Presentation
Swelling and pain in right wrist after mechanical fall
Patient Data
Good example of a patient's jewelry partially obscuring a fracture. In this case the lady's wrist was so swollen that she was unable to remove the bracelet.
Nevertheless, it is still clear that a distal radius fracture with volar angulation (Smith fracture) as well as a fracture of the base of the ulnar styloid process, are present.
Post fracture manipulation with POP.
Metallic bracelet had to be cut before it could be removed.
The distal radius fracture is now easier to appreciate.
Case Discussion
Jewelry artifact is often just annoying but does not have any real impact on patient safety/care. However in a case like this it could potentially lead to a diagnosis being completely missed or misinterpreted. Although a (very) junior radiology trainee overlooked the fracture here, it was not missed by ED nor the final reporting radiologist.
However a smaller fracture could be missed and really greater efforts should have been made in the first place by the radiographer and ED staff to remove the bracelet in view of the relatively high pretest probability that a distal radius fracture might be present.
The Smith fracture was described by Robert Smith (1807-1873), a later Professor of Surgery at Trinity College, Dublin, who's immediate predecessor was Abraham Colles (after whom the Colles fracture was named)!
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