| Discussion: |
Patients with chronic significant musculoskeletal pain may have occult disease that never does show up on a plain film. In these cases, a radionuclide bone scan is a nice way to screen the affected area (and the whole skeleton, if necessary) for an occult lesion. Below are palmar and dorsal views of a bone scan of this patient's hands.
A fracture of the trapezium is seen on these images (arrows). It is fairly subtle in certain of these views, and only appears as a cortical discontinuity. However, in the image on the right, the fracture fragments gape open a bit, making it much easier to see.
This case illustrates some helpful tactics in the workup of occult fractures. If initial plain films don't reveal the cause of a patient's pain, one might consider special views, such as a navicular view. Another helpful maneuver in the wrist is to treat the patient with a splint, and then bring them back in a 10 - 14 days for a repeat examination. After this interval, a fracture margin will have time to decalcify a bit, which may make even a subtle, nondisplaced fracture visible.
In this case, plain films never showed the subtle, minimally displaced fracture, and the radionuclide bone scan was an appropriate next step. Once we knew that there was indeed something going on in this wrist, CT provided an excellent way of clinching the diagnosis.