Wrist radiograph (an approach)

Last revised by Bahman Rasuli on 26 Feb 2021

Wrist radiographs are ubiquitous on any night of the week in emergency departments, especially when pavements are icy! 

Choosing a search strategy and utilising it consistently is a helpful method to overcome common errors seen in diagnostic radiology. The order in which you interpret the radiograph is personal preference. A recommended systematic checklist for reviewing musculoskeletal exams is soft tissue areas, cortical margins, trabecular patterns, bony alignment, joint congruency, and review areas. Review the entire radiograph, regardless of perceived difficulty. Upon identifying an abnormality, do not cease the review, put it to the side and ensure to complete the checklist

Assess all soft tissue structure for any associated or incidental soft tissue signs 

Check each bone in turn:

  • pay particular attention to the distal radius, proximal carpal row (especially the scaphoid) and the bases of the metacarpals

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.

  • 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

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