Standard X-ray Views for Wrist Injury
For acute wrist injuries, order a 4-view X-ray series consisting of posteroanterior (PA), lateral, 45° semipronated oblique, and scaphoid views. 1
Recommended Radiographic Protocol
The American College of Radiology establishes that imaging evaluation of wrist injuries should begin with radiographs, with a minimum 3-view series (PA, lateral, and oblique) being the standard approach. 2, 1 However, adding a fourth projection—the scaphoid view—significantly increases diagnostic yield for both distal radius fractures and scaphoid injuries. 1
Essential Views Include:
- Posteroanterior (PA) view in neutral position and rotation 2, 1
- Lateral view to demonstrate malalignments and soft-tissue swelling 2
- 45° semipronated oblique view 1
- Scaphoid view to improve detection of scaphoid fractures 1
Critical Pitfall to Avoid
Relying on only 2 views is inadequate for detecting wrist fractures and will miss important pathology. 1 This is particularly dangerous for scaphoid fractures, which can lead to significant morbidity including nonunion, avascular necrosis, and post-traumatic arthritis if missed. 1
When Initial Radiographs Are Negative
If clinical suspicion remains high despite negative initial radiographs, you have two evidence-based options:
- Place the patient in a short arm cast and repeat radiographs in 10-14 days 1
- Proceed directly to MRI without IV contrast for earlier definitive diagnosis 1
The American College of Radiology specifically recommends MRI without IV contrast as the most appropriate next imaging step when radiographs are normal or equivocal but clinical suspicion persists. 1
Additional Considerations for Specific Scenarios
For suspected wrist instability or ligamentous injury, stress views and dynamic maneuvers can be performed to elicit instability not visible on standard radiographs. 2 The lateral view should ideally be performed in neutral position, though some evidence suggests a 20° axial-lateral view may better visualize the radiocarpal joint by avoiding obscuration from the radial styloid process. 3