Yes, order a standard 3-view x-ray of the hand immediately.
In a 25-year-old with hand pain and swelling following a direct trauma (punching mechanism) three days ago, you should obtain a standard 3-view radiographic examination to evaluate for fracture, as this is the appropriate first-line imaging for acute hand trauma. 1, 2
Imaging Protocol
The American College of Radiology requires at minimum three views for adequate evaluation:
- Posteroanterior (PA) view
- Lateral view
- Oblique view 2
Relying on only 2 views is inadequate for detecting fractures in the fingers and hand. 2 Some centers add an internally rotated oblique projection in addition to the standard externally rotated oblique to increase diagnostic yield for phalangeal fractures. 2
Clinical Reasoning for This Case
This mechanism (punching/striking) is particularly concerning for several injury patterns:
- Metacarpal fractures (especially the 4th and 5th metacarpals in "boxer's fractures") are common with punching mechanisms 3
- Metacarpophalangeal (MCP) joint injuries including occult fractures and sagittal band disruptions can present with pain and swelling without obvious deformity 4
- The base of metacarpals can be difficult to assess radiologically due to overlying structures, making proper views essential 3
Important Pitfall to Avoid
The absence of erythema does not rule out fracture or significant injury. 1 The presence of swelling alone after trauma warrants radiographic evaluation. Patients with closed impact injuries can have significant internal damage including:
- Occult fractures
- Intra-articular injuries
- Partial ligamentous disruptions 4
If Initial X-rays Are Negative
If radiographs are negative but clinical suspicion remains high (persistent pain, swelling, limited mobility), you have two evidence-based options:
- Place the patient in a short arm cast and repeat radiographs at 10-14 days (downside: delays diagnosis which may lead to functional impairment) 1
- Consider MRI without IV contrast to detect occult fractures and evaluate soft tissue injuries including ligaments, tendons, and pulleys 1, 2
CT is usually not indicated for metacarpal and digital fractures during acute injury. 1, 2
Additional Red Flags in Punching Injuries
Be vigilant for "fight bite" injuries—any laceration over the MCP joint from a punching mechanism should raise concern for human bite with joint penetration and potential septic arthritis, even if the wound appears minor. 5