Wrist radiograph (an approach)

Wrist radiographs are ubiquitous on any night of the week in emergency departments, especially when pavements are icy! Choosing a search strategy and using it consistently is a helpful method to overcome common errors seen in diagnostic radiology.

Check the contour of the distal radius:

  • AP
    • the distal radial articular surface should cup the carpals
    • the articular surface should get progressively more distal towards the radial styloid
    • radial inclination angle should be 15-25°
  • lateral
    • the radial surface should be smooth
    • there should be a palmar tilt to the articular surface
    • volar tilt should be around 10-25°
  • if these features aren't present, think distal radial fracture

Check the carpal arcs:

  • the articular surfaces of the proximal and distal carpal rows should form three smooth arcs
  • trace these arcs on the AP film
  • the spacing between all carpal bones should be 1-2 mm
  • if the arc is broken or there is a widening of a joint space, think carpal dislocation

Check lateral alignment:

  • the distal radius, lunate and capitate should be in a straight line
  • if the line has been disrupted, think:
  • the scapholunate angle should be between 30o and 60o in the neutral position
  • capitolunate angle should be less than 30o in the neutral position

Check carpometacarpal joint space:

  • a 1-2 mm joint space should be seen between the carpals and metacarpals
  • if the joint space is narrowed, think carpometacarpal dislocation

One of the commonest misses in trauma films of the hand and wrist is a dislocation of the 5th carpometacarpal joint which may cause significant morbidity if the diagnosis is delayed.

Check each bone in turn:

  • pay particular attention to the distal radius, proximal carpal row (especially the scaphoid) and the bases of the metacarpals
  • the most common distal radial fracture in any adult group
  • peak incidence in elderly women
  • usually, following a fall onto an outstretched hand
  • dorsal angulation of the distal fracture component
  • important to determine if there is intra-articular extension
  • more: Colles fracture
  • account for less than 3% of forearm fractures
  • more common in young males and elderly females
  • fall onto flexed wrist or direct blowback of wrist
  • classically, an extra-articular distal radius fracture with palmar angulation of distal fracture fragment
  • also called the reverse Colles
  • more: Smith fracture
  • 80% of all carpal bone fractures
  • usually young adults
  • fall on an outstretched hand
  • 80% of fractures are through the waist of the scaphoid
  • if suspected, perform additional scaphoid views
  • may be radiographically occult - should be followed up if pain persists
  • more: scaphoid fracture
  • second most common carpal bone fracture
  • hyperextension or avulsive injury
  • frequently seen as dorsal chip fractures on lateral views only
  • more: triquetral fracture
  • typically occur in young adults
  • following a fall on the dorsiflexed wrist
  • best detected on lateral view - the lunate articulates with distal radius but capitate does not sit in lunate ‘cup’
  • 60% associated with scaphoid fracture
  • more: perilunate dislocation
  • rare but important injury to dominant hands of younger males
  • younger male predominance
  • often occur after a punch followed by a fall
  • reduction of joint space on the AP
  • best seen on an oblique study
  • more: carpometacarpal dislocation
Approaches to radiographs

Article information

rID: 28146
Section: Approach
Synonyms or Alternate Spellings:

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Cases and figures

  • Figure 1: anatomy of the AP wrist
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  • Figure 3: normal radiolunate angle
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  • Figure 4: normal scapholunate angle
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  • Figure 5: normal capitolunate angle
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  • Figure 2: anatomy of the lateral wrist
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  • Case 1: Colles fracture
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  • Figure 6: normal radial inclination angle
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  • Case 2: Smith fracture
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  • Case 3: scaphoid fracture
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  • Case 4: triquetral fracture
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  • Case 5: perilunate dislocation
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  • Case 6: scapholunate dissociation
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  • Case 7: lunate dislocation
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  • Case 8: carpometacarpal dislocation
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