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Anatomy 101: Are You Up To “Snuff?”

It’s time we get away from all of the serious nonsense and back to something I am far more comfortable with: Taking otherwise-useful information and twisting it into utter nonsense. Yes, it’s time to journey back to the wonderful world of the physical exam.

My ongoing mission is to explore the human body from my unique (albeit moderately unstable) perspective. For an overview of my previous posts on the physical exam see this post which features Dick Chaney on a Segway (reason enough to click on the link). Please visit a psychiatry blog to aid in recovery once you have done so.

My most recent post in this fine series covered the topic of psychics and about the examination of the hand. It was mainly about psychics examining the hand, but I did slip in a little doctor stuff to keep the cops off of me. But then I got a call from the department of homeland security and they said that if I didn’t shape up, I’d no longer be able to use the picture of Dick Cheney on the Segway. It’s hard to resist such harsh tactics.

Today I’ll take the high road. The really high road.

hands_of_god_and_adam-400.jpg

You see, the hand is not only celebrated by doctors on blogs, it is also a subject of divine consequence. The above picture is, of course, a representation of the most famous utterance of the words: “Pull my finger.”

(OK, I guess I can’t stay on the high road for long. I don’t think many of you would read this blog in the first place if I did.)

Now that we’ve gotten that out of the way, let’s get back to the subject at hand (har, har): The physical exam. As I said previously, the hand exam is done usually in response to complaints about the hand. There are a few common hand problems I am able to diagnose through the physical exam.

The Snuff Box

As a medical student, you are taught a whole lot of information that you wonder if you will ever use. Why, for example, did we have to use up valuable grey mater to learn about the Kreb’s cycle, that the spot where you most commonly hurt with appendicitis is called McBurney’s Point, that chickens have something called the Bursa of Fabricius (from which the B-Cell is named), and about the spot on the base of the thumb called the anatomical snuff box. Considering the amount of time spent on the anatomical snuff box, you would think it was a window to the soul or a portal to the demonic realm. I was skeptical about its significance. But my neurons were relieved to find out that the anatomical snuff box had significance (other than as a place powdered tobacco could be put before snorting it into the nose).

snuff_037.jpg

Photographic evidence of the usefulness of the snuff box by Dutch men in hats (credit).

So what exactly is the anatomical snuff box? It’s a depression just above the wrist and right below the thumb that is formed by the space between two thumb tendons.

snuff box.jpg

Technically it’s not a box, but the term anatomical snuff depression wouldn’t fly with anatomy profs (although I don’t think Dutch guys would mind.) The significance of the snuff box for me (I swear, I didn’t inhale) is that two conditions make the bones under it hurt. (Note that the above picture uses the term “snuffbox” instead of “snuff box,” which shows which side of the healthcare debate it supports).

Scaphoid Fracture

The first is a fracture of the scaphoid bone.

Carpus.jpeg

In this illustration, the scaphoid bone is pink, and has the letter “A” on it. Scientists are not certain of the significance of the big letters, but some have claimed this as evidence of an intelligent creator. Opponents of this theory point out that the giant number “3″ is actually pointing at 5 bones, which makes the intelligence of this so-called creator suspect.  The debate rages on.

The scaphoid bone can be fractured when a person falls on an outstretched hand. I broke mine when I was running backwards and was tripped by some microorganisms who jumped up and grabbed my ankles. I swear that’s how it happened. Normal wrist x-rays can miss a scaphoid fracture, but the astute clinician suspects it when the patient jumps, screams in pain, and threatens a curse on the doctor’s descendants when the doctor presses on the anatomical snuff box.

Day-Something Teno-Something

The second condition involving the anatomical snuff box is called De Quervain’s Tenosinovitis. This condition was first described by a Swiss doctor who was unfortunate enough to be named Fritz De Quervain, a name that has baffled doctors and patients ever since Fritz did his discovering. How do you pronounce the dang name? Is it “Dee-Kwer-Vain,” as it appears, is it “Duh-Kare-Vahs,” as the Mayo Clinic suggests, or is it “Deh-Ker-Vehs,” as Miriam Webster suggests? I suggest it be pronounced “Dang-my-thumb-hurts,” but this pronunciation hasn’t gained widespread acceptance.

The basic problem happens when the tendons (tough fibrous tissue that connects muscle to bone, allowing the muscle to move the bone from a remote location) that straighten out the thumb become inflamed due to repetitive use of said thumb.

Tenosynovitis.jpg

Fritz noticed the orange irregular outline, and decided to investigate. The rest is history. (Credit)

On exam, the person hurts at or near our old pal, the anatomical snuff box, when it is pressed while the person moves the thumb across the palm. This condition is treated by cortisone injection and a period of torture by a physical therapist.

There is another way to diagnose this condition –- a maneuver called the “Finkelstein Test.” The test is named after De Quervain’s arch rival, the evil Baron Von Finkelstein. This test is performed by making a fist with the thumb tucked under the other fingers and the wrist is flexed toward the pinkie.

ans7_finkelsteintest.jpg

From MayoClinic.com

When this procedure is performed, two things happen: the wrist hurts in the region of the snuff box, and it glows an eerie red. There are three reasons I don’t perform this test:

  1. Neither the patients nor me want anything to do with the evil Baron Von Finkelstein.
  2. The eerie red light freaks people out.
  3. The patient is simultaneously in pain and making a fist –- a situation most doctors try to avoid.

Well now I have burdened your neurons with more information about the anatomical snuff box than you could ever wish to know. But there is one more thing I would like to mention about this critical part of the body.

CHART-KOREAN-HAND-2.jpg

Chart-Korean-Reflex-Hand.jpg

These amazing pictures from the wonderful world of reflexology show that the snuff box is really a mirror to the top of the right leg. Now that’s information you’d never get on Kevin, MD! I’d better keep quiet about that, however, because he may just flip me the spleen.

*This blog post was originally published at Musings of a Distractible Mind*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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