Ultrasound Case of the Week (2/18/14)

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