Endgames Picture Quiz

A young man with wrist pain

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4466 (Published 13 July 2012) Cite this as: BMJ 2012;345:e4466
  1. Hamoun Rozati, foundation year 1 trainee, trauma and orthopaedics,
  2. Zahra N Jaffer, foundation year 1 trainee, trauma and orthopaedics,
  3. Nawfal Al-Hadithy, core trainee year 2, trauma and orthopaedics
  1. 1Lister Hospital, Stevenage, SG1 4AB, UK
  1. Correspondence to: H Rozati h.rozati{at}nhs.net

A 24 year old left handed builder presented to the emergency department after falling on to an outstretched hand two days ago while playing football. Since then he had been experiencing increasing pain in his wrist.

He was otherwise fit and well with no medical problems.

On examination his wrist was tender in the anatomical snuff box. He was neurovascularly intact distally and had a full range of movement. There was increased pain on dorsiflexion but no obvious swelling, bruising, or deformity. He had no other injuries.

A radiograph was taken of his right wrist (fig 1).

Questions

  • 1 Describe the radiographic image. What is the diagnosis?

  • 2 What clinical tests support this diagnosis?

  • 3 How would you initially manage this patient?

  • 4 How would you manage this patient in the longer term?

  • 5 What complications might be expected?

Answers

1 Describe the radiographic image. What is the diagnosis?

Short answer

This is an anterioposterior radiograph of the right wrist showing a fracture of the waist of the scaphoid, which appears undisplaced.

Long answer

This is an anterioposterior radiograph of the right wrist showing a fracture of the waist of the scaphoid, which appears undisplaced.

The scaphoid bone lies radially in the proximal carpal row and is the most commonly fractured carpal bone.1

Three fracture sites of the scaphoid are commonly recognised (fig 2):

  • Fractures through the waist (the narrowest part of the scaphoid and the most commonly injured part)

  • Fractures through the proximal pole

  • Fractures through the tubercle.1

Fig 2 Anterioposterior radiograph of the right wrist showing the three sites of fracture of the scaphoid: (A) a fracture of the tubercle, (B) a fracture through the waist of the scaphoid, and (C) a fracture of the proximal pole

The rates at which these sites are fractured are 70%, 20%, and 10%, respectively.2

Although the fracture does not …

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