What views are typically included in a standard X-ray of the hand?

Standard X-ray Views for Hand Imaging

A standard X-ray of the hand includes three views: posteroanterior (PA), lateral, and oblique views. 1

Standard Views for Hand Radiography

The American College of Radiology (ACR) Appropriateness Criteria clearly establishes that the standard radiographic evaluation of the hand includes three specific views:

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

These three standard projections allow comprehensive assessment of:

• Joint spaces and alignment
• Bone integrity
• Soft tissue swelling
• Mineralization patterns
• Erosions
• Static instability
• Chronic healed and nonunited fractures 1

Clinical Importance of Three-View Imaging

The superiority of a three-view examination compared to only two views has been demonstrated in multiple studies, showing increased diagnostic accuracy and reduced rates of misdiagnosis 3. The addition of an oblique view has been shown to:

• Change interpretation in 4.8% of examinations
• Convert equivocal findings to definitive diagnoses
• Reveal abnormalities not visible on other views
• Significantly increase diagnostic confidence from 13.9% with two views to 8.4% with three views 4

Special Considerations

• For weight-bearing assessment, standing radiographs are preferred when possible as they may detect dynamic abnormalities such as joint mal-alignment or subluxation 1
• In cases of suspected rheumatoid arthritis, the Brewerton view may be added as it is superior for detecting erosive disease 5
• Some institutions may use a modified four-view protocol that combines hand and wrist imaging, which has shown comparable diagnostic results to traditional seven-view protocols 6

Common Pitfalls to Avoid

1. Inadequate views: Relying on fewer than three views can lead to missed fractures or other pathology
2. Poor technique: Improper positioning can obscure important findings
3. Standard lateral limitations: In standard lateral wrist radiographs, the radiocarpal joint is often obscured due to the angulation of the radial styloid process; a modified 20° axial-lateral view may provide better visualization 7

When evaluating hand radiographs, ensure all three standard views are available for comprehensive assessment, as this approach is endorsed by major radiological societies and supported by evidence showing improved diagnostic accuracy.