Wrist (oblique view)

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The oblique wrist view is part of a three view series of the wrist and carpal bones. It is not generally performed in follow-up studies unless specifically requested.

Indications

The oblique wrist radiograph is requested for myriad reasons including but not limited to trauma, suspected infective processes, injuries the distal radius and ulna, suspected arthropathy or even suspected foreign bodies. It is also a handy projection to better assess the scaphoid and subtle distal radial fractures.

What is probably more useful is remembering that an oblique wrist radiograph will not rule out a forearm fracture given the limited coverage (for this, one would request a forearm series).

Patient position

  • patient is seated alongside the table
  • the affected arm if possible is flexed at 90° so the arm and wrist can rest on the table
  • the affected hand is placed, palm down on the image receptor
  • shoulder, elbow, and wrist should all be in the transverse plane, perpendicular to the central beam
  • wrist and elbow should be at shoulder height which makes radius and ulna parallel (lowering the arm makes radius cross the ulna and thus relative shortening of radius)
  • from the positioning of the PA projection, the wrist is externally rotated 40° - 45°; a sponge can be placed under the wrist to aid stability. In some departments, the DR systems will pick up the outline of the sponge so check your local protocol. 

Technical factors

  • posteroanterior projection
  • centering point
    • mid carpal region
  • collimation
    • laterally to the skin margins
    • distal to the midway up the metacarpals
    • proximal to the include one-quarter of the distal radius and ulna
  • orientation  
    • portrait
  • detector size
    • 18 cm x 24 cm
  • exposure
    • 50-60 kVp
    • 3-5 mAs
  • SID
    • 100 cm
  • grid
    • no

Image technical evaluation

The ulna head and distal radius are slight superimposed. The proximal metacarpals 3 to 5 also being partly superimposed.

Practical points

Wrist radiographs are very common in emergency departments; they are often associated with FOOSH injuries and be quite painful.

Due to the non-urgent nature of a "? fractured wrist", patients will often be triaged to a lower category and left waiting for longer than multi-trauma patients; an understandable factor in emergency hospitals.

It is important to remember this when examining your patient; it is easy to forget that just lifting your hand up and placing it on an image receptor could result in substantial pain and more often than not the pain has not been addressed yet. Offer to move things around to assist in positioning, simple things like lowering/raising the table go a long way and result in a better experience for the patient.

It is also possible to achieve the oblique wrist with the patient supine in bed, by simply following the basic positioning principles, the image receptor can be placed next to the patient on the bed under the affected wrist.

Imaging in practice
Radiographic views