Scaphoid, Pisiform, Triquetrum
February 7, 2014 | 15,00 EUR | answered by Dr. med. Ralf Berg
Dear Doctor,
here is a brief overview of my situation starting on 1.2.14:
Saturday: Wrist injury during football
Sunday: X-ray at the hospital - no clear diagnosis - temporary cast/splint
Monday: Call from the hospital - wrist is broken - full cast for a week, followed by X-ray/CT
Friday: Diagnosis of scaphoid fracture + pressure analysis below the thumb: However, I did not have any pain in this area as expected by the doctor - the pain is more in the area of the pisiform/triquetral bone (doctor's statement: muscular issues due to the cast) A X-ray or CT scan was not taken (scheduled in another 1-2 weeks) I then visited an accident doctor who allegedly could not perform an X-ray due to legal regulations. Now I am reaching out to you because I feel poorly advised. How can a scaphoid fracture (below the thumb) be diagnosed when the pain is in the area of the pisiform/triquetral bone (below the little finger)? Thank you in advance
Sincerely yours
Good evening,
first of all, you were probably not advised so badly. Although the doctor on duty on Sunday did not see anything, the temporary immobilization in a cast was correct. Usually, the X-rays from the weekend shift are re-evaluated by the radiologists on Monday (who are often not in the building on weekends). They then probably made the suspected diagnosis of a scaphoid fracture. "Normal" wrist fractures are quite easy to see, but it gets difficult with the carpal bones, as they cannot be shown individually. The scaphoid bone is a special case. Often, it is initially just a bone contusion from the impact, which may not be visible on the first X-ray and therefore diagnosed as a suspected fracture by the radiologist. This often does not cause pain at first. In the second phase, the "crumbled" bone mass is absorbed (after 1-2 weeks) and can be seen on the second X-ray as a fissure line = as a brightening. During this phase, the scaphoid bone is unstable and can completely break apart if not immobilized. In the worst case, the two parts can separate so far that there are two scaphoid bones, which usually causes discomfort. However, if it is immobilized with a forearm cast, it usually heals without further consequences. The discomfort on the outer edge of your hand is probably not related to this. Either the cast is pressing on something, or the hand edge also suffered a bruise from the fall. An accident doctor (also known as a D-Doctor or Durchgangsarzt) is actually not responsible for all accidents, but acts on behalf of the employers' liability insurance associations in the event of work accidents. I assume that you are a recreational footballer and not involved in professional sports, so this incident falls under a leisure activity and is likely not work-related. The "accident doctor" cannot intervene in this case. Summary: A scaphoid fracture may not initially cause pain as it often starts as a bone contusion that is initially stable and cannot be clearly defined on X-rays or imaging tests. However, if a lesion is suspected, it is important to immobilize the scaphoid bone. It makes sense to X-ray again after 1-2 weeks, as a fissure line can then be seen. If the trauma was not severe and no fracture is visible after 2 weeks, the issue is resolved. Otherwise, the cast must remain until the fracture gap has healed. The pain in the area of the pisiform bone is most likely unrelated. I hope I have been able to explain the connections to you clearly. Best wishes for your recovery, Dr. R. C. Berg
