Broken wrists are common in childhood, and most heal wellStrong evidence
The end of the forearm, by the wrist, is the commonest place children break a bone. In Umeå, Sweden, it accounted for 26% of 1,520 fractures in children and teenagers aged 0 to 19 in 2006 and 2007. Over the 10,203 fractures recorded there from 1993 to 2007, about 1 child in 3 broke a bone before 17, boys had 61% of the fractures, and wrist-end fractures peaked at 11 in girls and 14 in boys; play caused most fractures in the first 10 years of life, and sport most in the teens. Edinburgh recorded about 20 fractures a year for every 1,000 children, most of them in the arm, and the commonest cause was a fall from below bed height.
Wrist-end fractures cluster around the growth spurt (11 to 14 in boys and 8 to 11 in girls in one US population, where they became commoner between the 1970s and the 2000s), possibly because activity rises while the bone is briefly less dense. About 3 out of 4 forearm fractures in children are at the wrist end of the radius, US surgeons say, and the commonest of all is the buckle (torus) fracture, the commonest fracture in children.
Sources 1, 2, 3, 4, 5
After a fall, a sore wrist is often a small break, not a sprainStrong evidence
In 4 Dutch emergency departments, 364 of 787 children aged 3 to 17 (46.3%) seen with a painful wrist after an injury had a fracture at the end of the forearm. That share comes from children already taken to hospital, so it overstates the chance for a child who knocks a wrist and carries on playing, but it shows why the NHS says "It can be hard to tell if a wrist is broken, dislocated or badly sprained. You'll probably need an X-ray."
In a growing skeleton, the bone and its soft growth plates give way before the ligaments do, so an injury that would sprain an adult's wrist is more likely to break a child's bone. Reviews of children's sports injuries say this, and describe true sprains as less common than breaks in younger children; that is the reviews' statement, not a measured figure, because no study has counted sprains and breaks by age. Wrists are still among the commonest places for a sprain at any age, the NHS says, and most sprains feel better after 2 weeks.
Sources 6, 7, 8, 9, 10
Few children see a GP about a wristEmerging evidence
Most knocked wrists never reach a doctor. In 12 English general practices, wrist problems led to 19 consultations per 10,000 children aged 3 to 17 a year, rising to about 42 at 14 to 17. In population studies, children's arm complaints more often follow an injury, while leg complaints more often come on without one. In 2,953 Danish 12 to 19 year olds, 4.4% had forearm or hand pain at the time they were asked.
Sources 11, 12, 13
The usual causes, by ageEmerging evidence
Younger children: the commonest injury is a buckle fracture, from a fall onto an outstretched hand off a scooter, skates or monkey bars, or a knock in sport. One side of the soft bone squashes into a small bump rather than snapping, so the wrist is sore and a little swollen, and is often still used a little. A harder fall, from a height, a trampoline or a bike, can bend the bone right through (a greenstick fracture) or break it completely, which needs a cast for about 4 to 6 weeks.
Older children and teenagers: a fall can break through the growth plate, which is common at the end of the radius; growth plate fractures happen twice as often in boys as in girls, because girls finish growing earlier, and some can't be seen on the first X-ray. A broken scaphoid is mainly a teenager's injury (below). Gymnasts, cheerleaders and other athletes who take weight on their hands can get the gymnast's wrist, a stress injury of the growth plate: in 59 young gymnasts, 83% of those aged 10 to 14 had wrist pain, and half showed stress changes at the growth plate on X-rays.
Without a fall: a ganglion cyst is a smooth lump on the back or palm side of the wrist, often painless, at an average age of about 9 in one cohort. Very flexible joints (joint hypermobility), which usually affect children and young people, can bring aches and stiffness after activity, sprains and joints that pop out. Long spells of writing, gaming, phones or an instrument can bring an ache that eases with rest: two-thirds of 731 young Australian instrumentalists had had playing-related problems at some point.
Sources 14, 15, 16, 17, 18, 19, 20, 21, 22, 23
A broken scaphoid: mainly a teenager's injury, and a first X-ray can miss itMixed evidence
The scaphoid is a small bone at the base of the thumb, felt in the hollow on the back of the wrist (the snuffbox). It rarely breaks in young children: in an Edinburgh children's emergency department, 117 children aged 8 to 12 had scaphoid X-rays in a year and 12 had a confirmed fracture, and the authors judged one "extremely unlikely to occur under the age of 9"; pain in the snuffbox was "a poor indicator" at that age. In teenagers it behaves like an adult's fracture: of 26,364 in US children and teenagers (average age 13.5, 64.5% boys), 4.2% didn't heal, more often in older teenagers and displaced breaks, and 73% of those were found within 3 months of the first diagnosis, which the authors think means many came to care late. In a US series of 351 children's and teenagers' scaphoid fractures, 90% of those treated in a cast straight after the injury healed.
A first X-ray can miss a broken scaphoid in a child, but how often is unclear. In a review of 8 studies, all of poor methodological quality, X-rays picked up between 16% and 54% of fractures; yet in 28 children aged 10 and under with confirmed fractures, 93% could be seen on at least one view, and of 91 children with signs of a fracture and two normal X-rays, 5 (5.5%) turned out to have one, none needing an operation. No examination has been shown to pick out reliably which children need a scan. That is why a teenager with snuffbox pain after a fall needs a same-day check, and why the National Institute for Health and Care Excellence (NICE) says to consider a magnetic resonance imaging (MRI) scan as the first scan for a suspected scaphoid fracture after a thorough examination.
Sources 24, 25, 26, 27, 28, 29, 30, 31
Rare causes: infection, arthritis, nerve problems and bone tumoursStrong evidence
A joint infection at the wrist is rare: of 684 children with a joint infection in a US multicentre database, 68 had it in an arm joint, and only 4% of those in the wrist. Joint infections affected about 10 in every 100,000 children a year in Western Australia, mostly in the knee, hip and ankle, and bone infection about 13 in every 100,000 a year in Norway, about 3 times as often under 3. Both bring a hot, swollen, painful joint or bone, often with a high temperature, or a young child who won't use the arm (the warning signs).
Juvenile idiopathic arthritis affects the wrist in about a quarter of children at diagnosis, rising to 40% by 5 years, with swelling and stiffness that are worse in the morning or after rest; at least 10,000 young people under 16 in the UK have it, more often girls. In one cohort of 753, wrist arthritis went with more joints affected and a lower chance of remission. Carpal tunnel syndrome is rare in children and usually comes from another condition (29 of 38 children in one series, 76%); it often shows as clumsiness or a thin muscle at the base of the thumb rather than tingling.
Primary bone cancer is very rare, and leukaemia is rare too, though limb pain was present in 43% of children with leukaemia when it was diagnosed. NICE asks GPs to arrange a very urgent blood test for persistent or unexplained bone pain, and to consider a very urgent X-ray for unexplained bone swelling or pain. Rarely, a wrist slowly changes shape, aches and stiffens in late childhood or the teens (Madelung deformity), sometimes with a genetic condition that affects height; it needs a GP and a specialist.
Sources 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44
When an X-ray or scan helpsStrong evidence
After a fall, an X-ray is usually what decides it. In the Netherlands, a six-item check (age, swelling over the radius, a visible change of shape, tenderness over the radius or the snuffbox, and pain on turning the palm up) picked up 95.9% of fractures and, once put into practice, cut wrist X-rays by 19%; other rules tested on Dutch children missed 1.4% to 5.7% of fractures. In trained hands, ultrasound is about as accurate as an X-ray for children's wrist-end forearm fractures (pooled from 14 and 17 studies, picking up about 95%), and in an Australian trial of 270 children aged 5 to 15 with no visible bend, ultrasound first did as well for arm function at 4 weeks; it isn't routine NHS practice in the sources checked.
The X-ray changes the treatment. A buckle fracture means a bandage or splint and usually no follow-up; other breaks mean a cast and the fracture clinic, sometimes with straightening the bone or an operation; and a growth plate fracture means a review with a repeat X-ray at about a week, because some growth plate fractures can't be seen at first. Without an injury, a lump is usually recognised by how it looks and feels, with a scan only if it's unclear; suspected juvenile arthritis may need an ultrasound or MRI scan; tingling in a child's hand needs nerve tests and a search for the cause; and unexplained bone pain or swelling needs a very urgent blood test and X-ray.
Sources 7, 6, 45, 46, 47, 48, 49, 31, 50, 17, 51, 35, 38, 42
Growth plate fractures: serious problems are rare, but follow-up mattersMixed evidence
US surgeons say serious problems after growth plate fractures are rare. A review of 13 studies (616 growth plate injuries at the wrist) found the growth plate closed early in 7% to 23% of children followed with X-rays, more often after fractures into the joint and repeated attempts to straighten the bone; it is usually silent until the arm grows shorter or bent, so US surgeons suggest follow-up for at least a year and the review at least 18 months. These figures come from hospital series that followed children with X-rays, which likely overstate the risk after a minor injury.
Sources 17, 52, 53
How it usually goesEmerging evidence
Buckle fractures: most children start to use the wrist comfortably again after a couple of weeks, all heal clinically within 3 to 4 weeks (low-certainty evidence from 7 trials), and no refractures were seen in 455 children in 5 trials, whatever the support. A greenstick fracture heals in about 4 to 6 weeks. After a cast, stiffness for 2 to 3 weeks "will go away on its own, usually without the need for physical therapy", US surgeons say, and most children move fully within 2 to 4 weeks. Mild deformity reduces as the bone grows; children over 11 may keep a little, which doesn't normally affect how they use the arm.
Sprains: most feel better after 2 weeks, and the NHS advises avoiding strenuous exercise such as running for up to 8 weeks. Treated scaphoid fractures in children heal well: 96.2% united across 17 studies, and 99% regained normal wrist movement. Ganglions: about two-thirds of children's go on their own, on average after about 14 months, more often in the hand than at the wrist (84% against 55%); the NHS says they can take from several months up to a year. The gymnast's wrist and juvenile arthritis take weeks to months, with specialist care. No one can promise a timescale.
Sources 54, 55, 56, 16, 5, 57, 58, 10, 59, 20, 21
