Selected topics: emergency radiologySalter–Harris I fractures of the distal radius misdiagnosed as wrist sprain1
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
References (41)
Wrist and hand skeletal injuries in children
Hand Clin
(1990)- et al.
Magnetic resonance assessment of inversion ankle injuries in children
Injury
(1998) - et al.
Epiphyseal fractures
J Pediatr
(1961) Fractures of the carpal bones in children
Injury
(1987)Fracture of the forearm and wrist
Acta Ortho Scand
(1980)Children’s fractures
(1970)- et al.
Pseudodislocationan unusual birth injury
Can J Surg
(1967) Treatment of injuries to athletes
(1962)Pediatric orthopedic radiology
(1979)- et al.
Fractures of the proximal humeral epiphyseal plate
Clin Orthop
(1965)
A concealed injury to the knee
J. Bone Joint Surg
Traumatic separation of the epiphyses
Children’s fractures
Injuries involving the epiphyseal plate
J Bone Joint Surg
The development and growth of the musculoskeletal system
Chondro osseous development and growth in wrist. MR Fundamentals and clinical bone physiology
Epiphyseal plate cartilagea biomechanical and histological analysis of failure modes
J Bone Joint Surg
Skeletal trauma in children
Physical properties of epiphyseal plate cartilage
Surg Forum
The vascular contribution to osteogenesis. I. Studies by the injection method
J Bone Joint Surg
Cited by (16)
Wrist
2021, Skeletal Trauma: A Mechanism-Based Approach of ImagingFractures and Dislocations of the Forearm, Wrist, and Hand
2015, Green's Skeletal Trauma in Children: Fifth EditionPediatric Orthopedic Emergencies
2010, Emergency Medicine Clinics of North AmericaCitation Excerpt :Patients are typically in a cast for 2 to 4 weeks. Use of a short arm volar splint for the entire length of treatment is an acceptable alternative, obviating the need for urgent follow-up while providing comfort and protection from reinjury.9–11 Children with greenstick and complete fractures should be referred to an orthopedic surgeon within 3 to 5 days after injury, because they are at risk of displacement or reangulation associated with growth during healing.
Risk Management and Avoiding Legal Pitfalls in the Emergency Treatment of High-Risk Orthopedic Injuries
2010, Emergency Medicine Clinics of North AmericaCitation Excerpt :Approximately 80% of physeal injuries will occur between the ages of 10 and 16 years, with the median age being 13 years.156–158 Injuries to the physis occur much more frequently in boys than girls, reflective of the overall increased incidence of musculoskeletal injury in this population, as well as the late development of skeletal maturity in boys as opposed to girls.156,157,159 When unrecognized and improperly treated, Salter and Harris160 found that 15% of these injuries resulted in physeal arrest.
Orthopedic pitfalls in the ED: Pediatric growth plate injuries
2002, American Journal of Emergency MedicineCitation Excerpt :The distal radius is the most common anatomic site of physeal injury, accounting for 30% to 60% of cases.6,7,9-12 Physeal injuries occur most frequently in April through September when children are more likely to be playing outdoors.8 The physis is the fundamental mechanism of endochondral ossification (Fig 1).
Clinical characteristics of 1124 children with epiphyseal fractures
2023, BMC Musculoskeletal Disorders
- 1
Selected Topics: Radiology is coordinated by Jack Keene, md, of Emergency Treatment Associates, Rhinebeck, New York