?# Scaphoid

[Baby_Physio_Kieran]

Hi, I'm a recent physio graduate, which means I have enough knowledge to make me paranoid about every little ache, without the experience to tell me that it's probably nothing, or conversely that I should go to A+E.

I've had an intermittent dull ache localized on the radial aspect of my right wrist for a while now (not sure how long but it's quite a few weeks, if not more) It's only 1-2 out of 10 on the VAS. Aggrevating factors include opening particularly stiff door handles and driving (I drive using only right hand on wheel, so it takes a beating it terms of ROM - infact now that I think about it, I've changed my driving style around it to use 2 hands and I'm quite careful now) There is no latent pain after I come out of that position. As far as I'm aware there was no mechanism of injury, but I'm quite an active 22 year old male, so there may well have been without me noticing.

There is no loss of AROM or PROM or strength at wrist, although active radial deviation is painful at end of range, but not when done passively. Gripping is painful in radial deviation, but not in any other position. Resisted movements are not painful. Palpation of scaphoid is tender in snuffbox, and anterior to adductor pollucis tendon (is that the right name?) but it doesn't feel like "my pain" particularly, and it's fairly tender on my non-symptomatic left hand... (maybe I'm pressing too hard)

As I said it's only a niggle, but should I be worried about it? - I'm aware that an untreated scaphoid # can lead to problems later in life, and conceivably avascular necrosis.. - would it be more painful if this was the case?

The factors that point to scaphoid fracture in my mind are achy pain in scaphoid locality, painful at end of range, resisted movements not painful, grip in radial deviation painful... Would you not expect passive radial deviation to be painful though?

Would be very grateful for your experienced thoughts!

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[junior_physiotherapist]

Hallo Kieren,

Firstly wish to u a fast full recovery..
Actuallu # scaphoid may be over looked either because person considers it to be a strain and dosen't attend to a doctor or the fracture may not be visible on initial radiagragh. in the later case the arm should placed in plaster as a precaution and radiograghed again after a couple of weeks.
Healing is slowly oftenly in this fracuter ,unluckly there may be non-healing in some instances...

So plz note if the # occurs at waist of scaphoid bone ,THE blood sulpply to the proximal part of bone 'll be impaired and avascualr necrossis may be develop,,,,

Hope this could help u ...

[Baby_Physio_Kieran]

Thanks Junior Physio, but I'm more interested in, from your experience of similar problems, whether it sounds like it might be a #, based on what I've told you..

I've also just noticed that in the original post I said adductor pollucis tendon, where I think it should be ABDuctor pollucis tendon.

[junior_physiotherapist]

Hallo Kieren,

As it seems , i think u ve to make an x-ray inorder to exclude other causes of pain ,or it could be a wrist ganglion!! since u hadn't have a mechanism of injury!!

If i was u for sure i 'll go to a qaulified orthophysican ..its a matter of stability to wrist joint ligaments .

Hope this could help u

Regards

[umamadhu]

Hi there,

I feel it must be Dequiverain's disesae or the tenosynovitis.U got to better X-ray to rule out the #.If its the inflammation.JUS give adequate rest to the wrist,use a wrist binder.try cryotherapy.

[karen.hankey]

To test for DeQuervains syndrome place your thumb of the the affected hand into the the palm and wrap your fingers in a fist around it. Then ulnar deviate your wrist. This is called Finklesteins test and will cause pain if DeQuervains is present.

Possible signs for a fractured scaphoid would involve a fall onto an outstretched hand. You would find tenderness in the anatomical snuffbox (the dip around the base of the thumb).

If you are unsure always be cautious and seek an x-ray. Better to be safe then sorry.

[Baby_Physio_Kieran]

Hi, thanks for all the advice - Finklesteins was negative, and the snuff box is a bit tender, but not any more than other side...

I went to a drop-in clinic the other day to get a second (non-paranoid) opinion from a nurse. She was really nice, and didn't become defensive at all when she found out I was a graduate physio. (often happens) She seemed to think it was very unlikely to be a # because of the low intensity pain, although she was leaning more towards a repetitive strain injury, which I disagree with, as I cannot elicit the pain on resisted movements in any range. She also thought that I was unlikely to get a xray referral with the presentation.

I am, myself leaning towards a minor ligament sprain. (?Palmer radiocarpal ligament) The only reason I discounted this at the beginning was the unusual movement-pain pattern considering the site of the pain (i.e. lengthening at the site of pain, by extending and ulnar deviating wrist, was painless) But after looking more indepth at the anatomy of the wrist it would appear that radial deviation actually causes more of a separation between the distal radius and the scaphoid than any other movement. The pain is also at the end of range - which would suggest ligament also.

I have resorted to localised rest (although this is harder than it sounds on a dominant wrist) with movement in pain-free ranges and heat therapy (as it is now sub-acute/chronic stage).

Would appreciate any views on my thoughts/logic or any further treatment advice.

Will keep you updated.

[umamadhu]

HI,
Is that so difficult to get an x-ray rather break ur head unnecessarily? Anyways,give adequate rest,and continue with ice therapy.
uma madhu.

[karen.hankey]

I was always under the impression that a fractured scaphoid gave a deep, dull nagging pain. I am dubious about a ligament strain, just because with the size of the ligament and large movement would be needed to strain it which I think you would remember. But I understand the frustration of not being able to get any further with the x-ray.

Although the main mechanism for a schapoid fracture would be to fall on an outstretched arm, there is also punching and hitting something with the heel of your hand.

I would advise see how your rest and heat go, but if no improvement over the next few weeks then look into it again. Any ligament problem should heal within about 6 weeks, so you should see some improvement.

[Baby_Physio_Kieran]

Indeed Karen, that's my plan. I've come to the conclusion of ligament because I'm at a loss as to what else it could be.. Also, I have recently finished university, and that generally involves ashamedly large quantities of alcohol, so it is quite possible that I fell, and even that I damaged something, without remembering. It did start roughly around that time as well. I'd also like to stress that the pain is only present at end of range radial deviation. It's painless at rest, on resisted movements and in any other range. From you're experience, would you expect it to be more painful if it were a scaphoid fracture?

Uma Madhu - Yes, "getting an x-ray" generally involves a wait of around 4-6 hrs (if you're lucky) in an A+E waiting room, before the triage nurse tells you to go home and rest it. I'm not sure whether "head" is a typo or not, but I'm at a loss as to how I would break it? Also I'm not using ice, as it's in the sub-acute phase, and there's none of the signs of inflammation.

Thank-you for your continued input - it is much appreciated, more from a professional point of view, than a patient.

[umamadhu]

Hey Kieran,
Dont u worry so much,take rest and wear a wrist binder.or get an elastocrepe bandage,to provide adequate support and rest to that region.Don involve in activities that aggravate the condition.You'll be fine.-umamadhu.

[linbin]

hi friends
i think we should look for sprain of the intrinsic lig between scaphoid and lunate or any cartilage injury.xrays in normal AP VIEW,LATERAL VIEW,AP VIEW WITH WRIST RADIAL DEVIATION MAINTAINING A FIST,helps us to get an idea about any lesions in wrist