Bilateral wrist pain • limited range of motion • tenderness to palpation • Dx?

We obtained x-rays to assess for any new changes to the wrist and specifically the scaphoid bones. The x-rays showed almost completely healed scaphoid bones with good alignment, but the patient still had 5/10 pain in the left wrist and 8/10 pain in the right wrist with movement. We placed her in adjustable thermoformable polymer braces, which were removed when she bathed.

Scaphoid fractures are commonly missed on x-rays because they are usually nondisplaced and hidden by other structures superimposed on the image.

Due to the uniqueness of her injuries, our patient had weekly visits with her primary care provider (PCP) for the first 2 months of treatment, followed by bimonthly visits for the remainder. At 10 weeks after the fall, her pain with movement was almost gone and she began physical therapy. She also began removing the braces during sedentary activity in order to practice range-of-motion exercises to prevent excessive stiffness in her wrists. Our patient regained full strength and range of motion one month later.

One other published case report describes the successful union of bilateral scaphoid fractures using bilateral long-arm casts followed by short-arm casts.⁷ Similar to our patient’s case, full union of the scaphoid bones was achieved within 12 weeks.⁷ Together, these cases suggest that conservative treatment methods are a viable alternative to surgery.

TAKEAWAY

For patients presenting with wrist pain after trauma to the wrists, assess anatomical snuffbox tenderness and obtain x-rays. Do not be falsely reassured by negative x-rays in the presence of a positive physical exam, however, as scaphoid fractures are often hidden on x-rays. If tenderness at the anatomical snuffbox is present and doesn’t subside within a few days, apply a short-arm thumb splint and obtain subsequent imaging.

If tenderness at the anatomical snuffbox is present and doesn't subside within a few days, apply a short-arm thumb splint and obtain subsequent imaging.

If bilateral, nondisplaced, stable scaphoid fractures are diagnosed, conservative treatment with long-arm and short-arm casts is a viable alternative to surgery. This treatment decision should be made on an individual basis, however, as it requires the patient to have frequent PCP visits, assistance with ADLs, and complete adherence to the treatment plan.