Musculoskeletal Medicine/Office Orthopedics
Problem-Based
Learning in Family Medicine
X-RAY
INTERPRETATION and CASE MANAGEMENT
Original
July 1992, #5 5-21-97
Wm.
MacMillan Rodney, M.D., FAAFP, FACEP
Family
and Emergency Medicine
Reviewed by Phil Cheatham, M.D.
Radiology, 1993, 1994
Reviewed
by John R. Janovich, M.D.
Orthopedics,
1993, 1994
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Family Medicine Module II:
Hand
and Wrist Injuries--
Diagnosis,
X-Ray Interpretation, and Management
Case 1
A
13-year old White male complains of a painful and swollen hand. His past medical history is
unremarkable. The mechanism of injury
was a blow to the right hand while at football practice this afternoon.
Examination reveals a swollen proximal third digit
involving the distal metacarpals. There
is a decreased range of motion, secondary to swelling. The neurovascular examination is
intact. There is a small area of
ecchymosis along the ulnar edge of the right third metacarpal phalangeal joint.
X-ray views of the AP dimension and
oblique are available.
Teaching Points:
a) Review
of Salter classification system.
b) Neuroanatomy
of hand.
c) Metaphysis
versus epiphysis.
d) Others.
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Family Medicine Module II: Hand and Wrist Injuries-- Diagnosis, X-Ray Interpretation, and Management |
Case 2 (3 slides/2 post)
A 35-year old White
male hit his hand while working on his car two days ago. He has continued to work as an auto
mechanic, but increasing pain and swelling caused him to seek care today. His past medical history is
unremarkable.
Examination reveals 3+ pitting edema on the dorsum of the
right hand. He is right-handed. His review of systems is negative for fever
and chills.
On examination, there is a small laceration
on the dorsum of the right hand overlying the area of the fifth
metacarpal. It is clean. There is no streaking or
lymphadenopathy. The patient relates
that his last tetanus vaccination was five years ago. He has full range of motion of his fingers and the neurovascular
examination is intact. There is point
tenderness over the base of the right fifth proximal metacarpal.
X-ray
examinations available are AP oblique, and lateral views of the right
hand.
Teaching points: To
be addressed.
a) How many views of the hand are ideal?
b) Can you detect an abnormality if there is
one present?
c) What is the correct management of this
case?
d) Should there
be a release for work?
e) Is the ulna
in a correct relationship with the carpal bones?
f) Others?
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Family Medicine Module II: Hand and Wrist Injuries-- Diagnosis,
X-Ray Interpretation, and Management |
Case
3 (1 slide)
Twenty-eight-year old White male roofer
accidentally discharged a staple gun into his hand while at work today. His past medical history is
unremarkable. His last tetanus shot was
10 years ago.
Objective: The patient is in no
acute distress. He is unable to flex
his wrist. All fingers have a complete
range of motion and strength is 5/5.
The neurovascular examination of the hand is intact.
Available x-rays include a PA and lateral
view of the hand.
Teaching points:
a) What
is the correct management regarding the foreign object?
b) Should
there be follow-up x-rays?
c) Is
tetanus immunization adequate?
d) Should
antibiotics be prescribed?
In this case, the staple was removed and the
patient was given a Td 0.5cc IM of tetanus immunization, An antibiotic was prescribed qid times 5
days. There was a good result with no
subsequent disability.
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Family Medicine Module II: Hand and Wrist Injuries-- Diagnosis, X-Ray Interpretation, and Management |
Case 4 (pre/post)
This is a 53-year old White female who
stumbled and fell while getting off the bus two hours ago. Her past medical history is unremarkable and
her last tetanus immunization was over 10 years ago.
Objective: Her
vital signs are stable and she is in no acute distress. Three x-rays views of the thumb are
available. The skin is not broken. And other than the right thumb, there are no
abnormalities of the examination.
Teaching Points:
a) Should
you consider reducing the thumb now?
b) Will
this patient be likely to experience disability? Note that she is right handed.
c) Once
the thumb is reduced, what would be the appropriate management?
1) Splinting?
2) Casting?
3) Open surgery?
d) View
the post reduction films.
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Family
Medicine Module II:
Hand
and Wrist Injuries--
Diagnosis,
X-Ray Interpretation, and Management
Case 5
A 24-year
old Black male who slipped and jammed his fingers against his desk. His past medical history is unremarkable.
Clinical Examination:
There is pain in the area of the proximal phalanx of the middle finger
(i.e., third digit). There is full
range of motion. The neurovascular
examination is intact. An AP and
oblique set of x-rays are available.
The resident reports this as a "transverse, non-displaced fracture
of the proximal phalanx of the middle finger of the right hand." He suggests splinting the finger in a
functional position for four weeks.
Clinical Questions:
a) Do
you agree to this diagnosis?
b) Are
there any other abnormalities on this film which are significant?
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Family
Medicine Module II:
Hand
and Wrist Injuries--
Diagnosis, X-Ray
Interpretation, and Management
Case 6 (2 slides)
This
is a 26-year old male rugby player who states that someone stepped on his hand
during a rugby game two hours ago. His
last tetanus shot was four years ago, and his past medical history was
unremarkable.
Clinical Examination: Vital
signs are normal and he is in no acute distress. The third right finger is swollen with point tenderness over the
proximal segment. Range of motion is
limited by pain. The neurovascular
examination is intact. The skin is not
broken.
Clinical Questions:
a) Are
the x-rays adequate?
b) Is
there a fracture present?
c) Based
on the x-ray findings, how would you manage this patient?
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Family
Medicine Module II:
Hand
and Wrist Injuries--
Diagnosis,
X-Ray Interpretation, and Management
Case 7
This
is an 13-year old boy who fell from his horse onto his hand. He did not hear a pop or a snap, but noted
immediate severe, unrelenting pain. He
has come directly to the physician’s office where the following x-rays were
taken.
The
examination reveals point tenderness over the distal radius with swelling. Range of motion at the wrist is limited,
secondary to pain. There is full range
of motion of the fingers, but limited strength secondary to pain. Neurovascular examination is intact.
Teaching Point.
Describe this fracture and its management.
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Family
Medicine Module II:
Hand
and Wrist Injuries--
Diagnosis,
X-Ray Interpretation, and Management
Case 8
The
9-year old brother of the previous case also fell off his horse revealing the
following x-ray. He also has pain over
the distal forearm. The neurovascular
examination appears intact, although range of motion is limited by pain. The
skin is unbroken.
Teaching Point.
Describe this fracture and its management.
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Family
Medicine Module II:
Hand
and Wrist Injuries--
Diagnosis,
X-Ray Interpretation, and Management
Case 9
The
mother of the previous two cases was so upset that the father had taken the
boys horseback riding (against her wishes; they were supposed to go to church);
that she took a swing at her husband when she learned the news. He ducked.
Unfortunately, her swing carried through and she struck the side of the
truck. She has come complaining of pain
in the wrist.
On
examination, there is point tenderness primarily on the dorsal aspect of the
wrist. The range of motion of the
fingers is full. Wrist range of motion
is limited by pain. The neurovascular
examination is intact. The skin is
unbroken.
Teaching Points:
What is the radiographic diagnosis and what management would you
suggest?
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Family
Medicine Module II:
Hand
and Wrist Injuries--
Diagnosis,
X-Ray Interpretation, and Management
Case 10 (pre/post-2)
Having
been forbidden from further horseback riding, the father took his remaining 7
year old son out on a four-wheel all terrain vehicle. Unfortunately, the child fell off and emerged from the fall
complaining of pain over the left arm.
The past medical history is unremarkable.
Examination
reveals a young, tearful child cradling his left arm. The neurovascular examination reveals no gross
abnormalities. The child does not
cooperate fully to allow any examination of strength and/or range of motion.
Teaching Points.
What is the radiographic diagnosis and what management would you
suggest?
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Family
Medicine Module II:
Hand
and Wrist Injuries--
Diagnosis, X-Ray Interpretation, and
Management
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Case 11
A six-year old BM fell
onto an outstretched left arm while playing on the monkey bars at school. He immediately screamed out in pain, and the
school nurse noted that the arm was deformed.
Pulses were intact.
Initially, he was taken
to the nearest emergency department; TennCare rules required the primary care
physician be contacted for authorization to treat. His family physician requested that he come to the office where
transverse fractures of the distal radius and ulna were noted. Neurovascular exam was within normal limits.
Upon arrival at the
office, both parents were angry and hostile, feeling that the boy should have
been treated by an orthopedist at the emergency room.
IV sedation/analgesia
was achieved with 50mg Meperidine and 3 mg Midazolam. A Bier block was considered, but found to be unnecessary. After reduction maneuvers, the patient had a
long-arm cast placed. A sling was
administered and a cast check was scheduled for two days (R 27-15; U 27-0).
On cast check the next
day, no abnormalities of the neurovascular examination were noted. The cast was loosened slightly (9-24-96).
He returned November 4,
1996 (42 days). The cast was
removed. No point tenderness was noted
and the patient left without further casting.
Sequence
of Views
