Wrist Sprain
Jacksonville, FL
You fell on your wrist, it's sore, X-rays are negative — likely a wrist sprain. Dr. R. David Graham at JOI treats wrist sprains with brace and PT, but the key clinical discipline is knowing when a "wrist sprain" is actually something else. Scaphoid fracture, SL ligament tear, LT ligament tear, and TFCC injury can all look like a sprain on X-ray.
- Wrist sprain is a diagnosis of exclusion — scaphoid fracture ruled out first
- X-ray can miss scaphoid fractures — MRI if clinical suspicion persists
- Brace for six weeks, often with therapy, is the standard treatment
- MRI at 6–8 weeks if not improving — evaluating for SL, LT, or TFCC pathology
- Persistent wrist pain that isn't improving is not 'just a sprain'
The most important thing about wrist sprains is knowing when they aren't wrist sprains. The scaphoid fracture that is missed because the X-ray looked normal — and the SL ligament tear that presents as vague dorsal wrist pain — both start as 'wrist sprains.'
The Diagnosis of Exclusion
First, Rule Out What It Isn't
A wrist sprain is a soft tissue injury — stretched or partially torn ligaments in the wrist without a fracture, without complete ligament rupture, and without carpal instability. It is real, it is common, and it gets better. But "wrist sprain" is appropriately diagnosed only after more serious injuries have been excluded.
The scaphoid fracture is the most important condition to rule out. The scaphoid has a tenuous blood supply, and a missed fracture — treated as a sprain — can progress to avascular necrosis and nonunion over months. Critically, initial X-rays miss up to 20% of scaphoid fractures. A patient with anatomic snuffbox tenderness (pain at the base of the thumb, just distal to the radial styloid) after a fall gets an MRI even when the X-ray looks normal.
Once the workup confirms a true sprain — no fracture, no carpal instability on stress views — treatment is brace and therapy. That protocol, and the point at which it gets re-examined, is set out below.
- → Scaphoid fracture — X-ray can be normal; anatomic snuffbox tenderness = MRI
- → SL ligament tear — dorsal wrist pain, clunk with motion; MRI arthrogram confirms
- → LT ligament tear — ulnar wrist pain; ballottement test; MRI arthrogram
- → TFCC tear — ulnar-sided pain; positive TFCC stress test; MRI arthrogram
- → Triquetral avulsion fracture — dorsal chip on lateral X-ray; treat as sprain
- → Distal radius fracture — usually visible, but nondisplaced may be subtle
X-Ray First
PA, lateral, and oblique views. Rules out most fractures. If anatomic snuffbox tenderness is present — even with normal X-rays — a scaphoid fracture has not been excluded.
MRI if Scaphoid Concern Persists
The conventional approach is to immobilize the wrist and repeat X-rays two weeks later to see whether a fracture declares itself. Dr. Graham rarely takes that route. With snuffbox tenderness and a normal X-ray, he goes to MRI — it is the most sensitive study for an early scaphoid fracture, it evaluates the ligaments at the same time, and he has been misled by a CT before. Most patients would also rather know now than spend two weeks in a cast waiting to find out.
Treatment
The Brace Is Also a Test
A confirmed wrist sprain is treated with a removable brace, often with formal therapy alongside it. What makes this diagnosis different is that the treatment comes with a date attached — if it isn’t working, the next step isn’t more of the same. It is finding out why.
Why Bracing Rather Than Repair
A sprain means the ligament was stretched or partially torn — but structurally, nothing is broken. The ligament is weaker than it was, and it should still do its job: holding the wrist bones in position as they move together. That is why the first line of treatment is protection rather than repair. There is no failed connection to rebuild.
What the brace does over those six weeks is keep healing fibers from being re-strained before they have recovered. A partial tear can heal. It simply cannot do it while being pulled every day.
When therapy is part of the plan, it does something different, and it is worth being straight about what it does and does not do. Proprioception, strengthening, and flexibility work is mostly about controlling pain and restoring how the wrist moves. It has some protective effect against a repeat injury, but a modest one.
Brace and Therapy
Removable cock-up wrist brace for six weeks, often with formal therapy for grip strength, flexibility, and wrist proprioception.
Full Recovery
Most true wrist sprains recover fully in six to ten weeks with consistent brace use.
Imaging
MRI arthrogram, typically ordered somewhere in the six-to-eight week window, evaluating the scapholunate, lunotriquetral, and TFCC.
Stress views are often part of the picture before any MRI. Clenched-fist X-rays of both wrists, compared side by side, can show a scapholunate gap that ordinary films miss — and they can be obtained at any point the examination raises the question.
In Dr. Graham’s experience, a wrist that is still painful at 6–8 weeks is the point at which a ligamentous injury has to be considered rather than waited out. The sprain diagnosis was correct for what the initial workup could see; what it could not see is whether a ligament was injured alongside it. That is the reason for the scan — not a longer course of the same treatment.
The study has to be the right one. Standard MRI misses TFCC tears and partial ligament tears — at this point an MRI arthrogram is the required study, not an upgrade to consider.
And there is no rule that says you have to wait. Six to eight weeks is a default, not a requirement. If you would rather have the scan sooner, Dr. Graham is willing to order it sooner.
What a Positive Scan Changes
What the scan shows determines what happens next, and the answer is not the same for every finding.
If it shows a partial tear, that is structurally the same situation the brace was already treating: the ligament is weaker, but it is holding. Conservative management continues, and stress views — if they have not already been obtained — help confirm the wrist is still tracking normally under load.
If the tear is complete, the diagnosis is no longer a sprain. It is a specific ligament injury — scapholunate, lunotriquetral, or TFCC — and each has its own pathway. They do not all lead to the same place; some are considerably more likely to require surgical repair than others.
And if the scan shows nothing while the pain persists, that is not the end of the workup. After full conservative management has been given a real chance, diagnostic wrist arthroscopy remains the gold standard for ligament injury in the wrist — it allows a tear to be seen directly rather than inferred.
What moves a wrist sprain toward surgery is continued pain, an examination that corresponds to it, and a scan that agrees with both. Any one of the three, by itself, is not enough.
Not every ligament tear seen on an MRI was caused by the injury that brought you in. Some are degenerative — wear that was already there before the fall. That distinction matters, because it changes what a repair would accomplish.
“Awesome doctor, he did a fantastic job and was very informative in an understandable way. He is also very nice and friendly with a great smile. Definitely would see him again.”
FAQs
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Next Steps
Wrist pain that isn't improving
deserves a second look.
Most wrist sprains resolve with brace and PT. When they don't, the question is what was missed — and that question deserves a specific answer, not continued reassurance. Walk-ins welcome via JOI Now, Monday–Friday.
Jacksonville Beach, FL 32250
Walk-ins welcome via JOI Now. No pre-visit imaging required.