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Likelihood Ratio (LR) in Emergency Medicine

6/16/2014

Is my hand broken?

Clinical Scenario

A 24 y/o guy presents in ED with the left hand upraised. 
“I fell off my bike yesterday – he says – I remember a serious impact with an outstreched palm.”
There aren’t wounds, he feels pain on the radial side of  left wrist, there is an anatomical snuffbox tenderness. The clamp sign is positive, but the resisted pronation maneuvre and the longitudinal compression test are negative.  

Is it broken? Asks worried the guy.









Conclusion

If there’s a suspicion of a scaphoid fratture, clinical maneuvers have a little role in the diagnosis. Only the pain evocated by the resisted pronation or pinching the scaphoid, can increase the overall suspicion. Absence of the snuffbox tenderness cannot be used alone to rule out.
Of course, other tests are necessary. What about conventional X ray?



   to be continued...


Bibliography 

CR Carpenter
Adult scaphoid fracture
Acad Emerg med 2014 21:102-121 

CA Germann
Risk management and avoiding legal pitfalls in the emergency treatment of high-risk orthopedic Injuries
Emerg Med Clin N Am 2010 28: 969-996 

Ciro Paolillo


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