What is the treatment plan for a 7-year-old female with unresolved right wrist pain and an unhealed abrasion on the right leg after a fall?

Treatment Plan for Pediatric Wrist Pain with Negative X-ray

For this 7-year-old with persistent wrist pain 6 weeks post-injury and negative radiographs, thumb spica splinting for 4-6 weeks is the appropriate conservative treatment, combined with proper wound care for the unhealed leg abrasion. 1

Wrist Management

Splinting Protocol

• Apply a prefabricated thumb spica splint continuously for 4-6 weeks, worn day and night, removing only for bathing 1
• Position the wrist in neutral and thumb in slight extension 1
• This immobilization approach is effective for occult wrist injuries not visible on initial radiographs, including potential ligamentous injuries, occult carpal fractures, or soft tissue injuries 2, 3

Rationale for Conservative Management

• In pediatric patients with clinical wrist pain but negative radiographs, splint immobilization is the first-line treatment 1, 3
• The 6-week duration since injury without improvement warrants immobilization rather than continued observation 3
• Pediatric patients have high remodeling potential, making conservative management with splinting appropriate even when accepting some initial deformity 2

Follow-up Strategy

• Return to clinic if no improvement after 4 weeks of splinting or if symptoms worsen 1
• After 4-6 weeks, if improved, wean gradually from the splint 1
• If pain persists after 4-6 weeks of appropriate splinting, advanced imaging (MRI) should be considered to evaluate for occult fractures, ligamentous injuries, or avascular necrosis 2, 3

Pain Management

• Short-term NSAIDs are reasonable for pain relief, though they do not alter long-term outcomes 2
• Relative rest from aggravating activities is essential during the splinting period 2

Leg Abrasion Management

Wound Care Protocol

• Irrigate the unhealed abrasion thoroughly with copious amounts of warm potable water or sterile saline until no foreign matter remains 4
• After cleaning, apply antibiotic ointment or cream to the moist wound 4
• Cover with a clean occlusive dressing to maintain a moist environment and promote healing 4
• Change dressing daily or when soiled 4

Infection Monitoring

• Monitor for signs of infection: progressive erythema, increased pain/tenderness, warmth, purulent drainage, fever, or increasing swelling 4
• The current erythema and tenderness with occasional itchiness requires close observation 4
• If infection signs develop, initiate appropriate antibiotic therapy 4

Tetanus Prophylaxis

• Verify tetanus immunization status and administer toxoid if vaccination is outdated or unknown for this contaminated wound 4

Key Clinical Pitfalls

• Do not dismiss persistent wrist pain despite negative radiographs - occult fractures (especially scaphoid), ligamentous injuries, and soft tissue injuries are common in pediatric patients and may not appear on initial films 2, 3
• Avoid premature return to activities before adequate healing, as this can lead to chronic pain or instability 2
• Do not use topical antiseptics for initial wound irrigation - water or saline is preferred 4
• Ensure proper splint positioning (wrist neutral, thumb slightly extended) to prevent stiffness 1

Activity Restrictions

• Limit activities that stress the wrist during the splinting period 2
• Elevate the injured leg when possible to reduce inflammation 4
• The patient should avoid bearing weight or stressing the wrist until symptoms resolve 2