Is there neurovascular deficit requiring urgent intervention?.If there is anatomical snuffbox tenderness but normal x-ray, you should still apply immobilization and have the patient re-x-rayed and assessed in out patient clinic follow up (usually 2 weeks after the event). In the presence of a normal x-ray, a decision has to be made about the likelihood of an occult scaphoid fracture. Often there is a pin screws or wires placed to hold the pieces of bone together This is often referred to as ‘open reduction and internal fixation’ or ORIF.Īll patients who present with a FOOSH and have ongoing pain, tenderness, or neurovascular signs will require an x-ray.Ī normal x-ray does not mean there is no fracture. If its not possible to get an adequate reduction, or there is a reduction with a dislocation, or there is an open fracture, then its likely surgery will be required.In scaphoid fractures, a spica thumb cast is used instead of a volar slab.The joint my be re-x-rayed to check the bones have not shifted and then a full cast applied This is then usually reviewed in fracture clinic within a few days. This is a partial plaster of Paris cast that runs on the volar surface of the wrist and forearm, with crepe bandages to hold it in place. The mainstay of treatment is a back slab (aka volar slab).Full casts should be avoided in the first few days due to swelling (and possible compression and subsequent neurovascular compromise) that occurs in the days after the initial injury.Bearing in mind the point above, these often shouldn’t be given via the oral route. Make sure you provide adequate analgesia.Some individuals can have an airway compromise requiring intubation from only mild sedatives. Sedation carries some (not negligible) risks, particularly related to the airway.It is also possible to perform local anaesthesia, nerve blocks, or haematoma blocks, although conscious sedation is probably the most popular method. The exact agent, or combination of agents will be decided by the person performing the sedation. Suitable agents often include ketamine (especially in children) and benzodiazepines in adults (for example midazolam, or perhaps a combination of midazolam and fentanyl). Usually, sedation is not a general anaestheitc, but conscious sedation.Some sources state 1 hour of NBM is enough, but many places practice a 4 hour rule. Until you have an x-ray, try to keep all patients nil by mouth, as they may require sedation for manipulation and reduction.Most cases of wrist fracture are suitable for conservative management. Basics of Management Reduction and Manipulation There are two ‘rows’ of carpal bones, with four in each. Knowing the bones of the wrist is useful, but as long as you can point out a scaphoid, and know your ulnar from your radius anything involving the other carpal bones is a bit more specialist.
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