Worsening Wrist and Hand Pain After Fall Without Fracture on Initial X-rays
Obtain MRI of the wrist without IV contrast immediately to rule out occult fracture, ligamentous injury, or bone contusion that was missed on initial radiographs. 1, 2
Immediate Diagnostic Approach
The worsening pain 2 weeks post-injury despite negative initial radiographs is a red flag that demands advanced imaging. This clinical scenario parallels the hip fracture guideline case where initial radiographs were negative but MRI revealed a fracture—the same principle applies to the wrist. 1
Why MRI is the Next Step
MRI without IV contrast is the preferred advanced imaging modality when initial radiographs are negative or equivocal but clinical suspicion for fracture remains high, with sensitivity of 94.2% and specificity of 97.7% for occult fractures. 2
MRI changes clinical management in 69.5% of cases when patients present with persistent wrist pain after negative radiographs, making it highly clinically relevant. 1
MRI can detect multiple pathologies that explain worsening symptoms including: occult scaphoid fractures (missed in up to 30% of initial radiographs), bone contusions, ligamentous injuries (scapholunate or lunotriquetral tears), tendon injuries, and early avascular necrosis. 1, 2, 3
Alternative Imaging Options (If MRI Unavailable)
CT without IV contrast is an acceptable alternative with high diagnostic yield for occult fractures, particularly useful if the patient is casted, though it provides less information about soft tissue and ligamentous injuries compared to MRI. 2
Repeat radiographs at 10-14 days can be considered but are less sensitive than MRI and may delay definitive diagnosis in a patient whose symptoms are already worsening at 2 weeks. 1, 2, 3
Critical Occult Injuries to Rule Out
Scaphoid Fracture
- Most commonly missed carpal fracture, with conventional radiography missing up to 30% of cases initially. 3
- Untreated scaphoid fractures lead to nonunion, avascular necrosis, and post-traumatic arthritis—significant morbidity that directly impacts quality of life. 2
- Worsening pain at 2 weeks is highly concerning for this diagnosis. 3
Ligamentous Injuries
- Scapholunate or lunotriquetral ligament tears can present with normal initial radiographs but progressive pain and instability. 1
- These injuries require early diagnosis to prevent chronic wrist instability and arthritis. 4
Other Occult Fractures
- Hook of hamate, triquetrum, or distal radius fractures may not be visible on standard 3-view radiographs. 2
Management Pending Imaging
- Immobilize in a short arm splint or cast until MRI is obtained to prevent displacement of any occult fracture. 3
- Avoid weight-bearing activities with the affected hand. 1
- NSAIDs for pain control unless contraindicated. 3
Common Pitfalls to Avoid
- Do not dismiss worsening pain as a "wrist sprain"—this is considered one of the most treacherous ED diagnoses because radiographs do not rule out all acute injuries. 4
- Do not wait for symptoms to resolve spontaneously when pain is worsening at 2 weeks; this suggests significant underlying pathology. 1, 3
- Do not rely solely on repeat radiographs when MRI is available, as it provides superior diagnostic information for both bony and soft tissue injuries. 1, 2