Teini Elisara
Case
An 82 year old female with a past medical history of anemia of chronic disease, breast cancer, diabetes mellitus, hypertension, osteoporosis, rectal adenocarcinoma, scleroderma with pulmonary involvement, and systemic lupus erythematosus presented to the emergency department after a mechanical fall the night prior. She was getting into bed when she tripped and fell on the left side of her body landing on her left arm and hitting the side of her head on the floor. Patient endorsed severe pain to her left wrist.
Vitals: BP 162/64 | Pulse 67 | Temp 98 °F (36.7 °C) | Resp 16 | Wt 53 kg (116 lb 13.5 oz) | SpO2 98% | BMI 22.08 kg/m²
On physical exam of the left wrist, there was significant swelling and overlying bruising. She was unable to supinate due to severe pain. Sensation was intact throughout the hand and wrist. The wrist did not appear grossly displaced laterally or medially. She had decreased range of motion secondary to pain with sensation intact and was able to move her digits. There were no open wounds.
A bedside ultrasound was performed on the patient’s distal forearm, the following images were obtained:
Figure 1: Left distal ulna fracture.
Figure 2: Left distal radius fracture
The joint capsule was visualized and negative for signs of effusion. The right wrist also scanned for anatomy comparison.
Discussion
In this case, we identified fractures in both the distal radius and ulnar styloid of our patient. We were able to identify fractures quickly and with minimal discomfort to the patient. Left distal radius and ulnar styloid fractures were confirmed by two-plane x-ray.
Cortical fractures are a common presentation to the emergency department, with distal forearm fractures being amongst the most common in both adult and pediatric populations. Wrist fracture prevalence in the United States is 12% in adults over the age of 50, with significant increases over the last 20 years [1,2]. As X-ray is the gold standard for diagnosing fractures, ultrasound is not typically thought of as an option for identification. However, it is a possible alternative for fracture identification in the emergency department, with high specificity and sensitivity [3]. In addition, ultrasound can be used to assess the healing phases of fracture using grayscale and color doppler [4]. With increased prevalence and use of ultrasound, it is a quick alternative for patients where reduction of exposure to ionizing radiation is preferred, such as pediatrics or pregnancy.
References
- Ye J, Li Q, Nie J. Prevalence, Characteristics, and Associated Risk Factors of Wrist Fractures in Americans Above 50: The Cross-Sectional NHANES Study. Front Endocrinol (Lausanne). 2022 Apr 25;13:800129. doi: 10.3389/fendo.2022.800129. PMID: 35547001; PMCID: PMC9082306.
- Xu B, Radojčić MR, Anderson DB, Shi B, Yao L, Chen Y, Feng S, Lee JH, Chen L. Trends in prevalence of fractures among adults in the United States, 1999-2020: a population-based study. Int J Surg. 2024 Feb 1;110(2):721-732. doi: 10.1097/JS9.0000000000000883. PMID: 37921645; PMCID:PMC10871608.
- Douma-den Hamer D, Blanker MH, Edens MA, Buijteweg LN, Boomsma MF, van Helden SH, Mauritz GJ. Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. PLoS One. 2016 May 19;11(5):e0155659. doi: 10.1371/journal.pone.0155659. PMID: 27196439; PMCID: PMC4873261.
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