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

Optimal X-ray Views for Hand Evaluation of Displacement, Infection, and Foreign Bodies

For optimal evaluation of hand displacement, infection, and foreign bodies, standard 3-view radiographs (posteroanterior, lateral, and oblique) should be obtained initially, followed by ultrasound or CT for suspected foreign bodies when radiographs are negative. 1

Initial Radiographic Evaluation

Standard Views

• Posteroanterior (PA): Essential baseline view showing bone alignment and joint spaces
• Lateral: Critical for evaluating displacement and angulation
• Oblique (45° semipronated): Increases diagnostic yield for fractures and displacements 1, 2

Additional Considerations

• For phalangeal injuries, an internally rotated oblique projection in addition to the standard externally rotated oblique increases diagnostic yield 1
• For thumb injuries, while a 2-view examination may be sufficient, adding an oblique projection improves detection of fractures 1, 2

Foreign Body Detection Algorithm

Step 1: Plain Radiographs

• Begin with standard 3-view radiographs (PA, lateral, oblique) 1
• Radiographs detect most radiopaque foreign bodies (metal, glass, gravel) but are limited for radiolucent materials (wood, plastic) 3, 4
• The addition of oblique views increases diagnostic confidence from 86.1% to 91.6% compared to just frontal and lateral views 5

Step 2: If Radiographs Negative but Foreign Body Suspected

• Ultrasound (preferred first option):

  • High sensitivity for detecting superficial foreign bodies, including radiolucent materials 1, 6
  • Allows real-time guidance for removal 1
  • Enables assessment of surrounding tendons and vascular structures 7

• CT without IV contrast (if ultrasound negative or foreign body suspected in deep tissues/bone):

  • High sensitivity (63%) and specificity (98%) for foreign body detection 1
  • Superior to MRI for identifying water-rich fresh wood 1
  • Provides excellent anatomical detail for surgical planning 2

Step 3: For Complex Cases

• MRI without IV contrast:
  • Consider when complications like osteomyelitis or abscess are suspected 1
  • Less sensitive than CT for foreign body detection (58% sensitivity) 1
  • Useful for evaluating soft tissue complications 4

Infection Evaluation

• Standard 3-view radiographs should be obtained initially to evaluate for osteomyelitis, gas formation, or bone destruction 1
• For suspected soft tissue infection with possible retained foreign body:
  • Ultrasound is recommended for detecting foreign bodies that may be causing chronic inflammation 6
  • Consider foreign body as a cause when symptoms of cellulitis or osteomyelitis persist for over a month 6

Displacement Assessment

• For fracture displacement evaluation, standard 3-view radiographs are usually sufficient 1
• For suspected carpal instability or malalignment:
  • CT without IV contrast provides detailed evaluation of bony alignment 1
  • MRI without IV contrast helps assess associated ligamentous injuries 1, 2

Clinical Pitfalls and Caveats

• Radiolucent foreign bodies (especially wood and plastic) are frequently missed on plain radiographs 3, 4
• Up to 38% of patients with retained foreign bodies may not recall the initial injury, leading to delayed diagnosis 6
• Delayed diagnosis of foreign bodies can lead to chronic inflammation, abscess formation, and need for multiple surgical interventions 7
• Foreign bodies should be suspected in any patient with persistent hand inflammation, even without a clear history of penetrating injury 6

By following this evidence-based imaging approach, clinicians can optimize detection of hand displacement, infection, and foreign bodies while minimizing missed diagnoses that could lead to complications and impaired hand function.