A child with a painless, deformed wrist

A 7 year old boy presented to the emergency department after his mother noticed a painless deformity of his right wrist. The deformity had appeared the day after the child had tripped and fallen on to the wrist while playing at home. He had no known medical problems and was developing well. Specifically, he had experienced no previous injury or pain in his right wrist, although he was brought to the emergency department a few months previously for a minor injury to his right thumb. His father had noted a minor enlargement of the thumb, but the boy had not undergone radiography.

On examination, his right wrist was in radial deviation with prominence of the ulna. There were no areas of focal tenderness. The proximal phalanges of his thumb and index finger were wider in girth than the other fingers, with obvious bony protuberances. He could grasp an object using his fingers and thumb with good strength and no pain. He had a full range of movement of all joints of the hand and at the wrist. There were no skin changes or neurovascular abnormalities.

He was initially seen by the emergency team who took radiographs (fig 1) and referred him to the orthopaedic team for review.