# Improving the Quality of Lateral Wrist Radiographs: A Closed-Loop Audit of Radiographic Compliance With Standard Positioning Criteria

## TL;DR

This study shows that targeted education improves the quality of wrist X-rays, leading to better diagnostic accuracy and safer patient care.

## Contribution

The paper demonstrates that educational interventions can significantly improve radiographic compliance with positioning standards.

## Key findings

- Compliance with radiographic standards improved significantly after educational interventions.
- Superimposition of radial and ulnar styloid processes increased from 72% to 92%.
- The piso-scapho-capitate relationship visibility improved from 50% to 82%.

## Abstract

Background

Wrist injuries represent a substantial proportion of acute musculoskeletal presentations, with distal radius and carpal fractures among the most frequently encountered upper-limb fractures in emergency and orthopaedic services. Accurate lateral wrist radiographs are essential for detecting osseous and carpal alignment abnormalities, guiding management, and preventing complications. However, radiographic quality is highly dependent on adherence to established positioning standards. Inadequate positioning may obscure key anatomical relationships, contributing to diagnostic errors, treatment delays, unnecessary imaging escalation, and increased medico-legal vulnerability. This closed-loop audit aimed to evaluate baseline compliance with recognised radiographic standards for lateral wrist radiographs, implement targeted educational interventions, and reassess compliance to determine the effectiveness of these measures.

Methods

A retrospective audit was conducted at Poole District General Hospital, United Kingdom. Adult patients aged 18-65 years who underwent lateral wrist radiography were evaluated across two cycles (50 radiographs per cycle). Radiographs were reviewed independently by two senior registrars and assessed against three standards: superimposition of radial and ulnar styloid processes, inclusion of the distal radius/ulna, all carpal bones, and proximal metacarpals, and demonstration of the piso-scapho-capitate relationship. Educational interventions included posters, teaching sessions, and dissemination of positioning guidelines. Chi-square testing analysed differences between audit cycles, with a p-value of less than 0.05 considered statistically significant.

Results

A total of 50 radiographs were evaluated in each audit cycle. In the first cycle, compliance with Standard 1 (superimposition of the radial and ulnar styloid processes) was 72% (n=36/50), Standard 2 (appropriate anatomical inclusion) was 98% (n=49/50), and Standard 3 (piso-scapho-capitate relationship) was 50% (n=25/50). Following targeted educational interventions, compliance in the second cycle improved to 92% (n=46/50) for Standard 1, 100% (n=50/50) for Standard 2, and 82% (n=41/50) for Standard 3. Improvements were statistically significant for Standard 1 (p=0.047) and Standard 3 (p=0.014), while Standard 2 remained consistently high across both cycles (p=0.992). Overall, compliance across all standards increased substantially between cycles, demonstrating the clear effectiveness of the educational interventions in achieving and surpassing the 80% compliance target.

Conclusions

Simple, targeted educational interventions significantly improved adherence to radiographic positioning standards. Enhanced radiograph quality supports accurate diagnosis and clinical decision-making. Sustained improvement will require ongoing education and periodic re-audit, reinforcing high-quality imaging as a cornerstone of safe and efficient musculoskeletal care.