Wrist Injury

[gcoe]

does applying upward pressure on the thumb as the patient described usually bring-on scaphoid fracture pain, it sounds like it woud lmake sense to do so but it is nto mentioned in the literature as a possible indicator like anatomical snuff box sensitivity etc

Yes you are right that this is not a formal test but painful thumb movements can and do go with scaphoid # Why don't you review the diagnostic accuracy of various clinical tests. I have put a ref for you to look at below but there may be better ones. My understanding is that clinical pain provoking tests are for scaphoid are highly sensitive particularly when combined, but that they have poor specificity - so good for picking up suspected fractures but lousy at ruling out non scaphoid #s. So get familiar with the tests available.

I don't know much about scaphoid fractures but am about ot start a placement where I will be dealign with them no doubt,
are they usually pinned if found or treated conservatively,

conservative management is the first choice. the problem is when it has been missed (so no immobilisation) and/or one of the three main complications arise - malunion, nonunion and avascular necrosis. When this happens I understand the two main surgical approaches is internal fixation, or bone chip implants

I have a feelign that scaphoid # patients are divided into 2 groups, those who pick up on it straight away and those who start to improve, then get better then worse again, then come back 4 treatment.
How are these patients typically treated and is there usually a difference in how they progress, if scaphoid #'s are treated conservatively shodu lwe as physio's treat them differntly then the pinned ones?

If the patient is treated conservatively and pain then increases it may well be that the management has failed and one of the complications has set in. Likewise those who are missed and not treated who get better for a bit then get worse - same scenario with the development of complications. The physiotherapy is based on the method of orthopaedic management - so generally I would be guided by the surgeon. On the whole the management is pretty straight forward and doesn't vary from any standard post fracture situation - increasing ROM and strength etc. Obviously a good assessment before starting will identify the main impairments that are present. But we do play an important role in picking up an occult fracture and referring on[/QUOTE]

what are the main issues to address, it sounds like (from the case below) these patients are more limited by pain than range, are mobs the kep to easign their pain? or does one strenghten the joint?

The key thing is to do know harm by neglect. So not going on treating a wrist injury if you suspect it needs an orthopaedic review. Localised mobilisations - again depends on what you are dealing with but I would be very careful and seek supervision if you think mobilisations are warranted for stiffness or painful stiffness
Also there is an article that reviews the management of scaphoid fractures which might be worth reading. All the best with your studies

Diagnosis and Management of Scaphoid Fractures - September 1, 2004 - American Family Physician

ScienceDirect - The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand : Combining the clinical signs improves diagnosis of scaphoid fractures : : A prospective study with follow-up