What is the recommended X-ray view for assessing hand anatomy and potential injuries?

Recommended X-ray Views for Hand Assessment

For hand and finger injuries, obtain a standard 3-view radiographic series consisting of posteroanterior (PA), lateral, and oblique views to adequately assess anatomy and detect fractures. 1

Standard Hand Radiographic Protocol

Finger (Phalangeal) Injuries

• A minimum 3-view examination is necessary and includes PA, lateral, and oblique projections 1
• Two views alone are inadequate for detecting phalangeal fractures and will miss significant injuries 1
• Adding an internally rotated oblique view (in addition to the standard externally rotated oblique) increases diagnostic yield for phalangeal fractures 1
• Some centers include a PA view of the entire hand, while others limit imaging to the injured finger—both approaches are acceptable per the American College of Radiology 1

Metacarpal Injuries

• The same 3-view series (PA, lateral, and oblique) is required for metacarpal fractures 1, 2
• The lateral view is most commonly missing in clinical practice (absent in 38% of cases in one quality improvement study), leading to missed diagnoses 2

Clinical Evidence Supporting 3-View Protocol

• The oblique view uniquely reveals abnormalities in 4.8% of distal extremity examinations and increases diagnostic confidence significantly 3
• When the oblique view is added to standard PA and lateral films, the percentage of equivocal examinations decreases from 13.9% to 8.4% 3
• The oblique view changed interpretation in 70 of 1,461 examinations, including 28 cases changed from negative to positive (missed fractures) 3

Common Pitfalls to Avoid

• Relying on only 2 views is the most common error and leads to missed fractures, particularly in the fingers where oblique views are frequently omitted (64% of phalangeal injuries in one study) 2
• Inconsistent local radiology protocols contribute to inadequate imaging—less than half of hand fracture patients receive appropriate 3-view series in some centers 2
• CT is usually not indicated during acute hand injury evaluation 1

When Initial Radiographs Are Negative

• If clinical suspicion remains high despite negative radiographs, consider:
  • Immobilization with repeat radiographs in 10-14 days 1
  • MRI without IV contrast for persistent clinical concern 1

Wrist-Specific Considerations

• For wrist injuries, the standard protocol differs slightly: PA, lateral, and 45° semipronated oblique views are recommended 4
• Adding a fourth scaphoid view increases diagnostic yield for both distal radius and scaphoid fractures 4
• Missed scaphoid fractures lead to significant morbidity including nonunion, avascular necrosis, and post-traumatic arthritis 4