Author: Michael LeWitt, MD, MPH Reviewer: Corey Heitz
Case Title: Scapholunate Dislocation/ FOOSH
Target Audience: Residents in EM, attendings
Primary Learning Objectives: key learning objectives of the scenario
1. Identify anatomical features of the hand.
2. Identify a scapholunate dislocation on radiological studies.
3. Formulate a differential diagnosis for other related/distracting injuries.
4. Perform a workup to identify other injuries.
Secondary Learning Objectives: detailed technical goals, behavioral goals, didactic points
1. List indications for other diagnostic tests for complex hand fractures.
2. Appropriately refer patients with hand injuries.
Critical actions checklist
1. Primary and secondary survey, with special attention to head and neck.
2. Xray of injured left hand and wrist.
3. Identification of scapholunate dissociation and splinting
4. Orthopedic referral.
5. CT of head
5. Trauma/neurosurgical consultation.
For Examiner Only
Author: Michael LeWitt, MD, MPH Reviewer: Corey Heitz
Case Title: FOOSH
CASE SUMMARY
CORE CONTENT AREA
Orthopedics, neurosurgery, trauma, head injury
SYNOPSIS OF HISTORY/ Scenario Background
CC: HPI: Patient fell 6 feet from a ladder, onto outstretched hand. Struck head on way down. May be confused.
Past medical history: 43 year old painter, had appendectomy, left tibial fracture, mild hypertension, no head injuries.
Medications and allergies: HCTZ, no allergies.
Family and social history: Lives alone. Divorced. Occasional visitation with children. Smokes 1 pack of cigarette, chews tobacco. Drinks 2 – 3 beers per day. Family history: Diabetes, hypertension, cancer.
SYNOPSIS OF PHYSICAL
Contusion/abrasion of right parietal head. No laceration. No Battle’s sign. No hemotympanum, nose bleeding, intraoral bleeding. Neck not tender. Trachea midline. Heart, lungs, abdomen, skin, neuro all intact. Contusion, swelling and tenderness of left hand, dorsal surface. Neurovascular status intact. Remainder of extremity examination benign.
Vital signs
Temp 36.5 C
HR 84
RR 16
BP 142/72
SpO2 97% on room air
pain score 7/10.
For Examiner Only
CRITICAL ACTIONS
Scenario branch points/ PLAY OF CASE GUIDELINES
Key teaching points or branch points that result in changes in patient’s condition
1. Critical Action
Primary and secondary survey, attention to head and neck, left hand
Cueing Guideline: If not solicited initially, have nurse comment on swelling of hand when she tries to start IV there and say that patient is acting inappropriately and seems confused at times.
2. Critical Action
Xray of left hand (and wrist).
Cueing Guideline: If not ordered, have patient complain of wrist and hand pain. During physical exam, provide a picture of swelling of hand.
3. Critical Action
Identification of scapholunate dissociation and splinting.
Cueing Guideline: After looking at the film, if the participant does not discuss the findings prior to splinting, or does not attempt splinting, the patient should ask “doctor, what did you see?” and subsequently “so what do you need to do about that?”
4. Critical Action
Orthopedic consultation..
Cueing Guideline: If the participant attempts discharge without referral, the patient should ask for the plan from here. “Do I come back to see you?” If discharge is still attempted, the nurse should ask the participant, “are you sure this guy can go home?”
5. Critical Action
Head CT .
Cueing Guideline: If a head CT or other imaging is not ordered, the patient becomes more confused, disoriented
6. Critical Action
Trauma/neurosurgical consultation
Cueing Guideline: Radiologic report of CT scan or MRI is normal, but patient remains somewhat confused. If discharge is attempted, the nurse should state that he doesn’t seem to have gotten much better since he arrived. (He keeps asking what happened and why he’s here, but has periods of lucidity).
SCORING GUIDELINES
(Critical Action No.)
1. Complete 1° and 2° survey – failure to complete a full exam will result in failure of the case
2. Orders xray of hand – failure to order will result in failure of the case
3. Interprets xray and splints – failure to correctly interpret and/or to splint the patient will result in failure of the case
4. Orthopedic consultation – failure to consult orthopedics will result in failure of the case
5. CT of head – failure to order in response to confusion will result in failure of the case
6. Neurosurgical/Trauma consultation – failure to consult trauma/neurosurgery for admission for persistent confusion will result in failure of the case
For Examiner Only
HISTORY
Onset of Symptoms: One hour ago.
Background Info: Vital signs, HPI
Chief Complaint: I fell 6’ off of a ladder, hitting my head, and landing on my left hand
Given if requested:
Past Medical Hx: Hypertension.
Past Surgical Hx: Left tibia, appendectomy
Habits: Smoking: One pack per day
ETOH 2 – 3 beers per day
Drugs: None
Family Medical Hx: Hypertension, cancer, diabetes
Social Hx: Marital Status: Divorced
Children: 2, living with ex-wife
Education: High school graduate
Employment: Painter, works for company
ROS: Pain left hand. Head injury. No definite LOC. No other symptoms
For Examiner Only
PHYSICAL EXAM
Patient Name: Frank Foster Age & Sex: 43 year old male
General Appearance: Well-developed, well-nourished male in moderate distress
Vital Signs: Temp 36.5, HR 84, RR 16, BP 142/72, SpO2 97% on room air, pain score 7/10.
Head: Contusion right parietal area. No laceration. No Battle’s sign.
Eyes: PERL, EOMI, fundi benign.
Ears: Normal, no hemotympanum.
Mouth: Normal, no bleeding or laceration
Neck: Non-tender. No step-off, no pain with axial loading
Skin: Intact. Swelling of right parietal, left hand (dorsum)
Chest: Normal
Lungs: Normal
Heart: Normal
Back: Atraumatic
Abdomen: Normal, non-tender
Extremities: Swelling, tenderness, decreased range of motion left hand. Neurovascular status intact. Other extremities unaffected.
Rectal: Normal, if done.
Pelvic: N/A
Neurological: GCS 14, no focal deficits
Mental Status: Awake, alert, disoriented, conversant. At times, repeats questions and forgets where he is and what happened.
For Examiner Only
STIMULUS INVENTORY
#1 Emergency Admitting Form
#2 CT or MRI of brain
#3 Xray of left hand
#4 Debriefing materials
For Examiner Only
LAB DATA & IMAGING RESULTS
Diagnostic Imaging
Stimulus #2
Head CT: Negative
Stimulus #3
Xray of Left Hand
Learner Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name: Frank Foster
Age: 43 years
Sex: Male
Method of Transportation: Arriving from worksite by private vehicle
Person giving information: Patient and co-worker
Presenting complaint: Fall from ladder
Background:
Patient fell approximately 6 feet from a ladder, at work, injuring his left hand and head. He did not lose consciousness, but does feel somewhat confused. Pain score 7/10
Triage or Initial Vital Signs
BP: 142/72
P: 84
R: 16
T : 36.5oC
Learner Stimulus #2
Head CT or MRI of Brain
Negative
Learner Stimulus #3
Feedback/ Assessment Form
FOOSH
Candidate ______Examiner ______
Critical Actions:
r Complete primary and secondary survey
r Orders xray of left hand and wrist
r Interprets xray correctly and provides splint
r Orthopedic consultation
r CT of head
r Neurosurgical/Trauma consultation
Dangerous Actions: (Performance of one dangerous action results in failure of the case)
r Misinterpretation of hand Xray
r Failure to splint injury
r Failure to contact orthopedic surgeon
r Failure to identify potential head injury (failure to order CT)
r Attempted discharge of persistently confused patient
Overall Score:
r Pass
r Fail
For Examiner
Date: Examiner: Examinee(s):
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)
The learner should be scored (based on level of training) for each item above with one of the following:
NI = Needs Improvement
ME = Meets Expectations
AE = Above Expectations
NA= Not Assessed
Critical Actions / NI / ME / AE / NA / CategoryPerform primary and secondary survey / PC, MK, PBL
Xray left hand and wrist / PC, MK
Interprets xray as scapholunate dissociation and splints patient / PC, MK,
Orthopedic referral / PC, MK, PBL, SBP
Orders CT of head / PC, MK, PBL
Admits to Neurosurg/trauma / PC, MK, PBL, SBP
Category: One or more of the ACGME Core Competencies as defined in the SDOT
PC= Patient Care
Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
MK= Medical Knowledge
Residents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making
PBL= Practice Based Learning & Improvement
Involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
ICS= Interpersonal Communication Skills
Results in effective information exchange and teaming with patients, their families, and other health professionals
P= Professionalism
Manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
SBP= Systems Based Practice
Manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value
Debriefing Materials:
May use the included radiographs for demonstration of anatomic relationships; also, the first reference in Tintinalli (see below, figure 268 - 1) shows the anatomic relationships of the bones
The goal of this module is to assess the potential for injury to the carpal bones after a fall on an outstretched hand (FOOSH). The amount of force involved in such a fall, concentrated in a small area such as the palm of the hand, imparts a significant physical stressor to the delicate ligaments of the distal wrist and proximal hand. Frequently, this leads to disruption of the bony-ligament relationships, in addition to, or in lieu of, a fracture or dislocation. In the training images provided with this case, there is an opportunity to discuss and understand the relationships of the carpal and lunate bones, especially, and see how a small change in the relationship, as manifested on a plain film Xray, represents a significant ligamentous injury, with the potential for long-term disability. Scapholunate dissociation is one of the more difficult Xray findings, especially if one is less familiar with looking at plain films of the hand. Nonetheless, the abnormal appearance should provide a cue to the physician, or MLP, that the anatomy is distorted, and that further attention must be provided, generally, in this instance, by a hand or general orthopedic surgeon.
Keywords for future searching functions
Scapholunate dissociation, FOOSH, hand injuries, trauma, head injury
References
Tintinalli, Emergency Medicine, 6th edition, pp. 1664 - 1684, esp. pp. 1666 (picture of bones of hand, figure 268 - 1), 1677 (figure 269 - 4, scapholunate dissociation), and 1680 (figure 269 - 8), lunate dislocation.
Mercier, Practical Orthopedics, 4th edition, pp. 124 and 125 (figure 7 - 39 B, scapholunate dissociation)
Has this work been previously published?
No
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