Wrist Measurements

Introduction

When examining wrist plain film images it is useful to have an

understanding of the normal alignment of the wrist. This page
considers the normal wrist measurements and how they are utilised.

Radiography

Comment

These descriptions are from radiology-based texts rather than

radiography texts. The radiography technique textbooks do not
consider the position of the forearm/elbow when describing wrist
positioning. The positions as described above are akin to 'mixed
forearm' views which are performed when patients have limited
movement in their arm (usually from pain) or when the patient has
an above elbow cast. The wrist positioning approach described above
will tend to produce two views of the anatomy at 90 degrees because
the relationship between the radius and ulna does not change- the
90 degree movement occurs largely at the shoulder.

These are PA and lateral wrist

images. Note that the position
of the ulna in both images
appears identical despite that
fact that one is in a PA wrist
position and the other is a
lateral wrist position. It is
likely that the patient's wrist
was moved from PA to lateral
without any movement of the
 elbow. The radius has rolled
around the ulna at the DRUJ
without the ulna moving.
Observe the profile of the
ulnar styloid.

source : unknown
Source: unknown
It seems counter-intuitive to suggest
that when you pronate and supinate
your hand, the distal ulna does not
follow the movement of the radius
and also rotate through 180 degrees.
In fact the distal ulna moves very
little during pronation/supination of
the wrist. The ulna translates through
an arc of a cricle but does not rotate.
If you have any doubts, pronate and
supinate your hand and think about
what is happening to your ulna at the
elbow joint- if your ulna is not
rotating at the elbow, how could it be
rotating at the wri
adapted from
Raoul Tubiana, Jean-Michel
Thomine, Evelyn Mackin
Examination of the Hand and Wrist.
Edition: 2, 1998
The radius undergoes a rotation of
almost 180 degrees from full
pronation to supination. During this
movement of the radius, the ulna
translates through a short arc of a
circle.
The rounded head of the ulna
articulate with the ulnar notch on the
medial distal radius. A
fibrocartilagenous articular disc
binds the ends of the radius and ulna.
The base of the disc attaches to the
medial edge of the ulnar notch and
the apex of the disc is attached to the
lateral side of the base of the ulnar
styloid process. The disc separates
the cavity of the distal radioulnar
joint from the cavity of the wrist
joint.
adapted from
Raoul Tubiana, Jean-Michel
Thomine, Evelyn Mackin
Examination of the Hand and Wrist.
Edition: 2, 1998
This video shows the movement of
the distal radius and ulna during the
movement of the wrist from PA to
lateral. If you watch the ulna (and
ulnar styloid), there is no rotation
movement.
AP/PA

There is a difference between a PA and AP wrist image. The

difference is all about the divergence of the X-ray beam. The image
below is taken from an axial CT scan of the wrist. Note that the
orientation of the carpal bones is radial- they are directed towards a
point that is on the volar aspect of the wrist. An AP view of the wrist
(as represented below) will tend to benefit from this orientation of
the carpal bones by profiling the carpal bones, whereas, in a PA
projection, the divergent X-ray beam will work against the radial
layout of the carpal bones. The AP projection will tend to be better at
demonstrating parallelism of the carpal bones.

Note that this effect is limited. The divergence of the X-ray beam at
115cm is vastly different to the radial-like orientation of the carpal
bones as displayed below. An AP projection of the wrist with a short
FFD may be of some benefit if carpal alignment/parallelism is of
particular interest.

A further technique modification that can be employed to advantage

is to flex the patient's fingers to cause the carpus to come into closer
contact with the cassette/IR.
 Wheeless notes the following

Wheeless' Textbook of Orthopaedics,

Posterior Anterior View of the Wrist.
http://www.wheelessonline.com/ortho/posterior_anterior_view_of_the_wrist

PA Wrist AP Wrist

This is a PA wrist image. Note the
visualisation of the carpal joints,
particularly the distal row
Lateral
The is an AP view of the same wrist
is AP projection. Note the improved
visualisation of the intercarpal
joints. This is somewhat of an
unfair comparison given that the AP
projection is with a clenched fist.
Note the appearance of the ulnar
styloid compared to the PA
projection image.
Terry Thomas sign noted.
 A neutral lateral projection of the wrist may be obtained with the
arm adducted to the body wall, the elbow flexed 90degrees, the wrist
held with no ulnar or radial deviation and no palmar flexion or
dorsiflexion.

This patient has a scapholunate angle

This is a normal wrist with a
scapholunate angle of 48.4 degrees
(Normal scapholunate angle is 30 -
60°)
of 79 degrees which is likely to be
abnormal. The difficulty with this
finding is that the wrist is not lateral
which will cause the scapholunate
angle to be over or under estimated.

Wrist/Hand/Forearm
You can't expect to achieve good diagnostic standards with the
wrong images. The following is a quote from John Harris on the
subject.

"Anatomically and radiographically,

the forearm is not the wrist and the
wrist is not the hand. Therefore, it is
important for attending physicians to
indicate precisely the anatomical part
to be examined radiographically.
Specifically, the attending physician
must define, on the basis of history
and physical examination, whether
the forearm, wrist, or hand, is to be
examined, since the routine views of
one of these anatomic areas is of
limited practical value with respect to
the others. In spite of this
admonition, it is important to
remember that injuries of the distal
forearm may cause, or be associated
with, carpal injuries. Finally, contrary
to an often-repeated dictum, it is not
necessary to radiographically examine
both the wrist and the elbow in the
instance of a suspected radial or ulnar
shaft fracture in a patient who is alert,
responsive, and communicative and
on whom a proper physical
examination can be performed. In
patients who do not fulfil these
criteria, it is prudent to examine both
the wrist and the elbow."
John Harris, William Harris,
Robert Novelline.
The Radiology of Emergency
Medicine, Third edition.
Williams and Wilkins, 1993
These two images of a child's wrist
demonstrate that the ulna is in the
same position for both projections. If
there was a fracture of the ulna (in
addition to the fracture of the radius),
it could easily be missed because
there is only a single projection of the
ulna.

To permit pronation and supination,

the head of the ulna rotates in the
sigmoid notch of the radius. Giuseppe
Guglielmi, Cornelis Van Kuijk, Harry
K. Genant, Fundamentals of hand
and wrist imaging, 2001 If this was
not the case, the images to the left
would not be possible- that is, the
radius could not be imaged in two
views at 90 degrees without the ulna
similarly being imaged at right
angles.

Rotation in the distal radioulnar joint

(DRUJ) takes place around the ulna
as a fixed point around which the
radius rotates along with the hand.
Ulrich Lanz, Rainer Schmitt,
Wolfgang Buchberger, Diagnostic
Imaging of the Hand, 2008
This explains why you can rotate the
 wrist from a PA into a lateral position
without the ulna moving (see left). It
also explains why you shouldn't
execute this manoeuvre when
changing from a PA wrist
radiographic position to a lateral
wrist position- the change should
involve movement of the whole
forearm.

Anatomy

You tend to remember those things

that you regularly use. For example,
the vast majority of radiographers
will be able to identify the scaphoid
on a PA/AP wrist image.

There's nothing like a mnemonic for

remembering those things that you
don't use very often. One of the most
common and useful mnemonic types
is the acronym. It seems that the
easiest acronyms to remember are
the risqué ones and this one is no
exception. The carpal bones can be
thought of as two rows of 4 bones.
The memory aid acronym is as
follows

Some Lovers Try Positions That

They Can't Handle.

Read in number order.

A few other acronyms for the carpal

bones

•Sally Left The Party

To Take Cathy Home

•She Looks Too Pretty

Try To Catch Her

Some Ladies Try Painting

Their Nails Curious Hues

So Long to Pinky

Here Comes the Thumb (clever!)

"Another mnemonic, useful for

remembering the order of the
trapezium and trapezoid, is that
"trapezium" rhymes with "thumb"
and articulates with it."
Karen Nugent, PT, CHT and David
Nelson, M.D. RADIOLOGY OF THE
WRIST
If you are one of those wordsmiths
that like to know the
origins/derivations of words, you
may find the following helpful

Scaphoid

- Greek origins, boat shaped,

"skaphe" might be better
translated as "skiff".

Lunate

- lunar shaped (half moon) on

lateral image and trapezoidal
on PA

Triquetrum

- as the name suggests, it is

triangular

Pisiform

- pea shaped, the only carpal

sesamoid bone

Trapezium

- table shaped

Trapezoid

- same origins as trapezium-

table shaped

Capitate

- head (capit - head)

Hamate

- hooked. ( Latin hamatus

"hooked," from hamus which
means "hook.")

Karen Nugent, PT, CHT and

David Nelson, M.D.
 RADIOLOGY OF THE WRIST

Alignment and Measurement

Parallelism

All of the carpal bones

have approximately the
same thickness of
articular cartilage and
normally lie in
apposition to the
adjacent carpal bone. In
other words, normally
there is no space
between cartilage
surfaces of adjacent
carpal bones. It follows
that the joint spaces
seen on the PA view
should be
approximately the same
width.
RADIOLOGY OF THE
WRIST
Presented by Karen
Nugent, PT, CHT and
David Nelson, M.D. At
the 23rd Annual
Meeting of the
American Society of
Hand Therapists
5 October 2000

Normally the
intercarpal,
carpometacarpal and
(Note: Youtube videos radiocarpal joint spaces
are displayed at lower are 2mm wide or less.
resolution when 'hot- When a joint is > 4mm
linked'. Click on the wide it is usually
 bottom right corner of abnormal. Parallelism
the video and it will can only be applied to
open at full resolution.) the joints that are
demonstrated in profile.
(Gilula, L.A. and Totty
W.G. The Traumatised
Hand and Wrist,
Radiographic and
Anatomic Correlation,
1992, p221).

The MRI wrist

demonstrates that the
intercarpal distances
are approximately equal

Ulnar Variance syn. radioulnar index

Ulnar variance refers to the position of the

cortical margin of the distal ulna relative to that
of the distal radius. It gives insight into the degree
of axial loading transmitted to the lunate and may
therefore be helpful in determining the aetiology
of repetitive wrist trauma. Medscape General
Medicine, 1999, Imaging of the Wrist and Hand,
http://cme.medscape.com/viewarticle/408495_2

Ulnar variance is defined as neutral, positive

(plus), or negative (minus) on the basis of
whether the distal articular surface of the ulna is
aligned with the distal articular surface of the
radius on a neutral posteroanterior radiograph,
or lies distal (ulnar plus) or proximal (ulnar
minus) to the radius (4-6).

All patients with fractures of either of the forearm

bones require careful evaluation of both wrist and
elbow, and special attention should be given to
the distal radioulnar joint and ulnar variance.
 F. A. Mann, MD . Anthony J. Wilson, MB, ChB
Louis A. Gilula, MD.
Radiographic Evaluation ofthe Wrist:
What Does the Hand Surgeon Want to Know?’
Radiology, Volume 184, Number 1

Ulnar variance is independent of the length of the

ulnar styloid process, which may also vary.
However, wrist position is an important
determinant of ulnar variance (2,6 –9).
Maximum forearm pronation results in an
increase in positive ulnar variance, whereas
maximum forearm supination decreases ulnar
variance. Ulnar variance increases significantly
with a firm grip and
returns to its original state with cessation of grip.
Luis Cerezal, MD ● Francisco del Pinal, MD, PhD
● Faustino Abascal, MD ● Roberto Garcı´a-
Valtuille, MD ● Teresa Pereda, MD ● Ana Canga,
MD
Imaging Findings in Ulnar-sided Wrist Impaction
Syndromes. RadioGraphics 2002; 22:105–121

Radial length or Radial height

Radial length or height

Radial length is measured on the PA radiograph as the
distance between one line perpendicular to the long
axis of the radius passing through the distal tip of the
radial styloid.
A second line intersects distal articular surface of
ulnar head. This measurement averages 10-13 mm.
quoted from
http://www.radiologyassistant.nl/en/476a23436683b

Loss of radial height is a predictor of a less favourable

outcome in distal radial fractures. The normal mean
has been reported to be 11-12 mm (26). (also reported
as 13.5 mm ± 3.8 (2 standard deviations)
F. A. Mann, MD . Anthony J. Wilson, MB, ChB Louis
A. Gilula, MD.
Radiographic Evaluation ofthe Wrist:
What Does the Hand Surgeon Want to Know?’
 Radiology, Volume 184, Number 1

Radial Inclination syn Radial Angle, Radial inclination, radial deviation

Radial inclination
Radial inclination represents the angle between one
line connecting the radial styloid tip and the ulnar
aspect of the distal radius and a second line
perpendicular to the longitudinal axis of the radius.
The radial inclination ranges between 21° and 25°.
(another reference quotes 16- 28 degrees). Normal is
reported as 25.4 degrees with a standard deviation of
2.2 degrees.

Loss of radial inclination will increase the load across

the lunate.

quoted from
http://www.radiologyassistant.nl/en/476a23436683b

Patients treated for distal radial fractures who have a

radial inclination of less than 5 degrees have poorer
results than those with normal or near normal
inclination.
F. A. Mann, MD . Anthony J. Wilson, MB, ChB Louis
A. Gilula, MD.
Radiographic Evaluation ofthe Wrist:
What Does the Hand Surgeon Want to Know?’
Radiology, Volume 184, Number 1

Radiocarpal Angle

Radiocarpal Angle
The radiocarpal angle is
measured by first
establishing reference
lines. These are the
radial centreline and a
 right-angle line. The
radiocarpal angle is the
angle formed between
this right angle lien and
a line drawn from the
tip of the radial styloid
to the tip of the ulnar
styloid.

The Carpal Arcs syn. Gilula's arcs

The concept of three radiographic arcs was first

proposed by Gilula in 1979. The carpal bones all have
rounded edges to varying degrees, and as such the
arcs have small indentations at the joint lines.
However, there should be no stepoffs in the contour
of the arcs. Such a "broken arc" implies a ligament
tear or fracture at the site of the broken arc.

Three carpal arcs: smooth curves joining the surfaces

of the carpal bones as shown on the left.

Carpal Arc I
The first arc is a smooth curve outlining the proximal
convexities of the scaphoid, lunate and triquetrum.

Carpal Arc II
The second arc traces the distal concave surfaces of
the same bones

Carpal Arc III

The third arc follows the main proximal curvatures of
the capitate and hamate.

adapted from
http://www.radiologyassistant.nl/en/42a29ec06b9e8
Carpal Height

"Carpal height is a
radiologic concept to
aid in the quantification
of carpal collapse.
Sequential
measurements can aid
in the assessment of
disease severity and
progression. Carpal
height is defined as the
distance from the base
of the third metacarpal
to the subchondral
sclerotic line of the
distal radial articular
surface as measured
along the axis extended
from the third
metacarpal."

F. A. Mann, MD .
Anthony J. Wilson, MB,
ChB Louis A. Gilula,
MD.
Radiographic
Evaluation ofthe Wrist:
What Does the Hand
Surgeon Want to
Know?’
Radiology, Volume 184,
Number 1

The radiographic
technique for carpal
height measurement
requires that the hand
be positioned for a
neutral posteroanterior
examination.
Specifically, the
shoulder should be
abducted 90 degrees,
elbow flexed 90
degrees, the wrist
 without ulnar or radial
deviation and without
palmar flexion or
dorsiflexion.
F. A. Mann, MD .
Anthony J. Wilson, MB,
ChB Louis A. Gilula,
MD.
Radiographic
Evaluation ofthe Wrist:
What Does the Hand
Surgeon Want to
Know?’
Radiology, Volume 184,
Number 1

Carpal Height Ratio

"The carpal height ratio

is usually obtained by
dividing the carpal
height by the length of
the third
metacarpal"

McMurtry (1) found

that wrist examinations
are often performed
without inclusion of all
the metacarpals.
He therefore developed
an alternative
method for determining
the carpal
height ratio by using
only the carpal
bones, metacarpal
bases, and distal
radius. To calculate this
alternative
carpal height ratio, the
carpal height,
as defined above,
should be divided
by the capitate length.

F. A. Mann, MD .
 Anthony J. Wilson, MB,
ChB Louis A. Gilula,
MD.
Radiographic
Evaluation ofthe Wrist:
What Does the Hand
Surgeon Want to
Know?’
Radiology, Volume 184,
Number 1

Palmar Tilt syn volar tilt, volar inclination, and palmar slope

Its most common use is

in assessing initial and
residual deformities
associated with
fractures of the distal
radius and in planning
operative correction of
disabling deformities.
Palmar tilt represents
the saggital plane
inclination of the distal
radial articular surface.

In more than half of the

patients with greater
than 15 degrees of
dorsal angulation of
palmar tilt, the result is
unsatisfactory in that
grip strength and
endurance are
decreased

Normal measurements
vary by report and
gender of the subject.
Negative values for
palmar tilt are not
normal. Normal
variations have been
described as between 0
and 22 degrees with a
 mean of 14.5 degrees
and a standard
deviation of 4.3 degrees.
Women have been
reported to have a
palmar tilt of 11.3 - 13.5
degrees with a mean of
12.4 degrees. The same
study reports palmar tilt
in men to vary between
8.3 degrees and 10.3
degrees.

quoted from
F. A. Mann, MD .
Anthony J. Wilson, MB,
ChB Louis A. Gilula,
MD.
Radiographic
Evaluation ofthe Wrist:
What Does the Hand
Surgeon Want to
Know?’
Radiology, Volume 184,
Number 1

Scaphoid Axis

"The true axis of the

scaphoid is the line
through the midpoints
of its proximal and
distal poles. Since the
midpoint of the
proximal pole is often
difficult to appreciate,
an almost parallel line
can be used that is
traced along the most
ventral points of the
 proximal and distal
poles of the bone"

quoted from

Louis A. Gilula and

Ileana Chesaru

Wrist - Carpal
instability
The Radiology Assistant

Lunate Axis

"The axis of the lunate

runs through the
midpoints of the convex
proximal and concave
distal joint surfaces and
can best be drawn by
finding the
perpendicular to a line
joining the distal
palmar and dorsal
borders of the bone as
demonstrated on the
left."

quoted from

Louis A. Gilula and

Ileana Chesaru

Wrist - Carpal
instability
The Radiology Assistant
Scapholunate Angle

Scapholunate angle

Normal: 30 - 60°
Questionably
abnormal: 60 -
80°
Abnormal: > 80°
This indicates
instability of the
wrist.

quoted from

Louis A. Gilula and

Ileana Chesaru

Wrist - Carpal
instability
The Radiology Assistant

The numbers are soft,

but this is a guide

VISI < 30
degrees
Normal 30 - 60
degrees
DISI > 60
degrees

DISI (dorsal intercalated segmental instability)

 DISI, or dorsiflexion instability, is short for
dorsal intercalated segmental instability.

The intercalated segment is the proximal carpal row identified by

The term 'intercalated segment' refers to it being the part in betw
proximal segment of the wrist consisting of the radius and the uln
distal segment, represented by the distal carpal row and the meta
So all this means is that in DISI, or dorsiflexion instability, the lu
angulated dorsally.
If you think the lunate is tilted, measure the scapholunate angle
(30-60°is normal, 60-80°is questionably abnormal, >80° is abno
capitolunate angle (<30° is normal).

quoted from

Louis A. Gilula and Ileana Chesaru

DISI Wrist - Carpal instability

note The Radiology Assistant
that
this
angle DISI is due to disruption of the scapho-lunate articulation
has a
larger A DISI will typically demonstrate a scapho-lunate angle greater t
than degrees
Normal
normal
Carpal
error
Alignment
because
the
wrist is
not in a quoted from
true Giuseppe Guglielmi, Cornelis Van Kuijk, Harry K. Genant, Funda
lateral hand and wrist imaging, 2001
position
DISI pattern:

when the scapholunate joint is dissociated, the scaphoid is p

and the lunate is dorsiflexed
Scapho-lunate angle usually 30- 60degrees (average 46 deg
DISI it is greater than 70degrees

adapted from
http://som.flinders.edu.au/FUSA/ORTHOWEB/notebook/regio
VISI (Volar intercalated segmental instability)

Volar intercalated segmental instability, or palmar fle

when the lunate is tilted palmarly too much.
While most DISI is abnormal, in many cases VISI is a normal
especially if the wrist is very lax.

quoted from

Louis A. Gilula and Ileana Chesaru

Wrist - Carpal instability

The Radiology Assistant

VISI is secondary to disruption of the lunate and triquetral

VISI

adapted
from
PS
Normal McAlinden
Carpal andJ Teh, quoted from
Alignment Imaging of Giuseppe Guglielmi, Cornelis Van Kuijk, Harry K. Genant, Fun
the wrist, hand and wrist imaging, 2001
Imaging
15:180-192
(2003) VISI pattern:

lunate palmar flexed

if the lunate and triquetrum can be seen, the normal luno
of approximately -16 degrees becomes neutral or positive

adapted from
http://som.flinders.edu.au/FUSA/ORTHOWEB/notebook/re

Case 1

This patient presented to the Emergency Department following a fall.

Routine wrist views were performed
This series demonstrated no obvious fracture. Moreover, the scaphoid fat pad
(white arrow) and the pronator fat pad (black arrow) were normal.
 The palmar inclination is zero. This is
not diagnostic of a fracture, but is
suspicious.

The radiographer was convinced clinically that the patient had

sustained a fracture and considered whether the soft tissue signs were
misleading (as there are known to be on occasions). Supplementary
views were performed as shown below.
 The views performed are (from left to right)

1. a reverse oblique wrist

2. modified lateral wrist to profile articular surface of radius
3. modified pa wrist to profile the articular surface of radius

The reverse oblique image demonstrates a fractured distal radius (white

arrow). The fracture and step in the articular surface of the radius is also
demonstrated on the modified PA image (black arrow).

Case 2

This13 year old boy presented to the Emergency Department after a fall
onto an outstretched hand.

Comment

The subtle fracture of the wrist is evident from the buckle fracture
and supported by the negative palmar tilt.

Case 3
This 34 year old man presented to the Emergency Department after
hand vs ceiling fan trauma. The patient has a normal anatomical
variant known as short ulna.

The wrist looks There is There is a

abnormal. The increased radial decrease in the
There is negative
ulna appears to inclination radio-carpal
ulna variance
be abnormally (normal range 21 angle (normal 15
short. - 25 degrees) degrees)
 The radial height appears to be
Normal radial height
increased (unable to measure)

Comment

The abnormal wrist measurements are a normal anatomical variant

known as short ulna.

Case 4

This 32 year old man presented to the Emergency Department after

falling through a roof onto a concrete floor.
 There is loss of parallelism of the There is loss of the normal proximal
carpal bones and distal carpal arc lines

The loss of normal carpal arcs was noted by the radiographer who
proceeded to perform a lateral wrist view.
The lunate is normally located. The
remainder of the carpus is dislocated
in a dorsal direction. This is a
perilunate dislocation of the carpus.
The radiographer noted that there
was a negative palmar tilt of the
radius (the relationship between the There is a small dorsal radius fracture
distal radius articular surface and the which is likely to have been caused by
lunate is not normal). On questioning direct impact with the scaphoid.
the patient it was revealed that the
patient had sustained a wrist fracture
in his youth. This would explain the
negative palmar tilt and the
appearance of the ulnar styloid on the
PA image.
 This PA CT wrist image There is dorsal dislocation of the
demonstrated the position that the capitate with respect to the lunate.
lunate would normally occupy There is a also a bony fragment
(dotted line) demonstrated

Discussion

The measurements described above cannot be accurately determined

without correctly centred and positioned anatomy. Importantly,
positioning the patient for forearm imaging (rather than wrist) comes at
a high price- if wrist measurements are required forearm views will not
suffice.

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