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

Management of FOOSH (Fall On Outstretched Hand) Injuries

For FOOSH injuries, immediately obtain at least 2 radiographic views (AP and lateral) of the wrist to evaluate for fracture displacement and articular involvement, then initiate elevation, NSAIDs for pain control, and early mobilization based on fracture stability. 1, 2

Initial Assessment and Imaging

• Obtain at least 2 views (AP and lateral) of the wrist immediately to evaluate fracture displacement and articular involvement in all patients with suspected FOOSH injuries 1, 2
• Evaluate specifically for pain disproportionate to injury near bones or joints, which suggests periosteal penetration or joint involvement requiring prompt medical attention 2
• Assess for associated injuries including ulnar styloid fractures, carpal bone injuries, and elbow involvement, as FOOSH can cause injuries throughout the upper extremity 3, 4

Immediate Management (First 24-48 Hours)

Elevation and Immobilization

• 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
• For non- or minimally displaced distal radius fractures, 1 week of cast immobilization followed by gradually increasing wrist mobilization is as effective as 3-5 weeks of casting, with no difference in secondary dislocation rates (1.5% vs 1.0%) or need for surgery 5

Pain Management

• Prescribe oral NSAIDs at the lowest effective dose for limited duration (preferably on-demand) for pain relief 2
• Critical caveat: Do not prescribe NSAIDs without assessing cardiovascular, gastrointestinal, and renal risk factors, particularly in elderly patients 2
• Consider acetaminophen as an alternative analgesic for patients with contraindications to NSAIDs 1

Wound Care (if applicable)

• Cleanse any wounds with sterile normal saline without iodine or antibiotic-containing solutions, removing only superficial debris 2
• Ensure tetanus prophylaxis status is current (0.5 mL intramuscularly if outdated or unknown) 2

Surgical Considerations for Distal Radius Fractures

The decision between operative and non-operative management depends on fracture displacement, articular involvement, and patient functional demands 1:

• Displaced or unstable fractures may require open reduction and internal fixation with locking plates, Kirschner wires, or external fixation 1
• Non- or minimally displaced fractures can be managed with cast immobilization for 1 week followed by mobilization 5
• Surgery should be performed within 48 hours of injury when indicated to optimize outcomes 1

Rehabilitation Phase

Early Mobilization

• Begin early finger and hand motion immediately, even while immobilized 6
• For non-operatively managed fractures, start gradually increasing wrist mobilization after 1 week of casting 5
• Restrict above-chest level activities until fracture healing is evident 6

Structured Rehabilitation Program

• Provide education on ergonomic principles, activity pacing, and assistive devices as foundational care that improves self-management 2
• Implement early physical training and muscle strengthening exercises 1, 6
• Include long-term continuation of balance training and multidimensional fall prevention to reduce risk of subsequent injuries 1, 6

Postoperative Management (if surgical intervention required)

• Provide appropriate pain management after surgery 1
• Begin range-of-motion exercises within the first postoperative days 6
• Use a sling for comfort only, not for strict immobilization 6
• Restrict above-chest level activities until fracture healing is evident 6

Special Populations

Elderly Patients (≥50 years)

• Evaluate systematically for risk of subsequent fractures, including DXA of spine and hip, imaging for vertebral fractures, and assessment of falls risk 1
• Consider orthogeriatric comanagement to improve functional outcomes, reduce length of hospital stay, and reduce mortality 1
• Ensure adequate calcium and vitamin D intake, smoking cessation, and limitation of alcohol intake 1
• Consider pharmacological treatment for osteoporosis with drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures 1

Younger, Active Patients

• Higher energy mechanisms may result in more complex fracture patterns requiring surgical intervention 1
• Functional demands should guide treatment decisions, with surgical fixation often preferred for displaced fractures in this population 1

Common Pitfalls to Avoid

• Do not delay imaging: Obtain radiographs immediately to avoid missing displaced fractures that require surgical intervention 1, 2
• Do not over-immobilize: Prolonged casting (>1 week) for non-displaced fractures provides no additional benefit and may delay functional recovery 5
• Do not prescribe NSAIDs without risk assessment: Always evaluate cardiovascular, gastrointestinal, and renal risk factors, especially in elderly patients 2
• Do not neglect early mobilization: Begin finger and hand exercises immediately to prevent stiffness 6
• Do not ignore fall prevention: In elderly patients, implement multidimensional fall prevention strategies to reduce risk of subsequent fractures 1