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Wheeless' Textbook of Orthopaedics

Diff Dx of Dorsal and Radial Sided Wrist Pain



- Landmarks:
    - one can palpate proximally in the snuff box radial styloid and, in mid third, the waist and distal third of the scaphoid;
    - at the distal end of the snuff box the STT joint is identified;
    - elliptical bony prominence at base of thenar muscles, consisting of trapezoidal ridge and scaphoid tuberosity;

- Diff Dx:
    - scapholunate instability:
            - patient complains of a popping and clicking in the wrist joint associated with pain and limited motion;
            - scaphoid lift test: pain with dorsal volar shifting of the scaphoid;
            - scapholunate and lunate injuries cause tenderness just distal to Lister's tubercle;
            - marked prominence of the entire carpus dorsally is suggestive of a perilunate dislocation;
            - scaphoid shift maneuver
            - no tenderness to over navicular tuberosity (snuff box), or tenderness with axial compression of thumb toward the snuff box;
    - scaphoid fracture:
    - lunate dislocation:
            - causes pain on the dorsum of the wrist more to the center of wrist area and less on the radial side;
            - neurologic assessment of the median nerve is essential;
            - lateral x-ray shows the distal concavity of the lunate may rotated 90 degrees and may be palmar to the capitate;
    - rupture of FCR tendon;
            - occurs from a fall on an outstretched hand
            - separation occurs at the insertion of the F.C.R. deep to the thenar muscle;
            - pain is detected over the scaphoid on the palmar surface of the wrist or is present proximally along the course of the FCR;
            - this occurs from a fall on the out stretched hand, causing separation of the insertion of FCR deep to the thenar muscles;
            - chip of bone may separate w/ tendon, or, in pts > 35 years of age, tendon may rupture partially or completely;
            - pain is detected over the scaphoid on the palmar surface of the wrist or is present proximally along the course of the F.C.R.
    - radial styloid fracture:
            - from a direct blow or fall on the outstretched hand;
            - compression of the styloid process may cause pain about the same location as does compression of the scaphoid;
            - simultaneous radial styloid frx is relatively common w/ carpal dislocation, & pt w/ radial styloid frx should have radiographs to 
                   exclude SLD;
            - these radiographs should include AP (supination, palm up) and clenched fist AP in addition to the true lateral;
    - trapezium fracture:
            - follows a direct blow of the fist or a fall on the on the radially deviated closed hand may resemble findings associated scaphoid 
                   fracture (different mechanism from scaphoid frx)
            - swelling and pain are usually directed at the base of the thumb, rather than over the scaphoid;
    - ECRL avulsion:
            - avulses from the base of the second metacarpal occurs as a result of forceful injury with the hand in ulnar deviation;
            - there is pain around the anatomic snuffbox near the location that is painful with the scaphoid fracture, however, the palmar  
                    aspect of wrist is not painful;
            - from the base of 2nd metacarpal occurs as result of forceful injury w/ hand in ulnar deviation or a direct blow or a downward 
                    stroke such as might occur while individual is swinging a golf club and strikes the ground;
    - ECRB tendon avulsion;
            - occurs from a forced palmar flexion injury of the wrist;
            - avulsion may occur from a forceful palmar flexion injury of wrist;
            - palpation dorsally causes pain at base of 3rd metacarpal, more distal than that which would occur if scaphoid were fractured, &
                     palmar aspect of the wrist is not painful;
    - deQuervain's disease
    - basilar joint (CMC) Arthrosis



The scaphoid shift test.

The basal joint pain syndrome.

Examination of the scaphoid.    

Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, May 9, 2012 2:29 pm