What is the recommended assessment and treatment for a patient who sustained a fall on an outstretched hand?

Assessment and Management of FOOSH Injury

For a patient with a fall on an outstretched hand (FOOSH), obtain a minimum 3-view radiograph series (PA, lateral, and oblique) immediately to identify fractures—particularly distal radius, scaphoid, and carpal injuries—before initiating any treatment, as missed fractures fundamentally alter management and can lead to long-term complications. 1, 2

Initial Clinical Assessment

Key Historical Elements to Obtain

• Age of patient (bimodal distribution: <18 years and >65 years at highest risk) 1
• Exact mechanism and energy of fall (ground-level vs. high-energy trauma) 1
• Location and timing of maximal pain (radial-sided pain suggests scaphoid injury; ulnar-sided suggests TFCC or ulnar styloid) 3
• Ability to bear weight through the hand and grip strength 3
• Loss of consciousness or syncope (particularly in elderly patients, as this may indicate the fall was secondary to another medical event) 1
• Time spent on ground (in elderly, prolonged time down increases morbidity) 1

Physical Examination Priorities

• Inspect for deformity, swelling, and ecchymosis at wrist, hand, and elbow 4
• Palpate anatomic snuffbox (tenderness suggests scaphoid fracture even with negative initial radiographs) 3
• Assess neurovascular status including median, ulnar, and radial nerve function 4
• Evaluate elbow and shoulder for associated injuries, as FOOSH mechanism can cause injuries throughout the upper extremity kinetic chain 1, 4
• Test active and passive range of motion of all digits, wrist, and elbow 5

Diagnostic Imaging Strategy

Mandatory Initial Radiographs

Obtain a 3-view radiographic series (posteroanterior, lateral, and oblique views) of the injured area before any intervention, including wound closure in crush injuries. 2 The oblique view is critical because 2-view examinations miss a significant proportion of fractures. 2

Specific Fracture Patterns to Identify

Distal Radius Fractures:

• Most common FOOSH injury, accounting for 18% of fractures in elderly and 25% in pediatric populations 1
• Look for dorsal angulation, radial shortening, and intra-articular involvement 1
• Associated ulnar styloid fractures occur frequently (Frykman VIII pattern) 6

Scaphoid Fractures:

• Most commonly fractured carpal bone in FOOSH mechanism 3
• Conventional radiography misses up to 30% of scaphoid fractures initially 3
• If clinical suspicion exists (snuffbox tenderness) but radiographs are negative, immobilize in thumb spica splint and repeat radiographs in 10-14 days 3
• Consider MRI without IV contrast or bone scan if diagnosis remains uncertain and clinical suspicion is high 7, 3

Mallet Finger (Terminal Extensor Tendon Avulsion):

• Radiographs differentiate tendinous from bony mallet finger 8
• Surgical indications include: bony avulsion ≥1/3 of articular surface, volar subluxation of distal phalanx, interfragmentary gap >3mm, or open injury 8

Intra-articular Phalangeal Fractures:

• Articular step-off or gap ≥2mm requires surgical referral 2
• Stable fractures with <2mm displacement can be managed conservatively with buddy taping 2

Advanced Imaging Indications

• MRI without IV contrast is preferred when initial radiographs are equivocal but clinical suspicion remains high, or for evaluating tendon injuries and nerve compression 1, 7
• CT scan has limited utility for soft tissue injuries but may help characterize complex intra-articular fractures 7, 2

Treatment Algorithm

Immediate Management (Before Imaging Results)

• Apply ice-water mixture for 10-20 minutes with thin towel barrier to reduce swelling 8
• Splint in position found—do not attempt to reduce or straighten before proper evaluation 8
• Elevate extremity above heart level 4

Non-Operative Management Criteria

Distal Radius Fractures:

• Acceptable alignment parameters guide conservative treatment (specific criteria vary by age and functional demands) 1
• Immobilization typically required for 4-6 weeks 1

Scaphoid Fractures:

• Non-displaced fractures: thumb spica cast/splint for 6-12 weeks 3
• Critical: Even brief splint removal can restart healing timeline 8

Mallet Finger (Tendinous):

• Continuous DIP joint splinting in extension for 6-8 weeks 8
• Begin active PIP and MCP motion immediately while keeping DIP splinted to prevent stiffness 8
• Patient must understand that removing splint even briefly restarts the 6-8 week clock 8

Stable Phalangeal Fractures:

• Buddy taping with immediate mobilization for fractures with <2mm articular displacement 2

Surgical Referral Indications

Immediate orthopedic consultation required for:

• Distal radius fractures with significant displacement, comminution, or intra-articular involvement requiring surgical decision-making 1
• Any scaphoid fracture with displacement (>1mm step-off or gap) 3
• Mallet finger with bony avulsion ≥1/3 articular surface, volar subluxation, gap >3mm, or open injury 8
• Intra-articular fractures with step-off ≥2mm (to prevent post-traumatic arthritis) 2
• Open fractures or crush injuries with fracture 2
• Neurovascular compromise 4

Pain Management

• Topical NSAIDs preferred over oral NSAIDs for safety reasons, particularly in elderly patients 1
• Oral NSAIDs at lowest effective dose for shortest duration if topical agents insufficient 1
• Acetaminophen up to 4g/day is first-line oral analgesic for long-term use 1
• Ice therapy provides effective short-term pain relief during acute phase 8

Special Considerations for Elderly Patients (>65 years)

Fall Risk Assessment

• Evaluate for underlying cause of fall beyond just treating the injury 1
• Obtain orthostatic blood pressures 1
• Review medications, particularly vasodilators, diuretics, antipsychotics, and sedative/hypnotics 1
• Assess for syncope, melena, visual impairment, and neurological deficits 1

Discharge Safety Evaluation

• Perform "get up and go" test—patients unable to rise from bed, turn, and steadily ambulate should be reassessed for safe discharge 1
• Consider admission if patient safety cannot be ensured at home 1
• Arrange expedited outpatient follow-up with home safety assessment 1

Critical Pitfalls to Avoid

1. Never close a crush wound before obtaining radiographs—fractures and foreign bodies fundamentally alter management 2

2. Never dismiss snuffbox tenderness with negative initial radiographs—immobilize and re-image in 10-14 days or obtain MRI 3

3. Never accept 2-view radiographs as adequate—the oblique view is essential for detecting occult fractures 2

4. Never allow mallet finger patients to remove splint "just to check"—this restarts the entire healing timeline 8

5. Never assume isolated wrist injury in FOOSH—examine entire upper extremity including elbow and shoulder for associated injuries 1, 4

6. Never discharge elderly fall patients without assessing fall risk and home safety—the fall itself may indicate serious underlying pathology 1