A 79-year-old woman, a resident of an assisted living facility, presents to urgent care after slipping in the bathroom and landing on her outstretched left hand. She reports mild wrist pain and swelling but denies loss of consciousness, head trauma, or other injuries. She can move her fingers but has pain when trying to grip objects. Her past medical history is remarkable for hypertension, osteopenia, type 2 diabetes, and atrial fibrillation. Her medication list includes metformin, warfarin, amlodipine, vitamin D, and bisphosphonate.
On examination, she has mild swelling over the dorsal wrist, tenderness in the anatomical snuffbox and over the scaphoid tubercle, no gross deformity, normal capillary refill and sensation in all digits, and full finger range of motion but limited grip due to pain. After applying the Amsterdam wrist rules, wrist radiography is indicated. Plain x-rays of the wrist show no acute fracture.
In an elderly patient on anticoagulation with wrist trauma and snuffbox tenderness but normal x-rays, what is the next best step in management?
- Discharge with no immobilization and reassure
- Apply a thumb spica splint and arrange orthopedic follow-up
- Start NSAIDs for pain and encourage early wrist motion
- Proceed immediately to open reduction and internal fixation
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Answer: b. Apply a thumb spica splint and arrange orthopedic follow-up
You suspected an occult scaphoid fracture, which is common in this patient population with osteopenia and the mechanism of fall she had. Occult scaphoid fractures can be missed on initial x-rays, which is why orthopedic follow-up is important, especially if pain persists. Because the patient was on an anticoagulant, you avoided NSAIDs and ensured she had no signs of anticoagulant-related complications such as bleeding or bruising. Immobilization and prompt follow-up within 3 to 5 days are essential to prevent complications like avascular necrosis of the proximal pole. You called the assisted living facility to review the patient’s medication list with the nursing staff to minimize future fall risk.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
