Station Title & Timing
- Title: Focused Examination of Acute Wrist Trauma (Suspected Scaphoid)
- Duration: 10 minutes (2 minutes reading time + 8 minutes performance)
- Note: Candidate is expected to split time as 4 minutes for History/Communication and 4 minutes for Focused Physical Examination.
Learning Objective(s)
- Clinical Prioritization: Demonstrate the ability to perform a high-yield, focused examination under significant time pressure.
- Examination Precision: Execute “Money Tests” (Snuffbox palpation and Scaphoid Compression) accurately.
- Diagnostic Reasoning: Integrate clinical findings with the management of a radiologically occult fracture.
Patient Profile
- Name: Mr. Thomas “Tom” Shelby
- Age: 26 years old
- Occupation: Mechanical Apprentice (Heavy manual labor)
- Social History: Right-hand dominant. Plays weekend cricket.
Presenting Complaint
Tom fell onto his outstretched right hand while playing cricket yesterday. He thought it was just a “sprain,” but the pain at the base of his thumb has become sharp and prevents him from using his tools at work today.
Contextual Information
- HPC: FOOSH (Fall on Outstretched Hand). No head injury or loss of consciousness. Pain localized to the radial aspect of the wrist.
- PMH: No previous fractures.
- Medications: 400mg Ibuprofen taken 2 hours ago.
- Allergies: No known drug allergies.
Exam Instructions
Candidate Instructions
You are a GP. Tom Shelby presents with a wrist injury.
- Take a focused history (approx. 3-4 minutes).
- Perform a Focused Physical Examination (approx. 4 minutes).
- Explain the diagnosis and the importance of follow-up to the patient.
- Important: You must prioritize the most clinically relevant tests to avoid running out of time.
Standardised Patient (SP) Instructions
- Affect: Cooperative but impatient; he wants to get back to work quickly.
- Physical Findings:
- Palpation: Sharp pain (7/10) specifically in the anatomical snuffbox.
- Compression: Sharp pain when the candidate pushes your thumb/metacarpal toward your wrist.
- Movements: Wrist extension is painful but possible; thumb movement is restricted by pain.
- Key Question: “If it’s not broken on the X-ray, can I just wrap it in a bandage and go to work?”
Examiner Checklist Items
- Briefly screens for mechanism of injury (FOOSH).
- Neurovascular Fast-Track: Quickly verbalizes and checks radial pulse and capillary refill (CRT).
- Prioritization: Skips/shortens general upper limb neurological screen to focus on the wrist.
- Palpation Accuracy: Correctly identifies Anatomical Snuffbox and Scaphoid Tubercle.
- The “Money Test”: Performs the Scaphoid Compression Test (Axial pressure on the 1st metacarpal).
- Bilateral Rule: Briefly compares with the left side for range of motion/swelling.
- Safety Netting: Explains why a normal X-ray today does not rule out a fracture.
Key Clinical Findings
- Vitals: Stable.
- Inspection: Minimal swelling; no gross deformity or bruising.
- Palpation: Tenderness in Anatomical Snuffbox and Scaphoid Tubercle.
- Range of Motion: Pain on wrist extension and radial deviation.
- Neurovascular: Radial pulse $2+$, CRT $< 2$ seconds, sensation intact.
Communication Triggers (Murtagh-Aligned)
- Open-ended questions: “Tom, can you show me with one finger exactly where it hurts the most?”
- Summarising: “So, you fell yesterday, you’ve got sharp pain at the base of your thumb, and it’s stopping you from using your tools. Is that right?”
- Lay Language: “The scaphoid is a small bone that acts like a bridge in your wrist. It’s notorious for having a poor blood supply, which makes healing difficult.”
Assessment & Marking Guide
| Domain | Key Performance Indicators |
| Time Management | Completed the special tests before the 8-minute mark. |
| Clinical Focus | Spent less than 30 seconds on general inspection/NV and prioritized palpation. |
| Technical Skill | Correct hand placement for the Scaphoid Compression Test. |
| Reasoning | Recognized that clinical tenderness warrants treatment regardless of X-ray. |
| Global Rating | Pass: Targeted, systematic, and safety-focused. Fail: Wasted time on irrelevant neuro tests; failed to perform compression test. |
Sample Answers / Model Performance
The “Four-Minute” Exam Sequence (Model):
- Intro: “I’ll examine your wrist now. Please let me know if I cause any pain.”
- NV (30s): “I am checking the radial pulse and capillary refill—both are normal. Sensation is intact.”
- Inspection (15s): “There is minimal swelling and no bruising over the radial side.”
- Palpation (1 min): “I am palpating the anatomical snuffbox—tenderness noted. Palpating scaphoid tubercle—tenderness noted.”
- Special Test (45s): “I am performing the Scaphoid Compression Test by applying pressure through the first metacarpal. Tom, does this hurt? (Yes). This is a significant finding.”
- Comparison (30s): “Quickly checking the left side for comparison—normal.”
Explaining the Plan:
“Tom, based on my exam, I am very suspicious that you have a fracture of the scaphoid bone.
In about 20-25% of cases, this break is invisible on the first X-ray. However, because you have tenderness in that specific ‘snuffbox’ area, we must treat it as a break to be safe. If we miss it, the bone can ‘die’ (Avascular Necrosis), leading to long-term arthritis and weakness in your hand.
Plan:
- X-ray today: Even if it’s clear, we will move to step 2.
- Immobilization: I’m putting you in a Thumb Spica cast today.
- Review: You must come back in 10-14 days for a repeat X-ray. This is non-negotiable for your recovery.”
Statistics on Scaphoid Fractures
Research indicates that scaphoid fractures account for approximately 60-70% of all carpal bone fractures. Due to its unique retrograde blood supply, the proximal pole of the bone is at high risk of avascular necrosis (up to 30% of cases if displaced or improperly managed).