IS Case 381: Oblique fracture of the fourth proximal phalanx of the left hand
2009 URMC Imaging Sciences
Publication Date: 2010-03-02
Patient is a 22-year-old male presenting to the emergency department with history of trauma to the left hand and face. Left fourth digit / ring-finger is too swollen for a large ring to be removed prior to exam. Radiologist on duty cannot rule out fracture with ring in place and suggests elevation and icing to reduce swelling and allow removal of ring for definitive imaging.
Initial PA radiograph of the left hand demonstrates soft tissue swelling of the proximal fourth digit with metallic ring obscuring most of the fourth proximal phalanx diaphysis. Closer inspection demonstrates probable osseous fragment along the ulnar aspect of the distal fourth proximal phalanx. After an hour of elevation and ice, the ring was removed, demonstrating oblique fracture of the fourth proximal phalanx.
Small radiopaque objects can potentially obscure significant radiographic findings. Despite pressure from the Emergency Department to rule-out fracture in the context of a suboptimal exam, a radiologist cannot (and should not) assess structures that he/she cannot see. In this case, suggesting that elevation and ice to reduce visible swelling of the affected digit allowed the ED staff to ultimately remove the ring and expose the fracture described above.
- Brant WE, Helms CA. The Brant and Helms Solution: Fundamentals of Diagnostic Radiology. 3rd ed., Lippincott Williams and Wilkins, Philadelphia, 2006.