M u s c u l o s k e l e t a l I m a g i n g • R ev i ew

Gyftopoulos et al.
Errors in Reading Upper Extremity Trauma Radiographs

Musculoskeletal Imaging
Review
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FOCUS ON:

Misses and Errors in Upper

Extremity Trauma Radiographs
Soterios Gyftopoulos1 OBJECTIVE. The article reviews a select group of traumatic upper extremity injuries that
Munish Chitkara can be easily misinterpreted on radiographs.
Jenny T. Bencardino CONCLUSION. The awareness of these specific injuries and an understanding of their
underlying pathophysiology and the role that radiographs can play in their evaluation will
Gyftopoulos S, Chitkara M, Bencardino JT give the reader the best opportunity to make the important imaging findings and guide ap-
propriate treatment.

Keywords: missed fracture, radiographs
DOI:10.2214/AJR.14.12589
Received January 23, 2014; accepted after revision
March 20, 2014.
1
All authors: Department of Radiology, NYU Langone
Medical Center, 660 First Ave, New York, NY 10016.
Address correspondence to S. Gyftopoulos
(Soterios20@gmail.com).
AJR 2014; 203:477–491
0361–803X/14/2033–477
© American Roentgen Ray Society
T
he role of radiographs in the eval-
uation of patients with upper ex-
tremity trauma is well estab-
lished, serving an important role
alongside clinical history and physical exami-
nation. Radiographs can be especially helpful
for the patient who is a poor historian or is dif-
ficult to examine, providing information cru-
cial to identifying the underlying pathologic
abnormality and help direct management.
The diagnosis of a major dislocation or
comminuted fracture can usually be made
by the referring clinician, whether an emer-
gency medicine physician or an orthopedic
surgeon. Radiologists play an important role
in the diagnosis of more subtle easily missed
injuries and in recommending the best im-
aging protocol for evaluating the patient. A
radiologist may suggest additional views that
reveal injuries not easily apparent on the con-
ventional radiographic study. Radiologists
more fully understand the limitations of ra-
diography for certain diagnoses and can best
indicate the need for more advanced imag-
ing, such as CT or MRI, to arrive at the cor-
rect diagnosis in an appropriate time frame.
There are various reasons for a “miss” or
error when interpreting radiographs. The
most obvious reason is when the radiolo-
gist overlooks the finding, which is present
on the study, during the initial review. This
miss could be secondary to a number of dif-
ferent causes, such as an error of speed, er-
ror in search technique, satisfaction of search,
or error due to multitasking. Another reason
may be that your eyes “played a trick on you,”
and frankly you did everything correctly ex-
cept make the important finding. These types
of errors can be frustrating because on sec-
ond look, the diagnosis is rather obvious.
An analysis of these types of errors is be-
yond the scope of this review. Instead, we are
going to focus on the errors that can be mini-
mized by gaining a better understanding of
the underlying anatomy and pathophysio-
logy of the trauma, as well as the strengths
and weaknesses of radiographs, for a select
group of upper extremity injuries that can be
easily misinterpreted and result in long-term
complications for the patient.
Sternoclavicular Dislocation
Background
The sternoclavicular joint is a cartilage-
lined joint formed by incongruent articular
surfaces. Capsular and ligamentous struc-
tures, including the capsular, costoclavicu-
lar, and interclavicular ligaments, render the
sternoclavicular joint one of the most stable
joints in the body, with 1% of all dislocations
and 3% of all shoulder dislocations occurring
at this location [1–3]. Injuries to the sterno-
clavicular joint are a result of direct or indi-
rect forces usually occurring in the setting of
high-energy trauma (e.g., motor vehicle crash
or falls from a height) and contact sports (e.g.,
rugby, wresting, or football) [3]. The medial
aspect of the sternoclavicular joint is usual-
ly the target for injuries related to direct trau-
ma, whereas forces along the anterolateral or
anteromedial aspects of the shoulder can in-
directly disrupt the joint [3]. Because of the
propensity of this type of injury to occur in
high-energy trauma, sternoclavicular disloca-

AJR:203, September 2014 477


tions can be missed initially while the other
more apparent and possibly more serious inju-
ries are treated [4–6]. A careful evaluation of
the patient’s history and physical examination
findings may raise the possibility of a sterno-
clavicular joint disruption.
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Imaging
The initial imaging evaluation typically
consists of radiographs of the sternoclavicular
joints and sternum, both anteroposterior and
lateral views. A serendipity view, which is an
oblique view centered on the sternum and ori-
ented 40° of vertical that shows both sterno-
clavicular joints for comparison, should also
be included [7]. These images can be diffi-
cult to evaluate for several reasons, including
overlap of bones and soft tissues around the
joints and positioning, which may be limited
because of the patient’s condition.
High suspicion for injury in this location
should prompt further evaluation with CT,
the current imaging reference standard for
assessment of the sternoclavicular joints [6,
8]. CT allows a complete evaluation of the
sternoclavicular joints and any associated
injuries, including fractures and soft-tissue
injuries. CT is especially important when
there is concern for a posterior dislocation of
the medial clavicle head, a finding that can
be easily missed on radiographs, because it
can result in an emergent and possibly life-
threatening vascular injury [4, 6] (Fig. 1).
Long-Term Follow-Up and Complications
The predominant long-term complication
of a sternoclavicular dislocation is the de-
velopment of osteoarthrosis and associated
chronic pain [3]. The degenerative change
may also present as swelling over the sterno-
clavicular joint, which can be confused for a
soft-tissue or bone mass, resulting in an ad-
ditional workup [3].
Pearls
There are two keys to making a correct di-
agnosis of a sternoclavicular joint injury. First,
a high index of suspicion is necessary. Make
sure to evaluate the sternoclavicular joints in
any patient with a history of direct trauma to
the anterior neck and chest. Second, know
the limitations of radiographs for this diagno-
sis. The degree of overlap from the surround-
ing bones and soft tissues limits the ability to
evaluate these joints. If the history and physi-
cal examination findings fit, recommend a CT
of the sternoclavicular joints to make sure this
diagnosis is not missed.
478 AJR:203, September 2014
Gyftopoulos et al.
Posterior Shoulder Dislocation
Background
The glenohumeral joint provides the larg-
est range of motion of all the body’s large
joints, maintained by a coordinated interplay
of dynamic and static stabilizers [9, 10]. This
degree of mobility is mainly a function of the
discrepancy in sizes of the articular surfac-
es of the joint with the much larger humer-
al head articulating with the smaller glenoid,
similar to the relationship between a golf ball
and a tee. Failure of the stabilizing mecha-
nism will lead to shoulder instability.
Posterior shoulder dislocations are much
less common than anterior dislocations (1.1 vs
23.9 cases/100,000 population per year) but
are much more frequently misdiagnosed at ini-
tial presentation (up to 79% of the time) [11].
The most common cause for posterior shoulder
dislocation is high-energy trauma that results
in a force directed onto the shoulder placed in
a flexed, adducted, and internally rotated po-
sition [12–16]. Seizures are another common
cause (31% of the time) for posterior instabili-
ty, related to asymmetric sustained contraction
of the internal rotator muscles pulling the hu-
meral head posteriorly [11].
Imaging
The imaging evaluation should begin with
anteroposterior internal, anteroposterior exter-
nal, scapular Y, and axillary views of the in-
jured shoulder. The relationship between the
humeral head and glenoid is best evaluated on
the axillary and scapular Y views because the
humeral head is seen along the posterior mar-
gin of the glenoid, inferior to the acromion, in
the setting of a posterior dislocation (Fig. 2).
Evaluation of the glenohumeral joint align-
ment is more difficult on the anteroposterior
views because the humeral head may not look
displaced. Posterior dislocation can be sus-
pected when the humeral head appears to be
internally rotated on both anteroposterior in-
ternal and external rotation views, related to
the fixed position of the dislocated head.
The diagnosis can become more difficult
if the patient’s shoulder has relocated by the
time of presentation for imaging. A search
for osseous injuries related to posterior in-
stability can provide clues to the diagnosis.
The impaction fracture of the humeral head
is seen as a vertically oriented linear region
of sclerosis along the anterior half of the
humeral head, parallel to the anterior cor-
tex, and is referred to as the “trough line” or
“trough sign” [17] (Fig. 2A). The reciprocal
injury would be a fracture of the posterior
glenoid, known as a reverse bony Bankart.
This is best seen on the axillary view and
typically presents as a discrete osseous frag-
ment adjacent to the posterior glenoid. When
there is high suspicion for posterior disloca-
tion and negative radiographs, MRI is the
next imaging modality of choice given its
high diagnostic performance in the evalua-
tion of radiographically occult bone trauma
and associated capsulolabral injuries that
may require surgical repair [18, 19].
Long-Term Follow-Up and Complications
Delay in the diagnosis of posterior dis-
location can result in persistent pain, de-
creased function, and glenohumeral osteo-
arthrosis [14]. Osteonecrosis of the humeral
head has also been described in the setting of
posterior dislocation and fracture of the hu-
meral neck [20]. Unlike in the setting of an-
terior shoulder dislocation, recurrent posteri-
or dislocation is less common because of the
protracted positioning of the scapula, which
enhances the role of the posterior glenoid as
a barrier to instability [11, 21, 22].
Pearls
In any patient with shoulder trauma (es-
pecially with suspected instability), the re-
lationship between the humeral head and
glenoid is important to review. An axillary
view or transscapular Y view is mandatory to
evaluate the joint and rule out malalignment.
The presence of a sclerotic line (or lines)
parallel to the anterior humeral head cortex
is suggestive of an impaction fracture. This
finding should then lead to a careful evalua-
tion of the posterior glenoid rim for possible
fracture and to confirm the diagnosis of prior
posterior dislocation.
Scapular Fractures
Background
The scapula is a flat triangular bone that is
protected superficially and anteriorly by the
rib cage. In addition, the surrounding muscu-
lature, most notably the rotator cuff muscles,
serve as a protective layer, dissipating the
forces that may be directed toward the scap-
ula. For these reasons, fractures of the scap-
ula are rare injuries, accounting for less than
1% of all fractures and 5% of all shoulder
fractures [23, 24]. Scapular fractures are of-
ten the result of high-energy trauma, where
there is a direct force impacting the scapula
[23, 24]. Indirect forces, such as a humeral
head colliding with the glenoid, can also re-
sult in fractures. Finally, various avulsion in-
 Errors in Reading Upper Extremity Trauma Radiographs
juries can occur, including avulsions of the
coracoid process at the origin of the con-
joint tendon and of the acromion at the ori-
gin of the deltoid muscle [23, 24]. The most
common location for fracture is the scapu-
lar body or spine (50%), followed by the gle-
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noid neck (25%), glenoid articular surface
(10%), and coracoid process and acromion
(7% each) [23, 24].
Imaging
There is a tendency for these fractures to
be missed initially because the clinical focus
is on other more serious injuries that tend to
occur at the same time as the initial trauma
[23, 24]. The imaging evaluation should be-
gin with anteroposterior and lateral views
of the scapula and an axillary view of the
shoulder. Evaluation can be difficult because
of the complex scapular anatomy and osse-
ous and soft-tissue overlap. This is why the
radiologist should systematically review the
different parts of the scapula on each view,
including the coracoid process, glenoid, and
acromion, as well the three scapular articu-
lations (scapulothoracic, glenohumeral, and
acromioclavicular) for any incongruity (Fig.
3). If the radiographs fail to reveal a signif-
icant pathologic abnormality but there is a
persistent concern for a scapular fracture, CT
with 3D reconstructions should be consid-
ered as the next imaging tool [25]. CT will
best reveal the presence and extent of a frac-
ture and any associated injuries or impend-
ing complications to the surrounding mus-
cles and neurovascular structures [25].
Long-Term Follow-Up and Complications
Most scapular fractures are treated con-
servatively without surgery because the de-
gree of displacement, which can affect the
healing potential of a fracture, is usually
kept to a minimum by the adjacent muscu-
lature [24]. A good healing response with-
out significant impaired function is expected
usually within 6 weeks [24].
Pearls
The key to this diagnosis is to systemati-
cally review the different parts of the scapula
on each of the available radiographic views.
If suspicion persists despite negative radio-
graphs, CT with 3D reconstructions is in-
dicated for definitive evaluation. Although
most of these injuries are treated conserva-
tively, the diagnosis of a scapular fracture
may explain a person’s shoulder pain when
other causes have been ruled out or treated.
AJR:203, September 2014 479
Greater Tuberosity Fractures
Background
The greater tuberosity is the largest tuber-
cle found at the humeral head, with three fac-
ets (superior, middle, and inferior) serving as
the insertion sites for the supraspinatus, infra-
spinatus, and teres minor tendons. Fractures
of the greater tuberosity encompass 19% of
all humeral fractures [26]. Both its size and
its role as a tendon attachment site predispose
the greater tuberosity to injury, which typical-
ly occurs in one of two ways. The first mecha-
nism, direct impaction, occurs when a direct
blow results in impaction of the tuberosity
against the adjacent scapula [27, 28]. Depend-
ing on the direction of force and position of
the shoulder, the greater tuberosity can impact
the acromion, the superior glenoid, or, most
commonly, the anterior glenoid in the setting
of anterior shoulder instability. The second
mechanism is related to avulsion of the great-
er tuberosity in the setting of anterior shoulder
dislocation as the rotator cuff contracts in an
attempt to offset the displacement of the hu-
meral head [27, 28].
Imaging
The diagnosis of a greater tuberosity
fracture is difficult on the basis of clinical
grounds only. The imaging evaluation of the
patient with shoulder trauma typically con-
sists of anteroposterior internal and external
views, scapular Y, and axillary view of the in-
jured extremity. The anteroposterior external
view is of special interest and may provide
the best opportunity to diagnose a fracture,
especially when it is subtle [29] (Fig. 4). The
greater tuberosity is held in profile on this
view, which allows a clear depiction of its
cortex and any superior or lateral displace-
ment of the fracture fragments, an important
characteristic because of its treatment impli-
cations [29]. Similarly, the axillary view can
show lateral displacement of the fragments.
The axillary view along with the scapular Y
and anteroposterior internally rotated views
are also used to assess for associated inju-
ries, including glenohumeral dislocation and
glenoid fracture.
If further characterization of the greater
tuberosity fracture is needed for treatment
purposes (i.e., extent, comminution, and dis-
placement), a CT should be ordered [30, 31].
MRI is typically performed when the radio-
graphs are negative but there is high suspi-
cion for fracture, in cases with poor clinical
response, and when anterior glenohumeral in-
stability injuries are suspected. In these set-
tings, MRI can also be used to evaluate for
associated pathologic abnormalities involving
the rotator cuff, labrum, and glenoid, which
are not as well assessed on radiographs.
Pearls
Careful evaluation of the greater tuberos-
ity on anteroposterior external radiographs
is the key to this diagnosis, especially if the
fracture is not displaced or only minimally
displaced. The profile view of the tuberosity
will give the radiologist the best opportunity
to evaluate the tuberosity cortex and to ac-
curately assess the degree of displacement.
Radial Head Fractures
Background
The radial head plays an important role in
stabilization of the elbow and forearm [32].
It serves as an important stabilizer against
valgus-directed forces, especially when the
ulnar collateral ligament is insufficient or
torn [33]. The radiocapitellar joint serves
as an important stabilizer against axial or
compressive forces, both preventing proxi-
mal migration of the radius and maintain-
ing normal compressive load distribution at
the wrist along with the interosseous mem-
brane and triangular fibrocartilage complex
[34, 35]. The radial head also serves as a sec-
ond stabilizer against posterolateral directed
forces along with the lateral joint capsule and
ligaments (radial collateral and lateral ulnar
collateral ligaments) [32].
Radial head fractures are the most com-
mon fracture at the elbow, encompassing ap-
proximately one third of all the fractures that
occur at the elbow and 3% of fractures over-
all in the adult population [32, 36, 37]. Frac-
tures of the radial head typically occur in the
setting of a fall on an outstretched hand, oc-
curring in isolation or after elbow dislocation.
Imaging
The initial imaging evaluation typical-
ly includes anteroposterior, lateral, and
Greenspan views of the injured elbow.
The Greenspan view is a type of lateral
view taken with 45° angulation of the x-ray
beam toward the radial head [38]. This re-
sults in an isolated view of the radial head,
free of osseous overlap (i.e., coronoid proc-
ess). Nondisplaced fractures may not be ap-
parent on the initial radiographs, but sec-
ondary signs of a fracture can be seen. The
presence of a joint effusion in a patient with
recent trauma should make the radiologist
look at the images carefully for a fracture.

If one is not seen, then a “radiographically
occult” fracture should be considered and
the patient should be treated as such (Fig.
5). Follow-up radiographs obtained 7–10
days after this initial set of views may bet-
ter show the fracture because of the heal-
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ing-related changes (i.e., bone resorption at
the fracture site), which make the fracture
lines more obvious [39]. MRI could be con-
sidered for the patient with suspected radi-
al head fracture with negative radiographs,
given its proficiency in diagnosing radio-
graphically occult fractures [18]. CT can
also be used in the evaluation of the radi-
al head fracture, but usually when a frac-
ture is known and further characterization
is needed for treatment planning.
Long-Term Follow-Up and Complications
Nondisplaced or minimally displaced ra-
dial head fractures tend not to have asso-
ciated soft-tissue or bone injuries, whereas
more comminuted displaced fractures tend
to have associated injuries to the capsule,
surrounding ligaments (ulnar collateral lig-
ament and lateral collateral ligament), and
surrounding bones (capitellum and coro-
noid process fractures) [40]. To maintain
the stabilizing forces provided by the ra-
dial head, surgical management is consid-
ered when fragment displacement is greater
than 2 mm and in the presence of commi-
nution and decreased range of motion [32,
35, 41]. Repair of associated capsuloliga-
mentous and bone injuries should also be
considered at the same time as the radial
head treatment to decrease the risk of insta-
bility and prevent the long-term complica-
tions of chronic pain, decreased function,
and osteoarthrosis [35].
Pearls
The use of a Greenspan view to evaluate
the radial head is helpful, revealing frac-
tures that may not be apparent on the other
views. The presence of a joint effusion in
the patient with recent trauma is an impor-
tant red flag for fracture when no cortical
disruption or impaction is present. In this
scenario, the patient should be considered
as having a “radiographically occult frac-
ture” and should be asked to get additional
views in 7–10 days’ time when the diagno-
sis of a fracture should be more definitive.
Care should be taken in the patient without
trauma, because the effusion may be related
to a synovially based process, such as rheu-
matoid arthritis.
480 AJR:203, September 2014
Gyftopoulos et al.
Coronoid Process Fractures
Background
The coronoid process forms the anteri-
or half of the greater sigmoid notch of the
ulna, articulating with the humeral trochlea.
The process is often subdivided into differ-
ent segments, including the tip, anteromedial
facet (which includes the sublime tubercle),
and anterolateral facet. The coronoid proc-
ess plays an important role in elbow stabil-
ity, serving as one of the primary restraints
against varus-directed forces and, along with
the radius, valgus-directed forces. A coro-
noid process fracture can occur in low-ener-
gy trauma, such as a fall on an outstretched
hand, or in high-energy trauma. The location
of the fracture fragment can provide impor-
tant information on the underlying mecha-
nism of injury and prognosis [42, 43].
A fracture of the coronoid tip is typically
secondary to posterolateral rotatory instabil-
ity, which results in shearing of the tip from
abnormal contact between the coronoid and
trochlea related to tearing of the lateral cap-
sule [42]. The “terrible triad” is when the tip
fracture is found in the setting an elbow dis-
location, with a fracture of the radial head
[42]. This is a constellation of findings that
invariably needs surgical stabilization and
has been consistently associated with poor
outcomes [44]. A fracture of the anterome-
dial process is typically seen in the setting of
posteromedial elbow instability and results
from abnormal contact between the medial
trochlea and anteromedial facet as the olec-
ranon is subluxed or dislocated posteriorly
[45]. In this clinical setting (as opposed to the
posterolateral instability), a radial head frac-
ture and tearing of the medial capsule are un-
likely and a different type of surgical fixation
is necessary to maintain stability [45].
Imaging
The initial imaging evaluation should
consist of anteroposterior and lateral views
of the elbow (and a Greenspan view if there
is suspicion for an associated radial head
fracture). A fracture of the coronoid process
can be easily missed on radiographs. Over-
lap on the anteroposterior and lateral views
limits visualization of the coronoid process,
making it difficult to diagnose a fracture,
especially when it is nondisplaced (Fig. 6).
A fracture of the process may also be mis-
interpreted as a radial head fracture on the
lateral view because of their close proxim-
ity. If there is suspicion for a coronoid pro-
cess fracture or if there is a need to better
characterize the location or type of frac-
ture, CT is the next best imaging modality
to recommend. CT will show the extent of
the fracture, displacement of the fragments,
and intraarticular bodies. MRI is also ex-
cellent for radiographically occult fractures
and to evaluate associated injuries of the
capsuloligamentous structures (Fig. 6).
Pearls
It is important to carefully evaluate the
coronoid process on the lateral view, espe-
cially if there is evidence of a radial head
fracture, because of the surgical implica-
tions. A cortical disruption or deficiency is
likely posttraumatic in nature. An under-
standing of the size and location of the frac-
ture is also helpful in terms of defining the
underlying mechanism of injury and possible
associated soft-tissue and osseous injuries.
Galeazzi and Monteggia Fracture-
Dislocations
Background
The radius and ulna form the osseous
components of the forearm with articula-
tions proximally at the elbow and distally at
the wrist. The main stabilizer of the proxi-
mal joint is the annular ligament, a compo-
nent of the lateral collateral ligament com-
plex, with a contribution from the quadrate
ligament. The triangular fibrocartilage com-
plex stabilizes the distal joint. The remainder
of the radius and ulna are stabilized by the
interosseous membrane.
Galeazzi and Monteggia fracture-dis-
locations describe distinct injuries to the
bones and joints of the forearm. The Gale-
azzi fracture extends through the junction of
the middle and distal thirds of the distal ra-
dius with disruption of the distal radioulnar
joint [46] (Fig. 7). The Monteggia fracture
propagates across the proximal third of the
ulna with dislocation of the radiocapitellar
joint [47] (Fig. 8). Although the fractures are
usually easily diagnosed on radiographs, the
joint dislocations may be missed initially, af-
fecting patient outcome and treatment [48].
Fracture-dislocations of the forearm typical-
ly occur with an axial load, such as a fall on
an outstretched hand. In the setting of a Ga-
leazzi fracture, the force is strong enough to
fracture the distal radius and tear the interos-
seous membrane at the same time. In the set-
ting of a Monteggia fracture, the force frac-
tures the proximal ulna and tears the annular
and quadrate ligaments, which results in dis-
location of the radial head.
 Errors in Reading Upper Extremity Trauma Radiographs
Imaging
The initial radiographic assessment of
these patients should include evaluation of
the elbow, forearm, and wrist. Anteroposte-
rior and lateral radiographs of the forearm
should show the location and extent of the
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fracture. The elbow study, usually consist-
ing of anteroposterior, lateral, and oblique
views, will show the alignment of the joints
and any intraarticular injuries. The wrist ra-
diographs, consisting of posteroanterior,
oblique, and lateral views, show the align-
ment and any carpal injuries. The location
of the fracture on the forearm radiographs
should direct the reader to the most impor-
tant joint to evaluate next. A fracture within
the distal radius should bring the reader’s at-
tention toward the alignment of the distal ra-
dioulnar joint. Findings that would suggest a
joint disruption include widening of the dis-
tal radioulnar joint space with lack of over-
lap of the ulnar head over the distal radius
on the posteroanterior view, dislocation of
the ulnar head relative to the radius on the
lateral view, and shortening of the distal ra-
dius by more than 5 mm. Comparative wrist
views can be helpful to assess for asymme-
try. A fracture of the proximal ulna should
direct the reader’s attention to the radiocapi-
tellar joint alignment. A line drawn through
the center of the proximal radius should in-
tersect the capitellum on all the views, giv-
en any degree of flexion or extension. Cross-
sectional imaging is not typically needed in
either of these settings because most treat-
ment-related information is derived from the
radiographs only.
Long-Term Follow-Up and Complications
A delayed or missed diagnosis of a Ga-
leazzi fracture can lead to progressive sub-
luxation of the distal radioulnar joint, pain,
limited range of motion, and eventual osteo-
arthritis [49–51]. Persistent radiocapitellar
dislocation can result in chronic valgus in-
stability, because of the loss of the stabiliz-
ing force provided by the radial head, and in
radiocapitellar osteoarthrosis [52, 53]. If the
radial head remains anteriorly dislocated, it
can also result in radial neuropathy second-
ary to nerve impingement [53].
Pearls
Close attention to the location of a radial
or ulnar fracture is important because it will
guide the reader in terms of what to look for
next on the present radiographs and to deter-
mine whether additional imaging is necessary.
AJR:203, September 2014 481
Distal radial fractures require careful evalua-
tion of the distal radioulnar joint, whereas the
radiocapitellar joint should be carefully as-
sessed in proximal ulnar fractures.
Scaphoid Fracture
Background
The scaphoid plays an important role in sta-
bility of the carpus. Named after the Greek
word for “boat” because of its oblong shape,
the scaphoid’s complex anatomy can be di-
vided into different segments, including the
proximal pole, scaphoid waist, dorsal ridge,
and distal tubercle. The scaphoid is unique in
that most of its surface is covered by articular
cartilage, which limits the entry points for nu-
trient vessels to the nonarticular dorsal ridge
and the distal end of the scaphoid [54].
The scaphoid is the most commonly frac-
tured bone in the wrist [55]. This fracture is
typically seen in younger active patients and
results from a combination of axial and hy-
perextension forces on the wrist. The loca-
tion of the fracture and degree of displace-
ment play a major role in patient treatment
and outcome. The more proximal the frac-
ture location within the scaphoid, and the
more displacement present at the fracture
site, the higher the risk for poor healing in
the form of malunion and nonunion [55, 56].
This poor healing potential is related to dis-
ruption of the tenuous blood supply to the
proximal portion of the bone and the devel-
opment of osteonecrosis [55, 56].
Imaging
The initial imaging evaluation consists of
posteroanterior, oblique, and lateral views
and a posteroanterior ulnar deviated view
with 45° of extension (i.e., the “scaphoid
view”). The scaphoid’s curved shape and
palmar inclination can make its radiograph-
ic evaluation difficult, especially the eval-
uation of the distal tubercle and waist seg-
ments. These portions of the bone are best
seen on the oblique view. The scaphoid view
can also improve visualization of these seg-
ments, because the extended ulnar deviated
position elongates the scaphoid and reduces
the bone’s natural flexed position, limiting
osseous overlap (Fig. 9).
Nondisplaced fractures of the scaphoid
can be particularly challenging. The frac-
ture line and breaks in the cortexes may be
subtle or absent on the initial radiographs.
Even when a diagnosis of a fracture is made,
the degree of displacement may not be ac-
curately characterized on the radiographs.
CT has been advocated by some authors for
the evaluation of scaphoid fractures because
it provides a better representation of the ex-
act location of the fracture and the degree of
displacement of the fracture fragments. MRI
can also be used to show radiographically
occult fractures and associated injuries. In
a recent study, the use of early MRI in pa-
tients with suspected scaphoid fracture with
negative radiographs also proved to be cost
effective, reducing the patients’ immobiliza-
tion time, sick leave, and nonhospital costs
when compared with an algorithm consisting
of only radiographic follow-up [57].
Long-Term Follow-Up and Complications
Prompt treatment is crucial, with the onus
on the clinician or radiologist to make the
correct diagnosis. A delayed or missed diag-
nosis of a scaphoid fracture will prevent the
initiation of proper therapy, which usually
consists of surgical fixation [58]. This delay
increases the likelihood of a poor outcome,
including persistent pain and limited mobil-
ity related to malunion, nonunion, or osteo-
necrosis with subsequent development of ra-
diocarpal and intercarpal osteoarthritis [59].
Pearls
It is important to evaluate the scaphoid on
all radiographic views. An additional scaph-
oid view is indicated if the level of suspicion
is high but the initial radiographs are nega-
tive. For patients with negative radiographs
but a high index of suspicion, follow-up ra-
diographs in 7–10 days are recommended,
because the fracture line would be made
more obvious secondary to the healing re-
sponse. Because of the repercussions of a
missed fracture, the use of MRI should be
strongly considered if a radiographically oc-
cult scaphoid fracture is suspected.
Scapholunate Instability
Background
The primary stabilizer of the scapholunate
joint is the scapholunate ligament, which has
three components—dorsal, volar, and mem-
branous. The dorsal component is the stron-
gest and most important component in terms
of providing stability to the joint, whereas
the volar component contributes to rotational
stability [60]. The membranous component
has a minimal contribution to stability [60].
The secondary stabilizers of the scapholu-
nate joint are the extrinsic ligaments found
along the volar and dorsal aspects of the joint
[60]. The radioscaphocapitate, long radiolu-

nate (radiolunotriquetral), and short radio-
lunate ligaments are found along the volar
margin, whereas the dorsal radiotriquetral
and intercarpal (scaphotriquetral) ligaments
are found over the dorsum. These extrinsic
ligaments play an important role in main-
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taining normal scapholunate kinematics.
Scapholunate instability is defined as an
injury to the stabilizing forces of the scaph-
olunate joint that contributes to a wrist that
is symptomatic, has difficulty bearing loads,
and shows abnormal kinematics during at
least a portion of its normal motion [61]. A
patient’s clinical history, physical examina-
tion results, and imaging findings all contrib-
ute to this diagnosis.
The scapholunate ligament is most com-
monly injured in the setting of a fall on an out-
stretched hand with most of the force centered
onto the thenar region [62]. Imaging plays an
important complementary role to physical ex-
amination in the diagnosis of acute, subacute,
and chronic scapholunate ligament injury.
Imaging
Radiographic evaluation is the primary im-
aging tool in all three clinical scenarios and
should include posteroanterior, oblique, later-
al, and navicular views and, in some instanc-
es, the contralateral wrist for comparison
[62]. These “static” views allow the evalua-
tion of fractures and alignment abnormalities.
The radiographic findings will depend on
the degree and the chronicity of the injury.
With an isolated partial or complete tear of
the scapholunate ligament, static radiographs
may appear normal because of the stabiliza-
tion provided by the extrinsic ligaments [60].
In this setting, the history and physical exam-
ination findings are crucial to the correct di-
agnosis and patient management. If there is a
high suspicion of scapholunate ligament in-
jury, “stress” (dynamic) views should be per-
formed. The most common stress view is the
clenched fist frontal view, which allows imag-
ing of the wrist in a frontal position with su-
perimposed axial loading. This loading pro-
vides additional stress on the joint, which is
thought to make it more likely to reveal scaph-
olunate diastasis, defined as widening of the
scapholunate interval by greater than 4 mm
width at the central portion of the joint or
twice as wide an interval as compared with
other intercarpal joints, in particular the capi-
tolunate joint [63] (Fig. 10). The pencil grip
posteroanterior view is another stress radio-
graph that can reveal an occult injury. This
view places both wrists in pronation, adds ax-
482 AJR:203, September 2014
Gyftopoulos et al.
ial loading from the grip, and provides a com-
parison with the contralateral wrist. Diastasis
of the joint on the stress views with negative
static views is a common imaging presenta-
tion in the subacute setting [64].
The progressive tearing of the extrinsic lig-
aments along with the scapholunate ligament
will result in changes in alignment on the stat-
ic radiographs, including diastasis, rotatory
subluxation, and the “signet ring” sign, re-
sulting from the overlap of the distal scaphoid
pole cortical outline and the scaphoid waist
secondary to flexion (i.e., rotary subluxation)
and foreshortening of the scaphoid.
Malalignment of the scaphoid and lunate
can be assessed on the lateral view by mea-
suring the scapholunate angle (Fig. 11). This
angle, formed by drawing a line along the vo-
lar margin of the scaphoid and a perpendicu-
lar line to the volar and dorsal distal margins
of the lunate, normally measures between
30° and 60°. An increased angle is sugges-
tive of abnormal alignment and ligamentous
injury. Evidence of widening on the static
and dynamic imaging and rotary subluxation
of the scaphoid are suggestive of injury to the
extrinsic ligaments in addition to the scaph-
olunate ligament, a common presentation in
the chronic setting [65, 66]. With time, more
extensive tearing and degenerative change of
the primary and secondary stabilizers result
in a global disorder in the carpus, which is
termed “dorsal intercalated segment insta-
bility” and is characterized by proximal and
dorsal subluxation of the distal carpal row
and extension and palmar translation of the
lunate [63].
MRI plays a confirmatory role in the work-
up for patients with suspected scapholunate
ligament injury. MRI reveals the compo-
nents of the scapholunate ligament and the
extrinsic ligaments and can provide a more
detailed assessment of the extent of injury.
Associated pathologic abnormalities involv-
ing the surrounding bones and articular sur-
faces can also be seen. MR arthrography has
also been shown to be an effective diagnostic
tool, in some cases better than unenhanced
MRI, for the evaluation of the scapholunate
ligament, combining the mechanical advan-
tages of arthrography with the detail pro-
vided by MRI [67, 68]. At this point, MRI
cannot provide functional information. Ul-
trasound has also been shown to be an ac-
curate tool in the evaluation of the scapholu-
nate ligament, with several studies showing
its ability to visualize the ligament and to di-
agnose pathologic abnormalities [69, 70].
Long-Term Follow-Up and Complications
A chronically unstable scaphoid can eventu-
ally result in scapholunate advanced collapse
[71]. This is a progressive degenerative proc-
ess that begins at the articulation of the radi-
al styloid with the scaphoid. The degenerative
changes progress to involve the radioscaphoid,
lunatocapitate, and scaphotrapezius joints.
Pearls
Dynamic radiographic evaluation can be
crucial for the diagnosis of scapholunate in-
stability, especially in differentiating be-
tween intrinsic and extrinsic ligament injury
and estimating the stage of injury.
Perilunate Dislocation
Background
The lunate is the carpal keystone, serving
as the center of a network of ligaments and ar-
ticulations that stabilize the proximal and dis-
tal carpal rows. “Perilunate dislocation” is a
term that describes a continuum of carpal in-
stability related to injury to the ligaments sur-
rounding the lunate, which result in disloca-
tion of some or all of the surrounding carpal
bones. Perilunate, or “lesser arc,” disruption
or dislocation typically occurs in the setting of
a high-energy trauma that results in 3D load-
ing: hyperextension, intercarpal supination,
and ulnar deviation [72, 73]. The resulting
ligament trauma will be dependent on the de-
gree of load, the dominant component of the
3D injury, and the mechanical properties of
the ligaments [72, 73]. The rate of undetected
perilunate dislocation is high, with up to 25%
missed on initial evaluation [74].
Perilunate injuries typically progress in a
stepwise manner from the radial to the ul-
nar aspects of the lunate [73]. In stage I, the
injury is found along the radial aspect of the
wrist with tearing of the scapholunate liga-
ment resulting in scapholunate dissociation.
In stage II, an increased load will progress
to involve the volar radioscaphocapitate lig-
ament with resulting dorsal dislocation of
the capitate and widening of the space of
Poirier, known as perilunate dislocation.
In stage III, continued loading of the wrist
with a degree of intercarpal supination will
lead to tearing of the long radiolunate liga-
ment and disruption of the triquetrolunate
joint, known as midcarpal dislocation. In
stage IV, a persistent maximum force will
lead to disruption of the dorsal radiotrique-
tral ligament and rotation and palmer dislo-
cation of the lunate from the rest of the car-
pus, known as lunate dislocation.
 Errors in Reading Upper Extremity Trauma Radiographs
Imaging
Routine posteroanterior and lateral ra-
diographs typically are all that is needed
to make the correct diagnosis. The radio-
graphic appearance of stage I is identical
to the appearance of scapholunate disso-
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ciation. In stage II, there is disruption of
the arcs of Gilula along the lunate margins
on the posteroanterior view. Asymmetric
widening of the surrounding joint spaces
can also be seen, in the capitolunate joint
space in particular. The lunate maintains
its alignment with the radius in the lateral
view, but there is dorsal displacement of the
capitate (Fig. 12). In stage III, the lunate is
completely separated from the remainder
of the carpus. Thus, its position can vary.
On the posteroanterior view, the findings
are similar to those seen in stage II with arc
disruption and asymmetric joint gapping.
However, on the lateral view, the lunate is
tilted and possibly partially subluxed volar-
ly, whereas the capitate is dorsally dislocat-
ed but not to the same degree as in stage
II. In stage IV, the lunate may have a trian-
gular or “pie-shaped” appearance (this can
also be seen in earlier stages, but less often)
on the posteroanterior view with surround-
ing arc disruption and joint gapping. On the
lateral view, the lunate is dislocated volarly,
and the capitate is aligned with the radius.
Long-Term Follow-Up and Complications
Given the severity of injury that occurs
in perilunate dislocation, prompt diagno-
sis and treatment are important to improve
a patient’s outcome [75]. Delays in diagnosis
and appropriate management almost invari-
ably will result in decreased range of motion
and grip strength loss and in the development
of posttraumatic osteoarthrosis involving the
radiocarpal and midcarpal joints [76–79].
Pearls
Familiarity with the normal alignment of
the carpal bones, specifically the arcs of Gi-
lula on the posteroanterior and oblique views
and the radius-lunate-capitate articulation on
the lateral view, is crucial to the diagnosis of
perilunate dislocation.
Hook of Hamate Fracture
Background
The hook of the hamate is a volar excres-
cence extending from the distal hamate. It
serves as an attachment site for several liga-
ments (including the pisohamate and trans-
carpal ligaments) and tendons (flexor digit
AJR:203, September 2014 483
minimi and opponens digiti minimi). Partic-
ipants in racket and club sports, such as golf,
tennis, and baseball, are a population at risk
for this type of injury [80, 81].
A fractured hook of the hamate occurs af-
ter direct impact or avulsion at the transcar-
pal ligament insertion [81, 82]. This can be
a difficult diagnosis to make clinically given
the nonspecific symptoms, including chron-
ic pain along the volar or ulnar aspect of the
wrist, especially during a tight grip. Physical
examination may elicit pain with palpation
over the hook.
Imaging
Imaging plays a crucial role in this sce-
nario, typically beginning with postero-
anterior, oblique, and lateral views of the
wrist. The hook may be difficult to visual-
ize on these views because of the overlap by
the surrounding bones. The carpal tunnel
view, a specialized 20° supine oblique view,
may aid in the diagnosis because it isolates
the hook from the remainder of the carpus
(Fig. 13). If there is persistent suspicion for
a fracture in this location and negative ra-
diographs, CT should be the next imaging
modality selected because it should reveal
the fracture and any associated displace-
ment (Fig. 12). MRI could also be consid-
ered, especially if there is concern for as-
sociated ligamentous, tendinous, or ulnar
nerve injuries.
Long-Term Follow-Up and Complications
For the athlete, whether professional or
recreational, an undiagnosed fracture of the
hook of the hamate can result in persistent
pain and chronic disability at the wrist [81].
This can, in turn, lead to more time away
from the sport and in decreased performance
on returning [83].
Pearls
A high index of suspicion is key to mak-
ing the diagnosis of a fracture of the hook
of the hamate. An awareness of the limita-
tions of the typical wrist radiographic views
in evaluating the hamate is also important.
When there is high suspicion for fracture, but
negative radiographs, there are two options:
a carpal tunnel projection to help make the
diagnosis or proceed directly to CT.
Conclusion
Radiographs play an indispensable role in
the evaluation of patients with upper extrem-
ity trauma, especially for certain difficult di-
agnoses. The awareness of the specific inju-
ries presented here and an understanding of
their underlying pathophysiology will give
the reader the best opportunity to make the
important imaging findings and guide appro-
priate treatment.
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perilunate injury: 3 case reports with introduction
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B
Fig. 1—19-year-old man after motor vehicle crash.
A, Portable anteroposterior radiograph of clavicles shows asymmetric widening of right sternoclavicular joint
with inferior displacement of medial aspect of right clavicle (arrow). CT was recommended for further evaluation.
B, Axial image from CT of chest with IV contrast agent shows posterior displacement of right clavicle that nears
but does not contact brachiocephalic artery (arrow).

AJR:203, September 2014 485

 Gyftopoulos et al.

Fig. 2—63-year-old man with shoulder pain after fall.

A, Anteroposterior internal rotation radiograph of
shoulder shows “trough sign,” vertically oriented
linear area of sclerosis parallel to anterior cortex
(arrows), representing impaction fracture of
anterior humeral head. Glenohumeral joint appears
maintained.
B, Axillary radiograph of shoulder shows posterior
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dislocation of humeral head with impacted humeral

head engaged along posterior glenoid margin (curved
arrow). Major strength of axillary view is to provide
better assessment of glenohumeral joint and any
alignment abnormalities.

A B

A B C

Fig. 3—76-year-old woman with shoulder pain after

fall and dislocation.
A–C, Anteroposterior (A), scapular Y (B), and
axillary (C) radiographs of left shoulder show
evidence of prior anterior shoulder dislocation with
moderate-sized Hill-Sachs impaction deformity along
posterosuperior aspect of humeral head (arrow, C).
There is minimal cortical irregularity along coracoid
process on scapular Y view (arrow, B), which is
obscured by overlapping ribs and is not confirmed on
other two views.
D and E, Axial (D) and sagittal (E) images of left
shoulder from CT scan done on same day show
nondisplaced fracture of coracoid process (arrows).
D E

486 AJR:203, September 2014

 Errors in Reading Upper Extremity Trauma Radiographs

Fig. 4—39-year-old man after fall backward down

flight of stairs.
A, Anteroposterior external rotation view of shoulder
shows linear lucency involving greater tuberosity
(arrow), representing nondisplaced fracture.
B, Coronal CT image confirms presence of
nondisplaced greater tuberosity fracture (arrow).
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A B

A B

Fig. 5—36-year-old man with elbow pain after

snowboarding injury 3 weeks prior.
A and B, Anteroposterior (A) and lateral (B) views
of left elbow show faint linear lucency extending
through anterolateral margin of radial articular
surface (black arrows, A and B) and large joint
effusion (gray arrows, B).
C and D, Lucency is more apparent on Greenspan
view (arrow, C) and is suggestive of mildly
impacted fracture, which is confirmed on sagittal
fat-suppressed T1-weighted image (D) from MR
arthrogram performed day after radiographs
(curved arrow).
C D

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 Gyftopoulos et al.
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A B C
Fig. 6—63-year-old woman with history of recent fall.
A and B, Anteroposterior (A) and lateral (B) radiographs of left elbow show large joint effusion (gray arrows, B) and nondisplaced fracture through anteromedial facet of
coronoid process (black arrows, A and B).
C, Coronal fat-suppressed T2-weighted image shows nondisplaced coronoid fracture (straight black arrow) and tears of lateral capsule (white arrow) and common
extensor tendon (curved black arrow). This constellation of findings is consistent with recent episode of posteromedial elbow instability.

A B C
Fig. 7—65-year-old woman after fall.
A–C, Posteroanterior (A), oblique (B), and lateral (C) views of left wrist show mildly displaced fracture through distal third of radius (gray arrows, A–C) and nondisplaced
fracture of ulnar styloid (white arrow, A). Careful inspection of these views also shows offset of distal radioulnar joint (straight black arrows, A and B) with dorsal
displacement of distal ulna (curved arrow, C), consistent with Galeazzi fracture-dislocation.

488 AJR:203, September 2014

 Errors in Reading Upper Extremity Trauma Radiographs

Fig. 8—9-year-old boy after fall.

A and B, Anteroposterior (A) and lateral (B) views of
right forearm show nondisplaced fracture through
proximal third of ulna (black arrows). Proximal radius
(white lines) does not align with capitellum (white
arrows) on either view, consistent with dislocation
and Monteggia injury.
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A B

A B

Fig. 9—19-year-old female volleyball player with

chronic wrist pain after fall.
A and B, Posteroanterior (A) and oblique (B) views of
left wrist show focal region of lucency surrounded
by sclerosis along medial portion of scaphoid waist
(arrows). MRI was recommended to evaluate scaphoid.
C and D, Coronal T1-weighted (C) and fat-suppressed
T2-weighted (D) images show nondisplaced complete
fracture through scaphoid waist (arrows).
C D

AJR:203, September 2014 489

 Fig. 10—31-year-old man after fall with radial-sided
Gyftopoulos et al. wrist pain.
A, Posteroanterior view of right wrist shows no
fracture or abnormal alignment. Specifically,
scapholunate internal (arrow) is maintained without
offset or disproportionate widening.
B, On pencil grip view, there is diastasis of
scapholunate interval with gap measuring greater
than 4 mm (arrow). Presence of widening on
dynamic view that was not present on static view is
suggestive of injury to scapholunate ligament and not
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surrounding extrinsic ligaments.

A B

A B
Fig. 11—24-year-old man with scapholunate dissociation after injury during karate practice.
A, Posteroanterior “pencil grip” radiograph of bilateral wrists shows severe widening of left scapholunate interval, indicating scapholunate
diastasis (white arrow). Right scapholunate interval (black arrow) is normal.
B, Lateral view of left wrist shows scapholunate malalignment with increased dorsal tilt of lunate and volar tilt of scaphoid. Scapholunate
angle (lines) is greater than 60°, in keeping with ligamentous injury and rotatory subluxation of scaphoid.

Fig. 12—21-year-old man with wrist pain after fall.

A, Posteroanterior radiograph of wrist shows
disruption of second carpal arc (arrow) and triangular
configuration of lunate (dotted line).
B, Lateral radiograph shows volar displacement and
tilting of lunate (arrow), whereas capitate remains
aligned with radius consistent with lunate dislocation.
A B

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 Errors in Reading Upper Extremity Trauma Radiographs
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Fig. 13—23-year-old man with hook of hamate

fracture after fall on sidewalk.
A, Posteroanterior radiograph of wrist shows
maintenance of osseous alignment. Hook of hamate
(arrow) is seen without definitive evidence for fracture.
B, Carpal tunnel view shows subtle cortical step-off
at lateral margin of base of hook of hamate (arrow),
representing nondisplaced fracture.
C, Axial CT image confirms nondisplaced fracture at
base of hook of hamate (arrow).
C

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