What is the appropriate treatment for a patient with a suspected wrist injury, presenting with pain, bruising, and mild swelling after a fall?

Management of Acute Wrist Injury After Fall

The appropriate treatment for a patient with a suspected wrist injury presenting with pain, bruising, and mild swelling after a fall includes radiographic imaging, wrist brace application, pain management with ketorolac injection and oral NSAIDs/muscle relaxants, and appropriate patient education. 1, 2, 3

Initial Assessment and Imaging

1. Radiographic Evaluation:

   • Standard 3-view radiographs (posteroanterior, lateral, and 45° semipronated oblique) should be obtained to evaluate for fractures and displacements 1, 2
   • For wrist injuries, these views are essential to detect fractures, dislocations, and joint abnormalities 1

2. When to Consider Advanced Imaging:

   • If radiographs are negative but clinical suspicion remains high, consider:
     • MRI without contrast (high sensitivity for occult fractures and soft tissue injuries) 1, 2
     • CT without contrast (useful for complex fracture evaluation and surgical planning) 1

Treatment Plan

1. Immobilization:

   • Wrist brace application is appropriate for suspected sprains, strains, or minor fractures 1, 2
   • A functional splint is preferred over complete immobilization to maintain some mobility while providing support 2
   • The brace helps stabilize the wrist joint, reduce pain, and prevent further injury 4

2. Pain Management:

   • Ketorolac injection is appropriate for short-term management of moderately severe acute pain 3
     • Use the lowest effective dose for the shortest duration (≤5 days)
     • Monitor for potential adverse effects including GI bleeding
   • Oral medications:
     • Ibuprofen for ongoing pain control and anti-inflammatory effects
     • Methocarbamol as a muscle relaxant to reduce associated muscle spasm

3. Cold Therapy:

   • Apply cold (ice and water in a damp cloth) to the injured wrist for 20-30 minutes per application
   • Cold application decreases pain and swelling in acute injuries 1
   • Avoid direct contact with skin to prevent cold injury

Patient Education

1. Activity Modification:

   • Rest the injured extremity and avoid activities that cause pain 1
   • Limit use of the injured wrist to prevent worsening of the injury

2. Follow-up Care:

   • Seek medical follow-up if:
     • Pain persists beyond 3-5 days
     • Swelling increases
     • Bruising spreads
     • Numbness or tingling develops
     • Inability to move fingers or wrist

3. Home Care Instructions:

   • Continue cold application 3-4 times daily for the first 48-72 hours 1
   • Keep the wrist elevated when possible to reduce swelling
   • Perform gentle finger movements to prevent stiffness 2
   • Take medications as prescribed

Important Considerations and Cautions

1. Ketorolac Precautions:

   • Limited to short-term use (≤5 days) due to increased risk of adverse effects with prolonged use 3
   • Higher risk of GI bleeding in elderly patients and those with history of GI issues 3
   • Monitor for signs of adverse reactions

2. When to Escalate Care:

   • Severe pain unresponsive to treatment
   • Signs of vascular compromise (pallor, decreased pulses, severe swelling)
   • Progressive neurological symptoms
   • Inability to perform basic hand functions

3. Complications to Watch For:

   • Delayed treatment can compromise long-term function 2
   • Untreated ligamentous injuries can lead to chronic instability and osteoarthritic changes 2
   • Malunion, non-union, and complex regional pain syndrome are potential complications of wrist fractures 2

This treatment approach provides appropriate initial management for a suspected wrist injury while allowing for proper evaluation and follow-up care to ensure optimal recovery and prevent long-term complications.