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Re: Wrist Injury #2
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Re: Wrist Injury #2 - December 18, 2004 5:37:00 AM
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chiroortho
Posts: 655
Joined: February 18, 2004
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Jeep,
With all due respect I think you're reading way too much into the physeal issue.
It's my experience that when we're in school everything's textbook classic but in the real world, exceptions are the rule. Remember in school where we were taught dermatomal distributions, but when we went into practice we found that a lot of radiculopathies didn't follow the dermatomes that they were 'supposed' to follow? Remember how we were taught the Wexler reflex grading scale, and in clinic if an ankle jerk was a little hypo we got all worked up? Now we look at the whole picture and now, in the lack of any red flags, we don't give a hoot about a 1+ ankle jerk.
I don't think the little bit of delayed epiphyseal closure is of any concern whatsoever.
If I'm wrong I'll gladly eat crow here, and you can throw a resounding 'I told you so!' my way. :)
Merry Christmas and Happy Hanukkah to all.
Respectfully,
Greg
_____________________________
Greg Priest, DC, DABCO
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Re: Wrist Injury #2 - December 21, 2004 4:04:00 AM
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Jeep
Posts: 353
Joined: March 28, 2003
From: USA
Status: offline
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Chirortho-
x-rays always need to be coordinated with clinical findings in DDX. However, x-rays taken for one reason can end up, "discovering by accident" other things. I am sure you have encountered this many times in your clinical practice, as I have.
As to this particular post- it was probably posted because it is "not textbook", thereby it's "learning" purpose.
I've seen alot of sloppy/sub-par rad reports in my 20+yrs of practice. Missing something that is obviously or even vaguely visible, is not an option, yet it happens far too often.
BTW- When is the "answer" going to be posted?
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Re: Wrist Injury #2 - December 21, 2004 8:06:00 AM
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UTDC
Posts: 222
Joined: December 21, 2003
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[IMG]http://img.photobucket.com/albums/v317/utdc/IM000057.jpg[/IMG]
Ok, now that I have figued out the technology invloved, I can post this update (thanks for your patience). I decided to obtain a CT of the wrist because:
1. There was a mechanism for fracture
2. The patient's presentation was appropriate for fracture (lack of response to conservative therapy, painful crepitus)
If you would like to comment on this study and the possible complications of this particular injury, I will post the results and conclusion.
Thanks,
Jeff
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Re: Wrist Injury #2 - December 21, 2004 2:09:00 PM
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SJBird55
Posts: 2362
Joined: May 10, 2004
From: Michigan
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Looks like there's a problem now.
So... which bone was it? And sure, you always need to follow up with the rest of the information if you know it.
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Re: Wrist Injury #2 - December 22, 2004 6:02:00 AM
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cneup
Posts: 26
Joined: August 6, 2003
Status: offline
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Random guess: Lunate? Hard to tell since you can't see the rest of the wrist for landmarks
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Re: Wrist Injury #2 - December 22, 2004 6:19:00 AM
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fapt
Posts: 58
Joined: October 22, 2004
From: Taiwan, R.O.C.
Status: offline
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capitate bone?
i guess. I don't know if it is right?
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夏之日，冬之夜，百歲之後，歸于其居。
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Re: Wrist Injury #2 - December 22, 2004 7:20:00 AM
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UTDC
Posts: 222
Joined: December 21, 2003
Status: offline
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[IMG]http://img.photobucket.com/albums/v317/utdc/IM000059.jpg[/IMG]
Another view
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Re: Wrist Injury #2 - December 22, 2004 7:32:00 AM
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VagusX
Posts: 212
Joined: March 26, 2003
From: Savannah, GA, USA
Status: offline
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Looks like a bunson burner flame. I'm guessing lunate because of the concavity of the most inferior bone on the image (ulna?).
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Re: Wrist Injury #2 - December 22, 2004 9:27:00 AM
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gilbert thomson
Posts: 24
Joined: November 17, 2003
From: Elka Park, NY USA
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On the initial plain film radiographs, on the first oblique view, does anyone else think there might be a tiny fracture in the middle of the scaphoid? Was there tenderness to palpation in the "anatomical snuffbox" area?
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Re: Wrist Injury #2 - December 22, 2004 4:30:00 PM
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UTDC
Posts: 222
Joined: December 21, 2003
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OK Folks, looks like it's time to wrap this one up.
I must confess to a bit of trickery. The initial radiographs were 100% normal. I used this case as an example for a couple of reasons.
#1 A normal plain film xray in the context of a suspicious clinical presentation should lead to advanced imaging. CT, MRI and bone scans are many times more sensitive than xray.
#2 Open growth plates in the context of trauma can be a diagnostic (imaging) challenge.
#3 In a setting where all of the studies are abnormal (such as here), the experience ends up not being very realistic. In reality, a significant % of studies come back unremarkable.
The CT confirmed my suspicion of a mid carpal fracture, this is a comminuted lunate fracture. Fortunately, I was able to get the patient into a well known hand surgeon at the Steadman Hawkins clinic in Colorado. Unfortunately for the patient, this injury has most likely derailed his chances for a professional golfing career.
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Re: Wrist Injury #2 - December 22, 2004 5:47:00 PM
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UTDC
Posts: 222
Joined: December 21, 2003
Status: offline
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Keinbock's (sp?) disease is AVN of the lunate and can be a complication of such a fracture.
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Re: Wrist Injury #2 - December 22, 2004 5:49:00 PM
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UTDC
Posts: 222
Joined: December 21, 2003
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If you recall the timeline of the events, the patient suffered the trauma and was then treated with carpal mobilizations and a manipulation which most likely complicated the picture.
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Re: Wrist Injury #2 - December 29, 2004 6:11:00 PM
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UTDC
Posts: 222
Joined: December 21, 2003
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[IMG]http://img.photobucket.com/albums/v317/utdc/IM000060.jpg[/IMG]
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