X-Ray Views for FOOSH Hand Injury
For a fall onto an outstretched hand (FOOSH) injury, order a standard 3-view radiographic examination of the hand (posteroanterior, lateral, and oblique views) and a 3-view examination of the wrist (posteroanterior, lateral, and 45° semipronated oblique views) 1.
Initial Imaging Approach
The ACR Appropriateness Criteria clearly establish that two views alone are inadequate for detecting fractures in the hand and wrist 1. FOOSH injuries commonly affect both the wrist (particularly distal radius) and hand structures, requiring comprehensive imaging of both regions.
For the Wrist Component:
- Posteroanterior (PA) view
- Lateral view
- 45° semipronated oblique view
A fourth projection (semisupinated oblique) can increase diagnostic yield for distal radius fractures, though this is not standard 1.
For the Hand Component:
- Posteroanterior (PA) view of the entire hand
- Lateral view
- Oblique view (externally rotated)
Adding an internally rotated oblique projection increases diagnostic yield for phalangeal fractures 1. Recent evidence shows that approximately one-quarter of phalangeal fractures are visible in only a single projection, with four-view radiography detecting an additional 13.4% of fractures missed on standard two-view assessment 2.
Location-Specific Considerations
Thumb Injuries:
If clinical suspicion focuses on the thumb, a 2-view examination is usually sufficient, though adding an oblique projection (obtained with a PA view of the whole hand) slightly increases diagnostic yield 1.
Individual Finger Injuries:
Some centers image only the injured finger rather than the entire hand. However, four-view radiography of the affected digit (PA, lateral, oblique, and reverse oblique) may be warranted for central digit injuries where fracture detection is more challenging 2.
Common Pitfalls to Avoid
Don't order only wrist films: FOOSH injuries frequently cause metacarpal and phalangeal fractures that wrist-only imaging will miss 1.
Don't settle for two views: This is explicitly inadequate for extremity joints, especially the wrist, hand, and fingers 1.
Don't forget the scaphoid: If there is anatomic snuffbox tenderness, ensure proper scaphoid views are included or specifically requested, as scaphoid fractures are commonly radiographically occult initially 1.
Clinical Context Matters
The mechanism matters: higher radial height (>10.77mm) is associated with increased scaphoid fracture risk in FOOSH injuries 3. If initial radiographs are negative but clinical suspicion remains high (persistent tenderness, limited range of motion), CT without IV contrast is the next step for wrist injuries, while repeat radiographs at 10-14 days remain an option though this delays diagnosis 1.
Order both hand AND wrist series initially rather than trying to localize clinically—approximately 27% of patients with distal radius fractures have concomitant injuries elsewhere 4, and the diagnostic yield justifies comprehensive imaging from the outset.