Tender in the Snuffbox, Normal on the Film: Reading Wrist Radiographs After a Fall on an Outstretched Hand in a 27-Year-Old and Why the Negative X-Ray Is Not the Final Answer
[Student Name]
University of Phoenix
NRP/571: Advanced Health Assessment II and Clinical Procedures
Week 2 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Mr. G., a 27-year-old mountain biker, fell onto his outstretched right hand yesterday. He has pain on the thumb side of his wrist, worse with gripping. On examination there is mild swelling, and he is tender in the anatomic snuffbox and over the scaphoid tubercle, with pain on axial compression of the thumb. Neurovascular examination is normal. This paper describes the imaging, its interpretation and the plan.
Why a Scaphoid Series
Standard wrist radiographs may not show the scaphoid well. A scaphoid series adds an ulnar-deviated posteroanterior view that elongates the scaphoid and oblique views. The ACR Appropriateness Criteria for acute hand and wrist trauma support radiographs as the initial imaging for suspected scaphoid fracture (Ross et al., 2019).
A Systematic Read
I read each view in order: adequacy, alignment, bones, cartilage and joint spaces and soft tissues.
Adequacy: four views, correctly positioned and exposed.
Alignment: carpal arcs smooth; no scapholunate widening; distal radioulnar joint normal.
Bones: cortices of the distal radius, ulna and each carpal bone traced; no fracture line, cortical break or step. Scaphoid waist and proximal pole appear intact on all views.
Joint spaces: preserved.
Soft tissues: the scaphoid fat stripe, normally a thin lucent line lateral to the scaphoid, appears slightly displaced, a subtle sign that may accompany an occult fracture.
Impression: no radiographic fracture; subtle soft tissue change.
The film was normal; his snuffbox was not, and the snuffbox had been right about this kind of injury before.
Why a Normal Film Is Not Enough
Carpenter et al. (2014) systematically reviewed the diagnosis of scaphoid fracture and found that, except for the absence of snuffbox tenderness, which substantially lowers the probability, history and examination alone cannot rule a fracture in or out. They concluded that MRI is the most accurate test in patients without evidence of fracture on initial radiographs, while CT is adequate to rule in but not rule out fracture. Mallee et al. (2015) compared CT, MRI and bone scintigraphy for clinically suspected scaphoid fracture and found all three had high specificity, with differences in sensitivity and none perfect.
Why It Matters
The scaphoid's blood supply enters mainly at its distal end. A fracture of the waist or proximal pole can cut off blood to the proximal fragment, leading to nonunion or avascular necrosis and eventually arthritis of the wrist. Early diagnosis and immobilization reduce these risks, which is why a suspected fracture is treated as a fracture until proven otherwise.
The Plan
I place Mr. G. in a thumb spica splint and order an MRI of the wrist within the week, consistent with the ACR criteria for suspected scaphoid fracture with negative initial radiographs (Ross et al., 2019). If MRI is not available, repeat radiographs in 10 to 14 days in the splint are an alternative. I advise no biking or weight-bearing on the hand.
The MRI Result
MRI shows a nondisplaced fracture of the scaphoid waist with bone marrow edema. I refer him to hand surgery; nondisplaced waist fractures are often treated with cast immobilization, although surgical fixation may be offered to allow earlier return to activity.
How to Examine the Scaphoid
Three examination findings are commonly used: tenderness in the anatomic snuffbox, the hollow between the thumb extensor tendons; tenderness over the scaphoid tubercle on the palmar side; and pain with axial compression of the thumb toward the wrist. Carpenter et al. (2014) found that the absence of snuffbox tenderness substantially reduces the probability of fracture, which makes it a useful finding to rule out, while its presence is common in wrist sprains too. Mr. G. had all three findings, which raises concern even though none is definitive.
Why MRI and Not CT
CT shows bone detail well and can confirm a fracture, but Carpenter et al. (2014) found it inadequate for ruling out scaphoid fracture, because nondisplaced fractures may be missed. MRI shows bone marrow edema around a fracture and is the most accurate test after negative radiographs. When MRI is not available promptly, immobilization and repeat radiographs in 10 to 14 days, when bone resorption at the fracture line may make it visible, are an accepted alternative.
Cost and Access
MRI is more expensive than repeat radiographs, but early MRI can prevent weeks of unnecessary immobilization if negative and prevent a missed fracture if positive. For a young, active patient, the value of an early answer is high. I confirm coverage before ordering.
Other Injuries to Consider
A fall on an outstretched hand can also injure the distal radius, the scapholunate ligament and other carpal bones. A normal scapholunate interval on radiographs makes a major ligament injury less likely, and the MRI will show ligaments as well as bone.
Teaching
I explain that a scaphoid fracture can heal slowly, that immobilization may last several weeks and that stopping it early risks nonunion. Smoking impairs bone healing; he does not smoke.
Splint Care
I teach Mr. G. to keep the splint dry, to watch his fingers for numbness, color change or increasing swelling and to return if these occur. Elevating the hand reduces swelling in the first days.
Return to Biking
Return to mountain biking will depend on healing confirmed by the hand surgeon, often with repeat imaging, since falling on a partly healed scaphoid can displace the fracture.
Why Documentation of Negative Films Matters
Missed scaphoid fractures are a common source of malpractice claims. Documenting the clinical suspicion, the immobilization and the plan for advanced imaging protects the patient and shows that the negative film was not accepted as final.
Healing Time
Nondisplaced waist fractures often heal in 8 to 12 weeks with immobilization, longer for proximal fractures; follow-up imaging confirms union before full activity resumes.
Work
Mr. G. works as a graphic designer and can type with his left hand and a splinted right thumb; I provide a note for modified duties.
Pain Control
Acetaminophen and ice help; I suggest avoiding prolonged use of anti-inflammatory drugs, which some evidence suggests may slow bone healing.
Smoking and Healing
Although he does not smoke, I mention that nicotine in any form, including vaping, slows bone healing, since many young adults do not think of vaping as smoking.
Documentation
The note records the mechanism, the snuffbox tenderness and other findings, the systematic radiograph read, the reason for advanced imaging and the splint applied, with neurovascular status before and after.
Conclusion
Mr. G.'s wrist radiographs, read systematically, showed no fracture, but his snuffbox tenderness and mechanism made a scaphoid fracture likely. Because history and examination cannot exclude the fracture and initial radiographs miss many, he was immobilized and sent for MRI, which found a nondisplaced waist fracture. Treating the clinical suspicion rather than the normal film protected him from the complications of a missed fracture.
References
Carpenter, C. R., Pines, J. M., Schuur, J. D., Muir, M., Calfee, R. P., & Raja, A. S. (2014). Adult scaphoid fracture. Academic Emergency Medicine, 21(2), 101-121. https://doi.org/10.1111/acem.12317
Mallee, W. H., Wang, J., Poolman, R. W., Kloen, P., Maas, M., de Vet, H. C. W., & Doornberg, J. N. (2015). Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database of Systematic Reviews, 2015(6), Article CD010023. https://doi.org/10.1002/14651858.CD010023.pub2
Ross, A. B., Lee, K. S., Chang, E. Y., Amini, B., Bussell, J. K., Gorbachova, T., Ha, A. S., Khurana, B., Klitzke, A., Mooar, P. A., Shah, N. A., Singer, A. D., Smith, S. E., Taljanovic, M. S., & Kransdorf, M. J. (2019). ACR Appropriateness Criteria acute hand and wrist trauma. Journal of the American College of Radiology, 16(5S), S7-S17. https://doi.org/10.1016/j.jacr.2019.02.028
How this NRP 571 Week 2 example is structured
The NRP/571 Week 2 work usually addresses chest and extremity radiograph interpretation. This paper reads a wrist series in a fixed order and then explains why a normal film does not end the evaluation when the clinical findings point to a fracture that radiographs often miss. Students search this week as NRP 571 Week 2, NRP571 Wk 2 or NRP/571 Wk 2; all three are the same assignment.
NRP/571 Week 2 questions, answered
What does NRP/571 Week 2 usually ask for?
Many sections ask students to interpret chest or extremity radiographs and describe the clinical next steps.
Why are scaphoid fractures missed?
Many are not visible on initial radiographs, and the scaphoid's blood supply enters distally, so a missed fracture of the waist or proximal pole can lead to nonunion or avascular necrosis.
What should happen when a scaphoid fracture is suspected but the X-ray is normal?
Immobilize the wrist in a thumb spica splint and obtain advanced imaging, with MRI the most accurate, or repeat radiographs in 10 to 14 days if MRI is unavailable.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.