Hand and wrist injuries are among the most common reasons patients present for radiographic examination in emergency departments, urgent care centers, and outpatient orthopedic clinics. From a simple fall onto an outstretched hand (FOOSH injury) to suspected scaphoid fractures in young athletes, the radiologic technologist's ability to produce diagnostic-quality images of the hand, wrist, and digits directly impacts patient outcomes. A poorly positioned hand series can miss a subtle fracture, delay treatment, or lead to unnecessary repeat exposures — and no technologist wants to explain to a patient why they need a third image of an already painful injury.
This guide covers commonly used projections of the hand, wrist, and fingers. Exact series composition, naming, SID and special-view geometry vary by department and equipment. We cover positioning steps, centering points, anatomy inclusion, evaluation criteria, and common errors, but the order and radiologist-approved local protocol control in clinical practice.
This article covers the common hand series (PA, PA oblique, lateral), wrist series (PA, lateral, PA oblique), finger projections (PA, oblique, lateral for digits 2–5), thumb projections (AP, PA oblique, lateral), and special views including protocol-defined scaphoid projections, the Nørgaard view and the Gaynor-Hart carpal-canal view. We also address pediatric and trauma modifications.
Before positioning any part of the upper extremity, you must be comfortable with the underlying anatomy. The hand and wrist comprise 27 bones: 8 carpal bones in the wrist, 5 metacarpals in the palm, and 14 phalanges in the fingers (3 each for digits 2–5, 2 for the thumb). Knowing the bony landmarks helps you center accurately and evaluate your images for completeness.
Proximal row (radial to ulnar): Scaphoid (carpal navicular) — the most commonly fractured carpal bone, Lunate — frequently dislocated, Triquetrum, and Pisiform (a sesamoid bone sitting on the triquetrum). Distal row: Trapezium, Trapezoid, Capitate (the largest carpal bone), and Hamate (with its distinctive hook).
A helpful mnemonic is "So Long To Pinky, Here Comes The Thumb." It lists the proximal row radial-to-ulnar (scaphoid, lunate, triquetrum, pisiform), then reverses direction for the distal row ulnar-to-radial (hamate, capitate, trapezoid, trapezium). Do not use it as a radial-to-ulnar list for both rows.
Which carpal bone is most commonly fractured? The scaphoid. Much of its intraosseous supply enters distally, so a waist fracture can interrupt blood flow to the proximal pole; nonunion and proximal-pole osteonecrosis are important complications. The triquetrum, not the capitate, is generally the second most commonly fractured carpal bone.
A common routine hand series consists of posteroanterior (PA), PA oblique, and lateral projections. They provide complementary frontal, oblique, and lateral information about the phalanges, metacarpals, visible carpals, joints and soft tissues; series composition remains order- and protocol-dependent.
Positioning: The patient is seated at the end of the table with the affected arm extended. The hand is placed palm-down (pronated) on the IR with the fingers slightly separated. The central ray (CR) is directed perpendicular to the IR, entering at the third metacarpophalangeal (MCP) joint. The IR is centered to the same location.
Technical Factors: Use the validated technique chart for the detector, patient and presence of a cast rather than a universal kVp/mAs recipe. A small focal spot, manual exposure, tight collimation and a department-standard SID (commonly 100–115 cm / 40–44 in) are typical. A hand or wrist normally requires no grid; AEC chambers are poorly matched to this small anatomy. Review the detector exposure indicator against the manufacturer's target instead of judging exposure from display brightness.
Evaluation Criteria:
When positioning a patient with a painful or deformed hand, use a sponge cushion to support the forearm and elevate the wrist, allowing the hand to lie flat without the patient having to force the palm down. For suspected fractures, never force the hand into position — work with the patient's limited range of motion and document any positioning compromises.
Positioning: From PA, rotate the hand about 45 degrees with its ulnar side nearer the IR. Support the fingertips so the phalanges remain approximately parallel to the receptor and gently separate the digits. Direct a perpendicular CR to the third MCP joint. On a correctly rotated image the third through fifth metacarpal heads show slight overlap, while the second and third are generally separated; complete separation of every metacarpal is not the goal.
What It Shows: The oblique provides a different perspective on metacarpal and phalangeal cortex and joint alignment. It intentionally creates slight overlap of the third through fifth metacarpal heads, so it should not be described as producing less superimposition everywhere than PA.
Common Error: Too little rotation resembles PA; too much produces excessive metacarpal overlap and foreshortening. Aim for about 45 degrees with the ulnar side nearer the IR and evaluate the resulting metacarpal-head overlap rather than relying on unsupported hard cutoff angles.
Positioning: Place the ulnar aspect of the hand on the IR with the hand and wrist in a true lateral and the thumb up. For a fan lateral, spread the fingers and support them so their long axes are parallel to the IR; direct a perpendicular CR to the second MCP joint. Do not force a painful hand.
What It Shows: The fan lateral separates the phalanges but leaves the metacarpals largely superimposed. When localization of a metacarpal lesion or foreign body is the question, a straight/extension lateral (digits superimposed) or another local protocol may be requested. Lateral imaging demonstrates dorsal/volar displacement, but it does not make displacement invisible on the other views.
The wrist series is one of the most frequently ordered extremity exams. Accurate positioning is critical because subtle wrist fractures (scaphoid, lunate, distal radius) can be easily missed with suboptimal technique.
Positioning: Seat the patient with shoulder, elbow and wrist in the same plane. Pronate the hand, center the wrist to the IR, and gently flex the fingers enough to bring the anterior wrist into contact without making a fist. Direct a perpendicular CR to the midcarpal area. A tightly clenched fist is a separate stress projection for suspected scapholunate instability and must not be substituted routinely or performed without the ordered protocol.
Evaluation Criteria:
The radial styloid normally lies distal to the ulnar styloid on PA imaging, but apparent styloid level is affected by anatomy and beam/limb alignment and should not be used alone to diagnose rotation. Formal radial inclination and volar tilt are measured with defined methods on properly positioned PA and lateral images; they are interpretation measurements, not positioning absolutes.
PA is routine. If pronation is unsafe or impossible, an AP can be obtained with the dorsal wrist against the IR and a perpendicular CR to the midcarpal area. Label it AP: reversing the projection changes magnification and the appearance of the carpal and distal radioulnar relationships, so PA image criteria and measurements cannot simply be applied unchanged.
Positioning: Place the ulnar aspect of the wrist on the IR. Keep the elbow flexed about 90 degrees and the forearm, wrist and hand in the same plane; maintain neutral flexion/extension and avoid radial/ulnar deviation. Direct a perpendicular CR to the midcarpal area. Flexing the fingers may help relaxation, but do not let it flex the wrist.
Critical Evaluation: A true lateral has the distal radius and ulna largely superimposed. The pisiform should project roughly midway between the volar cortices of the distal scaphoid and capitate; its position is a more useful rotation check than demanding exact superimposition of the styloid tips. Radius–lunate–capitate–third-metacarpal alignment is assessable, but DISI/VISI diagnosis and any fracture/dislocation determination belong to the interpreting clinician.
Positioning: From PA, rotate the wrist about 45 degrees with the ulnar side nearer the IR and direct a perpendicular CR to the midcarpal area. This PA oblique demonstrates the radial carpus, especially the scaphoid and trapezium, with reduced superimposition. A reverse (medial-rotation) oblique is a different, less-routine projection that emphasizes the ulnar carpus; name and label the projection rather than saying only “oblique.”
| Projection | Centering Point | CR Angle | SID | Key Anatomy Shown |
|---|---|---|---|---|
| PA Hand | 3rd MCP joint | 0° (perpendicular) | 100–115 cm* | Phalanges, metacarpals, carpals and distal radius/ulna |
| PA Oblique Hand | 3rd MCP joint | 0°, hand rotated ~45° | 100–115 cm* | Metacarpals and phalanges in oblique profile |
| Lateral Hand (Fan) | 2nd MCP joint | 0° | 100–115 cm* | Separated phalanges; superimposed metacarpals |
| PA Wrist | Midcarpal area | 0° | 100–115 cm* | Distal radius/ulna, carpals and proximal metacarpals |
| Lateral Wrist | Midcarpal area | 0° | 100–115 cm* | Distal radius/ulna, radiocarpal and carpal alignment |
| PA Oblique Wrist | Midcarpal area | 0°, wrist rotated ~45° | 100–115 cm* | Scaphoid, trapezium, radial carpus |
| Scaphoid, PA Ulnar Deviation | Scaphoid | 0°; or Stecher 10–20° toward elbow* | 100–115 cm* | Elongated scaphoid; appearance depends on named method |
| Norgaard (Ball-Catcher's) | Midpoint between 5th MCP joints | 0°; bilateral AP oblique | 100–115 cm* | MCP joints and marginal erosions |
*SID and special-view angle vary by validated department protocol. The table is not an exposure chart; use local technique factors and clearly identify the selected Stecher or equivalent method.
A scaphoid series is a protocol-defined set of projections intended to visualize the scaphoid. A fracture can be radiographically occult initially. When clinical suspicion persists, obtain only the ordered dedicated views and follow the clinical pathway; dedicated radiographs, repeat radiographs, CT and MRI are not interchangeable technologist-selected options.
Positioning: With the hand PA, gently deviate the wrist toward the ulna only as tolerated. Center to the scaphoid, just distal and medial to the radial styloid. A basic PA ulnar-deviation view uses a perpendicular CR. The named Stecher method instead uses approximately 10–20 degrees toward the elbow (or elevates the hand about 20 degrees with a perpendicular ray). These are protocol alternatives, not angles to combine. Do not routinely clench the fist; that is a distinct stress maneuver and may reduce comfortable ulnar deviation.
Why This Works: Ulnar deviation moves the scaphoid away from the radius and into a more elongated, longitudinal position, reducing bony superimposition and allowing the waist of the scaphoid to be evaluated in profile.
Some departments include additional projections as part of the scaphoid series:
Negative initial radiographs do not exclude a clinically suspected scaphoid fracture, and a technologist should not “clear” it or independently repeat views. Follow the ordered scaphoid protocol and escalate persistent concern to the responsible clinician. Under the ACR Acute Hand and Wrist Trauma criteria, repeat radiographs in 10–14 days, MRI without contrast, and CT without contrast are alternative usually appropriate next studies after negative or equivocal initial radiographs; selection and immobilization are clinical decisions.
Each finger (digits 2–5) and the thumb (digit 1) can be imaged individually when a single digit is the clinical concern. Individual digit imaging allows for better detail and less superimposition than a full hand series.
A typical finger series uses three projections: PA, oblique, and lateral, subject to the order and local protocol. Include the entire digit from tip through the distal metacarpal and relevant joint; overly tight collimation that excludes the MCP joint or soft tissues is not acceptable.
PA Finger: Place the palmar surface of the affected digit on the IR, extend it without force, and move adjacent digits aside without obscuring the MCP joint. Direct the CR to the PIP joint (to the DIP joint for the distal phalanx only if the ordered area requires that modification).
Oblique Finger: Rotate the digit about 45 degrees and support it so its long axis remains parallel to the IR; center to the PIP joint. “External” rotation is side-dependent and is less useful than confirming a diagnostic 45-degree oblique without superimposing the digit of interest.
Lateral Finger: Place the affected digit in a true lateral, separate the other digits, and center to the PIP joint. A mediolateral is commonly used for the index finger and a lateromedial for digits 3–5 to keep the digit close to the IR, but comfort, injury and local protocol govern. Confirm superimposed phalangeal condyles rather than assuming one maneuver works for every digit.
The thumb is positioned differently from the fingers because of its unique orientation (rotated 90 degrees relative to the other digits).
AP Thumb (Anteroposterior): Rotate the hand/arm until the posterior surface of the thumb is against the IR, without forcing an injured thumb. Direct the CR to the first MCP joint and include the entire first metacarpal and trapezium.
PA Oblique Thumb: Place the hand in its natural arched position with the palm toward the IR; this usually places the thumb obliquely. Adjust support to obtain about a 45-degree oblique and center to the first MCP joint.
Lateral Thumb: With the hand pronated, flex the other fingers and gently abduct the thumb into a true lateral, supporting as needed. Center to the first MCP joint and check superimposition of the first metacarpal and phalangeal condyles. Radiographs may show fracture or joint alignment, but a routine lateral does not by itself diagnose an UCL tear.
Skier's/gamekeeper's thumb involves the ulnar collateral ligament of the first MCP joint. Never manually stress an acutely injured thumb unless a qualified clinician explicitly orders and supervises the maneuver under the facility protocol. An avulsion fragment may occur at the ulnar base of the proximal phalanx, but it is not synonymous with a Stener lesion; a Stener lesion is a displaced torn ligament lying superficial to the adductor aponeurosis and is generally assessed clinically and with ultrasound or MRI.
The Nørgaard (ball-catcher's) view is a bilateral AP oblique, not PA. Place both hands in about 45 degrees of semisupination with their medial borders supported, thumbs abducted and fingers slightly flexed as if holding a ball. Center between the hands at the level of the fifth MCP joints (or follow the department's bilateral-hand centering protocol). It profiles the second through fifth MCP margins and can demonstrate early marginal erosions of inflammatory arthritis; it is not a routine acute-trauma view.
The Gaynor-Hart inferosuperior tangential projection profiles the carpal canal, including the pisiform, hook of hamate and trapezial ridge. With the palm against the IR, extend the wrist only if safe and tolerable and rotate the hand slightly toward the radial side to reduce pisiform/hamate superimposition. Direct the CR about 25–30 degrees to the long axis of the hand, entering the palm roughly 2.5 cm (1 in) distal to the base of the third metacarpal. Exact geometry varies with equipment and named protocol. This view can assess bony canal anatomy or a suspected hook-of-hamate lesion; plain radiography does not establish median-nerve compression. Do not force hyperextension in acute trauma or suspected fracture—use an ordered alternative projection or cross-sectional imaging protocol.
Even experienced technologists make positioning errors on hand and wrist exams. Here are the most frequent mistakes and how to correct them:
The hand looks asymmetrical — one side appears wider. Ensure the palm is flat against the IR with no tilt. Use a small wedge under the forearm if needed.
Fingers touching obscure bony margins. Gently separate fingers using cotton balls or radiolucent spacers between digits. Explain to the patient why this is necessary.
Extraneous anatomy increases scatter and reduces image quality. Collimate tightly to the area of interest. For individual digits, the collimation should be just larger than the digit itself.
Use a short exposure time permitted by the validated technique and support the limb. Ask the patient to keep the hand still; routine breath-holding is unnecessary for a supported distal-extremity exposure.
Ulnar deviation elongates the scaphoid, but never force the “full range” in trauma. Use only tolerable movement and the named protocol; document limitations rather than repeating solely for ideal appearance.
Use distal radius/ulna overlap plus the pisiform's position about midway between the volar distal scaphoid and capitate. Exact styloid-tip superimposition is not required and is anatomically unreliable.
Pediatric hand and wrist imaging requires special attention. Children have open growth plates (physes) that can be mistaken for fractures by the untrained eye. The distal radial and ulnar physes are common sites of Salter-Harris fractures in children.
When a patient presents with a suspected fracture, dislocation, or severe deformity, standard positioning protocols must be adapted. The following principles apply:
Image the symptomatic/requested side and place a radiopaque R/L marker in the collimated field without covering anatomy; electronic annotation is not a substitute for an exposed side marker where policy requires one. For bilateral Norgaard imaging, mark both hands unambiguously. Verify patient, side and projection before exposure, collimate to the required anatomy, use manual technique rather than AEC for these small parts, and check the detector exposure indicator after acquisition.
Try these ARRT-style multiple choice questions based on this article. Click an option to check your answer — correct answers turn green, wrong ones turn red.
Positioning names, angles and SID may differ among validated department protocols. This guide labels important alternatives; it does not replace the examination order, equipment-specific technique chart, radiologist-approved protocol or local law. No page-specific claim is attributed here to Clark's Positioning in Radiography.
Try these ARRT-style multiple choice questions based on this article. Click an option to check your answer — correct answers turn green, wrong ones turn red.