Radiographic Views for Left Fifth Digit Impact Injury
Order a standard three-view radiographic series of the left fifth finger immediately: posteroanterior (PA), true lateral, and oblique views. 1, 2
Why Three Views Are Essential
The American College of Radiology explicitly recommends a minimum three-view examination (PA, lateral, and oblique) as the standard initial imaging for finger injuries, because two-view examinations miss a significant proportion of fractures. 2 Your clinical presentation—impact mechanism, substantial bruising and swelling, and limited flexion—creates high suspicion for fracture, making comprehensive imaging mandatory before any treatment decisions. 2
Critical Diagnostic Value of Each View
- The oblique view is particularly crucial because it detects phalangeal fractures that are completely occult on standard PA and lateral views alone, markedly improving fracture detection. 2
- The lateral view is essential for identifying volar (palmar) subluxation of the distal phalanx, which is an absolute surgical indication even with small fracture fragments. 1
- All three views together allow accurate assessment of articular involvement, interfragmentary gaps, and joint alignment—all of which determine whether you need conservative management versus urgent surgical referral. 1, 2
What You're Ruling In or Out
Your imaging must answer these specific questions that directly impact management:
For Mallet Finger (DIP Extensor Injury)
- Bony avulsion fracture involving ≥1/3 of the DIP joint articular surface requires surgical referral. 1
- Palmar subluxation of the distal phalanx on lateral view is an absolute surgical indication. 1
- Interfragmentary gap >3mm necessitates operative fixation. 1
For Middle or Proximal Phalanx Fractures
- Articular step-off or gap ≥2mm is the strongest predictor for surgical intervention and has the highest inter-observer agreement (kappa = 0.73). 2
- Stable fractures with <2mm articular displacement are appropriate for conservative buddy-taping treatment. 2
For Any Finger Fracture
- Rotational deformity requires hand surgeon evaluation and cannot be managed conservatively. 3
- Foreign bodies from the impact mechanism are best detected on initial radiographs. 2
Common Pitfall to Avoid
Do NOT proceed with splinting or definitive treatment before obtaining radiographs. 2 Delaying radiographs can lead to unreliable exclusion of fractures requiring surgery, and you may miss surgical indications that fundamentally alter the management approach. 1, 2 The American College of Radiology emphasizes that radiographs must be obtained before any wound closure or immobilization decisions in finger injuries. 2
If Initial Films Are Negative But Suspicion Remains High
- Splint the finger and repeat radiographs in 10–14 days, as occult fractures may become visible with early callus formation. 2
- Consider non-contrast CT scan for superior characterization of intra-articular extension if clinical findings strongly suggest fracture despite negative plain films. 2
- MRI without IV contrast can detect occult fractures and assess tendon injuries if diagnosis remains unclear. 2, 4
Practical Ordering Details
When ordering, specify:
- "Three-view left fifth finger series: PA, true lateral, and oblique" 2, 5
- Both approaches are acceptable: obtaining a PA view of the entire hand or focusing specifically on the injured fifth finger alone. 2
- Do not accept a two-view series—studies demonstrate that over half of patients with hand fractures receive inadequate imaging, with the oblique view missing in 64% of phalangeal fracture cases. 5