From the Guidelines
To diagnose a suspected fracture of the wrist, radiographs, specifically a 3-view examination of the wrist including a posteroanterior (PA), a lateral, and a 45 semipronated oblique view, are the initial imaging tests of choice. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of radiography in detecting fractures in the wrist, hand, and fingers 1.
Key Points for Diagnostic Tests:
- Radiography is always indicated as the initial imaging for suspected acute hand and wrist trauma 1.
- A 3-view examination of the wrist is usually adequate for detecting fractures, but a fourth projection, such as a semisupinated oblique, may increase diagnostic yield for distal radius fractures 1.
- For patients with suspected finger tendon injuries, radiographs are used to detect fracture fragments, and involvement of more than one-third of the articular surface usually requires operative fixation 1.
- If initial radiographs are negative or equivocal, repeat radiographs in 10-14 days, MRI without IV contrast, or CT without IV contrast are appropriate as the next imaging study 1.
Importance of Prompt Medical Attention:
Prompt medical attention is crucial because untreated wrist fractures can lead to improper healing, chronic pain, and reduced function. While waiting for medical care, following the RICE protocol (Rest, Ice, Compression, and Elevation) and taking over-the-counter pain relievers like acetaminophen or ibuprofen as directed can help manage symptoms 1. Only a medical professional can definitively diagnose a broken wrist through proper examination and imaging.
Additional Considerations:
In cases where radiographs show acute wrist fracture, MR arthrography of the wrist, MRI of the wrist without IV contrast, CT arthrography of the wrist, or US of the wrist may be appropriate as the next imaging study for suspected wrist tendon or ligament trauma 1. The choice of additional imaging depends on the specific clinical scenario and the presence of other injuries or complications.
From the Research
Diagnostic Tests for Suspected Fracture of the Wrist
The diagnostic tests for a suspected fracture of the wrist (radius and ulna bones) include:
- Conventional radiography (X-rays) 2, 3, 4, 5, 6
- Specialized views, such as posteroanterior in ulnar deviation and pronated oblique 2
- Repeat radiography in 10 to 14 days to improve sensitivity for scaphoid fractures 2
- Bone scan 2
- Magnetic Resonance Imaging (MRI) 2, 3, 6
- Computed Tomography (CT) scan 4
- Arthrography 4
- Arthroscopy 4
- Clinical decision rules, such as the Amsterdam wrist rules 5 and the clinical decision rule developed by 3
Clinical Decision Rules
Clinical decision rules can help determine the need for diagnostic tests, such as X-rays, and can reduce unnecessary immobilization and imaging 3, 5. These rules typically incorporate clinical parameters, such as:
- Trauma mechanism 5
- Physical examination findings, such as swelling and tenderness 3, 5
- Functional testing, such as painful ulnar deviation and axial thumb compression 3
Imaging Tests
Imaging tests, such as MRI, can have a high clinical impact in the detection of acute wrist fractures, particularly when plain radiographs are normal or indistinct 6. MRI can detect additional injuries of soft tissue and can help reduce economic costs due to shortened immobilization time in cases with a suspected fracture but normal plain radiographs 6.