Imaging of the Wrist and Hand

, Royal Victoria Hospital, McGill University, Montrèal, Canada.


Medscape General Medicine. 1999;1(1) 

In This Article

Nonconventional Radiography

Nonconventional radiographs, including scaphoid and carpal tunnel views, may show occult wrist fractures. Scaphoid view, a PA view with the wrist in ulnar deviation, is indicated when there is a strong clinical suspicion of scaphoid fracture but four-view wrist exam is negative (Fig. 8). A carpal tunnel view, obtained by any of three methods, should be requested if there is a strong suspicion of ventral carpal bone fractures, particularly to the trapezium, hook of the hamate, and pisiform (Fig. 9).[6]

Figure 8. Scaphoid view of the right wrist taken with the hand in ulnar deviation. A nondisplaced transverse fracture is identified through the scaphoid waist.
Figure 9. Carpal tunnel radiograph of the right wrist. The pisiform (thin arrow), hamulus (small *), capitate (large arrow), and trapezium (large *) are identified.

In cases where subtle fractures of the radial aspect of the metacarpal heads are suspected, the semisupinated (reverse) oblique radiograph of the hand is helpful. More often, this view is obtained as part of an arthritis series to assess for early erosive changes at the metacarpal heads.[7]

If ligamentous injuries are a consideration, stress views, instability series, arthrography, or magnetic resonance imaging (MRI) may be indicated. The ulnar collateral ligament (UCL) of the thumb is ideally assessed with stress radiography, whereas the intercarpal ligaments require fluoroscopy or advanced imaging techniques for evaluation.[8]

Stress views of both the symptomatic and contralateral asymptomatic joint should be performed to allow the contralateral joint to be used as a comparison (Fig. 10). This is important because there is quite a bit of variability in the laxity of even asymptomatic joints. In evaluating the quality of the stress exam, it is crucial that the joint be stressed in the correct plane. The stress exam is contraindicated in the setting of an intra-articular fracture at that joint (Fig. 11).[8]

Figure 10. Ulnar deviation of the (a) right and (b) left first metacarpo-phalangeal joints bilaterally tests the integrity of the radial collateral ligament (RCL). The loss of congruence and asymmetric widening of the joint space on the right side as compared with the left side suggests a sprain or rupture of the RCL.
Figure 11. Posteroanterior view of the right thumb. A comminuted intra-articular fracture of the ulnar aspect of the proximal phalanx of the thumb is identified. Stress views of the ulnar collateral ligament are contraindicated.