What is the most appropriate next step for a patient with wrist pain, numbness, and swelling after falling on an outstretched hand, with decreased sensation to light touch over the thumb and first 3 fingers?

Management of Wrist Pain, Numbness, and Swelling After Fall on Outstretched Hand

The most appropriate next step for a patient with wrist pain, numbness, and swelling after falling on an outstretched hand, with decreased sensation to light touch over the thumb and first 3 fingers, is to obtain a 3-view radiographic examination of the wrist (posteroanterior, lateral, and 45° semipronated oblique views). 1

Initial Assessment and Imaging Approach

Radiographs are the recommended initial imaging study for acute wrist trauma, as they can detect fractures, dislocations, and joint alignment issues. The three essential views include:

• Posteroanterior (PA) view: Evaluates bone alignment and joint spaces
• Lateral view: Assesses displacement and angulation
• Oblique (45° semipronated) view: Increases diagnostic yield for fractures and displacements 1, 2

The presentation of pain, swelling, and numbness in the median nerve distribution (thumb and first 3 fingers) after a fall on an outstretched hand raises concern for:

1. Distal radius fracture (most common wrist fracture)
2. Carpal bone fractures (particularly scaphoid)
3. Carpal dislocations or instability
4. Median nerve compression or injury

Follow-up Imaging Based on Initial Radiograph Results

If Radiographs Show a Fracture:

• For complex fractures with intra-articular extension or when surgical planning is needed, CT without IV contrast is recommended 2, 1
• MRI without IV contrast should be considered if there is concern for concomitant ligamentous injuries, which may affect surgical management 2, 1

If Radiographs are Negative or Equivocal:

• With high clinical suspicion for fracture, MRI without IV contrast is recommended as it can detect radiographically occult fractures and evaluate for ligamentous injuries 2, 1, 3
• CT without IV contrast is an alternative to exclude occult fractures, though it cannot evaluate ligamentous injuries 2

Important Clinical Considerations

The numbness in the median nerve distribution (thumb and first 3 fingers) requires special attention as it may indicate:

• Acute carpal tunnel syndrome due to fracture fragment compression
• Direct nerve contusion
• Compartment syndrome in severe cases

Surgical Indications to Watch For

Surgical intervention may be necessary for:

• Intra-articular fractures with >2mm step-off
• Unstable fractures or dislocations
• Fractures with volar displacement of fragments
• Interfragmentary gap >3mm 1, 2

Potential Complications

Delayed or inadequate treatment can lead to:

• Malunion or nonunion
• Avascular necrosis
• Carpal instability
• Complex regional pain syndrome
• Chronic median nerve compression
• Osteoarthritic changes 1

Common Pitfalls to Avoid

1. Failing to obtain proper radiographic views - all three views are essential for adequate evaluation
2. Missing scaphoid fractures - these can be radiographically occult initially
3. Overlooking median nerve symptoms - these may indicate emergent decompression is needed
4. Delaying appropriate imaging in high-suspicion cases - this can compromise long-term function 1

Remember that wrist injuries in patients over 50 years should prompt consideration of underlying osteoporosis 1.