Overview of acute wrist injuries in children and adolescents

INTRODUCTION — Injuries to the wrist are common in children and adolescents. Furthermore, three of the top five fastest growing sports have a high risk for acute injury to the wrist (rugby, lacrosse, and field hockey) [1].

Causes of acute wrist injuries in children and adolescents will be presented here (table 1). Causes of chronic wrist pain, wrist anatomy is discussed separately. (See "Overview: Causes of chronic wrist pain in children and adolescents".)

EVALUATION — The evaluation of wrist pain and injury in children and adolescents is discussed separately. (See "Evaluation of wrist pain and injury in children and adolescents".)

FRACTURES — Fractures are a frequent sports-related wrist injury in skeletally immature children and adolescents [2,3]. In such patients, the growing bones are more susceptible to stress than are the surrounding ligaments and joint capsules. (See "General principles of fracture management: Fracture patterns and description in children", section on 'Physeal (growth plate)'.)

Distal radius — Fractures of the distal radius are the most common fracture in children and adolescents, accounting for 35 to 47 percent of wrist fractures. Distal radius fractures occur most frequently during early adolescence; children with increased body mass and decreased bone mineral density are at increased risk. The mechanism of injury is usually a fall on a hyperextended wrist. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Epidemiology' and "Distal forearm fractures in children: Diagnosis and assessment", section on 'Mechanism of injury'.)

Fractures of the distal radius usually involve the metaphysis. Although physeal (growth plate) injuries are relatively rare, they must be considered carefully because they can result in premature growth arrest. Shortening of the radius can lead to ulnar impaction and triangular fibrocartilage complex (TFCC) tears. (See "Overview: Causes of chronic wrist pain in children and adolescents", section on 'Ulnar impaction' and 'TFCC injuries' below.)

Clinical findings of distal radius fractures include point tenderness, swelling, ecchymosis, and decreased grip strength. Associated injuries may include distal radioulnar joint (DRUJ) injuries and TFCC tears. Fractures of the radial shaft with associated dislocation of the DRUJ are known as Galeazzi fractures. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Clinical features' and 'DRUJ and TFCC injuries' below.)

The diagnosis of a distal radius fracture is confirmed by plain radiographs with the exception of children with nondisplaced Salter-Harris I injuries. Radiographic assessment, classification, and physical examination of these injuries are discussed in more detail separately. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Imaging' and "Distal forearm fractures in children: Diagnosis and assessment", section on 'Physical examination'.)

Metaphyseal — The two most common types of distal radial metaphyseal fractures are torus fractures and greenstick fractures. Torus fractures (also known as buckle fractures) are caused by compressive forces that lead to buckling or plastic deformation of a single cortex (image 1). Greenstick fractures are incomplete fractures in which one cortex breaks completely while the cortex on the opposite side undergoes plastic deformation; associated angulation or rotation are common (image 2). Recognition and treatment of these fractures are reviewed in detail separately. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Imaging' and "Distal forearm fractures in children: Initial management", section on 'Initial fracture management'.)

Physeal fractures — Distal radial physeal injuries must be carefully considered in children with wrist trauma. The physis (growth plate) is a relatively weak area of bone and is susceptible to injury, particularly during the adolescent growth spurt [4]. Physeal fractures are described using the Salter-Harris classification system (figure 1). (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Physeal fractures' and "General principles of fracture management: Fracture patterns and description in children".)

Patients with a nondisplaced Salter I physeal fracture of the distal radius or ulna (figure 1) usually have normal plain radiographs at initial presentation. However, bony tenderness is present over the physis in these patients and helps to differentiate this injury from a bruise or ligamentous strain or sprain. Other radiographic findings that may be present soon after injury include a volar fat pad on the lateral view and epiphyseal widening on stress views. However, stress views are painful for the patient and usually unnecessary. Plain radiographs obtained at least seven days after injury will show healing bone in children with nondisplaced Salter I fractures and also provides a definitive diagnosis. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Nondisplaced Salter I fracture'.)

The main concern with physeal fractures is premature closure and growth arrest at the site of injury. The risk of this complication increases with the severity of the fracture. (See "Distal forearm fractures in children: Initial management", section on 'Complications'.)

Management of distal radial physeal fractures is discussed in greater detail separately. (See "Distal forearm fractures in children: Initial management", section on 'Physeal fracture'.)

Distal ulna fractures — Fractures of the distal ulna include distal styloid fractures, fractures at the styloid base, and distal ulna physeal fractures. These fractures are typically associated with distal radial fractures. Complete fractures through the base of the ulnar styloid are uncommon but may be associated with triangular fibrocartilage complex (TFCC) instability since the TFCC attaches at the ulnar styloid (figure 2 and image 3). A distal ulna physeal fracture in association with a radial shaft fracture is a pediatric variation of the Galeazzi fracture pattern and often requires operative stabilization. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Ulnar styloid fractures' and "Distal forearm fractures in children: Diagnosis and assessment", section on 'Galeazzi fractures'.)

Management of ulnar styloid fractures is reviewed separately. (See "Distal forearm fractures in children: Initial management", section on 'Ulnar styloid fracture'.)

Carpal fractures — Carpal fractures comprise approximately 6 percent of all fractures in athletes but are probably underdiagnosed. Failure to recognize carpal fractures can result in long-term functional deficits and major complications. (See "Overview of carpal fractures".)

Scaphoid fractures — Scaphoid (navicular) fractures are the most common carpal fractures. Scaphoid fractures typically occur in individuals aged 15 to 30 years; they are particularly common among collegiate football players. Scaphoid fractures are rare in children younger than 10 years [5-7]. Injury patterns in children are similar to adults. Although 90 percent of pediatric scaphoid fractures will heal with immobilization, three months or more may be needed. Almost one-third of pediatric patients will initially present with chronic nonunions [8]. (See "Scaphoid fractures", section on 'Epidemiology'.)

The patient typically complains of pain along the radial aspect of the wrist after falling on an outstretched hand. The pain may be less severe than the patient or patient's parents expect from an acute fracture. Characteristic examination findings include tenderness of the anatomic snuff box, decreased range of motion in flexion and extension, pain with radial deviation or extension of the wrist, and a positive scaphoid compression test. The scaphoid compression test is performed by holding the thumb and gradually pushing in toward the scaphoid along the longitudinal axis of the thumb metacarpal; elicitation of pain over the palmar scaphoid tubercle constitutes a positive test. Complications of scaphoid fractures include carpal instability, osteonecrosis, and nonunion. (See "Scaphoid fractures", section on 'Symptoms and examination findings'.)

On plain radiographs, scaphoid fractures are best visualized with the anteroposterior (AP) scaphoid view with 30 degrees of ulnar deviation. They may not be evident on the standard wrist series, even if the ulnar deviation view is included. (See "Scaphoid fractures", section on 'Management of suspected acute fracture with negative plain radiographs'.)

If scaphoid fracture is suspected on the basis of clinical findings and the radiographs are normal, the wrist should be immobilized in a thumb spica splint (figure 3) pending confirmation or exclusion of the diagnosis at follow-up examination (with radiographs) 10 to 14 days after the injury (image 4). If the diagnosis must be confirmed or excluded in a shorter timeframe (eg, in an elite athlete), bone scan or magnetic resonance imaging (MRI) may be performed. (See "Scaphoid fractures", section on 'Management of suspected acute fracture with negative plain radiographs'.)

The management of scaphoid fractures is discussed separately. (See "Scaphoid fractures", section on 'Indications for surgical referral' and "Scaphoid fractures", section on 'Initial treatment'.)

Triquetral fractures — The usual mechanism of injury for triquetral fractures involves falling on an extended wrist in ulnar deviation, which causes impingement of the hamate or the ulnar styloid on the dorsal edge of the triquetrum. However, triquetral fractures may also occur following flexion injuries in which fragments of the triquetrum may be avulsed by the strong dorsal ligaments. Triquetral fractures are associated with carpal instability. (See "Triquetrum fractures", section on 'Clinical anatomy' and "Triquetrum fractures", section on 'Mechanism of injury'.)

Patients typically present with a history of injury and pain on the ulnar aspect of the wrist. Examination findings include pain and point tenderness either dorsally directly over the triquetrum, or on the ulnar border of the wrist, distal to the ulnar styloid (figure 4). The triquetrum is most easily palpated with the wrist in radial deviation. (See "Triquetrum fractures", section on 'Symptoms and examination findings'.)

Most triquetral fractures can be demonstrated on plain radiographs, particularly a partially pronated AP view (image 5 and image 6 and image 7). Lateral views must be examined closely for any malalignment or instability pattern. (See "Triquetrum fractures", section on 'Diagnostic imaging'.)

The management of triquetral fractures is discussed separately. (See "Triquetrum fractures", section on 'Indications for surgical referral' and "Triquetrum fractures", section on 'Treatment'.)

Hamate fractures — Fractures of the hook of the hamate, rare in the general population, are more common in skeletally mature players of racquet, stick, or club sports. The swinging action required in these sports transfers force directly to the hook of the hamate. The wrist nearest the handle is most susceptible (eg, the nondominant hand in baseball or golf, the dominant hand in racquet sports). Fractures of the body of the hamate typically result from significant crush injuries (eg, a fall while holding an object in which the object lands between the ground and the ulnar side of the palm). (See "Hamate fractures", section on 'History and mechanism of injury'.)

Patients may present with acute or chronic pain that can be mild. The typical presentation involves sharp ulnar pain after missing a swing or striking a stationary object. The pain progresses to a dull, ill-defined discomfort during sports-related but not daily activities. (See "Hamate fractures", section on 'History and mechanism of injury'.)

On examination, there is point tenderness over the hook of the hamate, located just distal and lateral to the pisiform (figure 5) and the hook of the hamate pull test is positive (figure 6). Callus or skin changes from repeated trauma may be noted overlying the area of the hamate. Associated ulnar motor and sensory deficit may be present (eg, paresthesia in and/or pain with resisted flexion of the fourth and fifth digits) (table 2). (See "Hamate fractures" and "Hamate fractures", section on 'Symptoms and examination findings'.)

Fractures of the hook of the hamate are best visualized on the 45 degrees supination oblique view, the carpal tunnel view, or with computed tomography (CT) (image 8 and image 9). Hamate body fractures are readily apparent on routine views (image 10). (See "Hamate fractures", section on 'Diagnostic imaging'.)

Indications for evaluation by a hand surgeon and initial treatment of these injuries is discussed separately. (See "Hamate fractures", section on 'Indications for surgical referral' and "Hamate fractures", section on 'Initial treatment'.)

Child abuse — The possibility of child abuse should be considered in all children with fractures, particularly those younger than three years of age and when there are inconsistencies in the history. Although most distal radial fractures in children are unintentional and occur after falls on an outstretched hand, metaphyseal chip or "corner" fractures are highly specific for child abuse (figure 7). (See "Physical child abuse: Diagnostic evaluation and management" and "Orthopedic aspects of child abuse".)

Suspicion of child abuse should prompt involvement of an experienced child protection team (eg, social worker, nurse, physician with more extensive experience in the management of child abuse), if available. In many parts of the world (including the United States, United Kingdom, and Australia), a mandatory report to appropriate governmental authorities is also required for cases of suspected abuse. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

LIGAMENTOUS AND CAPSULAR INJURIES — The complex anatomic relationship of the carpal bones and multiple ligamentous attachments helps to stabilize the wrist while permitting considerable mobility. However, when exposed to forces outside of their physiologic range as may occur in a fall, motor vehicle accident, or high-impact contact with another player, ball, or other object, ligamentous injury can occur.

Ligamentous injuries encompass stretching (simple sprain) and partial or complete tears, which lead to instability and dislocation.

Simple sprain — A simple sprain involves stretching of the supporting ligaments of the radiocarpal joint; the usual mechanism is a fall on an extended wrist. Simple sprains are associated with mild pain or stiffness and normal range of motion. A detailed history and clinical examination must be performed to exclude more serious injuries (eg, type I Salter-Harris distal radius fracture (figure 1), carpal fracture, or carpal instability) [9-12]. Patients with a simple sprain should have no bony tenderness over the distal radius and normal plain radiographs of the wrist (image 11). (See 'Fractures' above and 'Wrist instability and dislocation' below.)

Based upon our experience, most of these injuries resolve within two weeks with conservative therapy including rest, ice, immobilization of the wrist in 20 degrees of dorsiflexion and gentle flexion and extension of the wrist as pain allows. If pain persists, referral to a sports medicine specialist or orthopedic surgeon is warranted.

Wrist instability and dislocation — Carpal instability refers to the failure of the wrist joint to properly transfer kinematic loads and misalignment of the carpal bones [13]. Frank dislocations, which are closely related, involve the loss of contact between one or more carpal bones [14].

Traumatic wrist instability is rare in children. However, they may occur in adolescents, usually in association with distal radius physeal injury [15]. Acute dislocations also may be accompanied by fractures of the radial shaft (Galeazzi fracture).

Traumatic wrist instability is most likely to occur in contact sports and those that require twisting of the wrist (football, basketball, rugby, ice hockey, tennis) [16]. Injuries also can be caused by repetitive loading with the wrist in extension (eg, gymnastics) [17].

Carpal instabilities and dislocations share some features with wrist sprains but are distinct disorders. Similar to simple sprains, the typical mechanism of injury for carpal instability is a fall on an extended wrist. Radiographs in patients with instability are usually normal but must be carefully reviewed for malalignment (figure 8). In contrast to simple sprains, the pain of instability persists, and often is made worse by physical therapy.

A high index of suspicion is necessary to permit early identification and appropriate therapy of ligamentous injuries. Untreated injuries may result in chronic pain and functional deficits. The early involvement of a hand specialist in the management of wrist instability or dislocation optimizes long-term outcome.

Carpal instabilities are classified according to the involved joints [18,19]:

●Between joints in the same row (eg, scapholunate instability, lunotriquetral instability)

●Between the proximal and distal rows (midcarpal instability)

●Between joints in the same row and between proximal and distal rows (this category includes all of the carpal dislocations, of which perilunate dislocations are most common)

Provocative examination techniques can be helpful in localizing the instability. (See "Evaluation of wrist pain and injury in children and adolescents", section on 'Integrity of ligaments'.)

Lateral and anteroposterior (AP) radiographs can be diagnostic. Special instability views with the wrist in certain positions may be necessary to appreciate malalignments resulting from partial tears [18]. Magnetic resonance imaging (MRI) is also useful and is gaining popularity as a diagnostic tool [20]. (See "Evaluation of wrist pain and injury in children and adolescents", section on 'Imaging'.)

Scapholunate — With increased levels of athletic competition, injuries to the scapholunate are becoming more common in children [21]. The importance of early diagnosis and treatment cannot be overemphasized [22].

Scapholunate injuries are common in collision and contact sports. They result from excessive wrist extension and ulnar deviation with intercarpal supination, such as a fall on a pronated hand or jamming into another athlete [18,22]. With disruption of the scapholunate ligament, the scaphoid assumes a flexed position and the lunate and triquetrum extend, producing a dorsal intercalated segment instability (DISI) deformity (figure 8) [18]. Scapholunate injuries are associated with negative ulnar variance (ie, when the ulna is shorter than the radius) [23].

Examination findings include wrist swelling, focal pain and tenderness (out of proportion to the injury), decreased range of motion, decreased grip strength, and asymmetric clicking with the scaphoid stability test, although patients with scapholunate ligament injury often cannot tolerate this test [18,21,22,24,25]. (See "Evaluation of wrist pain and injury in children and adolescents", section on 'Scapholunate'.)

Abnormalities on the AP wrist radiograph include increased scapholunate distance (>3 mm, (image 12)) and flexed scaphoid [21]; the lateral view may demonstrate increased scapholunate angle [18] and the DISI deformity (figure 8) [22]. All views should be compared with radiographs of the uninjured wrist [18,24].

Plain radiographs may be normal in children with partial scapholunate injuries. In addition, scapholunate distance in children can be difficult to interpret because of eccentric ossification and the chondral nature of the carpus [21]. If scapholunate injuries are suspected, MRI may be more useful [21].

Most scapholunate ligament injuries have normal radiographs and are treated conservatively with immobilization of the wrist in 20 degrees of dorsiflexion for two to six weeks. However, a complete tear or a partial ligament injury which fails to respond to conservative therapy is an indication for arthroscopic evaluation and possible surgical reconstruction of the ligament [26]. Return to play guidelines vary depending on the severity of the illness and the demands of the sport and should be done under the guidance of a sports medicine physician or a hand specialist.

Scapholunate dislocation or dissociation requires prompt consultation with an orthopedic or hand surgeon but can be stabilized with a thumb spica splint (figure 3) [24,27].

Lunotriquetral — Injuries to the lunotriquetral ligament usually result from sudden axial loading with wrist extension and radial deviation with intercarpal pronation [18].

The typical presentation includes a fall on an outstretched hand and subsequent ulnar-sided wrist pain, weakness, giving way, and a clicking sound [18,25]. Examination findings include tenderness of the lunotriquetral ligament (in the ulnar snuff box: the sulcus distal to the ulnar head formed by the extensor carpi ulnaris and flexor carpi ulnaris tendons), clicking produced by passively loading the wrist from radial to ulnar deviation, and a positive lunotriquetral shear test (figure 9) [18,22]. (See "Evaluation of wrist pain and injury in children and adolescents".)

Radiographs are usually normal [18]. Occasionally, a stepoff may be noted along the proximal carpal row [18]. Lunotriquetral injury is associated with positive ulnar variance (ie, an ulna that is longer than the radius). Magnetic resonance imaging can be helpful in assessing these ligamentous injuries especially when combined with a midcarpal arthrogram [28]. This technique is superior to radial carpal arthrogram and has been noted to have a sensitivity of 93 percent for lunotriquetral ligament injuries.

The majority of lunotriquetral ligament injuries is also treated conservatively with long-arm immobilization of the wrist in 20 degrees of dorsiflexion and elbow in 90 degrees of flexion for four to six weeks [18,29]. Arthroscopic evaluation and possible surgical reconstruction is indicated for complete tears or partial tears which do not respond to immobilization. Return to play guidelines vary depending upon the severity of the illness and the demands of the sport and should occur with guidance from a sports medicine physician or a hand specialist.

Midcarpal — Midcarpal instability results from injury to the ligaments between the proximal and distal rows of carpal bones. Midcarpal instability can be palmar or dorsal; palmar instability is more common [30].

Clinical features include ulnar wrist pain, a sulcus in the dorsal ulnar wrist border, pain with resisted active extension of the fingers when the wrist is flexed, and a painful clunk when the wrist is actively deviated ulnarly [18,24]. The latter finding also may occur with lunotriquetral ligament tears, distal radio-ulnar joint injuries, triangular fibrocartilage complex tears, and ulnar impaction syndrome. Cineradiography or MRI can help to distinguish among these possibilities. Plain radiographs may demonstrate a volar intercalated segment instability pattern [18]. Midcarpal instability although not as common as scapholunate or lunotriquetral ligament injuries, usually signifies a more severe injury.

Although initial treatment is typically nonoperative, referral to a hand specialist is indicated.

Perilunate — Perilunate dislocation (dislocation of the carpus) results from excessive radiocarpal extension and ulnar deviation with intercarpal supination [18]. It should be suspected when significant swelling and decreased range of motion are observed after trauma in a contact sport [18]. Perilunate dislocation may be complicated by carpal tunnel syndrome. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis".)

The lateral radiograph demonstrates dorsal displacement of the capitate on the lunate (image 13) or, in palmar lunate dislocation, palmar displacement of the lunate into the carpal tunnel [18]. Perilunate dislocation is inherently a severe injury as all ligamentous attachments to the lunate, including both the scapholunate and lunotriquetral ligaments have been severed. Referral to a hand surgeon is important as prompt surgical intervention to establish anatomic alignment is necessary to reduce the long-term risk of avascular necrosis.

DRUJ and TFCC injuries — Distal radioulnar joint (DRUJ) and triangular fibrocartilage complex (TFCC) injuries are often discussed together because of their close anatomic relationship and overlapping symptoms [5]. Because the TFCC is the primary stabilizer of the DRUJ, injury to the TFCC may result in DRUJ instability. DRUJ instability also can occur with other injuries (eg, distal radius fracture).

Chronic DRUJ and TFCC injuries are discussed separately. (See "Overview: Causes of chronic wrist pain in children and adolescents".)

DRUJ injuries — Acute injuries to the distal radioulnar joint (DRUJ) often involve a fall on an extended wrist, particularly when the wrist is pronated. Acute DRUJ injuries are common in motor vehicle accidents, impact sports, and racquet, stick, and club sports [17]. They may be accompanied by distal radial fractures (Galeazzi fracture (image 14)).

Patients with DRUJ injuries usually present with complaints of pain on supination and pronation of the wrist. DRUJ instability may be partial or complete. Dislocation or subluxation of the DRUJ may be dorsal or palmar [22].

Examination findings include positive DRUJ compression (figure 10) and piano key tests. The piano key test is performed on a pronated wrist; it is positive if ballottement of the ulnar head in a palmar direction produces little resistance compared with the other side. Alternatively, the patient forcibly presses both palms into the examination table; exaggerated dorsal-palmar translation compared with the opposite side indicates DRUJ instability [5,18].

Imaging of the DRUJ begins with plain radiographs, although plain radiographs are often normal, particularly with mild DRUJ instability. DRUJ dislocation can be seen on posterior-anterior (PA) and lateral wrist radiographs [22]. MRI can demonstrate DRUJ subluxation as well at the surrounding soft tissues including the triangular fibrocartilage complex (TFCC), lunotriquetral ligaments, and articular surfaces of the carpus and ulna.

Isolated dislocation can be treated with reduction (often requiring the use of regional or general anesthesia) [31] followed by cast immobilization for six weeks. DRUJ dislocation accompanied by fracture of the radial shaft (Galeazzi fracture) requires operative reduction.

TFCC injuries — Similar to DRUJ injuries, acute injuries to the triangular fibrocartilage complex (TFCC) often involve a fall on an extended wrist, particularly when the wrist is pronated. In addition, sudden excessive pronation or supination may result in acute TFCC disruption and peripheral tears [17]. Peripheral tears may result in DRUJ instability [18].

The history in patients with TFCC tears often involves repetitive loading with heavy lifting in ulnar deviation or ulnar loading of the wrist (eg, in racquet sports or golf) [32]. Patients complain of a dull aching sensation radiating to the dorsal wrist and grip weakness that may be associated with clicking mechanical sensations during pronation and supination [32].

Clinical manifestations of TFCC injury include tenderness in the hollow between the pisiform and the ulnar styloid on the ulnar border of the wrist (figure 2) and pain with TFCC compression (figure 11). (See "Evaluation of wrist pain and injury in children and adolescents", section on 'Triangular fibrocartilage complex (TFCC) tears'.)

Plain radiographic findings are helpful but often not diagnostic [18]. Associated radiographic abnormalities may include widening of the DRUJ space on the AP view, dislocation/subluxation on the lateral view, positive ulnar variance, and fractures of the ulnar styloid.

Magnetic resonance imaging (MRI) demonstrates the TFCC, surrounding ligaments, DRUJ, and articular surfaces of the carpus and ulna. TFCC tears are viewed after the administration of intraarticular gadolinium contrast. High signal within the TFCC (which appears black on fluid-sensitive MRI sequences) or contrast fluid communicating between the radioulnar and radiocarpal joint signifies a TFCC tear.

Acute TFCC tears are treated initially with immobilization in a sugar tong splint followed by cast for six weeks to allow the TFCC to heal [33]. Because the blood supply to the TFCC is from the periphery toward the center, healing is more likely with peripheral tears; tears in the avascular central zone rarely heal. (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Sugar tong splints'.)

If patients are still not improved with conservative immobilization, arthroscopy with either debridement or repair of the TFCC is indicated. Arthroscopy permits better visualization of the TFCC than open procedures. In one small series of 16 competitive athletes TFCC injuries, arthroscopic debridement or repair was associated with pain relief and return to play within an average of three months [34].

NEUROVASCULAR INJURIES — Trauma to the wrist may be associated with injury to the median, ulnar nerves, or radial nerve. Median nerve injury may occur with dislocation of the lunate into the carpal tunnel. Ulnar nerve injury may occur with fractures of the pisiform or hamate [35]. Radial nerve injury may occur with direct trauma.

Direct impact to the hypothenar eminence (eg, from catching a baseball, in handball) can cause damage to the ulnar artery and superficial palmar arch. Clinical features include complaints of pain in the palm that may radiate to the forearm, coldness of the digits, and an abnormal modified Allen test (figure 12) [36]. Prompt consultation with a hand surgeon is required.

RETURN TO PLAY — Decisions regarding return to play after an acute wrist injury involve several factors. These include the type of injury, completeness of healing, extent of rehabilitation, age, sport, special skills, and level of competition [37]. Thus, any return to play decision in a child or adolescent with a significant wrist injury (eg, fracture, carpal instability, or dislocation) should be made in consultation with a sports medicine or orthopedic specialist.

As a general rule, the basic requirements for returning to competition include complete healing of the injury and thorough rehabilitation with restoration of a painless functional range of motion and near-normal strength. The rehabilitated wrist, whenever possible, should be protected from further trauma.

Wrist protectors have been shown to decrease the risk of injury in snowboarding and inline skating, but this may not be generalizable to other sports that do not permit this type of equipment. There are a number of athletic gloves for hockey and lacrosse to decrease injury, but there are no studies to substantiate their claims. Taping and padding of injury is individualized to the athlete and usually has little evidence to substantiate its efficacy [38].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Common wrist injuries (The Basics)")

SUMMARY

●Causes of acute wrist injury in children and adolescents include fractures, simple sprains, and ligamentous instabilities (table 1).

●Fractures of the distal radius are the most common fractures in children and adolescents. Clinical findings include point tenderness, swelling, ecchymosis, and decreased grip strength. (See 'Distal radius' above.)

●The distal radial growth plate (physis) is particularly susceptible to injury during the adolescent growth spurt. Distal radial physeal fractures may be associated with premature closure and growth arrest of the distal radius; the risk increases with the severity of the fracture. (See 'Physeal fractures' above.)

●Scaphoid fractures should be considered in adolescents with radial pain after a fall. Characteristic examination findings include tenderness of the anatomic snuff box, decreased range of motion, pain with radial deviation or extension of the wrist, and a positive scaphoid compression test. (See 'Scaphoid fractures' above.)

●Fractures of the hook of the hamate should be considered in skeletally mature players of racquet, stick, or club sports who complain of ulnar-sided palmar pain after missing a swing or striking an object. (See 'Hamate fractures' above.)

●Ligamentous and capsular injuries are uncommon in children and adolescents but should be considered when the mechanism of injury involves high-impact contact. Many of these injuries warrant prompt referral to an orthopedic or hand surgeon. (See 'Ligamentous and capsular injuries' above.)

●The basic requirements for returning to competition after an acute injury include complete healing of the injury and thorough rehabilitation with restoration of a painless functional range of motion and near-normal strength. (See 'Return to play' above.)