Wrist Pain: X-rays and the Differential

Wrists are the most commonly injured upper extremity joint, and 8.8% of injuries are missed, with 2% being clinically important. With 27 bones and 34 muscles, there is a significant possibility of missing a fracture. A high index of suspicion is required to prevent missing a significant injury. 

Common Injuries

• Colles Fracture
• Smith Fracture
• Scaphoid
• scaphoid-lunate dislocation

Reading the AP view

1. Find the thumb: Orient yourself to the film
2. Look at the radius: Identify dislocations, spacing changes, and fractures. The radius should end distal to the ulna in normal images. 
3. Look at the scaphoid: Identify fractures
4. Look at the carpal arches: Identify irregularities to the arches 
5. Look at the Carpo-metacarpal junction: Identify metacarpal fractures or dislocations

Reading the Lateral view

1. Check the radial surface
2. Check the dorsal surface
3. Check for volar tilt: typically 10 degrees towards the palmar surface
4. Check the posterior carpal space for triquetral fractures
5. Identify the cup/saucer of the lunate.