What is the recommended evaluation and management for a FOOSH (Fall On Outstretched Hand) injury with pain on pronation and supination?

Imaging Evaluation for FOOSH Injury with Pain on Pronation and Supination

Start with standard 3-view wrist radiographs (PA, lateral, and 45° semipronated oblique), and strongly consider adding a fourth semisupinated oblique view to maximize fracture detection, particularly for distal radius injuries. 1

Initial Imaging Approach

• Radiography is always indicated as the first-line imaging for suspected acute hand and wrist trauma following a FOOSH injury 1
• A minimum 3-view examination is essential, as 2-view studies are inadequate for detecting fractures in wrist injuries 1
• The standard 3 views include:
  • Posteroanterior (PA) view with wrist in pronation
  • Lateral view
  • 45° semipronated oblique view 1
• Adding a fourth projection (semisupinated oblique) increases diagnostic yield for distal radius fractures 1

Clinical Context for Pain on Pronation/Supination

Pain specifically with pronation and supination movements raises concern for:

• Distal radioulnar joint (DRUJ) instability or injury 1
• Triangular fibrocartilage complex (TFCC) tears 1
• Interosseous ligament injuries 1
• Occult fractures affecting forearm rotation 1

If Initial Radiographs Are Negative or Equivocal

When clinical suspicion remains high despite normal radiographs, proceed algorithmically:

For Suspected Occult Fractures:

• CT without IV contrast is the preferred next step to exclude or confirm suspected wrist fractures 1
• CT shows intra-articular extension of distal radius fractures more frequently than radiography 1
• Three-dimensional reconstructions are particularly helpful for complex articular injuries 1

For Suspected Soft Tissue Injuries (Given Pronation/Supination Pain):

• MRI without IV contrast is the ideal modality for evaluating ligamentous injuries, TFCC tears, and tendon pathology 1
• MRI can detect fractures of the distal radius and carpal bones when radiographs are normal 1
• For DRUJ instability specifically, CT is the modality of choice and should include imaging of both wrists in maximal pronation, neutral position, and maximal supination 1

Alternative Conservative Approach:

• Place patient in short arm cast and repeat radiographs at 10-14 days 1
• Major downside: delays diagnosis and may lead to functional impairment 1

Key Clinical Pitfalls

• Do not rely on 2-view radiographs alone – they miss significant fractures in wrist injuries 1
• Pain with pronation/supination is a red flag for DRUJ pathology that may not be visible on standard wrist radiographs 1
• MRI sequences should be performed in pronation and supination when evaluating for dynamic instability, as static imaging may miss pathology 1
• Radiographically occult fractures are common in FOOSH injuries, particularly scaphoid and distal radius fractures 1

Advanced Imaging Considerations

If standard MRI or CT findings are equivocal but clinical suspicion persists:

• MR arthrography increases diagnostic accuracy for TFCC tears, particularly proximal lamina (foveal) tears 1
• CT arthrography can evaluate DRUJ instability and traumatic TFCC injuries 1
• Ultrasound can show dynamic subluxation of the extensor carpi ulnaris tendon during forced supination 1

Contrast-enhanced CT and bone scans have no role in the initial or follow-up evaluation of acute wrist trauma 1