What type of wrist splint is recommended for a patient with radial wrist pain and discomfort radiating to the thumb after a fall, with pain on extension of the hand and a negative X-ray?

Recommended Wrist Splint Type

For this patient with radial-sided wrist pain radiating to the thumb, pain on extension, and negative X-ray following a fall, a thumb spica splint (wrist cock-up splint with thumb immobilization) is recommended to address the likely de Quervain's tenosynovitis or scaphoid injury.

Clinical Reasoning

The clinical presentation strongly suggests either:

• De Quervain's tenosynovitis (radial wrist pain radiating to thumb, pain with extension)
• Occult scaphoid fracture (radial wrist pain, negative initial X-ray)

Both conditions require thumb immobilization in addition to wrist support 1.

Specific Splint Specifications

Position and Design

• Wrist position: Neutral to slight extension (0-15 degrees, preferably 0-5 degrees) 2
• Thumb inclusion: The splint must immobilize the thumb to the interphalangeal joint 1
• Type: Rigid immobilization is preferred over removable splints for acute displaced or suspected injuries 1

Material Considerations

• Plaster volar wrist splints perform better than fiberglass in limiting wrist motion in flexion, extension, radial deviation, and ulnar deviation 3
• Plaster splints perform similarly to short-arm casts in most planes of motion 3
• No statistically significant differences exist between rigid and soft orthoses for long-term outcomes, but rigid is preferred acutely 2

Initial Management Algorithm

Immediate (Week 0-2)

• Apply thumb spica splint with wrist in neutral position 1, 2
• Rigid immobilization is suggested over removable splints for this acute presentation with suspected injury 1
• Repeat radiographs at 10-14 days if scaphoid fracture is suspected 1

Re-evaluation at 2 Weeks

• Assess range of motion, pain level, and splint effectiveness 4
• If symptoms persist or worsen: Consider MRI without IV contrast to evaluate for occult fracture or ligamentous injury 1
• MRI shows concomitant ligament injuries and occult fractures more effectively than CT 1
• MRI led to diagnosis change in 55% and management change in 66% of patients with unexplained wrist symptoms 1

Duration of Immobilization

• Continue immobilization for minimum 2-3 weeks with radiographic follow-up 1, 4
• Radiographic evaluation should occur at approximately 3 weeks and at cessation of immobilization 1, 5

Critical Pitfalls to Avoid

• Do not use a simple wrist splint without thumb immobilization - this will be inadequate for radial-sided pathology with thumb involvement 1
• Do not dismiss negative initial X-rays - occult scaphoid fractures are common and require repeat imaging at 10-14 days 1
• Avoid prolonged immobilization beyond necessary time - this leads to stiffness requiring additional therapy 5, 4
• Do not use removable splints for acute injuries - rigid immobilization is preferred for displaced or suspected fractures 1

When to Escalate Care

• Immediate referral if symptoms worsen despite appropriate splinting 4
• Consider hand therapy referral for comprehensive occupational therapy if symptoms persist beyond 2-3 weeks 1
• Advanced imaging (MRI) is indicated if pain persists at 2-week follow-up with negative repeat radiographs 1, 4