Purpose: To evaluate and identify clinical variables associated with wrist fractures (Fx) in pediatric wrist injuries presenting to the emergency department and to determine the predictive value of a careful clinical examination to detect Fx's after an acute wrist injury. Methods: This is a prospective blinded case series pilot study of patients 3-18 years of age presenting with an acute (<3days) wrist trauma without obvious deformity. Patients were evaluated by a team of 5 investigators blinded to any x-ray findings prior to clinical evaluation. Physical exam variables included: range of motion(ROM) , location of maximum tenderness and functional deficit (difference in grip strength between the injured & non-injured hands). Diagnostic x-rays were obtained on all patients. Univariate analysis using Wilk's Log Likelihood Ratio Test & Mann Whitney U Test were performed to identify clinical variables associated with confirmed wrist Fx's. Pilot sample size was determined based on ability to detect a maximum difference of 15 in the ROM variable with a β=0.8 & α=0.1. Results: Median age of patients in the Fx group was 6 years and 13.5 years in the non-Fx group (U=99.0, p=0.002). There were 14 patients in the Fx group, 8 in the non-Fx group. Percent difference in clinical functional grip strength between the injured and non-injured hand had a result of a 51.8% decrease in the non-Fx group versus an 85.2% decrease in the Fx group (t=-2.76, p=0.012). Clinical Variable G Statistic p value Swelling 0.43 0.51 Physical Exam Findings 5.29 0.02 Zone of Tenderness 0.89 0.34 Emergency Physician Diagnosis 13.0 0.0003. Conclusion: The data suggests a significant relation exist between (1) clinical suspicion based on physical exam alone, (2) percentage change in grip strength between injured hand and non-injured hand, (3) emergency physician's final diagnosis, (4) age and presence of a Fx (p<0.05). This data is useful for developing clinical decision rules, like the Ottawa ankle rules, to predict the need for x-rays in wrist injuries. Ultimately, this data will translate into potential savings from a decrease in use of radiographs.