Upper extremities (finger,hand,forearm)

Question 1

• Hand in extreme internal rotation with fingers extended.
• Best demonstrate base of 1st metacarpal for ruling out Bennett’s type fractures.
• CR perpendicular to 1st metacarpophalangeal joint
• If the patient cannot assume the AP projection, a PA projection can be obtained by having the patient rest the hand in a lateral position
• The PA is not advisable because of loss definition due to increased object-image receptor distance (OID).

Answer 1

THUMB AP PROJECTION

Question 2

• Pronate hand
• CR perpendicular to 1st metacarpophalangeal joint
• Abduct thumb, and place on cassette in 45° oblique position.

Answer 2

THUMB PA OBLIQUE

Question 3

Perpendicular to the 1st carpometacarpal joint (CMC).

Answer 3

ROBERTS METHOD

Question 4

• Pronate hand.
• CR perpendicular to 1st metacarpophalangeal joint.
• Have patient arch (cup) hand and abduct thumb until thumb lies in a lateral position.

Answer 4

THUMB LATERAL

Question 5

15° Proximally along the long axis of the thumb and entering the 1st carpometacarpal joint (CMC).

Answer 5

LONG AND RAFERT

Question 6

10°-15° proximally along the long axis of the thumb and entering the 1st metacarpophalangeal joint (MCP).

Answer 6

LEWIS MODIFICATION

Question 7

Commonly performed to demonstrate arthritic changes, fractures,
• Best demonstrate dislocation of the 1st CMC joint
• Best demonstrate base of 1st metacarpal for ruling out BENNETS fracture.

Answer 7

ROBERTS METHOD

Question 8

• AP PROJECTION FOR 1ST CMC JOINT
• Rotate the hand internally and abduct the thumb
• Hyperextend the hand
• 45° towards the elbow at the 1st CMC joint.
• Recommended SID is 18 inches to produce a magnified image that creates a greater field of view of the concavoconvex aspect of the joint.
• Best demonstrate a clearer image of the 1st CMC joint than the standard AP projection.
• Trapezium in concave profile
• Base of the 1st MC in convex profile
• Magnified concavoconvex outline of the 1st CMC joint.

Answer 8

BURMAN METHOD

Question 9

• Hand rotated laterally into 45 degree oblique position; resulting in true PA projection of the thumb
• CR perpendicular to level of the MCP joints.
• Useful for the diagnosis of the ulnar collateral ligament (UCL) rupture in the MCP joint of the thumb (Skier’s thumb).
• Also known as the patient controlled stress radiography of the thumb.

Answer 9

FOLIO METHOD

Question 10

• Hand & forearm in same horizontal plane
• Hand pronated with fingers extended

Answer 10

DIGITS 2ND TO 5TH
PA PROJECTION

Question 11

• Hand and forearm in same horizontal plane as film.
• Pronate hand with fingers extended.
• Oblique hand from prone towards lateral.
• MCP joint form a 45° angle with plane of IR.
• Some radiographers rotate the second digit medially from the prone position. The advantage of this position is that the part is closer to the IR for improved recorded detail and increased ability to see certain fractures.

Answer 11

DIGITS 2ND TO 5TH PA OBLIQUE

Question 12

next

Question 13

– recommended when there is a suspected joint injury.
• The lateral projection demonstrates anterior or posterior displacements of the bony structures and to localize foreign bodies.

Answer 13

DIGITS 2ND TO 5TH
• AP PROJECTION

Question 14

recommended when there is a suspected joint injury.
• The lateral projection demonstrates anterior or posterior displacements of the bony structures and to localize foreign bodies.

Answer 14

DIGITS 2ND TO 5TH
• PA PROJECTION

Question 15

• CR perpendicular to the 3rd MCP joint
• 1 inch or 2.5 cm of distal forearm should be included in the radiograph.
• Flex elbow 90°

Answer 15

HAND PA PROJECTION

Question 16

• CR perpendicular to 3rd MCP joint
• Flex elbow 90°.
• Pronate hand.
• Oblique hand toward the lateral so that MCP joint form a 45° angle with plane of film.

Answer 16

HAND PA OBLIQUE

Question 17

• Flex elbow 90°
• Hand in lateral position with the ulnar aspect down (lateromedial) against the IR.
• Palmar surface perpendicular to IR
• Flex elbow 90°
• Flex fingers into a natural flexed position with thumb slightly touching the 1st finger.
• Thumb should be parallel to film
• Fingers are superimposed with the entire hand in a true lateral position.

Answer 17

HAND LATERAL
EXTENSION FLEXION

Question 18

• Align long axis of hand to long axis of film
• Rotate hand and wrist into a lateral position with the thumb side up (ulnar side down).
• Spread fingers and thumb into a fan position.
• Thumb should be projecting away from the palm and parallel to the film.
Align long axis of hand to long axis of film
• Rotate hand and wrist into a lateral position with the thumb side up (ulnar side down).
• Spread fingers and thumb into a fan position.
• Thumb should be projecting away from the palm and parallel to the film.

Answer 18

HAND LATERAL
FAN LATERAL

Question 19

• Best demonstrate anterior or posterior displacements of bony structures.
• Routine projection for localization of foreign body.
• This projection provides a true PA projection of the thumb.
• The lateral in flexion will demonstrate anteroposterior displacements of fractures of metacarpals.
• The fan lateral is useful for diagnosing possible trauma to the digits. It is also the preferred lateral position for the hand.

• The extension and flexion are alternate to fan lateral.
• The lateral in extension is use for localization of foreign bodies and fractures of metacarpals.
• The lateral with the wrist in palmar flexion best demonstrate the carpal boss.

Answer 19

HAND LATERAL
EXAM RATIONALE

Question 20

• small bony growth occurring on dorsal surface of the 3rd metacarpocarpal joint

Answer 20

CARPE BOSSU or carpal boss:

Question 21

• Semi-or half supinated both hand at 45 degrees
• Cupped as if the patient were going to catch a ball
• CR perpendicular to level of the MCP joints.
• Best demonstrate fractures at the base of the 5th metacarpal.
• Best demonstrate early evidence of rheumatoid arthritis.

Answer 21

NORGAARD
BALL CATCHERS POSITION

Question 22

• Flex the MCPJ so that shaft of the MC forms 45 degrees with IR
• CR 45° entering at 3rd CMC joint.
• Used to demonstrate bony erosion of MC heads & phalangeal bases of finger.
• Common erosion - early findings in rheumatoid arthritis

Answer 22

HAND AP AXIAL BREWERTON METHOD

Question 23

• Arch (cup) hand by flexing fingers at middle phalangeal joints to place carpals in contact with cassette.
• Place entire upper extremity in same horizontal plane as film.
• Flex elbow 90°.
• Pronate hand.
• Best demonstrate individual carpal bone fracture.
• Best demonstrate
scaphoid fat stripe.
• The absence or displacements of this fat stripe may be the only indicator of a fracture on the radial aspect of the wrist.

Answer 23

WRIST PA

Question 24

• Slightly oblique projection of ulna.

Answer 24

WRIST PA

Question 25

• Best demonstrate distal ulna & carpal interspaces.

Answer 25

WRIST AP

Question 26

• Flex elbow (about 90°) with wrist and hand laterally (externally) rotated 45° from the prone position. • Best demonstrate the carpals on the lateral side of the wrist (scaphoid and trapezium). • Best demonstrate the anatomic snuff box

Answer 26

WRIST PA OBLIQUE

Question 27

• Rotate the wrist medially approximately 45° to the image receptor. • Best demonstrate the carpals on the medial side of the wrist. • Best demonstrates the pisiform • This position separates the pisiform from adjacent carpal bones

Answer 27

WRIST AP OBLIQUE

Question 28

• Flex elbow 90° • Best demonstrate the pronator fat stripe • Best demonstrate widening of the wrist joint due to fracture or dislocation. • Good projection to assess the relationship of capitate, lunate and distal radius (normally in a straight line).

Answer 28

WRIST LATERAL

Question 29

• Flex elbow 90° • Pronate hand • Have patient evert (turn outward) hand as far as can be rotated. • Best demonstrate fractures of the scaphoid. • This projection opens the spaces between adjacent carpals on the lateral side.

Answer 29

PA WRIST ULNAR DEVIATION

Question 30

• Flex elbow 90° • Pronate hand • Have patient invert (turn inward) hand as far as can be rotated. • Best demonstrate the joint spaces on the medial carpals or the ulnar side of the wrist. • Best demonstrate the lunate, triquetrum, pisiform and hamate.

Answer 30

PA WRIST PROJECTION RADIAL DEVIATION

Question 31

• Hold wrist & evert (turn outward) on ulnar side. • Place hand & wrist palm down with hand elevated 20 degrees angle on sponge.

Answer 31

WRIST PA SCAPHOID STETCHER METHOD

Question 32

• This projection opens the spaces between adjacent carpals on the lateral side. • Best demonstrate fractures of the scaphoid. • Alternative method for wrist ulnar deviation with CR angulation. • CR 20 degrees towards elbow.

Answer 32

BRIDGEMAN VIEW

Question 33

• Perpendicular to the scaphoid • 10 degrees cephalad • 20 degrees cephalad • 30 degrees cephalad • Position the wrist on film for a PA projection. • Turn the hand outward until the wrist is in extreme ulnar deviation. Best demonstrate scaphoid fractures using a four image multiple angle central ray series.

Answer 33

SCAPHOID SERIES RAFERT-LONG METHOD ULNAR DEVIATION

Question 34

• Place a 45 degrees sponge against anterior surface & rotate hand to place in contact with sponge • Hand in ulnar flexion • CR 45° distally to enter the anatomic snuff box of the wrist and pass through the trapezium Best demonstrate trapezium fractures • Best demonstrate articular surface of the trapezium to treat osteoarthritic patient.

Answer 34

CLEMENTS-NAKAYAMA METHOD PA AXIAL OBLIQUE PROJECTION

Question 35

• Have patient hyperextend wrist (dorsiflex) by elevating hand • Rotate hand slightly toward radial side to prevent superimposition of pisiform and hamate • CR 25°-30° to the long axis of the hand. • Best demonstrate the palmar aspect of the carpal known as carpal tunnel or canal.

Answer 35

CARPAL CANAL/TUNNEL TANGENTIAL, INFEROSUPERIOR PROJECTION GAYNOR-HART METHOD

Question 36

• Hand & forearm forms as near a 90 degrees angle. • CR 45° to midpoint of distal forearm about 1 1⁄2 inches proximal to the wrist joint. • Demonstrate any calcification and foreign body in the dorsal aspect of the carpal bones. • Chips fracture of the dorsal aspect of the carpal bone

Answer 36

CARPAL BRIDGE TANGENTIAL PROJECTION

Question 37

• Fully extend elbow, and supinate hand. • Humeral epicondyles parallel to cassette. • Best demonstrate the humeral epicondyles in profile.

Answer 37

FOREARM AP

Question 38

• PA projection is never performed because it crosses the radius over the ulna at its proximal 3rd and rotates the humerus medially resulting in an oblique projection of the forearm.

Answer 38

FOREARM AP

Question 39

• Flex elbow 90° • Place hand in lateral position • Humeral epicondyles perpendicular to cassette. • Thumb side of the hand must be up. • Best demonstrates the olecranon process. Demonstrate the fat stripe of the wrist and fat pad of the elbow. • Demonstrate the humeral epicondyles superimposed on each other.

Answer 39

FOREARM LATERAL

Question 40

• Fully extend elbow • Supinate hand • Humeral epicondyles parallel to IR. • Demonstrate an open elbow joint space. • Best demonstrates the humeral epicondyles in profile.

Answer 40

ELBOW AP PROJECTION

Question 41

• Flex elbow 90° • • EXCEPTION: For soft tissue injury around the • elbow is suspected. The elbow should only be flexed 30-35° Best demonstrate the olecranon process. Best demonstrate the posterior fat pad (visualization is a common indication of elbow joint pathology). • Place hand in lateral position. • Humeral epicondyles perpendicular to IR. • Demonstrate any tear drop sign.

Answer 41

ELBOW LATERAL

Question 42

• Fully extend elbow • Pronate hand • Rotate entire upper extremity (including hand) to place elbow joint in a 45° medial (internal) oblique position. • Best demonstrate the coronoid process in profile. • Trochlea in profile • Olecaranon process of ulna should appear seated in olecranon fossa of humerus.

Answer 42

ELBOW AP OBLIQUE MEDIAL/INTERNAL ROTATION

Question 43

• Elbow acutely flexed with fingertips resting on shoulder. • Epicondylar plane parallel to image receptor. CENTRAL RAY: 1. Distal Humerus – perpendicular to 2 inches (5cm) superior to the olecranon process. • 2. Proximal Forearm – perpendicular to the flexed forearm approximately 2 inches (5cm) distal to the olecranon process. • Performed if the elbow is flexed more than 90° • This position is used primarily to demonstrate injuries to the olecranon process.

Answer 43

AP ELBOW IN ACUTE FLEXION JONES METHOD

Question 44

RADIAL HEAD • Elbow flexed 90° if possible • Hand pronated. • 45° towards shoulder. CORONOID PROCESS • Elbow flexed only 80 degrees from extended position. • Hand pronated. • 45° from shoulder into mid elbow joint Special projections taken for pathologic process or trauma to the radial head and or coronoid process. • Effective or alternative projections when patient cannot extend elbow fully for medial or lateral obliques of the elbow.

Answer 44

ELBOW AXIAL LATEROMEDIAL PROJECTIONS TRAUMA AXIAL LATERALS COYLE METHOD