Radiographic Findings in Hand Injuries

Definition and Clinical Significance

The American College of Radiology indicates that the longhorn sign is an important radiographic finding that suggests an intra-articular fracture pattern of the distal radius, which may require surgical intervention to restore articular congruity and prevent long-term complications such as osteoarthritis 1

The American College of Radiology recommends a standard 3-view radiographic examination of the wrist to identify the longhorn sign, which includes posteroanterior, lateral, and 45° semipronated oblique views 1
The presence of a coronally oriented fracture line or die-punch depression on initial radiographs should raise suspicion for the longhorn sign, according to the American College of Radiology 1
Additional imaging, such as CT, may be necessary to properly characterize the longhorn sign when radiographs are equivocal, as noted by the American College of Radiology 2

The American College of Radiology suggests that CT without IV contrast is valuable for better visualization of the longhorn sign when radiographs are equivocal, as it is superior for detecting intra-articular extension of distal radius fractures 2
Three-dimensional CT reconstructions can be helpful in preoperative planning for complex articular injuries showing the longhorn sign, according to the American College of Radiology 2

The American College of Radiology indicates that the presence of the longhorn sign is often an indication for operative intervention, as it represents a significant intra-articular injury 1
Operative fixation is typically necessary when there is >2 mm of residual articular surface step-off to avoid long-term complications such as osteoarthritis, as recommended by the American College of Radiology 1
CT arthrography may be considered if there is concern for associated ligamentous injuries, as it has high sensitivity and specificity for detecting scapholunate and lunotriquetral ligament tears, according to the American College of Radiology 3

The American College of Radiology notes that failure to obtain adequate radiographic views may lead to missed diagnosis of the longhorn sign; a minimum of 3 views is necessary 1

Extra-articular fractures occur outside the radiocarpal joint space, not involving the articular surface of the distal radius, according to the American College of Radiology 4
Die-punch fractures, a type of intra-articular fracture, involve depression of the lunate facet, as defined by the American College of Radiology 5

A standard 3-view radiographic examination, including posteroanterior, lateral, and 45° semipronated oblique views, is the first-line imaging for suspected wrist fractures, as recommended by the American College of Radiology 5
CT without IV contrast is recommended when radiographs are equivocal, as it is superior for detecting intra-articular extension of distal radius fractures, according to the American College of Radiology 4
MRI without IV contrast can detect occult fractures when radiographs are normal but clinical suspicion remains high, and shows both intra-articular extension and concomitant ligament injuries, as noted by the American College of Radiology 4
MRI is particularly useful for evaluating scapholunate ligament tears that may affect surgical treatment, as stated by the American College of Radiology 6

Extra-articular fractures are often managed non-operatively with cast immobilization, but surgical fixation may be indicated if there is significant displacement or angulation, according to the American Academy of Orthopaedic Surgeons 7
Arthroscopy is an option during surgical treatment of intra-articular fractures to improve diagnostic accuracy for wrist ligament injuries, as recommended by the American Academy of Orthopaedic Surgeons 7