What X-ray views are recommended for a patient presenting with a wrist mass?

Standard X-ray Views for Wrist Mass Evaluation

For a patient presenting with a wrist mass, obtain a minimum 3-view radiographic series consisting of posteroanterior (PA), lateral, and oblique views, with consideration of adding a fourth scaphoid view to increase diagnostic yield. 1

Initial Radiographic Protocol

• Start with plain radiographs as the most appropriate first imaging study to identify fractures, arthritis, bone tumors, and alignment abnormalities before considering soft tissue pathology 1
• The standard examination should include:
  • Posteroanterior (PA) view in neutral position and rotation 1
  • Lateral view to demonstrate malalignments and soft-tissue swelling 1
  • 45° semipronated oblique view 1
  • Optional fourth projection (scaphoid view) increases diagnostic yield for both distal radius fractures and scaphoid injuries 1

Enhanced Lateral View Technique

• Consider using a 20° axial-lateral view instead of standard 0° lateral as this demonstrates the radiocarpal joint more clearly in 75% versus 23% of cases and is preferred by radiologists in 76% of evaluations 2
• The 20° lateral view reduces obscuration of the radiocarpal joint by the radial styloid process and orthopedic hardware 2

Critical Pitfall to Avoid

• Relying on only 2 views is inadequate for detecting fractures in the joints of the extremities, especially those involving the wrist 1
• Even 3-view series can miss important pathology, highlighting the need for comprehensive evaluation 1

Next Steps if Radiographs Are Nondiagnostic

When radiographs fail to explain a palpable wrist mass:

• MRI without IV contrast is usually appropriate as the next imaging study 3
• Ultrasound is an alternative initial examination that is usually appropriate for evaluating palpable masses 3
• MRI is useful for diagnosing fluid-filled and synovial-lined structures including ganglia, cysts, bursa, and tendon sheaths 3
• Some authors recommend use of IV contrast to distinguish ganglia from synovitis, though this is not routine 3

Ultrasound Positioning for Wrist Mass Evaluation

If ultrasound is chosen as the imaging modality:

• Position the patient in a sitting position 3
• Place the hand on top of the thigh or on an examining table 3
• Perform dynamic examination with active flexion/extension of the fingers 3
• Standard scans should include volar transverse, volar longitudinal, dorsal transverse (radial and ulnar), and dorsal longitudinal (radial, median, and ulnar) views 3