P14) Forearm pain after fall on outstretched hand

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pediatric patient with pain after a fall.
  2. Review the DDx considerations in a pediatric patient with pain after a fall.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a pediatric patient with pain after a fall.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
This patient most likely has a forearm fracture based on the location of the findings of the physical exams. Scaphoid fractures and lunate are less common in this age group and would show different physical exam findings.
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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This patient requires routine, but expedited workup as their suspected condition is not immediately life or limb threatening.

First Imaging Study

What is the first imaging study you will order?

A forearm X-ray is a readily available, inexpensive imaging modality that can effectively identify fractures.
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

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Second Imaging Study

What is the next imaging study you will order?

No further imaging is required as the diagnosis is made with the plain radiographs.
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What is your Diagnosis now that you have seen the imaging results?

This patient presents with a buckle, or torus fracture, evidenced by the buckling of the radial cortex visible on imaging. It is crucial to distinguish this from greenstick fractures, which display a partial fracture line and typically require different management.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

This patient requires routine, but expedited workup as their suspected condition is not immediately life or limb threatening.

Assessment and Plan

Please provide your assessment and plan for this patient

A 5-year-old male presents with a buckle fracture following a fall on an outstretched hand. Depending on the caregiver's management preferences, a removable soft arm splint or soft elastic bandage can be used for three weeks. The caregiver should be instructed on how to remove the bandage. No follow-up is needed if there is no pain after three weeks.

Lessons Learned:
- Buckle fractures are usually stable injuries that occur due to a compressive force, and surgery is not typically necessary. They commonly occur at the distal metaphysis where the bone is most porous.
- An axial loading force from a fall on an outstretched hand is the most common cause of a buckle fracture. In contrast, greenstick fractures usually result from a rotational force.
- X-ray findings of a buckle fracture typically include buckling out of one or both cortexes of the long bone.
- Buckle fractures are generally stable and can usually be managed with a removable soft arm splint or soft elastic bandage for a few weeks to immobilize the affected area.
- Buckle fractures have an excellent prognosis, and complications are rare. Follow-up appointments or imaging are not usually necessary if the pain resolves at home.

Socioeconomic Factors: Several clinical trials have generally suggested that home care is effective, and that uncomplicated buckle fractures do not require outpatient primary care provider follow-up or imaging.

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