How to Order an X-ray for Suspected Finger Fracture
Order a standard 3-view radiographic series of the affected finger consisting of posteroanterior (PA), lateral, and oblique views—relying on only 2 views is inadequate and will miss fractures. 1
Standard Radiographic Protocol
The minimum acceptable imaging for a suspected finger fracture requires three orthogonal views: 1
- Posteroanterior (PA) view of the injured finger 1
- True lateral view to assess displacement and angulation 1, 2
- Oblique view (externally rotated) to increase diagnostic yield 1
Some institutions include a PA view of the entire hand for comparison, while others limit the examination to the injured finger alone—both approaches are acceptable per the American College of Radiology. 1
Enhanced Diagnostic Yield
Consider adding an internally rotated oblique projection in addition to the standard externally rotated oblique view, as this increases detection of phalangeal fractures that may be missed on standard 3-view series. 1 This fourth view is particularly valuable when clinical suspicion is high despite adequate initial imaging.
Common Pitfall to Avoid
Never accept a 2-view series as adequate—this is the most common imaging error in finger fracture evaluation and leads to missed diagnoses. 1, 3 The American College of Radiology explicitly states that relying on only 2 views is inadequate for detecting fractures in the phalanges. 1
When Initial X-rays Are Negative But Clinical Suspicion Remains High
If radiographs are negative but you strongly suspect a fracture based on mechanism, swelling, point tenderness, or loss of function: 1
- Option 1: Place the patient in a short arm cast or finger splint and repeat radiographs in 10-14 days to detect fractures that become visible after bone resorption at the fracture line 1
- Option 2: Order MRI without IV contrast for immediate diagnosis of occult fractures, bone contusions, or ligamentous injuries 1
CT is usually not indicated during acute finger injury evaluation and should be reserved for complex intra-articular fractures requiring surgical planning. 1
What to Document in Your Order
When ordering the X-ray, specify:
- "3-view finger series: PA, lateral, and oblique views"
- The specific finger involved (e.g., "right index finger")
- Clinical indication: "suspected fracture" with mechanism if known (e.g., "crush injury," "direct blow," "hyperextension injury")
This ensures the radiology technician obtains proper positioning and the radiologist has appropriate clinical context for interpretation. 2, 3