Station Title & Timing
- Title: Assessment of Acute Hand and Wrist Injury (FOOSH)
- Duration: 10 minutes (2 minutes reading time + 8 minutes performance)
Learning Objectives
- Examination Skills: Execute a systematic “Look, Feel, Move” and Neurovascular (NV) assessment for a FOOSH injury.
- Clinical Reasoning: Demonstrate the “Joints Above and Below” rule and identify specific sites of bony tenderness (Distal Radius vs. Scaphoid).
- Management: Formulate an appropriate plan for clinical suspicion of a scaphoid fracture with a normal initial X-ray.
- Professionalism: Maintain patient comfort and perform bilateral comparisons.
Patient Profile
- Name: Mr. Alex Varma
- Age: 28 years old
- Occupation: Carpenter (dominant right hand)
- Relevant Social History: Active lifestyle, plays basketball. Non-smoker.
Presenting Complaint
“I fell onto my outstretched right hand during a basketball game yesterday. My wrist is quite sore today, and I’m worried I won’t be able to work tomorrow.”
Contextual Information
- HPC: Accidental trip on court. Landed with palm flat on the ground. Immediate pain, though he finished the game. Pain has increased overnight.
- PMH: No previous wrist or hand fractures.
- Medications: Took 400mg Ibuprofen this morning with minimal relief.
- Allergies: Nil.
Exam Instructions
Candidate Instructions
You are a GP seeing Alex Varma. He presents with a right-hand injury.
- Take a brief, focused history of the injury.
- Perform a systematic physical examination of the right upper limb.
- Explain your clinical suspicion and the immediate management plan to Alex.
- Note: You must verbalize your findings and demonstrate bilateral comparison where appropriate.
Standardised Patient (SP) Instructions
- Affect: Calm but concerned about his ability to use his tools at work.
- The “Point” Test: If asked to point to the pain with one finger, point specifically to the Anatomical Snuffbox.
- Palpation Findings: * Pain is sharp (7/10) when the candidate presses in the Snuffbox or on the Scaphoid Tubercle (base of the thumb on the palm side).
- No pain when they press on the distal radius (the wrist bone) or the elbow.
- Special Tests: If the candidate performs scaphoid compression (pushing the thumb/metacarpal toward the wrist), say “Ow, that really pinches.”
- Neurovascular: If they check sensation or pulses, tell them everything feels normal and “the same as the other side.”
Examiner Checklist Items
- Checks for analgesia/comfort before beginning.
- Asks the patient to point with one finger to the site of maximal pain.
- Bilateral Assessment: Inspects and compares both hands/wrists.
- Joints Above/Below: Briefly palpates/checks the elbow and shoulder.
- Palpation (The Triple Crown): Correctly identifies and palpates the Distal Radius, Anatomical Snuffbox, and Scaphoid Tubercle.
- Neurovascular Check: Checks Radial pulse, Capillary Refill Time (CRT), and motor/sensory function of the Median, Ulnar, and Radial nerves.
- Safety-Netting: Explains that a “clear X-ray” does not rule out a scaphoid fracture.
Key Clinical Findings
| System | Findings |
| Inspection | Mild swelling over the radial aspect of the right wrist. No “dinner fork” deformity. |
| Palpation | Positive: Tenderness in the anatomical snuffbox and scaphoid tubercle. Negative: Distal radius and ulnar styloid are non-tender. |
| Neurovascular | Radial pulse equal bilaterally. CRT < 2 seconds. Sensation (C6, C7, C8) intact. All motor functions (OK sign, Thumbs up, Starfish) intact. |
| Special Tests | Pain on axial compression of the first metacarpal. |
Communication Triggers (Murtagh-Aligned)
- Open-ended questions: “Alex, could you describe exactly how you landed and where it hurts the most?”
- Summarising: “So you fell on your palm, and while the wrist bone itself doesn’t hurt, it’s very tender in that small dip below your thumb. Have I got that right?”
- Addressing Concerns: “I understand you’re worried about work. Because of where you are tender, we need to be very cautious to ensure you have a full recovery for your carpentry.”
- Lay Language: Instead of “Non-union of the Scaphoid,” use “The small bone in your wrist has a poor blood supply and may not heal properly if we miss a small break.”
Assessment & Marking Guide
| Marking Item | Global Rating / Criteria |
| Systematic Approach | Did the candidate follow “Look, Feel, Move” and check the joints above/below? |
| Bilateral Comparison | Did the candidate compare the injured side to the healthy side? |
| Neurovascular Safety | Did the candidate check the “tubes” (pulses) and “wires” (nerves)? |
| Clinical Reasoning | Did the candidate identify the risk of a scaphoid fracture despite a potentially clear X-ray? |
| Management Plan | Did the candidate suggest immobilization (Thumb Spica) and a repeat X-ray in 10-14 days? |
Sample Answers / Model Performance
Suggested History Questions:
- “Can you show me with one finger exactly where the pain is most intense?”
- “Have you noticed any numbness, tingling, or weakness in your fingers since the fall?”
- “Apart from your wrist, do you have any pain in your elbow, shoulder, or neck?”
Explaining the Diagnosis and Plan:
“Alex, thank you for letting me examine you. Based on the fact that you are very tender in the ‘anatomical snuffbox’—this little dip here—I am concerned you may have a fracture of the scaphoid bone.
This is a small but very important bone for your wrist movement. The tricky thing about the scaphoid is that fractures often don’t show up on an X-ray immediately after the injury.
Here is the plan:
- We will get X-rays today to look for any obvious breaks.
- Even if the X-ray is normal, because you are so tender there, I must treat this as a fracture to be safe. We will put your arm in a special splint or cast that includes your thumb (a Thumb Spica).
- You will need to come back in 10 to 14 days for a repeat X-ray. By then, if there is a small crack, it will be visible.
- If you notice your fingers turning blue, feeling cold, or if the pain becomes unbearable, you must go to the Emergency Department immediately.”