SplintER Series: Pain in the Snuff Box

Scaphoid Fracture
 
A 16-year-old male presents to the ED after injuring his wrist during a track meet. The patient was running hurdles when he fell forward, planting his wrist into the ground. The imaging is shown below (courtesy of Dr. Hani Makky ALSALAM, Radiopaedia.org).
Scaphoid fracture (Image 2).

  • Pearl: The scaphoid is the most frequently fractured carpal bone [1,2].
  • Pearl: Fractures occur at the waist, proximal third, and distal portion: 65%, 25%, and 10% respectively [3].

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].

Snuff Box

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.

  • Pearl: There is also a scaphoid view that is recommended if the department technician is trained. This image is a posterior-anterior view of the scaphoid that is obtained with the wrist in ulnar deviation [7].

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].

  • Pearl: Initial imaging can miss 5-20% of fractures [8].

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].

  • Pearl: AVN is of high concern and directly correlated to the site of fracture. The scaphoid receives blood supply via retrograde flow – the more proximal the fracture, the higher the risk of AVN [1-4,6].
  • Pearl: SNAC occurs when the proximal scaphoid remains attached to the lunate and the distal fragment rotates into flexion. This results in early osteoarthritis between the distal scaphoid and radial styloid, leading to pain and decreased functionality [9].

 

References & Resources:

For a review of other causes of traumatic wrist pain check out the SplintER archives.

  1. Tada K, Ikeda K, Okamoto S, Hachinota A, Yamamoto D, Tsuchiya H. Scaphoid Fracture–Overview and Conservative Treatment. Hand Surg. 2015;20(2):204-209. PMID 26051761.
  2. Sabbagh MD, Morsy M, Moran SL. Diagnosis and Management of Acute Scaphoid Fractures. Hand Clin. 2019;35(3):259-269. PMID 31178084.
  3. Gupta V, Rijal L, Jawed A. Managing scaphoid fractures. How we do it?. J Clin Orthop Trauma. 2013;4(1):3-10. PMID 26403769.
  4. Basu A, Lomnassey LM, Demos TC, et al: Your Diagnosis? scaphoid fracture. Orthopedics 28:177, 2005. PMID 15751361
  5. Watson HK, Weinzweig J. Physical examination of the wrist. Hand Clin. 1997;13(1):17-34. PMID 9048180.
  6. Stapczynski, JS, Tintinalli, JE. Wrist injuries. In Tintinalli’s emergency medicine: A comprehensive study guide, 8th Edition. New York, NY: McGraw-Hill Education; 2016: 1853-1854
  7. Cheung GC, Lever CJ, Morris AD. X-ray diagnosis of acute scaphoid fractures. J Hand Surg Br. 2006;31(1):104-109.PMID 16257481.
  8. Ashmead D 4th, Watson HK, Damon C, Herber S, Paly W. Scapholunate advanced collapse wrist salvage. J Hand Surg Am. 1994;19(5):741-750. PMID 7806794.
  9. Moritomo H, Tada K, Yoshida T, Masatomi T. The relationship between the site of nonunion of the scaphoid and scaphoid nonunion advanced collapse (SNAC). J Bone Joint Surg Br. 1999;81(5):871-876. PMID: 10530853.
  10.  

SplintER Series: A Case of Inability to Move the Knee

Normal knee radiograph

29-year-old F presents to ED with acute onset knee pain. Reports hearing an audible “pop” after twisting her leg while running down the stairs at home. She explains that her right knee is stuck, and she can neither flex nor extend it. An image is shown below (courtesy of Andrew Murphy, Radiopaedia.org)

 

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SAEM Clinical Image Series: Knee Pain

knee

A fifty-six-year-old male with a past medical history of legal blindness and remote right quadricep tendon rupture presents to the emergency department via emergency medical services (EMS) after a mechanical fall, complaining of left knee pain. According to the patient, he is in his regular state of health and was walking with his cane when he had a mechanical fall on the sidewalk after tripping on an unknown object and falling onto his left knee.

The patient did not hit his head, did not lose consciousness, and has no head, neck, or back pain. The patient states that he fell directly onto his knee and felt a popping upon hitting the ground, and remembers all events surrounding the incident. The patient was not ambulatory prior to coming to the emergency department.

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SplintER Series: A Collision at the Plate

Proximal avulsion fracture

A 17-year-old male baseball catcher presents with right knee pain after an opponent slid into home plate, striking the anteromedial aspect of the patient’s knee while it was in extension trying to block the plate. An x-ray of the tibia and fibula was obtained (courtesy of Dr. Haytham Bedier, Radiopaedia.org).

This is a proximal avulsion fracture of the styloid process of the fibula, indicating injury to the posterolateral corner (PLC) of the knee [1].

  • Pearl: In most cases, the avulsed fragment is attached to the lateral collateral ligament and/or the biceps femoris [2].

This injury usually occurs from varus stress in a hyperextended knee- think a blow to the anteromedial tibia with the knee in extension [2].

The arcuate sign is a horizontal linear lucency through the head of the fibula that represents a fracture of the styloid process [3].

  • Pearl: This injury may be confused with a Segond fracture, which is a small avulsion fracture fragment from the lateral tibial plateau associated with anterior cruciate ligament injury.

A proximal fibular avulsion fracture is commonly associated with injury to the posterior cruciate ligament, anterior cruciate ligament, popliteus, or meniscus. It is frequently seen with bone contusions and sometimes a tibial plateau fracture [2].

  • Pearl: Injury to the common peroneal nerve may occur as well. Remember to perform a thorough neurovascular examination [1].
  • Pearl: This fracture is a sign of posterolateral instability and likely internal derangement of the knee. Outpatient MRI can be used to evaluate the soft tissue components of the injury and diagnose associated injuries [2].

This injury indicates potential significant instability of the knee and requires outpatient follow-up with MRI. Operative management will be dictated on an individual basis, after evaluating MRI results. In the emergency department, place the patient in a knee immobilizer and recommend non-weight-bearing status until further imaging. Follow-up with orthopedics or sports medicine within 1 week.

  • Pearl: As always, perform a thorough neurovascular examination and consult orthopedics immediately if there is evidence of compromise. If your exam demonstrates significant instability and you are concerned about a spontaneously-reduced knee dislocation, consider ankle-brachial indices and/or further vessel imaging.

If diagnosis of this injury is delayed, posterolateral instability may develop. If not recognized and managed appropriately, this may hinder the success of a cruciate ligament reconstruction [1].

 

References and Resources:

Want more information about the knee exam? Check out the SplintER archives.

  1. Shon OJ, Park JW, Kim BJ. Current concepts of posterolateral corner injuries of the knee. Knee Surg Relat Res. 2017;29(4):256-268. PMID: 29172386
  2. Juhng SK, Lee JK, Choi SS, Yoon KH, Roh BS, Won JJ. MR evaluation of the “arcuate” sign of posterolateral knee instability. Am J Roentgenol. 2002;178(3):583-588. PMID: 11856678
  3. Strub WM. The arcuate sign. Radiology. 2007; 244(2):620-621. PMID: 17641383

SplintER Series: A Pain in the Elbow

Little League Elbow

A 12-year-old male pitcher for a traveling club baseball team complains of acute worsening of right elbow pain that has been bothering him for 3 months. The radiograph is shown below (Frontal elbow view. Case courtesy of Dr. Levente István Lánczi, Radiopaedia.org, rID: 46853). What is your diagnosis? What causes this injury? What patient demographic is most susceptible to this injury? How can this injury be prevented? What is the management of this injury in the Emergency Department?

 

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Announcing ALiEMU SplintER Course: Approach to Splinting

ALiEMU Course Approach to Splinting badge

We are so thrilled to announce that we created an ALiEMU Course on the Approach to Splinting, using one of our most popular series, the SplintER Series, as the learning foundation. We have created a custom quiz assessing the learning objectives. Are you a medical student getting ready for your EM rotation or internship? Or an EM resident needing to brush up on your splinting knowledge? Take this free course for 2 hours of ALiEMU course credit, and receive your “Approach to Splinting” badge.

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By |2020-09-05T17:26:39-07:00Sep 9, 2020|ALiEMU, Orthopedic, SplintER|

SplintER Series: An Easily Missed Shoulder Injury

posterior shoulder dislocation xray

A 30-year-old male presents with right shoulder pain after a motorcycle accident. You obtain shoulder x-rays and see the following images (Image 1: AP, scapular Y, and axillary views of the right shoulder. Author’s own images). What is the most likely diagnosis, typical mechanism of injury, expected physical exam findings, appropriate imaging modalities, and management plan?

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