What physical exam should be performed on a patient with a FOOSH (Fall On Outstretched Hand) injury?

Physical Examination for FOOSH Injury

A comprehensive physical examination for a FOOSH (Fall On Outstretched Hand) injury should include radiographs of the affected area as the initial imaging modality, followed by a systematic assessment of bones, joints, tendons, and nerves to detect potential fractures, dislocations, or soft tissue injuries. 1

Initial Assessment

• Obtain radiographs of the area of interest as the first step in evaluating acute blunt trauma to the hand or wrist 1
• Include at least two views (PA and lateral), with consideration of additional oblique views to increase diagnostic yield 2
• Be aware that conventional radiography alone can miss up to 30% of scaphoid fractures 3

Systematic Examination Components

Bony Structures Assessment

• Palpate for tenderness in the anatomical snuffbox with the wrist in ulnar deviation (highly sensitive for scaphoid fracture) 4
• Check for tenderness over the scaphoid tubercle 4
• Assess for pain upon longitudinal compression of the thumb (axial loading) 4
• Evaluate for tenderness over the distal radius and ulna 5
• If initial radiographs are negative but clinical suspicion remains high, consider repeat radiographs in 10-14 days 1

Joint Evaluation

• Assess the distal radioulnar joint for stability and pain 1
• Evaluate metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints for malalignment or instability 1
• Check range of motion of all wrist and finger joints, noting any limitations or pain 6

Tendon Assessment

• Perform dynamic examination with active flexion/extension of the fingers to evaluate tendon integrity 1
• Assess the flexor and extensor tendons for signs of injury or tenosynovitis 1
• Evaluate the extensor hood for injuries, which can be difficult to detect clinically 1, 7

Nerve Examination

• Test for sensory changes in the median, ulnar, and radial nerve distributions 3
• Assess motor function of all three nerves 7
• Pay particular attention to the posterior interosseous nerve (branch of radial nerve), which can be injured in wrist trauma 7

Special Tests

• Watson's test (scaphoid shift test) to assess for scaphoid instability 6
• Finkelstein's test to evaluate for de Quervain's tenosynovitis (should be negative in acute trauma) 3, 6
• Grind test to assess for carpometacarpal arthritis or fracture 3, 6
• Lunotriquetral shear test to evaluate for lunotriquetral ligament injury 6

Follow-up Imaging Considerations

• If scaphoid fracture is suspected but not confirmed on initial radiographs, consider MRI without IV contrast or CT without IV contrast 1
• For suspected tendon or ligament injuries with negative radiographs, MRI without IV contrast is the preferred advanced imaging modality 7
• For suspected foreign body with negative radiographs, ultrasound or CT without IV contrast is recommended 1

Clinical Pearls and Pitfalls

• A Clinical Scaphoid Score (CSS) ≥4 (combining anatomical snuffbox tenderness, scaphoid tubercle tenderness, and pain on longitudinal compression) has high sensitivity for occult scaphoid fracture 4
• Consider scaphoid fracture even without a typical FOOSH mechanism and in the absence of scaphoid tenderness if there was hyperextension injury 8
• Wrist pain that persists despite negative imaging may require referral for more specialized evaluation 6
• Remember that the scaphoid is the most commonly fractured carpal bone, implicated in approximately 60% of wrist fractures 8