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System for Reading Wrist Xrays

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


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:

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!

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