AdultPediatric
Pediatric wrist pain is most often post-traumatic (FOOSH). Open physes make Salter-Harris and torus fractures far more common than ligamentous injury. Always evaluate the scaphoid in adolescents — missed fractures lead to AVN.
🚩 Red-flag clues (must not miss)
- •Snuffbox tenderness after FOOSH = scaphoid fracture (often radiographically occult)
- •Pain + deformity + median nerve symptoms = displaced distal radius (median n. injury)
- •Open fracture, neurovascular compromise, compartment signs = emergent ortho
- •Atraumatic swelling + fever = septic wrist or osteomyelitis
History
- Mechanism (FOOSH, axial load, twisting), hand dominance
- Time since injury, swelling progression, neuro symptoms
- Prior injury, sports, gymnast (overuse: distal radius physeal stress)
Exam
- Inspection — deformity (dinner-fork = Colles), swelling, ecchymosis
- Palpation — distal radius/ulna, snuffbox, scaphoid tubercle, lunate, ulnar styloid
- ROM, grip; neurovascular (median, ulnar, radial; cap refill)
- Axial load of thumb (scaphoid stress test)
Labs
- Generally not needed for trauma
- If atraumatic + swelling/fever: CBC, CRP, ESR, blood cx; consider aspiration
Imaging
- Wrist XR — PA, lateral, oblique
- Scaphoid views (PA in ulnar deviation) if snuffbox tender
- If XR negative + clinical scaphoid concern: thumb spica + repeat XR / MRI in 7–14 days
- MRI for occult fracture, TFCC injury, osteomyelitis
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Distal radius torus (buckle) fracture | FOOSH, dorsal cortex buckle, minimal displacement | Removable wrist splint × 3 wk, no ortho needed |
| Distal radius Salter-Harris II | FOOSH, physeal widening + metaphyseal fragment | Reduction PRN, sugar-tong splint, ortho follow-up |
| Greenstick fracture | Incomplete cortical break with angulation | Reduction if angulated, long-arm cast, ortho |
| Colles / displaced distal radius | Dorsal angulation, deformity | Reduction, sugar-tong, urgent ortho if median n. symptoms |
| Scaphoid fracture | Snuffbox tenderness, FOOSH, often XR-occult | Thumb spica splint, repeat XR/MRI 7–14 d, ortho |
| Triquetrum / lunate / capitate fracture | Focal carpal tenderness | Splint, ortho referral |
| Perilunate / lunate dislocation | High-energy, 'spilled teacup' on lateral XR | Emergent ortho reduction |
| TFCC injury | Ulnar-sided pain, click with rotation | Splint, ortho/MRI |
| Gymnast wrist (distal radius physeal stress) | Repetitive loading, dorsal pain, physeal widening | Activity rest 4–6 wk |
| Septic wrist / osteomyelitis | Atraumatic swelling, fever, ↑ inflammatory markers | Aspiration, IV abx, MRI |
| JIA | Morning stiffness, multiple joints, chronic | Rheumatology |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Ibuprofen | 10 mg/kg PO q6–8h (max 600 mg) | |
| Acetaminophen | 15 mg/kg PO q4–6h (max 1 g) |
Management / next steps
- Snuffbox tenderness with normal XR → thumb spica + ortho follow-up — never discharge as 'sprain'
- Torus fractures — removable splint as effective as cast
- Any displacement / angulation > 15° → reduction and ortho
Pearls
- Children rarely sprain wrists — assume fracture until proven otherwise.
- Scaphoid AVN risk ↑ with proximal pole fractures and delayed diagnosis.
- Both-bone forearm fractures often need reduction — check elbow on every wrist film.