Part I: A 27-year-old man presents to urgent care with left wrist pain after a fall onto his outstretched hand while playing basketball an hour ago. He reports immediate pain and swelling on the wrist but denies any numbness, tingling, or weakness. He can move his fingers but has limited range of motion in his wrist due to pain. This patient has no remarkable past medical history, is not taking any medications, and has no allergies. On examination, there is mild swelling over the dorsal radial aspect of the left wrist, tenderness over the distal radius, no tenderness in the anatomical snuffbox, normal capillary refill in all fingers, and no gross deformity. The neurovascular examination is intact.
According to the Amsterdam wrist rules, which of the following clinical findings would typically prompt wrist radiography in an adult following trauma?
- Painful active wrist movement alone
- No tenderness over the distal radius
- Visible deformity of the wrist
- No swelling or tenderness
Click to see the answer
Answer: c. Visible deformity of the wrist
The Amsterdam wrist rules recommend radiographs in adults after wrist trauma when there is tenderness of the distal radius, visible deformity, and/or other specific criteria. Painful active wrist movement alone without tenderness or deformity would not necessarily meet criteria. In the case of this patient, the Amsterdam Wrist Rules were applied:
- Patient aged >17 years ✔️
- Pain on palpation of the distal radius ✔️
- No visible deformity ❌
- No tenderness in anatomical snuffbox ❌
- No painful active wrist motion ❌
Wrist radiography is indicated.
Part II: Plain wrist radiographs showed a nondisplaced distal radius fracture without intra-articular involvement or significant angulation.
What is the next best step in the management of this patient?
- Provide over-the-counter analgesic, apply a short-arm wrist splint, and arrange outpatient follow-up with primary care provider or orthopedic specialist in 5 days.
- Refer the patient to an orthopedic specialist for immediate surgical intervention.
- Advise the patient to limit wrist movement, ice, and continue taking a nonsteroidal anti-inflammatory drug as needed.
- Discharge the patient after informing him it’s just a sprain. Provide return instructions if he has pain longer than 1 week post-injury.
Click to see the answer
Answer: a. Provide over-the-counter analgesic, apply a short-arm wrist splint, and arrange outpatient follow-up with primary care provider or orthopedic specialist in 5 days.
Since no surgical intervention was needed, you provided acetaminophen, administered a short-arm wrist splint, and provided a referral to an orthopedic specialist for reassessment and possible transition to a removeable brace or continued immobilization. You advised the patient to use the RICE method as needed to improve pain and discomfort.
For an in-depth review of this topic, access the full course.
Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
