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Musculoskeletal Injuries

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While playing in his family's annual Thanksgiving Day touch-football game, a 41-year-old man fell onto his outstretched hand upon attempting to make the game winning catch. He presents to the emergency department (ED) complaining of right wrist pain.

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Which of the following carpal bones is most frequently fractured during a fall on an outstretched hand (FOOSH)?

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a. Triquetrum

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b. Lunate

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c. Capitate

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d. Scaphoid

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e. Pisiform

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The answer is d. The scaphoid is the most common carpal bone injured in a FOOSH injury. On examination, patients will exhibit tenderness at the anatomic snuffbox (the space between the extensor pollicis longus and the extensor pollicis brevis) and pain referred to the anatomic snuffbox with longitudinal compression (axial loading) of the thumb.

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A triquetral (a) dorsal chip injury is the second most common carpal bone fracture and occurs with a FOOSH or direct blow to the dorsum of the hand. Lunate fracture (b) is the third most common carpal fracture. This injury is also at risk for avascular necrosis (AVN) and any suspected injury should be placed in a thumb spica splint. The capitate (c) is the largest carpal bone and comprises 5% to 15% of all carpal fractures. The pisiform (e) is the only carpal bone with one articulation (with the triquetrum). Anatomically it is important because the deep branch of the ulnar nerve and artery pass in close proximity to the radial surface of the bone. It is an uncommon fracture.

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While playing in his family's annual Thanksgiving Day touch-football game, a 41-year-old man fell onto his outstretched hand upon attempting to make the game winning catch. He presents to the emergency department (ED) complaining of right wrist pain.

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On examination of the patient's right wrist, you note tenderness at the anatomic snuffbox and pain with axial loading of his thumb. You suspect he has a scaphoid fracture. A series of wrist radiographs are performed and are negative for fracture. Which of the following is the most appropriate next step in management?

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a. Place an ACE wrap around the hand and wrist and advise him to wear this until the pain resolves

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b. Immobilize in a thumb spica splint and discharge home with outpatient follow up with an orthopedist for repeat radiographs in 10 to 14 days

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c. Advise him to ice the wrist and take ibuprofen for the next 24 to 48 hours

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d. Order a CT scan to evaluate ...

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