Hand fractures on X‑ray

Written by the X-Ray Atlas editorial team from the sources listed below · Medical review pending · Updated 24 October 2026 · Level: Beginner

Hand injuries are among the commonest reasons for an emergency department X-ray. Most are straightforward, but a few patterns carry a real risk of long-term loss of function if missed or mismanaged: intra-articular fractures at the base of the thumb, rotational deformity of a metacarpal, tendon avulsions, and the "fight bite" over a knuckle. Good hand reporting depends on the right views for the right finger and on knowing where the small avulsion fragments sit.

1. Views: hand, finger or thumb?

Choosing the right series matters more in the hand than almost anywhere else:

• Hand series: PA and oblique. Good for metacarpals and an overview, but the fingers overlap on a lateral and individual joints are not well shown.
• Finger series: PA and a true lateral of the individual finger, with the other fingers moved out of the way. Small avulsions and joint subluxations are often visible only on the true lateral.
• Thumb series: AP and lateral of the thumb. The thumb lies at an angle to the hand, so a hand film shows it obliquely.

Then read systematically: trace every cortex, check each joint for congruity and subluxation, look at the soft tissues for swelling, gas and foreign bodies (glass is usually visible; wood often is not).

2. Metacarpal fractures

Boxer's fracture

A fracture of the neck of the 5th metacarpal (sometimes the 4th), typically from punching. The metacarpal head angulates towards the palm (volar angulation of the head, apex dorsal). Measure the angulation on the oblique or lateral view. Acceptable angulation is greater for the 5th than for the 2nd and 3rd metacarpals, because of the mobility of the ulnar carpometacarpal joints; the exact thresholds are an orthopaedic decision and vary between sources.

Shaft and base fractures

• Shaft fractures: transverse, oblique or spiral. Spiral and oblique fractures can cause rotational deformity (scissoring of the fingers when making a fist), which is a clinical finding that the film can underestimate. Also note shortening.
• Base fractures and carpometacarpal (CMC) dislocations: injuries at the bases of the 4th and 5th metacarpals are easily missed on a PA because of overlap. On the PA the CMC joints should show parallel joint lines, like an "M"; loss of this pattern, or a lateral or oblique showing the base displaced dorsally, suggests a CMC fracture-dislocation. CT may be needed.

3. The thumb: Bennett, Rolando and gamekeeper's

Injury	Description	Why it matters
Bennett fracture	An intra-articular fracture at the base of the 1st metacarpal in two parts. A small volar-ulnar fragment stays attached to the trapezium by ligament, and the shaft is pulled dorsally and radially by abductor pollicis longus.	Unstable; usually needs fixation to restore the joint and prevent arthritis
Rolando fracture	A comminuted intra-articular fracture of the 1st metacarpal base with three or more fragments, often Y- or T-shaped	Worse prognosis than Bennett
Extra-articular base fracture	A transverse or oblique fracture of the 1st metacarpal base that does not enter the joint	More forgiving; distinguish from Bennett on the views
Gamekeeper's / skier's thumb	Injury to the ulnar collateral ligament (UCL) of the thumb MCP joint. May show a small avulsion fragment from the ulnar base of the proximal phalanx.	A complete tear with the adductor aponeurosis caught between the ligament and its insertion (Stener lesion) will not heal without surgery. It is diagnosed with ultrasound or MRI, not X-ray.

A normal thumb film does not exclude a UCL tear. "Gamekeeper's" originally described a chronic injury and "skier's" thumb the acute one; the terms are now used interchangeably.

4. Phalangeal fractures and avulsions

Several important injuries show up only as a small fragment of bone at a tendon or ligament attachment. Knowing where to look is half the diagnosis.

Injury	Fragment location	Mechanism and significance
Mallet finger	Dorsal base of the distal phalanx	Avulsion of the extensor tendon; the DIP joint droops in flexion. May be purely tendinous with a normal film. A large fragment with volar subluxation of the distal phalanx may need surgery.
Volar plate avulsion	Volar base of the middle phalanx	Hyperextension of the PIP joint. Check for subluxation on the true lateral.
Jersey finger	Volar base of the distal phalanx (if bony)	Avulsion of flexor digitorum profundus, most often the ring finger, from grabbing a shirt. The tendon can retract into the palm; needs early surgical referral.
Central slip avulsion	Dorsal base of the middle phalanx	Can lead to a boutonnière deformity

Other phalangeal fractures

• Shaft fractures of the proximal and middle phalanges angulate because of tendon pull; check for rotation clinically.
• Condylar fractures at the head of the proximal or middle phalanx are intra-articular and often unstable.
• Tuft fracture: a crush injury of the tip of the distal phalanx. If the nail bed is lacerated, or there is a subungual haematoma with a wound, treat it as an open fracture.

5. Dislocations

• PIP joint dislocation is usually dorsal. After reduction, a true lateral is essential to show joint congruity and any volar plate fragment.
• DIP and MCP dislocations are less common. A complex (irreducible) MCP dislocation can occur when the volar plate becomes trapped in the joint; on X-ray a sesamoid within the joint is a clue.
• CMC dislocations of the ulnar metacarpals: see above; easily missed on the PA.

6. Pitfalls and mimics

• Using a hand series for a finger injury: a hand film can miss a volar plate avulsion or subluxation that a true finger lateral shows clearly.
• Sesamoid bones (at the thumb MCP joint, and sometimes at the 2nd and 5th MCP joints) are smooth, round and corticated. Do not call them avulsion fragments.
• Nutrient canals and growth plates can mimic fracture lines. Physeal fractures in children are common at the bases of the phalanges: see Salter-Harris fractures.
• Rotation is a clinical diagnosis. The film can look acceptable while the finger scissors.
• Non-radio-opaque foreign bodies (wood, some plastics) may not show on X-ray. Ultrasound can help.

Red flags: act now

What to focus on, by role

Role	Priorities
Medical student	Boxer's, Bennett vs Rolando, mallet finger and the fight bite.
Nurse / ENP	Request the right series (finger vs hand vs thumb), recognise avulsion fragments, check for rotation and wounds.
Junior doctor	Measure angulation, look for intra-articular extension, examine for rotation, and know which injuries go to the hand surgeons.
Radiographer	True lateral of the injured finger with the others moved clear. Dedicated thumb views. Flag soft-tissue foreign bodies.
Advanced / FRCR	CMC fracture-dislocations, condylar fractures and subtle avulsions.

Practise on real upper limb X-rays →

References

1. Radiopaedia. Bennett fracture. radiopaedia.org
2. Radiopaedia. Rolando fracture. radiopaedia.org
3. Radiology Masterclass. Musculoskeletal X-ray tutorials and galleries. radiologymasterclass.co.uk
4. NICE NG38. Fractures (non-complex): assessment and management. nice.org.uk
5. British Orthopaedic Association. BOAST guidelines. boa.ac.uk

For education only. Not a substitute for a formal report, senior review or your local policy. Never use this page to make decisions about a real patient.