What is the most appropriate care for a 16-year-old boy with left wrist pain, tenderness, and swelling after a fall, with negative radiographs (x-rays) for fracture?

From the Guidelines

The most appropriate care for a 16-year-old boy with left wrist pain, tenderness, and swelling after a fall, despite negative radiographs, is conservative management with a wrist splint or brace for 1-2 weeks. He should rest the wrist, avoid activities that cause pain, and use ice for 15-20 minutes every 2-3 hours for the first 48-72 hours to reduce swelling. For pain relief, over-the-counter medications like ibuprofen (400-600mg every 6-8 hours with food) or acetaminophen (650mg every 6 hours) can be used 1. After the acute phase, gentle range-of-motion exercises should be started to prevent stiffness. If symptoms persist beyond 2 weeks, worsen, or if he develops numbness or tingling, he should return for reassessment as this could indicate a scaphoid fracture or other injury that wasn't visible on initial x-rays. A follow-up x-ray or MRI might be needed in this case, as MRI is highly sensitive to changes in bone marrow composition and can identify radiographically occult acute fractures throughout the skeleton, including in the wrist 1.

Key Considerations

• The patient's clinical presentation, including tenderness and swelling over the dorsum of the wrist, suggests a possible wrist sprain or occult fracture.
• The negative radiographs do not rule out a fracture, particularly a scaphoid fracture, which may not be immediately visible on initial imaging.
• Conservative management with a wrist splint or brace is a reasonable initial approach, given the patient's age and the likelihood of a wrist sprain.
• Close follow-up and reassessment are crucial to ensure that the patient's symptoms are improving and to rule out a more serious injury.

Potential Complications

• If the patient's symptoms persist or worsen, a scaphoid fracture or other injury may need to be ruled out with further imaging, such as an MRI.
• Delayed diagnosis of a fracture can lead to functional impairment and increased morbidity.
• The patient should be advised to return for reassessment if he develops numbness or tingling, as this could indicate nerve compression or other complications.

From the Research

Diagnosis and Treatment

The patient's symptoms, including tenderness and swelling over the dorsum of the wrist on the radial side in between the abductor pollicis longus and extensor pollicis longus tendons, suggest a possible injury to the triangular fibrocartilage complex (TFCC) [ 2 ]. The negative radiographs for fracture indicate that the injury may not be related to a bony fracture.

Possible Injuries

The patient's symptoms are consistent with a TFCC injury, which can occur due to acute trauma [ 2 ]. The TFCC is a complex structure that includes the fibrocartilage articular disk substance and meniscal homolog, as well as radioulnar ligament avulsions.

Treatment Options

Nonsurgical management of TFCC injuries includes temporary splint immobilization of the wrist and forearm, oral nonsteroidal anti-inflammatory medication, corticosteroid joint injection, and physical therapy [ 2 ]. Surgical strategies, such as débridement, acute repair, and subacute repair, may also be considered, depending on the severity of the injury and the presence of distal radioulnar joint instability [ 2 ].

Imaging Studies

Further imaging studies, such as CT or MRI, may be necessary to confirm the diagnosis and evaluate the extent of the injury [ 3 ]. These studies can help identify ligamentous trauma, fractures, and other abnormalities that may not be visible on radiographs.

Conservative Management

Conservative management, including wrist splinting and nonsteroidal anti-inflammatory medications, may be effective in treating mild to moderate wrist injuries [ 4 ]. However, the effectiveness of these treatments depends on the severity of the injury and the individual patient's response to treatment.

Determinants of Treatment

The use of wrist working splints in patients with rheumatoid arthritis is influenced by factors such as symptom severity, functional abilities, and intentional decisions based on perceived benefits and barriers [ 5 ]. Similarly, the treatment of wrist injuries in young adults may depend on various factors, including the severity of the injury, the presence of fractures or ligamentous trauma, and the individual patient's needs and preferences.

Role of CT

CT scans can be useful in evaluating the results of treatment for wrist injuries, particularly in cases where radiographs are inconclusive or negative [ 6 ]. CT scans can provide detailed images of the wrist and help identify fractures, ligamentous trauma, and other abnormalities.