of distal humeral fractures
- Milch classification (lateral humeral condyle fracture)
- Weiss classification (lateral humeral condyle fracture)
- Bado classification of Monteggia fracture-dislocations (radius-ulna)
- Mason classification (radial head fracture)
- Frykman classification (distal radial fracture)
- Mayo classification (scaphoid fracture)
- Hintermann classification (gamekeeper's thumb)
- Eaton classification (volar plate avulsion injury)
- Keifhaber-Stern classification (volar plate avulsion injury)
- upper limb fractures by region
- shoulder
- clavicular fracture
-
scapular fracture
- acromion fracture
- coracoid process fracture
- glenoid fracture
- humeral head fracture
- proximal humeral fracture
- humeral neck fracture
- arm
- elbow
- forearm
- wrist
-
carpal bones
- scaphoid fracture
- lunate fracture
- capitate fracture
- triquetral fracture
- pisiform fracture
- hamate fracture
- trapezoid fracture
- trapezium fracture
- hand
- shoulder
- classification
- lower limb fractures
- classification by region
- pelvis
- hip
- Pipkin classification (femoral head fracture)
- Garden classification (hip fracture)
- American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture)
- Cooke and Newman classification (periprosthetic hip fracture)
- Johansson classification (periprosthetic hip fracture)
- Vancouver classification (periprosthetic hip fracture)
- femoral
- knee
- Schatzker classification (tibial plateau fracture)
- Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture)
- tibia/fibula
- Watson-Jones classification (tibial tuberosity avulsion fracture)
- ankle
- foot
- Berndt and Harty classification (osteochondral lesions of the talus)
- Sanders CT classification (calcaneal fracture)
- Hawkins classification (talar neck fracture)
- Myerson classification (Lisfranc injury)
- Nunley-Vertullo classification (Lisfranc injury)
- pelvis and lower limb fractures by region
- pelvic fracture
- sacral fracture
- coccygeal fracture
-
hip
- acetabular fracture
- femoral head fracture
-
femoral neck fracture
- subcapital fracture
- transcervical fracture
- basicervical fracture
-
trochanteric fracture
- pertrochanteric fracture
- intertrochanteric fracture
- subtrochanteric fracture
- thigh
- mid-shaft fracture
- bisphosphonate-related fracture
- knee
- avulsion fractures
- Segond fracture
- reverse Segond fracture
- anterior cruciate ligament avulsion fracture
- posterior cruciate ligament avulsion fracture
- arcuate complex avulsion fracture (arcuate sign)
- biceps femoris avulsion fracture
- iliotibial band avulsion fracture
- semimembranosus tendon avulsion fracture
- Stieda fracture (MCL avulsion fracture)
- patellar fracture
- tibial plateau fracture
- avulsion fractures
- leg
- tibial tuberosity avulsion fracture
- tibial shaft fracture
- fibular shaft fracture
- Maisonneuve fracture
- ankle
- foot
- tarsal bones
- metatarsal bones
- phalanges
- classification by region
- terminology