What is the recommended initial management for acute right wrist pain without red‑flag signs?

Initial Management of Acute Right Wrist Pain Without Red Flags

Obtain standard three-view plain radiographs (posterior-anterior, lateral, and oblique views) as the first-line imaging study for all patients presenting with acute wrist pain. 1, 2

Immediate Diagnostic Approach

Initial Imaging Protocol

• Plain radiographs are the mandatory first step and should include a neutral-position posterior-anterior view, a true lateral view, and at least one oblique view to assess bone architecture, alignment, joint space symmetry, and soft-tissue structures. 2

• Standard radiographs reliably identify fractures, dislocations, and bony abnormalities that guide immediate management decisions. 1, 2

When Initial Radiographs Are Negative or Equivocal

If radiographs show no abnormality but pain persists, three equivalent options exist for next-step imaging: repeat radiographs in 10-14 days, MRI without IV contrast, or CT without IV contrast. 1

The American College of Radiology designates these as equivalent alternatives, but in clinical practice:

• Repeat radiographs in 10-14 days are appropriate for suspected occult fractures (particularly scaphoid fractures, which are missed in up to 30% of cases on initial films). 1, 3

• MRI without IV contrast is the preferred advanced imaging modality when radiographs remain normal or nonspecific and symptoms persist, because it accurately depicts bone marrow edema, cartilage, intrinsic and extrinsic ligaments, TFCC, synovium, tendons, and neurovascular structures. 1, 2

• CT without IV contrast is reserved for specific scenarios where bony detail is critical but is not routinely the next study for undifferentiated wrist pain. 1

Conservative Management During Diagnostic Workup

Immobilization

• Immobilize the wrist in a custom-fitted splint maintaining neutral wrist alignment and neutral forearm rotation for at least 4 weeks if clinical suspicion for occult fracture or ligamentous injury exists, even with negative initial radiographs. 4

• Continuous splint wear during this period is critical; premature mobilization predicts poor outcomes and persistent symptoms. 4

Pain Control

• Use oral NSAIDs or acetaminophen for analgesia during the initial evaluation period. 5

• Avoid activities involving repetitive loading or forceful gripping until diagnosis is established. 5, 3

Location-Specific Considerations

Radial-Sided Pain

• MRI without IV contrast is usually sufficient for radial-sided wrist pain, as it accurately diagnoses scapholunate ligament tears and other radial pathology. 1, 2

• Direct MR arthrography has higher sensitivity than non-contrast MRI for complete and incomplete scapholunate ligament tears but is reserved for cases where initial MRI is equivocal. 1, 6

Ulnar-Sided Pain

• MRI without IV contrast is highly accurate for central TFCC tears, which are the most common cause of ulnar-sided wrist pain. 1, 2

• MR arthrography or CT arthrography may be needed for peripheral TFCC lesions if initial MRI is nondiagnostic. 2

Dorsal Wrist Pain

• MRI is the recommended next study when radiographs are normal or nonspecific, as it depicts all relevant structures including ligaments, TFCC, and bone marrow. 6

Common Pitfalls to Avoid

• Never omit plain radiographs even when the clinical impression seems straightforward; baseline films can uncover unexpected pathology. 2

• Do not assume a negative initial radiograph excludes scaphoid fracture; specialized views (posteroanterior in ulnar deviation, pronated oblique) or repeat imaging in 10-14 days improves sensitivity. 1, 3

• Avoid routine use of CT or CT arthrography as first-line advanced imaging for undifferentiated wrist pain; these are not appropriate initial studies according to the American College of Radiology. 1, 2

• Do not initiate wrist mobilization exercises before 4 weeks of immobilization if occult fracture or significant ligamentous injury is suspected; early motion is associated with treatment failure. 4

When to Advance to MRI

Order MRI without IV contrast when:

• Radiographs are normal or equivocal and symptoms persist beyond 10-14 days. 1, 2

• Clinical examination localizes pain to a specific anatomic region (radial, ulnar, or dorsal) but radiographs show no abnormality. 6, 2

• There is concern for soft-tissue pathology (tendon, ligament, TFCC) that cannot be assessed by plain films. 1, 2

Timeline for Conservative Management

• Weeks 0-4: Continuous splint immobilization in neutral position. 4

• Weeks 4-8: Begin gentle active wrist motion only after completing the immobilization phase. 4

• Weeks 8-12: Introduce progressive strengthening exercises. 4

• After 3 months: Resume heavy tasks and sports only if all phases completed without persistent symptoms. 4