![]() ![]() The scaphoid and hamate are the most common bones to have nonunion after a fracture because their blood supplies are delicate and prone to complete disruption. Patients presenting with a spontaneous onset of wrist pain and a vague or distant history of trauma or repetitive loading activities could be suffering from a carpal bone nonunion or avascular necrosis. Direct palmar trauma from swinging a baseball bat or golf club may result in a hook-of-the-hamate fracture (i.e., golfer’s fracture). If the wrist has sustained direct trauma, the nature of the injury must be considered, including the force, frequency, and direction of the event. TTP and crepitus along dorsal aspect of distal radius Ultrasonography may show synovial thickening Radiography (“clenched-fist” and supinated oblique views) Midcarpal TTP with a painful and audible “clunk” on ulnar deviation Radiography (widened distal radioulnar joint space on PA view-usually normal) Pain, instability with radioulnar “grind” test TTP in distal hollow between pisiform and ulnar styloidĪrthroscopy may be necessary to rule out a false-negative MRI Variable history of trauma with TTP at the scaphoid or lunate Radiography (“scaphoid view” or the carpal tunnel and supinated oblique views )Īvascular necrosis of the scaphoid (Preiser’s disease) or the lunate (Kienböck’s disease) History of trauma with TTP at the anatomic snuffbox (scaphoid) and the proximal hypothenar area 1 cm distal to flexion crease of the wrist (hamate) Nonunion of scaphoid or hook of the hamate Occult fractures identified with delayed radiography, CT, MRI, or bone scan If all studies are negative and clinically significant wrist pain continues, the patient may need to be referred to a specialist for further evaluation, which may include cineroentgenography, diagnostic arthrography, or arthroscopy. When the diagnosis remains unclear, or when the clinical course does not improve with conservative measures, further imaging modalities are indicated, including ultrasonography, technetium bone scan, computed tomography, and magnetic resonance imaging. When radiography is indicated, the posterior-anterior and lateral views are essential to evaluate the bony architecture and alignment, the width and symmetry of the joint spaces, and the soft tissues. Special tests can help support specific diagnoses (e.g., Finkelstein’s test, the grind test, the lunotriquetral shear test, McMurray’s test, the supination lift test, Watson’s test). The hand and wrist can be palpated to localize tenderness to a specific anatomic structure. Patients who present with spontaneous onset of wrist pain, who have a vague or distant history of trauma, or whose activities consist of repetitive loading could be suffering from a carpal bone nonunion or from avascular necrosis. A detailed history alone may lead to a specific diagnosis in approximately 70 percent of patients who have wrist pain. ![]()
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