What interventions are available in the emergency room (ER) for a screw backing out of hardware placed in the wrist that is pushing outward into the skin and causing extreme pain?

Emergency Management of a Protruding Screw in the Wrist

Immediate surgical consultation for hardware removal is the definitive intervention for a screw backing out of wrist hardware that is causing extreme pain and pushing into the skin. 1

Initial Assessment and Management

• Obtain radiographs to assess the position of the hardware and the protruding screw, which is essential for proper evaluation 2
• Provide appropriate pain management with IV or oral analgesics while awaiting definitive treatment 3
• Assess for signs of infection such as increased redness, warmth, purulent discharge, or increasing pain which would require more aggressive intervention 4
• Evaluate neurovascular status of the affected hand to ensure adequate circulation and sensation 5

Pain Management Options

• Administer appropriate analgesia based on pain severity:
  • For severe pain, IV morphine sulfate may be appropriate as it provides effective pain control while awaiting surgical intervention 3
  • Consider regional nerve blocks (median, ulnar, or radial) performed by an emergency physician or anesthesiologist for temporary pain relief 5

Temporary Stabilization Measures

• Apply padded dressing around the protruding hardware to prevent further movement and skin irritation 6
• Avoid overtightening any dressing as this can compromise circulation 6
• Immobilize the wrist in a neutral position with a well-padded splint to minimize movement of the hardware 6

Definitive Management

• Arrange urgent orthopedic or hand surgery consultation for hardware removal or revision 1
• Hardware complications, including screw loosening, account for a significant portion of complications following internal fixation of wrist fractures (approximately 27% overall complication rate) 1
• Delayed management can lead to tendon irritation, rupture, or infection, which may compromise long-term hand function 1

Important Considerations and Pitfalls

• Do not attempt to manipulate or push the screw back in place in the emergency department as this may cause further damage 1
• Avoid local wound exploration around the hardware as this may introduce infection 4
• Be aware that hardware complications often require surgical intervention and cannot be definitively managed with conservative measures alone 1
• Monitor for signs of complex regional pain syndrome, which can develop following wrist injuries and surgical interventions 1

Follow-up Care

• If surgical intervention cannot be performed immediately, schedule close follow-up within 24-48 hours 6
• Provide clear instructions about signs of infection or neurovascular compromise that would warrant immediate return 4
• Ensure the patient understands the importance of maintaining the splint and keeping the area clean until definitive treatment 6