Selected topics: emergency radiology
Salter–Harris I fractures of the distal radius misdiagnosed as wrist sprain1

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Abstract

Over a period of 5 years, 65 children under 12 years of age were diagnosed as having ″wrist sprain″ at the American University of Beirut Medical Center, Emergency Department. Thirty-eight children were reevaluated; 33 patients (86.8%) were diagnosed as having a Salter–Harris I fracture of the distal radius that necessitated further treatment to relieve symptoms and allow early wrist function. The diagnosis of ″wrist sprain″ is often inadequate in establishing a proper treatment regimen. Rather, by taking a careful history, performing an exacting examination, and utilizing appropriate diagnostic aids, an accurate diagnosis of wrist injury can be established.

Introduction

Wrist injuries in children are frequently seen in emergency departments (EDs). The difficulties in examining an injured child and the limited ability of X-rays to provide details of the immature skeleton challenge the physician treating a child with wrist injury 1, 2. The epiphysis of the distal radius is among the body’s most frequently injured areas. When wrist pain after trauma is the presenting complaint, it is overwhelmingly likely that the forces were transmitted through the distal radial physis, not the carpus (3). Epiphyseal separation in the young has been properly identified as the analog of dislocation or ligamentous injury in the adult 4, 5, 6, 7. Neer and Horowitz report on 2500 consecutive physeal injuries, almost half (43.8%) of which occurred in the distal radius (8). It has been stated that the joint capsule and ligamentous structures are two to five times stronger than the physis or cartilagenous growth plate (4). Forces that would produce a ligamentous injury or dislocation of a major joint in an adult will more likely result in epiphyseal separation or fracture in a child or adolescent. Therefore, if clinical evaluation suggests either a dislocation or a ligamentous injury in the young, the possibility of an underlying epiphyseal injury should be considered 5, 8.

Section snippets

Materials and methods

Between January 1993 and December 1997, 297 children under the age of 12 years with wrist injuries were seen in the ED of the American University of Beirut Medical Center. Sixty-five children (21.9%) were diagnosed as having a ″wrist sprain″ and were discharged with analgesia or ace wrapping; none of the patients were treated with a volar splint (Table 1). All patients were advised to seek the opinion of a private physician if wrist pain or swelling persisted for more than 48 to 72 h.

Results

On physical examination, all patients were noted to have swelling and tenderness with or without discoloration at the distal radial epiphyseal region as well as limitation of active and passive motion of the wrist joint, mainly in flexion and extension. The physical examinations were comparable to those described in the ED medical records at the time of injury. Evaluation of the radiographs was performed and official radiologist reports were reviewed. All patients had comparative radiographs

Discussion

A fracture is a disruption in the continuity of a bone. This is evident on a radiograph predominantly as an abnormal line of radiolucency, the width of which is dependent on the degree of the displacement of the fracture fragments. In the absence of displacement, this line may be very thin and quite difficult to perceive (9). Poland in 1898 detailed the discovery, denial, and final acceptance of physeal separations as an entity distinct from fractures (10). They were first described by Realdus

Conclusion

Fracture–separation of the distal radial physis occurs in the infant or young child. The mechanism of injury is a fall on the outstretched hand. The young child is reluctant to use the involved limb and cries in pain when the wrist is touched. Physical examination reveals local swelling and tenderness at the distal radial physis. In the infant, plain radiographs usually appear to be normal but the fat pad sign may be positive. In the child 2 years and older, comparison radiographs of the

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    Selected Topics: Radiology is coordinated by Jack Keene, md, of Emergency Treatment Associates, Rhinebeck, New York

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