Hospital Corpsman Sickcall Screener's Handbook
BUMEDINST 6550:9A
Naval Hospital Great Lakes
1999

1. Inspection

   1. Alignment/deformity

      1. bow legs (genu varum).

      2. knock knees (genu valgum).

      3. flexion contracture (unable to extend fully).

   2. Look for loss of normal hollows superior to patella/adjacent to patella. The loss is an early sign of:

      1. synovial thickening.

      2. fluid in joint (effusion).

2. Palpation

   1. Suprapatellar pouch between thumb and fingers.

   2. Compress suprapatellar pouch with one hand and palpate with other hand:

      1. either side of patella.

      2. tibiofemoral joint space itself.

      3. note tenderness, thickening, warmth or bogginess in joint spaces or near femoral condyles. Finding warmth and tenderness is indicative of synovial inflammation. Nontender effusion common in osteoarthritis.

   3. Palpate popliteal space for swelling and cysts.

   4. Signs of effusion:

      1. Bulge sign: milk upward with hand on knee 2-3 times then tap patella and watch for bulge of returning fluid in medial hollow area adjacent to patella.

      2. Ballottable patella: grasp leg just above knee firmly and displace fluid into space behind patella. Briskly tap patella down against femur, if fluid is present a palpable "tap" is noted.

   5. Patellofemoral compartment

      1. compress patella and move against femur and flex knee.

      2. have patient tighten quadriceps while pushing patella distally.

      3. note any pain or crepitus which occurs in chondromalacia patella and osteoarthritis.

         1. Patella Inhibition Test: Have patient relax quadriceps. Push down on proximal tendon above the patella while patient tightens the quadriceps. If patient quickly releases the tightening or shows sign of pain, the test is positive. Often seen in chondromalacia patella.

         2. Patellar Apprehension Test: Push the patella medially and observe the patient for any sign of resistance or appearing worried. Patients with patella subluxation often positive.

   6. Tibiofemoral joint

      1. Flex knee to 90^o with the patients foot resting on the exam table. Palpate along tibial margins from the patella tendon toward each side of the knee, and then along the course of collateral ligaments. joint line tenderness is indicative of a damaged meniscus.

   7. Tibial tuberosity

      1. Press on the tibial tuberosity and note any swelling or pain. Tenderness and swelling suggests Osgood-Schlatter Disease.

3. Test for ROM

   1. Rotation at hip.

      1. Flex leg to 90° at hips and knees. Swing leg medially for external rotation and laterally for internal rotation. Internal rotation restriction is indicative of hip disease.

   2. Flexion at the hip and knees.

      1. Flex knee upwards and pull firmly against abdomen. Note if opposite leg remains on table fully extended. Flexion of opposite leg indicates a flexion deformity of that hip.

   3. Abduction of the hips

      1. Stand at the end of table and hold feet and spread legs apart.

4. Test for injury of knee joint.

   1. Drawer sign: Flex knee at 90° and stabilize foot by gently sitting on it while grasping thelower leg at the joint line with thumbs anterior and fingers posterior. Attempt to push forward and backward.

      1. Increased mobility anteriorly indicates anterior cruciate ligament instability.

      2. Increased mobility posteriorly indicates posterior cruciate ligament instability.

   2. McMurrays sign: Flex the knee until the heel neatly reaches the buttocks while grasping the knee with one hand at the joint line and rotate the foot/lower leg laterally with the other. Then extend the knee to 90° with the foot still in lateral rotation, repeat with foot in medial rotation. Most sensitive for medial meniscus injuries.

      1. A palpable or audible click in lateral rotation suggests a torn medial meniscus.

      2. A click in medial rotation suggests a torn lateral meniscus.

   3. Appleys Grind test: Useful to tell apart meniscal and ligamentous injuries. With the patient lying on their stomachs, hold the heel of the foot and press down firmly while alternately moving the andle medially and laterally. Then pull up and stress the joint medially and laterally. Pain with compression indicates meniscal injuries, while pain with distracion is indicative of collateral ligament damage.

1. Inspection

   1. Profile for cervical, thoracic and lumbar curves.

   2. Posterior view for any lateral curvature (scoliosis).

      1. Note difference in shoulder height.

      2. Note difference in levels of iliac crest. Pelvic tilt suggests unequal leg lengths.

2. Test ROM (Observe spinal curves during maneuvers.

   1. Toe touch (flexion). Lumbar concavity should flatten. Muscle spasm may prevent the flattening.

   2. Side bend (lateral bending) while stabilizing pelvis in seated postion.

   3. Backward bending (extension).

   4. Twisting shoulders (rotation).

3. Palpatation

   1. Have patient sitting or standing.

   2. Using thumb, palpate each spinous process. (percuss with ulnar aspect of fist if necessary).

      1. Pain with palpation of the spinous processes may indicate herniated disc.

      2. Pain with percussion may indicate osteoporosis/compression fracture, infection or malignancy. CVA tenderness indicative of kidney disease.

   3. Inspect/palpate paravertebral muscles for tenderness or spasm.

      1. Muscle spasms appear prominent, tight feeling and usually tender.

4. Evaluation for herniated lumbar disc/sciatica.

   1. Straight leg raises (SLR).

      1. Patient supine.

      2. Raise leg passively until pain in posterior leg occurs. Pain in back alone is not a positive straight leg raise.

      3. Dorsiflex foot.

      4. Leg pain exacerbated by dorsiflexion of foot is a positive SLR and is indicative of lumbosacral nerve root ittitation. (note: tight hamstrings may produce discomfort behind knees).

GROUP AID STATION
Headquarters Company
Headquarters & Service Battalion
2D Force Service Support Group
U. S. Marine Corps Forces, Atlantic
Camp Lejeune, North Carolina 28542-0125

STUDENT HANDOUT
MUSCULOSKELETAL DISORDERS

GAIN ATTENTION: During normal routine the CA will be called upon to recognize potential problems and properly examine the musculoskeletal system.

PURPOSE: The purpose of this lesson is to teach the student the proper procedure for examining, diagnosing and treating musculoskeletal disorders.

INTRODUCE LEARNING OBJECTIVES:

1. TERMINAL LEARNING OBJECTIVE: Given a simulated patient with simulated symptoms, the student will be able to recognize potential problems and properly perform the needed exam.

2. ENABLING LEARNING OBJECTIVES:

   1. Be able to identify the different disorders of the musculoskeletal system by shading the correct response.

   2. Be able to identify the signs and symptoms of musculoskeletal disorders shading the correct response.

   3. Be able to isentify the treatment of these disorders by shading the correct response.

3. The instructor will give this class by lecture and demonstration.

4. This material will be covered on a daily quiz and the final oral exam.

MUSCULOSKELETAL AND ORTHOPEDIC PROBLEMS

1. History

   1. Mechanism of Injury (MOI): describe in great detail what happened. What forces and direction acted on the extremity. What motion occurred at the extremity (i.e., twisting, hyperextension, valgus, varus, etc.).

2. Examination

   1. Inspection (effusion, edema, deformity, ecchymosis, etc.).

   2. Palpation: following anatomical landmarks.

   3. Test for ligamentous stablilty.

   4. Range of Motion (ROM): active and passive.

   5. Neuro status: always assess motor, sensory and vascular status distal to the injury (include pulses and capillary refill).

   6. X-ray if any possiblilty of fracture.

3. Assessment and Plan: as indicated. NOTE: Be sure to stress rest and rehab exercises when given.

4. Education (patient)

5. Return (follow up)

COMMON DISORDERS

1. Bursitis: an acute or chronic inflammaion of a bursa

   1. Bursa: A synovial lined sac aontaining synovial fluid at sites of friction between tendons and bones. Located at shoulders, elbows (olecranon bursitis "students elbow"), wrists, knees (prepatellar bursitis "housemaids knee"), and ankles.

   2. Etiology

      1. Friction: At sights of repeated excessive friction.

      2. Chemical: Commonly calcium deposits or gout.

      3. Infection/Septic: Introduction of bacteria into bursa may progress to septic arthritis.

   3. Signs and Symptoms

      1. Localized pain and tenderness.

      2. Pain with range of motion (ROM).

      3. Swelling (especially superficial bursa such as prepatellar, infrapatellar, and olecranon).

      4. Redness and warmth (think of infection).

   4. Diagnosis

      1. Must rule out other causes (i.e., tendon/muscle tear, cellulitis, arthritis).

      2. X-ray: May reveal calcium deposits.

   5. Treatment

      1. Anti-inflammatory medications (Motrin 800mg TID or ASA 10-15grs QID, or other NSAID).

      2. Rest with intermittent ROM exercises.

      3. Splinting may be necessary in severe or refracture cases.

      4. Severe bursitis or any sign of infection refer to MO.

      5. Follow up in 3-5 days.

Tendonitis and Tenosynovitis - Inflammaiton of a tendon and/or tendon sheath. Usually occurs together.

1. Etiology

   1. Often undetermined

   2. Commonly "overused" due to extreme or repeated traumatic strain or excessive, unaccustomed exercise.

   3. May be due to systemic disease (i.e., rheumatic syndrome)

2. Commonly affected areas

   1. Shoulder capsule and associated tendons

   2. Flexor carpi radialis or ulnaris.

   3. Flexor Digitorum

   4. Hip capsule and associated tendons

   5. Hamstrings

   6. Achilles tendon

3. Signs and Symptoms

   1. Pain with activity:

      1. Increased with passive stretching.

      2. Increased with forceful contraction against resistance.

   2. Localized tenderness

   3. May have swelling and inflammation.

   4. May have friction rub or crepitus over the site. Crepitus is a sign of a more severe disease.

4. Diagnosis

   1. Must rule out tendon rear or rupture.

5. Treatment

   1. Rest

   2. Heat or cold (either may benefit). Cold for acute injuries.

   3. Anti-inflammatory medications (Motrin, ASA, etc.)

   4. Immobilization may be necessary in severe or refractory cases.

   5. Severe or any sign of infection refer to MO.

   6. Follow up in 3-5 days.

Septic Arthritis - An orthopedic emergency.

1. Etiology

   1. Entrance to joint usually be direct extension from an adjacent infection or by hematogenous spread.

   2. Staphylococcus is usually the offending organism.

   3. Gonococcal arthritis presents commonly in our population. It is a monarticular septic arthritis and is generally in the knee.

2. Commonly affected areas:

   1. Knee

   2. Hand

   3. Elbow

3. Signs and Symptoms

   1. Pain most common early symptom.

   2. Warm, swollen, diffusely tender joint.

   3. Usually held in slight flexion.

   4. Passive motion extremely painful.

   5. Fever and other signs of systemic infection may be present.

4. Diagnosis

   1. Any question of early septic arthritis or severe cellulitis near a joint requires immediate referral to an MO, who will probably refer to orthopedics on a "today" consult for hospitalization and IV antibiotics.

Epicondylitis or "Tennis Elbow" (lateral humeral)

1. Etiology (lateral epicondylitis)

   1. An "over use syndrome" caused by repetitious, strenuous supination of the wrist against resistance (i.e., screwdriver, tennis) or by violent extension of wrist with hand pronated.

   2. Exact cause unknown, but minor tear in the tendonous attachments of the muscles are often present.

   3. Essentially a "strain" of the lateral extensor forearm muscles near their origin of the lateral epicondyle of the humerus.

2. Signs and Symptoms

   1. Amount of pain mild to moderate but usually constant.

   2. Pain over lateral epicondyle with radiation to outer side of forearm.

      1. Increases with extension of the wrist and supination of the forearm against resistance.

      2. Often point tenderness distal to lateral epicondyle.

   3. May have weakness of wrist extenors secondary to pain.

3. Treatment

   1. Rest - Avoid pain producing motions.

   2. Anti-inflammatory medications (ASA, Motrin, etc.).

   3. Immobilization with a sling, arm band..

   4. Severe or refracroty cases refer to MO who may try casting or splinting.

ACUTE TRAUMATIC INJURIES

Ankle Strains - Usually results from an acute inversion injury in which a ligament is stretched beyond their normal ROM.

1. Classification

   1. Grade I: (mild) Ligaments stretched but not torn. Mild tenderness and mild swelling.

   2. Grade II: (moderate) Ligaments torn but not completely ruptured. Marked swelling and tenderness, but with negative anterior drawers test.

   3. Grade III: (severe) A complete ligamentous rupture. Marked swelling and tenderness with instability indicated by a positive anterior drawers test.

2. Signs and Symptoms

   1. Pain, swelling, ecchymosis over ligaments.

   2. Difficult, painful ROM.

   3. Must try to palpate each ligament individually (anterior talofibular, calcaneofibular, however is difficult in initial presentation because of swelling.

3. Diagnosis

   1. Must obtain X-ray. (ankle series to rule out fracture).
      When should you order X-rays?

      THE OTTAWA ANKLE RULES

      Ankle Injuries:

      An ankle radiographic series is only required if there is any pain in malleolar zone and any of these findings:

      1. Bone tenderness at A (see diagram).
         or,
         

      2. Bone tenderness at B
         or,
         

      3. Inability to bear weight immediately and in clinic.

      Foot Injuries:
      A foot radiographic series is only required if there is any pain in midfoot zone and any of these findings:

      1. Bone tenderness at C (see diagram)
         or,
         

      2. Bone tenderness at D
         or,
         

      3. Inability to bear weight both immediately and in clinic.

   2. Order foot series or tib/fib series, is indicated, to rule out associated fractures.

   3. Must rule out associated fractures by palpating for tenderness on proximal 5th metatarsal and proximal fibula.

4. Treatment

   1. Initial (all grades)

      1. Compressive dressing (posterior splint or modified Robert-Jones).

      2. Rest-ligth duty with crutches if difficult ambulation.

      3. Ice and elevation.

      4. NSAID (Motrin, ASA, etc.)

      5. Follow up in 3 days.

   2. Follow up

      1. Grade I:

         1. Continue light duty for one (1) week.

         2. Continue analgesics.

         3. Begin ankle rehab exercise.

         4. Begin physical training at own pace.

      2. Grade II and III:

         1. Refer to MO who may place in straight leg wlaking cast x 3-5 weeks followed by ankle rehab.

1. MOI usually forseful stress.

   1. Valgus stress damages MCL (medial collateral ligament). MCL is damaged more often than LCL typically due to being tackled from the outside forcing the knee inward.

   2. Varus stress damages LCL (lateral collateral ligament).

   3. ACL (anterior cruciate ligament) is injured by the knee being forced into hyperextension. Typical injury occurs when tackled from the front.

   4. Most serious of knee disorders because delay in treatment my lead to a clinically unstable knee.

2. Signs and Symptoms

   1. Acutely the ability to bear weight is often lost.

   2. Effusion (joint swelling) may be large and immediate due to hemorrhage.

   3. A "pop" or tearing may have been heard.

   4. Ligamentous instability on physical exam: often difficult to determine in an acute injury due to guarding of muscle spasm.

   5. Incomplete tear or sprain are often more painful than complete rupture.

   6. Patients with old injuries and clinically unstable knees often complain of knee "going out" or "giving way" and often hove chronic effusion.

3. Physical Exam

   1. Inspection: effusion in all, and ecchymosis over the affected ligaments in LCL and MCL.

   2. Palpation: point of maximum tenderness is often along course of collateral ligaments.

   3. Stablility: (patient relax and supine):

      1. Ab/Adduction stress at 30° flexion (cruciates relaxed). Prevents false negative.

      2. Ab/Adduction stress at 0° (cruciate tightened if stable at 30° collateral intact (will be stable at 0°).

         1. If unstable at 30° and stable at 0°, collateral out but cruciate intact.

         2. If unstable at 30° and stable at 0°, both collateral and cruciate out.

      3. Drawers sign - anterior and posterior. Hip at 45° and 90° of knee. Look for firm, solid point without laxity. A test for ACL alone.

   4. X-rays to rule out avulsion fracture.

4. Classification of MCL and LCL injuries.

   1. Grade I: pain over ligament. No laxity. Strained but not torn.

   2. Grade II: partial tear. May have small amount of laxity.

   3. Grade III: complete rupture: (+) laxity.

5. Treatment (Refer to MO if any question of ACL instability.)

   1. Grade I and II: RICE (Rest, Ice, Compressive dressing, and Evaluation) and analgesics.

   2. Grade III: early surgical repair.

   3. Chronic ligament instability usually requires reconstructive surgery in order to prevent further joint deterioration.

1. Meniscus: "c" shaped cartilage which acts as a cushion between the femur and tibia.

2. Most common of all knee injuries.

3. MOI: usually a twisting injury of the knee with the foot in weight bearing portion.

4. Medial meniscus is injured 10 times more frquently because it is more firmly attached and less mobile.

5. Clinical features:

   1. Often history of a "popping", "grinding", or "tearing" sensation inside joint.

   2. Often history of "locking (preventing full extension). Indications of a "bucket handle" tear.

   3. Joint line tenderness (medial or lateral) is the most reliable physical sign.

   4. Effusion usually occurs slowly over several hours.

   5. McMurray’s and Appley’s tests may be positive.

   6. Acute symptoms usually subside to be replaced by intermittent episodes of locking, clicking, buckling, swelling and pain.

6. Treatment

   1. Initial: rest, light duty and anti-inflammatory meds.

   2. If unable to fully extend knee it is called a locked knee and needs immediate referral.

   3. Refer to MO for orthopedic consult. Arthroscopy may give definitive diagnosis and treatment.

1. MOI fall on shoulder or direct blow to top of shoulder.

2. Classification

   1. 1° AC sprain (shoulder pointer): inclomplete tear of the AC ligament without separation.

   2. 2° AC sprain (partial separation): more severe disruption of the joint capsule that allows subluxation of the AC joint: acromioclavicular ligament is torn but coracoclavicular ligament is intact.

   3. 3° AC sprain (shoulder separation): complete AC joint subluxation, both AC ligaments and CO ligament are torn.

3. Clinical Features:

   1. Tenderness and swelling over AC joint.

   2. Outer clavicle may be elevated depending on degree of sprain.

   3. Downward traction of the arm may cause increase deformity.

4. X-ray indicated: order bilateral shoulder AP comparison views without and with weights.

   1. 1° AC sprain: usually appears normal.

   2. 2° AC reveals small amount of dispacement of distal clavicle with weights compared to opposit side.

   3. 3° AC sprain: distal end of the clavicle displaced upward in relation to acromion.

      1. Distance between coracoid process and clavicle is also widened.

5. Treatment

   1. 1° and 2° AC sprains:

      1. Sling until tenderness subsides (usually 10 days to 3 weeks).

      2. Analgesic/anti-inflammatory medications.

      3. Then ROM exercise program.

   2. 3° AC sprain: Orthopedic consult for possible surfical intervention with reduction of dislocation and repair of ruptured ligaments.

CHRONIC KNEE PAIN

1. Patellofemoral Pain Syndrome (PFS)

   1. A clinical diagnosis which encompasses a myriad of known and unknown causes of knee pain.

2. Chondromalacia patella (one known cause is a surgical diagnosis characterized by softening, and fragmentation of the articular cartilage of the posterior surface of the patella).

3. There is no direct correlation between the extent of chondromalacia changes of the cartilage and the amount of pain experienced, therefore PFS is a better term clinically.

4. Signs and Symptoms

   1. Typically a several month history of increasing knee pain (parapatella, deep inside).

   2. Pain increases with activity and decreases with rest.

   3. Increasing knee pain wiht extended periods of knee flexion (i.e.: sitting). Positive "movie sign": will periodically try to straighten knee.

   4. Pain increases with excess distance running, hiking, stair climbing, jumping and over-zealous use of "knee machines".

   5. May complain of clicks, pops, grinds, swelling, some slight giving way and weather changes.

5. Exam may reveal

   1. Pain and apprehension with patellofemoral compression.

   2. Tenderness over medial facet of patella.

   3. Grinding or crepitus with articulation during flexion and extension with compression.

   4. Quadriceps muscle weakness and/or atrophy.

   5. If severe may have joint effusion.

6. Management

   1. Counseling, reassurance usually a manageable problem with return to activity.

   2. Rehablilitation. quadriceps conditioning, physical therapy, and/or exercise sheet. Studies show good results with structured supervised rehab program.

   3. Anti-inflammatory drugs.

Osgood-Schlatter Disease (osteochondritis of the tibia tubercle)

1. Etiology

   1. Trauma is a frequent factor.

   2. A single violent or lesser repeated flexion of the knee against a tight quadriceps.

   3. Causes disruption of secondary growth plate obstructing blood supply and leading to aseptic necrosis and fragmentation of the tibial tubercle.

   4. Commonly affects children in rapid growth period of puberty, especially boys.

   5. Complication is a nonunion of the tibial tubercle which remains syptomatic into adult life. Most heal in childhood.

2. Clinical Fractures

   1. Pain, tenderness and soft tissue swelling (without inflammatory signs) over tibial tubercle.

   2. Increases pain with activity impairing strong quadriceps contractions and therefore strain on tibial tubercle (i.e.: stair climbing, running).

   3. Active extension of knee agaist resistance is painful.

   4. Kneeling aggravates condition.

   5. X-rays: order knee series to confirm diagnosis (AP & lateral views).

3. Treatment

   1. Rest/decreased activity: maintain knee in full extension.

   2. Ice

   3. Anti-inflammatory medications.

   4. Severe cases may require knee immoblilizer for several months.

   5. Physical therapy: CMP exercise may be helpful.

   6. Orthopedic consult for surgical evaluation if all else fails.

1. Is a symptom, not a diagnosis.

2. Not easy to find objective evidence.

3. Etiology:

   1. Mechanical LBP: postural, usually chronic, a diagnosis of exclusion, treatment: change habits, back school, exercise.

   2. Acute lumbar muscle strain: non radiating: often with sprain.

   3. Disc herniation: LBP with radiation down one leg and/or localizing changes in motor or sensory function or reflexes.

   4. Referred pain

      1. Female: endometriosis, ovarian tumor, PID, UTI.

      2. Male: UTI, prostatitis.

      3. Both: pancreatitis.

      4. Psychosocial problem

      5. Neoplasma

      6. Infections

      7. Miscellaneous medical problems and diseases.

1. Subjective (Questions that must be asked).

   1. Pain: character, location, radiation, duration.

   2. Precipitating factors, prior history.

   3. Numbness, weakness, bowel, bladder problems. Sign of disc disease.

   4. Fevers, weight loss, other systemic symptoms.

2. Objective

   1. General: discomfort, ease of movement, undressing.

   2. Back: note any deformities.

      1. Tenderness over vertebra or paraspinous muscles.

      2. Muscle spasm.

      3. ROM: flexion/extension and side bending.

      4. Straight leg raises (positive procedures).

      5. Check for CVA tenderness.

   3. Neurologic: motor, sensory and DTR’s.

   4. GU/rectal: checking for anal and sphincter tone. Prostate should be checked for signs of inflammation.

   5. Genitals/Hernia: look for epididymitis, testicular cancer, and hernias.

3. Assessment: rule out serious injury first.

4. Plan

   1. Lumbar strain

      1. Rest: light duty or bed rest depending on severity.

      2. Muscle relaxants/analgesics (ex. Parafon Forte DSC or Flexeril and an NSAID i.e. Motrin).

      3. Back exercises and postural instructions

      4. Physical therapy: back school if chronic

      5. Heat or cold may help symptoms.

   2. With neurologic findings

      1. Refer to MO.

   3. Evidence of systemic disease

      1. Refer to MO.

COMMON AFFLICTIONS OF THE HAND

1. Paronychia: infection of the soft tissue around the fingernail which often begins as a hangnail and is usually caused by a staph infection.

   1. Signs and Symptoms: erythematous, swollen, tender, soft tissue at nail margin. May have purulent drainage or fluctuant area.

   2. Treatment: refer to MO who will I&D abscess and treat with antibiotics (Rocephin and Dicloxacillin or Velosef) and saline soaks.

2. Felon: Infection of pulp of the distal phalanx

   1. Usually secondary to a local puncture wound.

   2. Characterized by increasing pressure and pain over pulp of the distal phalanx.

   3. Treatment: refer to MO who will I&D abscess and give antibiotics.

3. Purulent Tenosynovitis: infection of the tendon sheath of a digit

   1. Etiology

      1. Extension of a felon

      2. Directly from a puncture wound, typically from a human tooth from punching someone in the mouth.

   2. Signs and Symptoms

      1. May appear as innocent appearing cut over knuckles.

      2. Puncture wound or laceration near involved tendon.

      3. Regard as human bite until proven otherwise.

   3. Kanavel’s - Four cardinal signs.

      1. Finger is uniformly swollen.

      2. Finger is held in slight flexion for comfort.

      3. Intense pain on passive extension of the finger.

      4. Marked tenderness along course of inflamed sheath.

   4. Treatment

      1. Refer to MO immediately

      2. Requires surgery to drain the infected tendon sheath and IV antibiotics.

BOXER’S FRACTURE

1. A fracture of the fifth metacarpal head caused by striking a hard object or second party. (Important to note if hit someone in the mouth).

   1. Signs/Symptoms

      1. Pain, swelling, and deformity usually over the fifth MCP joint or fifth metacarpal.

      2. Look for abrasions or lacerations and rule out human bite.

      3. X-ray - hand series to determine fracture versus contusion.

2. Treatment

   1. Refer to MO.

   2. Will probably require reduction of fracture and application of a short arm cast with 5th digit outrigger or ulnar gutter splint for 4-6 weeks.

1. Mechanism of injury - usually patient fell on outstretched hand with hyperextension of the wrist.

2. Scaphoid is the carpal bone most prone to fracture.

3. Precarious blood supply.

   1. Blood supply enters distal portion of scaphoid, therefore, a fracture through the midsection may lead to aseptic necrosis of the proximal fragment.

   2. Nonunion occurs frquently.

4. Signs/Symptoms

   1. Localized pain and swelling over distal radius and wrist.

   2. Significant pain over the "anatomical snuffbox" (bone of first metacarpal and scaphoid tubercle) is pathognomonic.

5. X-rays are normal initially but a fracture will become visible in 2-4 weeks if present.
   Order scaphoid series, not just wrist.

6. Diagnosis is made by positive "snuffbox" tenderness.

7. If suspected fracture:

   1. Refer to MO

   2. Will need short arm cast with thumb spica.

   3. Re X-ray in 3-4 weeks.

   4. If fracture present continur short arm cast until healed (6 weeks - 6 months)