Station Title & Timing
- Title: Right Wrist Injury with Normal X-ray
- Duration: 10 minutes (2 minutes reading time + 8 minutes performance)
Learning Objective(s)
- Examination Skills: Demonstrate precision in palpating the scaphoid “Triple Crown” and performing a neurovascular safety check.
- Clinical Reasoning: Manage a radiologically occult fracture by prioritizing clinical tenderness over a negative X-ray.
- Risk Management: Communicate the risk of Avascular Necrosis (AVN) and the necessity of “Review and Repeat” protocols.
Patient Profile
- Name: Jane Roberts
- Age: 30 years old
- Occupation: Head Chef at a busy restaurant (dominant right hand)
- Social History: Non-smoker, relies on her hand for fine motor tasks (chopping, plating).
Presenting Complaint
“I slipped in the kitchen and fell on my outstretched hand two hours ago. My wrist is throbbing, and I can’t grip my chef’s knife.”
Contextual Information
- HPC: Accidental slip on a wet floor. Landed with palm flat. Pain is localized to the base of the thumb.
- PMH: Generally fit; no previous wrist injuries or bone disease.
- Medications: Nil.
- Allergies: NKDA.
Exam Instructions
Candidate Instructions
You are the GP. Jane has just returned from the imaging department with her X-rays.
- Take a brief, focused history.
- Perform a physical examination of the right wrist and hand with a running commentary.
- Interpret the provided X-ray (which is reported as normal).
- Explain the diagnosis and management plan to Jane.
Standardised Patient (SP) Instructions
- Affect: Anxious about work. You are protective of your right hand.
- Examination Findings:
- Tenderness: If the candidate presses in the “dip” at the base of your thumb (Snuffbox) or the palm side of the thumb base (Tubercle), wince and say, “Ouch, that’s the spot.”
- Compression: If they push your thumb/metacarpal toward your wrist, say it feels like a sharp pinch.
- Specific Question: “If the X-ray is clear, can I go back to work tonight? I have a big banquet to run.”
Examiner Checklist Items
- Identifies the mechanism of injury (FOOSH).
- Performs Bilateral Neurovascular check (Radial pulse and CRT).
- Performs the “Triple Crown” of scaphoid palpation: Anatomical Snuffbox, Scaphoid Tubercle, and Axial compression.
- States the “Joints Above and Below” (Elbow and fingers).
- Correctly interprets the X-ray as “Normal/No visible fracture.”
- Critical Safety Step: Does not discharge the patient; insists on immobilization despite the normal X-ray.
- Explains the concept of a “Radiologically Occult” fracture and the 10-14 day repeat rule.
Key Clinical Findings
- Vitals: HR 88, BP 120/80, Temp 36.6°C.
- Inspection: Mild swelling in the radial aspect of the wrist. No “dinner fork” deformity.
- Palpation: Sharp tenderness in the anatomical snuffbox and scaphoid tubercle.
- Neurovascular: Radial pulses $2+$ bilaterally. CRT $< 2$ seconds. Sensation (Median, Ulnar, Radial) intact.
- X-ray: No fracture line visible on AP, Lateral, or Scaphoid views.
Communication Triggers (Murtagh-Aligned)
- Open-ended: “Jane, can you tell me exactly how you fell and what happened to your hand immediately after?”
- Summarising: “So, you fell on your palm, the pain is right at the base of the thumb, and you’re worried about getting back to the kitchen. Is that right?”
- Addressing Emotions: “I understand being away from the kitchen is difficult, but my priority is making sure this bone heals properly so you don’t have permanent issues with your grip.”
Assessment & Marking Guide
| Domain | Criteria for Pass |
| History | Screened for FOOSH mechanism and occupational impact. |
| Examination | Performed Snuffbox, Tubercle, and Compression tests. Checked pulses. |
| Clinical Reasoning | Acknowledged that up to 20-30% of scaphoid fractures are not visible on initial X-ray. |
| Management | Applied a Thumb Spica splint and arranged a 14-day repeat X-ray. |
| Safety | Warned about the risk of the bone “dying” (AVN) if missed. |
Sample Answers / Model Performance
The Running Commentary (Sample):
“I am examining Jane’s right wrist. First, I check the tubes and wires: the radial pulse is strong, and capillary refill is under 2 seconds on both sides. Sensation is normal. Now, I palpate the Triple Crown: I find significant tenderness in the anatomical snuffbox, the scaphoid tubercle on the palm side, and pain on axial compression of the first metacarpal. I have checked the elbow and fingers, which are normal. Although the X-ray I am holding shows no fracture line, these clinical findings are highly suggestive of a scaphoid fracture.”
Explaining the Diagnosis to Jane:
“Jane, I have reviewed your X-rays. At the moment, they don’t show a break. However, because you are so tender in that specific spot, we have to treat this as a ‘hidden’ fracture.
The scaphoid bone is very small and has a fragile blood supply. In about 25% of cases, a break doesn’t show up on a camera until about two weeks later when the bone starts to change. If we miss this and you keep using it, there is a risk the bone could ‘die’ from lack of blood, which would mean permanent hand weakness.
The plan is:
- We will put your arm and thumb in a Thumb Spica cast today to keep it perfectly still.
- You must not use this hand for heavy lifting or cooking.
- You will come back in 10 to 14 days for a repeat X-ray. If there is a break, it will show up then. If it is still clear but you still have pain, we may order an MRI.”