Case 5

Question 1

Patient age and gender:

Answer 1

16 year­ old Male

Question 2

HPI

Answer 2

A 16­year­old right­hand dominant male was
involved in a dirt bike accident while riding at approximately 15–25 mph and
struck a tree. He experienced immediate, severe pain with obvious deformity
to his left wrist, associated with numbness in the median nerve distribution, as
well as pain in the right hip and lower back. He reported no loss of
consciousness or head trauma. There were no treatments prior to hospital
evaluation, and he was transported to the emergency department by private
vehicle. Upon arrival, his injuries were found to include a comminuted, intraarticular distal left radius fracture with displaced fragments, minimally
displaced fractures of the L4 and L5 spinous processes, and a right­sided
lower trunk subcutaneous hematoma, along with multiple abrasions. Initial
management in the emergency department consisted of closed reduction and
splinting of the left distal radius under procedural sedation, which resulted in
improvement of his median nerve symptoms.

Question 3

Relevant past medical history:

Answer 3

None. Otherwise healthy.

Question 3

Relevant physical findings:

Answer 3

On presentation, the patient had significant
deformity of the left wrist with an obvious gross deformity of the distal radius,
severe pain with markedly limited range of motion, focal tenderness, and
decreased median nerve distribution pre­reduction. After closed reduction
under sedation, sensation in the median nerve distribution improved and
capillary refill was less than 2 seconds. There was also minimal right lower
torso/hip swelling and soft tissue abrasion without significant open wounds.

Question 4

Interpretation of laboratory and imaging studies:

Answer 4

Pre­operative radiographs of
the left wrist demonstrated an acute, comminuted, displaced intra­articular
distal radius fracture with approximately 11 mm of dorsal translation of the
distal fracture fragment relative to the radial metaphysis, as well as a
minimally displaced ulnar styloid fracture. CT imaging of the cervical, thoracic, and lumbar spine revealed acute, minimally displaced L4 and L5 spinous
process fractures with no cervical or thoracic spine involvement. CT of the
chest, abdomen, and pelvis demonstrated a subcutaneous hematoma of the
right flank with no extravasation, intra­articular distal radial fracture with
posterior subluxation, fracture of the L5 spinous process, and a questionable
fracture of the mid­L4 spinous process. CT head was negative for acute
pathology. Pelvis x­rays did not demonstrate diastasis or acute pelvic fracture.