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The scaphoid shift test
letters to the Editor
The Scaphoid Shift Test
The Wrist Tourniquet: An Alternative Technique in Hand Surgery
To the Editor: To the Editor: I am writing this letter with the intention of clarifying and correcting any potential misunderstanding that may have arisen from my article’ published in the Department of Technique in the March 1993 issue. I described a maneuver to provoke dorsal subluxation of the scaphoid. This particular method of examining the scaphoid, as I understand it, is different from that described by Watson.* He describes taking the wrist from ulnar to radial deviation with counterpressure on the tubercle of the scaphoid and noting whether or not the scaphoid subluxes dorsally and whether it “thunk(s)” back into place. The technique I described maintains the wrist in neutral and the examiner forcefully pushes the scaphoid dorsally, trying to sublux it. I have subsequently learned of many hand surgeons who use the same or similar maneuver, but my search of the literature has revealed no similar published descriptions. I regret having entitled my article “The Scaphoid Shift Test,” as Watson had already described his maneuver as “the scaphoid shift.“* I clearly erred and wish to withdraw the term “scaphoid shift.” I would like to submit another name for the maneuver. Dr. Scott Wolfe3 has suggested “scaphoid ballottement,” and Drs. William Cooney and James Dobyns use the term “scaphoid lift test” (conversation with S. Wolfe, May, 1993). While these terms are entirely reasonable, I have tried to find a word that implies the forceful shoving of the scaphoid dorsally. Therefore, I wish to submit the term “scaphoid thrust test” as more accurate and descriptive. Lewis B. Lane, MD 800 Community Drive Manhasset, NY 11030
References 1. Lane LB. The scaphoid shift test. J Hand Surg 1993: 18A:366-8. 2. Watson HK, Ashmead D, Makhoulf MV. Examination of the scaphoid. J Hand Surg 1988;13A:657-60.
Guirguis and Bell, in their article “The Wrist Tourniquet: An Alternative Technique in Hand Surgery” (J Hand Surg 1990;15A:516-9), proposed a new and interesting approach to avoiding some of the hazards associated with conventional tourniquets. They pointed out that the upper-arm site unnecessarily renders the forearm ischemic and suggested that a wrist tourniquet, created by wrapping a size 8-l/2 surgical glove three times around the wrist, would minimize the attendant discomfort and potential for injury. They reported two cases of mild-to-moderate discomfort and one case of failure to achieve haemostasis among 25 cases in which the wrist tourniquet was used. Based on these results, they claimed that this technique is a safe and effective alternative to the upper-arm tourniquet. 1 hesitate to accept their conclusion, however, and believe that it is first necessary to assess the choices of occlusion site and occlusive device independently. Regardless of the occlusion site, there are at least two reasons to suspect that the surgical glove is intrinsically more dangerous than a pneumatic tourniquet. First, the pressure the glove applies is extremely variable, ranging from 110 to 260 mmHg with the same application protocol, so that excessive pressures can be applied unintentionally. Pneumatic tourniquets, in contrast, can be reliably inflated to within 10 mmHg of the target pressure. ’ Second, a wrapped glove is likely to cause the same sorts of skin-shear and local stress injuries associated with Esmarch bandages, while a pneumatic tourniquet offers some protection against such injuries. In their study, Guirguis and Bell wrapped the glove over a partially inflated blood pressure cuff in order to measure the pressure the glove applied; the net effect was probably quite similar to applying a pneumatic tourniquet to the wrist, so their protocol would have prevented the kinds of injuries we might expect during routine use of a glove applied to bare skin. I therefore believe that while Guirguis and Bell have done us the service of suggesting that the wrist site may be used to avoid the forearm pain someThe Journal of Hand Surgery
341
The Scaphoid Shift Test
The Wrist Tourniquet: An Alternative Technique in Hand Surgery
To the Editor: To the Editor: I am writing this letter with the intention of clarifying and correcting any potential misunderstanding that may have arisen from my article’ published in the Department of Technique in the March 1993 issue. I described a maneuver to provoke dorsal subluxation of the scaphoid. This particular method of examining the scaphoid, as I understand it, is different from that described by Watson.* He describes taking the wrist from ulnar to radial deviation with counterpressure on the tubercle of the scaphoid and noting whether or not the scaphoid subluxes dorsally and whether it “thunk(s)” back into place. The technique I described maintains the wrist in neutral and the examiner forcefully pushes the scaphoid dorsally, trying to sublux it. I have subsequently learned of many hand surgeons who use the same or similar maneuver, but my search of the literature has revealed no similar published descriptions. I regret having entitled my article “The Scaphoid Shift Test,” as Watson had already described his maneuver as “the scaphoid shift.“* I clearly erred and wish to withdraw the term “scaphoid shift.” I would like to submit another name for the maneuver. Dr. Scott Wolfe3 has suggested “scaphoid ballottement,” and Drs. William Cooney and James Dobyns use the term “scaphoid lift test” (conversation with S. Wolfe, May, 1993). While these terms are entirely reasonable, I have tried to find a word that implies the forceful shoving of the scaphoid dorsally. Therefore, I wish to submit the term “scaphoid thrust test” as more accurate and descriptive. Lewis B. Lane, MD 800 Community Drive Manhasset, NY 11030
References 1. Lane LB. The scaphoid shift test. J Hand Surg 1993: 18A:366-8. 2. Watson HK, Ashmead D, Makhoulf MV. Examination of the scaphoid. J Hand Surg 1988;13A:657-60.
Guirguis and Bell, in their article “The Wrist Tourniquet: An Alternative Technique in Hand Surgery” (J Hand Surg 1990;15A:516-9), proposed a new and interesting approach to avoiding some of the hazards associated with conventional tourniquets. They pointed out that the upper-arm site unnecessarily renders the forearm ischemic and suggested that a wrist tourniquet, created by wrapping a size 8-l/2 surgical glove three times around the wrist, would minimize the attendant discomfort and potential for injury. They reported two cases of mild-to-moderate discomfort and one case of failure to achieve haemostasis among 25 cases in which the wrist tourniquet was used. Based on these results, they claimed that this technique is a safe and effective alternative to the upper-arm tourniquet. 1 hesitate to accept their conclusion, however, and believe that it is first necessary to assess the choices of occlusion site and occlusive device independently. Regardless of the occlusion site, there are at least two reasons to suspect that the surgical glove is intrinsically more dangerous than a pneumatic tourniquet. First, the pressure the glove applies is extremely variable, ranging from 110 to 260 mmHg with the same application protocol, so that excessive pressures can be applied unintentionally. Pneumatic tourniquets, in contrast, can be reliably inflated to within 10 mmHg of the target pressure. ’ Second, a wrapped glove is likely to cause the same sorts of skin-shear and local stress injuries associated with Esmarch bandages, while a pneumatic tourniquet offers some protection against such injuries. In their study, Guirguis and Bell wrapped the glove over a partially inflated blood pressure cuff in order to measure the pressure the glove applied; the net effect was probably quite similar to applying a pneumatic tourniquet to the wrist, so their protocol would have prevented the kinds of injuries we might expect during routine use of a glove applied to bare skin. I therefore believe that while Guirguis and Bell have done us the service of suggesting that the wrist site may be used to avoid the forearm pain someThe Journal of Hand Surgery
341