A 40-year-old male comes to your office with pain over the lateral aspect of his right elbow. On examination there is tenderness over his right lateral epicondyle, which is pronounced with wrist extension.
Which one of the following would be the most appropriate basis for making the diagnosis in this patient?
Correct Answer A: This case is a typical presentation of lateral epicondylitis (tennis elbow). This condition is a clinical diagnosis and imaging or other tests are not necessary.
A 20-year-old man falls onto his outstretched left hand. On examination, there is pain on deep palpation at the base of the thumb.
Which one of the following bones is most likely fractured?
Correct Answer C: A fall on an outstretched arm often results in a fracture of the scaphoid (navicular) bone in the wrist. This small bone is one of 8 carpal bones in the wrist. The scaphoid sits below the thumb, and is shaped like a kidney bean. This complex bone has a unique and limited blood supply that can be easily disrupted by a fracture.
If there is pain or deep aching on the thumb-side of the wrist, typically after a fall on an outstretched arm, the patient likely has a scaphoid fracture.
Other symptoms include swelling in the wrist, difficulty gripping objects, and tenderness or pain in the anatomical snuff box (a sunken space between tendons of the wrist). Many patients are diagnosed with a wrist sprain, when they actually have a fracture. Diagnosis is difficult because the fracture often doesn't appear on x-rays until weeks later, after healing has begun. Because of this, it is common for physicians to treat a wrist injury as though it were a scaphoid fracture initially, and then repeat x-rays within two weeks.
You see a 30-year-old male who has just fallen on an outstretched hand. He complains of wrist pain and edema. Examination reveals tenderness over the anatomic snuffbox and over the scaphoid tubercle at the proximal wrist crease with the hand in extension. Radiographs of the wrist are negative.
Which one of the following would be the most appropriate action at this point?
Correct Answer D: Snuffbox tenderness and tenderness over the scaphoid tubercle are very sensitive for fracture of the scaphoid, but their specificity is only 40% and 60% respectively. Therefore, while the lack of tenderness at these sites almost rules out fracture, further imaging is needed in positive cases. Plain films are recommended as the next step. A bone scan or follow-up films after immobilization for 2 weeks should be done if the initial films are negative. Bone scans may be negative until enough time has passed for osteoblastic activity to begin. Ultrasonography is not helpful for evaluation of scaphoid fractures.
Note: A fracture may not be radiologically evident up to 2 wks after acute injury, so if a patient complains of wrist pain and has anatomical snuffbox tenderness but a negative x-ray, scaphoid fracture should be suspected and his/her hand should be splinted and repeat x-ray 2 wks later to rule out a fracture. If x-ray still negative order CT or MRI. Until a definitive diagnosis is made, the patient should remain splinted to prevent movement of a possible fracture.
A 30-year-old female sees you after a fall on her outstretched hand. Examination reveals tenderness to palpation of the anatomic snuffbox, with no swelling. Radiographs of the hand, wrist, and distal forearm are negative.
Which one of the following would be most appropriate at this time?
Correct Answer A: This patient is at high risk for a scaphoid fracture. It is unlikely to be visible on a radiograph initially unless it is displaced. It is more likely to be apparent in 2 weeks. The injury will not heal well if it is not immobilized and can be a cause of chronic pain and disability. Immobilization for 6 weeks would be excessive if the injury turned out to not be a fracture, and would lead to stiffness in the wrist.
A 32-year-old male comes to your office for the second time for wrist pain following a fall on the ice 10 days ago. At his first visit, examination of the wrist showed no deformity or swelling, but extension was decreased and he had diffuse tenderness over the dorsum of the wrist, particularly just distal and dorsal to the radial styloid.
Which one of the following do the radiographs reveal?
Correct Answer B: A dorsiflexion injury will typically cause a scaphoid fracture in a young adult, resulting in tenderness to palpation over the anatomic snuffbox. Often the plain posterior-anterior wrist radiograph is normal. However, a special view with the wrist prone in ulnar deviation elongates the scaphoid, often demonstrating subtle fractures. Hook of the hamate fractures cause tenderness at the proximal hypothenar area 1 cm distal to the flexion crease of the wrist. When this fracture is suspected, carpal tunnel and supinated oblique view radiographs should be obtained. A scapholunate dislocation can be identified with a “clenched-fist” view and the supinated view in ulnar deviation.
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