Wrist fractures are occasionally very difficult to demonstrate radiographically, indeed, they are sometimes evident on MRI scanning or bone scan only. This page looks at some cases of tricky wrist fractures and the techniques for demonstrating them with plain film radiography. As is often the case, a clinical approach to radiography will yield better results than a photographic approach.

This lady presented to the Emergency Department after a fall and was referred for wrist radiography. The image left shows her wrist after the bandage was removed. She was in considerable pain and the focal swelling over the dorsum of her wrist suggested that she had sustained a fractured radius.

Routine wrist views were performed

This series demonstrated no obvious fracture. Moreover, the scaphoid fat pad (white arrow) and the pronator fat pad (black arrow) were normal.

The radiographer was convinced clinically that the patient had sustained a fracture and considered whether the soft tissue signs were misleading (as there are known to be on occasions). Supplementary views were performed as shown below.

The views performed are (from left to right) a reverse oblique wrist modified lateral wrist to profile articular surface of radius modified pa wrist to profile the articular surface of radius The reverse oblique image demonstrates a fractured distal radius (white arrow). The fracture and step in the articular surface of the radius is also demonstrated on the modified PA image (black arrow).

The 40 year old lady presented to the Emergency Department after falling over her dog. She was examined and was found to have a very painful right wrist. In addition, there was localised swelling over the dorsum of her wrist. She was referred for right wrist radiography.

There is an impression of a vertical lucent line through the distal radial metaphysis.	There is an impression of a vertical lucent line through the distal radial metaphysis (arrowed).

There appears to be a step in the articular surface of the distal radius.	There appears to be a step in the articular surface of the distal radius (arrowed)

There is evidence of localised swelling over the dorsal aspect of the wrist	There is evidence of localised swelling over the dorsal aspect of the wrist (arrowed)

Intermission

The radiographer thought that the patient had sustained a wrist fracture based on clinical evidence (pain, swelling, limitations of movement). The radiographic evidence of wrist fracture on the routine projection images was inconclusive- on balance, supplementary projections were warranted

This is an AP oblique wrist projection. There is evidence of cortical irregularity of the distal radial metaphysis	This is an AP oblique wrist projection. There is evidence of cortical irregularity of the distal radial metaphysis (arrowed)

This is a PA reverse oblique position. There is an osteochondral fracture of the radial styloid with minimal displacement.	There is an osteochondral fracture of the radial styloid with minimal displacement (arrowed)

Comment

This is a good example of trauma radiography. The radiographers clinical assessment was the key factor that led to demonstration of the fracture. The radiographer was not satisfied that the routine projections had demonstrated a fracture conclusively in a patient who had convincing clinical signs of fracture.

This 14 year old boy presented to the Emergency Department after a fall from his skateboard and was referred for wrist radiography. On examination, he had a painful wrist.

The PA wrist shows no evidence of displaced fracture	There is a suggestion of a subtle cortical buckle on the oblique image	There is no clear evidence of a displaced fracture on the view lateral image. The pronator quadratus fat pad is not clearly abnormal	There is a subtle cortical buckle demonstrated on the reverse oblique image. Compare with the smooth even contours of the other metaphyseal cortices (radius and ulna)

Comment

This is a very subtle fracture of the distal radius. There is a suggestion of dorsal palmar tilt on the lateral view although this is not convincing (zero degrees of palmar tilt can be a normal finding). Irregularity of the distal metaphysis immediately adjacent to the physis is normal. However, this does not appear to be typical of this commonly seen normal feature. As is often the case, the non-routine view (reverse oblique) demonstrates the cortical buckle most convincingly.

This 87 year old lady presented to the Emergency Department after a fall onto an outstretched hand. On examination she had a painful swollen wrist.

Unlabelled PA wrist	The PA wrist image demonstrates a cortical irregularity on the medial aspect of the radial metaphysis (black arrow). There is an additional cortical contour deformity on the lateral aspect of the distal radius (white arrow). There is associated soft tissue swelling (grey arrow).	Unlabelled lateral wrist	There is evidence of trabecular disruption (white arrow). There is soft tissue swelling on the dorsal aspect of the wrist (grey arrow) and the pronator quadratus fat pad is displaced away from the radial cortex (black arrow).

Comment

This14 year old boy presented to the Emergency Department after a fall onto an outstretched hand. On examination he had a painful swollen wrist.

Unlabelled PA wrist	The PA wrist image demonstrates a cortical irregularity along the medial border of the radius (white arrow).	Unlabelled lateral wrist	There is evidence of buckle fracture of the distal radius (black arrow). The pronator quadratus fat pad is normal.

Comment

This14 year old girl presented to the Emergency Department after a fall onto an outstretched hand while playing netball. On examination she had a painful wrist.

Unlabelled PA wrist	There is a cortical irregularity on the medial aspect of the radial metaphysis immediately proximal to the physis. There is also an associated irregularity of the trabecular pattern. There is a spur seen at the base of the 5th metacarpal of uncertain aetiology.	Unlabelled lateral wrist	There is a cortical defect of the radial metaphysis (arrowed).

Comment

This16 year old boy presented to the Emergency Department after a fall onto an outstretched hand. On examination he had a painful wrist.

There is no evidence of displaced fracture in this view.	Unlabelled lateral wrist	There is a buckling of the dorsal aspect of the radial metaphysis with a possible associated lucency extending into the distal radius.	This is an elongated reverse oblique view. There is a defect in the postero-anterior radial cortex (arrowed) with an associated trabecular defect obliquely traversing the radial metaphysis.

Comment

This14 year old boy presented to the Emergency Department after a fall from his pushbike. On examination he had a painful swollen wrist.

There is no evidence of displaced fracture in this view. The cortical irregularity immediately adjacent to the growth plate is normal. This appearance is associated with the rapid bone growth that is occurring at the physis.	Unlabelled lateral wrist	The cortical irregularity on the dorsal aspect of the radius (white arrows) appears to be too florid to be dismissed as normal irregularity associated with the physis. In addition, there is soft tissue swelling over the dorsum of the wrist and there is a large pronator quadratus fatpad sign (black arrow)	This is an over-rotated lateral position. Note that the pisiform is projected clear of the other carpal bones. There is a cortical buckling of the dorso-radial aspect of radial metaphysis (arrowed)

Comment

This13 year old boy presented to the Emergency Department after a fall onto an outstretched hand.

There is no evidence of displaced fracture in this view.	There is a subtle cortical irregularity along the ulnar aspect of the radial metaphysis. There is an equally subtle associated trabecular oblique defect line		There is a buckle of the dorsal aspect of the radial metaphysis (arrowed)

Comment

This 17 year old boy presented to the Emergency Department after a fall onto an outstretched hand.

There is a cortical irregularity on the ulnar aspect of the radial metaphysis (arrowed)		The cortical buckle is seen again on the oblique image (arrowed)	There is a buckle of the dorsal aspect of the radial metaphysis (arrowed).

Comment

This 45 year old man presented to the Emergency Department after a fall onto an outstretched hand.

	There is a fracture of the distal radius which extends into the wrist joint.(arrowed)	The cortical buckle is seen on the dorsal aspect of the wrist. (arrowed) There is obliteration of the pronator quadratus fat pad	There is cortical irregularity of the radio-dorsal aspect of the wrist (white arrow). There is a fracture of the ulna (black arrow)

This 31 year old man presented to the Emergency Department after a fall onto an outstretched hand.

No convincing evidence of a fracture	There is some loss of smooth contour of the radial aspect of the radial styloid. This is not convincing of a fracture	There is a loss of continuity of the dorsal aspect of the radial metaphysis. There also appears to be a pronator quadratus soft tissue sign.	The radiographic findings were considered to be equivocal. The patient's symptoms persisted. The referring doctor considered that the patient may have sustained a fractured scaphoid. The patient was referred for MRI scanning which revealed a radial metaphysis transverse fracture.

This 13 year old boy presented to the Emergency Department after a fall onto an outstretched hand while running backwards.

There is a very subtle buckle in the radial aspect of the radial metaphysis.	There is an even more subtle defect in the radial metaphysis demonstrated on the lateral wrist image. The findings are consistent with a subtle buckle fracture of the wrist	T1 weighted MRI image with transverse irregular low T1 band consistent with the fracture seen on the plain film images.

This 10 year old boy presented to the Emergency Department after a fall from his pushbike and was referred for wrist radiography. On examination, he had a painful wrist.

The PA wrist shows no evidence of displaced fracture	There oblique wrist projection image shows no evidence of displaced fracture	The lateral wrist projection image is not clearly abnormal.

Comment

The radiographer noted the dorsal angular displacement of the distal radius and considered the possibility of a subtle distal radius fracture. A repeat off-lateral wrist projection was considered justified.

The off-lateral wrist projection image demonstrates a buckle fracture of the dorsal aspect of the radial metaphysis.	Buckle fracture arrowed.

Comment
The radiographer should have a high level of willingness to undertake what would normally be considered poor quality radiography in order to demonstrate a suspected pathology. The off-lateral projection is a case-in-point.... doctrinaire thinking can be at the detriment of the diagnosis.

The radial and ulnar cortical contours should appear as smoothly curved lines on plain film images of the wrist. . Any appearance other than a smooth curve should be considered as a possible fracture. The radial metaphysis in children and adolescents is fertile territory for subtle buckle fractures. Supplementary views such as reverse oblique and off-lateral can be useful in confirming the presence of a fracture. A clinical approach by the radiographer is particularly important- the radiographer should consider the patient's mechanism of injury, the clinical presentation and the soft tissue signs (clinical and radiographic).

Is the diagnosis of these fractures important? The simple answer is yes. A patient who has sustained a subtle buckle fracture will be treated with an immobilising plaster which will protect the fractured bone from further injury and reduce pain. Importantly, the patient's pain will be accounted for and appropriate pain relief prescribed. The patient will be assured that their symptoms have been explained and the patient be unlikely to represent for further diagnosis/treatment. The fracture can be followed up at a subsequent orthopaedic clinic appointment to ensure that it was not more serious than originally thought and remains minimally displaced. Appropriate limitations of activity can be explained to the patient to reduce the possibility of re-injury while the bone is healing. I also believe that there is an innate benefit in getting the diagnosis correct- satisfying for the patient, satisfying for the radiographer, and reassuring for the referring clinician. A more subtle benefit to the radiographer will be in the form of admiration and trust from the referring doctor- the radiographers can be left to their own devices if their radiography and judgements can be relied upon.

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