A 22-year-old man presents to the urgent care clinic after falling onto his outstretched right hand during a basketball game. He reports immediate pain on the radial side of his wrist. Past medical history is negative. On physical examination, there is no obvious deformity or swelling. However, there is significant tenderness to palpation within the anatomical snuffbox. Range of motion of the wrist is limited by pain, particularly with radial deviation. Initial posteroanterior, lateral, and scaphoid view radiographs of the wrist show no evidence of a fracture.
Which of the following is the most appropriate next step in management?
The correct answer is:
E) Thumb spica splinting and repeat imaging in two weeks
This patient has a clinical presentation highly suggestive of a scaphoid fracture, despite negative initial radiographs. The scaphoid is the most commonly fractured carpal bone, typically occurring from a fall on an outstretched hand (FOOSH). Initial X-rays have a low sensitivity for non-displaced scaphoid fractures, which may not become radiographically apparent until bone resorption occurs at the fracture site 7–14 days later. The standard of care for a patient with snuffbox tenderness and negative initial imaging is immobilization in a thumb spica splint followed by repeat clinical evaluation and X-rays in 10–14 days. Alternatively, advanced imaging like MRI could be performed if an immediate diagnosis is required.
Answer choice A: Computed tomography of the wrist, is incorrect. While CT is excellent for evaluating fracture union or displacement, MRI is the preferred advanced imaging modality for detecting occult scaphoid fractures acutely. However, the most cost-effective and common strategy is splinting and delayed re-imaging.
Answer choice B: Diagnostic arthroscopy, is incorrect. Arthroscopy is an invasive procedure used for ligamentous injuries or unexplained chronic wrist pain, but it is not a first-line diagnostic tool for an acute suspected fracture.
Answer choice C: Open reduction and internal fixation, is incorrect. Surgical intervention is reserved for displaced fractures (>1 mm), certain fracture locations (like the proximal pole), or non-unions. It is not indicated for a suspected fracture that has not yet been visualized.
Answer choice D: Reassurance and symptomatic treatment with ibuprofen, is incorrect. Because the scaphoid has a tenuous blood supply via retrograde flow from the radial artery, missing a fracture can lead to avascular necrosis and non-union. Conservative wait and see management without immobilization is contraindicated.
Key Learning Point
In the setting of a fall on an outstretched hand (FOOSH) and anatomical snuffbox tenderness, a scaphoid fracture must be suspected even if initial radiographs are negative. The most appropriate next step is immobilization in a thumb spica splint and repeat imaging in 10–14 days to rule out an occult fracture and prevent complications like avascular necrosis.
