There are many ways to do this. If it doesn’t work for you. That’s fine! Develop a system that does work. Take this one and make it better. Always be on the look out for being more efficient and making things better.
System for Reading Wrist Xrays
If applicable verify patient, laterality, and quality of xrays
Say what views your are looking at (AP, Lateral, Oblique)
If you aren’t sure, just say 3 views of a R wrist… for example
Skeletally mature or immature?
Look for obvious injuries and comment on them. Use the most straightforward and correct answer.
Don’t jump into the details right away
After you have established the obvious. Go back and systematically go through the images in each view
AP view: Work your way proximal to distal
Outline distal radius and ulna
Look at cortices when outlining then look at medulla for any abnormalities
(Remember the important angles of what is acceptable)
Look at distal radioulnar joint (DRUJ), widening of the DRUJ can communicate instability
Look at the radiocarpal joint, 2/3rds of the lunate should articulate with the distal radius
The left AP wrist is normal. The right shows <2/3rd of lunate articulating with the distal radius which means there is ulnar subluxation and some pretty serious ligamentous injury (Credit: Llyas JAAOS, 2008).
Look at the Gilula lines 1, 2, and 3 in that order (See picture below that show Gilula lines)
Look at the space in-between each carpal bone to look for intercarpal widening (widening between carpal bones), start looking proximal then work distal
Gilula Lines:
Gilula lines are just imaginary lines that carpal bones make that can help you tell if there is something wrong (Credit: Orthobullets).
Lateral View: Proximal to distal
Assess xray quality
The palmar border of the pisiform should overlap with the middle third of the scaphoid
Credit: https://pubs.rsna.org/doi/full/10.1148/radiology.219.1.r01ap1311
This is close to being a perfect lateral, the palmer border of the pisiform is close to overlapping with the middle third of the scaphoid
Credit: Wikiradiography
Outline the radius and ulna then the look at the medullary canals
Assess DRUJ, the ulna subluxing dorsally is characteristic of DRUJ instability
This is why it is important to have a good lateral based on pisiform overlap with the scaphoid
Then look at radius-lunate articulation (the moon (lunate) sitting on the radius), then lunate-capitate articulation (the capitate sitting in the cup or moon-shaped lunate)
Assess scaphoid position
Oblique View: Proximal to distal
Great for assessing radial styloid fractures
Review from proximal to distal outline of radius and ulna, then carpal bones
Outline metacarpals
Soft tissue: Proximal to distal
Case example:
https://commons.wikimedia.org/wiki/File:Collesfracture.jpg
This is an AP and Lateral of a left wrist in a skeletally mature individual showing a distal radius fracture. (Generally it is good to avoid eponyms, like Colles Fracture).
If you are in a fracture conference, that is all you may have time to say, but you should be looking back over the image using a system. Work from proximal to distal, outline the bones, look in the medullary canals, visualize important/imaginary lines to help you pick up on abnormalities, and don’t forget about the surrounding soft tissue!
