Is the lateral view the primary radiographic projection for evaluating hand injuries?

Standard Radiographic Views for Hand Injuries

For hand injuries, the standard radiographic examination should include three views: posteroanterior (PA), lateral, and oblique views, with the lateral view being a critical component for evaluating displacement and angulation. 1

Importance of Three-View Radiographs

The American College of Radiology recommends a standard three-view examination for hand injuries, which includes:

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

The lateral view specifically plays a crucial role in demonstrating malalignments and soft-tissue swelling 2. It is particularly important for evaluating displacement and angulation of fractures 1.

Evidence Supporting Three-View Radiographs

Recent research strongly supports the use of three-view radiographic examination for hand injuries:

• A 2023 quality improvement study found that less than half (45%) of patients with confirmed hand fractures had three-view radiographic examinations performed, with the lateral view most commonly lacking (38%) in metacarpal fractures 3.

• The superiority of a three-view examination compared to only two views has been demonstrated by multiple studies, showing increased diagnostic accuracy and reduced rates of misdiagnosis 3.

• Addition of the oblique view has been shown to change interpretation in 4.8% of examinations and significantly increase diagnostic confidence from 13.9% with two views to 8.4% with three views (p<.0001) 4.

Clinical Implications

When evaluating hand injuries:

• The lateral view is particularly important for:

  • Demonstrating malalignments
  • Evaluating soft-tissue swelling
  • Assessing displacement and angulation of fractures
  • Guiding treatment decisions

• Inadequate imaging can lead to:

  • Missed fractures
  • Improper treatment planning
  • Potential long-term complications including malunion and functional impairment

Common Pitfalls to Avoid

1. Relying on fewer than three views - This may lead to missed diagnoses, particularly for fractures that are only visible on specific projections.

2. Omitting the lateral view - The lateral view is critical for evaluating displacement, which directly impacts treatment decisions.

3. Inconsistent protocols - Many institutions have inconsistent protocols, particularly for phalangeal injuries, where only two views might be ordered despite evidence supporting three views 3.

4. Delayed diagnosis - Inadequate imaging can lead to delayed treatment, which may compromise long-term function 1.

While some recent research has questioned whether the oblique view changes surgical decision-making in distal radius fractures 5, the consensus from guidelines and most research supports that a complete three-view examination, including the lateral view, remains essential for comprehensive evaluation of hand injuries.