What's the next step for a patient who fell on an outstretched hand and presents with wrist pain, numbness, a swollen wrist, and decreased sensation over the thumb and first three fingers?

Immediate Wrist Radiography (4-View Series)

Order a 4-view wrist radiograph series immediately, including posteroanterior (PA), lateral, oblique, and scaphoid views to evaluate for distal radius fracture, scaphoid fracture, and other carpal injuries. 1

This clinical presentation—fall on outstretched hand (FOOSH) with wrist swelling, pain, and numbness in the median nerve distribution (thumb and first three fingers)—suggests both osseous injury and possible acute carpal tunnel syndrome from compartment swelling.

Why 4-View Radiography First

• The American College of Radiology establishes that radiographs are the most appropriate initial imaging study for acute wrist trauma, with a minimum 3-view series (PA, lateral, and oblique) being standard. 2

• Adding a fourth projection—a scaphoid view—increases diagnostic yield for both distal radius fractures and scaphoid injuries, which are commonly missed on standard 3-view series. 1

• Relying on only 2 views is inadequate for detecting wrist fractures, and even 3-view series can miss important pathology. 1

• The lateral view demonstrates malalignments and soft-tissue swelling, which is critical in this case given the clinical swelling. 1

Critical Pitfall: Scaphoid Fractures

• Missed scaphoid fractures can lead to significant morbidity including nonunion, avascular necrosis, and post-traumatic arthritis. 1

• Scaphoid fractures are among the most commonly missed wrist injuries on initial radiographs, making the dedicated scaphoid view essential. 1

If Initial Radiographs Are Negative But Clinical Suspicion Remains High

Two appropriate next-step options exist:

Option 1: Presumptive Treatment with Follow-up

• Place the patient in a short arm thumb spica cast and repeat radiographs in 10-14 days. 1
• This allows time for fracture lines to become visible as bone resorption occurs at the fracture site. 1

Option 2: Immediate Advanced Imaging (Preferred for Neurologic Symptoms)

• Proceed directly to MRI without IV contrast, which has 94.2% sensitivity and 97.7% specificity for occult fractures. 1

• MRI is particularly valuable in this case because it can simultaneously evaluate for:

  • Occult scaphoid or distal radius fractures 1
  • Bone contusions 1
  • Ligamentous injuries (scapholunate or lunotriquetral ligament tears) 1
  • Median nerve compression explaining the numbness 2
  • Tendon injuries 1

• CT without IV contrast is an alternative if MRI is unavailable, providing high-detail bone imaging with shorter acquisition times, though it has lower sensitivity for soft-tissue injuries. 1

Addressing the Neurologic Component

The decreased sensation over the thumb and first three fingers indicates median nerve involvement, likely from:

• Acute carpal tunnel syndrome from compartment swelling following the trauma 2
• Direct nerve injury from fracture fragments or displacement 2

If neurologic symptoms are severe or progressive:

• Urgent hand surgery consultation is warranted to evaluate for acute compartment syndrome requiring decompression. 1
• Document baseline motor function (thumb opposition, index finger flexion) in addition to sensory deficits. 3

Management Pending Imaging Results

• Immobilize the wrist in a volar splint to prevent displacement of any occult fracture. 1
• Elevate the extremity to reduce swelling that may be contributing to median nerve compression. 3
• Avoid weight-bearing activities with the affected hand until fracture is definitively ruled out. 1
• Provide adequate analgesia while maintaining ability to monitor neurologic status. 3

When to Refer to Hand Surgery

Refer urgently if imaging reveals:

• Scaphoid fracture (high risk of nonunion and avascular necrosis) 1
• Ligamentous injury requiring repair 1
• Displaced distal radius fracture 1
• Any fracture with persistent or worsening neurologic symptoms 1