Wrist XRay

Aka: Wrist XRay, Wrist Imaging, Radial Inclination, Radial Height, Volar Tilt, Gilula Lines

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II. Imaging: Views

  1. Standard
    1. Anterior-Posterior XRay (or Posterior-Anterior XRay)
      1. True AP View needed to isolate the two rows of Carpal Bones (oblique view obscures Fractures)
      2. Evaluate for Scaphoid Fracture, Scapholunate Dissociation and other Carpal BoneFractures
    2. Lateral XRay
      1. True lateral xray is needed to assess Lunate-Capitate alignment
      2. Check alignment: Radius, Lunate/Scaphoid, Capitate
        1. Perilunate Dislocation
        2. Lunate Dislocation
  2. Special
    1. Scaphoid Fracture suspected
      1. Scaphoid View
    2. Pisiform Fracture or hook of hamate Fracture suspected
      1. Carpal Tunnel view
      2. Supinated oblique view
    3. Scapholunate Dissociation
      1. Clenched-fist view
      2. Supinated wrist with ulnar deviation

III. Imaging: Other imaging modalities

  1. Wrist Ultrasound
    1. Evaluates soft tissue (tendon, synovium)
    2. Variable efficacy based on operator
  2. Bone scan
    1. Finds occult Fractures (Scaphoid), Stress Fractures
    2. Highly sensitive but not specific for Fracture
  3. Wrist CT Scan
    1. Identifies Fractures and articular subluxations
  4. Wrist MRI
    1. Identifies Fractures and soft tissue injuries
    2. Expensive, but most sensitive and specific study

IV. Evaluation: Interpretation

  1. Post-Reduction Wrist XRay confirms normal radius length
  2. Images
    1. wristXRayLateral.png
    2. radialFractureXRayMeasureLat.png
    3. radialFractureXRayMeasureAP.png
  3. AP View
    1. Landmarks on AP View at distal radius
      1. Distal line (line 1)
        1. Draw a horizontal line at the level of the radial styloid at the distal radius (point A)
        2. Represents the distal most point of the radial articular surface
      2. Proximal line (line 2)
        1. Draw a horizontal line at the level of the ulnar articulation of the medial distal radius (point B)
        2. Represents the distal most point of the radial-ulnar articular surface
        3. Radial length (Radial Height) represents the distance between distal line 1 and proximal line 2
      3. Articular plane (line 3)
        1. Draw a line between the points A and B above (between ulnar aspect of radius and ulnar styloid)
        2. Radial Inclination represents the angle between Line 1 (proximal transverse) and this oblique Line 3
    2. Normal anatomic relationships
      1. Radial Inclination (normal measurements are for adults)
        1. Angle formed between the articular plane and the proximal line (see above)
        2. Normal Radial Inclination: 23.6 +/- 2.5 degrees
        3. Acceptable inclination: 13-30 degrees
      2. Radial Height (radial length) shortening (normal measurements are for adults)
        1. Distance between the proximal and distal lines (see above)
        2. Normal Radial Height: 11-12 mm
        3. Acceptable Radial Height: 8-18 mm
      3. Gilula Lines (3 carpal arcs)
        1. orthoWristXrayGilulaLines.jpg
        2. Three intact arcs indicate normal carpal alignment on the AP View
        3. Disrupted arc may indicate Ligamentous Injury or Fracture
  4. Lateral View
    1. Landmarks on Lateral View at distal radius
      1. Distal dorsal rim
        1. Point on the distal radius at the dorsal aspect
      2. Distal volar rim
        1. Point on the distal radius at the volar aspect
      3. Vertical line at distal radius
        1. Perpendicular to the long axis of the radius
      4. Volar Tilt Line
        1. Line drawn between distal dorsal rim and distal volar rim
    2. Appearance of tea cup and saucer (4Cs)
      1. Proximal Capitate (most distal C)
      2. Distal Lunate Bone
      3. Proximal Lunate Bone (crescent shape)
      4. Distal radius (most proximal C)
    3. Normal anatomic relationships
      1. Volar Tilt angle: 11.2 +/- 4.6 degrees
        1. Angle formed between Volar Tilt line and vertical line at distal radius
      2. Radius articular surface directed down, forward, in
      3. Ulnar styloid points to the more Triquetrum Bone
      4. Normal fat stripe volar to the distal radius on lateral view
        1. Represents the border of the pronator quadratus
        2. Fat stripe displaced or compressed in Wrist Injury with swelling or Hematoma
  5. Oblique View
    1. Primarily evaluates the proximal Carpal Bone row (esp. Scaphoid Bone) and thumb base
    2. May also demonstrate TriquetrumFracture

V. Findings

  1. Forearm Fracture
    1. Galeazzi Fracture-Dislocation
    2. Monteggia's Fracture
  2. Distal Radius Fracture
    1. Colles Fracture
      1. Dinner fork deformity
      2. Fracture apex volar with dorsal angulation of distal fragment
    2. Smith Fracture
      1. Inverse of Colles Fracture
      2. Fracture apex dorsal, and volar angulation of the distal fragment
    3. Barton Fracture
      1. Smith Fracture with intraarticular involvement
  3. Wrist bone Fracture
    1. Scaphoid Fracture (60-70% of carpal Fractures, esp. FOOSH injuries)
      1. Best seen on oblique view (or dedicated Scaphoid view)
      2. Associated with other Fractures in 5-12% of cases
      3. False Negative first XRay in up to 30% of cases
    2. TriquetrumFracture (TriquetralFracture)
      1. Seen primarily on the lateral view, at the dorsal wrist (posterior to the Capitate)
      2. Second most common Carpal BoneFracture (esp. with FOOSH injuries)
      3. Most Fractures are dorsal chip Fractures (90-95%)
        1. Remaining body Fractures are higher risk (high mechanism)
  4. Wrist Dislocations on AP View
    1. Distal Radius Ulna Joint (DRUJ) Disruption
      1. Distal radius and ulna should slightly overlap on AP film
      2. DRUJ Disruption is an unstable wrist condition
    2. Scapholunate Dissociation
      1. Wide gap (>2 mm in adults) between Scaphoid and Lunate Bones on AP View (Terry Thomas Sign)
      2. Scapholunate distance on AP View is normally 1-2 mm in adults (may appear wider in children)
        1. Should normally be roughly similar to other Carpal Bone distances
    3. Scaphoid Rotary Subluxation
      1. Scaphoid ligaments are completely disrupted and allows the Scaphoid to rotate volarly
      2. Appears as a "Signet Ring Sign"
  5. Wrist Dislocations on Lateral View (disrupted 4Cs)
    1. Lunate Dislocation (volar Lunate Dislocation, "spilled teacup sign")
    2. Perilunate Dislocation (dorsal Capitate dislocation)
      1. Spectrum of ligament disruption (complete disruption results in complete dislocation)
  6. Children
    1. See Forearm Fracture in Children
    2. Radial Epiphyseal Fracture

VI. References

  1. Tubbs and Janicki (2025) Wrsit XRay, Mastering Emergency Imaging, CCME, accessed 2/15/2026
  2. Medoff (2005) Hand Clin 21(3): 279-88 [PubMed]

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