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 optimal radiographic projection for revealing overlapping of multiple carpal bones, as it provides a profile view that naturally demonstrates the superimposition of carpal bones.

Standard Radiographic Views for Hand and Wrist

The American College of Radiology (ACR) recommends a standard approach to hand and wrist imaging that includes multiple views:

• For wrist imaging, a standard 3-view examination includes 1:

  • Posteroanterior (PA) view
  • Lateral view
  • 45° semipronated oblique view

• For hand imaging, a standard 3-view radiographic examination is recommended 1

Why the Lateral View Is Optimal for Carpal Bone Overlap

The lateral view provides several advantages for visualizing overlapping carpal bones:

1. It demonstrates the natural superimposition of carpal bones in profile 1
2. It shows the alignment relationships between carpal bones 1
3. It clearly displays malalignments and soft-tissue swelling 1

Enhancing Visualization with Modified Lateral Views

Standard lateral views can sometimes be limited by:

• Obscuration of the radiocarpal joint by the radial styloid process 2
• Superimposition of orthopedic hardware in post-surgical patients 2

Research supports that a modified lateral projection at a 20° axial-lateral angle can improve visualization:

• This view demonstrates the distal radius in profile without superimposing structures over the wrist joint 2
• In a study of 124 cases, the 20° lateral view showed the radiocarpal joint more clearly than the standard 0° lateral view (75/124 vs. 23/124, p<0.001) 2
• It was preferred by both radiologists (76%) and technologists (83%) 2

Complementary Views for Complete Assessment

While the lateral view is optimal for showing overlapping carpal bones, a complete assessment requires additional views:

• Oblique views (both pronated and supinated) help visualize specific carpal bones that may be obscured in standard views 3, 4
• For comprehensive scaphoid assessment, a specialized approach includes 4:
  • PA view with ulnar deviation and fist position
  • Oblique view in 60° pronation
  • Oblique view in 60° supination
  • Lateral view

Clinical Considerations

When evaluating for carpal bone abnormalities:

• Multiple radiographic views are necessary to improve identification of fractures, erosions, or other abnormalities due to the degree of overlap of osseous structures 1
• For hand radiographs specifically, posteroanterior, oblique, lateral, and semisupinated views are recommended to maximize diagnostic yield 1
• In cases of suspected congenital variants or fusions of carpal bones, lateral views are essential to demonstrate the overlapping relationships 5

Advanced Imaging When Radiographs Are Insufficient

If standard radiographs don't provide adequate visualization:

• CT without IV contrast is ideal for characterizing cortical bone abnormalities and is considered the reference standard for evaluating carpal bone relationships 1
• MRI without IV contrast is recommended when soft tissue evaluation is also needed 3

In summary, while a complete radiographic assessment requires multiple views, the lateral view provides the best single projection for revealing the overlapping relationships of multiple carpal bones.