A 54-year-old woman comes to the office due to left wrist pain 3 days after a fall. She was walking her dog when it suddenly ran after another dog, causing her to fall. She landed forcefully on her left palm. She had no other injuries. The patient has been taking acetaminophen, which provides partial relief. She does not use tobacco or illicit drugs and drinks alcohol socially. Blood pressure is 120/70 mm Hg and pulse is 84/min. Physical examination shows left wrist tenderness with maximal tenderness at the dorsoradial wrist lateral to the tendon of the extensor pollicis longus. Left wrist radiographs reveal a radiolucent line across the waist of the scaphoid bone. She is treated nonsurgically with analgesics and immobilization. This patient should be monitored closely during treatment due to which of the following potential complications?

Question

A 54-year-old woman comes to the office due to left wrist pain 3 days after a fall.  She was walking her dog when it suddenly ran after another dog, causing her to fall.  She landed forcefully on her left palm.  She had no other injuries.  The patient has been taking acetaminophen, which provides partial relief.  She does not use tobacco or illicit drugs and drinks alcohol socially.  Blood pressure is 120/70 mm Hg and pulse is 84/min.  Physical examination shows left wrist tenderness with maximal tenderness at the dorsoradial wrist lateral to the tendon of the extensor pollicis longus.  Left wrist radiographs reveal a radiolucent line across the waist of the scaphoid bone.  She is treated nonsurgically with analgesics and immobilization.  This patient should be monitored closely during treatment due to which of the following potential complications?

Quizplus · Accepted Answer

This patient has a fracture of the scaphoid, the most commonly fractured carpal bone. Scaphoid fractures typically present with pain at the radial wrist proximal to the base of the thumb. Examination shows tenderness in the shallow depression at the dorsoradial wrist bounded medially by the tendon of the extensor pollicis longus and laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis ("anatomic snuffbox"). Scaphoid fractures carry a significant risk of osteonecrosis because the blood supply enters at the distal pole and flows proximally, and can be disrupted by the fracture. "anatomic snuffbox" blood supply Initial x-rays can be normal in nondisplaced scaphoid fractures. If scaphoid fracture is suspected, CT scan or MRI can confirm the diagnosis, or repeat x-rays can be performed in 7-10 days. Displaced fractures should be considered for surgical intervention. Wrist immobilization with a cast can be considered for nondisplaced fractures, but patients should be monitored with serial x-ray to rule out osteonecrosis of the proximal segment and nonunion of the fracture. (Choice A) Bacterial tenosynovitis typically occurs following penetrating injury to the hand (eg, cat bite) or from hematogenous spread of a distant infection (eg, Neisseria gonorrhoeae). (Choice B) Fat embolism is most common following major fracture of long bones (eg, femur) or extensive soft-tissue injury (eg, burns). (Choice C) Synovial cysts of the wrist (ganglion cysts) are most common in individuals age 15-40 and are thought to arise in most cases due to repetitive stress or inflammation. (Choice D) Lunate dislocation following a fall on an outstretched hand can cause compressive neuropathy of the median nerve. Nerve injury is not common following scaphoid fracture. Educational objective: Displaced scaphoid fractures should be considered for surgical intervention. Wrist immobilization with a cast can be considered for nondisplaced fractures, but patients should be monitored with serial x-ray to rule out osteonecrosis of the proximal segment and nonunion of the fracture. References: Scaphoid fractures. (http://www.ncbi.nlm.nih.gov/pubmed/25455395)

A 54-Year-Old Woman Comes to the Office Due to Left