What is the management and treatment for a Fall Onto an Outstretched Hand (FOOSH) injury?

Management of FOOSH (Fall Onto an Outstretched Hand) Injury

Immediate assessment must focus on identifying the specific fracture pattern through clinical examination and radiographic imaging, as FOOSH injuries encompass a spectrum of injuries from distal radius fractures to scaphoid fractures, perilunate dislocations, and supracondylar fractures, each requiring distinct management approaches.

Initial Assessment and Diagnosis

Clinical Examination Priorities

• Assess for point tenderness over the anatomic snuffbox, as scaphoid fractures can occur even without typical FOOSH mechanisms and may not show initial tenderness, yet missing this diagnosis leads to significant morbidity 1
• Evaluate for pain disproportionate to injury near bones or joints, which suggests periosteal penetration or joint involvement 2
• Examine both dorsal and volar wrist surfaces for swelling and assess range of motion, as perilunate and lunate dislocations present with pain and swelling on both aspects with limited wrist mobility 3
• Document neurovascular status immediately, particularly median nerve function, as these injuries can cause nerve compression requiring urgent intervention 3

Radiographic Evaluation

• Obtain at least 2 views (AP and lateral) of the wrist immediately to evaluate fracture displacement and articular involvement 4
• The lateral view is critical for identifying perilunate and lunate dislocations, which disrupt the relationship between the lunate and capitate or displace the lunate from both radius and capitate 3
• If initial radiographs are normal but scaphoid tenderness exists, treat as a scaphoid fracture and arrange follow-up imaging, as scaphoid fractures are frequently missed on initial films 1

Immediate Management (First 24-48 Hours)

Acute Inflammation Control

• Apply ice immediately to the injured site as the cornerstone of early inflammation control, which speeds rehabilitation when initiated promptly 5
• Elevate the injured extremity using a sling for outpatients or tubular stockinet with IV pole for inpatients during the first few days after injury, as elevation accelerates healing when swelling is present 2
• Ensure adequate rest for the injured site as a fundamental physical method for controlling acute inflammation in mild to moderate injuries 5

Pain Management

• Prescribe oral analgesics, particularly NSAIDs at the lowest effective dose for limited duration (preferably on-demand) for pain relief, with attention to gastrointestinal, cardiovascular, and renal risk factors especially in elderly patients 2, 4
• Consider a single initial dose of parenteral antimicrobial before starting oral therapy if there are concerns about wound contamination from the fall 2

Wound Care (if applicable)

• Cleanse any wounds with sterile normal saline without iodine or antibiotic-containing solutions, removing only superficial debris 2
• Do not close infected wounds or perform deep debridement unless absolutely necessary, as this enlarges wounds and impairs skin closure 2

Definitive Management Based on Injury Pattern

Distal Radius Fractures (e.g., Frykman VIII)

• Assess for associated ulnar styloid fractures, as these commonly occur together in FOOSH injuries 6
• Determine if closed reduction with casting versus surgical fixation is required based on fracture displacement, articular involvement, and patient factors 6

Scaphoid Fractures

• Immobilize in a thumb spica splint immediately even with negative initial radiographs if clinical suspicion exists 1
• Arrange follow-up within 10-14 days for repeat clinical examination and radiographs or consider MRI/CT if high suspicion persists 1
• Refer to orthopedics for definitive management, as scaphoid fractures require 4-6 week courses for proper healing and can develop osteomyelitis if inadequately treated 2, 1

Perilunate/Lunate Dislocations

• These require emergent orthopedic consultation for reduction and stabilization via closed or open surgical reduction, as delays lead to long-term pain and disability 3
• Do not attempt reduction in the emergency department without orthopedic backup, given the complexity and potential for neurovascular compromise 3

Supracondylar Fractures (in pediatric patients)

• Classify using Gartland typing, as this predicts functional outcome and guides treatment decisions 7
• Higher Gartland types require open reduction with pinning rather than closed management 7
• Limit cast immobilization duration, as prolonged immobilization negatively impacts Mayo Elbow Performance Score at 6 months 7

Follow-Up and Rehabilitation

Early Follow-Up (24-48 hours)

• All outpatients should be followed up within 24 hours either by phone or office visit to assess for progression of infection or complications 2
• If infection or symptoms progress despite appropriate therapy, hospitalize immediately for intravenous antibiotics and possible surgical intervention 2

Rehabilitation Phase

• Once inflammation is controlled and repair is underway, prescribe therapeutic exercises to restore range of motion, strength, and endurance 5
• Protect the injured site (e.g., with taping) during exercise until rehabilitation is complete 5
• For hand/wrist injuries, provide education on ergonomic principles, activity pacing, and assistive devices as foundational care that improves self-management 4

Critical Pitfalls to Avoid

• Do not dismiss scaphoid fractures based on negative initial radiographs alone, as they are frequently missed and require high clinical suspicion 1
• Do not overlook perilunate/lunate dislocations on lateral wrist films, as these serious injuries are easily missed and require emergent reduction 3
• Do not prescribe NSAIDs without assessing cardiovascular, gastrointestinal, and renal risk factors, particularly in elderly patients 4
• Do not delay orthopedic referral for displaced fractures, joint involvement, or neurovascular compromise, as these require specialized surgical management 3, 7
• Ensure tetanus prophylaxis status is current (0.5 mL intramuscularly if outdated or unknown) 2