In mid-September, I fell over my back door step and landed on my wrist. The pain was so bad it made me vomit, and a lengthy trip to the local Minor Injuries Unit ensued. X-rays were done and a partial plaster cast applied, only to be removed 24 hours later at the Trauma Unit in the major regional hospital, where it was replaced with a splint. I returned there for more X-rays two weeks later.
One of the pieces I’m writing at the moment is on narrative medicine, so I’m interested in the stories we tell around our illnesses and accidents, and how patients’ stories relate to physicians’ diagnoses. Stories can influence the diagnosis, shift the blame, or make an injury a badge of pride. Unfortunately, I don’t have a good story to comfort myself with, only a typical tale of a moment’s forgetfulness: I’d left the house, remembered something, and returned to get it. This only involved stepping inside to grab it from the stool just inside the back door, so I didn’t bother to enter the house properly, and as a result I left backwards rather than forwards. Doing this, I forgot about the step down. Helpful friends have made up “better” stories for me, most involving me in some energetic sporting activity, thus making my injury a badge of my physical prowess, or suggesting a fight in which my imaginary opponent looks far worse than I do. If only…
Like any medical historian worth her salt, I have of course been obsessed with the anatomical history of the bones of the hand and wrist since I returned from hospital. Possibly the most famous story is that of the bone named for Andreas Vesalius, whose extraordinary On the Fabric of the Human Body (1543) was intended as a comprehensive guide to every part of the body. Most people, Vesalius observed, think the body is made up of only “ten or twelve parts,” but in fact it comprises “several thousand diverse parts.” I’ve been back to read, with fresh eyes, Vesalius’ guide to boiling up parts of the body to make a skeleton, including the helpful tip, “Do not divide the wrist bones from one another but disjoint them in their entirety from the forearm and from the first bone of the thumb and the metacarpals” followed by advice to wrap each hand separately so the bones don’t get mixed up. (331) Wrist bones are complicated, and difficult to put back together if they get out of order.
“Vesalius’ bone,” the os vesalianum carpi, is located at the base of the fifth metacarpal. Although it’s only present in around 0.1% of the population, he chose to include it in his illustration of the hand and wrist. This is an excellent example of Vesalius’ approach to the body. Rather than illustrating an ideal man or woman, he includes variations. In his teaching dissections, in contrast, he said he would pass over any variations which became apparent in the cadaver of the day, because he didn’t want students to think of them as normal.
And the os vesalianum carpi provides just one helpful reminder of the potential for variability of the human body. It’s not the only oddity in the wrist. Even without any trauma, the bones in the wrist may fuse, or appendages can exist as separate bones. Another rare bone, the os centrale, comes from a nodule which normally merges into the scaphoid, but can present as an entirely separate bone; if this happens, what looks like a scaphoid fracture on X-ray may actually be a bone which has never formed part of the scaphoid.
And this is pertinent to my own case. Because the bone which was originally thought to be fractured was indeed my scaphoid, a bone about the size and shape of a cashew nut. The casualty officer (emergency room physician) who examined me in the first instance was sure, from moving my wrist and asking how the accident happened, that the scaphoid was the issue, and told me that the X-rays, while necessary, would possibly not show the fracture, but I would be treated as if they did because not all scaphoid fractures are visible. And, indeed, the four X-rays revealed nothing, but I still ended up in a splint. As a historian, it interests me that this is an example where the technology is ignored if it doesn’t fit the instincts of the clinician. I’ve always been interested in the use of the senses in medicine, and what is, and is not, visible.
So, in my splint, like any patient in the internet age, I researched my condition. This is not a good bone to fracture. A useful guide to how scaphoid fractures and suspected fractures are diagnosed and treated makes it clear that there’s huge variation in what hospitals across the world do with them, and how they balance instinct with imaging; the human with the technological. The report helpfully notes that “Knowledge of surface anatomy of the carpal bones is often poor.”1 On the specific practice of my own regional hospital, which carries out a second set of X-rays around two weeks after the injury because evidence of the formation of new bone will show there has been a fracture, the report notes that even if these X-rays too show nothing, the scaphoid can still be fractured. But what happens to the patient then? Further immobilization, or exercises?
On that second visit to the regional hospital, I found out. The junior doctor who saw me gave me confusing information. The new X-rays are clear; but you still may have a fractured scaphoid; but maybe you don’t; so leave off the splint and do exercises. But if it hurts, put the splint back on, but not all the time, and come back if it still hurts in another 6 weeks, and we may arrange an MRI.
I went home and thought about it. My wrist was hurting from the maneuvers the doctor had put it through. The National Health Service is chronically underfunded. Yet MRI allows complete certainty. I decided to invoke my private medical insurance and went for a second opinion. The examination of my wrist was much more thorough. The consultant made me do the same movements with the good and the bad wrist — I wasn’t being graded against an ideal wrist, but against myself. He arranged an MRI, which showed three bones — none of them the mysterious scaphoid — broken. The splint was replaced by a cast, and I’m still wearing that.
Whether these fractures should have been seen from the X-rays isn’t clear. Did the scaphoid story mean that nobody was looking at the other bones? Was this an example of a medical narrative that not only turned out to be wrong, but which turned round to damage the patient: me?
The X-ray of a wrist plays a key role in the history of imaging. Wilhelm Roentgen discovered X-rays in 1895, and sent an image of his wife’s hand and wrist to his colleagues at the end of that year. It’s an example of how science meets art; at first glance the image is purely scientific, but once one knows whose hand it is — and the wedding ring stands out — it’s impossible not to think of Roentgen’s life outside his research, which interests me when the story of the development of this imaging technology features him living and sleeping in his laboratory for weeks at a time: the classic narrative of the ‘driven’ scientist. Finding more about Anna, “the woman behind the man,” is challenging; they had no children, but adopted a niece. Anna and Wilhelm shared a love of chocolate.
On first seeing this image, Anna Roentgen is reported as exclaiming “I have seen my death!” Before — and also after — the X-ray, the power of the skeleton as an image of death was present alongside its scientific value. This image also makes the modern viewer reflect on the dose of radiation needed, estimated at around 1500 times what is used today. As stories of the “martyrs of X-rays” make clear, not only physicians experimenting on themselves, but also those who worked in the industry, suffered injury or death from their exposure to radiation.
X-ray and other imaging has also had its effect on the study of the wrist. In the Preface to his A Clinical Atlas: Variations of the Bones of the Hands and Feet (Philadelphia and London, 1907) the Harvard Professor of Anatomy, Thomas Dwight, noted that “The constantly increasing use of the X-ray has shown that the study of variations is not a scientific fad but a matter of very great practical importance. Not only are the ordinary variations (still but little known to the surgeon) constantly appearing, but very uncommon ones are occasionally seen. In fact the number of hands and feet examined by the X-ray is so much greater than that of those seen post mortem by anatomists, that it is not surprising that variations thought excessively rare should repeatedly be brought to light.”
But I don’t have any extra bones, or missing ones. Just a normal, but damaged, wrist. And one which, I hope, is now correctly diagnosed, thanks to a technology superior to that of Roentgen. In my MRI, I’ve seen not my death, but my diagnosis.
- Emma Machin, Julian Blackham, and Jonathan Benger, “GEMNet guideline: Management of Suspected Scaphoid Fractures in the Emergency Department [PDF],” The College of Emergency Medicine, September 2013. Return to text.
I’m interested in your fascination about when doctors use insight as opposed to medicine. My mother suffered for 11 months before pericardial constriction was finally diagnosed. When I spoke to her surgeon, an older man, he said that today’s doctors make their diagnoses on X rays and ultrasounds, usually without having seen the patient. This condition did not show up on those scans and he said that if he had been in charge and taken one look at my mother, he would have realised the condition whatever the scans said.
Great example of how the patient (symptoms and story?) should sometimes override the imaging. Thanks!
And Asa in the thirty and ninth year of his reign was diseased in his feet, until his disease was exceeding great: yet in his disease he sought not to the LORD, but to the physicians.
Have not faith in the physicians, Mistress Helen, but in the culturally appropriate narrative.
By the way, if anyone’s interested, there’s a lot more that could be milked out of Vesalius, his hand, and the dissected hand.
Certainly, David. Following Aristotle et al., there’s lots on the hand as the instrument that sets us apart from the rest of the animal kingdom, and on why Vesalius chose to be shown dissecting the hand in the image which comes first in the ‘Fabrica’, after the title page image…!
Alisa’s daughter Sophia has done something painful to her wrist and had roughly the same treatment by hospital ie nothing showing on xray but might have broken something!!
my advice to anyone in this situation would be: if there’s any doubt, treat it as if it’s broken and keep going back until they take you seriously! Since I had my injury, I’ve also been told that if it swells very quickly it’s probably a break, whereas if it swells over 24 hours or so it probably isn’t. Other readers may well be able to advise on this point!