A 25-year-old man comes to the emergency department with pain in his right hand and wrist. A few hours earlier, he fell forward and landed on his outstretched right hand while playing football. He could not continue playing due to intolerable pain. The patient has no other medical problems and does not use tobacco, alcohol, or illicit drugs. Examination shows mild swelling in the dorsum of the right hand with preserved range of motion. Right hand grip strength is reduced. There is severe tenderness on palpation of the radial dorsal aspect of the wrist. An x-ray of the wrist reveals no evidence of dislocation or fracture. After receiving analgesic therapy, the patient reports that the pain in his wrist is almost gone. Which of the following is the most appropriate next step in management of this patient?

Question

A 25-year-old man comes to the emergency department with pain in his right hand and wrist.  A few hours earlier, he fell forward and landed on his outstretched right hand while playing football.  He could not continue playing due to intolerable pain.  The patient has no other medical problems and does not use tobacco, alcohol, or illicit drugs.  Examination shows mild swelling in the dorsum of the right hand with preserved range of motion.  Right hand grip strength is reduced.  There is severe tenderness on palpation of the radial dorsal aspect of the wrist. An x-ray of the wrist reveals no evidence of dislocation or fracture.  After receiving analgesic therapy, the patient reports that the pain in his wrist is almost gone.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Initial plain radiography of a scaphoid fracture may reveal the fracture but may appear normal if the fracture is compressed or minimally displaced. In light of the limited sensitivity of initial x-rays, patients with suspected scaphoid fracture should have additional imaging: fracture MRI (or CT scan) of the wrist Repeat radiographs in 7-14 days Radioscintigraphy bone scan in 3-5 days MRI is the most sensitive test and allows for immediate assessment of a fracture, but is subject to limited availability and high up-front costs. Alternatively, the patient may be placed in a thumb spica splint with repeat x-rays in 7-14 days, but this approach can lead to delayed diagnosis, unnecessary immobilization, and greater follow-up costs. Patients with a confirmed scaphoid fracture should be referred to an orthopedic surgeon if they are found to have associated tilt of the lunate, a fracture displaced >1 mm, nonunion during follow-up, osteonecrosis, or scapholunate dissociation (Choice D). Patients with a nondisplaced fracture who do not meet surgical indications should be placed in a short arm thumb spica cast; serial x-rays should be done in 2-week intervals to monitor healing. (Choice A) Patients with a fracture should have wrist immobilization until there is evidence of radiographic union. However, confirmation of fracture should be obtained first as prolonged immobilization of a minor soft-tissue injury may impede return to normal function. (Choices B and C) Patients in whom a fracture has been definitively ruled out may be managed with light splinting and early mobilization. However, light or full mobilization is not advised in a patient with possible scaphoid fracture. Patients with a confirmed fracture may return to work or resume noncontact sports with a thumb cast, but should have rigid wrist protection for 2 months after cast removal to prevent re-injury. Educational objective: X-rays can initially be negative for nondisplaced scaphoid fractures. Patients with suspected scaphoid fracture should be evaluated further with either an immediate MRI or CT scan, repeat x-ray in 7-14 days, or bone scan in 3-5 days. Nondisplaced fractures should be treated with a short arm thumb spica cast, but other fractures should be referred to an orthopedic surgeon for evaluation. References: Diagnosis of occult scaphoid fractures: a cost-effectiveness analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26582616) Adult scaphoid fracture. (http://www.ncbi.nlm.nih.gov/pubmed/24673666)

A 25-Year-Old Man Comes to the Emergency Department with Pain