What is the management for a FOOSH (Fall Onto an Outstretched Hand) injury to the right wrist?

Management of FOOSH Injury to the Right Wrist

The management of a Fall Onto an Outstretched Hand (FOOSH) injury to the right wrist should begin with a 3-view radiographic examination including posteroanterior (PA), lateral, and 45° semipronated oblique views to assess for fractures, dislocations, and joint alignment. 1, 2

Initial Radiographic Assessment

• Standard 3-view radiographic examination is essential for detecting:

  • Distal radius fractures (most common FOOSH injury)
  • Scaphoid fractures
  • Carpal bone injuries
  • Joint dislocations
  • Ulnar styloid fractures

• Some centers may include a fourth view (semisupinated oblique) to increase diagnostic yield for distal radius fractures 1

When Initial Radiographs Are Negative

If initial radiographs are negative but clinical suspicion remains high:

1. Advanced imaging should be pursued:
   • CT scanning for suspected complex fractures with intra-articular extension or for preoperative planning 2
   • MRI without contrast for detecting occult fractures and concomitant ligamentous injuries 2
   • Ultrasound for detecting superficial foreign bodies or soft tissue injuries 2

Management Based on Findings

For Stable, Non-displaced Fractures:

• Functional splinting is preferred over complete immobilization
• Early exercises including active finger movement
• Supervised exercises focused on proprioception, strength, and coordination 2

For Unstable Fractures:

Surgical intervention is indicated for:

• Intra-articular fractures with >2mm step-off
• Fractures with coronal orientation
• Die-punch depression
• Multiple articular fragments
• Unstable dislocations 1, 2

Common FOOSH Injuries to Watch For

1. Distal Radius Fractures:

   • Most common FOOSH injury, accounting for up to 18% of fractures in the elderly 1
   • Restoration of radial length, inclination, and tilt is crucial for successful treatment

2. Scaphoid Fractures:

   • Most commonly fractured carpal bone (approximately 60% of wrist fractures) 3
   • May be radiographically occult initially
   • Should be suspected even in the absence of scaphoid tenderness 3

3. Perilunate and Lunate Dislocations:

   • Serious injuries that can be easily missed
   • Present with pain and swelling over both dorsal and volar aspects of the wrist
   • Require emergent reduction and stabilization 4

4. Frykman Fractures:

   • Classification for distal radius fractures with or without ulnar styloid involvement 5

Potential Complications

• Malunion
• Non-union
• Avascular necrosis
• Carpal instability
• Complex regional pain syndrome
• Osteoarthritic changes 2

Important Considerations

• Delayed diagnosis is common as some fractures (particularly scaphoid) may be radiographically occult initially
• Operative fixation resulting in <2mm of residual articular surface step-off is usually necessary to avoid long-term complications such as osteoarthritis 1
• In patients over 50 years, wrist fractures should prompt investigation for osteoporosis 2
• Delayed treatment can lead to vascular compromise and long-term hand/wrist impairment 2

Pitfalls to Avoid

• Relying on only 2 radiographic views (insufficient for detecting many fractures)
• Missing scaphoid fractures due to normal initial radiographs
• Overlooking lunate or perilunate dislocations, which can lead to long-term pain and disability 4
• Underestimating the long-term impact of these injuries, which can result in hand/wrist impairment even a decade after trauma 2