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Purpose: To evaluate the relationship between wrist circumference, markers of adipose dysfunction, and cardiovascular risk in youths with obesity. Methods: In this cross-sectional study, we measured body mass composition by dual-energy X-ray absorptiometry, wrist circumference, waist-to-height ratio, fasting blood insulin, glucose, lipid profile, adiponectin, and leptin in 280 children with overweight/obesity and without diabetes (age: 7–18 years). Cardiovascular risk was estimated by “metabolic syndrome score” (MetS score). Results: Study participants had median [25th–75th percentile] wrist circumference of 17.5 [16.7–18.5] cm and waist-to-height ratio of 0.62 [0.59–0.67]. Lower adiponectin–leptin ratio was found among subjects in the upper 50th percentiles of wrist circumference [0.17 (0.09–0.36) vs. 0.38 (0.16–0.79); p < 0.001]. Wrist circumference was independently associated with MetS score (r = 0.5 p < 0.001). Among MetS score components, an independent association between wrist circumference HDLc, triglycerides, and systolic blood pressure was found (r = − 0.253 p < 0.001; r =+ 0.204 p < 0.001; r = + 0.403 p = < 0.001, respectively). The coefficient of determination for MetS score was nominally higher when considering wrist circumference as independent variable (Adj-R2= 0.30) then when considering body mass index SD (Adj-R2= 0.28), waist-to-height ratio (Adj-R2= 0.26) or truncal fat percentage (Adj-R2= 0.01). The addition of wrist circumference in age and gender adjusted models, accounting to any other anthropometric parameters, resulted in a significant improvement of the Adj-R2(p < 0.001 for all). Conclusions: Our study shows that wrist circumference independently relates to adiponectin–leptin ratio and to the prediction of cardiovascular risk, suggesting it as an efficient and adjunctive anthropometric marker of cardiometabolic risk in children with obesity.