Emergency Medicine

Orthopaedic Emergencies 293

INJURIES TO THE WRIST AND HAND

3 Look for localized pain and tenderness by:
(i) Compressive pressure along the thumb metacarpal.
(ii) Palpating in the anatomical ‘snuff box’ between extensor pollicis
longus and abductor pollicis longus.
(iii) Palpating the scaphoid tubercle.

4 Ask specifically for scaphoid views as well as for anteroposterior and lateral
wrist X-ray views. Unless the fracture is complete, it may be difficult to
detect in the acute phase.
(i) Repeat X-ray in 10–14 days allows time for decalcification to
occur at the fracture site and for the fracture to become visible.

5 Alternatively, request a CT, bone scan or even magnetic resonance imaging
(MRI) depending on availability, and local practice.

MANAGEMENT

1 Place the wrist in a removable splint or a double-elasticated stockinet
bandage, if the X-rays are normal and pain or tenderness are minor. Provide
a high-arm sling.
(i) Review every patient in either the ED or orthopaedic clinic within
10 days of injury depending on local policy.
(ii) Repeat the X-ray if pain persists.

2 Otherwise, if a fracture is conf irmed on X-ray, or if there is marked pain and
tenderness particularly on moving the thumb or wrist, place the forearm in a
scaphoid plaster.

3 Scaphoid plaster (see Fig. 9.3).

(i) The wrist should be fully pronated, radially deviated and partially

dorsiflexed, and the thumb held in mid-abduction.

(ii) Apply the plaster from the mid-shaft of the forearm to the

metacarpal heads, to include the base of the thumb proximal to

the interphalangeal joint.

Figure 9.3 The scaphoid plaster
This extends from the angle of the elbow to the metacarpal heads, and around the base
of the thumb to below the interphalangeal joint.