An 18-year-old male presents with a painful and swollen left thumb. He removed a splinter from his finger a few days ago however, 2 days after removal, he began to experience edema and pain that has progressively gotten worse. An image of his finger is shown above (Image 1. Picture courtesy of Rosh Review [1]).
Figure 1. Case courtesy of Dr Hani Makky ALSALAM, Radiopaedia.org, rID: 8720
Stress fracture at the distal tibial metaphysis – note the faint sclerotic line at the tibial metaphysis (Figure 2).
Figure 2. Arrows identifying the stress fracture. Case courtesy of Dr. Hani Makky Al Salam, Radiopaedia.org, rID: 8720
When coupled with the amenorrhea, consider the female athlete triad.
Plain film ankle views should be obtained. If a stress fracture is acute, sensitivity on plain films can be as low as 10% [6]. MRI can be performed outpatient with a sensitivity approaching 100% [4,5,7,8]. A pregnancy test should be performed as well given the amenorrhea. A standard workup for amenorrhea should be performed as an outpatient. Inquire about eating habits and anxiety/depression.
The three components of the female triad are on a spectrum of severity in the disruption of bone mineral density/osteoporosis, menstrual dysfunction/dysmenorrhea, and low energy with or without an eating disorder [1,9-11]. Patients will have a degree of dysfunction of all three components.
Stress fracture treatment included rest and analgesics. Immobilization is not necessary, but refraining from activity which exacerbates pain is crucial. NSAIDs may be used for pain control [5,7]. Female athlete triad is multifactorial and outpatient follow up should be ensured. Referral to adolescent medicine, sports medicine, or close primary care follow up is important.
Check out ALiEM’s SplintER Series to brush up on other can’t miss diagnoses of ankle pain.
Image 2. Fracture of scaphoid. Case courtesy of Dr. Hani Makky ALSALAM, Radiopaedia.org, rID: 10398 (arrow added by authors).
Occurs when there is an axial load across hyper-dorsiflexed, pronated and ulnar deviated wrists or from a fall on the outstretched hand (FOOSH) [1-3].
Snuff box tenderness, scaphoid tubercle tenderness over the volar aspect of the wrist, and/or positive scaphoid compression test (pain reproduced with an axial load applied through thumb metacarpal) [4-6].
Image 3. Location of scaphoid tubercle (S) at the base of the thenar eminence (left) and the location of the snuffbox (SB) on the radial aspect of the wrist (right). Images by authors.
Plain film imaging with anterior-posterior, oblique, and lateral views to assess for injury.
Abnormal exam: If not neurovascularly intact or if there is an open fracture, consult orthopedics in the ED.
Identified scaphoid fracture: Thumb spica splint and prompt orthopedic follow-up usually within 1-3 days as though some fractures only require immobilization for treatment; surgery may be required for some fracture patterns [1-3,6].
Suspicion for fracture without radiographic evidence: Place in thumb spica splint and repeat imaging in 14 days to evaluate for occult fracture. If negative again at that time with high clinical suspicion, the patient should have an outpatient MRI [1-3,6].
Classic complications include vascular necrosis (AVN), and scaphoid nonunion advanced collapse (SNAC). Associated fractures and dislocation of the surrounding carpal bones, distal radius, ligamentous disruption may be seen as other pathology occurs secondary to a FOOSH [1-4,6].
For a review of other causes of traumatic wrist pain check out the SplintER archives.
A 48-year-old female presents to the emergency department after a high-speed motor vehicle collision (MVC). She is complaining of left hip pain. Her radiographs are shown (Image 1 courtesy of Dr Ayaz Hidayatov, Radiopaedia.org, rID: 52760). What is your diagnosis? What is the likely mechanism of injury? What physical exam findings are expected? What is your management in the emergency department and when should you consult orthopedics?
