What X-ray views are best for evaluating hand displacement, infection, and foreign bodies?

X-ray Views for Hand Displacement, Infection, and Foreign Body Evaluation

For optimal evaluation of hand displacement, infection, and foreign bodies, standard 3-view radiographs (posteroanterior, lateral, and oblique) should be the initial imaging study, with ultrasound or CT as secondary options for radiolucent foreign bodies. 1

Initial Radiographic Evaluation

Standard Views

• Posteroanterior (PA): Evaluates bone alignment, joint spaces, and most fractures
• Lateral: Assesses volar/dorsal displacement and angulation
• Oblique (45° semipronated): Visualizes areas obscured in standard views and increases diagnostic yield 1, 2

Additional Specialized Views

• Internally rotated oblique projection: Increases diagnostic yield for phalangeal fractures by 4.8% compared to standard two views 1, 2
• Semisupinated oblique: Improves detection of distal radius fractures 1

Foreign Body Detection Algorithm

1. Initial Assessment: Standard 3-view radiographs

   • Highly effective for radiopaque materials (metal, most glass, some stones) 1
   • Limited for radiolucent materials (wood, plastic, thorns) 3

2. If radiographs negative but foreign body suspected:

   • Ultrasound: First choice for suspected radiolucent foreign bodies in superficial tissues
     • High sensitivity for detection in superficial soft tissues
     • Allows real-time guidance for removal
     • Permits assessment of surrounding tendons and vascular structures 1, 4, 5

3. If ultrasound inconclusive or deep foreign body suspected:

   • CT without IV contrast: Superior for deep-seated foreign bodies or those near bone
     • 63% sensitivity, 98% specificity for foreign bodies 1
     • Better than MRI for detecting water-rich fresh wood 1

4. For suspected infection with retained foreign body:

   • MRI without IV contrast: Best for evaluating associated soft tissue infection, osteomyelitis, or abscess
     • 58% sensitivity, 100% specificity for foreign bodies 1
     • Particularly useful for complications of retained foreign bodies 3

Infection Evaluation

• Standard radiographs: Initial imaging to assess for bone involvement, gas formation, or joint effusion
• MRI without IV contrast: For suspected osteomyelitis or deep soft tissue infection
• Ultrasound: For localized superficial abscesses or cellulitis with suspected foreign body 4

Displacement Assessment

• Standard 3-view radiographs: Essential for evaluating fracture displacement, joint malalignment
• CT without IV contrast: For complex intra-articular fractures with displacement
  • Particularly useful for preoperative planning with 3D reconstructions 1
• MRI without IV contrast: For associated ligamentous injuries with carpal instability 1, 6

Clinical Pearls

• Patients with chronic hand inflammation (>1 month) without diagnosis should be evaluated for retained foreign bodies 4
• Radiolucent foreign bodies are commonly missed on initial evaluation and can present as late infections months after injury 4, 5
• The addition of oblique views increases diagnostic confidence from 86.1% to 91.6% compared to two-view radiography 2
• Wooden foreign bodies, especially when wet, are best seen by CT and MRI, not standard radiographs 7

Common Pitfalls

• Relying solely on two-view radiography can miss up to 4.8% of abnormalities 2
• Failure to obtain appropriate oblique views for specific anatomical areas
• Overlooking the possibility of radiolucent foreign bodies when radiographs are negative
• Not considering ultrasound as a valuable tool for superficial foreign body detection and guided removal 1, 5