Evaluation of wrist pain and injury in children and adolescents

INTRODUCTION — Injuries to the wrist are common in children, adolescents, and young adults. A thorough understanding of the anatomy of the growing wrist, common wrist injuries, and other causes of wrist pain are essential to accurate diagnosis and appropriate treatment.

An overview of the relevant anatomy, epidemiology, and evaluation of wrist injuries in children and adolescents will be presented below. Causes of wrist pain and injury are discussed separately. (See "Overview of acute wrist injuries in children and adolescents" and "Overview: Causes of chronic wrist pain in children and adolescents".)

CLINICAL ANATOMY — The wrist and hand are described in the anatomic position with the fifth digits medial and the palm facing anterior. "Lateral" and "radial" describe the thumb side (picture 1); "medial" and "ulnar" describe the little finger side (picture 2). The anterior aspect is "palmar" or "volar" (picture 3) and the posterior aspect is "dorsal" (picture 4).

●Bones – The wrist is formed by articulations between the radius, ulna, and the carpal bones. There are eight carpal bones distributed in proximal and distal rows (figure 1). The scaphoid (ie, navicular) bone provides a stabilizing link between the proximal and distal carpal bones (image 1). During development, the carpal ossification centers and the growth plates of the distal radius and ulna appear and fuse in a predictable stepwise fashion that is used to determine skeletal age (table 1) [1].

●Joints – The distal radioulnar joint (DRUJ) is a small, J-shaped, fluid-filled joint where the ulnar head articulates with the ulnar notch in the distal radius (figure 2). It serves as the main point for supination and pronation of the forearm.

The articulation between the distal radius and the scaphoid and lunate bones forms the radiocarpal joint (figure 2). The radiocarpal joint and the midcarpal joint, which is between the proximal and distal rows of carpal bones, are responsible for the majority of wrist flexion and extension.

There is no direct bony articulation between the distal ulna and the carpal bones; the ulnar side of the wrist is supported by the triangular fibrocartilage complex (TFCC), interposed between the distal ulna and triquetrum (figure 3). The TFCC is the major stabilizer of the DRUJ; it includes the triangular fibrocartilage, ulnar collateral ligament, dorsal and palmar radioulnar ligaments, ulnolunate and ulnotriquetral ligaments, and the extensor carpi ulnaris tendon sheath [2].

●Ligaments and capsule – The wrist is supported by a thin joint capsule, a thick complex of crisscrossing ligaments, and the fascia covering the flexor and extensor tendons (the retinaculum). The ligaments of the wrist are divided into two main categories: intrinsic and extrinsic. Intrinsic ligaments bind the carpal bones together; extrinsic ligaments bind the distal radius and ulna to the carpal bones, providing stability.

The palmar radiocarpal, scapholunate, and lunotriquetral ligaments are the most clinically important (figure 4). The palmar radiocarpal ligaments ensure that the carpal bones move with the radius during supination and pronation. Disruption of the scapholunate and lunotriquetral ligaments can lead to chronic pain and instability.

●Muscles and tendons – The muscles of the wrist are divided into two major groups: palmar and dorsal. The palmar group includes the wrist and finger flexors and the forearm pronators. They are innervated by the median and ulnar nerves. The dorsal group includes the wrist and finger extensors and thumb extensors and abductors. They are innervated by the radial nerve.

The tendon sheaths of the fifth flexor digitorum superficialis and profundus share a common sheath in the carpal tunnel that extends just distal to the wrist (figure 5). Thus, infections from the sheath of the 5th digit can extend to the wrist via direct communication with the common flexor sheath.

●Vessels – The ulnar and radial arteries, branches of the brachial artery, are the main arteries of the forearm. At the level of the wrist, each of these arteries contributes branches to form the superficial and deep palmar arches that supply the hand.

●Nerves – The wrist is innervated by the median, ulnar, and radial nerves (table 2). The median nerve traverses the carpal tunnel, an elliptically shaped canal enclosed by the inelastic flexor retinaculum ventrally and the carpal bones dorsally (figure 6). In addition to the median nerve, eight deep and superficial flexor tendons and their sheaths, the flexor pollicis longus tendon and sheath, and occasionally the radial and ulnar palmar bursae or the median artery pass through the carpal tunnel (figure 5).

The ulnar nerve traverses Guyon's canal, which is bordered by the palmar carpal ligament, the transverse retinacular ligament, the pisiform, and the hook of the hamate [3].

●Biomechanics – The four principal movements of the wrist are flexion, extension, pronation, and supination; the wrist can also be deviated ulnarly and radially.

•Wrist flexion and extension are initiated at the base of the metacarpals where the flexor carpi radialis and ulnaris (the major wrist flexors) and the extensor carpi radialis and ulnaris (the major wrist extensors) insert. Seventy to 90 degrees of flexion occurs at the wrist. The radiocarpal joint accounts for approximately 60 percent of the motion and the midcarpal joint for approximately 30 to 40 percent [3].

•The radioulnar joint is responsible for pronation and supination.

•The wrist has about 30 to 40 degrees of ulnar and 15 to 30 degrees of radial deviation. Much of this motion is due to translation of the proximal and distal carpal row on the radius, which slide in opposite direction of movement (ie, radial wrist deviation has carpal ulnar deviation).

MECHANISM OF INJURY — Mechanisms of wrist injury can be divided into four major categories [3-7]:

(1) Impact

(2) Weightbearing

(3) Twisting

(4) Throwing or repetitive motion

●Impact – Fall onto the wrist (the most common mechanism of acute injury) or direct impact from contact with a fellow player, ball, or other object (eg, puck, racquet).

Impact injuries include fractures (distal forearm, scaphoid, triquetral, hook of hamate), Kienböck's disease, and injuries to the ligaments and capsule [3]. Repetitive impact can lead to overuse injuries [6]. (See "Overview of acute wrist injuries in children and adolescents" and "Overview: Causes of chronic wrist pain in children and adolescents", section on 'Overuse injuries'.)

Most falls occur with the wrist in an extended and pronated position. If the wrist was radially deviated at the time of the fall, scaphoid injuries are more likely; if the wrist was ulnarly deviated, ulnar styloid and TFCC injuries should be considered.

●Weightbearing – Weightbearing injuries occur most frequently in gymnasts, wrestlers, weight lifters, and rock-climbers. Weightbearing injuries include dorsal wrist impaction syndrome, distal radius physis stress syndrome, DRUJ dislocation, TFCC injury, ganglion cyst, carpal tunnel syndrome, and intersection syndrome [3]. (See "Overview: Causes of chronic wrist pain in children and adolescents".)

●Twisting – Forceful rotation of the wrist can occur in any sport. Twisting injuries affect joint stability, typically at the DRUJ.

●Throwing and/or other repetitive motion – Throwing and/or other repetitive motion is common among players of racquet, stick, and club sports; weight lifters; rowers; and gymnasts. Repetitive motions can lead to overuse injuries including tendonitis, distal physeal stress reaction, and neuropathy. (See "Overview: Causes of chronic wrist pain in children and adolescents" and "Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach".)

ETIOLOGY

Traumatic — Traumatic causes of wrist pain in children include acute injuries (fractures, ligamentous injuries) and overuse injuries. (See "Overview of acute wrist injuries in children and adolescents" and "Overview: Causes of chronic wrist pain in children and adolescents", section on 'Overuse injuries'.)

When considering potential etiologies, it is helpful to consider whether the pain is acute (<4 weeks) or subacute/chronic (≥4 weeks), ulnar or radial, and dorsal or palmar (table 3 and table 4).

Nontraumatic — Nontraumatic causes of wrist pain in children and adolescents include:

●Referred neurologic pain (eg, cervical nerve root or brachial plexus impingement)

●Osteomyelitis (see "Hematogenous osteomyelitis in children: Evaluation and diagnosis" and "Hematogenous osteomyelitis in children: Clinical features and complications", section on 'Clinical features')

●Septic arthritis (see "Bacterial arthritis: Clinical features and diagnosis in infants and children")

●Juvenile idiopathic arthritis (see "Systemic juvenile idiopathic arthritis: Clinical manifestations and diagnosis" and "Polyarticular juvenile idiopathic arthritis: Clinical manifestations, diagnosis, and complications" and "Oligoarticular juvenile idiopathic arthritis")

●Rickets (see "Overview of rickets in children")

●Congenital anomalies (see "Overview: Causes of chronic wrist pain in children and adolescents", section on 'Congenital anomalies')

●Carpal tarsal osteolysis (see "Overview: Causes of chronic wrist pain in children and adolescents", section on 'Carpal tarsal osteolysis')

●Ulnar neuritis caused by subluxation of the ulnar nerve within the cubital tunnel

HISTORY — Important aspects of the history include [2,8,9]:

●For patients with injuries, what was the exact mechanism of injury and the location of the wrist during the traumatic force? (See 'Mechanism of injury' above.)

●Where is the pain? Causes of wrist pain can be categorized according to whether they are ulnar or radial, or dorsal or palmar (table 3 and table 4).

●How long has the pain been present? Was it preceded by an injury? Acute (<4 weeks) and subacute/chronic (≥4 weeks) wrist pain have differing etiologies (table 3 and table 4). Chronic wrist pain following an injury is suspicious for carpal instability, whereas chronic bilateral wrist pain or swelling may be a presentation of arthritis or other rheumatologic conditions. (See "Overview: Causes of chronic wrist pain in children and adolescents".)

●How intense is the pain? What makes it better? What makes it worse?

●Are there associated complaints (neck, shoulder, or elbow complaints); swelling, paresthesias in the hand; or muscle weakness in the forearm or hand, fever? Paresthesias and/or muscle weakness suggest neuropathy. Paresthesias in the median nerve distribution (figure 7) after acute trauma may indicate dislocation of the lunate into the carpal tunnel; paresthesias in the ulnar nerve distribution (figure 8) after acute trauma may indicate fracture of the pisiform or hamate [9]. Fever may indicate acute infection (osteomyelitis or septic arthritis).

●Does the patient hear sounds in the wrist during specific movements?

•A high-pitched snap may be present in extensor carpi ulnaris (ECU) tendon subluxations. (See "Overview: Causes of chronic wrist pain in children and adolescents", section on 'Tendon injuries'.)

•Medium-pitched clicks may be present in scapholunate instability. (See "Overview of acute wrist injuries in children and adolescents", section on 'Scapholunate'.)

•Low-pitched clunks often are associated with midcarpal instability. (See "Overview of acute wrist injuries in children and adolescents", section on 'Midcarpal'.)

•Crepitus may be present in wrist tenosynovitis or intersection syndrome. (See "Overview: Causes of chronic wrist pain in children and adolescents", section on 'Tendon injuries'.)

●What is the training routine and intensity of training? Increasing the intensity of training too quickly increases the risk of overuse injury [6,10]. (See "Overview: Causes of chronic wrist pain in children and adolescents", section on 'Overuse injuries'.)

EXAMINATION — Important components of the examination of the child with complaints of wrist pain or injury include [11]:

●Inspection

●Neurovascular examination

●Palpation

●Measurement or estimation of grip strength

●Assessment of range of motion

●Provocative testing to assess the integrity of the supporting ligaments

Findings should be compared with the uninjured/nonpainful wrist. Patients with a traumatic injury and severe pain should be evaluated by radiograph following assessment of their neurovascular status. (See 'Imaging' below.)

Inspection — The wrist should be inspected for swelling, ganglion, and signs of trauma or inflammation.

Neurovascular exam — The neurovascular examination includes palpation of the radial and ulnar pulses, and assessment of motor and sensory function in the distribution of the radial (figure 9), ulnar (figure 8), and median (figure 7) nerves (table 2).

Palpation — Palpation of the affected area and determination of a point of maximal tenderness may aid in diagnosis. Diffuse mild tenderness in the radiocarpal joint line is consistent with a simple sprain, but more significant discrete tenderness is consistent with more severe injuries, such as fracture or ligamentous injury. Focal tenderness over the tendons may indicate tendinitis.

●Dorsal palpation – The dorsal wrist has important surface landmarks that can assist the clinician to accurately identify the likely source of pain (figure 10):

•Lister's tubercle is proximal to the point where the distal radius, scaphoid, and lunate meet (picture 4). Tenderness and swelling in this area may indicate tearing of the scapholunate ligament.

•The distal radioulnar joint (DRUJ) is located just on the radial side of the large protuberant ulnar dome. Tenderness over the DRUJ can indicate triangular fibrocartilage complex (TFCC) injury.

•The lunotriquetral (LT) interval is just distal to the DRUJ and pain in the interval could indicate LT instability.

•The TFCC is best palpated in the hollow between the pisiform, the flexor carpi ulnaris, and the ulnar styloid on the ulnar border of the wrist (picture 2 and figure 3).

•The extensor carpi ulnaris (ECU) tendon, extensor carpi radialis (ECR) tendon, lunate, and ulnar styloid can also be palpated on the dorsal surface of the wrist (picture 4 and figure 11). Focal tenderness along either the ECU or ECR is consistent with tendonitis. Focal tenderness distal to the ulnar styloid is consistent with TFCC injury. (See "Overview of acute wrist injuries in children and adolescents" and "Overview: Causes of chronic wrist pain in children and adolescents".)

●Anatomic snuffbox – Anatomical snuffbox tenderness may be due to fracture, avascular necrosis, or arthritis of the scaphoid. The bony prominence on the radial side of the wrist is the radial styloid, which is the proximal border of the anatomic snuffbox. The radial border is the first extensor compartment containing the abductor pollicis longus and extensor pollicis brevis, which travel superficial to the radial styloid (picture 5 and figure 12 and picture 6). Focal tenderness on the first extensor compartment or radial styloid is consistent with de Quervain's tenosynovitis. The distal border of the anatomic snuffbox is the base of the first metacarpal, and the floor is the scaphoid (figure 13). The ulnar border is the third extensor compartment containing extensor pollicis longus, which crosses the wrist joint just on the ulnar side of Lister's tubercle. (See "Overview of acute wrist injuries in children and adolescents", section on 'Scaphoid fractures' and "de Quervain tendinopathy".)

●Ulnar snuffbox – The ulnar snuffbox is the sulcus distal to the ulnar head formed by the ECU and flexor carpi ulnaris (FCU) (picture 2). Tenderness in the ulnar snuffbox is suggestive of TFCC injury, ulnar styloid fracture, or lunotriquetral instability [12,13]. (See 'Lunotriquetral' below and "Overview of acute wrist injuries in children and adolescents", section on 'Lunotriquetral'.)

●Palmar palpation – The scaphoid tuberosity, flexor carpi radialis (FCR) tendon, palmaris longus (PL) tendon, and radial pulse can be palpated in the radial palmar region (figure 14). The scaphoid tuberosity is palpated distal to the palmar aspect of the radial styloid. The FCR is felt just radial to the PL with the wrist in flexion; they run in the middle of the wrist in the same orientation and in approximate alignment with the middle finger.

The pisiform, hook of the hamate, FCU, and ulnar pulse can be palpated in the ulnar palmar region (figure 14). The pisiform is the bony prominence at the base of the hypothenar eminence; the hook of the hamate lies just radial and distal to the pisiform. Focal pain over the hamate in patients with an appropriate history is consistent with a fracture [11]. (See "Overview of acute wrist injuries in children and adolescents", section on 'Hamate fractures'.)

Range of motion — Range of motion for flexion (picture 7), extension (picture 8), pronation, supination, and ulnar and radial deviation (picture 9 and picture 10) should be assessed. The intact ability to pronate and supinate the wrist against resistance excludes pathology of the DRUJ and TFCC [14]. Decreased range of motion may indicate fracture, ligamentous instability, wrist impingement, and Kienböck's disease.

Integrity of ligaments

Scapholunate — The scaphoid shift test is used to detect laxity of the scaphoid ligaments (picture 11 and picture 12 and picture 13 and picture 14). With one hand, the examiner passively moves the patient's hand from a position of extension and ulnar deviation to one of flexion and radial deviation, while the thumb of the examiner's other hand maintains firm pressure on the palmar aspect of the scaphoid. The examiner then releases pressure on the scaphoid and, if laxity is present, the subluxed scaphoid will move back into alignment with a palpable "clunk." The injured wrist should be compared with the uninjured wrist. (See "Overview of acute wrist injuries in children and adolescents", section on 'Scapholunate'.)

Lunotriquetral — The lunotriquetral shear (or ballottement) test is performed by stabilizing the lunate and moving the pisotriquetral mass back and forth past the lunate in the anterior and posterior direction. A positive test is increased movement and pain compared with the other side (figure 15). (See "Overview of acute wrist injuries in children and adolescents", section on 'Lunotriquetral'.)

Another test is to apply lateral pressure to the triquetrum while the wrist is radially deviated.

Distal radioulnar joint instability (DRUJ) — The piano key test and the DRUJ compression test may be helpful in assessing DRUJ instability.

●The piano key test is performed on a pronated wrist (picture 15); it is positive if ballottement of the ulnar head in a palmar direction produces little resistance compared with the other side. Alternatively, the patient forcibly presses both palms into the examination table; exaggerated dorsal-palmar translation compared with the opposite side indicates DRUJ instability [13].

●In the DRUJ compression test, the examiner compresses the radial and ulnar heads together and then rotates the forearm (figure 16). Pain with this maneuver is suggestive of DRUJ instability.

Triangular fibrocartilage complex (TFCC) tears — Provocative maneuvers for TFCC tears include the TFCC compression test, the supination lift test, and the press test [4,13,15]. Elicitation of ulnar pain with any of these maneuvers constitutes a positive test, suggestive of TFCC injury.

●In the TFCC compression test, the examiner applies axial compression to the ulnar side of the wrist during radial and ulnar deviation (figure 17). Point tenderness is in between the ulnar styloid and triquetrum.

CMC joint — Pain with compression of the base of the thumb in the AP direction suggests the carpometacarpal (CMC) joint as the source of wrist pain (picture 16).

Additional maneuvers

Scaphoid fractures — The scaphoid compression test (also called the axial grind test) is used in combination with palpation of the scaphoid in the anatomic snuff box to evaluate for scaphoid fractures. It is performed by holding the thumb and gradually pushing in toward the scaphoid along the longitudinal axis of the thumb metacarpal; the test is positive if this elicits pain over the palmar scaphoid tubercle. The scaphoid compression test is sensitive and moderately specific for scaphoid fractures [16-18]. (See "Overview of acute wrist injuries in children and adolescents", section on 'Scaphoid fractures'.)

de Quervain's — Diagnostic maneuvers for de Quervain tenosynovitis include the Finkelstein test (picture 17). These are discussed in greater detail separately. (See "de Quervain tendinopathy", section on 'Diagnosis'.)

Carpal tunnel — Diagnostic maneuvers for carpal tunnel syndrome include the Phalen (picture 18) and Tinel (picture 19) tests. These are discussed in greater detail separately. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis".)

IMAGING — Plain radiographs are the initial imaging test of choice for patients with wrist injuries. They are a critical tool in the diagnosis of many acute wrist injuries (eg, fractures, dislocations). Magnetic resonance imaging is more helpful in patients with chronic complaints and may be indicated for better visualization of specific anatomic pathology.

Plain radiographs — Plain films of the wrist are indicated in patients with suspected fracture and should be obtained in any patient with a history of trauma and focal pain or tenderness.

Routine views — Four views are usually obtained in the initial evaluation: anteroposterior (AP), lateral, scaphoid view in ulnar deviation, and 45 degrees semi-pronated oblique.

●Anteroposterior – The anteroposterior (AP) view is usually the best for identifying carpal fractures (image 2). Absence of the scaphoid fat stripe (a small linear or triangular collection of fat, distal to the radial styloid and parallel to the radial border of the scaphoid) is suggestive of acute bony or ligamentous injury [9,19].

Ulnar variance, or the relationship between the lengths of the radius and ulna, should be assessed. Ulnar variance is positive if the ulna is longer than the radius and negative if the ulna is shorter than the radius [4]. Positive ulnar variance is associated with a thinner TFCC, making it more prone to injury. Positive ulnar variance is also associated with lunotriquetral injury. Negative ulnar variance is associated with scapholunate injury [20]. (See "Overview of acute wrist injuries in children and adolescents".)

On the AP view, carpal malalignment and ligamentous injury may be indicated by:

•An increased distance between the carpal bones. In the normal wrist, the distances between the carpal bones on the AP radiograph are equivalent (image 3). An increased distance (>3 mm) is significant for displacement (image 4). The increased distance is often better appreciated if the fist is clenched; clenched fist views may be necessary if the initial AP radiograph is unrevealing. These findings may be difficult to interpret in skeletally immature children because of eccentric ossification and the chondral nature of the carpus; MRI imaging may be more useful [21].

•Disruption of Gilula's lines (three arcs connecting the proximal carpals that should form smooth curved lines, (image 5)) can signify carpal malalignment [22].

●Lateral – On the lateral view, the alignment of the carpals, particularly the lunate, capitate, and scaphoid, should be noted (image 6). Normally, the capitate and lunate should be bisected by a line along the long axis of the radius, and the scaphoid should form an angle with the lunate of about 45 to 60 degrees on the lateral (figure 18). If these relationships are not preserved, referral to a hand surgeon is indicated for evaluation of malalignment and carpal instability.

●Scaphoid view in ulnar deviation – The scaphoid view in ulnar deviation permits better visualization of scaphoid (image 7). This view may need to be specifically requested as it is not included in the standard wrist series at many facilities.

●45 degrees semi-pronated oblique – The oblique view is best for looking at the trapeziotrapezoidal joint and for basilar joint arthritis. Oblique views (picture 20) also are helpful for looking at scaphoid fractures and fractures of the hook of the hamate.

Additional views — If the routine series is not diagnostic, additional radiographs may be helpful:

●A scaphoid series, which includes six views.

●An instability series, which is taken with the fist clenched (image 8 and image 9) and the wrist in flexion, extension, and radial and ulnar (image 7) deviation [23].

●A carpal tunnel view (image 10), which provides better visualization of the hook of the hamate, pisiform, and trapezium.

Ultrasound — For appropriately trained clinicians, ultrasound is a useful tool for assessing a wide range of potential causes of wrist pain. The utility, limitations, and performance of the wrist ultrasound examination are discussed separately. (See "Musculoskeletal ultrasound of the wrist".)

Other imaging techniques — In the subacute setting (four weeks to nine months) or the chronic setting (more than nine months), the differential diagnosis broadens from fracture, ligament sprains, and instabilities to TFCC injuries and other non-traumatic causes such as synovitis, avascular necrosis (AVN), and osteoarthritis (table 4) [24]. (See "Overview: Causes of chronic wrist pain in children and adolescents".)

●Bone scan shows increased uptake in fractures that may not be evident on plain radiographs.

●CT scan is superior to MRI for detection of fractures and cortical bone processes.

●MRI is superior to CT for bone marrow pathology; osteonecrosis; synovial pathology; and visualization of the TFCC, ligaments, and soft tissues.

●MRI is becoming the diagnostic procedure of choice for most wrist injuries not detected on plain films.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Common wrist injuries (The Basics)")

SUMMARY

●Mechanisms of injury – Mechanisms of wrist injury include impact (fall or direct blow), weightbearing, twisting, and throwing or repetitive motion. A fall on an outstretched hand is the most common mechanism for acute wrist injuries in children and adolescents. (See 'Mechanism of injury' above.)

●Duration of symptoms – When considering potential causes of wrist pain, it is helpful to consider whether the pain is acute (<4 weeks) or subacute/chronic (≥4 weeks), ulnar or radial, and dorsal or palmar (table 3 and table 4).

●History – Important aspects of the history in children and adolescents include the mechanism of injury, characteristics of the pain (duration, location, exacerbating and relieving factors), associated findings (swelling, paresthesia, fever, sounds), and details of the training routine. (See 'History' above.)

●Physical examination – Important aspects of the examination in children and adolescents with wrist pain include assessment of neurovascular status, palpation of the affected area, determination of the point of maximal tenderness, range of motion, grip strength, and assessment of the integrity of the ligaments. (See 'Examination' above.)

●Diagnostic imaging – Plain radiographs are the initial imaging test of choice for patients with wrist injuries. Four views are usually obtained in the initial evaluation: anteroposterior (AP), lateral, scaphoid view in ulnar deviation, and 45 degrees semi-pronated oblique. (See 'Plain radiographs' above.)

Computed tomography (CT), bone scan, arthrography, and magnetic resonance imaging (MRI) are more helpful in patients with chronic complaints and may be indicated for better visualization of specific pathology. (See 'Other imaging techniques' above.)