Extremity Fracture Clinical Pathway, Emergency Department – Radiographic Views for Identifying Fractures by Location

Extremity Fracture Clinical Pathway — Emergency Department

Radiographic Views for Identifying Fractures by Location

MD/PNP X-ray Ordering Guidelines for Extremity Trauma

  • Use ED Epic Fracture Orderset
  • 2 views = AP/Lateral
  • Requirements for additional views is Attending dependent
  • Comparison views need to be cleared by Radiology resident
    • High energy mechanisms or displaced fractures: include joint above and below
      the fracture
    • Buckle, toddler's, nondisplaced: do not include joint above and below
Location Standard Comments
Elbow 2 views
  • Add internal oblique
  • If lateral is non-diagnostic, consider external rotation on repeat lateral view
Forearm 2 views
  • Includes wrist, elbow
  • Order separate wrist and elbow X-rays
  • Concern for fracture and 2 view is negative
  • If only 1 forearm bone broken
Wrist 3 views
  • Does not include the hand
  • 2 view only for foreign body or post-reduction
  • Displaced wrist: obtain elbow and hand X-rays
  • Concern for scaphoid fracture – obtain scaphoid view
Hand 3 views
  • Includes wrist but just very distal radius and ulna
  • Obtain separate wrist views if concern for fracture
  • 2 view only for foreign body or post-reduction
Finger 3 views
  • Specify digit
  • Multiple digits: order hand and specify which digits need lateral
Shoulder 3 views
  • Standard: AP (internal and External rotation) and Y view
  • Velpeau view if concern for dislocation or proximal humerus fracture
Knee 2 views
  • Tunnel view if concern for osteochondritis dissecans in chronic knee pain
  • Oblique view if concern for acute knee fracture not visible on standard imaging
TIB/FIB 2 views
  • Includes ankle and knee, but mortise is not seen fully seen
  • Obtain separate ankle X-rays if concern for ankle injury
Ankle 3 views Includes base of 5th metatarsal
Foot 3 views Obtain if any concern of fracture more distal to the ankle joint