Ultrasound Case of the Week (2/18/14)
Pt is a 7y/o female with no pmh who presented to the ED with complaints
of left lower forearm pain for 9 days.
Pt reported that her sister stepped on her left distal forearm while she
was trying to pull it up, resulting in pain.
Mother has been treating the pt with OTC pain meds (Tylenol/Ibuprofen)
and a cultural specific form of Bengay.
The child no longer complains of pain unless she has to use the left
wrist. The mother took the patient to
her Pediatrician, who suggested that the child be bought to the ED for further
evaluation.
ROS: negative except for as stated above
Vital Signs: T 35.8 HR
94 RR 20 SpO2 98
Physical:
Gen: NAD
MS: left
distal forearm with mildly visible bowing and swelling, no erythema, no
tenderness to palpation, FROM of wrist and fingers, sensation intact, radial
pulse intact with good cap refill, pt uses left forearm/wrist to motion while
talking but will not bear weight with it
In the ED, bedside Musculoskeletal US revealed a left ulnar fracture
Click on the video below to view the clip of the patient’s left ulnar
fracture. Note the cortical interruption on the right side of the video
XRay of Left Wrist-3Views: (one view below):
Three views of the left
wrist demonstrate healing fracture of the distal third of the ulna. Fracture fragments in alignment. Significant
periosteal reaction is seen. Deformity of the ulnar styloid the process may be
related to injury..The metacarpals and carpal bones are unremarkable. There Is
minimal soft tissue swelling over the dorsal aspect.
IMPRESSION: fracture
left distal ulna.
Wrap Up: Typically,
when there is an abnormal limb, the normal limb is used for comparison. In this situation, adjacent bones were used
for comparison. Since the left radius
had no cortical disruption, it was a great comparison in terms of what the bone
should look like when comparing it to the ulnar, which clearly had cortical
disruption. The XRay confirmed the
ultrasound findings by showing a nondisplaced and healing left ulnar fracture
that was in good alignment. However, when
viewing the fracture with Ultrasound, it appeared as if the fracture was
incomplete. This could have been
operator error.
The pt was splinted and placed in sling with
Ortho follow up prior to discharge
