FOOSHing Off My Board - Review

It’s a beautiful fall day on your local college campus and the dudes and dudettes are out riding their longboards between classes. Suddenly– a pebble in the path, a wobble and screech of the board, and FOOSH!- down goes Mary Jane on her way to Sociology class. She comes in to the ED complaining of severe wrist pain and swelling.

This is her XR:

Based on this XR, what specific (classic) physical exam findings would you expect?

Snuffbox tenderness, pain with axial loading of the thumb, pain at the radial wrist, pain intensified when resisting pronation

Good! So our dudette has all of these findings. What's her diagnosis?

Scaphoid Fracture!

The most common carpal bone fracture. Happens to FOOSHes all the time. I foosh you not, my friend.

BTW… FOOSH = Fall On Out-Streched Hand – which really means a force or blow to the wrist while it is hyperextended and radially deviated.

How do you treat this initially in the ER, and what are the complications?

Scaphoid fractures must be placed in a thumb spica splint, with the wrist in dorsiflexion and radial deviation.

Why? Because there are serious complications to scaphoid fractures: avascular necrosis (blood flow enters bone through the proximal segment, which is easily disrupted), delayed union, nonunion, and malunion.

What would be your ED treatment if the XRay looked stone-cold normal, but the same physical exam findings were there?

Treat it the same! Scaphoid fractures may not be evident on xray, but the risk and severity of these complications from avascular necrosis are high. So any patient with a FOOSH, wrist pain, and tenderness at the snuffbox, radial wrist, and with axial loading should be thumb-spica’d, with a repeat XRay in 2 weeks with ortho follow up.

References

Tintinalli’s 7th ed

Picture (and wisdom) from Orthobullets.com