ABSTRACT
A 15-month-old girl was staying with her grandmother for the weekend. While bathing her on the first night, she noticed swelling over her forearm. She had fallen over earlier that evening but only cried for a short while and then continued playing normally. The next day she took her to her family physician who noted mild tenderness and some swelling. She was referred for a paediatric assessment. The paediatrician found a well-nourished, happy baby and wonders about a congenital anomaly of her forearm or a tumour. She requests a radiograph (Image 52). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig52.jpg"/>
What does this image show?
What would you do next?
Could this be an accidental injury?
120This single view shows a healing, undisplaced transverse fracture of the ulna, without a radial fracture. In a toddler this can be due to a fall onto the outstretched hand. More commonly both bones fracture together and may be angulated. When one bone fractures the intact bone may splint the fractured bone and may not be easy to identify clinically. The healing reaction on either side of the fracture site means this is an old injury. The tenderness suggests a recent fracture – in this case a re-fracture – at the site of old injury.
Child protection investigations were started as there was no clear explanation for the original fracture at presentation. A full skeletal survey and biochemical assessment revealed no other injuries or underlying bone disorder.
A few days later her parents recalled her falling off the sofa 3 weeks previously. They thought she had sprained her wrist and she was reluctant to use it. They gave her pain relief with paracetamol, for 2 days after which she used the arm normally. Not all carers bring their child to hospital rapidly. A casual observer may notice swelling or deformity when a regular carer did not. Once a bone is fractured (but not casted) it is relatively vulnerable to clinical re-fracture with minor trauma. It was appropriate to perform a full child protection assessment due to the initial absence of history to explain the fracture. 1 The final history offered was accepted as a reasonable explanation for the old injury at presentation.
