Hand radiograph (an approach)

Andrew Murphy and Dr Jeremy Jones et al.

Hand radiographs are commonplace in the Emergency Department or the trauma reporting list.

A hand radiograph contains a PA and oblique view of the distal radius and ulna and the carpus.

  • check the wrist as you would for a wrist radiograph (an approach)
    • distal radius
    • carpal alignment
    • carpometacarpal articulation
    • bone cortex

Assess the carpal and carpometacarpal joint space:

  • 1-2 mm joint space should be seen between the carpals and metacarpals
  • look specifically at the base of the 4th and 5th metacarpals
  • if the joint space is narrowed, think carpometacarpal dislocation

Assess the interphalangeal joint space:

  • metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints should be congruent and there should be a visible joint space

Assess the cortex of each metacarpal in turn:

  • pay particular attention to the 1st and 5th metacarpals
  • metacarpal injuries or those affecting several phalanges may coexist with injuries to other digits
  • if cortical disruption of the 5th metacarpal neck, think Boxer fracture
  • be wary of fractures involving the joint surface - they are unstable
  • if intra-articular cortical disruption of the 1st metacarpal base, think Bennett fracture dislocation or Rolando fracture

Assess the alignment of the metacarpals and phalanges:

Assess the cortex of each phalanx in turn, proximal to distal:

  • common upper extremity dislocation
  • usually a hyperextension injury
  • typically dorsal dislocation of PIP joint +/- bony avulsion
  • palmar bony fragment indicates avulsion of volar plate
  • more: interphalangeal joint dislocation
  • disruption of extensor mechanism at DIP joint leading to tendon injury +/- bony avulsion
  • extended finger struck at the tip or crushed
  • dorsal bony fragment indicates avulsion of the extensor tendon
  • more: Mallet finger
  • minimally comminuted, transverse fracture of the 5th metacarpal
  • 25% of all metacarpal fractures
  • usually young male adults
  • caused by a direct blow when the fist is clenched
  • more: Boxer fracture
  • unstable intra-articular fracture of the base of 1st metacarpal 
  • caused by forceful thumb abduction
  • large metacarpal fragment dislocated by a pull of abductor pollicis longus
  • small metacarpal fragment remains attached to MCP joint
  • more: Bennett fracture
  • rupture of ulnar collateral ligament of 1st MCP joint
  • there may be an associated bony avulsion
  • avulsion fracture occurs at the ulnar corner of the proximal phalanx base
  • caused by forceful thumb abduction
  • more: Gamekeeper's thumb
  • base of 1st metacarpal intra-articular fracture - comminuted (3 fragments) and highly unstable
  • axial blow to partially flexed metacarpal
  • fracture line typically T or Y-shaped
  • more: Rolando fracture
  • rare but significant injury to dominant hands of younger males
  • younger male predominance
  • often occur after a punch followed by a fall
  • reduction of joint space on the AP
  • best seen on an oblique study
  • more: carpometacarpal dislocation
  • common benign medullary cartilaginous neoplasm
  • tend to be seen in young adults
  • 50% lesions found in small tubular bones
  • complicated by pathological fracture
  • more: enchondroma
Approaches to radiographs
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Article information

rID: 28414
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Cases and figures

  • Figure 1: annotated
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  • Case 1: IP joint dislocation
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  • Case 2: Mallet finger
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  • Case 3: boxer fracture
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  • Case 4: Bennett fracture
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  • Case 5: gamekeeper's thumb
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  • Case 6: Rolando fracture
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  • Enchondroma & pat...
    Case 8: enchondroma
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