Case: 8yo Male - Distal Radius Fracture
Type II
Initially Missed
4
Diagnostic Steps
7 days
Time to Diagnosis
1
Missed Findings
2
Confusion Factors
94%
Extraction Confidence
Diagnostic Journey
🏥
Initial Presentation
Emergency Department Visit
Day 0
Jan 15, 2024
Chief Complaint
Right wrist pain and swelling after fall
Mechanism
Fall from playground equipment onto outstretched hand
Physical Exam
Point tenderness over distal radius, mild swelling, no deformity, intact neurovascular status
Extraction confidence:
96%
🔬
Initial X-ray
AP and Lateral Views
Day 0
Jan 15, 2024
Finding
"No acute fracture or dislocation identified"
Interpretation
Soft tissue swelling noted, interpreted as sprain
Action Taken
Splint applied, discharged with follow-up instructions
Missed Finding: Subtle widening of the distal radial physis (approximately 2mm) was present but not identified. No comparison views were obtained.
Extraction confidence:
92%
⭐
Pivot Point: Return Visit
Persistent Symptoms Trigger Re-evaluation
Day 7
Jan 22, 2024
Trigger
Persistent pain despite immobilization, parents concerned
Clinical Finding
Continued point tenderness, minimal improvement
Decision
Repeat imaging with comparison views ordered
Key Insight: Persistent symptoms in pediatric patients with normal initial X-rays should prompt re-evaluation. Comparison views are essential for detecting subtle physeal injuries.
Extraction confidence:
94%
🔬
Follow-up X-ray with Comparison
Bilateral Views Obtained
Day 7
Jan 22, 2024
Finding
Asymmetric widening of right distal radial physis compared to left, small metaphyseal fragment visible
Interpretation
Findings consistent with Salter-Harris Type II fracture
Extraction confidence:
95%
✓
Final Diagnosis Confirmed
Orthopedic Consultation
Day 7
Jan 22, 2024
Diagnosis
Salter-Harris Type II fracture of the distal radius
Classification
Non-displaced, stable fracture pattern
Treatment Plan
Short arm cast for 4-6 weeks, follow-up in 1 week
Outcome: Fracture healed without complication at 6-week follow-up. No growth disturbance noted at 6-month evaluation.
Extraction confidence:
97%
Confusion Factors
Subtle Physeal Widening
High Impact
The 2mm widening of the distal radial physis was subtle and easily overlooked without comparison views. This is a common pitfall in pediatric wrist injuries.
✓
Resolved by obtaining bilateral comparison radiographs
No Comparison Views Initially
Medium Impact
Standard practice recommends comparison views in pediatric patients with suspected physeal injuries, but these were not obtained during the initial evaluation.
✓
Resolved at follow-up with bilateral imaging
Key Teaching Points
Always Consider Comparison Views
In pediatric patients with wrist injuries, bilateral comparison radiographs can reveal subtle physeal widening that may be missed on unilateral imaging.
Persistent Symptoms Warrant Re-evaluation
When a pediatric patient returns with persistent symptoms despite a "normal" initial X-ray, growth plate injuries should be reconsidered.
Type I and II Fractures Can Be Subtle
Salter-Harris Type I and II fractures may have minimal radiographic findings. Clinical suspicion should guide further workup.