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June 2002
By James R. Roberts, MD
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An 11-year-old boy was brought to the emergency department with
unilateral diffuse soreness of the hand, wrist, and forearm three
days after a minor playground mishap. While swinging at a baseball,
he had slipped and fallen forward, extending his arms to break his
fall and landing on his outstretched hands. No crack or pop was
felt. He had been favoring one arm, his mother noted, but had not
asked for pain pills; otherwise, he seemed normal and continued
to attend school. Only when asked to do minor household chores did
he complain of pain. On examination, no ecchymosis or soft-tissue
swelling was detected and no point tenderness elicited. In fact,
an intern who had not been present for the history-taking could
not tell which arm was the injured one based on visual inspection.
The emergency department was overwhelmed with patients, and the
wait for an x-ray was over an hour. Sensing that the clinicians
considered a fracture highly unlikely, the family was anxious to
leave. They requested that some type of wrap be applied and a note
provided to excuse the child from gym class due to a sprain. Would
you agree that a minor sprain is the likely diagnosis?
CLICK HERE FOR ANSWER
DIAGNOSIS AND COMMENT
Given the age of the patient, the type of fall, and the persistence
of pain, this presentation will almost always prove to be a buckle,
or greenstick, fracture of the distal radius, ulna, or both. Sprains
are rare in 11-year-old children, and they do not usually complain
for three days of pain from seemingly insignificant soft-tissue
injuries, but that age group is particularly vulnerable to nondisplaced
fractures as a consequence of wrist trauma. The physical exam and
external findings are typically unimpressive for trauma that would
produce prominent external findings in an adult, perhaps reflecting
a navicular (scaphoid) fracture in a 30-year-old workman, for example,
or a displaced Colles' fracture in an 80-year-old. With a child
there is often no specific point tenderness and it is even difficult
to tell whether the hand, wrist, or forearm is the site of the injury.
X-ray findings in this setting can be quite
subtle and easily missed by a quick look. The more advanced clinician
can appreciate subtle volar displacement of the pronator quadratus
fat pad on the x-ray, indicating bleeding from the occult fracture
site. In this case, comparison with the opposite wrist reveals two
small bumps in the cortex of the radius and a kink in the ulna (arrows)
that identify the fracture. The findings are actually fairly obvious
so long as the interpreter has them in mind and is not misled by
the expectation of a traditional fracture line. Often, though, this
clandestine deformity is visible on only one view of the x-ray series,
and these cases regularly end up on the "missed fracture/x-ray call-back"
list.
If, with a young patient in similar circumstances,
a buckle fracture in the forearm is suspected but cannot be detected
on the films, it is still a good idea to apply a fracture-protecting
splint for three or four days. The family should be informed about
the possibility of an "occult" fracture and told to seek follow-up
if any symptoms persist after the splint is removed. Though these
injuries are neither serious nor debilitating, no physician wants
to have to call a childıs parents to tell them that a fracture was
missed, or worse, have them hear it from an orthopedist days later.
Emerg Med 34(6):53, 2002
Dr. Roberts is professor of emergency medicine at the Medical
College of Pennsylvania and chairman of the department of emergency
medicine at Mercy Catholic Medical Center in Philadelphia. He is
also a member of the Emergency Medicine editorial board.
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