Streamlining emergent hand and wrist radiography with a modified four-view protocol

Henry Y. Chou, Scott D. Steenburg, Jeffrey W. Dunkle, Sean D. Gussick, Matthew J. Petersen, Marc D. Kohli, Changyu Shen, Hongbo Lin

Research output: Contribution to journalArticle


This study aims to determine whether a modified four-view hand and wrist study performs comparably to the traditional seven views in the evaluation of acute hand and wrist fractures. This retrospective study was approved by the institutional review board with waiver of informed consent. Two hundred forty patients (50 % male; ages 18–92 years) with unilateral three-view hand (posteroanterior, oblique, and lateral) and four-view wrist (posteroanterior, oblique, lateral, and ulnar deviation) radiographs obtained concurrently following trauma were included in this study. Four emergency radiologists interpreted the original seven images, with two radiologists independently evaluating each study. The patients’ radiographs were then recombined into four-view series using the three hand images and the ulnar deviated wrist image. These were interpreted by the same radiologists following an 8-week delay. Kappa statistics were generated to measure inter-observer and inter-method agreement. Generalized linear mixed model analysis was performed between the seven- and four-view methods. Of the 480 reports generated in each of the seven- and four-view image sets, 142 (29.6 %) of the seven-view and 126 (26.2 %) of the four-view reports conveyed certain or suspected acute osseous findings. Average inter-observer kappa coefficients were 0.7845 and 0.8261 for the seven- and four-view protocols, respectively. The average inter-method kappa was 0.823. The odds ratio of diagnosing injury using the four-view compared to the seven-view algorithm was 0.69 (CI 0.45–1.06, P = 0.0873). The modified four-view hand and wrist radiographic series produces diagnostic results comparable to the traditional seven views for acute fracture evaluation.

Original languageEnglish (US)
Pages (from-to)333-338
Number of pages6
JournalEmergency Radiology
Issue number4
StatePublished - Aug 1 2016


  • Fracture
  • Hand
  • Radiography
  • Trauma
  • Wrist

ASJC Scopus subject areas

  • Emergency Medicine
  • Radiology Nuclear Medicine and imaging

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    Chou, H. Y., Steenburg, S. D., Dunkle, J. W., Gussick, S. D., Petersen, M. J., Kohli, M. D., Shen, C., & Lin, H. (2016). Streamlining emergent hand and wrist radiography with a modified four-view protocol. Emergency Radiology, 23(4), 333-338.