Investigations
1st investigations to order
plain x-rays of the wrist
Test
Order plain radiographs in all patients to make a conclusive diagnosis.[17][32][33]
For a suspected distal radius fracture, obtain posteroanterior and lateral views centred at the wrist.[17][32] Ensure that the entire radius, along with the wrist and elbow joints, are clearly visualised.[32] In children, orthogonal x-rays should be available to allow proper diagnosis and planning.[33]
Fractures may be minimal cracks, extra-articular fractures, or intra-articular fractures.
Practical tip
Ensure the patient is comfortable for radiography, with sufficient analgesia.
Radiographs also suggest the degree of osteopenia, and may offer some information about the degree of articular involvement or comminution.
Combined injuries of the distal radius and scaphoid are possible but uncommon.
Scaphoid fractures can be missed on x-ray and so x-rays must be carefully examined for these fractures.[2]
For fractures of the distal radius, radiographic features that suggest the need for surgical treatment include:[40]
Post-reduction radial shortening of >3 mm
Dorsal tilt of >10º
Intra-articular step-off of >2 mm.
Result
fracture of the distal radius, distal ulna, or scaphoid
Investigations to consider
CT wrist
Test
A CT scan is generally useful for assessing fracture morphology, displacement, union, and deformity, and for preoperative planning.
In patients where surgical fixation is considered, a CT scan of the distal radius or scaphoid may be beneficial for the analysis of extra- and intra-articular fracture geometry and preoperative planning.[41]
A CT scan may also reveal any occult fractures around the carpus.[Figure caption and citation for the preceding image starts]: CT scans of the wrist provide excellent detail to assess fracture geometry, articular involvement, as well as degree of comminution [Citation ends].
Result
fracture of the distal radius or ulna, with clarification of extent of comminution and/or articular involvement
MRI (without contrast) wrist
Test
MRI is useful for evaluating soft tissue injury and bone oedema suggestive of acute injuries.
Use MRI (without contrast) if you suspect an occult fracture of the scaphoid.[31] It may also be used to define associated ligamentous injuries.[42][43]
In practice, it may be that an x-ray is performed in the emergency department, with an MRI arranged if the patient’s symptoms have not resolved after 7 to 10 days. Have a high index of suspicion for this injury and arrange an MRI if the patient has pain despite a normal x-ray.[38][39]
Result
fracture of the scaphoid; defines associated ligamentous injuries
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