Disclosures: Martin Pico, MD: No financial relationships or conflicts of interest

Case Diagnosis: Scaphoid Fracture

Case Description or Program Description: A 39-year-old otherwise healthy male presented to clinic with persistent left wrist pain. 6 weeks prior, he sustained a fall onto his hand while biking. Initial radiographs were negative for fracture and the patient was provided with a forearm-based splint by urgent care. Pain was dull, nonradiating, and worsened by typing and yoga. His exam demonstrated mild snuffbox tenderness but was otherwise unremarkable. Point-of-care ultrasound revealed a notable cortical step-off irregularity and hyperemia of the volar and dorsal contours at the scaphoid waist. The patient was referred to a hand specialist and placed in a short-arm cast. CT demonstrated evidence of delayed union. The patient preferred to proceed non-operatively and underwent placement of an ultrasound bone stimulator.

Setting: Outpatient Clinic

Assessment/Results: After 12 weeks, repeat CT showed near-complete scaphoid healing and he began a course of occupational therapy with improvement in pain symptoms during everyday activities and modified yoga.

Discussion (relevance): Up to a fourth of scaphoid fractures are occult with negative findings on initial radiographs. Delays in diagnosis and lack of immobilization for fractures involving the proximal pole or waist can lead to severe complications including delayed union, malunion, osteonecrosis, and osteoarthritis. Ultrasound represents a definitive, accessible, and inexpensive test for the detection of occult fractures. Cortical disruption indicates direct evidence of fracture and other findings such as hematomas, hyperemia, and effusion may also be present. In the setting of persistent hand pain, physiatrists should have a high suspicion for occult fracture as early ultrasound diagnosis can lead to proper referral and identification of patients who may be appropriate candidates for bone stimulators or surgery.

Conclusions: Physiatrists should have a high suspicion for occult scaphoid fractures in the setting of persistent pain after hand trauma. Early ultrasound identification and referral for surgical intervention or adjunctive therapies can help prevent chronic and severe complications.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/the-utility-of-ultrasound-in-the-diagnosis-and-treatment-of-an-occult-scaphoid-fracture-a-case-report/