What should I do for radial side pain after boxing?

Radial-Sided Wrist Pain After Boxing

For radial-sided wrist pain following boxing trauma, obtain standard wrist radiographs immediately, followed by MRI without IV contrast if radiographs are normal or equivocal, while initiating multimodal analgesia and early active finger motion exercises to prevent stiffness.

Initial Diagnostic Approach

Obtain standard wrist radiographs as the first-line imaging study for any traumatic wrist pain, as recommended by the American College of Radiology 1. Radiographs serve as the essential initial examination to identify fractures, particularly scaphoid fractures which are common with radial-sided pain after impact sports like boxing 1.

When Radiographs Are Normal or Equivocal

• MRI without IV contrast is the preferred next step when radiographs fail to reveal the source of radial-sided pain 1
• The American College of Radiology specifically recommends MRI without IV contrast for persistent radial-sided wrist pain with normal or equivocal radiographs 1
• MRI provides superior visualization of soft tissues, ligaments, and occult fractures that may not be visible on plain films 1

Special Consideration for Scaphoid Injury

• Scaphoid fractures are particularly common with radial-sided wrist trauma and may be radiographically occult initially 1
• If scaphoid fracture is suspected clinically (anatomic snuffbox tenderness), proceed with either MRI or CT without contrast even if initial radiographs appear normal 1
• Early detection prevents complications including nonunion, malunion, and osteonecrosis 1

Immediate Pain Management

Implement multimodal analgesia immediately rather than relying on single-agent therapy 1. The French Society of Anesthesiology and Emergency Medicine strongly recommends this approach for traumatic limb injuries 1.

Specific Analgesic Strategy

• Combine paracetamol (acetaminophen) with morphine for additive pain relief if pain is severe 1
• Morphine via intravenous titration is the technique of choice when IV access is available, with 82% efficacy when properly protocolized 1
• Low-dose ketamine (0.15-0.3 mg/kg) combined with morphine improves analgesia and reduces required morphine doses 1
• Assess pain using the Numeric Rating Scale (NRS), which is validated and correlates strongly with visual analog scales 1

Critical Early Management: Prevent Stiffness

Begin active finger motion exercises immediately following diagnosis, even before definitive treatment is determined 2. This is one of the most important interventions to prevent the functionally disabling complication of hand stiffness.

Why Early Motion Is Essential

• The American Academy of Orthopaedic Surgeons emphasizes that finger motion does not adversely affect adequately stabilized fractures regarding reduction or healing 3, 2
• Hand stiffness results from pain, swelling, immobilization, or patient apprehension—all of which worsen with delayed mobilization 2
• Stiffness is one of the most functionally disabling complications of upper extremity trauma 3

Immobilization Guidelines

• For confirmed acute avulsion fractures or significant injuries, use rigid splinting for 3-6 weeks as recommended by the American Academy of Orthopaedic Surgeons 3
• Rigid immobilization is preferred over removable splints for displaced fractures 2
• Fingers should remain mobile throughout the immobilization period 3, 2

Follow-Up Protocol

Radiographic Monitoring

• No difference exists in outcomes based on frequency of radiographic evaluation for conservatively treated injuries 3
• Obtain follow-up radiographs at approximately 2 weeks only if: new trauma occurs, pain score exceeds 6/10 on VAS, loss of range of motion develops, or neurovascular symptoms appear 3
• For fractures, obtain radiographs at approximately 3 weeks and at immobilization removal 2

Red Flags Requiring Reevaluation

Reevaluate immediately for unremitting pain during follow-up, as this may indicate complications including 3, 2:

• Compartment syndrome
• Malunion or nonunion
• Occult fracture progression
• Ligamentous instability

Post-Immobilization Rehabilitation

• A home exercise program is an effective option after the immobilization period ends 3, 2, 4
• Studies show no significant difference in outcomes between home exercise programs and supervised therapy for uncomplicated injuries 2
• Progressive resistance training should advance over 12 weeks, focusing on wrist and forearm strengthening 4

Common Pitfalls to Avoid

Missed Scaphoid Fractures

• Scaphoid fractures may not be visible on initial radiographs but cause persistent radial-sided pain 1
• Do not dismiss persistent radial-sided pain with normal radiographs—proceed to MRI 1

Prolonged Immobilization Without Finger Motion

• Prolonged immobilization without finger motion significantly increases permanent stiffness risk 2
• Even with wrist immobilization, fingers must move actively from day one 3, 2

Inadequate Pain Control

• Undertreated pain leads to patient apprehension and voluntary immobilization, worsening stiffness 2
• Multimodal analgesia is superior to single-agent therapy and should be standard practice 1

Delayed Advanced Imaging

• Waiting too long for MRI when radiographs are equivocal delays diagnosis of soft tissue injuries, ligament tears, and occult fractures 1
• The American College of Radiology specifically recommends MRI without IV contrast for persistent radial-sided pain with normal radiographs 1