WIDI - M8) Fall on an outstretched hand

M8) Fall on an outstretched hand

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with hand pain.
Review the DDx considerations in patients with hand pain.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with hand pain.

History

A 25-year-old man presents to the ED after falling on an outstretched hand during his morning jog. He reports focal tenderness on the radial aspect of his right wrist just proximal to his thumb metacarpal and pain with circumduction of the wrist.

Physical Exam

BP: 115/75, HR 65, RR 12, Temp 37C, O2 saturation 99%. General: Well developed male appears mildly uncomfortable. MSK: Mild swelling at the proximal radial aspect of the hand. Palpation discloses point tenderness in the anatomical snuffbox. Right grip strength is reduced compared to the left secondary to pain.

Labs

None.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Distal radius fracture

De Quervain's Tenosynovitis

Scaphoid fracture

First metacarpal fracture

The patient most likely has a scaphoid fracture considering the mechanism of injury (fall on an outstretched arm) and physical exam findings of pain and swelling in the anatomic snuffbox.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient will require prioritized workup and management.

First Imaging Study

What is the first imaging study you will order?

Wrist CT

Wrist MRI

Wrist X-rays

Standard plain films of the wrist including the posteroanterior (PA), true lateral, oblique and scaphoid views are the best initial imaging modality to assess for a suspected scaphoid fracture. They are quick and relatively inexpensive, but may be equivocal in the acute setting.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Right hand x-rays

The carpal bones are malaligned or dislocated.

Yes

The carpal bones are in their normal anatomic position. There is no evidence of a lunate dislocation, for example.

There is evidence of an acute fracture.

Yes

There is a minimally displaced fracture scaphoid bone.

The fracture is at which part of the scaphoid?

Distal

Waist

Proximal

N/A

The fracture occurs at the proximal pole of the scaphoid bone.

View Report

Watch our video

View the full study if you'd like to take a look yourself.

Launch Dicom

Second Imaging Study

What is the next imaging study you will order?

Wrist CT

Wrist MRI

None

No further imaging is needed as the diagnosis is confirmed with the initial hand x-rays.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Scaphoid fracture

Avascular necrosis

Both A and B

The patient’s history, physical exam, and imaging findings are consistent with a diagnosis of an acute scaphoid fracture. While it may occur if left untreated, there are no signs or imaging findings to suggest avascular necrosis.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient will require prioritized workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 25-year-old male presenting with an acute, minimally displaced fracture of the proximal pole of his right scaphoid bone. Given the elevated risk for neurovascular compromise and nonunion in a proximal pole fracture, the patient will be referred to a hand surgeon to undergo evaluation for operative intervention.

Lessons Learned:
- Scaphoid fracture is an important diagnostic consideration in a patient with wrist pain following a fall on an outstretched hand.
- Anatomic snuffbox tenderness is the most sensitive physical examination finding for a scaphoid fracture.
- A fracture of the proximal pole of the scaphoid places a patient at an elevated risk of avascular necrosis due to arterial supply to the scaphoid entering distally and feeding proximally.
- X-rays of the hand are the initial imaging modality of choice in a suspected scaphoid fracture.

Socioeconomic Factors: Hand trauma care is considered suboptimal in the United States because of the severe on-call hand-specialist shortage.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Jordan Turetsky, MS4 - Content Contributor
Khalida Clark - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator