Treatment of Right Wrist Injury from Slip and Fall
Initial radiographs (X-rays) of the wrist are the first and most appropriate imaging study for any adult with acute wrist trauma from a fall. 1
Immediate First Aid Management
- Do not attempt to move or straighten the injured wrist, as this can cause further harm and worsen the injury 1
- Splint the wrist in the position found to limit pain, reduce chance for further injury, and facilitate safe transport 1
- If the hand appears blue or extremely pale, activate emergency medical services (EMS) immediately, as this indicates potential vascular compromise 1
- Apply ice to reduce swelling while awaiting medical evaluation 2
Initial Diagnostic Approach
Standard 3-view radiographic examination is required, including posteroanterior, lateral, and 45° semipronated oblique views 3
Key radiographic findings to identify:
- Distal radius fractures (most common wrist fracture from falls on outstretched hand) 4
- Scaphoid fractures (most commonly fractured carpal bone, can be missed on initial X-rays in up to 30% of cases) 4
- Intra-articular extension (look for the "longhorn sign" suggesting articular involvement requiring surgery) 3
- Carpal malalignment or dislocation 1
When Initial Radiographs Are Negative or Equivocal
If clinical suspicion remains high despite negative initial radiographs, three equivalent options exist 1:
- Repeat radiographs in 10-14 days with specialized views (posteroanterior in ulnar deviation, pronated oblique) to detect occult scaphoid fractures 1, 4
- MRI without IV contrast to detect occult fractures and evaluate ligament injuries 1
- CT without IV contrast to confirm or exclude suspected fractures 1
Choosing between these options:
- Repeat radiographs at 10-14 days: Most cost-effective but delays definitive diagnosis; requires short arm cast immobilization during waiting period 1
- MRI: Best for detecting both occult fractures AND concomitant ligament injuries (scapholunate tears, lunotriquetral injuries); shows intra-articular extension better than plain films 1, 3
- CT: Superior for characterizing bone detail and intra-articular extension; useful for preoperative planning with 3D reconstructions 1, 3
Critical Red Flags Requiring Urgent Evaluation
Seek immediate medical evaluation if any of the following are present 1:
- Blue or extremely pale hand (vascular compromise)
- Absent or weak pulses at the wrist
- Progressive swelling or pain
- Inability to move fingers
- Numbness or tingling (potential nerve injury) 4, 2
Common Pitfalls to Avoid
- Failure to obtain adequate radiographic views (minimum 3 views required) can lead to missed diagnosis of significant fractures 3
- Dismissing persistent pain after negative initial radiographs: Scaphoid fractures are notoriously difficult to see initially and require follow-up imaging 4
- Attempting to "straighten" a deformed wrist: This causes additional harm and should never be done by first aid providers 1
- Delaying evaluation of vascular compromise: A pale, pulseless hand requires immediate action to prevent limb loss 1
Specific Injury Patterns from Falls
Falls on outstretched hand typically cause:
- Distal radius fractures (80% of axial load transmitted through radial side of wrist) 5
- Scaphoid fractures (compression injury from dorsiflexion) 6, 4
- Scapholunate ligament tears (tension injury on palmar aspect) 6
- Carpal instability (requires careful attention to radiographic positioning to detect) 1
Advanced Imaging for Suspected Ligament Injury
If radiographs show acute wrist fracture AND there is suspicion of tendon or ligament trauma, four equivalent advanced imaging options exist 1:
- MR arthrography of wrist
- MRI of wrist without IV contrast
- CT arthrography of wrist
- Ultrasound of wrist
MRI is particularly valuable as it shows both the fracture AND associated ligament injuries (scapholunate tears) that may affect surgical decision-making 1, 3
Surgical Indications
Operative intervention is typically necessary when 3: