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. Subsequent assessment confirms a nondisplaced scaphoid fracture. The patient is managed by a short arm cast and returns to his physician for follow-up in 2 weeks. Inadequate management of this injury is most likely to produce which of the following potential complications?

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. Subsequent assessment confirms a nondisplaced scaphoid fracture.  The patient is managed by a short arm cast and returns to his physician for follow-up in 2 weeks.  Inadequate management of this injury is most likely to produce which of the following potential complications?

Quizplus · Accepted Answer

Explanation: Scaphoid fractures are most commonly complicated by nonunion and avascular necrosis. The arterial blood supply to the scaphoid enters in the distal pole and travels to the proximal pole. Scaphoid fractures (particularly at the waist and proximal end of the scaphoid) can compromise the blood supply, causing avascular necrosis and increasing the risk of nonunion in up to 10% of cases. As a result, proximal fractures of the scaphoid require longer immobilization (up to 12 weeks) for adequate healing. Other factors that cause nonunion include delay of care, an unstable fracture fragment, and delay in surgical treatment when indicated. (Choice A) Acute carpal tunnel syndrome is a possible early complication in patients with a displaced or comminuted distal radial (Colles) fracture that has been treated with multiple reductions or splinted in extreme wrist flexion. (Choice B) Complex regional pain syndrome (CRPS) can occur as a complication of a distal radial fracture and in patients with wrist fracture splinted with palmar flexion >15 degrees. Early mobilization and vitamin C have been recommended to reduce the incidence of CRPS. (Choice C) Dupuytren contracture is characterized by progressive fibrosis of the palmar fascia of unknown etiology. It is associated with diabetes mellitus, exposure to repetitive vibration to the hands, CRPS, alcohol consumption, and occasionally malignancy. (Choice D) Malunion is more commonly seen in physeal fractures of the distal forearm in children (less common in adults) due to injury of the growth plate and growth arrest; this causes growth disparity between the radius and ulna and results in possible wrist deformity. Educational objective: Scaphoid fractures that are not treated appropriately or in a timely fashion can result in avascular necrosis and increase the risk of nonunion.

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