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.

Extremity X-Ray (Hand)

📋 Indications

⛔ Contraindications & Cautions

🧑‍⚕️ Patient Preparation

⚙️ Technique & Parameters

🔎 Systematic Review

🩻 Key Findings & Significance

🧠 Differential Considerations

💡 Pearls & Pitfalls

📝 Structured Report

📚 References