Knee, Wrist and Ankle Radiograph Reports: Normal and Fracture Examples

Start with the examination that was actually obtained

A useful extremity radiograph report states the side and projections, compares prior images when available, describes alignment and the bones and joints included, and answers the clinical question. Projection sets vary by institution and indication. Name the views that were acquired rather than letting a template imply a view that is absent.

The examples below are fictional teaching cases. Bracketed fields in the reusable report structure are placeholders, not findings to retain automatically.

Complete normal report frameworks

Knee radiographs

Examination: [Right/left] knee radiographs, [number] views: [list actual views].

Comparison: [Prior examination and date / None available.]

Findings: Alignment is maintained. No acute fracture or focal osseous lesion is identified. The joint spaces are [maintained / described by compartment]. No sizable joint effusion is evident on the provided views. The included soft tissues are unremarkable.

Impression: No acute osseous abnormality of the [right/left] knee.

Wrist radiographs

Examination: [Right/left] wrist radiographs, [number] views: [list actual views].

Comparison: [Prior examination and date / None available.]

Findings: Carpal alignment is maintained. No acute fracture or dislocation is identified. Joint spaces are preserved. The included soft tissues are unremarkable.

Impression: No acute osseous abnormality of the [right/left] wrist.

Ankle radiographs

Examination: [Right/left] ankle radiographs, [number] views: [list actual views].

Comparison: [Prior examination and date / None available.]

Findings: Ankle alignment and the mortise are maintained. No acute fracture or focal osseous lesion is identified. No sizable joint effusion is evident. The included soft tissues are unremarkable.

Impression: No acute osseous abnormality of the [right/left] ankle.

Only retain a negative statement when the relevant anatomy is included and adequately assessed. If the examination is limited to two views, rotated, obscured by an immobilization device, or does not include the area of focal concern, say so and narrow the conclusion.

Fully worked normal examples

Normal knee

Examination: Right knee radiographs, four views (AP, lateral, tunnel, and patellar axial).

Comparison: None available.

Findings: Alignment is maintained. Joint spaces are preserved. No acute fracture or focal osseous lesion is identified. No sizable joint effusion is evident.

Impression: No acute osseous abnormality of the right knee.

Normal wrist

Examination: Left wrist radiographs, three views (PA, oblique, and lateral).

Comparison: None available.

Findings: Carpal alignment is maintained. No acute fracture or dislocation is identified. Joint spaces are preserved.

Impression: No acute osseous abnormality of the left wrist.

Normal ankle

Examination: Right ankle radiographs, three views (AP, mortise, and lateral).

Comparison: None available.

Findings: Ankle alignment and the mortise are maintained. No acute fracture or focal osseous lesion is identified. No sizable joint effusion is evident.

Impression: No acute osseous abnormality of the right ankle.

Fracture description checklist

For a visible fracture, describe the details that are shown and matter to the clinical question:

• Site and side: bone, segment, and laterality.
• Pattern: transverse, oblique, spiral, comminuted, impacted, or another clear morphology.
• Extent: extra-articular or intra-articular; identify an involved articular surface when visible.
• Alignment: displacement, angulation, translation, rotation, shortening, and impaction when relevant and reliably assessed.
• Associated findings: joint alignment, dislocation, additional fracture, effusion, and soft-tissue swelling when visible.
• Comparison and limits: whether the finding is new, unchanged, or difficult to characterize on the available projections.

Avoid adding every descriptor to every fracture. Do not infer stability, ligament integrity, or an exact fracture configuration beyond what the views show. If radiographs are negative or equivocal but clinical concern persists, further imaging may be appropriate under the relevant clinical pathway; state the imaging limitation without claiming that an occult injury is excluded.

Fictional fracture examples

Knee: lateral tibial plateau fracture

Case: A fictional adult presents after a fall. Four knee views are available. The following example demonstrates a complete report, including articular involvement and effusion.

Examination: Left knee radiographs, four views (AP, lateral, tunnel, and patellar axial).

Comparison: None available.

Findings: Mildly depressed fracture of the lateral tibial plateau with approximately 2 mm of articular surface depression. Moderate joint effusion. No dislocation.

Impression: Mildly depressed intra-articular fracture of the lateral tibial plateau with moderate joint effusion.

State a depression measurement only when it can be assessed reliably on the obtained views. Do not use this radiograph alone to imply that the full fracture pattern or soft-tissue injury has been excluded.

Wrist: distal radius fracture

Case: A fictional adult has a fall on an outstretched hand. Three standard wrist projections show a distal radius fracture.

Examination: Right wrist radiographs, three views (PA, oblique, and lateral).

Comparison: None available.

Findings: Transverse extra-articular fracture of the distal radial metaphysis with mild dorsal angulation and minimal displacement. The radiocarpal alignment is maintained. No additional fracture is identified.

Impression: Mildly angulated, minimally displaced extra-articular distal radius fracture.

If the fracture extends to the joint, describe that extension and the articular step-off or gap only when visible. Report an associated ulnar styloid fracture or distal radioulnar joint alignment abnormality when present.

Ankle: distal fibular fracture

Case: A fictional adult twists the ankle. The mortise view is included and shows a fracture at the level of the syndesmosis.

Examination: Left ankle radiographs, three views (AP, mortise, and lateral).

Comparison: None available.

Findings: Oblique fracture of the distal fibula at the level of the syndesmosis with approximately 2 mm of lateral displacement. The ankle mortise remains congruent on these views. No additional acute fracture is identified.

Impression: Minimally displaced trans-syndesmotic distal fibular fracture. The ankle mortise is congruent on the provided views.

Describe mortise alignment as imaged; avoid calling an injury “stable” based on a routine non-weight-bearing series unless the required assessment has been performed.

Limited or negative examinations

Focal wrist tenderness with no visible fracture

Examination: Right wrist radiographs, three views.

Comparison: None available.

Findings: No acute fracture or dislocation is identified. Carpal alignment is maintained.

Impression: No acute osseous abnormality identified. If there is persistent focal clinical concern, additional imaging may be considered because an occult fracture may not be visible on initial radiographs.

This wording is appropriate only when the relevant history is known and the local pathway supports follow-up imaging. A negative radiograph does not exclude every occult fracture.

Incomplete field of view

If the images do not include the area of tenderness or a required projection could not be obtained, state the limitation specifically. Avoid a broad “normal” impression when the examination did not cover the question.

Quick reporting checklist

• Verify the side, patient identifiers, indication, and the projections actually obtained.
• Review alignment before individual bones, then examine each included bone systematically.
• Check joint spaces, articular surfaces, and adjacent joints included on the images.
• Look for a fracture, dislocation, focal lesion, effusion, and relevant soft-tissue abnormality.
• Compare with prior images when available and distinguish chronic from acute findings.
• For a fracture, describe location, pattern, articular extension, displacement/angulation, and alignment.
• State image-quality or coverage limits and keep the impression within those limits.

Common wording pitfalls

“No fracture” can be too broad when a region is obscured or only partially included. “Alignment is normal” should be reserved for a study in which the relevant joints and views are adequate. Do not say “no joint effusion” if the knee lateral view is unavailable or nondiagnostic. Do not call an ankle mortise congruent if the mortise projection was not obtained.

Separate what is seen from what is suspected. If a lucency could represent a nutrient channel or a nondisplaced fracture, describe the uncertainty and the relevant comparison or follow-up option. A radiograph is a projectional examination; subtle articular depression, trabecular injury, and some occult fractures may require a different modality when clinically indicated.

References

• American College of Radiology, Society for Pediatric Radiology, and Society of Skeletal Radiology. Practice Parameter for the Performance of Radiography of the Extremities, revised 2023 (opens in a new tab).
• American College of Radiology. ACR Appropriateness Criteria: Acute Trauma to the Knee (opens in a new tab).
• American College of Radiology. ACR Appropriateness Criteria: Acute Hand and Wrist Trauma (opens in a new tab).
• American College of Radiology. ACR Appropriateness Criteria: Acute Trauma to the Ankle (opens in a new tab).

Clinical note: Examples are educational and fictional. Adapt report wording to the actual images, projection set, patient age, indication, and local protocol.