What X-ray views are recommended for an arm injury?

X-Ray Views for Arm Injury

For acute arm trauma, order a minimum 3-view radiographic series of the specific anatomic region injured (anteroposterior, lateral, and oblique views), as 2-view examinations are inadequate for detecting fractures in extremity joints. 1

Initial Imaging by Anatomic Location

Wrist Injuries

• Standard 3-view series includes: posteroanterior (PA), lateral, and 45° semipronated oblique 1
• A fourth projection (semisupinated oblique) increases diagnostic yield for distal radius fractures 1
• The oblique view uniquely reveals abnormalities in 4.8% of cases and significantly increases diagnostic confidence from 13.9% to 8.4% 2

Hand Injuries

• Standard 3-view examination: PA, lateral, and externally rotated oblique 1
• Adding an internally rotated oblique projection increases diagnostic yield for phalangeal fractures 1
• For individual finger injuries, some centers image the entire hand PA view while others limit to the injured digit 1

Thumb Injuries

• Minimum 2-view examination is usually sufficient 1
• Adding an oblique projection provides slight increase in diagnostic yield 1
• The oblique can be obtained along with a PA examination of the whole hand 1

Shoulder Injuries

• Standard series: anteroposterior (AP) and either axillary lateral or scapular Y view 1
• The axillary lateral or scapular Y view is essential if instability or dislocation is suspected 1
• Caution: Positioning for axillary lateral may be painful and can cause redislocation in recently reduced shoulders 1

Common Pitfalls to Avoid

Two-view examinations miss significant pathology. Studies demonstrate that oblique views change interpretation in nearly 5% of cases, with 28 examinations changed from negative to positive when the third view was added 2. This is particularly critical for:

• Distal radius fractures where articular surface assessment determines operative vs. non-operative management 1
• Phalangeal fractures where standard 2-view series may miss fracture lines 1

Standard AP shoulder radiographs are frequently malpositioned. Research shows that routine clinical AP shoulder views often have mean angular offset of 38° from true AP, which can compromise fracture assessment 3. Ensure proper patient positioning to avoid this error.

If Initial Radiographs Are Negative or Equivocal

Next Steps:

• CT without IV contrast is the preferred advanced imaging to exclude occult fractures 1
• CT shows intra-articular extension more frequently than radiography and aids preoperative planning with 3D reconstructions 1
• MRI without contrast can detect occult fractures and evaluate concomitant ligamentous injuries that CT cannot assess 1
• Alternative: Place in short arm cast and repeat radiographs at 10-14 days, though this delays diagnosis and may lead to functional impairment 1

Never use CT with IV contrast for acute extremity trauma—there is no evidence supporting this practice. 1