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Wrist Injury #2
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Wrist Injury #2 - December 13, 2004 10:26:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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This case comes from forum member UTDC. All images obtained with permission.
History:
This is a 19 year old male, collegiate golfer with the prospect of playing professional golf. 1 month ago, while walking home from the bar, the patient attempted to jump over a fire hydrant, falling on his right wrist (FOOSH). He awoke the next morning with moderate mid carpal wrist pain and minimal swelling, proceeded to the student health center and the below radiographs were obtained.
[IMG]http://img.photobucket.com/albums/v85/brennerak/Wrist.jpg[/IMG]
What are the findings?
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Alex Brenner, PT, MPT, OCS
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Re: Wrist Injury #2 - December 14, 2004 5:02:00 AM
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fapt
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From: Taiwan, R.O.C.
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hmm
It is obviously that i can see the fracture line at the radial and ulnar epiphseal...
And i can see the distal radioulnar joint has small displacment.
That is all.
Lin,MS,PT, Taiwan
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Re: Wrist Injury #2 - December 14, 2004 6:16:00 AM
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UTDC
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Hi Lin. Thanks for your comments, I'll start posting some answers and a follow-up study once some others have chimed in.
Jeff
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Re: Wrist Injury #2 - December 14, 2004 7:29:00 AM
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tr6454
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If this patient was in my room, I would have to go back in to reexamine the wrist since the films are unremarkable to me at first glance. The physis are open, but otherswise WNL. Some additional clinical cues may help to focus in on any boney pathology, if present. If these films are a month old and he still is having pain I may get another series or consider bone scan if I was suspicious.
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Terry
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Re: Wrist Injury #2 - December 14, 2004 7:48:00 AM
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jma
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From: NY
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Hello,
I see a few fracture lines at the distal radius and distal ulna at the epiphseal areas. Also noted is fracture at the proximal 1 MCP in the oblique x-ray.
JMA
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Re: Wrist Injury #2 - December 14, 2004 8:43:00 AM
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chiroortho
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JMA,
That's not a fx at the 1MCPJ, those are sesamoid/accessory bones. Completely normal, but good find anyway. Often mistaken for fx. There's a fabella at the insertion of the lateral head of the bicep femoris that's often mistaken for fx as well, and sometimes at the first MTPJ.
Great job picking up details.
Greg
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Greg Priest, DC, DABCO
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Re: Wrist Injury #2 - December 14, 2004 8:56:00 AM
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Jeep
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From: USA
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I suspect an endocrine disorder. The epiphysis of the radius and ulna should be ossified by 19 yrs.
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Re: Wrist Injury #2 - December 14, 2004 9:44:00 AM
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UTDC
Posts: 222
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Ok Folks, good calls all around.
This was a patient of mine who showed up in my office with the above history. In that 1 month time, he had undergone physical therapy (approx 10 visits) involving passive modalities, active range of motion exercises, forearm and intrinsic hand strengthening and joint mobs of the wrist and elbow. There was minimal pain relief, although swelling was decreased. He could not play golf. His family practice physician wanted him to continue with PT.
So....The patient went to see a local chiropractor who had a reputation for doing well with extremity manual therapy. After reviewing his xrays, the dc started with some wrist mobilizations and progressed to a carpal manipulation after which the patient experienced a 20% increase in wrist pain.
The patient then presented to my office. Upon examination, he demonstrated no carpal instability (neg watsons/ballotment), minimal effusion, moderately decreased active range of motion in flexion and extension and painful crepitus through the midcarpals. Neurovascular evaluation was unremarkable.
I reviewed his xrays.
What would be your next move?
Let me know if you need any clarification.
Jeff
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Re: Wrist Injury #2 - December 14, 2004 3:47:00 PM
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hlavacek
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From: Georgia
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Sounds like the TFCC. Very common in golfers
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Re: Wrist Injury #2 - December 14, 2004 5:23:00 PM
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UTDC
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Thanks Hlavacek, remember that this was not a golfing injury and the pain is not ulnar sided.
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Re: Wrist Injury #2 - December 14, 2004 6:25:00 PM
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Jon Newman
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From: Amherst, WI
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Well I didn't turn up anything real satisfying in my short search. Not being able to order diagnostic imaging, I would refer her to her MD. It would seem reasonable to get a bone scan to determine if there was ++ uptake suggesting a stress injury.
jon
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Re: Wrist Injury #2 - December 15, 2004 1:50:00 AM
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SJBird55
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From: Michigan
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I'm not able to see anything in particular.
I'm assuming both you and the other chiropractor ran your own radiographs? In other words, you didn't just use the original set to set your plan of care.
So... was there any change in the radiographs from initial to when you first saw the person?
Based both on his age, time since injury and by his response to treatment from the other chiropractor, I would logically assume that he does have some sort of pathology. What does FOOSH mean?
If you do a tap test or a vibratory kind of test with a tuning fork, does he have any kind of response? If he did, then I would think that a bone scan could be in order. If he did not, then whichever imaging would be best to view the ligaments (I don't know which is best in this situation MRI or CT).
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Re: Wrist Injury #2 - December 15, 2004 1:55:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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FOOSH = Fall On Outstretched Hand. Very common mechanism for scaphoid injuries.
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Alex Brenner, PT, MPT, OCS
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Re: Wrist Injury #2 - December 15, 2004 2:37:00 AM
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SJBird55
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From: Michigan
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I just popped on because I figured those letters out while I was making the kids' lunches. As I've said before, I suck at acronyms. I actually don't document acronyms and I spell everything out. (For the simple reason, if I were ever in court and on the stand, I could see myself forgetting what the heck they meant and blundering so much that I really wouldn't be able to hide how much of an idiot I really am.)
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Re: Wrist Injury #2 - December 15, 2004 6:22:00 PM
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chiroortho
Posts: 655
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His epiphyses are nearly closed, but if he was younger I'd be concerned about a Salter-Harris V.
If you look really closely at oblique view you can imagine a transverse lucency in triquetrum, if you have a good imagination. More likely possibility is scaphoid fx as Army so aptly points out, but no fx there. But anything's possible in orthopedics and war, right Army? On lateral view tiny raised surface on distal radius could fool us, but remember Lister's tubercle?
Doubt it's a TFCC issue, but if I was really concerned MR would be study of choice. Radioulnar lig more of a concern.
Splint X4 weeks round the clock in neutral position splint, re-xray in 4 weeks, and all will likely be well.
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Greg Priest, DC, DABCO
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Re: Wrist Injury #2 - December 16, 2004 6:41:00 AM
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Jeep
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Chirortho-
Hx above says 19 yo.
Assuming this did not happen on his birthday, he is 19+ yo.
The un-ossified epiphyses is atypical.
as per Paul and Juhl-
Distal radius- fusion by 18 yrs.
Distal ulna- fusion by 171/2 yrs.
Do you have anything otherwise?
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Re: Wrist Injury #2 - December 16, 2004 10:50:00 AM
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chiroortho
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Jeep,
I stated that his epiphyses were 'nearly closed', and the difference between 18 and '19+' isn't too much of a stretch. What was his actual age? 19+ could mean 74. If that's the case, then he's got real problems with delayed epiphyseal closure. :)
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Greg Priest, DC, DABCO
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Re: Wrist Injury #2 - December 16, 2004 1:43:00 PM
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SJBird55
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Joined: May 10, 2004
From: Michigan
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The only way to know with this male is if his opposite wrist/hand were radiographed. If the left wrist looked pretty similar to the right wrist, then he is the way he is.
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Re: Wrist Injury #2 - December 17, 2004 4:11:00 AM
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Yogi
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From: San Antonio, Tx., USA
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UT, ok, when do we get the answer as to what it is?
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Re: Wrist Injury #2 - December 18, 2004 5:06:00 AM
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Jeep
Posts: 353
Joined: March 28, 2003
From: USA
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Chirortho-
First- all we have here is an x-ray and an incomplete medical history.
However, at this age, 2+ years outside the norm is of concern(at least to me).
I may be "ascew"- being an X-ray forum- but X-rays are only one component of the diagnostic process. The failure of ossification at 19 yrs(+ 1-364 days.) just raised a "flag".
Just trying to add an element of diagnosis here.
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