suspicion should be maintained if there is a concerning mechanism or presence of a joint effusion in the absence of radiographic abnormalities of the bone These fractures have the worst prognosis for growth disturbance as the compressive force may result in premature closure of the physis Unfortunately, the diagnosis is often made in hindsight after a growth arrest becomes evident Torus Fractures Torus (buckle) fractures are common fractures in young children They most often occur at the junction of metaphysis and diaphysis from a compressive load The cortex of the bone buckles in a small area, resulting in a stable fracture pattern ( Fig 111.3 ) As the child matures, the strength of the metaphyseal region increases, and the incidence of this fracture pattern decreases Greenstick Fractures The composition of pediatric bones makes them less likely to propagate the force of injury into comminuted fragments Thus, with greenstick injuries, the bone bends before it breaks, with the thick and active periosteum remaining intact on one cortex and acting like a hinge: torn on the convex side of the fracture while remaining intact on the concave side The intact cortex thus maintains apposition at the site of fracture; however, to obtain an anatomic reduction, the fracture must often first be completed The emergency clinician must be attuned to this pattern of injury as inadequate reduction of the deformation or bowing of the bone can result in an abnormal growth pattern and loss of function ( Fig 111.4 )