sBMJ | Picture quiz: A teenage problem
Need an
article?
search the site
...
studentBMJ
|Home
|Current Issue
|- Editorials
|- News
|- Education
|- Careers
|- Paper+
|- Life
|- Letters
|- Reviews
|Web Only
|Archive
|Topic Collections
|Subscribe
Picture quiz: A teenage problem
A left handed 17 year old presented to the emergency
department after falling on to the dorsal aspect of both
hands. He was complaining of pain and loss of function in
both hands. He was not taking any drugs and had no
relevant past medical or family history.
On examination he had swelling over the dorsal aspects
of both wrists and a limited range of movement within
wrists and fingers due to pain (fig 1). He was tender over
the ulna and radial styloid processes on palpation but had
normal sensation and capillary refill in all digits.
Interactive
|Article Response
|International Experience
|Careers Zone
Write For Us
|Author Guidelines
|How To Write
About Us
|About studentBMJ
|Posters
|Contact Us
|Site Map
|Accessibility
Fig 1 Radiograph of the right distal radius and ulna with carpal bones
(above left) and close up of the right wrist joint (above right). Radiograph
of the left distal radius and ulna with carpal bones (below left) and close
up of the left wrist joint (below right)
Questions
(1) What is the diagnosis?
Out There
|Links
|Notice Board
(2) What is the immediate management of this patient?
(3) Which classification is used to describe the diagnosis,
and how many types are there?
http://www.studentbmj.com/issues/04/04/education/148.php (1 of 5)29/10/2005 23:04:49
BMJ
HEADLINES
sBMJ | Picture quiz: A teenage problem
(4) What are the three principles of fracture management?
Answers
(1) Bilateral Salter-Harris type III fractures of the radius;
the fracture occurs through the epiphysis and involves the
joint.
(2) Assessment and treatment of airway, breathing, and
circulation. Assess for neurovascular compromise distal
to fracture sites. Splint fractures and provide analgesia
through oral, inhaled, intravenous, intramuscular, or
intranasal channels. Assess for other injuries. Consider
definitive fracture management.
(3) Salter and Harris classification, first described in 1963.
There are five types based on radiological appearance
and anatomical pattern of breakage (see discussion).
(4) Reduction (open or closed). Immobilisation (internal,
external, or intero-external). Rehabilitation (physical and
occupational).
Discussion
About a third of all children's fractures involve the
epiphyseal growth plate, the radiolucent cartilaginous
zone present in abundance in all long bones (except the
clavicle) of children (fig 2).1 Salter and Harris described
and classified these fractures depending on radiological
appearance and anatomical pattern of fracture.2 Each
type requires treatment, and if mismanaged may result in
growth disturbance, deformity, and functional impairment
(fig 2).
Fig 2 Normal anatomy of immature (growing) long bones
Interpreting plain radiographs of epiphyseal fractures is
http://www.studentbmj.com/issues/04/04/education/148.php (2 of 5)29/10/2005 23:04:49
sBMJ | Picture quiz: A teenage problem
notoriously tricky, but imaging the unaffected side may
improve the chances of recognising abnormalities. This
case is unusual in that the patient sustained bilaterally
identical fractures simultaneously.
Direct trauma is the usual cause of fracture in children,
but the history is often absent. A child with a fracture is
likely to be in pain and withdrawn; the child is also likely to
be reluctant to use the affected limb. Swelling and
deformity may be minimal; a high index of suspicion is
needed (fig 3).
Types I and II are common and have an excellent
prognosis because although they extend through the
growth plate, the germinal layer is usually left intact so
that growth disturbance is uncommon. Undisplaced
fractures simply require immobilisation in a plaster of
Paris cast.
Types III and IV are uncommon, and a precise reduction
is required; involvement of the articular surface and
germinal layer make growth disturbance and functional
impairment more likely if not managed correctly. This
manipulation will usually involve a general anaesthetic.
Type V is a crushing injury to the epi-physis, not originally
described by Salter and Harris. It is rare and has a poor
prognosis due to disruption of the blood supply to the
epiphysis. Unfortunately, this is usually diagnosed
retrospectively when limb deformity becomes apparent.
As well as limb deformity, clinicians need to be aware of
more immediate problems after fracture--resolve any
distal neurovascular compromise and consider
compartment syndrome in the hours after injury or
manipulation under anaesthetic.
http://www.studentbmj.com/issues/04/04/education/148.php (3 of 5)29/10/2005 23:04:49
sBMJ | Picture quiz: A teenage problem
Fig 3 Salter-Harris classification of epiphyseal injuries. Type I--the
epiphysis slips or separates from the metaphysic; type II--a fracture
through the epiphyseal plate leaves a fragment of metaphysis attached
to the epiphysis; type III--a fracture through the epiphysis extends to the
epiphyseal plate; type IV--a fracture extends from the articular surface,
though the epiphysis, and through the metaphysic; type V--a crush injury
obliterates the epiphyseal plate
Further reading
McRae R, Esser M. Practical fracture treatment. 4th ed.
London: Churchill Livingston, 2002
Bulstrode C, Buckwalter J, Carr A, Marsh L, Fairbank J,
Wilson-MacDonald J. Oxford textbook of orthopedics
and trauma. Oxford: Oxford University Press, 2002
James S Dawson senior house officer, Alexandra Hospital, Redditch
Email: dawson@mailvivo.co.uk
C J L Hetherington specialist registrar in emergency medicine,
Selly Oak Hospital, Birmingham
studentBMJ 2004;12:133-176 April ISSN 0966-6494
1. Rang M. Children's fractures. 2nd ed. Philadelphia: Lippincott,
1984:1.
2. Salter RB, Harris WR. Injuries involving epiphyseal plates. J
Bone Joint Surg Am 1963;45:587-622.
http://www.studentbmj.com/issues/04/04/education/148.php (4 of 5)29/10/2005 23:04:49
sBMJ | Picture quiz: A teenage problem
-Copyright© 2005 BMJ Publishing Group LtdPrivacy Policy - Terms and Conditions
http://www.studentbmj.com/issues/04/04/education/148.php (5 of 5)29/10/2005 23:04:49