Radiographic views for hand fractures – call for three-view national UK guidelines – a quality improvement study

A three-view radiographic examination (comprising of antero-posterior, oblique and lateral views) is crucial for the accurate assessment and subsequent decision-making in hand fracture management. The superiority of a three-view examination, compared to only two views, has been demonstrated by multiple studies, citing increased diagnostic accuracy and reduced rates of misdiagnosis. As such, the American College of Radiology (ACR) now recommends a standard three-view examination for finger and hand injuries; despite this, no formal guidance exists in the United Kingdom. Out of the 235 patients referred to our tertiary hand trauma unit with a confirmed hand fracture, less than half (45%) had three-view radiographic examination performed. Less than two-thirds (57%) of metacarpal fractures had three views available at assessment in our unit, with the lateral radiograph most commonly lacking (38%). Less than a third (30%) of phalangeal fractures had all three views, with the oblique view most commonly absent (64% of cases). Reviewed radiology protocols from six local hospitals were inconsistent; all recommended three views for suspected metacarpal fractures, but only two for suspected phalangeal injuries. Despite the superiority of a three-view examination and no additional cost of a third view, over half of the patients in this study lacked a three-view radiographic series. The authors would like to call for national published guidance advocating the use of three-view radiographic series in all patients with a high hand fracture suspicion (as defined by the presence of swelling, bruising and/or deformity) to reduce variability in local radiology hand fracture protocols and increase availability of three-view radiographs in the primary, secondary and tertiary settings.