Wrist injury (Full Version)

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Alex Brenner PT MPT OCS -> Wrist injury (December 3, 2004 1:02:00 AM)

Hi all. I normally would post these on Sunday and run them for one week, however, I will be out of town until the middle of next week so here is case #2 early.

22 year old male was walking in the woods at night and tripped over a stump. He landed and immediately felt wrist pain. He was seen in the ER where they took films of the wrist. He was released from ER with diagnosis of wrist sprain. His wrist is progressingly getting worse. He can not get an appointment to see his family doctor for two weeks so he decides to see you on direct access. He is hand carrying his radiographs which were read normal by the ER physician.

The patient has global wrist pain and swelling.

What are the findings?
(Images obtained and used with permission)

[image]http://img.photobucket.com/albums/v85/brennerak/test.jpg[/image]



SJBird55 -> Re: Wrist injury (December 3, 2004 2:49:00 AM)

I haven't seen hardly any adult wrist radiographs... but maybe the proximal end of the scaphoid a small nondisplaced fracture? The radius and ulna seem to look okay.

I've only seen radiographs of kids and their little carpal bones aren't formed very well.



tr6454 -> Re: Wrist injury (December 3, 2004 2:51:00 AM)

There is a fracture line across the proximal pole of the scaphoid. Not as common as fx's at the waist but still consistent with the trauma. The "global wrist pain" is worrisome to me, but if he has not been immobilized it could just be from the Fx.



Jon Newman -> Re: Wrist injury (December 3, 2004 3:03:00 AM)

Hi Army,

I'm terrible at this stuff. I love this forum. I going about this from a totally experiental learning sort of way without any texts. Might there be a non-displaced fracture of the radius. There seems to be a tiny bit of cortical discontinuity but I may trying to find something that's not there (how ironic).
I agree with the scaphoid stuff.

jon



jma -> Re: Wrist injury (December 3, 2004 4:02:00 AM)

Hello,

A proximal transverse fx on the scaphoid from the first x-ray. Hard to interpret the others because the images look very dark on my screen and is hard to figure out details, although I can see contours of the wrist but not much else. Wish my screen had a back light to highlight the backround. The global swelling also concerns me. Has the blood supply around that area been compromised?

JMA



SJBird55 -> Re: Wrist injury (December 3, 2004 10:03:00 AM)

How can you differentiate swelling from a big, fat hand?



steve -> Re: Wrist injury (December 3, 2004 10:56:00 AM)

Very interesting,

Looks like it is a stable fracture of the tubercle pf the scaphoid proximally. Blood supply should not be an issue, particularly as (If I remember correctly) the branch of the radial artey enters distally and flows to the proximal. Immobilize until proven otherwise. Prognosis is good as these fractures almost always unite.

Steve



Jeep -> Re: Wrist injury (December 4, 2004 1:26:00 AM)

The navicular is questionable for fracture, IMO. Many new, non-displaced, fractures can be hard to visualize. I would take another set of films @ 2 wks. post injury to rule out-rule in. If there is a fracture, callus formation will have begun, making visualization much easier. I would also clinically evaluate for hamate dislocation/displacement. I would treat as if it is a fracture until second set of films are obtained.



wplashdc -> Re: Wrist injury (December 10, 2004 2:49:00 PM)

Possible fracture of proximal scaphoid.
Terry



Alex Brenner PT MPT OCS -> Re: Wrist injury (December 10, 2004 11:11:00 PM)

There is a non displaced fracture through the proximal pole of the scaphoid. In addition there is a chip fracture on the lateral side of the radius.

Good job to SJBird, Terry, Jma, Steve, Jeep, and wplashdc for correct answers. Good job Jon on recognizing the chip fracture on the radius.

See images below.

[IMG][image]http://img.photobucket.com/albums/v85/brennerak/test2.jpg[/image][/IMG]

Here is a blown up picture to better visualize.

[IMG][image]http://img.photobucket.com/albums/v85/brennerak/RScropped2.jpg[/image][/IMG]

I took this from Wheeless online concerning blood supply to the wrist.

Discussion:
- scaphoid receives majority of its blood supply via dorsal vessels at or just distal to waist area;
- these vessels perfuse the proximal pole in a retrograde fashion;
- most important vascular branches of radial artery enter scaphoid thru foraminae along its dorsal ridge;
- it supplies 70-80% of bone, including entire proximal pole;
- second group of vessels, arise from palmar & superficial palmar branches of radial artery & enter carpal scaphoid in region of its distal tubercle;
- it perfuses distal 20-30 % of bone, including tuberosity;

- Proximal Scaphoid:
- proximal two thirds to three fourths of scaphoid is supplied by vessels entering dorsal surface;
- vessels enter thru dorsal ridge in 79 %, distal to waist in 14 %, & proximal to waist in 7 %;
- vessels branched soon after entering bone and then coursed proximally and palmarly as far as the subchondral bone;

- Distal Scaphoid:
- tubercle & distal 20-30 % of scaphoid are supplied by palmar vessels;
- in few specimens, two or three vessels enter tip of tubercle & penetrated the bone as far as waist;
- there were no anastomoses between the dorsal and palmar vessels in any of the specimens;

In the Army, if available, I would walk this patient down to orthopaedics and talk to one of the surgeons. How would you manage this patient if you saw him on direct access in your private clinic?



SJBird55 -> Re: Wrist injury (December 11, 2004 1:23:00 AM)

Technically I wouldn't manage him. He'd have to see ortho. Behind the scenes, the orthos would comment on how crappy the ER physician was... then they'd be slighly pissed the guy wasn't immobilized. They would then put on their smiley face and tell the patient that they did see something that concerned them that looks like a potential fracture and that they'd like to have radiographs done in the office. They would redo radiographs to compare images. I'd assume if there wasn't a change, then they would either splint or cast depending on the amount of edema. Their goal would be toward a long arm cast to keep the radius stabilized too. If they weren't worried about the nondisplaced fracture becoming displaced, they'd have him have a return visit in 4-6 weeks... if they did feel that the fracture would become displaced, they'd have him return in 2 weeks. If things looked fine, they wouldn't need to do anything... if things weren't going well, they'd probably pin the scaphoid. For some reason I doubt if the radius chip would get too much attention, it isn't in the joint line and it should calcify down.



Jon Newman -> Re: Wrist injury (December 11, 2004 1:21:00 PM)

According to an OT that is quite close to me (and this is OT territory where I work), the patient ought to see an ortho MD ASAP. If that isn't essentially the same day, a long thumb spica could be used for the interim.

jon



nari -> Re: Wrist injury (December 11, 2004 5:11:00 PM)

I have come in late to this great discussion, and the site is good.

I might add that there was a study done last year (I'll try to locate it) which demonstrated that immobilising scaphoid fractures increases the risk of AVN. The recommendation was that an ordinary bandage be used so as not to compromise the circulation, but to assist in reducing oedema.

Nari



Jon Newman -> Re: Wrist injury (December 12, 2004 11:04:00 AM)

Nari,

Please do try to find that article, I have an interested party.

jon



nari -> Re: Wrist injury (December 12, 2004 7:15:00 PM)

jon,

Cannot find that article - even a database and PubMed search drew zero. I have a feeling it was in the Aust Med journal...but cannot locate it.
Will look in a few more places before I give up.

nari



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