A 23-year-old man comes to the office due to right wrist pain. Earlier today, while running to home plate during a baseball game, he landed forcefully on his outstretched right hand with the palm facing down. Since then, the patient has had right wrist pain and swelling. He has had partial relief with acetaminophen and local application of ice packs, but the pain still limits his activities. The patient's medical history is unremarkable. Vital signs are normal. Physical examination shows mild swelling at the dorsum of the right wrist. There is maximal tenderness proximal to the base of the first metacarpal, and the pain worsens with radial deviation of the wrist. Radiographs of the wrist in multiple views reveal no fracture or dislocation. Which of the following is the most appropriate next step in management of this patient?

Question

A 23-year-old man comes to the office due to right wrist pain.  Earlier today, while running to home plate during a baseball game, he landed forcefully on his outstretched right hand with the palm facing down.  Since then, the patient has had right wrist pain and swelling.  He has had partial relief with acetaminophen and local application of ice packs, but the pain still limits his activities.  The patient's medical history is unremarkable.  Vital signs are normal.  Physical examination shows mild swelling at the dorsum of the right wrist.  There is maximal tenderness proximal to the base of the first metacarpal, and the pain worsens with radial deviation of the wrist.  Radiographs of the wrist in multiple views reveal no fracture or dislocation.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d2c6_97f1_bc81_db3ee798f3d1_MD0003_00 Scaphoid fractures are the most common carpal bone fractures. They frequently result from falls onto an outstretched hand that cause axial compression or wrist hyperextension. The arterial supply to the scaphoid (from the radial artery) enters through foramina in the bone's distal pole before proceeding to the proximal pole; scaphoid fracture can disrupt flow to the proximal segment, leading to avascular necrosis and nonunion. Scaphoid fractures Scaphoid fractures are characterized by tenderness in the anatomic snuffbox, a finding that has high sensitivity for fracture and warrants additional evaluation with imaging. The snuffbox is a 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. snuffbox X-ray at the time of injury has low sensitivity for scaphoid fracture. Therefore, if initial x-rays are negative, CT scan or MRI of the wrist is recommended to confirm the fracture. As an alternative, the wrist can be immobilized briefly in a thumb spica splint, followed by repeat imaging in 7-10 days. Either approach can be considered; repeat x-ray is associated with lower up-front costs, whereas MRI may allow for earlier return to normal activity. (Choice A) Nondisplaced scaphoid fractures are usually managed with cast immobilization. Physical therapy may assist in return to activity following casting but is not recommended as part of initial management. (Choice B) Corticosteroid injections are used in the short-term treatment of joint inflammation and bursitis but are not appropriate for fractures as they can impede healing. (Choice C) Tendon injuries are typically acquired in penetrating injuries or extreme loading of a digit (eg, "jamming" a finger while trying to catch a ball). This patient's fall on an outstretched hand is unlikely to cause tendon injury. (Choice D) Synovial fluid analysis is appropriate for evaluating inflammatory, crystalline, or infectious arthropathies. It is rarely useful in acute traumatic injury. Educational objective: Arterial supply to the scaphoid enters at the distal pole; fracture can disrupt flow to the proximal segment, leading to avascular necrosis and nonunion. Nondisplaced fractures may not be immediately visible on x-ray. If initial x-rays are negative, CT scan or MRI is recommended, or the wrist should be immobilized and x-rays repeated after 7-10 days. References: Scaphoid fractures. (http://www.ncbi.nlm.nih.gov/pubmed/25455395)

A 23-Year-Old Man Comes to the Office Due to Right