Case02

A 23yo playing basketball lands on their outstretched hand on the palmer side. The hand was sore for most of the day and the patient went to the emergency room for an x-ray which showed no fractures. The emergency room indicated there was no bony injury and sent the patient home. Several days later there is still considerable pain that is not getting better the patient presents to physiatrist. The physiatrist notes particularly prominent pain upon palpation of the anatomic snuffbox. There is minimal discomfort when the forearm and elbow are examined and palpated. Normal sensory responses are present in all five digits.

Question 1/3 - What injury(s) would be on the physiatrists differential diagnosis?

Click on your selected option(s) below (correct = 1, possible = 2, over-thinking = 3+)

Incorrect. While a fall-on-outstretched-hand (FOOSH) mechanism of injury, this is a fracture of the distal radius. The patient history has normal/minimal discomfort of the forearm and with this fracture there would be pain in the distal forearm. Additionally the wrist would displace in a 'dinner fold' deformity with dorsal angulation of the wrist/hand. Also, x-ray has a high sensitivity for this type of fracture and should have shown up on the emergency room x-ray in present.

Incorrect. This occurs with direct impact of a closed hand most commonly, not consistent with the fall-on-outstretched-hand (FOOSH) reported injury. Pain would also occur distally on the digit 5,little finger, medial (ulnar) side and not at the anatomic snuff box on the lateral (radial) side of the hand. Also, x-ray has a high sensitivity for this type of fracture and should have shown up on the emergency room x-ray in present.

Correct! The scaphoid is located deep to the anatomic snuff box location on the radial side of the hand, consistent with high pain from that location. A scaphoid fracture often occurs with fall-on-outstretched-hand (FOOSH) and is frequently missed on initial x-ray so the physiatrist would have a high degree of suspicion for this type of fracture. The scaphoid bone is the most frequently fractured carpal bone.

Incorrect. Usually the result of high energy injury (e.g. motor vehicle) more than falling height injury fall-on-outstretched-hand (FOOSH),. The dislocation would, however, cause anterior (palmar) displacement of the lunate bone so the most sensitive/painful point should be palmar and not at the anatomic snuff box. Commonly also compromises the median nerve at that location which would have distal neurologic symptoms from the hand which are negative in this patient. The lunate bone is the most frequently dislocated carpal bone.

Possible. This injury is consistent with a fall-on-outstretched-hand (FOOSH). Manifests as pain at the wrist particularly on the thumb (radial) side, though not specifically at the anatomic snuff box. Additionally, the injury would not be detectable with an x-ray. Widening and instability of the carpal joint would occur, which was not noted on physical exam. However, symptoms and mechanism are generally consistent with this patient so a ligament rupture would be on a differential, though perhaps not the top suspician.

Incorrect. This is a lump on the back of the hand (a cyst). Generally painless unless pressing on some other structure. Not consistent with deep pain at the anatomic snuff box.

Incorrect. This is known as 'trigger finger' where repetitive trauma causes inflammation of the synovial tendon sheath and a 'locking' of the finger in position stuck in flexion or extension. Not consistent with an acute injury or the normal finger positioning of this patient.