The Clinical Assessment and Differential Diagnosis of Scaphoid Fractures - Assignment Example

Care and Management of a Scaphoid Fracture from the Perspective of an Emergency Nurse Practitioner Emergency nurse practitioners have a role of offering holistic emergency care to patients. These nurses have to deal with several minor illnesses and injuries in their line of work. One of the most common injuries that emergency nurses deal with almost hourly is bone fractures, especially scaphoid fractures (Gunal, Barton and Calli, 2010). The scaphoid is a bone located on the wrist. It is part of the eight small carpal bones. Scaphoid fractures are the most common types of fractures that occur on the wrist. I chose to focus on scaphoid fractures since they are part of the injuries that I am likely to come across as an emergency nurse practitioner (Rutter, 2008). This paper touches on the clinical assessment and differential diagnosis of scaphoid fractures. I will discuss different assessments that a nurse can perform and the diagnosis process that is supposed to be followed when dealing with a fractured scaphoid. I will also look at the psychological as well as the cultural factors that might affect the patient suffering from a fractured scaphoid. I will also include the treatment options available for scaphoid fractures. There are several issues related to the management of fractured scaphoids. And I will delve deep into some of these issues in my discussion. Clinical assessment and differential diagnosis Scaphoid fractures are quite difficult to diagnose correctly since X-Ray interpretations are normally vague (Gunal, Barton and Calli, 2010). This draws to attention the need of clinical assessment in the diagnosis process. The diagnostic process of a fractured scaphoid needs to be thorough enough to be able to make accurate diagnosis. Signs and Symptoms It is quite challenging to diagnose fractured scaphoids due to the lack of apparent signs that are common with bone fractures. The most common symptom or sign of a fractured scaphoid is tenderness and pain, which is usually accompanied by swelling on the wrist (Elhassan and Shin, 2006). However these signs are not very specific and one might make unnecessary outpatient reviews. In the health facility where I worked, MRI technology was used to a certain the presence of a fractured scaphoid on a patient (Garcia and Holtz, 2001). However, the patient had to undergo plain-film radiographs to ascertain that indeed there was a fracture on the wrist. The first step of the clinical assessment of the suspected fractured scaphoid was to take the patients history (Bickley, 2005). Taking the history of the patient was important as it showed the injury mechanism. For a fractured scaphoid, the injury mechanism normally involved: Falling onto the outstretched hand Forced dorsiflexion, with a radially deviated wrist Sometime there could be palmar flexion After checking the common signs of a fractures wrist such as swelling, lack of a strong grip and pain, the next step involved the use of radiographs (Elhassan and Shin, 2006). The lateral radiograph was used to indicate whether or not there was any sign of inconsistency in the alignment of the carpal and distal joints (Edwards and Stillman, 2006). If the patient had positive radiograph results but negative initial clinical findings were treated using cast immobilization for two weeks. After two weeks, the examination was repeated to examine whether there had been any form of healing or bony resorption at the site of the fracture. Emergency nursing practitioners carried out the initial clinical evaluation which in most cases showed the following (Muscari. 2001): Pain on the wrist Fullness and swelling off the snuffbox, which was a clear indication of effusion Tender palpation in the anatomical snuffbox and scaphoid tubercle Reduction in the range of motion Pronation and ulnar deviation that caused pain Reduced strength of grip When the radiographs failed to indicate the fracture, even when it was apparent there was one, the other option used was MRI. In many health facilities which deal with emergency care for minor injuries, MRI has been used as a superior technique to repeat radiography in detecting scaphoid fractures. MRI has 95%-100% sensitivity and a specificity of almost 100% (Johnson, Hill-Smith and Ellis, 2000). One of the benefits of using MRI is that there is no contact with ionizing radiation. When one uses the MRI, there is normally no need to reposition the injured wrist. Apart from identifying fractures, an MRI can identify other causes of wrist pain such as bruises (Smith, Cooney and Chao, 1988). Differential diagnosis was arrived at using MRI (Bethel, 2009). This was due to the fact that follow up radiology could not be relied on to give accurate results of the cause of pain in the wrist. Radiology has poor sensitivity when compared to MRI (Ewles and Simmnett, 2003). It was on this basis that the health facility where I worked used MRI as the gold standard for the detection of suspected scaphoid fractures. Following differencial diagnosis, the following could be identified: Instability in the scapholunate area Dislocation of the lunate Fracture in the radial styloid Fracture on the trapezium A ruptured flexor carpi radialis tendon Carpometacarpal joint arthritis De Quervain illness When there is a displacement on the scaphoid fracture, instability and ligament injury should be suspected (Steinmann and Adams, 2006). The instability might be either dynamic or static (Davis, 2005). If the patient has static instability, he cannot position his carpal bones as they should be positioned. This abnormal positioning is normally easily visible through a radiograph. A dynamic instability on the fracture may appear normal on the radiograph, however, it slowly becomes abnormal when the wrist is moved (Khalid, et al., 2010). Psychological/cultural factors Most of the patients who came to the hospital with fractured scaphoids were athletes and people who did heavy duties, which mostly included lifting heavy things. For the athletes, having a fractured scaphoid meant that they could not continue with their sports since it would be difficult to handle things. Participating in their sports activities also increased their chances of injuring their wrists further. For the heavy labour workers, having a fractured scaphoid meant that they had to stop their work for a few weeks to give their injuries time to heal. This affected negatively on their daily routines. Some of them were affected financially s they could not work with injured wrists. In most parts of the world today, one must work in order to fend for him or herself. Damage to the wrist is normally immobilizing, making the individual not able to carry out duties that he would have done with ease if he was not injured (Steinmann and Adams, 2006). It is in this background that patients with fractured scaphoid bones normally resist prolonged immobilization as part of the treatment process. Emergency nursing practitioners are normally faced with a challenge of considering some of the cultural and psychosocial lifestyles of their patients before they begin treatment (Bickley, 2005). During the clinical examination of the patient, emergency nurses have to consider treatment options that will not have an adverse effect on the cultural and psychosocial aspect of the patient’s life (Douglas, Nicol and Robertson, 2009). Treatment Treatment of a scaphoid depends on the type of fracture (Khalid, et al., 2010). There are stable fractures which are normally incomplete. These types of fractures are not related with any type of ligament injury and they are treatable by immobilization alone. However immobilization is not necessary for these kinds of fractures, they can heal on their own. Unstable fractures on the other hand are normally complete and findings indicate that fractures need fixation. Cast immobilization on its own cannot heal this kind of fracture (Cooney, 2010). Proper treatment of a fractured scaphoid depends on early identification and complete immobilization of the affected area (Young and Giachino, 2009). There are many controversies that surround the issue of treatment through immobilization, which is standard for any suspected scaphoid fracture. The normal duration of immobilization is 10 to 14 days after which the casting is removed to evaluate the healing process of the facture. Due to the fact that it is hard to visualize the fracture of a scaphoid, most patients will continue having fracture symptoms after the 14 days (Rettig, 2000). Most fractures on the scaphoid should be visible at this point. This means that if a patient continues complaining of pain on the wrist area, further radiologic tests have to be carried out to find out the source of pain. If a fracture is found, then further immobilization is normally suggested for the following two weeks (Young and Giachino, 2009). Immobilization Immobilization is normally done through the use a thumb spica splint or a cast. The cast is used for is used to provide enough immobilization and can accommodate any swelling that may occur around the injured part. Unstable fractures normally require longer thump spica casts which should stay in place for about six weeks (Rettig, 2000). Ideally, the duration of a fracture depends on the exact location of the scaphoid fracture (Bethel, 2009). Non-displaced fractures normally take a shorter time to heal and 6 to 8 weeks of immobilization is enough. However fractures at the central third of the scaphoid healing can take up to 12 weeks. Proximal third scaphoid take a much shorter time to heal, about 3 to 4 weeks. Traverse fractures may take anywhere from 4 to 8 weeks of healing time (Rettig, 2000). MRI scanning can be used justifiably by emergency nursing practitioners as the gold standard of investigating scaphopid fractures (Brydie and Raby, 2003). This scanning enables for more accurate emergency nursing practitioners to come up with the correct diagnosis early enough to avoid any future complications. In my experience as an emergency nursing practitioner, I think it is possible to use MRI scanning at a cost effective manner. Other prolonged and repetitive treatment options may be cheaper but more money is normally used on the subsequent treatments (Jenkins, Cooke and Glucksman, 1994). For MRI, the patient rarely needs repetitive treatments, therefore the patient ends up saving a lot of money. Another advantage of MRI scanning is the fact that there is no need for special repositioning of a painful wrist. There is also no danger of exposure to ionizing radiation. The MRI also enables one to identify bruises in the absence of a fracture (Walsh and Kent, 2001). Issues related to scaphoid fractures Professional perspective Difficulty in diagnosis: one of the major problems associated with the management of scaphoid fractures for emergency nurses is difficulty in coming up with a diagnosis (Guly, 1996). Due to the position of the bone on the wrist, it is hard to determine whether pain is coming from an injured scaphoid or from something else (Brydie and Raby, 2003). Emergency practitioners have to carry out numerous tests to ascertain that indeed the cause of pain on the wrist is actually a fractured scaphoid. Limited prognostic value: fractured scaphoids normally do not have enough and reliable prognosis. A nursing practitioner cannot take the history of the patient and rely on it to determine whether or not one has a fractured wrist. The only valuable prognostic information that en emergency nursing practitioner can use is the manner in which the patient gained the wrist injury (Jones, Endacott and Crouch, 2002). However, even this is not enough to diagnose a fractured scaphoid. More tests and analyses are needed to be fully sure that the patient really has fractured his scaphoid. Poor reliability of scaphoid fracture classification systems among observers is another professional challenge in the management of scaphoid fractures (Brydie and Raby, 2003). The methods of diagnosis and treatment are not standard in all medical facilities. This makes it hard for most emergency nursing practitioners to offer holistic care for patients who have fractured scaphoids (Walsh and Kent, 2001). Ethical perspective Unnecessary immobilization is one of the most common ethical issues that are associated with scaphoid fracture management (Purcell, 2003). There are many instances where emergency nursing practitioners have had to diagnose fractured scaphoid even when there was no fracture. Unnecessary immobilization might have negative effects on the livelihood of patients since they can not go about their daily routines like they used to. Misdiagnosis in itself is also a big ethical issue as it negatively reflects on the clinical profession (Howard and Boyle, 2005). Exposure to harmful radio rays is also an ethical dilemma that comes with management of scaphoid fractures. These rays can cause further complications in the health of patients (Schoen, 2000). A few years ago, with no MRI scanning technology, the available treatment options posed the danger of causing illnesses as a result of the radioactive materials involved in the testing. Emergency nursing practitioners have to be careful about the treatment options they use so as to avoid dilemmas such as these. Scaphoid Non-Union is the situation where the fracture fails to unite after a few days of treatment. Scaphoid non-union might pose more problems for the patient as it can affect other parts of the wrist bone as well (Walsh, Crumbie and Reveley, 1999). Scaphoid non-unions normally occur due to the delayed treatment or misdiagnosis of scaphoid fractures. To avoid this problem, it is important for emergency nursing practitioners to be more thorough and professional in their work. Nursing practitioners in the emergency room need to work together as a team, but they also to be autonomous so as to be effective as much as possible (Jones, Endacott and Crouch, 2002). Legal perspective From the legal perspective, it can be argued that scaphoid management poses many legal challenges, especially when it comes to the immobilization treatment of scaphoid fractures (Howard and Boyle, 2005). In many instances, where radiographs are used as the standard treatment methods, there is likelihood for many types of misdiagnosis to occur. If a scaphoid fracture is misdiagnosed, and the patient is unnecessarily given immobilization treatment, he may sue the emergency nursing practitioner or the medical facility that misdiagnosed his condition (Walsh, Crumbie and Reveley, 1999). Emergency nursing practitioners need to adapt high level treatment options such as MRI which give clear and reliable diagnosis than the traditional x-rays (Douglas, Nicol and Robertson, 2009). This will reduce the number of misdiagnosis of fractured scaphoids that are likely to occur at any given time. Emergency nursing practitioners normally deal with several cases at any given time, and treating some of these cases differently is normally not so easy (Joanna Briggs Institute, 2004). Scaphoid fracture patients are usually given the same standard treatment for scaphoid fractures. In many instances, nurses are not really concerned with how the treatment might affect the lives of the patients. For instance, one of the patients with a fractured scaphoid might be a professional rugby player who has an imminent game in awaiting him. The athlete might be reluctant to undergo prolonged treatment as it will definitely interfere with his schedule. It is the duty of the emergency nurse to ensure that the athlete gets the best scaphoid treatment available (Joanna Briggs Institute, 2004), that will also allow him to practise for his upcoming match. However, if the treatment has to be prolonged, then the nurse has an obligation to let the athlete know so that he can choose to continue with or stop the treatment (Douglas, Nicol and Robertson, 2009). If the emergency nurse treats him like she treats all her other patients with similar problems, he might not get to play in that important game and this might lead to legal complications. Conclusion The scaphoid fracture is a common and important problem in the emergency nursing practitioners’ working environment. Most of the fracture cases that are reported daily in the emergency room are related to wrist injuries and scaphoid fractures, in particular. Nurses in different clinical settings have different preferences for investigating and imaging injuries related to scaphoid fractures. However, as technology becomes more advanced, so does the manner in which clinicians manage scaphoid fractures. More and more nurses in the emergency rooms are adapting the use of MRI in the diagnosis of scaphoid fractures in patients. This follows the low reliability of the traditional radiographs and x-rays. In my experience as an emergency nurse practitioner, I experienced first hand the unreliability of radiographs when compared to the high sensitivity and specificity of MRI. MRI scanning could detect significant inconsistencies within the wrist bone structure. When a scaphoid fracture was suspected, the MRI could be sued to identify exactly the type of fracture, enabling the clinicians to identify an appropriate method of treatment. However, not all patients could afford to pay for MRI scanning, making it difficult to clearly identify factures in those who could only afford radiography. There are many issues associated with the management of fractured scaphoids in patients. The issue of difficulty in diagnosis, misdiagnosis and unnecessary prolonged immobilization is one of the biggest problems that emergency nursing practitioners have to deal with. However, the issue is not a problem in a few medical facilities which have adopted the use of MRI imaging as the gold standard for fracture diagnosis. Another issue related to scaphoid injury management is an ethical one and it has to do with the exposure of radioactive rays to patients. This exposure might lead to further complications and this might lead to legal problems for the nursing practitioner who administered the MRI. Despite the professional, ethical and legal issues associated with the diagnosis and treatment of scaphoid fractures, emergency nursing practitioners have to be properly trained on how to care for patients with these kinds of injuries. They have to combine effort in their efforts of taking care of patients with fractured scaphoids. Although individual clinicians have their own preferences when it comes to methods of diagnosing scaphoid fractures, nurses have the responsibility of using the best available resources to ensure that scaphoid fracture patients receive the treatment they need. Best practices within the clinical setting will enable the nurses to offer quality medical services which will have maximum benefits for the patients. References Berger, R.A. (2001). The anatomy of the scaphoid. Hand Clinics. Vol.17, pp. 525-532. (Berger, 2001) Bethel, J. (2009). Scaphoid Fracture: Diagnosis and Management. Accessed 22 January 2011 from: http://www.ncbi.nlm.nih.gov/pubmed/19639802 Bickley S (2005) Bates Guide to Physical examination and History taking (9th Ed) Philadelphia. Lippincott Williams Wilkins Brydie, A. and Raby, N. (2003). Early MRI in the Management of Clinical Scaphoid Fracture. British Journal of Radiology. Vol. 76, pp.296-300 Cooney, W.P. (2010). The Wrist: Diagnosis and Operative Treatment. 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Clinical Examination of Scaphoid Fractures. Phys Sportsmed. Vol. 37(1), pp. 97-105 Read More