WIDI - P22) Forearm pain after fall

P22) Forearm pain after fall

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

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

History

A 14-year-old male presents with left forearm pain after falling on an outstretched arm while playing basketball. The patient reports a sudden sharp pain in the forearm and limited movement following the fall. The patient denies any prior injuries or fractures.

Physical Exam

BP: 116/80, HR 88, RR 20 , Temp 98.5 , O2 saturation 98%. Left medial forearm swelling and tenderness. Intact sensation and capillary refill.

Labs

None

Provisional Diagnosis

Select the Dx you believe is most appropriate

Forearm fracture

Scaphoid fracture

Lunate dislocation

This patient most likely has a forearm fracture based on the location of the findings of the physical exam. Scaphoid fractures and lunate dislocations are less common in this age group and would show different physical exam findings.

Well done. You were correct

Potential Acuity

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

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

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?

Forearm X-ray

CT scan of the forearm

MRI of the forearm

A forearm X-ray is a quickly obtainable initial imaging modality to evaluate for the presence and type of fracture.

Well done. You were correct

Pertinent Imaging Observations

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

Forearm X-ray

What best describes the findings on X-rays of the forearm?

Buckling of the distal ulnar cortex

Buckling of the distal radius cortex

Partial fracture line extending through the distal ulnar cortex

Partial fracture line extending through the distal radius cortex

There is an acute partial transverse fracture line at the junction of the middle and distal thirds of the ulnar shaft with apex radial angulation.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

CT of the forearm

MRI of the forearm

None

No further imaging is needed as the diagnosis is confirmed with X-ray.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Buckle fracture

Spiral fracture

Comminuted fracture

Greenstick fracture

The imaging findings are consistent with a greenstick fracture, which is an incomplete fracture with bending and a partial fracture of the bone.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

This patient requires routine, but expedited management.

Assessment and Plan

Please provide your assessment and plan for this patient

The 14-year-old male has been diagnosed with an acute, closed, greenstick transverse fracture at the junction of the middle and distal thirds of the ulnar shaft with apex radial angulation. X-ray has confirmed the diagnosis. The initial management plan should involve immobilization of the fracture with a splint or cast. Pain control measures such as acetaminophen or ibuprofen should also be initiated. However, considering that there is some angulation, referral to an orthopedic specialist is necessary to evaluate for a reduction prior to splinting. The patient should be advised to follow up following discharge to assess for alignment. A repeat X-ray may be necessary to ensure proper alignment and healing.

Lessons Learned:
- A greenstick fracture is a type of incomplete fracture seen in children and adolescents, where the bone is bent and partially broken. X-ray is the initial imaging modality of choice, as it is quick, inexpensive, and highly sensitive in detecting fractures.
- Greenstick fractures can be distinguished from complete fractures and torus fractures by the presence of bending and partial breakage of the bone, without complete displacement or separation of the fragments. Treatment for greenstick fractures may involve immobilization with a cast or splint, pain control measures, and close follow-up to monitor healing and alignment. Referral to an orthopedic specialist may be necessary if there is significant displacement or angulation.
- Prognosis for greenstick fractures is generally good, with most patients experiencing full recovery within several weeks to months.

Socioeconomic Factors: Pediatric fracture patients with government-funded health insurance may experience longer periods of time before receiving treatment. Additionally, malnutrition, specifically vitamin-D deficiency, has been shown to increase the risk of greenstick fractures after a trauma. Thus, proper nutrition and access to healthcare are important factors in preventing and managing pediatric fractures.

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