Hand X-Ray Positioning Guide: Master Oblique & Lateral Views

X-Ray Hand Oblique and Lateral Views: Positioning, Technique, Clinical Indications & Image Evaluation


Hand radiography is one of the most frequently performed musculoskeletal X-ray examinations in emergency departments and radiology clinics. Accurate positioning is essential for detecting fractures, joint abnormalities, foreign bodies, and degenerative or inflammatory diseases. Proper patient positioning also minimizes repeat exposures and improves diagnostic confidence.

This guide explains the Hand Oblique (Nørgaard/Ball Catcher's View) and Hand Lateral View, along with finger and thumb positioning techniques, clinical indications, image evaluation criteria, and radiation protection tips.



Why Are Hand Oblique and Lateral X-Rays Performed?


A hand X-ray is commonly requested by orthopedic surgeons, emergency physicians, rheumatologists, and general practitioners when patients present with pain, swelling, trauma, or reduced hand movement.

  • Common Clinical Indications

  • Hand injury following trauma

  • Suspected metacarpal or phalangeal fracture

  • Carpal bone fracture

  • Joint dislocation

  • Rheumatoid arthritis

  • Osteoarthritis

  • Soft tissue swelling

  • Foreign body localization

  • Boxer’s fracture

  • Follow-up after fracture treatment

  • Assessment of congenital abnormalities




Hand Oblique (Posterior Oblique / Ball Catcher's / Nørgaard Projection)


The Ball Catcher's View, also called the Nørgaard Projection, is a specialized bilateral oblique projection primarily used to evaluate early rheumatoid arthritis and subtle erosive changes in the metacarpophalangeal (MCP) joints. It is also useful for assessing fractures involving the base of the fifth metacarpal.

Patient Position

  • Seat the patient comfortably beside the X-ray table.

  • If the patient's condition does not allow side seating, position them facing the table while maintaining radiation protection.

  • Place both forearms in the supinated position.

  • Rest the dorsal surfaces of both hands on the image receptor.

  • Rotate both hands 45° medially, creating the characteristic "ball-catching" position.

  • Keep the fingers relaxed, slightly separated, and fully extended.

  • Support the hands with 45° radiolucent wedges if necessary.

  • Immobilize the forearms using a sandbag to reduce motion.


Central Ray

Vertical beam

Center midway between both hands

Level of the 5th metacarpophalangeal joints


Image Evaluation Criteria

  • A satisfactory radiograph should demonstrate:

  • Entire phalanges including fingertips

  • Soft tissue margins

  • Metacarpals

  • Carpal bones

  • Distal radius and ulna

  • Open MCP joint spaces

  • No superimposition of metacarpal heads

  • Adequate exposure demonstrating fine joint detail



Hand Lateral Projection

The lateral projection complements the routine PA hand examination and is valuable for evaluating fractures, dislocations, and foreign bodies.

Clinical Indications

Doctors commonly request a lateral hand X-ray for:

Hand trauma

  • Suspected carpal fractures

  • Foreign body localization

  • Joint dislocations

  • Metacarpal fractures

  • Post-operative assessment


Patient Position

  • Begin from the PA hand position.

  • Rotate the hand 90° externally.

  • Place the little finger side of the hand against the detector.

  • Keep the palm perpendicular to the cassette.

  • Fully extend the fingers.

  • Abduct the thumb and support it using a radiolucent sponge.

  • Ensure the radial and ulnar styloid processes are superimposed.


Central Ray

Vertical beam

Center over the head of the second metacarpal


Image Evaluation Criteria

  • A properly positioned lateral hand should demonstrate:

  • Entire hand including fingertips

  • Soft tissues

  • Distal radius and ulna

  • Superimposed metacarpal heads

  • Clearly visualized thumb without overlap

  • Minimal motion blur




Foreign Body Localization

When a patient presents with a suspected glass fragment, metal splinter, or other foreign body:

Reduce the kVp to improve soft tissue contrast.

Place a radiopaque marker over the puncture site.

Obtain at least two projections to accurately localize the foreign body.



Finger Radiography

Finger injuries are extremely common and require dedicated imaging to identify fractures, ligament injuries, tendon avulsions, and joint dislocations.

Routine examination usually includes:

Posteroanterior (PA)

Lateral projection


Adjacent fingers may be included when clinically indicated while carefully avoiding superimposition.

PA Finger Position

  • Forearm pronated

  • Finger extended

  • Finger separated from adjacent digits

  • Palm resting flat on the detector

  • Immobilize wrist with a sandbag


Central Ray

  • Center over the proximal interphalangeal (PIP) joint.

  • Image Criteria

  • Fingertip included

  • Distal one-third of the metacarpal included

  • Open interphalangeal joints

  • No rotation




Lateral Finger Projection

  • Different positioning techniques are used depending on the affected finger.

  • Index and Middle Finger

  • Place the lateral aspect of the finger on the detector.

  • Extend the affected finger.

  • Slightly flex the adjacent finger to avoid overlap.

  • Support using a radiolucent foam pad.


Ring and Little Finger

  • Rest the medial side of the little finger on the detector.

  • Extend the affected finger.

  • Flex remaining fingers into the palm.

  • Support with a radiolucent pad if required.


  • Central Ray

  • Center over the proximal interphalangeal joint.

  • Image Criteria

  • A diagnostic lateral finger image should demonstrate:

  • Fingertip

  • Distal third of the metacarpal

  • Superimposed condyles

  • Sharp cortical margins

  • No rotation



Thumb Radiography

  • The thumb differs anatomically from the other fingers and therefore requires dedicated projections.

  • Routine examination includes:

  • AP Thumb

  • Lateral Thumb


Lateral Thumb Position

  • Seat patient beside the table.

  • Flex the elbow.

  • Rest the forearm on the table.

  • Slightly flex the thumb.

  • Raise the palm using a radiolucent sponge.

  • Place the lateral surface of the thumb against the detector.


Central Ray

  • Center over the first metacarpophalangeal joint.

  • Image Evaluation

  • The radiograph should include:

  • Entire thumb

  • First metacarpal

  • Carpometacarpal joint

Surrounding soft tissues



AP Thumb Position

  • Extend the arm backward.

  • Medially rotate the shoulder.

  • Lean forward until the first metacarpal becomes parallel with the detector.

  • Slightly rotate the hand if necessary to prevent overlap.


Central Ray

Center over the base of the first metacarpal.



Common Radiological Findings

  • A properly performed examination may demonstrate:

  • Boxer's fracture

  • Bennett fracture

  • Rolando fracture

  • Metacarpal fractures

  • Phalangeal fractures

  • Carpal fractures

  • Joint dislocations

  • Rheumatoid arthritis

  • Osteoarthritis

  • Foreign bodies

  • Mallet finger deformity

  • Soft tissue calcification

  • Accessory ossicles

  • Scleroderma-related soft tissue changes



Radiation Protection

  • Radiation safety should always be maintained throughout the examination.

  • Recommended precautions include:

  • Use the smallest practical radiation field (collimation).

  • Shield the patient whenever appropriate.

  • Protect the gonads and lower limbs if the patient faces the table.

  • Remove jewelry and metallic objects before imaging.

  • Immobilize the hand adequately to avoid repeat exposures.

  • Follow the ALARA (As Low As Reasonably Achievable) principle.





Tips for Radiographers

  • Explain the procedure clearly to reduce patient anxiety.

  • Ensure the patient is comfortable before exposure.

  • Confirm the correct side using an anatomical marker.

  • Check positioning carefully before making the exposure.

  • Repeat images only when absolutely necessary.

  • Evaluate image quality immediately to avoid patient recall.


Conclusion

    The Hand Oblique (Nørgaard/Ball Catcher's View) and Lateral Hand X-ray are essential projections in musculoskeletal imaging. Accurate positioning, correct centering, proper exposure, and careful image evaluation help identify fractures, arthritis, dislocations, foreign bodies, and other hand pathologies. Following standardized positioning techniques and radiation safety principles ensures high-quality diagnostic images while minimizing patient radiation exposure.


Frequently Asked Questions

1. What is the primary clinical use for the Nørgaard / Ball Catcher's View?

The Nørgaard view is a specialized bilateral oblique projection primarily used to evaluate early signs of rheumatoid arthritis and detect subtle erosive changes in the metacarpophalangeal (MCP) joints.

2. How should a patient be positioned for a Hand Oblique projection?

The patient sits beside the table with both forearms supinated. Rest the backs of the hands on the image receptor, then rotate both hands medially by 45 degrees into a "ball-catching" pose with fingers relaxed and extended.

3. Where should the central ray be directed for an oblique hand X-ray?

The vertical X-ray beam should be centered midway between both hands, perfectly level with the fifth metacarpophalangeal (MCP) joints.

4. Why do doctors order a lateral hand projection?

A lateral projection complements the standard PA view to help locate foreign objects, evaluate displaced fractures or dislocations, and assess trauma or post-operative healing.

5. Where is the centering point for a lateral hand X-ray?

The central ray should be aimed vertically and centered directly over the head of the second metacarpal bone.

6. What adjustment should you make when looking for a foreign body in the hand?

You should reduce the kVp setting to improve soft tissue contrast, place a radiopaque marker right over the puncture wound, and take at least two different projection views to pinpoint the exact location.

7. Where do you center the X-ray beam for an individual finger projection?

For standard finger projections (both PA and lateral), the central ray must be centered directly over the proximal interphalangeal (PIP) joint of the affected digit.

8. Why does thumb radiography require different positioning than the fingers?

The thumb is anatomically distinct and oriented differently from the other fingers. It requires its own dedicated AP and lateral views to visualize the entire first metacarpal and the carpometacarpal joint properly without overlap.

9. What are some common fractures found during hand X-ray evaluations?

Properly positioned hand X-rays frequently reveal common issues like Boxer’s fractures, Bennett fractures, Rolando fractures, as well as various phalangeal and carpal bone injuries.

10. How can radiographers practice radiation safety during hand exams?

Radiographers should follow the ALARA principle by collimating tightly to the specific hand area, utilizing patient shielding (especially for the gonads if the patient faces the table), removing metallic jewelry, and using immobilization tools to prevent repeated shots.


About the Author

I am a radiographer technician currently working in a hospital setting. My daily work involves performing various imaging procedures, and I’ve seen firsthand how overwhelming a scan can feel for a patient. I started this blog to share professional insights, helpful tips, and step-by-step guides so you can walk into your next appointment with confidence and clarity.

Disclaimer

This content is for informational purposes only and does not replace professional medical advice, diagnosis, or treatment. Always consult with your healthcare provider regarding your medical conditions.