A 13-year-old boy falls onto an outstretched hand and is assessed in the emergency department. No fracture is identified at the time, and he is discharged. He returns a week later with persistent pain in his hand. What is the most likely underlying injury?
A. Fracture of the distal radius
B. Fracture of the scaphoid
C. Dislocation of the lunate
D. Rupture of the flexor pollicis longus tendon
E. Bennett’s fracture
✅ Correct answer: Fracture of the scaphoid
📌 Explanation:
A scaphoid fracture is a common occult injury in adolescents and young adults following a fall on an outstretched hand (FOOSH). It may not be visible on initial X-rays, especially if non-displaced, and pain may be mild early on, leading to it being missed clinically.
🩺 Clues pointing to scaphoid fracture:
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Delayed presentation: The child re-presents a week later due to persistent pain.
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Classic mechanism: FOOSH is the classic injury mechanism.
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Often missed: Initial X-rays can be falsely negative.
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Typical symptom: Tenderness in the anatomical snuffbox is classic.
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Complication: Risk of avascular necrosis due to poor blood supply to the proximal pole.
❌ Why not the others?
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Fracture of the distal radius: Usually evident on initial exam and imaging; rarely missed if symptomatic.
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Dislocation of the lunate: More common in adults; presents with wrist deformity, paresthesia (median nerve compression), and usually not missed.
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Rupture of flexor pollicis longus tendon: Associated with distal radius fractures or lacerations, not typical in FOOSH without obvious trauma.
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Bennett's fracture: Intra-articular fracture at the base of the 1st metacarpal — usually presents with thumb base pain and dysfunction; not the typical delayed presentation seen with occult scaphoid fractures.
🔑 High-Yield Summary:
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Mechanism: FOOSH
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Diagnosis: Suspect scaphoid fracture with persistent wrist pain, especially in anatomical snuffbox
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Management: Immobilize and repeat imaging in 10–14 days or do early MRI
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Complication: Avascular necrosis → monitor closely
🧠Mnemonic:
SCAphoID =
Snuffbox pain, Can be missed, Avascular necrosis risk, ID it early!
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