During a weekend snowboarding trip, a 24-year-old man falls forward onto his outstretched right hand. He presents to an urgent care clinic three hours later reporting pain in his right wrist. On physical examination, there is mild swelling and focal tenderness over the dorsal radial aspect of the wrist, specifically in the depression bounded by the extensor pollicis longus and extensor pollicis brevis tendons. Range of motion is limited by pain, but there is no gross deformity. Sensation and radial pulses are intact. Initial anterior-posterior, lateral, and scaphoid views of the right wrist on radiography show no abnormalities. Which of the following is the most appropriate next step in management?
- AProvide an elastic compression bandage and reassure the patient
- Apply a thumb spica splint and arrange for follow-up imagingAnswer
- CObtain an immediate computed tomography scan of the wrist
- DPerform a closed reduction of the wrist under procedural sedation
- EConsult orthopedic surgery for immediate operative fixation
Answer
The correct next step is to apply a thumb spica splint and arrange for follow-up imaging.
The clinical presentation of a fall on an outstretched hand with focal tenderness in the anatomical snuffbox is highly suspicious for a scaphoid fracture. Because up to 30% of these fractures are occult and do not appear on initial plain radiographs, a negative x-ray does not rule out the injury. The standard of care is to assume a fracture is present, immobilize the wrist using a thumb spica splint, and repeat the radiographs in 7 to 14 days when osteoclastic activity makes the fracture line more visible.
Step-by-Step Solution
Key Concept
Management of clinically suspected, radiographically occult scaphoid fractures