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Normal Hand X-Ray Report Template (3-View)
Normal hand radiograph report template: PA, oblique and lateral views, alignment, metacarpals and phalanges, carpal arcs and visualized distal radius and ulna, joint spaces, mineralization and soft tissues, with notes on boxer's fracture angulation, scaphoid views, erosive arthritis and foreign bodies.
EXAMINATION: [Right / Left] hand radiograph, 3 views. CLINICAL HISTORY: [indication, e.g. “Punch injury, pain and swelling over the fifth metacarpal” / “Fall on outstretched hand, hand pain” / “Polyarthralgia, evaluate for inflammatory arthritis”] COMPARISON: None available. TECHNIQUE: PA, oblique and lateral views of the [right / left] hand. FINDINGS: Alignment: Normal alignment of the metacarpals and phalanges. No dislocation or subluxation of the carpometacarpal, metacarpophalangeal or interphalangeal joints. The carpal arcs are intact and the carpal bones are normally aligned. Metacarpals and phalanges: The first through fifth metacarpals and all phalanges are intact. No fracture, cortical irregularity or periosteal reaction. No fracture of the fifth metacarpal neck. Carpus and distal forearm: The visualized carpal bones, including the scaphoid, are intact. The visualized distal radius and ulna are unremarkable. Normal distal radioulnar joint. Joint spaces: Preserved at the carpometacarpal, metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints. No erosion, joint space narrowing, subchondral sclerosis or osteophyte. No periarticular osteopenia. Mineralization: Normal. Soft tissues: No soft tissue swelling, radiopaque foreign body, soft tissue calcification or gas. [Mild soft tissue swelling over the dorsum of the hand.] Growth plates: [Not applicable, skeletally mature. / The physes are open and normal in appearance for age.] IMPRESSION: 1. No acute fracture or dislocation of the [right / left] hand. 2. [No radiographic evidence of erosive arthropathy.]
Dictation notes
- The fifth metacarpal neck (boxer's) fracture is reported with its apex-dorsal angulation in degrees measured on the lateral or oblique view, any rotational deformity and shortening — angulation beyond about 30-40 degrees at the fifth and 10-20 at the second and third is the referral threshold.
- A hand series is not a scaphoid series: when the history is a fall on the outstretched hand with snuffbox tenderness, say the scaphoid is incompletely assessed and recommend dedicated scaphoid views or wrist radiographs.
- For arthritis indications, describe the distribution before the diagnosis — proximal (MCP, PIP, carpal) with marginal erosions and periarticular osteopenia favors rheumatoid; DIP-predominant with central erosions and osteophytes is erosive osteoarthritis; pencil-in-cup and periostitis favor psoriatic arthritis.
- Metal and glass are radiopaque; most wood and plastic are not. A negative radiograph for a wooden splinter is reported as such, with ultrasound as the next test.
- In children, the Salter-Harris type is the diagnosis, and a rotational malalignment of the fingers (overlapping nails on the lateral view, metacarpal heads out of the normal cascade) is a clinical and radiographic finding worth one sentence.
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