From the Guidelines
The maximum number of views for radiographs of the hand to assess a hand fracture is typically 3 views, including posteroanterior (PA), lateral, and oblique views, as this is usually sufficient to diagnose most hand fractures and provide information about fracture displacement, angulation, and comminution 1.
Key Points to Consider
- A standard 3-view radiographic examination of the hand shows most fractures and dislocations of the metacarpals and phalanges 1.
- For phalangeal injuries, some centers include a PA examination of the entire hand, whereas others limit the examination to the injured finger 1.
- An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures 1.
- Most fractures of the thumb are visible on a 2-view radiographic examination, although there is a slight increase in diagnostic yield with the addition of an oblique projection 1.
Imaging Approach
- The initial imaging approach for assessing a hand fracture should include standard radiographs (X-rays) with a minimum of 2 views and a maximum of 3 views, depending on the clinical presentation and suspected fracture location 1.
- Advanced imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) may be necessary if standard radiographs are inconclusive but clinical suspicion remains high 1.
Clinical Considerations
- The choice of imaging should be guided by the clinical presentation, mechanism of injury, and initial radiographic findings, with the goal of accurately characterizing the fracture to determine appropriate treatment 1.
- The treatment of hand fractures may range from conservative management to surgical intervention, depending on fracture stability, location, and displacement 1.
From the Research
Recommended Imaging Approach
The recommended imaging approach for assessing a hand fracture involves a three-view radiographic examination, including:
- Antero-posterior view
- Oblique view
- Lateral view This approach is crucial for accurate assessment and decision-making in hand fracture management, as demonstrated by multiple studies 2.
Diagnostic Accuracy
The use of a three-view examination has been shown to increase diagnostic accuracy and reduce rates of misdiagnosis compared to using only two views 2. The American College of Radiology (ACR) recommends a standard three-view examination for finger and hand injuries.
Variability in Radiology Protocols
Despite the superiority of a three-view examination, there is variability in radiology protocols, with some hospitals recommending only two views for suspected phalangeal injuries 2. The authors of the study call for national published guidance advocating the use of three-view radiographic series in all patients with a high hand fracture suspicion.
Additional Views
In some cases, additional views may be necessary to diagnose specific types of fractures, such as scaphoid waist fractures. The 45-degree reverse oblique view of the carpal palm has been shown to be valuable in diagnosing scaphoid waist fractures and displacement 3.
Management of Hand Fractures
Hand fractures are common injuries that require proper management to achieve optimal hand function. The majority of hand fractures are managed conservatively, and operative management should be carefully considered on a case-by-case basis 4. Recent innovations in hand fracture management include minimally invasive surgery and the use of wide-awake anesthesia 5.