A 28-year-old male labourer presents to the emergency department with pain and swelling over the dorsal aspect of his left wrist following a fall on an outstretched hand (FOOSH) while working at a construction site 6 hours ago. On examination, he has tenderness in the anatomical snuffbox and pain on axial loading of the thumb. Plain radiographs (PA, lateral, and scaphoid views) appear normal. What is the most appropriate next step in management?

Explanation

## Clinical Presentation & Diagnosis **Key Point:** Clinical suspicion for scaphoid fracture is based on mechanism (FOOSH), anatomical snuffbox tenderness, and pain on axial thumb loading—NOT radiographic findings alone. **High-Yield:** Up to 20% of scaphoid fractures are radiographically occult on initial plain films, particularly non-displaced or minimally displaced fractures. The gold standard approach is **clinical immobilization** with repeat imaging at 10–14 days, when bone resorption at the fracture line becomes radiographically visible. ### Rationale for Correct Answer In a patient with strong clinical signs of scaphoid fracture but normal initial radiographs: 1. **Immobilization is therapeutic and diagnostic** — prevents displacement and allows early healing 2. **Repeat radiographs at 10–14 days** — bone resorption creates a lucent line, making the fracture visible 3. **Cost-effective and evidence-based** — avoids unnecessary advanced imaging in a young, fit patient 4. **Prevents complications** — early immobilization reduces risk of nonunion and avascular necrosis (AVN) ### Why Other Imaging Modalities Are Not First-Line | Modality | Role | Timing | |----------|------|--------| | **MRI** | Excellent for detecting occult fractures but expensive; reserved for high-risk patients (athletes) or when diagnosis remains uncertain after repeat X-rays | Day 10–14 if repeat X-rays negative | | **CT scan** | Better than X-ray for fracture line definition but not standard for initial diagnosis; useful for preoperative planning | After diagnosis confirmed | | **Bone scan** | Sensitive but nonspecific; rarely used in modern practice | Obsolete | **Clinical Pearl:** The "scaphoid fracture protocol" in most Indian orthopaedic units is: clinical suspicion → thumb spica immobilization → repeat X-rays at 2 weeks. This approach has >95% sensitivity for detecting true fractures while avoiding overdiagnosis. ## Complications of Missed/Delayed Diagnosis **Warning:** Failure to immobilize a suspected scaphoid fracture risks: - Nonunion (5–10% of untreated fractures) - Avascular necrosis (proximal pole fractures; blood supply retrograde) - Post-traumatic osteoarthritis (scaphoid nonunion advanced collapse, SNAC wrist) **Mnemonic: SNAP** — **S**caphoid fractures need **N**ot be **A**lways **P**roven immediately; immobilize on suspicion.