What is the appropriate treatment for a suspected wrist fracture in a 12-year-old?

Wrist Injury in a 12-Year-Old: Diagnostic and Treatment Approach

For a suspected wrist fracture in a 12-year-old, obtain plain radiographs immediately (posteroanterior, lateral, and oblique views) as the initial diagnostic step, and if a torus (buckle) fracture is confirmed, offer a soft bandage with immediate discharge rather than rigid immobilization, as this provides equivalent pain control and functional outcomes. 1, 2

Initial Imaging Strategy

Plain radiographs are the mandatory first-line imaging study for any acute wrist trauma in children. 1 The standard three-view examination should include:

• Posteroanterior (PA) view
• Lateral view
• 45° semipronated oblique view 3

This establishes baseline assessment and identifies the vast majority of clinically significant fractures. 1, 3

Critical Caveat: Scaphoid Fractures

While scaphoid fractures are the most commonly fractured carpal bone in adults, they are exceedingly rare in children aged 4-11 years. 4, 5 In this age group, the positive predictive value of clinical suspicion for scaphoid fracture is only 2.1% to 12.5%, suggesting that routine immobilization for suspected scaphoid injury may not be necessary in younger children. 5 However, at age 12, the child is approaching adolescence where scaphoid fractures become more common, so maintain appropriate clinical vigilance. 4

If scaphoid fracture is suspected but initial radiographs are negative or equivocal, consider:

• Repeat radiographs in 10-14 days 1
• MRI without IV contrast 1
• CT without IV contrast 1

These are equivalent alternatives according to the American College of Radiology. 1

Treatment Based on Fracture Type

Torus (Buckle) Fractures

The highest quality evidence demonstrates that soft bandage immobilization with immediate discharge is equivalent to rigid immobilization for torus fractures. 2

In a 2022 randomized controlled equivalence trial of 965 children aged 4-15 years with distal radius torus fractures:

• Pain scores at 3 days were equivalent between bandage (3.21 points) and rigid immobilization (3.14 points) groups
• No differences in pain or function occurred during 6 weeks of follow-up
• 94% follow-up rate confirms robust findings 2

This approach offers significant advantages:

• Eliminates need for follow-up appointments
• Reduces healthcare burden
• Provides equivalent pain control and functional outcomes
• Allows earlier return to activities 2

Other Fracture Patterns

For fractures other than simple torus fractures (displaced fractures, complete fractures, or complex patterns):

• Rigid immobilization is appropriate
• Orthopedic consultation should be obtained
• Follow-up imaging may be necessary to confirm healing 1

When Initial Radiographs Are Negative or Equivocal

If clinical suspicion remains high despite negative initial radiographs, the American College of Radiology recommends three equivalent options: 1

• Repeat radiographs in 10-14 days
• MRI without IV contrast
• CT without IV contrast

Important consideration for pediatric patients: Radiation exposure is a critical factor in children due to higher organ sensitivity and longer life expectancy. 1 This makes MRI particularly attractive as a follow-up modality when additional imaging is needed, as it avoids additional radiation exposure.

Red Flags Requiring Immediate Attention

High-energy mechanisms warrant heightened vigilance for:

• Complex distal radius fractures
• Radiocarpal dislocations
• Perilunate dislocations
• Associated median nerve compression or contusion 6

These injuries require immediate reduction of any dislocation and relief of neurovascular compression, with definitive treatment (bone fixation, ligament repair) performed simultaneously or delayed based on the specific injury pattern. 6

Common Pitfalls to Avoid

• Do not skip initial radiographs even if the injury seems minor—radiographic confirmation is essential for appropriate treatment decisions 1, 3
• Do not routinely immobilize all children with wrist pain in the absence of confirmed fracture, particularly in younger age groups where scaphoid fractures are rare 5
• Do not over-treat confirmed torus fractures with rigid casts and multiple follow-up visits when soft bandage provides equivalent outcomes 2
• Do not delay imaging or treatment for suspected fractures, as optimal outcomes depend on prompt recognition and appropriate early management 7