April 2000 • Volume 6 • Number 4
Befuddled by a FOOSH?
Mechanism of injury could solve puzzleBY SHARON DENT
Las VegasChances are you recently treated someone who suffered a FOOSH -- a fall on an outstretched hand. But did you know that taking a good FOOSH history can practically make the diagnosis for you?
Alice Epperson, M.D., left, of San Antonio and Shayla Kasel, M.D., of Simi Valley, Calif., practice the steps in a wrist exam at an AAFP CME conference."In medical school, we were taught that 'fall on an outstretched hand' was all we needed to know, but the position of the hand determines where the mechanical and vector forces were transferred up the arm," said Joseph Moore, M.D., of Quantico, Va., who chaired the AAFP's Office Procedures and Management of the Musculoskele-tal System CME course Feb. 21-25.
Ask the patient to describe the fall in detail. "Tell them to show you how it was done," Moore said at the course. "Did they fall forward and skin their hands up, or did they fall back and jam their hands and shoulders into the ground?"
The answers can help you make a differential diagnosis:
I fell forward and landed on my outstretched hand. The force from the fall typically transmits to the distal radius. "Nine times out of 10, they'll get a distal radial fracture," said Moore.
If an X-ray confirms that diagnosis, do a closed reduction to correct any dorsal or volar angulation. Then cast the arm in that position, immobilizing the elbow and the wrist. Do a follow-up X-ray in plaster in a week, switching to a short-arm cast in about three weeks, Moore said. A healthy adult likely will heal within four to six weeks.
Children often experience a "buckle fracture," in which the bone is partially collapsed. In that situation, a short-arm cast for about three weeks usually does the trick, Moore said.
I fell forward on my hand, and I think I sprained my wrist. Don't assume pain means sprain. Always look for a scaphoid fracture, said Moore. "If you suspect a scaphoid fracture and there's nothing on X-ray, you typically put them in a short-arm thumb spica cast for two weeks, and then you re-X-ray out of plaster," he said. "If you're still suspicious and the X-ray still doesn't show anything, do a bone scan. The exam for scaphoid is that classic 'snuff box' tenderness; feel the distal pole of the scaphoid in the crease of the wrist."
About 70 percent of scaphoid fractures occur at the waist, said Moore. "However, pay particular attention to the less common but more severe fractures at the proximal pole," he added.
When should you refer the patient to an orthopedic surgeon? If you can answer yes to any of these questions, then a referral is warranted:
- Was there a delay in presentation?
- Is the fracture in the proximal third of the scaphoid?
- Are the fragments displaced?
If a nondisplaced waist or distal pole scaphoid fracture is confirmed, put the patient in a long-arm thumb spica cast and X-ray in plaster that day and again in a week, said Moore. After three more weeks, remove the cast for an X-ray but replace it for another four to six weeks, possibly switching to a short-arm spica cast for the duration of the treatment.
"The biggest thing is that you've got to prepare the patient psychologically to be in a cast for 12 to 16 weeks," Moore said.
My daughter fell out of a swing and landed on her hand with her arm outstretched behind her. "Typically, those forces will be transmitted up through the radius to the elbow, so they'll have fractures at about the distal humerus," said Moore. "They are typically treated in a long-arm cast from three to six weeks." Consult with an orthopedic surgeon if fragments are displaced.
Keep an eye on growth plates in your younger patients, he said. "Watch for the medial epicondylar and supracondylar fractures when they fall on a backstretched hand."
I fell down the stairs and landed on my outstretched hand with my elbow locked. A child reporting this type of fall is likely to have suffered a supracondylar fracture, Moore said. Consider a referral if you're not comfortable treating these tricky fractures.
If this patient is an adult, the diagnosis typically is radial head fracture. How can you be sure? "Look for the fat pad sign," Moore said. "Fat resides in the capsule of the joint, and when there's a fracture -- even if it isn't evident on X-ray -- the fat pad will float up out of its bed because of blood in the joint. A billowed anterior fat pad is positive, and any visualization of the posterior fat pad is pathologic."
Radial head fractures in adults should be treated in a sling for comfort for four to seven days. Then the patient can remove the sling and begin extending the elbow and supinating and pronating the hand to regain mobility. "Over four to six weeks, they'll gradually get better," Moore said. A referral is in order if the fragment is displaced or depressed or involves more than a third of the articular surface, he said.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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