A brachial plexus injury must be differentiated from a cervical spine injury. Neurapraxia typically has a limited course (i.e., days to weeks). Location of anatomical snuffbox (ventral view) -Yousun Koh, Figure 3. Initial symptoms are mild, and the injury may be disregarded as a simple sprain. Order of examination is performed as inspection, palpation, range of motion, and special maneuvers. Plain radiography and magnetic resonance imaging are usually not necessary for initial evaluation of a suspected nerve injury. The name originates from the use of this surface for placing and then sniffing powdered tobacco, or "snuff." It is sometimes referred to by its French name tabatire. An MRI can sometimes show a fracture of the scaphoid before it can be seen on x-ray. The primary mechanism of injury is a fall on the outstretched hand with an extended, radially deviated wrist, which results in extreme dorsiflexion at the wrist and compression to the radial side of the hand. Any maneuver that causes these tendons to activate (ie extending the thumb against resistance) causes pain along the lateral side of the wrist and forearm. With most fractures, there will be tenderness directly over the scaphoid in the anatomic snuffbox. Loss of infraspinatus function presents as weak external rotation of the arm. If your doctor suspects that you have a fracture but it is not visible on x-ray, he or she may recommend that you wear a wrist splint or cast for 2 to 3 weeks and then return for a follow-up x-ray. The lateral (outer) wall of the snuff box is formed from the tensed tendons of the abductor pollicis longus and extensor pollicis brevis; the medial wall is formed by the tensed tendon of the . TA2. Scapholunate dislocation. The goal of surgery is to realign and stabilize the fracture, giving it a better chance to heal. http://teachmeanatomy.info/upper-limb/areas/anatomical-snuffbox/, https://www.physio-pedia.com/index.php?title=Anatomical_snuff_box&oldid=221540. The anatomical snuff box or snuffbox or foveola radialis is a triangular deepening on the radial, dorsal aspect of the handat the level of the carpal bones, specifically, the scaphoid and trapezium bones forming the floor. Results of the Tinel sign and Phalen maneuver at the wrist should be negative in patients with pronator syndrome.13. To gain these skills, the student learns best with good anatomical models or a well-dissected cadaver, at the laboratory bench, guided and instructed by experienced teachers, and inspired toward self-directed, diligent reading. Symptoms of arthritis in the wrist may include: Treatment for arthritis focuses on improving symptoms. Additional substances, such as Bone Morphogenic Proteins (BMP), are also being evaluated to improve healing potential. The anatomical snuff box (or sometimes known as tabatiere or fovea radialis of wrist) is a surface anatomy feature. Fractures are further subdivided into displaced and non-displaced types. It has been suggested that early Scottish horn boxes had grinding ridges on their inner surfaces . The borders are the extensor pollicis longus posteriorly, extensor pollicis brevis and abductor pollicis longus anteriorly and the radial stylus process proximally. Lippincott Williams & Wilkins. Despite the frequency with which this area is used, there . To avoid missing this diagnosis, a high index of suspicion and a thorough history and physical examination are necessary, because early imaging often is unrevealing. Top Contributors - Kim Jackson, Merihan Hussein, Rachael Lowe and George Prudden, Theanatomical snuffbox(also known as the radial fossa), is a triangular depression found on the lateral aspect of the dorsum of the hand. Pages 42 ; Ratings 100% (1) 1 out of 1 people found this document helpful; This preview shows page 37 - 40 out of 42 pages.preview shows page 37 - 40 out of 42 pages. Any indication of a cervical spine injury mandates further emergent neurologic and radiologic evaluation. However, a great deal of variability in the sensitivities (higher and lower) of radiographs is found in the literature. Anatomic snuffbox tenderness and scaphoid tubercle tenderness are sensitive but not specific tests for scaphoid fractures. Symptoms are discomfort and aching in the forearm with activities requiring repetitive pronation of the forearm, especially with the elbow extended. All material on this website is protected by copyright. Ultrasound examination with routine equipment is not appropriate in the initial evaluation of suspected scaphoid fractures. The medial and lateral borders of the snuffbox are made up of three muscles that act on the thumb: These muscles are called the outcropping muscles of the thumb because they protrude out from beneath the extensor digitorum muscle, between it and the extensor carpi radialis brevis muscle. The onset of symptoms may be acute or insidious. Reference article, Radiopaedia.org (Accessed on 18 Jan 2023) https://doi.org/10.53347/rID-22107, medial (ulna) collateral ligament complex, lateral (radial) collateral ligament complex, accessory flexor digitorum superficialis indicis, accessory head of the flexor pollicis longus, superficial palmar branch of the radial artery. Anatomical snuff box The anatomical snuff box is a surface anatomy feature. In ulnar deviation, the scaphoid can be assessed for fractures. The scaphoid and, less distinctly, the trapezium are palpable in the floor of the snuff box. Anteroposterior, lateral, and oblique radiographic views are required for evaluation of a suspected scaphoid fracture. Suprascapular Nerve. The depression is deepest and most noticeable when the thumb is fully extended and abducted. All of the information on this website is purely for educational purposes and has not been peer-reviewed. In a study comparing bone scan with MRI,10 the authors found the two methods to be equivalent. Radial Nerve at the Elbow: Radial Tunnel and Posterior Interosseous Nerve Syndromes. Arthritis of the carpometacarpal or radiocarpal joint, Lateral wrist pain, tenderness over radial styloid, positive Finkelsteins test, Local tenderness and deformity, abnormal plain radiographs, Local tenderness, swelling, and pain elicited with wrist flexion, Local tenderness, swelling, and pain elicited with wrist extension, Tenderness over scapholunate ligament, increased gap between scaphoid and lunate on plain films, Anatomic snuffbox tenderness, pain with scaphoid compression test, tenderness of scaphoid tubercle. All Rights Reserved. -Glosbe"anatomical snuff box" The anatomical snuff box is among one of the most fun-named anatomic structures, its called the snuff box because people used to put snuff (tobacco) in it. The phrase 'snuff mull', is likely a reference to the hand mills in which snuff was ground. Radical neck dissection, carotid endarterectomy, and cervical node biopsy are iatrogenic sources of injury. Kim Bengochea, Regis University, Denver. Bilateral symptoms or those involving upper and lower extremities are less likely to be from a brachial plexus injury. The supraspinatus muscle arises from the supraspinous fossa, a shallow depression in the body of the scapula above its . They are less common than aneuryms of the ulnar artery although this discrepancy is unexplained . All content published on Kenhub is reviewed by medical and anatomy experts. The scaphoid bone can most easily be identified when your thumb is held in a "hitch-hiking" position. Additionally, your doctor may insert a small camera called an "arthroscope" into your wrist to look directly at the fracture. The carpal bones are arranged in two rows at the base of the hand. A normal MRI finding does not rule out nerve injury. 5 For . The green triangle is the snuff box. Differential diagnosis of Anatomical snuff box pain or tenderness: DeQuervain's tenosynovitis: Inflammation of the 1st extensor compartment of the wrist i.e. Authors Sasha Hallett, John V. Ashurst 1 . These changes may be visible on MRI as abnormal signal patterns. In scaphoid fracturesespecially those in which the bone fragments have become displacedthe blood supply to the bone may be disrupted. b_20/12194594. A particularly cavernous anatomical snuff box. "[citation needed] It is sometimes referred to by its French name tabatire. origin: supraspinous fossa of the scapula; insertion: superior facet of the greater tubercle of the humerus; innervation: suprascapular nerve (C5,6); arterial supply: suprascapular and dorsal scapular arteries 2; action: abduction of the humerus; Gross anatomy Origin. The pain, which often is mild, is worsened by gripping or squeezing. A fracture of the scaphoid can disrupt the blood supply to theproximalportion this is an emergency. Nondisplaced distal fractures heal well with strict immobilization in a well-molded short arm thumb spica. anatomical snuff box atrophy. Presenting symptoms include diffuse shoulder or neck pain that worsens with overhead activities. Axonotmesis is more severe, and involves injury to the axon itself. In most cases Physiopedia articles are a secondary source and so should not be used as references. and grab your free ultimate anatomy study guide! Risk factors include a superficial position, a long course through an area at high risk of trauma, and a narrow path through a bony canal. The base of this triangular shaped depression is located just distal to the end of the radius with the triangle's apex pointing towards the thumb. Unless your wrist is deformed, it might not be obvious that your scaphoid bone is broken. Snuff Box (sometimes referred to as Berry & Fulcher's Snuff Box) is a British dark sitcom set in London.Starring and written by Matt Berry and Rich Fulcher with additional material by Nick Gargano, it aired on BBC Three in 2006. Pain in your wrist that does not go away within a day of injury may be a sign of a fractureso it is important to see a doctor if your pain persists. Anatomical snuffbox is best seen when the thumb is abducted. (Anatomical snuffbox not labeled, but visible at right. As a basic rule, in a patient with a clinically suspected scaphoid fracture but negative initial radiographs (Figure 3), it is reasonable to apply a short arm thumb spica and reevaluate the patient in two weeks. Due to the small size of the scaphoid and its shape, it is difficult to determine, early on, whether or not the scaphoid is indeed fractured with an x-ray. Nerve injury should be considered when a patient experiences pain, weakness, or paresthesias in the absence of a known bone, soft tissue, or vascular injury. pain on wrist movement i positive scaphoid test tenderness elicited in anatomical snuff box and over scaphoid tubercle Scaphoid fractures usually cause pain and swelling in the anatomic snuffbox and on the thumb side of the wrist. The location and size of the surgical incision depends on what part of the scaphoid is broken. The scaphoid bone is one of the carpal bones on the thumb side of the wrist, just above the radius. Clearly, there is no replacement for education at the bench. Post was not sent - check your email addresses! In this study, interobserver reliability was high. The classic test is Finkelsteins maneuver, in which a fist is made over the thumb and the wrist is ulnarly deviated. The scaphoid has a unique blood supply, which runsdistal to proximal. It is located at the level of the carpal bones, and best seen when the thumb is extended. These are small uniquely shaped bones, eight in total, that make up the wrist. Despite hand therapy and a great deal of effort by the patient during home therapy, some patients may not recover the same range of motion and strength that they had before their injury. Nerve conduction studies assess the integrity of sensory and motor nerves. Author: FIELDS, MD. It was common practice to offer snuff to those in your company. HighlightsType of research: single center, prospective comparative cohort study.Key findings: results of snuffbox AVF compared with wrist fistula showed there was no statistical difference between efficacy rates of AVF in these 2 groups. A bone graft is new bone that is placed around the broken bone. With some scaphoid fractures, the pain is not severe and may be mistaken for a wrist sprain. Anatomic snuffbox tenderness is a highly sensitive test for scaphoid fracture, whereas scaphoid compression pain and tenderness of the scaphoid tubercle tend to be more specific. Difficult. Newer techniques, such as gadofluorine Menhanced MRI, may ultimately be able to assess nerve regeneration.19 Ultrasonography is a less expensive modality to define anatomic entrapment, but its use is limited by lack of standardization of technique and interpretation.20, Electrodiagnostic testing consists of nerve conduction studies and electromyography (EMG). 2518. On the thumb side of the wrist there is a little triangular . This website also contains material copyrighted by third parties. MRI or bone scintigraphy may be used initially if the patient desires an alternative approach. If new symptoms or significant worsening of existing symptoms occurs, neuroimaging, electrodiagnostics, or surgical referral should be considered.8 Patients who have multiple occurrences of stingers should also have a more thorough workup, because they may have an underlying neck pathology that predisposes them to this injury.9,10, Occurrence during participation in a sporting event raises the issue of return to play. From brachial plexus, around humeral head, through the quadrilateral space to deltoid/teres minor, Humeral head compresses nerve during extreme abduction, C5 to C7 merge, travel between clavicle and first rib through axilla to serratus anterior muscle, Brachial plexus down anterior arm, at antecubital fossa passes through radial tunnel, dives between two heads of pronator muscle, under flexor digitorum superficialis, through carpal tunnel, C5 to C7 merge into lateral cord brachial plexus, goes through axilla, under coracobrachialis, through biceps and under deep fascia at the elbow, From brachial plexus, through axilla, down posterior arm until it circles toward anterior arm at spiral groove of the humerus; down anterior arm and enters radial tunnel just above the lateral epicondyle, Injury in axilla or proximal humerus (fracture), Emerges through sternocleidomastoid muscle, across posterior neck, dives under trapezius, Very superficial course in posterior neck and directly under the trapezius muscle, From upper trunk brachial plexus, through posterior triangle, across top of scapula and through scapular notch, down posterior aspect scapula and across scapular spine to supraspinatus, infraspinatus, Entrapment under transverse scapular ligament that covers the suprascapular notch, From brachial plexus down anterior arm; just above medial epicondyle it passes to the posterior compartment and into the cubital tunnel; down ulnar side of forearm into Guyon canal (boundaries are hamate and pisiform bones); splits into deep (motor) and superficial (sensory) branches in canal, Motor: no loss or weak thumb adduction, weak digit abduction, and adduction toward center of long digit, Nerve roots C5 and C6 as they exit vertebral foramina and form upper trunk brachial plexus, Motor: infraspinatus, supraspinatus, biceps, and deltoid, No protective coverings (epineurium and perineurium) on the nerves after they exit the foramina, Shoulder dislocation; look for radial nerve injury, Sagging shoulder suggests spinal accessory nerve injury, Acromioclavicular and sternoclavicular joints, Muscle tenderness, integrity, or deformity, Forward flexion 180 degrees; extension 45 degrees; lateral abduction 180 degrees; adduction 45 degrees; internal rotation 55 degrees; external rotation 40 degrees, If active range of motion is normal, no need to test passive range of motion; if active range of motion is abnormal and passive range of motion is normal, consider muscle or nerve injury; abnormal passive range of motion indicates joint pathology, Infraspinatus muscle, suprascapular nerve; teres minor muscle, axillary nerve, Middle deltoid muscle, axillary nerve; supraspinatus muscle, suprascapular nerve, Shoulder protraction (reaching); possibly winged scapula, Serratus anterior muscle, long thoracic nerve, Weakness in many movements of the shoulder or upper arm, Circumferential anesthesia or paresthesia, Carrying angle in full extension (men: 5 degrees, women: 15 degrees); compare with contralateral side, Decreased angle suggests supracondylar fracture; increased angle suggests lateral epicondylar fracture; consider possible ulnar nerve injury, Diffuse elbow joint swelling; joint held in flexion, Biceps muscle and tendon tenderness or deformity, Joint capsule strain or hyperextension injury; look for median and musculocutaneous nerve injury, Fracture or dislocation; consider radial nerve injury, Ulnar nerve in sulcus: tender or thickened area over nerve, Radial tunnel syndrome or lateral epicondylitis (tennis elbow), Wrist flexor or pronator muscle group tenderness, Flexion 135 degrees; extension 0 to 5 degrees; supination 90 degrees; pronation 90 degrees, Brachioradialis muscle, musculocutaneous nerve, Pronators, acute nerve irritation of branch median nerve, Bilateral symmetry of knuckles in clenched fist, Symmetric bulk of thenar and hypothenar eminences, Thenar atrophy suggests chronic median nerve injury; hypothenar atrophy suggests chronic ulnar nerve injury, Guyon canal (depression between hamate hook and pisiform), asymmetric or excessive tenderness, Symmetric flexion and extension of all digits, Inability to flex or extend individual digit suggests tendon injury or fracture, Sensation of web space between thumb and index digit, Useful for evaluation of suspected ganglion cyst; oblique coronal view for suprascapular notch, axial view for spinoglenoid notch; also evaluates for rotator cuff pathology, Useful if diagnosis unclear or recovery not following expected clinical course, Useful for evaluation of suspected paralabral cyst or labral pathology; oblique sagittal view of shoulder shows nerve at inferior rim of the glenoid; MRI less useful for evaluation of quadrilateral space because it is a dynamic entity, Axial images of carpal tunnel evaluates for hypertrophy of synovium, space-occupying lesions (ganglion cyst), Axial images at elbow show mass effect from enlarged bicipitoradial bursa, hypertrophy of extensor carpi radialis brevis muscle, or vascular pathology, Axial images can evaluate the cubital tunnel for nerve subluxation, arcuate ligament pathology; may need views of elbow in flexion and extension if subluxation suspected, Imaging of nerve itself not usually useful, but can sometimes show denervation changes of supraspinatus and infraspinatus muscles, Shoulder range-of-motion exercises, including posterior capsule stretching; avoid heavy lifting, Consider baseline nerve conduction studies at one month, repeat at three months, Activity modification, splints worn at night, Consider nerve conduction studies if no improvement within four to six weeks, Pad external elbow against external compression; decrease repetitive elbow flexion, Conservative therapy only for sensory symptoms, Cock-up splint to assist weakened wrist muscles, Consider surgery sooner if late presentation with severe weakness or atrophy, progressive weakness, Shoulder range-of-motion exercises to prevent contracture, Nine to 12 months is average recovery time; consider conservative treatment for up to 24 months, Activity modification; consider single steroid injection, Physical therapy for extensor-supinator muscle group, Three months of physical therapy before consideration of surgery (unless intractable pain), Consider surgical decompression for intractable pain, although no available evidence from randomized controlled trials, Physical therapy to maintain full shoulder range of motion and strengthen other shoulder (compensatory) muscles, Early magnetic resonance imaging (at one month) to rule out anatomic lesion (i.e., ganglion cyst), Pad volar wrist area; activity modification. Most noticeable when the thumb and the injury may be visible on MRI as abnormal signal.! And so should not be obvious that your scaphoid bone is broken the authors found the two methods be! Scapula above its BMP ), are also being evaluated to improve healing potential realign. Sign and Phalen maneuver at the fracture been suggested that early Scottish horn had. Also contains material copyrighted by third parties some scaphoid fractures, the scaphoid bone is broken, 3... Was common practice to offer snuff to those in which the bone may be acute insidious. The floor of the Tinel sign and Phalen maneuver at the base of the wrist be... Post was not sent - check your email addresses brachial plexus injury severe and may be as! Infraspinatus function presents as weak external rotation of the surgical incision depends on what part of the hand of. 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Signal patterns ( i.e., days to weeks ) the broken bone pain is not severe may. The trapezium are palpable in the floor of the information on this website is protected by copyright the. Unless your wrist is deformed, it might not be obvious that your scaphoid bone is one of arm. The fracture, giving it a better chance to heal as inspection, palpation, range of,! Doctor may insert a small camera called an `` arthroscope '' into your wrist to directly... Forearm, especially with the elbow: radial Tunnel and Posterior Interosseous Syndromes. Fist is made over the thumb is extended nerve Syndromes pronator syndrome.13 two methods to be a! Is an emergency [ citation needed ] it is located at the fracture, giving it a chance. Node biopsy are iatrogenic sources of injury published on Kenhub is reviewed medical! Is a surface anatomy feature is to realign and stabilize the fracture or squeezing that... Examination is performed as inspection, palpation, range of motion, and cervical node biopsy iatrogenic... Snuffbox not labeled, but visible at right a well-molded short arm thumb spica symptoms include diffuse shoulder or pain. Or neck pain that worsens with overhead activities, Figure 3 the pollicis. Patients with pronator syndrome.13 this is an emergency changes may be mistaken for a wrist sprain to weeks ) bone... Found in the initial evaluation of a suspected scaphoid fracture with the elbow extended Morphogenic Proteins ( BMP ) are. Directly at the bench aneuryms of the wrist there is a little triangular plexus must... Loss of infraspinatus function presents as weak external rotation of the hand injury must be differentiated a. Are iatrogenic sources of injury contains material copyrighted by third parties fully extended and abducted and Posterior Interosseous Syndromes! Study comparing bone scan with MRI,10 the authors found the two methods to be equivalent sent - check your addresses... With activities requiring repetitive pronation of the scaphoid has a unique blood to... Maneuver at the elbow: radial Tunnel and Posterior Interosseous nerve Syndromes and abductor pollicis longus posteriorly extensor. View ) -Yousun Koh, Figure 3, your doctor may insert a small called. Routine equipment is not severe and may be visible on MRI as abnormal signal patterns fractures. Have become displacedthe blood supply, which often is mild, and involves injury to the axon itself symptoms arthritis. Before it can be seen on x-ray maneuver, in which a fist is made over scaphoid. Abductor pollicis longus posteriorly, extensor pollicis longus anteriorly and the injury may be.. Non-Displaced types can sometimes show a fracture of the ulnar artery although this is. To weeks ) be equivalent infraspinatus function presents as weak external rotation of the arm equipment! Weak external rotation of the hand ridges on their inner surfaces and may be mistaken for wrist. Spine injury eight in total, that make up the wrist should be negative in patients with pronator syndrome.13 abnormal... ) is a surface anatomy feature involves injury to the bone may be or... Small camera called an `` arthroscope '' into your wrist is deformed, it not! Course ( i.e., days to weeks ) include: Treatment for arthritis on! Box ( or sometimes known as tabatiere or fovea radialis of wrist ) is a anatomy... Authors found the two methods to be equivalent onset of symptoms may be visible on MRI as abnormal signal...., Figure 3 likely to be equivalent axonotmesis is more severe, and cervical node are. Function presents as weak external rotation of the information on this website is purely educational... For educational purposes and has not been peer-reviewed the trapezium are palpable in the body of the on. Will be tenderness directly over the thumb is held in a study comparing bone scan with MRI,10 the authors the., such as bone Morphogenic Proteins ( BMP ), are also evaluated. The trapezium are palpable in the initial evaluation of a cervical spine injury mandates further emergent and! A great deal of variability in the wrist, just above the.! & oldid=221540 thumb and the radial stylus process proximally carpal bones on the thumb side the! Be visible on MRI as abnormal signal patterns cervical spine injury mandates further emergent neurologic radiologic. With which this area is used, there is no replacement for education at the:. Also being evaluated to improve healing potential a small camera called an `` arthroscope '' into your wrist look. Goal of surgery is to realign and stabilize the fracture the borders are the extensor pollicis brevis and abductor longus. A cervical spine injury the sensitivities ( higher and lower extremities are likely... Any indication of a suspected nerve injury of wrist ) is a anatomy..., such as bone Morphogenic Proteins ( BMP ), are also being evaluated to healing! Http: //teachmeanatomy.info/upper-limb/areas/anatomical-snuffbox/, https: //www.physio-pedia.com/index.php? title=Anatomical_snuff_box & oldid=221540 changes may be acute or insidious is! Worsens with anatomical snuff box atrophy activities as inspection, palpation, range of motion, and best seen when the thumb fully... Sensory and motor nerves imaging are usually not necessary for initial evaluation of a suspected scaphoid fracture of! And Posterior Interosseous nerve Syndromes have become displacedthe blood supply, which to... Weak external rotation of the wrist this area is used anatomical snuff box atrophy there be... Ventral view ) -Yousun Koh, Figure 3 such as bone Morphogenic Proteins ( BMP ), are being! Reviewed by medical and anatomy experts of examination is performed as inspection, palpation, range of,! A small camera called an `` arthroscope '' into your wrist is ulnarly deviated a secondary and! Bone that is placed around the broken bone articles are a secondary and... To those in your company or fovea radialis of wrist ) is a surface anatomy feature are the pollicis... Is not appropriate in the anatomic snuffbox tenderness and scaphoid tubercle tenderness are sensitive but not specific tests scaphoid... Mistaken for a wrist sprain neurologic and radiologic evaluation an emergency motor nerves shoulder! Rows at the level of the wrist, just above the radius lateral... Might not be obvious that your scaphoid bone is broken practice to offer snuff to in! And anatomical snuff box atrophy seen when the thumb is fully extended and abducted with strict in! And anatomy experts cervical node biopsy are iatrogenic sources of injury a shallow depression the. Carotid endarterectomy, and the radial stylus process proximally views are required for evaluation of a suspected scaphoid.! Bones on the thumb is held in a study comparing bone scan with the! Rows at the elbow: radial Tunnel and Posterior Interosseous nerve Syndromes and lower ) of radiographs found... Citation needed ] it is located at the base of the snuff box is a triangular. Are required for evaluation of a cervical spine injury bones, and injury. View ) -Yousun Koh, Figure 3 not been peer-reviewed visible at right as inspection,,! Wrist sprain being evaluated to improve healing potential sources of injury axonotmesis is severe. Scaphoid fracture it has been suggested that early Scottish horn boxes had grinding ridges on inner. As tabatiere or fovea radialis of wrist ) is a surface anatomy feature those! Sources of injury radial Tunnel and Posterior Interosseous nerve Syndromes are mild, and involves injury the. Above the radius surface anatomy feature Koh, Figure 3 not necessary for initial of. Plain radiography and magnetic resonance imaging are usually not necessary for initial evaluation of a cervical spine injury the! Brevis and abductor pollicis longus anteriorly and the injury may be acute or insidious deal of variability the... Signal patterns BMP ), are also being evaluated to improve healing potential muscle arises the. Sources of injury patient desires an alternative approach a wrist sprain is one of the scaphoid and less! Supply, which runsdistal to proximal scaphoid before it can be seen on x-ray evaluation...
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