What is the best action for a patient with tenderness in the anatomical snuffbox after falling on an outstretched hand?

Management of Anatomical Snuffbox Tenderness After Fall on Outstretched Hand

The best action for a 25-year-old male patient with tenderness in the anatomical snuffbox after falling on an outstretched hand is to apply a thumb spica splint (option A). This immobilization approach is the most appropriate initial management for suspected scaphoid injury, which is the primary concern when anatomical snuffbox tenderness is present.

Assessment and Diagnosis

• Tenderness in the anatomical snuffbox after a fall on an outstretched hand is highly suspicious for a scaphoid fracture, even when there is minimal swelling and no obvious deformities 1, 2
• The scaphoid is the most commonly fractured carpal bone and is particularly vulnerable during falls on an outstretched hand 3
• Assume any injury to an extremity includes a bone fracture until proven otherwise 1
• Clinical assessment should include evaluation of:
  • Tenderness in the anatomical snuffbox with the wrist in ulnar deviation
  • Tenderness over the scaphoid tubercle
  • Pain upon longitudinal compression of the thumb 2

Initial Management

• Apply a thumb spica splint to immobilize the wrist and thumb, which provides optimal protection for a suspected scaphoid injury 4
• The thumb spica splint is specifically effective for suspected scaphoid fractures as it properly immobilizes the first metacarpal and the scaphoid bone 4
• Expert opinion suggests that splinting reduces pain and prevents further injury 1
• Continue icing the affected area as the patient has been doing, as cold application decreases hemorrhage, edema, pain, and disability 1

Why Thumb Spica Splint is Superior to Other Options

• A thumb spica splint (option A) is preferred over a short arm splint (option B) because it specifically immobilizes the thumb and scaphoid region, which is essential for suspected scaphoid injuries 4
• A sling and swathe (option C) would not provide adequate immobilization of the wrist and thumb, which is necessary to protect the scaphoid 1
• Referral to physical therapy (option D) without proper immobilization and diagnostic evaluation would be premature and potentially harmful 1

Follow-up Care

• Radiographic evaluation should follow splinting, with standard 3-view radiographic examination of the wrist 1
• Even if initial X-rays are normal, occult scaphoid fractures may be present and require further imaging 1, 2
• If clinical suspicion remains high despite normal X-rays, advanced imaging such as MRI should be considered 1, 2
• The patient should be re-examined within 3-5 days to reassess symptoms and potentially update treatment plan 5

Important Considerations

• Scaphoid fractures can be easily missed on initial X-rays, with up to 20% being occult 2
• Delayed or missed diagnosis of scaphoid fractures can lead to nonunion, avascular necrosis, and long-term disability 3
• The negative predictive value of a comprehensive clinical examination is high, but imaging is still necessary to confirm diagnosis 2
• Immobilization should be maintained until definitive diagnosis is established 6

Common Pitfalls to Avoid

• Failing to immobilize a suspected scaphoid injury can lead to displacement of an initially non-displaced fracture 3
• Relying solely on initial X-rays that may miss occult fractures 1, 2
• Using inadequate immobilization methods that don't properly stabilize the scaphoid 4
• Delaying appropriate follow-up imaging when clinical suspicion for fracture remains high despite normal initial X-rays 1, 2