How do I write an order for a hand x-ray to evaluate for fracture or internal damage?

How to Write an X-ray Order for Hand Fracture Evaluation

Order a minimum 3-view hand radiograph series consisting of posteroanterior (PA), oblique, and lateral views to adequately evaluate for fracture or internal damage. 1, 2

Standard Radiographic Protocol

Minimum Required Views

• A 3-view series is the standard of care and should never be reduced to only 2 views, as two-view imaging is inadequate for detecting fractures in the extremities and leads to missed diagnoses 1, 2
• The three essential views are:
  • Posteroanterior (PA) view in neutral position and rotation 1
  • Oblique view (typically 45° semipronated) 1, 2
  • Lateral view to demonstrate malalignments and soft-tissue swelling 1

Writing the Order

Your order should specify:

• "Hand radiograph, 3 views: PA, oblique, and lateral" 2
• Include the specific hand (right or left) 3
• State the clinical indication: "evaluate for fracture" or "rule out fracture" 3

Evidence Supporting 3-View Protocol

Diagnostic Superiority

• The American College of Radiology recommends a standard 3-view examination for finger and hand injuries based on increased diagnostic accuracy and reduced misdiagnosis rates 1, 2
• Studies demonstrate that relying on only 2 views leads to missed fractures, particularly in joint injuries 1
• A UK quality improvement study found that less than half (45%) of hand fracture patients had appropriate 3-view imaging, with the lateral view most commonly missing (38% of cases) for metacarpal fractures and the oblique view absent in 64% of phalangeal fractures 2

Clinical Consequences of Inadequate Imaging

• Missed hand fractures can lead to significant morbidity including malunion, nonunion, and post-traumatic arthritis 1
• Inadequate initial imaging may require repeat visits and delayed diagnosis 2

Common Pitfalls to Avoid

Ordering Errors

• Do not order "hand x-ray 2 views" - this is substandard and increases missed fracture rates 1, 2
• Do not assume the radiology department will automatically perform 3 views - explicitly specify all three views in your order 2
• Be aware that some local protocols may only recommend 2 views for phalangeal injuries, which contradicts best practice guidelines 2

When Additional Imaging May Be Needed

• If initial 3-view radiographs are negative but clinical suspicion remains high (persistent swelling, bruising, deformity, or point tenderness), consider: 1
  • Immobilization in a short arm cast with repeat radiographs in 10-14 days 1
  • MRI without IV contrast (sensitivity 94.2%, specificity 97.7%) for occult fractures 1
  • CT without IV contrast for detailed bone cortex evaluation, particularly useful if the patient is already casted 1

Special Considerations for Wrist Involvement

If the injury involves the wrist or distal radius:

• Order a 4-view wrist series (PA, lateral, 45° semipronated oblique, and scaphoid view) as this increases diagnostic yield for both distal radius and scaphoid injuries 1
• The scaphoid view is particularly important as missed scaphoid fractures can lead to avascular necrosis 1