drk1980
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A young man comes to you 2hours after a hard fall on his right hand. Chief complaint is right wrist pain whcih aggravates on movement. P/E shows tenderness in right anatomical snuff box. Xray of right wrist shows no evidence of fracture in scaphoid bone. Your "immediate next step in management" should be which of the following?
1) Long arm cast for 4 weeks and physiotherapy soon after.
2) Send home on analgesics and repeat xray in 15 days.
3) Bone scan or CT scan to evaluate better the presence of fracture.
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| som
Forum Guru
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scaphoid # are easily missed on initial x-rays...so i go with 1)with the given options
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| drk1980
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som, you are right. and you wud hv been right again even if u chose option 2...
UW has two separate Qs, wth a similar scenario, but different options. In one the 1st was the correct ans and in anthr the 2nd!
Wanted to know what everyone else thot abt this...
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| achilles
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from the history and xray findings it seems that its an undisplaced scaphoid fracture and thus thumb spica cast is indicated(and in some cases even based only on history and physical findings). in such a case xray will show fracture about 2-3 wks after.
and if the fracture is displaced then open reduction and internal fixation is needed. i dont think sending home on analgesics and xray 15 days later should be right in any situation.
what were the options in the other question drk1980.
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| drk1980
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Let me just go over the 2 Q scenarios..
In the Q above where the xray is normal the answer is Long Arm Cast.
In another Q, the Xray pic showed a radioluscent line across the waist of the scaphoid bone. The right answer was Cast immobilization for 6-12 weeks. And the explanation went: ..
"initial xrays maybe normal or show fine radioluscent line in non-displaced fractures. Cast immobilization is recommended in the treatment of all non-displaced fractures (<2mm displacement and no angulation)." But then in explaining another option it says,.."Sending the patient home with analgesics and repeat Xray after 15days would have been an appropriate choice had his initial xray been normal/showed no fracture."
I realise in the USMLE, scaphoid bone point tenderness means stick the arm in a cast. But wht abt the above contradictory statements?....i guess maybe iam just being nitpicky abt this! ;-p
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| webjeee
Forum Guru
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P/E shows tenderness in right anatomical snuff box, almost 100% sure the diagnosis, start the splint first please. 3-4w xr will show a fracture line, very thin though. immobilization is mandatory, especially for active patient.
usually, without displacement, if any, further op, nonunion rate still high.
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| goodyear
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UW said that always assume that there's a fracture if scaphoid is involved that's why they do long arm cast for 6-12 weeks. Plus if you do the xray right after the accident it won't show any fracture, usually shows up afte 2 weeks.
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