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

Radiographic Evaluation of Hand Injuries

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

Standard Radiographic Views for Hand Injuries

The American College of Radiology and current guidelines recommend a standard three-view radiographic examination for hand injuries:

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 plays a particularly important role in hand injury evaluation as it:

• Demonstrates malalignments that may not be visible on other views 2
• Shows soft-tissue swelling 2
• Is critical for evaluating displacement and angulation of fractures 1

Evidence Supporting Three-View Radiography

Recent research strongly supports the use of all three views:

• A 2023 quality improvement study found that despite the superiority of a three-view examination, over half of patients with hand fractures lacked a complete three-view series, with the lateral view most commonly missing in metacarpal fractures (38% of cases) 3

• Adding the oblique view to PA and lateral views changes interpretation in 4.8% of cases and significantly increases diagnostic confidence, reducing equivocal findings from 13.9% to 8.4% 4

Clinical Implications

Failure to obtain all three views can lead to:

• Missed fractures and dislocations
• Inadequate assessment of displacement and angulation
• Suboptimal treatment planning
• Potential long-term functional impairment

Specialized Considerations

For specific hand injuries:

• Phalangeal injuries: An internally rotated oblique projection in addition to the standard externally rotated oblique increases diagnostic yield 1
• Thumb injuries: Adding an oblique projection improves detection of fractures 1

Common Pitfalls to Avoid

1. Relying on two views only: Despite the ACR recommendation for three views, many facilities still use only two views for hand injuries, particularly for phalangeal fractures 3

2. Missing the lateral view: The lateral view is frequently omitted but is essential for evaluating displacement and angulation 1, 3

3. Inadequate positioning: Proper positioning is crucial for accurate assessment; the lateral view should be obtained with the hand in true lateral position

4. Delayed treatment: Incomplete radiographic evaluation can lead to missed injuries and delayed treatment, which may compromise long-term function 1

While a recent study of distal radius fractures showed strong agreement between treatment decisions made with and without the oblique view (κ = 0.81), the authors still concluded that elimination of the oblique view cannot be supported as it did result in some meaningful intervention changes 5