A 53-year-old male presents with right wrist pain after falling onto the ground earlier today. Exam reveals a diffusely swollen and tender wrist, but neurovascular status is intact. An X-ray is shown. What is the next best step in management?

• A. Refer to ED
• B. Immediate casting and discharge
• C. Oral analgesics with follow-up in 1 week
• D. Physical therapy referral only

Answer: (A)

Focus on recognizing injuries that can masquerade as a simple sprain but actually require urgent evaluation and possible intervention. After a fall onto the palm, a painful, swollen wrist with preserved sensation and pulses can still hide a fracture or dislocation. In adults, wrist injuries often involve the distal radius, scaphoid, or even carpal dislocations. These injuries may be unstable or associated with complications that won’t wait for a routine clinic visit.

Because the X-ray is shown and the patient has significant swelling and tenderness, the safest, most appropriate next step is to refer the patient to the emergency department. There, clinicians can reassess neurovascular status, perform additional imaging (sometimes CT or MRI if a fracture is occult on initial films), immobilize properly, provide adequate analgesia, and pursue urgent orthopedic or hand surgery consultation if a fracture or dislocation is confirmed or suspected. This approach ensures any need for reduction, surgical planning, or advanced imaging is addressed promptly.

Choosing immediate casting and discharge or relying on oral analgesics with a 1-week follow-up would risk missing an unstable injury or an occult fracture. Physical therapy alone is not appropriate at this acute stage.