Rosen & Barkin's 5-Minute Emergency Medicine Consult (633 page)

• Carpal fractures are rare in children (and the elderly), as the distal radius usually fails 1st.
  
• If present, carefully evaluate mechanism.
  

• Radiographic imaging should include 3 views of the wrist: PA, lateral, oblique, and scaphoid views (wrist prone and in ulnar deviation).
  
• Pay special attention to the middle 3rd, or waist, of the bone: 70% of injuries occur here.
  
• Fracture may be identified by subtle findings such as a displaced fat pad.
  
• 10–15% of all fractures are not visible on radiographs at the time of injury.
  
• Bone scintigraphy or MRI as early as 3 days postinjury can rule out fracture and allow for earlier rehabilitation:
  
  • CT is not as reliable.
    

• If fracture is open or associated injuries are identified, urgent surgical intervention may be indicated.
  
• Associated injuries with scaphoid fracture:
  
  • Scapholunate dissociation
    
  • Distal radial fracture
    
  • Lunate fracture/dislocation
    
  • Bennett fracture of thumb
    
  • Radiocarpal joint dislocation
    
  • Proximal and distal carpal bone joint dislocations
    

• Bennett fracture
  
• Rolando fracture
  
• Extra-articular fracture at the base of the thumb metacarpal
  
• Gamekeeper thumb
  
• De Quervain tenosynovitis
  
• Perilunate dislocation
  
• Scapholunate dissociation
  
• Lunate fracture or dislocation
  

TREATMENT

Splint or immobilize as appropriate.

• Evaluate patient for other injuries.
  
• Dress open wounds.
  
• Immobilize with thumb in neutral position, ice, and elevate.
  

• Assess mechanism of injury and point of maximal tenderness.
  
• Exam with special attention to skin integrity and neurovascular status.
  
• If snuffbox tenderness is present, place in thumb spica splint.
  
• Counsel patient regarding risk of malunion (10%) and avascular necrosis.
  
• Clinically suspected scaphoid fractures without radiographic evidence:
  
  • Should be treated as a nondisplaced scaphoid fracture
    
  • Spica splint thumb in a position as if the patient was embracing a wine glass.
    
  • Repeat physical/radiographic exam in 7–10 days.
    
• Nondisplaced scaphoid fractures:
  
  • Thumb spica splint
    
• Displaced scaphoid fractures:
  
  • Nonunion rate of 50%
    
  • Often an indication for internal fixation
    

Pain control with NSAIDs or narcotics as needed

FOLLOW-UP

Open fracture or presence of other more serious injuries

• Closed injuries, with 72-hr orthopedic follow-up
  
• Patients with splints for nondisplaced fractures may be allowed to return to full work or activity of work/sport if the cast does not interfere with the exercises of work or specific sport activities.
  

• If fracture is angulated or displaced >1 mm, immediate orthopedic referral is indicated.
  
• All scaphoid or suspected scaphoid injuries must be referred to orthopedics.
  
• If no radiographic abnormalities found on initial radiograph, after placing in thumb spica splint, refer to orthopedics or primary care in 7–10 days with repeat radiographs at that time.
  

• Perfusion enters scaphoid bone distally.
  
• Avascular necrosis (especially with proximal 3rd fractures), occurs with inadequately reduced or immobilized fractures.
  
• Patients presenting with symptoms of a sprained wrist must have the diagnosis of acute scaphoid fracture ruled out.
  

• Chudnofsky CR, Byers SE.
  Clinical Procedures in Emergency Medicine: Splinting Techniques
  . 5th ed. Philadelphia, PA: Saunders Elsevier; 2010.
  
• Kumar S, O’Connor A, Despois M, et al. Use of early magnetic resonance imaging in the diagnosis of occult scaphoid fractures: The CAST study (Canberra Area Scaphoid Trial).
  N Z Med J.
  2005;118(1209):U1296.
  
• Pillai A, Jain M. Management of clinical fractures of the scaphoid: Results of an audit and literature review.
  Eur J Emerg Med.
  2005;12(2):47–51.
  
• Plancher KD. Methods of imaging the scaphoid.
  Hand Clin.
  2001;17(4):703–721.
  
• Simon RR, Sherman SC, Koenignecht SJ.
  Emergency Orthopedics: The Extremities
  . 5th ed. New York, NY: McGraw-Hill; 2007:189–193.
  

See Also (Topic, Algorithm, Electronic Media Element)

Lunate Fracture and Dislocations

CODES

814.01 Closed fracture of navicular [scaphoid] bone of wrist

BASICS

• A chronic psychotic disorder characterized by delusions, hallucinations, disorganization, negative symptoms, and cognitive deficits:
  
  • Premorbid phase:
    
    • Development of negative symptoms with deterioration of personal, social, and intellectual functioning
      
  • Active phase:
    
    • Development of active delusions, hallucinations, and bizarre behavior
      
    • May be precipitated by a stressful event
      
  • Residual phase:
    
    • Patients are left with impaired social and cognitive abilities
      
    • Psychotic symptoms may persist
      
  • Subtypes: Catatonic, disorganized, paranoid, residual, undifferentiated
    
• Onset typically early in adulthood (age <30)
  
• Comorbid substance abuse (alcohol, cannabis, tobacco, and stimulants) is common
  
• Violence may result from impaired judgment, paranoia, and command hallucinations
  
• Life expectancy 12–25 yr less than general population likely because:
  
  • 41% of patients have metabolic syndrome with increased risk of death due to cardiovascular events
    
  • 5–10% of patients commit suicide
    
  • Patients have decreased access to medical care
    
• Disorganized thinking, abnormal behavior, and delusions may obscure the detection of medical illness
  
• Medication noncompliance is a key reason for psychiatric decompensation and presentation to the ED
  

• Pathophysiology unclear but dopamine pathway strongly implicated
  
• Genetic component (concordance rate of 50% in monozygotic twins)
  
• Specific genes uncertain:
  
  • Higher risk in patients with DiGeorge syndrome (22q11.2 deletion)
    
• Perinatal risk factors:
  
  • Influenza during 2nd trimester
    
  • Maternal and postnatal infections
    
  • Advanced paternal age
    
• Use of cannabis may unmask psychosis in predisposed individuals
  

DIAGNOSIS