Emerg Radiol DOI 10.1007/s10140-014-1289-y

ORIGINAL ARTICLE

Musculoskeletal: what’s different in children? Fall, right hand braces fall, pain in forearm and wrist Leonard E. Swischuk

Received: 5 December 2014 / Accepted: 11 December 2014 # American Society of Emergency Radiology 2014

Keywords Fracture . Radius . Salter Harris I

Case history This 10 year old was on a table about 2 ft above a concrete floor. He lost his balance and fell landing mostly on his

Fig. 1 a, b AP and lateral view of both wrists L. E. Swischuk Department of Radiology, The University of Texas Medical Branch, Galveston, TX 77555, USA L. E. Swischuk (*) Pediatric Radiology, The University of Texas Medical Branch, Galveston, TX 77555-0709, USA e-mail: [email protected]

stomach but broke his fall with the right hand. He immediately complained of wrist/hand pain. The pain was worse with movement. He had a small skin break on the right side of his abdomen, but he did not complain of any abdominal/ stomach pain. On physical examination apart from the skin break on the abdomen, everything was normal except for

Emerg Radiol Fig. 2 a AP view of both wrists. Note slight widening of the right epiphyseal radial plate (arrow). b Lateral view of both wrists. Note swelling around the right wrist and that the epiphyseal plate is a little wider than on the left. In addition, note that the epiphysis itself is slightly posteriorly/ dorsally displaced (arrow). Compare with the normal location of the epiphysis on the other side

examination of the wrist and lower forearm. He refused to move his wrist fully and there was mild swelling around the wrist. There was normal range of movement of the fingers. Radiographs of his wrist were obtained (Fig. 1). Do you see a fracture?

Discussion This type of accident happens frequently where the patient is doing something above ground level, loses his balance, and then falls. Almost instinctively, the fall is broken with the extended upper or lower extremity. In our case, the fall was braced with the right hand and arm. Almost immediately, the patient experienced pain and did not have full range of motion at the wrist. Something had to be wrong to have symptoms come this quickly. When he arrived at our emergency room (ER), there was a little swelling around the wrist. In addition, he did not move the wrist fully and did complain of pain upon palpation. No other abnormalities were detected, and radiographs of the wrist with comparative views of the other side were obtained.

The findings on these images are very subtle but are important because they indicate that a fracture is present and that the extremity needs to be immobilized in a cast and so what are these findings? First, there is swelling around the wrist and then one should note that the epiphyseal plate through the distal right wrist is slightly wider than the one on the left side. This is seen on both the AP and lateral views (Fig. 2) but a little more apparent on the lateral view. One other finding is present on the lateral view and that is that the epiphyseal plate is slightly posteriorly (dorsally) displaced. This constitutes a displaced Salter Harris I fracture, and the slight displacement as seen on lateral view is a very important additional finding in detecting this fracture. The patient was immobilized in a plaster cast and had no subsequent problems. The epiphyseal plate is a weak area in the long bones. When transverse forces such as those applied to our patients’ wrist exist, Salter Harris fractures result. One of the most subtle of these is the mildly displaced Salter Harris I fracture as seen in our patient. Conflict of interest Authors do not have any items to disclose and no conflict of interest.

Musculoskeletal: what's different in children? Fall, right hand braces fall, pain in forearm and wrist.

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