What is the appropriate evaluation and management of wrist injuries?

Wrist Injury Evaluation and Management

Initial Imaging Protocol

For acute wrist trauma, obtain a minimum 4-view radiographic series: posteroanterior (PA), lateral, 45° semipronated oblique, and a scaphoid view. 1

• The American College of Radiology establishes that a 3-view examination (PA, lateral, and 45° semipronated oblique) is the minimum standard for suspected distal radius fractures 2, 1
• Adding a fourth projection—the scaphoid view—significantly increases diagnostic yield for both distal radius fractures and scaphoid injuries 1
• Relying on only 2 views is inadequate and will miss fractures in wrist joints 2, 1

Critical Pitfall to Avoid

Missed scaphoid fractures lead to devastating complications including nonunion, avascular necrosis, and post-traumatic arthritis. 1

• Distal radius and scaphoid fractures are frequently radiographically occult on initial imaging 2
• Failure to obtain adequate radiographic views is the most common reason for missed diagnoses 3

When Initial Radiographs Are Negative But Clinical Suspicion Remains High

Place the patient in a short arm cast and repeat radiographs in 10-14 days, or proceed directly to MRI without IV contrast. 1

Advanced Imaging Algorithm:

• MRI without IV contrast is the preferred next step for detecting occult fractures when radiographs are normal but clinical suspicion persists 1, 3

  • MRI shows both intra-articular extension and concomitant ligament injuries 3
  • Particularly useful for evaluating scapholunate ligament tears that affect surgical planning 3

• CT without IV contrast is indicated when radiographs are equivocal rather than completely normal 1, 3

  • Superior for detecting intra-articular extension of distal radius fractures 3
  • Three-dimensional CT reconstructions aid preoperative planning for complex articular injuries 3

Identifying High-Risk Fracture Patterns Requiring Surgery

Look for the "longhorn sign," coronally oriented fracture lines, die-punch depression, or >3 articular fragments—these indicate need for operative fixation. 2, 3

• The longhorn sign represents significant intra-articular injury requiring surgical intervention 3
• Die-punch fractures involve depression of the lunate facet and are a type of intra-articular fracture 3
• Operative fixation is necessary when there is >2 mm of residual articular surface step-off to prevent osteoarthritis 2, 3

Management Principles

• Extra-articular fractures are often managed non-operatively with cast immobilization unless there is significant displacement or angulation 3
• Intra-articular fractures require restoration of radial length, inclination, tilt, and realignment of articular fragments 2
• Arthroscopy during surgical treatment improves diagnostic accuracy for wrist ligament injuries 3