What are the next steps for a patient with a swollen hand and wrist fracture, presenting with new onset discoloration, who is currently in a sling and cast?

Immediate Cast Removal and Urgent Orthopedic Evaluation Required

This patient requires immediate cast removal or splitting to prevent compartment syndrome, which is a surgical emergency that can lead to permanent tissue damage, limb loss, or death. 1

Critical Red Flags Present

Your patient is displaying warning signs of impending compartment syndrome:

• New onset hand swelling despite cast immobilization 2
• Discoloration (pinky finger) indicating vascular compromise 1
• Symptoms starting acutely ("just started today") 2

Immediate Management Steps

Within the next 1-2 hours, you must:

1. Remove or bivalve the cast immediately - A tight cast can cause compartment syndrome by restricting tissue expansion from post-injury swelling 1

2. Assess the 5 P's of compartment syndrome:

   • Pain (especially pain out of proportion or with passive finger extension)
   • Pallor (discoloration you already noted)
   • Paresthesias (numbness/tingling)
   • Pulselessness (check radial/ulnar pulses)
   • Paralysis (late finding - do not wait for this) 1

3. Elevate the limb to heart level ONLY - You correctly instructed elevation, but ensure it's not above heart level as this can paradoxically decrease perfusion 1

4. Contact orthopedics emergently (not just "ASAP") - This is not a routine follow-up situation; if compartment syndrome is developing, the patient needs fasciotomy within 6-8 hours to prevent permanent damage 1

Why Repeat X-ray is Secondary

While you appropriately planned repeat radiographs (recommended at 3 weeks per ACR guidelines 1), imaging must not delay cast removal and vascular assessment. The discoloration and new swelling are clinical diagnoses that require immediate action regardless of radiographic findings 2, 1.

Finger Motion Assessment

Once the cast is removed/split and vascular status confirmed:

• Immediately assess active finger range of motion - The patient should have been performing active finger exercises through complete range of motion from day one of casting 2, 1
• Finger stiffness is one of the most functionally disabling complications and is extremely difficult to treat after fracture healing 2
• If the patient has NOT been moving fingers due to cast obstruction or lack of instruction, this is a critical missed step in initial management 2, 1

Common Pitfall You're Avoiding (Partially)

The ACR emphasizes that failure to prescribe immediate finger motion exercises during immobilization is a major preventable complication 1. However, the more urgent pitfall here is missing early compartment syndrome, which requires cast removal before any other intervention 1.

Next 24-Hour Plan

After addressing the acute vascular concern:

• Obtain repeat radiographs to assess alignment (as you planned) 1
• Apply a well-padded short arm splint (NOT a circumferential cast) until swelling resolves 1
• Ensure patient demonstrates active finger motion through complete range 2, 1
• Schedule orthopedic follow-up within 24-48 hours (not just "ASAP") 1
• Provide written instructions for home finger exercises 2, 1

Bottom line: Remove or split that cast now, assess neurovascular status, and get orthopedics involved today - not next week.