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Endgames Picture Quiz

The perils of a “FOOSH”

BMJ 2010; 340 doi: (Published 07 January 2010) Cite this as: BMJ 2010;340:b5438
  1. Anand Shantilal Patel, core trainee 2 in trauma and orthopaedics,
  2. Alan Macleod, consultant in trauma and orthopaedics
  1. 1Department of Trauma and Orthopaedics, Royal Berkshire Hospital Foundation Trust, Reading RG1 5AN
  1. Correspondence to: A S Patel anandspatel{at}

    A 14 year old, right hand dominant boy was brought into the accident and emergency department at 9.00 pm, five hours after he was injured in a tackle during a rugby match. He had fallen on to his outstretched left hand (FOOSH) and had experienced immediate pain in the wrist, with swelling. He had no other injuries, and he was otherwise medically fit.

    On examination, he had an obvious “dinner fork” deformity, with severe swelling and pronounced tenderness over the wrist, together with reduced sensation in the thumb, index finger, and middle finger. Immediate anteroposterior and lateral radiographs were taken (figs 1 and 2) and analgesia given.

    Fig 1 Anteroposterior radiograph of the wrist


    • 1 What is the abnormality on the radiographs?

    • 2 Are the radiographs adequate?

    • 3 What structures are of immediate concern?

    • 4 How would you test for them?

    • 5 What classification can be applied to this type of injury?

    • 6 How would you manage this child?


    Short answers

    • 1 The radiograph shows completely displaced Salter-Harris II distal radial fracture with dorsal angulation.

    • 2 The radiographs are inadequate because they should extend to the elbow.

    • 3 The neurovascular structures are of concern, particularly the median nerve, and to a lesser degree the radial artery and superficial branch of the radial nerve.

    • 4 Median nerve motor function can be assessed by testing the abductor pollicis brevis via thumb abduction; sensory function can be tested in the radial 3 1/2 fingers (classic distribution of thumb, index …

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