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Wrist injury & scaphoid
Fall on the outstretched hand — distal radius vs scaphoid.
Typical consult⏱ 20 min
Investigations🔬 X-ray wrist + scaphoid views if bony tenderness
Usual outcome💊 Splint + analgesia + fracture clinic
0–5Red flags + history5–12Examine12–17Decide17–24Treat + explain24–30Safety-net + document
1Rule out first — red flags
| If you find… | …then |
|---|---|
| Deformity with neurovascular compromise or skin tenting | Reduce in ED urgently |
| Numbness in median nerve distribution / acute carpal tunnel | Urgent ortho |
| Open wound over fracture | Open fracture pathway |
| Elderly with low-impact fall | Fragility fracture — bone health assessment |
2Focused history
3Focused examination
4Decide — investigate only if it changes the plan
Clinical scaphoid assessment
- Anatomical snuffbox tenderness
- Scaphoid tubercle tenderness
- Pain on axial compression of the thumb
- Pain on ulnar deviation / wrist movement
Any positive with a relevant mechanism → X-ray wrist with scaphoid views. If X-ray normal but clinically suspected → splint and MRI / virtual fracture clinic (NICE NG38).
| Investigation | Only if… |
|---|---|
| Wrist X-ray (AP + lateral) | Bony tenderness, deformity or loss of function |
| Scaphoid views | Scaphoid signs present |
| MRI (via fracture clinic) | Suspected scaphoid fracture with normal X-ray |
5Treat & send home
Management & advice
- Undisplaced distal radius fracture → removable splint or cast per local pathway
- Displaced fracture → ED for reduction
- Suspected scaphoid fracture → wrist splint (or scaphoid cast per local policy), MRI pathway
- Sprain with negative X-ray and no scaphoid signs → support splint for comfort, early movement
- Elevation; remove rings now
Refer / follow-up
- Fracture or suspected scaphoid → fracture clinic / virtual fracture clinic
- Fragility fracture → bone health (FLS / GP)
℞
Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.
| Drug | Dose | Duration / notes |
|---|---|---|
| Paracetamol | 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) | As needed |
| Ibuprofen | 400 mg three times a day with food | 3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy |
6Safety-net
Say it like this
Your X-ray doesn’t show an obvious break, but the scaphoid bone in the wrist can hide on early X-rays. So we’ll treat it as if it might be broken: keep this splint on and the fracture clinic will arrange follow-up. Keep your hand raised and take off any rings. Come back straight away if your fingers go numb, cold or blue, or the splint feels too tight.
Come back / call 111 — or 999 if severe — if:
- Fingers become numb, cold, pale or blue
- Cast/splint feels too tight or pain becomes severe
- Pain not improving after 2 weeks with a “sprain” (missed scaphoid)
7Patient leaflets — scan & go
Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.
8Document
Wrist injury & scaphoid — clinic note
A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.
URGENT CARE — WRIST INJURY & SCAPHOID
PRESENTING COMPLAINT:
HISTORY
Mechanism: fall on outstretched hand (FOOSH), height, speed:
Hand dominance, job, driving, hobbies:
Pain site; tingling in fingers:
Previous wrist injuries:
PMH: osteoporosis, anticoagulants:
RED FLAGS (record present / absent)
[ ] Deformity with neurovascular compromise or skin tenting
[ ] Numbness in median nerve distribution / acute carpal tunnel
[ ] Open wound over fracture
[ ] Elderly with low-impact fall
PMH:
DRUG HISTORY:
ALLERGIES:
SOCIAL (job / who is at home / driving):
OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 )
EXAMINATION
Look: deformity (dinner-fork), swelling, skin:
Feel: distal radius, ulnar styloid, anatomical snuffbox, scaphoid tubercle:
Scaphoid compression (axial load of the thumb):
Elbow and hand — joint above and below:
Median, ulnar and radial nerve sensation and power; radial pulse, capillary refill:
DECISION RULE — Clinical scaphoid assessment: result ______
INVESTIGATIONS: none required / Wrist X-ray (AP + lateral), Scaphoid views, MRI (via fracture clinic) — result:
IMPRESSION:
PLAN
Treatment / TTO (drug, dose, duration):
Advice given:
Leaflet given (QR / printed): Broken arm or wrist
Follow-up / referral:
SAFETY-NETTING (told to return / call 111 / 999 if):
- Fingers become numb, cold, pale or blue
- Cast/splint feels too tight or pain becomes severe
- Pain not improving after 2 weeks with a “sprain” (missed scaphoid)
Patient understands and agrees with the plan: Y / N
Seen by: Grade: Date/Time:
✓Guidelines
Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.
More injuries & musculoskeletal
Ankle & foot injuryTwisted ankle or foot — Ottawa rules decide the X-ray.Knee injuryTwisting or direct knee injury — Ottawa knee rule, spot the ACL and locked knee.Hand & finger injuryBoxer’s fracture, mallet finger, crush injuries and the hand you must not miss.Shoulder & collarbone injuryCollarbone fractures, ACJ injuries and the dislocated shoulder.