What is the best hand x-ray view to reveal overlapping of multiple carpal bones: lateral, dorsal, medial, or oblique?

Best Hand X-ray View for Revealing Overlapping of Multiple Carpal Bones

The lateral view is the most appropriate radiographic projection for revealing overlapping of multiple carpal bones in the wrist, as it provides a profile view where carpal bones naturally superimpose on each other. 1

Radiographic Views of the Hand and Wrist

Standard Views

• Posteroanterior (PA): Shows carpal bones with minimal overlap but doesn't demonstrate superimposition
• Lateral: Provides profile view with natural overlapping of carpal bones
• Oblique (45° semipronated): Shows intermediate overlap but not as complete as lateral view
• Dorsal: Not a standard projection for carpal bone evaluation

Why Lateral View Is Superior for Visualizing Overlapping

The lateral view positions the wrist so that:

• All carpal bones are superimposed in a single plane
• The radiocarpal joint relationship can be assessed
• The entire carpal row alignment can be visualized 1

Specialized Lateral Variations for Enhanced Visualization

For optimal visualization of overlapping carpal bones, consider these specialized lateral view variations:

1. Standard Lateral: Wrist in neutral position, thumb up
2. 20° Axial-Lateral View: Superior to standard 0° lateral in demonstrating the radiocarpal joint without obscuration by the radial styloid 2
3. Lateral Tilt View: Positions the wrist at approximately 18° from horizontal using the contralateral hand for positioning 3

Additional Considerations for Complex Cases

In cases where standard views are insufficient:

• Multiple oblique views (60° pronation and 60° supination) may help visualize specific carpal relationships 4
• CT imaging provides superior visualization of complex carpal relationships and is recommended when radiographs are equivocal 1
• MRI is valuable for evaluating associated soft tissue injuries but not typically needed for basic carpal bone alignment assessment 1

Common Pitfalls to Avoid

• Inadequate positioning: Ensure true lateral position with superimposition of radius and ulna
• Insufficient views: Never rely on a single view; at minimum, use a 3-view examination (PA, lateral, and oblique) 1
• Missing congenital variants: Be aware that numerical variants and congenital fusions of carpal bones can complicate interpretation 5
• Overlooking subtle fractures: Carpal fractures may be radiographically occult on standard views 1, 6

The lateral view remains the gold standard for evaluating overlapping carpal bones, but should be supplemented with additional views for comprehensive assessment of the wrist.