Carpal navicular fracture, also known as scaphoid fracture, is a common type of wrist fracture that affects the scaphoid bone in the wrist. Understanding the anatomy, causes, symptoms, diagnosis, and treatment options of this fracture is crucial for proper management and recovery. A reputable source, the American Academy of Orthopedic Surgeons, provides comprehensive information on this topic.

Anatomy of the Carpal Navicular Bone

The carpal navicular bone, also known as the scaphoid bone, is an important component of the wrist’s anatomy. Situated on the proximal row of carpals, this boat-shaped bone has a rounded proximal surface and a flattened distal surface. With dimensions of approximately 3 cm in length and 1.5 cm in width, it provides stability and allows for proper movement of the wrist joint by articulating with neighboring bones like the radius, lunate, and scaphoid.

Ligaments play a pivotal role in maintaining the carpal navicular bone’s stability, enabling various wrist movements. The bone’s blood supply primarily derives from branches of the radial artery. Its significance lies in its ability to transmit forces between the forearm and hand, contributing to wrist joint flexibility and stability.

This bone is susceptible to fractures, often resulting from falls or direct trauma to the wrist. Fractures can cause pain, swelling, and limited mobility of the wrist.

Understanding the anatomy of the carpal navicular bone is crucial for healthcare professionals and individuals seeking knowledge about wrist structure.

It facilitates accurate diagnosis and effective management of injuries, particularly carpal navicular fractures. Medical practitioners can apply this knowledge to provide appropriate treatment and rehabilitation strategies.

Simultaneously, individuals can gain insight into their wrist’s functionality and comprehend the importance of safeguarding its health.

While this summary provides an overview, it is advisable to consult medical professionals for a more detailed understanding.

Causes of Carpal Navicular Fractures

Carpal navicular fractures happen for various reasons. Understanding these causes can help people prevent these injuries. Here are the common causes:

1. Trauma: The main cause is trauma, like falling on an outstretched hand or a direct blow to the wrist. The force applied to the wrist can break the carpal navicular bone.
2. Repetitive Stress: Activities involving repetitive wrist movements, like typing or certain sports, can lead to carpal navicular fractures. Over time, the stress weakens the bone, making it more prone to fractures.
3. Osteoporosis: Weakening of bones due to osteoporosis makes them more susceptible to fractures. Individuals with osteoporosis have reduced bone density and a higher risk of fracturing their carpal navicular bone even with slight trauma.
4. Age: Older individuals are more prone to carpal navicular fractures due to aging. As we age, our bones become weaker and more susceptible to fractures.
5. Poor Nutrition: Inadequate intake of essential nutrients like calcium and vitamin D weakens bones and increases the risk of fractures, including carpal navicular fractures.
6. Overuse: Overusing the wrist joint without proper rest and recovery can cause stress fractures in the carpal navicular bone.

Preventing carpal navicular fractures is important. Here are some suggestions to minimize the risk:

• Use proper protective gear, like wrist guards, for activities that pose a high risk for wrist injury.
• Practice good ergonomics, especially while working on a computer, to minimize wrist stress.
• Maintain a balanced diet rich in calcium and vitamin D to support bone health.
• Incorporate weight-bearing exercises and resistance training into your fitness routine to strengthen bones.
• Take breaks and use proper form during repetitive activities to reduce strain on the wrist joints.

By understanding the causes and taking preventive measures, individuals can reduce the risk of carpal navicular fractures and maintain optimal wrist health.

Symptoms of Carpal Navicular Fractures

The symptoms of carpal navicular fractures, also known as scaphoid fractures, can manifest in various ways. It is common to experience pain, tenderness, and swelling in the affected area. Gripping objects might become difficult, and weakness may be felt. There may be a decreased range of motion and instability, along with difficulty using the thumb. It is essential to note that these symptoms may not always be present and can vary in severity. If you encounter any of these symptoms following a wrist injury, seeking immediate medical attention is crucial. A healthcare professional will be able to provide an accurate diagnosis and recommend suitable treatment options for carpal navicular fractures.

Diagnosis of Carpal Navicular Fractures

The diagnosis of carpal navicular fractures involves clinical evaluations and imaging tests. Here are the steps in diagnosing carpal navicular fractures:

1. Obtain a detailed medical history from the patient to gather information about the injury, previous hand/wrist injuries, and existing medical conditions.
2. Conduct a physical examination to assess swelling, tenderness, deformity, and restricted range of motion. Perform specific tests to evaluate the stability and integrity of the carpal navicular bone.
3. Use x-rays for the initial evaluation. These images can identify cracks or fractures, but additional imaging tests may be necessary in some cases.
4. Order an MRI if x-rays are not conclusive or if there is a suspected fracture that is not visible on standard x-rays. (An MRI provides detailed images of bones, ligaments, tendons, and soft tissues.)
5. Consider a CT scan to assess the extent of the fracture and obtain a more detailed view of the bone structure. (CT scans use x-rays and computer technology to create cross-sectional images of the bones.)

Note: The diagnosis of carpal navicular fractures may require a combination of these methods. Seeking medical attention and obtaining an accurate diagnosis is crucial for proper treatment and successful recovery.

Treatment Options for Carpal Navicular Fractures

Various options are available when treating carpal navicular fractures. The choice depends on factors such as fracture severity, patient age and overall health, and recovery goals.

1. Immobilization: Minor fractures can be treated with a cast or splint. This allows natural healing without the need for surgery. The cast or splint is worn for several weeks, with regular follow-up appointments to monitor healing.
2. Surgery: Severe cases may require surgery. Surgical options include internal fixation (using screws or wires to hold bones together) or external fixation (using a device outside the body). The specific technique depends on the fracture characteristics.
3. Physical therapy: After initial healing, physical therapy helps regain wrist strength, flexibility, and function. Tailored exercises and techniques are provided by physical therapists to promote healing and prevent complications.
4. Pain management: Pain management is crucial during recovery. Pain medications (such as NSAIDs) and treatments like ice or heat therapy may be used.
5. Lifestyle modifications: Patients should make lifestyle changes to support healing. This includes avoiding wrist-stressing activities, following a healthy diet for bone health, and practicing proper ergonomics to prevent further injury.

Recovery and Rehabilitation

After a carpal navicular fracture, the recovery and rehabilitation process is crucial for restoring hand function. Recovery and rehabilitation are important factors to consider in the healing journey. Here are some important factors to consider:

1. Immobilization: stabilizing the fractured wrist with a cast or splint. This promotes proper healing and typically lasts 6-8 weeks.
2. Physical Therapy: After removing the cast, physical therapy is vital for recovery and rehabilitation. It improves wrist range of motion, strength, and flexibility. Start with gentle exercises and gradually progress to more challenging ones.
3. Occupational Therapy: This therapy focuses on restoring daily life activities and skills. Recovery and rehabilitation are achieved through occupational therapy. Your therapist may recommend adaptive techniques and devices to aid in writing, using utensils, and performing self-care tasks.
4. Pain Management: Managing pain and inflammation is important during the recovery and rehabilitation process. Follow the pain management plan prescribed by your healthcare provider. NSAIDs (nonsteroidal anti-inflammatory drugs) can help with pain and inflammation. Ice packs and rest can also alleviate discomfort.
5. Gradual Return to Activities: Gradually reintroduce activities involving the injured wrist to prevent re-injury. Your healthcare provider will guide you on when it is safe to resume specific activities.

Sarah, a passionate pianist who suffered a carpal navicular fracture in her dominant hand. Sarah diligently followed her physical therapy exercises and occupational therapy recommendations. With time, she noticed improvements in her wrist mobility and finger dexterity. Her commitment paid off, and after several months of recovery and rehabilitation, she was able to play the piano again. The recovery and rehabilitation process not only restored her hand function but also cultivated a newfound appreciation for her body’s resilience.

Remember, each individual’s recovery journey is unique, and the time taken to regain full function may vary. By following healthcare professionals’ guidance and staying committed to the recovery and rehabilitation process, a successful outcome after a carpal navicular fracture can be achieved.

Complications and Risks

Complications and Risks of Carpal Navicular Fractures

A carpal navicular fracture can cause complications and risks that affect wrist and hand function.

1. Infection: If the fracture breaks through the skin or if surgery is needed, there is a risk of infection. Prompt medical attention and proper wound care can help prevent infections.
2. Non-union: Sometimes the fractured bone may not heal properly or at all. This is called non-union. It can happen due to poor blood supply, excessive movement, or inadequate immobilization. Surgery may be needed to promote bone healing.
3. Malunion: When a fracture heals in the wrong position, it is called malunion. Malunion can lead to limited wrist and hand function, limited movement, and chronic pain. Corrective surgery may be necessary depending on the severity and effect on daily activities.
4. Instability: Navicular fractures can make the wrist joint unstable, causing chronic instability, pain, and difficulty with wrist movement. Physical therapy and, in severe cases, surgery may be needed to restore stability.
5. Post-traumatic arthritis: Fractures involving the joint surface increase the risk of post-traumatic arthritis. This condition causes pain, stiffness, and decreased joint function. Physical therapy, medications, and, in severe cases, joint surgery may be necessary to manage symptoms and restore joint function.
6. Nerve or blood vessel damage: The carpal navicular is close to important nerves and blood vessels. A fracture can potentially harm these structures, leading to numbness, tingling, weakness, or impaired blood flow to the hand. Prompt medical attention is crucial to assess and address any nerve or vascular injuries.
7. Compartment syndrome: Carpal navicular fractures can rarely cause compartment syndrome, a serious condition characterized by increased pressure within a muscle compartment. Compartment syndrome can result in tissue damage, loss of function, and require emergency surgery to release the pressure.

It is important to note that the specific complications and risks of a carpal navicular fracture may vary depending on the severity, overall health, and treatment approach. Consulting with a healthcare professional is essential to understand and address potential complications and risks associated with this type of fracture.

Prevention of Carpal Navicular Fractures

To prevent carpal navicular fractures, it is important to incorporate the following steps into your daily routine:

1. Strengthen your bones: Engage in weight-bearing exercises like weightlifting to improve bone density and reduce the risk of carpal navicular fractures. Aim for at least 30 minutes of exercise most days to maintain good wrist health.
2. Use protective gear: When participating in high-risk sports or activities, always wear wrist guards or gloves to absorb shock and prevent carpal navicular fractures.
3. Improve workplace ergonomics: Properly set up your workspace to minimize strain on your wrists when engaging in repetitive wrist movements at work. Use ergonomic equipment such as wrist rests and adjustable chairs to maintain a neutral wrist position and prevent carpal navicular fractures.
4. Avoid overuse injuries: Take regular breaks during activities that involve repetitive wrist movements, such as typing or using a computer mouse, to prevent overuse injuries and carpal navicular fractures. Incorporate stretching exercises for the wrists and hands to maintain good wrist health.
5. Modify activities: If you participate in sports or activities that put excessive stress on your wrists, consider modifying them or choosing alternative exercises that are less likely to cause carpal navicular fractures. Opt for low-impact exercises instead of high-impact ones to prevent wrist injuries.
6. Maintain a healthy lifestyle: To strengthen your bones and reduce the risk of carpal navicular fractures, it is crucial to eat a balanced diet rich in calcium and vitamin D. Avoid smoking and excessive alcohol consumption, as these can negatively impact bone health.

 

Pro-tip: Pay attention to any warning signs or symptoms of wrist pain or discomfort. If you experience persistent wrist pain or have concerns about your wrist health, consult a healthcare professional for assessment and guidance on preventive measures to avoid carpal navicular fractures.

By incorporating these preventive measures and adopting healthy habits into your daily routine, you can greatly reduce the risk of carpal navicular fractures and maintain good wrist health. Remember, prevention is always better than treatment when it comes to carpal navicular fractures.

How Long Does it Take to Recover from a Carpal Navicular Fracture?

Recovering from a carpal navicular fracture can vary depending on multiple factors. Each individual’s recovery time may differ, so it is crucial to consult with a medical professional for specific advice.

The estimated duration for recovery from a carpal navicular fracture is typically 8 to 12 weeks.

During recovery, it is important to immobilize the affected wrist with a cast or splint for proper healing. This immobilization period usually lasts 6 to 8 weeks. Follow your healthcare provider’s instructions regarding the duration and usage of the cast or splint.

In some cases, physical therapy may be recommended to regain wrist strength, flexibility, and range of motion. Physical therapy sessions may occur 1 to 2 times per week, with the duration depending on individual progress.

The healing process can be influenced by factors like age, overall health, and adherence to the treatment plan. Younger individuals tend to recover faster due to higher bone density and healing capabilities. Maintaining a healthy lifestyle and balanced diet can also contribute to a faster recovery.

Adhering to the designated recovery time frame, following healthcare provider instructions, and avoiding risky activities are crucial for successful recovery. Returning to strenuous activities too soon can delay healing or cause further damage to the wrist.

What Can I Do to Help Myself Heal Faster?

If you have a carpal navicular fracture, you may be wondering what you can do to help yourself heal faster. Fortunately, there are several things you can do to promote healing and expedite the recovery process. It is crucial to closely follow your doctor’s instructions for proper healing. This will ensure that you are taking the necessary steps to aid in the healing of your fractured bone.

Wearing a splint or cast, as directed by your doctor, is essential for immobilizing the fractured bone. By immobilizing the affected area, you are providing stability and support, allowing the bone to heal properly.

To reduce swelling and improve blood flow, elevate your hand above heart level. This simple yet effective technique can significantly contribute to the healing process.

Applying ice to the affected area for 15-20 minutes several times a day can help reduce pain and swelling. Cold therapy is a tried and tested method for managing pain and promoting healing.

Non-prescription pain relievers such as ibuprofen or acetaminophen can be taken following the recommended dosage guidelines. These medications can provide temporary relief from pain, making the healing process more tolerable.

Maintaining a balanced diet that is rich in vitamins and minerals is crucial for supporting the healing process. By providing your body with the necessary nutrients, you are giving it the fuel it needs to repair and heal. Staying hydrated by drinking an adequate amount of water is also important for facilitating healing. Water helps in transporting nutrients to the affected area and flushing out toxins, promoting optimal healing conditions.

During the healing process, it is crucial to avoid activities that can further injure the hand. Implementing caution and being mindful of potential risks will prevent setbacks and promote a more efficient healing process. Attending physical therapy sessions, as recommended by your doctor, is essential for regaining strength and functionality. These sessions will help you restore mobility and improve overall hand function.

Regularly following up with your doctor is important to monitor progress and make any necessary adjustments. Your doctor will be able to assess your healing and provide guidance if any modifications to your treatment plan are required.

By incorporating these guidelines into your recovery process and taking proactive steps, you can aid in your healing and potentially accelerate the overall healing time. Remember to always follow your doctor’s instructions and prioritize your well-being for a successful recovery.

What Are the Long-Term Effects of a Carpal Navicular Fracture?

A carpal navicular fracture has long-term effects on a person’s hand and wrist. The severity of the fracture and the individual’s recovery process determine the variation in these effects. Here are some notable long-term effects of a carpal navicular fracture:

1. Limited range of motion: Individuals may have a limited range of motion in their hand and wrist. This can make it challenging to perform tasks that require fine motor skills, such as writing or gripping objects.
2. Persistent pain: Many individuals with a carpal navicular fracture experience ongoing pain in their hand and wrist, even after the fracture has healed. Certain movements or activities can exacerbate the pain and significantly impact their quality of life.
3. Arthritis: A carpal navicular fracture increases the risk of developing arthritis in the hand and wrist. Arthritis causes inflammation and stiffness in the joints, further limiting the range of motion and causing discomfort.
4. Weakness and muscle atrophy: Immobilization during the healing process weakens and atrophies the muscles in the affected area. Consequently, this leads to a decrease in grip strength and difficulties in activities that require strength and dexterity.
5. Functional limitations: The long-term effects of a carpal navicular fracture can restrict everyday tasks. Simple activities like opening jars, typing, or playing sports may become challenging or even impossible.

It’s important to note that the long-term effects can vary based on factors such as fracture severity, age, overall health, and adherence to rehabilitation exercises.

To mitigate these effects, it is crucial to follow a comprehensive rehabilitation plan prescribed by a medical professional. This may include exercises to improve range of motion and strength, as well as monitoring pain and addressing potential complications like arthritis.

What Are the Success Rates of Surgery for Carpal Navicular Fractures?

Carpal navicular fractures are a common wrist injury that can be debilitating if not treated properly. surgery is often recommended to repair the fracture and restore normal function. But what are the success rates of surgery for carpal navicular fractures?

1. Success rates: Surgery for carpal navicular fractures has an average success rate of 80% to 90%. Factors such as the severity of the fracture, the surgeon’s skill, and the patient’s adherence to postoperative care can affect the success rate. Most patients who undergo surgery can expect a successful outcome and a return to normal wrist function.
2. Types of surgery: Surgical techniques like open reduction and internal fixation (ORIF) and percutaneous screw fixation are used to repair carpal navicular fractures. Both techniques have high success rates ranging from 80% to 95%. The choice of technique depends on factors like the location and stability of the fracture.
3. Rehabilitation: Surgery is only part of the treatment for carpal navicular fractures. After surgery, patients need to undergo rehabilitation to regain wrist strength and mobility. Following their surgeon’s instructions and attending all recommended therapy sessions is crucial for a successful recovery.
4. Complications: Potential complications of surgery for carpal navicular fractures include infection, nerve damage, stiffness, or non-union of the fracture. The overall risk of complications is relatively low, ranging from 5% to 15% according to studies.
5. Patient factors: Success rates of surgery for carpal navicular fractures can also be influenced by patient factors such as age, overall health, and compliance with postoperative care. Younger patients tend to have better outcomes due to better healing potential. Patients who have other health conditions or do not follow their surgeon’s instructions may have a higher risk of complications and a lower chance of success.

What Are Other Types of Wrist Fractures and Their Symptoms?

Wrist fractures have various types, each with its own symptoms. Understanding these types and their symptoms helps with diagnosis and treatment. Here are common wrist fractures and their symptoms:

Colles Fracture:

• Symptoms: Pain, swelling, tenderness, and wrist deformity. The wrist appears bent and the hand displaced backward.

Smith Fracture (Reverse Colles Fracture):

• Symptoms: Pain, swelling, tenderness, and deformity similar to Colles fracture. In a Smith fracture, the hand is displaced forward.

Scaphoid Fracture:

• Symptoms: Pain, tenderness, and swelling at the base of the thumb. Limited wrist motion, difficulty gripping objects, and possible bruising or discoloration.

Barton’s Fracture:

• Symptoms: Pain, swelling, and tenderness on the back of the wrist. Wrist bones displacement can cause visible deformity and misalignment.

Chauffeur’s Fracture (Radial Styloid Fracture):

• Symptoms: Pain, swelling, and tenderness on the thumb side of the wrist. Limited motion, difficulty gripping objects, and pain with thumb movements.

Hamate Fracture:

• Symptoms: Pain, especially during gripping activities. Pain felt on the pinky side of the wrist. Swelling, tenderness, and possible deformity.

These are some examples of wrist fractures and their symptoms. Other types may have distinct symptoms. If you suspect a wrist fracture, seek medical attention for diagnosis and treatment. What Are Other Types of Wrist Fractures and Their Symptoms?

How Can I Prevent Wrist Injuries?

Preventing wrist injuries is crucial for maintaining the health of your hands and wrists. If you’re wondering how you can prevent wrist injuries, here are some steps to follow:

• Evaluate your surroundings: Take a look around and identify any potential hazards that could lead to wrist injuries. Make sure to remove or fix uneven surfaces, loose rugs, or cluttered areas that might cause you to trip and fall.
• Use proper ergonomics: When working or performing repetitive tasks, maintain good posture and use ergonomic tools and equipment. It’s important to set up your workspace correctly to minimize strain on your wrists.
• Stretch and warm up: Before engaging in any physical activity that involves your wrists, make sure to warm up your muscles and perform wrist stretching exercises. By doing so, you increase flexibility and reduce the risk of injuries.
• Strengthen your wrists: Incorporate exercises into your fitness routine that specifically target wrist strength. These can include wrist curls, wrist rotations, and grip strengthening exercises.
• Wear protective gear: If you take part in activities with a higher risk of wrist injuries, such as sports or manual labor, it’s essential to wear appropriate protective gear like wrist guards or braces. These provide extra support and stability for your wrists.
• Avoid repetitive strain: If you regularly perform repetitive motions with your wrists, it’s important to take breaks and vary your activities. Prolonged repetitive movements can lead to overuse injuries like carpal tunnel syndrome.
• Practice proper lifting techniques: When lifting heavy objects, use the strength of your entire arm and leg muscles instead of relying solely on your wrists. Lift with your legs and keep your wrists in a neutral position to prevent excessive stress.
• Stay hydrated and maintain a healthy lifestyle: Proper hydration helps keep your joints, including your wrists, lubricated. A balanced diet and regular exercise can improve overall joint health and reduce the risk of injuries.
• Keep your wrists protected during sports: If you participate in sports activities, make sure to wear appropriate wrist protection like guards or wraps. This helps absorb impact and prevent wrist injuries during falls or collisions.
• Listen to your body and seek help if needed: Pay attention to any pain, discomfort, or signs of injury in your wrists. If you experience persistent pain or difficulty using your wrists, it’s important to consult a healthcare professional for proper diagnosis and treatment.

By following these steps and being mindful of your wrist health, you can significantly reduce the chances of wrist injuries and maintain optimal hand and wrist function. Always remember that prevention is key when it comes to wrist injuries.

What Is the Rehabilitation Process Like for Wrist Fractures?

The rehabilitation process for wrist fractures is crucial for restoring strength and function to the injured wrist. What Is the Rehabilitation Process Like for Wrist Fractures? Here is an overview of the process:

1. Physical therapy: Patients will undergo exercises to improve range of motion, flexibility, and strength in the wrist. These include wrist rotations, flexion and extension exercises, and grip strengthening.
2. Splinting and immobilization: A splint or cast may be applied to immobilize the wrist and promote healing, depending on the severity of the fracture.
3. Gradual mobilization: Once the fracture has healed, the rehabilitation process focuses on gradually mobilizing the wrist by removing the cast or splint and starting gentle exercises.
4. Functional exercises: Rehabilitation shifts towards functional exercises that simulate daily activities as the wrist becomes more mobile. These exercises aim to strengthen the wrist and improve coordination.
5. Progressive resistance training: To further enhance wrist strength, progressive resistance training is introduced using therapy putty, hand grip devices, or resistance bands.
6. Activity-specific training: Towards the end of rehabilitation, therapy incorporates activities specific to the patient’s lifestyle or occupation. This may involve sports-specific exercises or tasks that simulate daily demands.
7. Education and self-management: Throughout the process, patients receive education on proper wrist care, injury prevention, and self-management. This empowers patients to take an active role in their recovery and minimize the risk of future injuries.

The duration and intensity of rehabilitation may vary depending on the severity of the wrist fracture and individual factors. Compliance with recommended exercises and ongoing communication with healthcare professionals are essential for successful rehabilitation and optimal recovery.

What Are the Different Treatment Options for Wrist Fractures?

Treating a wrist fracture requires medical intervention and care. When it comes to wrist fractures, there are several treatment options available. One option is casting, where a plaster or fiberglass cast is applied to immobilize the wrist and promote natural healing. This cast helps reduce pain and provides stability during the healing process.

Another treatment option is splinting, which is similar to casting. It involves using a rigid or semi-rigid support to immobilize the wrist. Splints are recommended for minor fractures or as a temporary measure before a cast is applied.

For complex fractures, a closed reduction may be necessary. This procedure manually realigns the broken bones without the need for surgery. Following a closed reduction, the wrist is immobilized with a cast or splint.

In severe or misaligned fractures, surgery may be required. Open reduction and internal fixation (ORIF) is a surgical procedure where the broken bones are realigned and held together with screws, plates, or pins. This promotes proper healing.

In certain cases, external fixation is used. It involves placing pins or wires into the bone and connecting them to an external frame to stabilize the fracture during healing.

Physical therapy plays a crucial role in the recovery process. After the initial healing phase, physical therapy helps regain strength, flexibility, and range of motion in the wrist. Various exercises and rehabilitation techniques are used to restore functionality and prevent stiffness.

It is important to note that the specific treatment option for a wrist fracture depends on the type and severity of the fracture. Consulting a healthcare professional is essential in order to determine the most suitable course of action.

Fact: In the United States, approximately 250,000 wrist fractures occur each year. To ensure a successful recovery and prevent long-term complications, early and appropriate treatment is essential.

Some Facts About Carpal Navicular Fractures:

• Scaphoid fractures are the most common type of carpal bone injuries.
• Scaphoid fractures are usually caused by wrist hyperextension, often during a fall on an outstretched hand.
• Scaphoid fractures can disrupt the blood supply to the proximal scaphoid, leading to a condition called osteonecrosis.
• Symptoms of scaphoid fractures include swelling and tenderness on the radial side of the wrist.
• Diagnosing scaphoid fractures can be challenging, as plain X-rays may not initially show the fracture.