From the Guidelines
For a FOOSH injury, the recommended radiographic views should include anteroposterior (AP) and lateral views of the elbow, as well as AP and lateral views of the forearm, with an additional oblique view of the elbow to better visualize the olecranon process. These standard views are essential for evaluating potential fractures of the distal radius, ulna, and elbow joint, which are common in FOOSH injuries 1. According to the most recent guidelines, radiographs are beneficial as the initial imaging assessment for acute elbow and proximal forearm pain, and conventional radiographs are often the first-imaging modality used to exclude a fracture or dislocation 1.
In cases where there is specific concern for an olecranon fracture based on physical examination (point tenderness, swelling, or limited extension), a dedicated "trauma axial" or "olecranon view" with the elbow flexed at 90 degrees can provide optimal visualization of the olecranon process. The American College of Radiology recommends radiography as the initial imaging for suspected acute hand and wrist trauma, and for patients with suspected distal radius fractures, a 3-view examination of the wrist usually includes a posteroanterior (PA), a lateral, and a 45 semipronated oblique view 1.
Key points to consider when ordering radiographic views for a FOOSH injury include:
- AP and lateral views of the elbow and forearm
- Oblique view of the elbow to visualize the olecranon process
- Dedicated "trauma axial" or "olecranon view" if concerned for olecranon fracture
- Advanced imaging such as CT scan if standard radiographs appear normal but clinical suspicion remains high 1.
It is crucial to prioritize these views to ensure accurate diagnosis and appropriate management of FOOSH injuries, which commonly result in distal radius fractures, radial head fractures, olecranon fractures, or elbow dislocations.
From the Research
Radiographic Views for FOOSH Injuries
The following radiographic views are recommended for evaluating arm and olecranon injuries in patients with a FOOSH (Fall On Outstretched Hand) injury:
- Anteroposterior (AP) and lateral views of the wrist, forearm, and elbow to assess for fractures and dislocations 2
- Oblique views of the distal extremities, including the wrist and forearm, to increase diagnostic confidence and reveal abnormalities not visible on AP and lateral views 3
- Additional views, such as radial and ulnar deviation, and stress views, may be necessary to evaluate ligamentous injuries and instability 4
Specific Considerations for Monteggia Fracture-Dislocation
In cases of suspected Monteggia fracture-dislocation, which involves a proximal ulnar fracture with a concomitant dislocation of the radial head, the following views are recommended:
- AP and lateral views of the elbow and forearm to assess for ulnar fracture and radial head dislocation 5, 6
- Oblique views of the elbow and forearm to evaluate the relationship between the ulna and radius and to assess for any additional fractures or dislocations 3
Limitations of Concurrent Imaging
Concurrent imaging of the wrist, forearm, and elbow in pediatric patients with a FOOSH injury may have limited benefit, with only 1.7% of cases identifying traumatic abnormalities outside of the documented region of interest 2