Fall on the outstretched hand (FOOSH) with wrist in radial deviation.

(MOI also for # dorsal radius and S-L ligament)

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Fracture VISIBLE on X-Ray Fracture NOT VISIBLE on X-Ray

Determine if fracture is stable or unstable Were the x-ray films adequate?
(according to the Herbert Classification) Is a fracture suspected clinically?

Stable fracture
(Herbert Classification A):
Treat in ‘scaphoid cast’
(Use polyester cast if no/minimal
swelling and adequately trained)
And
Organise fracture clinic follow up
with repeat x-ray out of plaster:
! 6 week review for scaphoid
tubercle fractures
! 2 week review for other
stable fractures
Unstable fracture Fracture SUSPECTED, if: Fracture NOT SUSPECTED, if:
(Herbert Classification B ! 2mm
displacement): Two or more clinical signs <2 clinical signs
Call the Orthopaedic Registrar Atypical Mechanism
Typical Mechanism
And/Or Atypical Demographic
Arrange CT to determine fracture
orientation and stability
Treat Symptomatically
Place in a scaphoid cast and arrange for
fracture clinic review in 1-2 weeks Bandage/Brace/Removable backslab
Is a definitive diagnosis
If there is a trans-scaphoid perilunate Arrange/Advise GP review if symptoms persist
dislocation, it requires immediate surgery
required immediately? beyond 1/52 post injury
Document on discharge summary!

Herbert Classification System Trans-scaphoid perilunate dislocation

Yes, if: No:

Elite athlete Treat in thumb spica POP/backslab

Injury affects their ability to work Review in fracture clinic in 1-2 weeks,
(dominant hand), care for with repeat x-ray out of plaster
themself or others

PA and lateral X-ray of left wrist,

showing scaphoid fracture, capitate
fracture and trans-scaphoid
perilunate dislocation
Arrange for a outpatient CT scan of
wrist if:
>3 clinical signs (see above)
11 years or older
Arrange for an outpatient MRI of wrist if:
Not eligible for CT scan due to age etc.
There is a strong suspicion of ligamentous
injury

Not pregnant At the two week follow up, there is no

fracture on x-ray but a strong suspicion of
Consent
bony or ligamentous injury

Normal PA and lateral x-ray of If FRACTURE IS SEEN on CT: If FRACTURE IS NOT seen:
right wrist
Treat accordingly Treat as soft tissue injury

Discharge to GP