Case Study:
A 13-year-old boy fell on an outstretched hand during a soccer game and sat out the rest of the game. Afterwards he is brought to the ED for wrist swelling and pain. His swelling is localized to the wrist with tenderness to palpa¬tion of the snuffbox and distal radius.
The x-rays look normal to you but the amount of pain and swelling are concerning for fracture. Several ques¬tions come to mind. Do children get wrist sprains? Could he have a Salter-Harris I (SH I) fracture of the radius or a scaphoid fracture? Is additional imaging indicated? What is the best plan for management?
You immobilize the wrist in a forearm splint. The patient wants to know when he can return to practice and if he will be able to play in the game a week from today. When is it safe for children to return to sports activities? What kind of follow-up does he need?
Case Study Conclusion:
No fracture was noted on the soccer player’s x-rays. He had a thumb spica splint applied in the ED. On orthope¬dic follow-up 2 days later, his wrist remained tender and an MRI showed a fracture of the distal third of the scaph¬oid. A thumb spica cast was applied. His fracture healed without complications.
Risk Management Pitfalls:
“I don’t see any wrist tendon involvement.” Don’t be fooled. Short lacerations can conceal deep underlying injury. Physical examination tends to underestimate the amount of damage to tendons, arteries, and nerves. If there are localized findings or the examination is inconclusive, referring your patient for operative exploration is indicated.
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