01Approach to the Critical Patient/attcp30

Immediate threats

›Time-critical stabilization

›Open fracture

›Immediate IV antibiotics if open wound

›Immediate orthopedic or hand surgery consultation

›Neurovascular compromise

›Absent or diminished radial pulse

›Progressive median nerve symptoms

›Compartment syndrome

›Pain out of proportion

›Pain with passive finger stretch

›Associated perilunate injury suspicion

›Gross carpal deformity

›Median nerve compression signs

Key decision points

›Diagnostic and management pivots

›High clinical suspicion with negative initial radiographs

›Immobilization in thumb spica splint

›Advanced imaging pathway selection

›Displacement or instability concern

›Urgent hand surgery follow-up

›CT for displacement characterization

›Proximal pole fracture concern

›Higher avascular necrosis risk

›Earlier MRI consideration

Monitoring and reassessment

›Reassessment triggers

›Worsening pain despite immobilization

02History/hx30

Mechanism and timeline

›Injury context

›FOOSH mechanism

›Wrist extension at impact

›Radial deviation at impact

›Direct blow to radial wrist

›Sports injury

›Altercation injury

›Time from injury

›Acute within 48 hours

›Delayed presentation beyond 7 days

Symptoms and function

›Symptom pattern

›Radial-sided wrist pain

›Worse with gripping

›Worse with push-off from chair

›Snuffbox pain

›Persistent at rest

›Worse with thumb motion

›Functional limitation

›Reduced grip strength

›Difficulty with key pinch

Risk factors for nonunion

›Healing risk modifiers

›Tobacco or nicotine exposure

›Increased nonunion risk

›Delayed union risk

›High energy mechanism

03Physical Exam/exam30

Inspection and palpation

›Local findings

›Anatomic snuffbox tenderness

›Pain with palpation

›Pain with wrist ulnar deviation

›Scaphoid tubercle tenderness

›Volar radial wrist tenderness

›Increased specificity compared with snuffbox alone

›Swelling and ecchymosis

›Dorsoradial swelling

›Thenar bruising

Provocative maneuvers

›Stress findings

›Thumb axial compression pain

›Pain reproduced with longitudinal thumb load

›Supports scaphoid injury when combined with tenderness

›Wrist range of motion limitation

›Pain with extension

›Pain with radial deviation

›Grip strength reduction

›Pain-limited grip

›Pain with key pinch

Neurovascular and associated injury exam

›Distal status and adjacent structures

›Median nerve distribution symptoms

›Thenar sensation changes

›Thumb opposition weakness

›Radial and ulnar pulses

04Differential Diagnosis/ddx30

Traumatic radial wrist pain mimics

›Bony injury alternatives

›Distal radius fracture ICD-10 S52.5

›Point tenderness over distal radius

›Dorsal deformity

›Radial styloid fracture ICD-10 S52.51

›Radial styloid focal tenderness

›Association with scapholunate injury

›Trapezium fracture ICD-10 S62.16

›Thumb CMC pain

›Pain with thumb opposition

›Lunate fracture ICD-10 S62.12

›Central dorsal wrist pain

›Kienbock risk if chronic

Ligamentous and soft tissue

›Nonfracture causes

›Scapholunate ligament injury SNOMED CT concept compatible

›Dorsal wrist pain

›Watson test pain or clunk

›Thumb ulnar collateral ligament injury ICD-10 S63.64

›MCP ulnar tenderness

›Valgus laxity

›Triangular fibrocartilage complex injury ICD-10 S63.59

›Ulnar-sided wrist pain

›Pain with ulnar deviation

Nontraumatic mimics

›Overuse and inflammatory

›De Quervain tenosynovitis ICD-10 M65.4

05Laboratory Tests/lt21

Routine testing

›Labs usually not required

›No routine labs for isolated closed injury

›Imaging-driven diagnosis

›Clinical exam-driven suspicion

›Pregnancy test when status unknown and advanced imaging planned

›Urine hCG point-of-care

›Shared decision making for imaging choices

Preoperative or complication-driven

›Labs for specific scenarios

›Open fracture or suspected infection

›Complete blood count for systemic infection concern

›C-reactive protein for inflammatory trend

›Anticoagulation or bleeding concern

›INR for warfarin exposure

›Platelet count for thrombocytopenia concern

Interpretation pearls

›Lab limitations

›Normal inflammatory markers do not exclude open injury contamination

›Early infection may be absent

›Clinical wound assessment priority

›Coagulation results do not replace local hemostasis evaluation

›Compartment syndrome remains clinical

›Expanding hematoma requires reassessment

06Diagnostic Tests/dt56

Scoring Systems

›Classification and instability frameworks

›Herbert and Fisher scaphoid fracture classification

›Type A stable acute fractures

›A1 tubercle fracture

›A2 incomplete waist fracture

›Type B unstable acute fractures

›B1 distal oblique fracture

›B2 complete waist fracture

›B3 proximal pole fracture

›B4 fracture dislocation

›B5 comminuted fracture

›Type C delayed union

›Persistent fracture line

›Incomplete healing after weeks

›Type D established nonunion

›Sclerotic margins

›Cystic change

›Displacement and angulation markers

›Displacement greater than 1 mm as instability marker

›Humpback deformity as instability marker

MRI

›MRI for occult fracture and vascular risk

›Indications

›High clinical suspicion with negative radiographs

›Proximal pole fracture suspicion

›Performance

›High sensitivity for occult scaphoid fracture

07Disposition/dispo27

Discharge criteria

›Outpatient pathway

›Closed injury

›Intact neurovascular status

›Pain controlled with oral agents

›Immobilization in thumb spica splint

›Splint fit comfortable

›Fingers well perfused

›Follow-up plan

›Hand surgery or orthopedics within 7 to 14 days

›Repeat imaging plan documented

Admission or transfer criteria

›Higher level care triggers

›Open fracture

›IV antibiotics

›Urgent operative evaluation

›Associated perilunate dislocation or fracture dislocation

›Emergent reduction considerations

›Urgent hand surgery consultation

›Neurovascular compromise

›Emergent specialist evaluation

›Consider acute carpal tunnel syndrome

Follow-up imaging strategy

›Imaging after initial negative radiographs

›Repeat radiographs at 10 to 14 days

›Scaphoid views

›Clinical re-exam correlation

›Early MRI as alternative to delayed radiographs

08Treatment/t47

Immobilization

›Initial immobilization strategy

›Thumb spica splint for suspected or confirmed scaphoid fracture

›Short arm thumb spica as common ED choice

›Long arm thumb spica for select unstable patterns

›Immobilization position

›Wrist slight extension

›Thumb in functional position

›Skin and swelling precautions

›Padding over bony prominences

›Recheck swelling within 24 to 48 hours

Analgesia

›Pain control options

›Acetaminophen

›Adults 650 mg to 1000 mg PO every 6 to 8 hours as needed

›Maximum 3000 mg per day typical outpatient ceiling

›Lower maximum with liver disease

›Ibuprofen

›Adults 400 mg PO every 6 to 8 hours as needed

›Maximum 2400 mg per day typical outpatient ceiling

›Avoid with significant renal disease

›Naproxen

›Adults 250 mg to 500 mg PO every 12 hours as needed

›Maximum 1000 mg per day

›Avoid with active GI bleeding

›Opioid rescue for severe pain

›Hydromorphone

›Adults 1 mg PO every 4 to 6 hours as needed

09Special Populations/sp34

Pregnancy

›Pregnancy-specific considerations

›Imaging selection

›Plain radiographs with shielding when needed

›MRI preferred over CT when feasible for occult fracture

›Analgesia safety

›Acetaminophen preferred first line

›NSAID avoidance in later pregnancy per obstetric guidance

›Follow-up coordination

›Obstetric communication if advanced imaging or opioids used

›Return precautions for swelling and neurovascular symptoms

Geriatric

›Older adult considerations

›Osteoporosis and fragility mechanisms

›Lower energy falls still fracture risk

›Higher risk of concomitant distal radius fracture

›Medication cautions

›NSAID renal and GI risk

›Opioid fall risk and delirium risk

›Follow-up reliability

›Earlier definitive imaging when access barriers expected

›Splint checks for skin breakdown risk

Pediatrics

›Pediatric considerations

›Epidemiology differences

›Scaphoid fracture less common in younger children

›Increasing incidence in adolescents

›Imaging and exam nuances

10Background/b30

Epidemiology

›Population patterns

›Most common carpal bone fracture

›Higher prevalence in adolescents and young adults

›Sports and FOOSH association

›Common fracture location

›Waist fractures most frequent

›Proximal pole fractures less frequent but higher risk

›Missed fracture risk

›Initial radiographs can be negative

›Clinical suspicion remains key

Pathophysiology

›Anatomy and blood supply

›Retrograde blood supply predominance

›Proximal pole perfusion vulnerability

›Avascular necrosis risk with proximal fractures

›Biomechanics

›Compression and shear across waist with wrist extension

›Humpback deformity from flexion collapse in unstable fractures

›Complication pathways

›Nonunion progression to scaphoid nonunion advanced collapse

›Radiocarpal arthritis over time

Therapeutic Considerations

›Management principles

›Immobilization importance with suspected occult fracture

›Prevent displacement and nonunion

›Protect blood supply

›Imaging strategy impact

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Scaphoid fracture suspected or confirmed

›Thumb spica splint until follow-up

›Keep splint clean and dry

›Do not remove splint unless instructed

›Activity limits

›No lifting or gripping with injured hand

›No sports until cleared

›Pain control

›Acetaminophen as directed

›Ibuprofen or naproxen only if safe for you

›Elevation and swelling

›Hand elevated above heart when possible

›Finger motion encouraged if not painful

›Follow-up

›Hand surgery or orthopedics appointment within 7 to 14 days

›Repeat imaging or MRI plan at follow-up

›Return to ED now for

›Increasing numbness or tingling

›Fingers turning blue or very cold

›Severe pain not improving

›Splint feels too tight with worsening swelling

›New deformity after a new injury

›Fever or spreading redness if wound present

12References/r20

Clinical guidelines and core sources

›Reference set

›Hand and wrist fracture management consensus statements

›Immobilization for suspected occult scaphoid fracture with negative radiographs

›Advanced imaging options MRI and CT for occult injury and displacement

›Orthopedic and hand surgery texts

›Scaphoid vascular supply and avascular necrosis risk

›Herbert and Fisher scaphoid fracture classification

Evidence levels documentation tags

›Evidence level tags for database use

›ACEP Level C tag

›Expert consensus management when evidence limited

›Immobilize and arrange follow-up for high suspicion with negative radiographs

›Class I tag

›Strong recommendation based on consistent evidence or broad consensus

›Immobilization and timely follow-up for suspected scaphoid fracture

›Class IIa tag

›Moderate recommendation favoring benefit

›Early MRI for occult fracture when available

›Class IIb tag

›Weak recommendation with mixed evidence

›Ultrasound as adjunct in select settings

Evidence & Review

Evidence & Review