1. Managing Minor Musculoskeletal Injuries and Conditions First Edition. David Bradley. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/bradley/musculoskeletalwww.wiley.com/go/bradley/musculoskeletal

2. Wrist X-rays

3. Wrist 1 What can you see in this single AP view of the wrist? The patient, an elderly woman, fell in the street injuring the wrist. After you have studied it, look at the next slide.

4. Wrist 1 – alternative view This blown-up view shows the changes of a Colles fracture. The arrows point to the break in the cortex of the radius and the avulsed ulna styloid. Also you should have noted the extensive arthritic changes throughout the wrist. A clear example of this would be the deformed joint between the trapezium and the first metacarpal.

5. Wrist 2 Another fall on an outstretched hand with this patient. What can you see on the X-ray? How would you describe this over the telephone to a colleague who cannot see the X-ray? See my notes below.

6. Wrist 3 What do you see? See my notes below.

7. Wrist 4 What can you see on the film? Would you want to see another view? What particular immediate danger is there with a fracture like this? Once ready, see my notes below.

8. Wrist 5 Displacement of this mid shaft fracture of the radius and ulna is not as severe as on the previous slide. However, the state of the circulation and nerves is just as important. Note that the elbow has been included in this film, but, if the patient is complaining of pain, separate views of the elbow may still have to be taken to get the angles correct. Similarly with the left hand, this film will only give information for a gross injury. If the fracture was caused by a FOOSH, the patient could just as easily have an associated scaphoid requiring more films. Never ‘give in’ when you have recognised one injury.

9. Wrist 6 A young lad with a history of a FOOSH earlier in the day. Painful wrist, but can move it with encouragement. Do you see anything, or can they just have a support and go on their way with analgesia and SOS instructions? See my notes below.

10. Wrist 7 I am used to looking at wrist X-rays this way up, so am far more likely to notice an abnormality this way. So if you have a particular way of looking at an X-ray, move it around to increase your chances of making a ‘hit’. Arrows here show the slight discrepancies in the cortex of the radius.

11. Wrist 8 Comment on the X-ray. See my notes below.

12. Wrist 9 Here I have drawn a line on the previous lateral to show the posterior tilting of the radius. This line should be upright or tilting just a little the opposite way. Note that the classical ‘dinner fork’ deformity can even be seen on the X-ray. On the lower AP view I have arrowed the associated fracture of the ulna styloid. The above are just two points that make a fracture a Colles. Can you remember any others? Look at the notes below or read Chapter 8 of the book.

13. Wrist 10 Comment on this film. What is the yellow arrow pointing to? Which is the bone the white arrow points to? See my notes below.

14. Wrist 11 Three views of the same patient following a FOOSH Can you see anything, or have I just popped a normal set in to catch you out? See my notes below.

15. Wrist 12 Well, for those of you who are well practised at viewing paediatric X-rays, this is an obvious greenstick fracture showing on the two right-hand views. I have put arrows to highlight it for those of you who are new to this injury. The fracture is just about invisible on the left-hand view. Lots of practice is the one and only way to become good at reading these X-rays.

16. Wrist 13 Another film from a FOOSH. What can you see? See my notes below.

17. Wrist 14 Take your time and enlarge the views if necessary. The patient had a FOOSH. See my notes below.

18. Wrist 15 Compare this normal line (from the anterior to posterior borders of the articular surface) to the same one for a Colles fracture (Wrist 9). Other points for you to note are the first MC, white arrow; the pisiform, yellow arrow; and the ‘C’ shape articulation between the lunate and the capitate.

19. Wrist 16 A lateral view of the wrist. What is the name of the bone with the white arrow? What is the bone just above the yellow arrow in the palmar surface? Has it been dislocated? See notes below.

20. Wrist 17 Another example of a greenstick fracture of the radius for you and I hope that an arrow is not necessary this time. These are called greenstick ‘buckle’ fractures by some; others call them ‘torus’ fractures. They are very, very common, and easily missed clinically if the mechanism isn’t understood.

21. Wrist 18 Interpret this X-ray; there was a FOOSH MOI. What does the small yellow arrow point to? What does the small white arrow point to? Don’t forget to enlarge the film if necessary to make it clearer. See my notes below.

22. Wrist 19 This wrist was injured in a fall during a school sports session. The arrow points to a line near the base of the first MC. Is it a fracture? When ready, read my notes below.

23. Wrist 20 Clinically this wrist is swollen with generalised tenderness following trauma. What do you see on the X-ray? Do you think that there may be a dislocation? After consideration, read my comments below.