Radiographic views for hand fractures - call for three view national uk guidelines - a quality improvement study.

Abstract

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 recommend 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. We 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 setting.