Management of Acute Wrist Pain with Normal Initial Radiographs in a Runner
Your current management plan is appropriate: thumb spica immobilization with orthopedic follow-up and MRI if symptoms persist is the correct approach for suspected occult scaphoid or carpal injury with normal initial radiographs. 1
Immediate Management
- Continue thumb spica cast immobilization for suspected occult scaphoid fracture despite negative radiographs, as conventional radiography alone misses up to 30% of scaphoid fractures 2
- The American College of Radiology recommends this conservative approach as one valid option: place the patient in a short arm cast and repeat radiographs at 10-14 days 1
- Thumb spica casting is the standard non-operative treatment for stable scaphoid fractures and suspected fractures 3, 4
Timing Decision for Advanced Imaging
You face a critical decision point: obtain MRI now versus wait 10-14 days for repeat radiographs. The evidence supports both approaches, but your choice should depend on specific clinical factors:
Consider immediate MRI (before orthopedic follow-up) if:
- Pain is worsening or not improving after initial immobilization 5
- Patient is a high-level athlete requiring rapid return to sport 3
- High clinical suspicion based on anatomical snuffbox tenderness and mechanism of injury 2, 4
- Patient cannot tolerate prolonged immobilization uncertainty 1
MRI without IV contrast has 94.2% sensitivity and 97.7% specificity for occult scaphoid fractures and can detect concomitant ligament injuries (scapholunate, lunotriquetral) that affect management 1, 5
The "wait and repeat radiographs" approach is reasonable if:
- Symptoms are improving with immobilization 1
- Patient accepts potential 10-14 day delay in definitive diagnosis 1
- Cost or access to MRI is a barrier 1
The downside of delayed imaging is that it results in delay of diagnosis, which may lead to functional impairment 1
What the MRI Will Reveal
Beyond confirming or excluding fracture, MRI provides critical additional information:
- Occult scaphoid fractures (most common missed injury) 1, 5
- Scapholunate ligament tears that may require surgical repair to prevent chronic instability and arthritis 1, 5
- Bone contusions that explain persistent pain 5
- Other carpal fractures (hamate hook, capitate) 6
- Tendon injuries (De Quervain tenosynovitis, extensor carpi ulnaris pathology) 1, 2
Critical Pitfalls to Avoid
- Inadequate initial radiographs: Ensure a minimum 3-view series (PA, lateral, oblique) was obtained; 2-view imaging is inadequate 7, 5
- Missing specialized scaphoid views: A 4th view (scaphoid view with wrist in ulnar deviation) increases diagnostic yield 5, 3
- Premature return to activity: Avoid weight-bearing activities with the affected hand until fracture is definitively excluded, as displacement of an occult fracture can occur 5
- Delayed diagnosis of scaphoid fracture: Leads to nonunion, avascular necrosis (especially proximal pole fractures), and post-traumatic arthritis 5, 4
- Missing ligamentous injuries: Scapholunate dissociation requires early diagnosis; chronic instability develops if untreated 1, 5
Orthopedic Referral Indications
Ensure orthopedic follow-up occurs promptly if MRI reveals:
- Any scaphoid fracture (even non-displaced, as percutaneous screw fixation is increasingly preferred over prolonged casting for athletes) 3
- Displaced or unstable fractures requiring open reduction and internal fixation 3
- Scapholunate or lunotriquetral ligament tears requiring surgical repair 1, 5
- Proximal pole scaphoid fractures (highest risk of avascular necrosis and nonunion) 4
Alternative to MRI
CT without IV contrast is an acceptable alternative if MRI is contraindicated or unavailable, though it cannot evaluate ligamentous injuries 1, 5. CT has high diagnostic yield for occult fractures and shorter acquisition times, making it easier in casted patients 5.