From the Guidelines
When examining a hand for a fracture, a standard 3-view radiographic examination is essential to detect most fractures and dislocations of the metacarpals and phalanges, and should be performed as the initial imaging modality, as indicated by the American College of Radiology 1. The examination should start with a thorough observation of the hand for any obvious deformity, swelling, bruising, or open wounds. A detailed history of the mechanism of injury should be taken, and the location of pain should be assessed through gentle palpation of each bone.
- Key areas to check include:
- Tenderness over the anatomical snuffbox, which may indicate a scaphoid fracture
- Range of motion, comparing with the uninjured hand
- Neurovascular status by checking capillary refill, sensation, and pulses
- Specific tests such as the piano key test for ulnar styloid fractures and axial loading of digits for phalangeal fractures should also be performed. For patients with suspected distal radius fractures, a 3-view examination of the wrist, including a posteroanterior (PA), a lateral, and a 45 semipronated oblique view, is usually adequate 1.
- In some cases, a fourth projection, such as a semisupinated oblique, may be necessary to increase diagnostic yield for distal radius fractures 1.
- For phalangeal injuries, an internally rotated oblique projection, in addition to the standard externally rotated oblique, can increase diagnostic yield 1. A radiographic examination that includes only 2 views is not adequate for detecting fractures, especially those involving the wrist, hand, and fingers 1.
From the Research
Hand Examination Findings for Fractures
- A hand examination for a fracture typically involves a radiographic examination, which may include antero-posterior, oblique, and lateral views 2
- The American College of Radiology (ACR) recommends a standard three-view examination for finger and hand injuries 2
- A three-view radiographic examination is crucial for the accurate assessment and subsequent decision-making in hand fracture management, with increased diagnostic accuracy and reduced rates of misdiagnosis 2
- The majority of hand fractures are managed conservatively, with operative management considered on a case-by-case basis, taking into account patient and fracture-related factors 3
Common Presentations and Assessment
- Hand fractures are the most common fractures of the upper extremity, with a reported incidence of 3.7 per 1000 per year for men and 1.3 per 1000 per year for women 3
- Appropriate evaluation at first presentation, as well as during management, can significantly prevent morbidity and disability to a patient 4
- Assessment of hand fractures should consider factors such as age, hand dominance, occupation, and co-morbidities 4
Radiographic Views and Diagnostic Accuracy
- A three-view radiographic examination is superior to a two-view examination, with increased diagnostic accuracy and reduced rates of misdiagnosis 2
- The lateral radiograph is the most commonly lacking view in metacarpal fractures, while the oblique view is the most commonly absent in phalangeal fractures 2
- Less than half of patients with confirmed hand fractures had a three-view radiographic examination performed, highlighting the need for national guidelines 2