4-View Wrist X-ray Is Recommended for Initial Wrist Assessment
A 4-view wrist X-ray that includes posteroanterior (PA), lateral, oblique, and scaphoid views should be used for initial wrist assessment to maximize diagnostic accuracy and minimize missed fractures. 1, 2
Standard Radiographic Protocol for Wrist Assessment
- The American College of Radiology (ACR) recommends that for patients with suspected distal radius fractures, a standard examination should include at minimum a 3-view series consisting of posteroanterior (PA), lateral, and 45° semipronated oblique views 1
- However, research indicates that adding a fourth projection—a scaphoid view—increases diagnostic yield for both distal radius fractures and scaphoid injuries 1, 2
- Relying on only 2 views is inadequate for detecting fractures in the joints of the extremities, especially those involving the wrist 1
- The scaphoid view is particularly important as scaphoid fractures may be radiographically occult on standard views and delayed diagnosis is common 1, 2
Evidence Supporting 4-View Approach
- A cadaver study determined that four specific views provide the most comprehensive visualization of the scaphoid: PA view in ulnar deviation, oblique view in 60° pronation, oblique view in 60° supination, and lateral view 3
- In a survey of practice patterns, 64.3% of hospitals and 68.4% of consultant radiologists recommended four views for suspected scaphoid fractures, indicating this is the most common standard of care 4
- The addition of a scaphoid-specific view helps visualize the scaphoid bone, which is particularly prone to occult fractures that may be missed on standard 3-view series 2, 5
Clinical Implications and Pitfalls
- Missed wrist fractures, particularly of the scaphoid, can lead to significant morbidity including nonunion, avascular necrosis, and post-traumatic arthritis 1
- If initial radiographs are negative but clinical suspicion remains high, options include placing the patient in a short arm cast and repeating radiographs in 10-14 days, or proceeding to advanced imaging such as MRI without IV contrast 6
- A common pitfall is relying on too few views, particularly in cases of suspected scaphoid injury, which can lead to missed diagnoses and poor outcomes 4, 5
Special Considerations
- For dynamic scapholunate instability assessment, both PA ulnar deviation and clenched fist stress views are equally effective in showing diastasis following wrist injury 7
- In cases where initial radiographs are normal but clinical suspicion for fracture remains high, MRI without IV contrast or CT without IV contrast may be appropriate next steps 1
- For chronic wrist pain evaluation, the standard radiographic assessment also includes 3 views (PA, lateral, and oblique), but may require additional specialized views depending on the clinical scenario 1