Pediatric hand (lateral view)

The lateral hand view for pediatrics is an orthogonal view taken along with the PA view of the hand. The lateral view is used to primarily assess for foreign bodies and/or displacement of fractures/dislocations.

Indications

This view is useful in assessing suspected dislocations, fractures or localizing foreign bodies in the metacarpals, phalanges and joints in the hand. It can also help in evaluating juvenile idiopathic/rheumatoid arthritis particularly in the phalanges.

Patient position

• patient is seated alongside the table
• the affected arm if possible is flexed at 90° so the arm and hand can rest on the table
• the hand is rotated externally by 90° from the basic PA position so that the palm is perpendicular to the image receptor
• shoulder, elbow, and wrist should all be in the transverse plane, perpendicular to the central beam
• fingers are kept extended with thumb abducted
• fingers should ideally be separated to minimize superimposition and increase diagnostic information contained in the image

Technical factors

• lateral projection
• centering point
  • over the head of the second metacarpal
• collimation
  • anteroposterior to the skin margins
  • distal to the tips of the distal phalanges
  • proximal to include distal radioulnar joint; patients may have referred pain from pathology other than the hand
• orientation  
  • portrait
• detector size
  • 18 cm x 24 cm
• exposure ¹
  • 40-52 kVp
  • 2-3 mAs
• SID
  • 100 cm
• grid
  • no

Image technical evaluation

Fingers should appear equally separated. The third and fourth digits in this lateral view are mostly superimposed so more care should be taken to separate these. (This, however, is of no concern if that is not the area of interest - e.g. if the patient states no pain in that area.)

Correct lateral positioning is evidenced by the following:

• interphalangeal joint spaces are open
• metacarpals are mostly superimposed, with slight over-rotation externally allowing the fracture at the base of the 5th metacarpal to be visualized
• posterior aspect of the distal radius and ulna are superimposed

Practical points

Preparing the room beforehand (setting up the detector, exposure and preparing lead gowns) is extremely beneficial for hand imaging as young children may not remain still when their affected hand is brought away from their body.

To separate the fingers, get patients into a fan lateral position by getting them to give you an "okay" gesture.

Immobilization techniques

Ideally, if parental holding is required, the parent holds the proximal part of the child’s arm from anterolaterally in order to be in the child's direct line of sight:

• this will require clear instructions for parents to follow, hence preventing malrotation/motion artifact from a wriggling child
• if the parent is accompanying the child by holding them in position, whilst the parent puts on a lead gown, it is the radiographer's responsibility to ensure the child does not fall off the chair
• if other methods can be used such as distraction techniques, this is ideal to avoid scattered radiation to parents and staff ²