What are the differential diagnoses and management options for acute wrist pain in a pediatric patient?

Differential Diagnoses for Acute Wrist Pain in an 8-Year-Old Female

In an 8-year-old with acute wrist pain, fracture—particularly of the distal radius or scaphoid—is the most critical diagnosis to exclude, followed by soft tissue injuries including ligamentous sprains and tendon injuries.

Primary Differential Diagnoses

Traumatic Causes (Most Common in Pediatrics)

• Distal radius fracture (including buckle/torus fractures, which are extremely common in this age group) 1, 2
• Scaphoid fracture (less common in children under 10 but must be considered with snuffbox tenderness) 3, 4
• Other carpal bone fractures (rare in this age group but possible) 3
• Physeal injuries (growth plate fractures unique to pediatric patients) 2
• Ligamentous injuries including scapholunate or lunotriquetral ligament sprains 4, 5

Soft Tissue Pathology

• Tendinopathy/tendinosis (though more common after age 40, can occur with overuse activities) 1
• De Quervain tenosynovitis (if pain localizes to radial/thumb side of wrist) 1, 3
• Ganglion cyst (common in pediatrics, may present acutely if ruptured or rapidly enlarged) 6, 3

Inflammatory/Infectious Causes

• Septic arthritis (RED FLAG: requires urgent evaluation if fever, erythema, or warmth present) 1
• Juvenile idiopathic arthritis (consider if bilateral involvement, morning stiffness, or multiple joint involvement) 1

Other Considerations

• Triangular fibrocartilage complex (TFCC) injury (presents with ulnar-sided pain, often from twisting injuries) 1
• Referred pain from cervical spine, shoulder, or elbow pathology 7

Diagnostic Algorithm

Step 1: Initial Clinical Assessment

Key history elements to elicit:

• Mechanism of injury (fall on outstretched hand suggests fracture) 4
• Timing and progression (sudden vs. insidious onset) 1
• Location of pain (radial vs. ulnar sided, dorsal vs. volar) 1, 2
• Activities that reproduce pain (loading, twisting, specific movements) 1

Critical physical examination findings:

• Anatomic snuffbox tenderness (suggests scaphoid fracture) 3, 4
• Localized bony tenderness (suggests fracture) 1
• Swelling, erythema, warmth (suggests infection—requires urgent aspiration) 1
• Deformity (suggests fracture-dislocation requiring urgent evaluation) 1
• Pain with specific loading maneuvers (suggests tendinopathy) 1

Step 2: Initial Imaging

Plain radiographs are the mandatory first imaging study and should include a minimum 3-view series: posteroanterior (PA), lateral, and 45° semipronated oblique views 2. Adding a fourth scaphoid view increases diagnostic yield for both distal radius and scaphoid fractures 2.

Critical pitfall: Relying on only 2 views is inadequate and can miss significant fractures 2. Conventional radiography alone misses up to 30% of scaphoid fractures 4.

Step 3: Management Based on Initial Radiographs

If Fracture Identified:

• Appropriate immobilization and orthopedic referral 1

If Radiographs Normal but High Clinical Suspicion for Fracture:

Two evidence-based options:

1. Conservative approach: Place in short arm cast and repeat radiographs in 10-14 days 2, 4
2. Advanced imaging: MRI without IV contrast is the preferred next study for suspected occult fractures, offering superior sensitivity for bone bruises and soft tissue injuries 2, 3
   • CT without IV contrast is an acceptable alternative, particularly if MRI unavailable or contraindicated 3
   • Bone scintigraphy has high sensitivity but lower specificity than MRI 3

If Radiographs Normal and Soft Tissue Pathology Suspected:

For radial-sided pain:

• MRI without IV contrast is usually appropriate to evaluate for tendinopathy, ligamentous injury, or early inflammatory changes 2
• Ultrasound is effective for examining tendons, tendon sheaths, and can guide therapeutic injections 1

For ulnar-sided pain:

• Either MRI without IV contrast or MR arthrography is appropriate for TFCC evaluation 6

For palpable mass or suspected ganglion:

• MRI without IV contrast, MRI with IV contrast, or ultrasound are all appropriate options 6, 3

Initial Conservative Management (When Fracture Excluded)

• Relative rest and reduced activity to decrease repetitive loading 1
• Cryotherapy with melting ice water through wet towel for 10-minute periods for acute pain relief 1
• NSAIDs for short-term pain relief (2-3 weeks maximum); topical NSAIDs have fewer systemic side effects 1

Red Flags Requiring Urgent Evaluation

• Fever, erythema, or warmth suggesting infection (requires joint aspiration) 1
• Severe deformity suggesting fracture-dislocation 1
• Night pain or pain at rest (suggests more advanced pathology or alternative diagnosis) 1
• Multiple symptomatic joints (prompts evaluation for rheumatic disease) 1

Common Pitfalls to Avoid

• Do not diagnose "wrist sprain" without specific anatomic localization 8
• Do not rely on 2-view radiographs alone—this misses significant pathology 2
• Do not dismiss scaphoid fracture possibility even with negative initial radiographs if snuffbox tenderness present 3, 4
• Do not overlook growth plate injuries unique to pediatric patients 2
• If conservative treatment fails after 3-6 months, surgical evaluation is warranted 1