- Case History
- Nursing Records
- Results
- Investigations
- Prescription Sheets
- Correspondence
Questions
1. Comment on the XRay
There is a spiral fracture of the mid humerus. This injury is consistent with a rotational force being applied to the arm. The radial nerve is potentially at risk as it passes through the spiral groove on the back of the humerus and it's function should always be checked. Remember that the nerves to the triceps muscles come off very high and are unlikely to be affected, so you must look at the muscles and sensation of the forearm to determine if there has been any damage.
2. Comment on the clinical history
The fracture and the story do not match. This injury is consistent with a twisting injury, not a direct fall, although as this fall was not witnessed by the persons who brought the child to hospital.
This particular injury is consistent with physical abuse and should raise alarm bells in the clinician.
See http://www.bestbets.org/cgi-bin/bets.pl?record=00135 for more information on this injury
3. What would you do next?
From a clinical perspective the child needs a humeral cast, splintage and analgesia. These injuries generally heal well.
Because of the nature of the inury it is essential that the child is fully examined by a senior physician and that careful documentation is made of any injuries found and how these were explained by the parents and carers.
The child protection issues must be explored properly. A full history should be taken from the family and an assessment made of whether the child is at risk (you can also check the at risk register - though this is not a catch all system). if there are any doubts then the child should be referred to the paediatric team for further assessment. Even if after initial investigation you decide to send the patient home then a referral to the health visitor and social services would be appropriate.
There is the additional issue that a 15 year old should not be babysitting for a small child and this would need further contact with the family. It may be another indication of problems at home.
