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Difficulty: EasyOrthopedic Surgery

A 19-year-old college student presents to the urgent care clinic with right wrist pain after falling on an outstretched hand while skateboarding yesterday. Vital signs are within normal limits (temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 78/min, respirations 14/min). On physical examination, there is mild swelling over the radial aspect of the wrist and exquisite tenderness to palpation in the anatomical snuffbox. Sensation to pinprick is intact in all digits, and radial and ulnar pulses are 2+ and symmetric. Capillary refill is less than 2 seconds. Radiographs of the right wrist reveal no evidence of fracture or dislocation. What is the most appropriate next step in management?

  1. Application of a thumb spica splintAnswer
  2. B
    Reassurance and treatment with oral NSAIDs
  3. C
    Immediate open reduction and internal fixation
  4. D
    Corticosteroid injection into the first dorsal compartment
  5. E
    Application of a short arm cast without thumb inclusion

Answer

Application of a thumb spica splint.
The correct next step is the application of a thumb spica splint. A fall on an outstretched hand resulting in anatomical snuffbox tenderness is the classic presentation for a scaphoid fracture. Because up to 20% of these fractures are occult (not visible) on initial radiographs, any patient with this specific clinical presentation must be treated as having a fracture until proven otherwise. A thumb spica splint provides the necessary immobilization of both the wrist and the thumb, preventing fracture displacement and mitigating the high risk of avascular necrosis and nonunion. These complications are common due to the tenuous retrograde blood supply to the proximal pole of the scaphoid. The patient should be re-evaluated with repeat radiographs in 7 to 14 days, at which time bone resorption will typically make an occult fracture visible.

Step-by-Step Solution

1
Analyze the mechanism of injury and physical exam findings.
A fall on an outstretched hand (FOOSH) with localized anatomical snuffbox tenderness strongly suggests a scaphoid fracture.
The scaphoid is the most commonly fractured carpal bone and classically presents with these specific signs after this mechanism.
2
Interpret the radiographic findings in the context of the clinical picture.
Initial radiographs are negative, which occurs in up to 15-20% of acute scaphoid fractures.
It takes time for bone resorption at the fracture site to make the fracture line visible on plain films.
3
Determine the appropriate management for a clinically suspected but radiographically occult fracture.
The patient must be treated empirically as having a fracture using a thumb spica splint.
Immobilization prevents displacement and reduces the high risk of nonunion and avascular necrosis due to the scaphoid's unique retrograde blood supply.

Key Concept

Management of clinically suspected scaphoid fractures with negative initial radiographs requires empirical immobilization with a thumb spica splint and repeat clinical and radiographic evaluation in 7-14 days.
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Orthopedic Surgery

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