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Analgesia with restricted activity and lifting
32%
12/37
Analgesia with casted immobilization for 6 weeks
57%
21/37
Wrist MRI
5%
2/37
Physical therapy
0%
0/37
Surgical exploration
Select Answer to see Preferred Response
This patient most likely has a scaphoid fracture, even with a negative radiograph, which is not a sensitive test immediately after trauma. The best option is a long thumb spica cast for 6 weeks. The scaphoid is the most commonly fractured carpal bone, most often as result of a fall on outstretched hand. This fracture is seen mainly in young adults as in older adults the point of fracture is the distal radius (Colle's fracture). This fracture requires a high index of suspicion, as clinicians must assume there is a fracture if there is tenderness in the anatomical snuff box. An radiograph may take up to two weeks to show a fracture. Scaphoid fracture complications include avascular necrosis (AVN), as a result of the distal to proximal blood supply of the scaphoid bone. Philips et al. discuss the diagnosis and management of scaphoid fractures. They note that anatomic snuffbox tenderness is a highly sensitive test for scaphoid fractures. Nondisplaced distal fractures generally heal well with casting, which typically includes the thumb, but it may not be necessary. Murthy discusses the role of MRI in scaphoid fractures, stating that If the initial post-injury radiographs are inconclusive, MRI provides an immediate diagnosis, if one is needed, as in the case of athletes. An added benefit in the cases in which no scaphoid fracture is present, is the ability to allow for alternative diagnoses such as identification of other fractures, osseous contusions, and soft tissue injuries. CT is a reasonable alternative if MRI is contraindicated. Illustration A displays an wrist radiograph with a scaphoid fracture noted by the arrow. Illustration B displays the anatomy of the wrist and the anatomical snuff box. Incorrect Answers: Answer 1: Immobilization is required to prevent AVN and non-union. Answer 3: MRI or Bone scan is useful for athletes that require definitive diagnoses, but this patient is not an athlete. Answer 4: Immobilization is required to prevent AVN and non-union. Answer 5: Surgical treatment (ORIF) is only required for displaced fractures, which would have been seen on radiograph.
2.3
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