Does a patient with an acute scaphoid fracture and on Eliquis (apixaban) for a confirmed clot in the cephalic vein require an emergency room visit or can an urgent outpatient orthopedic visit be scheduled?

Management of Acute Scaphoid Fracture in Patient on Apixaban for Upper Extremity DVT

This patient can be managed with an urgent outpatient orthopedic visit within 24-48 hours rather than requiring emergency room evaluation, provided there are no signs of compartment syndrome, neurovascular compromise, or uncontrolled bleeding. 1

Rationale for Outpatient Management

Fracture Characteristics

• Acute scaphoid fractures without displacement can be safely managed non-operatively with immobilization 2, 3, 4
• The X-ray report does not indicate displacement, instability, or other high-risk features that would necessitate immediate surgical intervention 3, 5
• Scaphoid fractures are not considered emergency surgical cases unless there is >1 mm displacement or associated complications 3, 5

Anticoagulation Considerations

• The patient is on apixaban (Eliquis) for cephalic vein thrombosis, which creates a bleeding risk but does not automatically mandate ER evaluation 1
• For urgent surgery (defined as 6-24 hours), patients on DOACs can be managed with timing strategies rather than immediate reversal if DOAC levels are <50 ng/mL 1
• Scaphoid fracture treatment typically involves immobilization first, not immediate surgery, giving time for anticoagulation management planning 2, 3
• The cephalic vein is a superficial vein, and the thrombosis indication may allow for brief interruption of anticoagulation if surgery becomes necessary 1

Immediate Actions at SNF

Clinical Assessment Required

• Evaluate for compartment syndrome: progressive pain, paresthesias, pain with passive stretch, tense forearm compartments 1
• Check neurovascular status: radial pulse, capillary refill, median/ulnar/radial nerve function 1
• Assess for active bleeding or expanding hematoma at the fracture site 1

Initial Immobilization

• Apply a thumb spica splint immediately to prevent fracture displacement and reduce pain 2, 3
• A removable splint is preferable to a cast initially, especially given anticoagulation status 1
• Position the wrist in slight volar flexion and radial deviation 5

Urgent Orthopedic Referral Protocol (Within 24-48 Hours)

Information to Provide Orthopedics

• Anticoagulation details: apixaban dose, timing of last dose, indication (cephalic vein DVT), and duration of therapy planned 1
• Fracture location on X-ray (waist, proximal pole, or distal third affects management) 2, 3
• Patient's functional status, hand dominance, and ability to comply with immobilization 4

Orthopedic Decision Points

• Non-displaced fractures: typically managed with 6-12 weeks of thumb spica cast immobilization 3, 4
• Displaced fractures (>1 mm): require surgical fixation, necessitating perioperative anticoagulation management 3, 5
• Proximal pole fractures: higher risk of avascular necrosis, may warrant earlier surgical consideration 2, 4

Anticoagulation Management Strategy

Coordination with Hematology/Thrombosis Service

• Contact the prescribing physician or thrombosis service to discuss temporary interruption if surgery is needed 1
• Apixaban has a half-life of approximately 12 hours; holding 24-48 hours before elective surgery is typically sufficient 1
• For cephalic vein thrombosis (superficial system), brief interruption carries lower risk than for deep system thrombosis 1

If Urgent Surgery Required

• Measure apixaban level if available (anti-factor Xa activity) to guide timing 1
• If level <50 ng/mL, surgery can proceed safely without reversal 1
• If level ≥50 ng/mL and surgery cannot be delayed, consider 4-factor PCC (25 units/kg) for reversal 1
• Andexanet alfa is FDA-approved for apixaban reversal but is expensive and typically reserved for life-threatening bleeding 1

Indications That Would Require ER Evaluation

Send to ER if Any of the Following Present:

• Progressive neurological deficits (median nerve compression is concerning) 1
• Signs of compartment syndrome (severe pain, tense compartments, pain with passive finger extension) 1
• Active uncontrolled bleeding or rapidly expanding hematoma 1
• Open fracture (requires urgent irrigation and debridement within 6-8 hours) 1
• Associated carpal instability on X-ray (scapholunate dissociation, lunate dorsal tilting) 5

Common Pitfalls to Avoid

• Do not delay immobilization while arranging follow-up; immediate splinting prevents displacement 2, 3
• Do not automatically discontinue apixaban without consulting the prescribing physician, as the thrombosis risk must be weighed 1
• Do not assume all scaphoid fractures need immediate surgery; most are managed conservatively initially 3, 4
• Do not use NSAIDs for pain control in a patient on anticoagulation due to additive bleeding risk; use acetaminophen or opioids if needed 1
• Ensure orthopedic follow-up is truly urgent (24-48 hours), not routine (weeks), as delayed diagnosis increases nonunion risk 2, 6

Documentation for Continuity

• Document neurovascular examination findings clearly 1
• Note time of last apixaban dose and planned dosing schedule 1
• Confirm orthopedic appointment is scheduled and patient/family understand urgency 1
• Provide written instructions about splint care and warning signs requiring immediate ER evaluation 1