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XRAY
Upper ExtremityDemonstration data

Extremity X-Ray (Hand)

Radiography of the hand is a fast, high-resolution study for evaluating fractures, dislocations, arthropathies, soft-tissue foreign bodies and, in children, skeletal maturation. The hand's superficial bones and thin soft tissues make plain film highly informative, and standardised PA, oblique and lateral projections give complementary views of the metacarpals, phalanges and carpus. A non-dominant left hand PA is the reference standard for bone-age estimation.

Indications

  • Acute trauma with suspected fracture or dislocation of phalanges, metacarpals or carpus
  • Evaluation of inflammatory or degenerative arthritis (rheumatoid, osteoarthritis, psoriatic, gout)
  • Suspected radiopaque foreign body
  • Bone-age assessment in paediatric endocrine and growth disorders
  • Assessment of bone lesions, enchondroma or other tumours
  • Soft-tissue swelling, infection or suspected osteomyelitis
  • Post-reduction and postoperative assessment of alignment and hardware

Contraindications & Cautions

  • No absolute contraindications
  • Very low radiation dose (~0.001 mSv); the extremity is far from radiosensitive organs
  • Pregnancy is not a contraindication; use a lead apron for reassurance and justify
  • Apply ALARA, particularly with repeated films and in children
  • Collimate tightly to the region of interest

Patient Preparation

  • Remove rings, watches, bandages and jewellery from the hand where possible
  • No fasting or sedation required
  • Position the hand flat on the detector for the PA view, palm down, fingers slightly separated
  • Explain positioning for oblique and lateral views; support the hand as needed
  • For bone age, use the PA of the non-dominant (usually left) hand and wrist
  • In paediatrics, comparison with the contralateral side may aid interpretation of growth plates

Technique & Parameters

  • Standard projections: PA, oblique (45-degree semipronated) and lateral views of the hand
  • PA is centred over the third metacarpophalangeal joint
  • Low kVp (50-60 kVp) high-detail technique with a small focal spot; no grid
  • Include the distal radius and ulna and all digit tips within the field
  • Dedicated finger or thumb views when a single digit is the focus (thumb requires a true AP and lateral)
  • Include the adjacent joint when clinical concern extends beyond the hand
  • Bilateral comparison films in selected paediatric cases and for symmetric arthropathy

Systematic Review

  • Confirm correct patient, side marker and adequacy of the three views
  • Trace the cortical outline of each phalanx, metacarpal and carpal bone for step or lucency
  • Assess joint spaces at the DIP, PIP, MCP, carpometacarpal and radiocarpal joints
  • Evaluate alignment and the normal carpal arcs (Gilula's lines) on the PA view
  • Assess bone density, trabecular pattern and any focal lytic or sclerotic lesion
  • Inspect soft tissues for swelling, foreign body, gas or calcification
  • In children, evaluate growth plates and epiphyses for injury or maturation
  • Compare with prior films where available

Key Findings & Significance

  • A cortical break, step-off or lucent line indicates a fracture; assess displacement, angulation and intra-articular extension
  • Marginal erosions, periarticular osteopenia and MCP/PIP joint involvement suggest rheumatoid arthritis
  • Osteophytes, joint-space narrowing and subchondral sclerosis at DIP joints and the thumb base suggest osteoarthritis
  • Well-defined lucent lesion in a phalanx with chondroid matrix suggests enchondroma
  • Erosions with overhanging edges and preserved bone density suggest gout
  • Soft-tissue swelling and periosteal reaction may indicate infection or osteomyelitis
  • Displaced radiopaque foreign body localised on two orthogonal views
  • Scaphoid tenderness with a subtle waist lucency indicates a scaphoid fracture (may be occult initially)

Differential Considerations

  • Periarticular erosions: rheumatoid arthritis, psoriatic arthritis, gout, erosive osteoarthritis
  • Lytic phalangeal lesion: enchondroma, giant cell tumour, infection, glomus tumour, metastasis
  • Symmetric joint-space narrowing with sclerosis: osteoarthritis, post-traumatic change
  • Diffuse osteopenia: disuse, hyperparathyroidism, osteomalacia, inflammatory arthropathy
  • Acro-osteolysis: scleroderma, psoriasis, hyperparathyroidism, thermal/occupational injury
  • Soft-tissue calcification: scleroderma/CREST, tumoral calcinosis, prior injury
  • Pencil-in-cup deformity: psoriatic arthritis, erosive osteoarthritis

Pearls & Pitfalls

  • The scaphoid fracture is frequently occult on initial films; if clinically suspected, immobilise and re-image or obtain MRI/CT
  • Always image a joint above and below the site of concern to avoid missing a second injury
  • A single view is insufficient to exclude a foreign body or subtle fracture - use orthogonal projections
  • Assess the carpal arcs (Gilula's lines); disruption suggests carpal instability or dislocation such as perilunate/lunate dislocation
  • Sesamoid bones, accessory ossicles and nutrient canals should not be mistaken for fractures
  • In bone-age assessment, use a standardised atlas (Greulich and Pyle or Tanner-Whitehouse)
  • Distribution of arthritis (DIP versus MCP, symmetric versus asymmetric) is key to the diagnosis

Structured Report

  • State views obtained, side and adequacy
  • Describe any fracture: bone, location, pattern, displacement, angulation and articular involvement
  • Describe joint spaces, erosions, alignment and the pattern/distribution of any arthropathy
  • Report bone lesions with size, margin and matrix, and soft-tissue abnormalities or foreign bodies
  • For bone age, state the estimated skeletal age and the atlas used
  • Impression: concise summary and recommendation (e.g. immobilisation, MRI for occult scaphoid fracture, follow-up)

References

  • ACR-SPR-SSR Practice Parameter for the Performance of Radiography of the Extremities
  • Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist
  • Resnick D. Diagnosis of Bone and Joint Disorders, Elsevier
  • Royal College of Radiologists iRefer guidelines
  • Raby N, Berman L, de Lacey G. Accident and Emergency Radiology: A Survival Guide, Elsevier

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.