Imaging Guidelines for Hand Trauma

Introduction to Imaging Options

MRI without IV contrast is an effective secondary imaging option for detecting fractures of the hand not visible on conventional radiographs, especially when clinical suspicion for fracture remains high 1
Radiographs, including a 3-view radiographic examination, are the best initial study for wrist pain, with or without prior injury, to detect fractures, dislocations, and joint alignment 1, 2

The American College of Radiology recommends MRI without IV contrast for detecting occult fractures, bone marrow edema, and concomitant soft tissue injuries, such as ligaments, tendons, and cartilage, when radiographs are negative but clinical suspicion remains high 1
MRI is not typically indicated as first-line imaging for metacarpal and digital fractures during acute injury, according to the American College of Radiology 1

The American College of Radiology states that MRI did not predict the need for treatment better than the combination of physical examination and radiography in one study 1
No evidence supports the use of MRI with IV contrast in acute hand trauma, as recommended by the American College of Radiology 1
CT without IV contrast is an alternative for excluding occult fractures, better for complex fractures with intra-articular extension, and useful for preoperative planning, but cannot evaluate concomitant ligamentous injuries, according to the American College of Radiology 1

Applying direct pressure to bleeding wounds is a recommended initial step, and if ineffective, more advanced measures should be considered, such as a finger tourniquet as a temporary measure, which must be reassessed frequently, as suggested by the Anaesthesia guideline society 3
If a fracture is suspected, do not attempt to straighten the injured extremity, as this may cause further injury, as advised by the American Heart Association 4 and reaffirmed by later guidelines 5
Vascular compromise, characterized by a pale or blue extremity, requires immediate EMS activation, as stated by the American Heart Association 4 and supported by subsequent guidelines 5

Essential views for wrist imaging include posteroanterior (PA) view, lateral view, and oblique (45° semipronated) view to evaluate bone alignment, joint spaces, displacement, and angulation 1
CT without IV contrast is recommended for complex fractures with intra-articular extension or when surgical planning is needed, and MRI without IV contrast for detecting concomitant ligamentous injuries or radiographically occult fractures, as recommended by the American College of Radiology 1

Surgical intervention is indicated for intra-articular fractures with >2mm step-off, volar displacement of fragments, interfragmentary gap >3mm, or postreduction radial shortening >3mm or dorsal tilt >10°, as recommended by the American Academy of Orthopaedic Surgeons 6, 1
Unstable fractures or dislocations, and fractures with specific characteristics, also require surgical intervention, with a strength of evidence level of low to moderate 1

Functional splinting is preferred over complete immobilization for stable, non-displaced fractures, with early exercises and supervised exercises focused on proprioception, strength, and coordination, as recommended by the American Academy of Orthopaedic Surgeons, with a strength of evidence level of moderate to low 6, 7, 1
A wrist splint in neutral position should be applied to reduce pressure in the carpal tunnel, and cold application can be used to reduce swelling and pain, according to the American Heart Association 4
Cold application should be limited to 20 minutes to prevent cold injury, and a barrier should be placed between the cold container and skin, as recommended by the American Heart Association 4

Wrist fractures in patients over 50 years should prompt investigation for osteoporosis, and systematic investigation of fracture risk is important for prevention of subsequent fractures, as recommended by the American College of Radiology, with a strength of evidence level of moderate to high 8, 2
Delayed treatment can lead to vascular compromise, and underestimating long-term impact can result in hand/wrist impairment a decade after trauma, highlighting the importance of prompt and appropriate management, with a strength of evidence level of moderate 9

Potential complications of wrist fractures include malunion, non-union, avascular necrosis, carpal instability, complex regional pain syndrome, and osteoarthritic changes, with untreated ligamentous injuries evolving into osteoarthritic changes, and delayed treatment compromising long-term function, as noted by the American College of Radiology, with a strength of evidence level of high to moderate 6, 8, 9, 1
Operative fixation resulting in <2mm of residual articular surface step-off is usually necessary to avoid long-term complications such as osteoarthritis in patients with wrist injuries 1
Distal radius fractures are a common type of wrist injury, accounting for up to 18% of fractures in the elderly, and restoration of radial length, inclination, and tilt is crucial for successful treatment, according to the American College of Radiology 1