Review Question - QID 108421

This patient is presenting with right wrist pain and tenderness in the anatomic snuff box after a fall onto an outstretched right hand. This presentation is suggestive of a scaphoid fracture.

Scaphoid fractures often occur after a fall onto an outstretched hand. Patients will frequently have pain with or without mild swelling around the wrist. Tenderness at the anatomic snuff box, the anatomic space between the tendons of the extensor pollicus longus, extensor pollicus brevis, and abductor pollicus longus, is a specific sign for scaphoid fracture. Due to a retrograde blood supply, fractures of the proximal scaphoid are at high risk of avascular necrosis or fracture non-union as the blood supply may be compromised as a result of the injury. The most appropriate first step in evaluation of a suspected scaphoid fracture is a plain radiograph of the affected wrist to visualize the fracture. Initial radiograph often fails to detect fracture when present. In this case, a thumb spica splint should be placed with repeat radiograph in 7-10 days.

Clementson et al. discuss the diagnosis and clinical management of suspected scaphoid fractures. They recommend plain radiographs of the wrist as the most appropriate initial step in management. They also discuss the management of negative initial radiographs and subsequent follow-up studies.

Incorrect Answers:
Answer 1: Conservative management with rest and ibuprofen may be appropriate for a simple sprain of the wrist without associated fracture. Given this patient's concerning mechanism of injury and exam, scaphoid fracture must first be ruled out.

Answer 2: CT scan of the right upper extremity may be used in subsequent management of scaphoid fracture with a negative initial radiograph. It is not the most appropriate initial study and should not precede a radiograph of the wrist.

Answer 3: Placement of a thumb spica splint, with repeat radiograph in 7-10 days, would be the most appropriate next step for a suspected scaphoid fracture with negative initial radiographs. An initial radiograph should be performed at the time of presentation.

Answer 5: Referral for physical therapy would not be appropriate in this patient with a likely scaphoid fracture. Physical therapy may be appropriate for chronic wrist pain related to a sprain injury.

Bullet Summary:
For patients with a clinical presentation concerning for scaphoid fracture, evaluation should begin with a plain radiograph of the affected wrist.