Child With a Sprained Wrist
Radiology Cases in Pediatric Emergency Medicine
Volume 1, Case 13
Linton L. Yee, MD
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
     A ten year old boy fell during a soccer game, injuring 
his right wrist.  He reportedly tripped when trying to kick 
the ball and landed backwards on his outstretched right 
hand.  After the patient complained of pain and swelling 
in the right wrist, ice was placed on his wrist and he 
was brought to the ED.
     Exam:  The right distal wrist is tender with mild 
swelling.  There is point tenderness over the volar 
lateral aspect of the distal radius.  There is a mild 
amount of loss of range of motion of the right wrist in 
flexion, extension, abduction, and adduction.  Deformity 
and ecchymosis are not present.  No tenderness or 
deformities are present in the fingers, hand, mid and 
proximal forearm, elbow, humerus, shoulder, or clavicle.  
Full range of motion is present in the hand, elbow, and 
shoulder.  There is no tenderness in the anatomic snuff
box.  Radiographs of the right wrist are taken.

View radiographs of wrist.

     Clinically, he appears to have a fracture over the 
distal radius where there is point tenderness and mild 
swelling.  Do you see the fracture?
     This is normal.  No fracture is seen.  The growth 
plate is not widened, nor is there any displacement of 
the epiphysis from the metatphysis.  However, this does 
not mean that a fracture is ruled out.

Teaching Points:
     1.  Salter-Harris Type I injuries are based on clinical 
suspicion.  This is often a clinical diagnosis rather than 
a radiographic diagnosis.  Tenderness and/or edema at 
the growth plate are more diagnostic than normal 
radiographic findings.  Type I fractures are only visible 
radiographically if the segments are displaced; 
however, this is uncommon.

View example of displaced SH Type I fracture.

     In this radiograph, the AP view of the wrist looks 
normal except for a small chip fracture of the ulnar 
styloid.  In examining the lateral view, describe the 
position of the radial epiphysis in relation to the 
metaphysis.  Note that the epiphysis is not centered 
over the metaphysis.  The epiphysis is displaced 
dorsally relative to the metaphysis indicating 
radiographically, a displaced Salter-Harris Type I 
fracture.  See Case 18 (Salter-Harris) for more 

     2.  SH Type I fractures of the distal radius are 
common.  Ulnar involvement is not common.
     3.  The fall on the outstretched hand is the 
mechanism of injury most commonly associated with 
fractures of the distal radius and ulna.
     4.  A sprained wrist is a diagnostic pitfall that should 
be avoided.  The patient in this case does NOT have a 
sprained wrist.  Tenderness over the physis region of 
any bone, especially at the wrist, is a Salter-Harris I 
fracture until proven otherwise by special studies or 
long term follow-up, even if initial radiographs are 
     5.  What might appear to be an ankle sprain may 
also turn out to be a SH type I fracture of the distal 
fibula.  The patient's history may not be very helpful, 
since both an ankle sprain and a fibula fracture may be 
difficult to distinguish.  On examination, a Salter Harris 
type I fracture will be tender directly over the distal 
fibular physis.  An ankle sprain may be tender more 
distally where the ligaments/syndesmosis attach the 
fibula to the talus.  This is a clinical diagnosis as well.  
Sometimes, there is  evidence of rotation or 
displacement of the distal fibular epiphysis, but the 
absence of this does not rule out a non-displaced type I 

View ankle SH-I example.

     This patient presented with an ankle injury.  He was 
noted to have only mild swelling over the lateral 
malleolus, but he refused to bear weight on the foot, 
preferring to hop instead.  He was not tender over the 
distal tip of the fibula, but he was very tender more 
proximally, over the fibular physis.  He was placed in a 
splint for a suspected Salter Harris Type I fracture of 
the distal fibula.  At orthopedic follow-up, he was placed 
in a short leg cast for 17 days.  Upon removal of the 
cast, he had no pain, and he could bear weight without 
problems.  It is difficult to say with certainty whether this 
truly was an SH-I fracture of the distal fibula; however, 
this diagnosis should be considered when examination 
findings suggest it.

     1.  Lawton LS.  Fractures of the Distal Radius and 
Ulna.  In:  Letts RM (ed).  Management of Pediatric 
Fractures.  New York, Churchill Livingstone, Inc., 
1994, pp.345-368.
     2.  Rang M.  Children's Fractures.  Philadelphia,
J.B. Lippincott Co., 1983.
     3.  Anderson AC.  Injury-Ankle.  In:  Fleisher GR, 
Ludwig S (eds).  Textbook of Pediatric Emergency 
Medicine, third edition.  Baltimore, Williams & WIlkins, 
1993, pp. 259-267.

Return to Radiology Cases In Ped Emerg Med Case Selection Page

Return to Univ. Hawaii Dept. Pediatrics Home Page

Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine