A 28-year-old male labourer presents to the emergency department 6 hours after a fall on an outstretched hand (FOOSH). He has tenderness in the anatomical snuffbox and mild swelling. Plain radiographs (PA, lateral, and scaphoid views) appear normal. What is the most appropriate next step in management?

## Clinical Context A high-energy mechanism (FOOSH) with clinical signs of scaphoid injury (snuffbox tenderness, swelling) warrants presumptive treatment even when initial radiographs are normal. Occult (radiographically occult) scaphoid fractures occur in 10–15% of cases. ## Management Algorithm for Suspected Scaphoid Fracture ```mermaid flowchart TD A[FOOSH + Snuffbox tenderness]:::outcome --> B{Plain X-rays show fracture?}:::decision B -->|Yes| C[Classify: Proximal, waist, distal]:::outcome C --> D[Immobilize based on location]:::action B -->|No| E{High clinical suspicion?}:::decision E -->|Yes| F[Immobilize in scaphoid cast]:::action F --> G[Repeat X-rays in 10-14 days]:::action G --> H{Fracture line visible?}:::decision H -->|Yes| I[Continue immobilization]:::action H -->|No| J[Consider MRI/CT if persistent symptoms]:::action E -->|No| K[Discharge, advise precautions]:::action ``` ## Key Point: **Presumptive immobilization is the gold standard for clinically suspected scaphoid fractures with normal initial radiographs.** This prevents complications (nonunion, avascular necrosis) and is more cost-effective than immediate advanced imaging in most cases. ## High-Yield Facts: - Scaphoid fractures may not be visible on plain radiographs for 10–14 days due to initial lack of displacement. - Immobilization in a scaphoid cast (thumb spica) is the first-line management for suspected fractures. - Repeat radiographs at 10–14 days allow callus formation to become visible. - MRI and CT are reserved for: (1) persistent clinical suspicion after repeat X-rays remain negative, (2) need for urgent diagnosis in high-demand athletes, or (3) assessment of fracture complexity before operative planning. ## Clinical Pearl: **Snuffbox tenderness + FOOSH mechanism = treat as scaphoid fracture until proven otherwise.** Missing a scaphoid fracture leads to chronic wrist pain, nonunion, and avascular necrosis of the proximal pole. ## Immobilization Details by Location | Fracture Location | Immobilization | Duration | Rationale | |---|---|---|---| | Distal third | Short arm thumb spica | 4–6 weeks | Best blood supply; lowest nonunion risk | | Waist | Long arm thumb spica → short arm | 8–12 weeks | Moderate blood supply; highest nonunion risk | | Proximal third | Long arm thumb spica | 12–16 weeks | Poor blood supply; high AVN risk | ## Tip: In the exam, when you see "normal X-rays + snuffbox tenderness + FOOSH," the answer is almost always **immobilize and repeat imaging in 10–14 days**. This is the standard of care in India and aligns with international guidelines.