What are the recommended X-rays (x-rays) for a hand or wrist injury?

Recommended X-rays for Hand or Wrist Injury

For wrist injuries, a standard 3-view radiographic examination including posteroanterior (PA), lateral, and 45° semipronated oblique views is essential for detecting fractures, dislocations, and evaluating joint alignment. 1

Standard Radiographic Views for Wrist Injuries

The American College of Radiology recommends the following essential views:

1. Posteroanterior (PA) view

   • Evaluates bone alignment and joint spaces
   • Patient's palm faces downward (pronation)

2. Lateral view

   • Assesses displacement and angulation of fractures
   • Evaluates volar/dorsal alignment

3. Oblique view (45° semipronated)

   • Increases diagnostic yield for fractures and displacements
   • Provides additional perspective of the carpal bones

These three views together form the standard initial assessment for wrist injuries and can detect most common injuries including distal radius fractures, scaphoid fractures, carpal bone injuries, joint dislocations, and ulnar styloid fractures 1.

Additional Views for Specific Concerns

When there is clinical suspicion of specific injuries, additional views may be necessary:

• Scaphoid view

  • Specifically targets the scaphoid bone
  • Essential when scaphoid fracture is suspected clinically 2, 3

• Supination view

  • With palm facing upward
  • May be required in certain cases to complete the assessment 2

Advanced Imaging When Needed

If initial radiographs are negative but clinical suspicion remains high:

• CT scanning

  • Consider for complex fractures with intra-articular extension
  • Useful for preoperative planning 1

• MRI without contrast

  • Recommended when radiographs are normal but clinical suspicion remains high
  • Particularly useful for detecting ligamentous injuries 1

• Ultrasound

  • Preferred first option for detecting superficial foreign bodies
  • Especially valuable for radiolucent materials
  • Allows real-time guidance for removal 1

Dynamic/Stress Views

For suspected ligamentous injuries or instability:

• If clinical evidence suggests wrist instability, stress views may be necessary
• These views can detect subtle instabilities not visible on standard radiographs 2, 4
• Should be performed bilaterally for comparison 2

Common Pitfalls to Avoid

1. Inadequate positioning: Proper standardized positioning is crucial to avoid missing pathology 5

2. Overlooking scaphoid fractures: These can be missed on standard views, which is why a dedicated scaphoid view is important when clinically indicated

3. Failing to get additional views: When initial radiographs are negative but clinical suspicion remains high, additional imaging is necessary to avoid missed diagnoses

4. Not comparing with the contralateral side: In cases of suspected instability, bilateral comparative imaging may be necessary 2

Remember that delayed diagnosis of wrist injuries, particularly ligamentous injuries, can lead to long-term complications including chronic instability and osteoarthritic changes 1.