Radiologic technique
Special Thumb
AP Axial Projection - Modified Robert's Method: Thumb PA Stress Thumb Projection (Folio Method)
Special Hand
AP Oblique Bilateral Projection: Hand (Norgarrd Method/Ball catchers method)
Special Elbow
Acute Flexion Projections: Elbow Trauma Axial Laterals - Axial Lateromedial Projections: Elbow Radial Head Laterals - Lateromedial Projections: Elbow
Radial Head Laterals - Lateromedial Projections: Elbow - Critique
Elbow should be flexed 90° in true lateral position, as evidenced by direct superimposition of epicondyles. • Radial head and neck should be partially superimposed by ulna but completely visualized in profile in various projections. • Radial tuberosity should be visualized in various positions and degrees of profile as follows (see small arrows): (1) Fig. 4-152, slightly anterior; (2) Fig. 4-154, not in profile, superimposed over radial shaft; (3) Fig. 4-156, slightly posterior; (4) Fig. 4-158, seen posteriorly, adjacent to ulna when hand and wrist are at maximum internal rotation. • Optimal exposure with no motion should clearly visualize sharp, bony margins and clear trabecular markings of radial head and neck area.
AP Oblique Projection - Medial (Internal) Rotation: Elbow
IR SIze: Medium Patient Position: WES, Seated at table end Part Position: pronate hand and rotate medially the entire arm so that the distal humerus and anterior surface of the elbow joint are approximately 45` to IR, use support sponge under hand if needed, palpate epicondyles to achieve 45` CR: Perpendicular to IR, mid-elbow joint (2cm distal to elbow joint line) Collimated: distal humerus and proximal radius and ulna Clinical Use:Fractures and dislocations of the elbow, primarily coronoid process, pathologies (osteoporosis, arthritis)
AP Oblique Projection - Lateral (External) Rotation: Elbow
IR SIze: Medium Patient Position: WES, Seated at table end Part Position: supinate hand and rotate laterally the entire arm so that the distal humerus and anterior surface of the elbow joint are approximately 45` to IR, use sand bag and 45` support sponge, Palpate epicondyles to asses epicondyle obliquity CR: Perpendicular to IR, mid-elbow joint (2cm distal to elbow joint line) Collimated: distal humerus and proximal radius and ulna Clinical Use: Fractures and dislocations of the elbow, primarily the radial head and neck, pathologies (osteoporosis, arthritis)
Routine Finger
PA PA Oblique Lateral
Routine Wrist
PA PA Oblique Lateral
Routine Hand
PA PA Oblique Lateral
Special Wrist
PA and AP Axial Scaphoid with ulnar deviation: Wrist PA Scaphoid - Hand Elevated and Ulnar Deviation: Wrist PA Projection - Radial Deviation: Wrist Carpal Canal (Tunnel) - Tangential, Infrosuperior Projection: Wrist Carpal Bridge - Tangential Projection: Wrist
Routine Humerus
AP Rotational Lateral Horizontal beam lateral
AP Oblique Projection - Medial (Internal) Rotation: Elbow - Critique
Anatomy Demonstrated: • Oblique view of distal humerus and proximal radius and ulna is visible. Position: • Long axis of arm should be aligned with side border of IR. • Correct 45° medial oblique should visualize coronoid process of the ulna in profile. • Radial head and neck should be superimposed and centered over the proximal ulna. • Medial epicondyle and trochlea should appear elongated and in partial profile. • Olecranon process should appear seated in olecranon fossa and trochlear notch partially open and visualized with arm fully extended. • CR and center of collimation field should be at mid-elbow joint.
Carpal Bridge - Tangential Projection: Wrist - Critique
Anatomy Demonstrated: • Tangential view of the dorsal aspect of the scaphoid, lunate, and triquetrum is visible. • Outline of the capitate and trapezium superimposed is visible. Position: • Dorsal aspect of the carpal bones should be visualized clear of superimposition and centered to IR. • CR and center of collimation field should be to the area of the dorsal carpal bones.
Special Humerus
Transthoracic lateral
Routine Elbow
AP (full extension and partial extension8) Oblique - Lateral and medial rotation Lateral
Routine Forearm
AP Lateral
Routine Thumb
AP PA Oblique Lateral
PA Oblique Projection - Medial or Lateral Rotation: Fingers - Critique
Anatomy Demonstrated: • 45° oblique view of distal, middle, and proximal phalanges; distal metacarpal; and associated joints. Position: • Long axis of finger should be aligned with side border of IR. • View of finger being examined should be 45° oblique. • No superimposition of adjacent fingers should occur. • IP and MCP joint spaces should be open, indicating correct CR location and that the phalanges are parallel to IR. • CR and center of collimation field should be to the PIP joint.
AP Projection: Forearm - Critique
Anatomy Demonstrated: • AP projection of the entire radius and ulna is shown, with a minimum of proximal row carpals and distal humerus and pertinent soft tissues, such as fat pads and stripes of the wrist and elbow joints. Position: • Long axis of forearm should be aligned with long axis of IR. • No rotation is evidenced by humeral epicondyles visualized in profile, with radial head, neck, and tuberosity slightly superimposed by the ulna. • Wrist and elbow joint spaces are only partially open because of beam divergence. • CR and center of collimation field should be to the approximate midpoint of the radius and ulna.
AP Axial Projection (Modified Robert's Method): Thumb - Critique
Anatomy Demonstrated: • An AP projection of the thumb and first CMC joint are visible without superimposition. • Base of first metacarpal and trapezium should be well visualized. Position: • Long axis of the thumb should be aligned with side border of IR. • No rotation, as evidenced by the symmetric appearance of both concave sides of the phalanges and by the equal amounts of soft tissue that appear on each side of the phalanges. • First CMC and MCP joints should appear open. • CR and center of collimation field should be at first CMC joint.
AP Oblique Bilateral Projection: Hand (Norgarrd Method/Ball Catchers Method) - Critique
Anatomy Demonstrated: • Both hands from the carpal area to the tips of digits in 45° oblique position are visible. Position: • 45° oblique as evidenced by the following: midshafts of second through fifth metacarpals and base of phalanges should not overlap; MCP joints should be open; no superimposition of the thumb and second digit should occur. • CR and center of collimation field to midway between both hands at level of fifth MCP joints.
Lateral Position: Thumb - Critique
Anatomy Demonstrated: • Distal and proximal phalanges, first metacarpal, trapezium (superimposed), and associated joints are visualized in the lateral position. Position: • Long axis of thumb should be aligned with side border of IR. • Thumb should be in a true lateral position, evidenced by the concave-shaped anterior surface of the proximal phalanx and first metacarpal and relatively straight posterior surfaces. • Interphalangeal and metacarpophalangeal joints should appear open if the phalanges are parallel to the IR and if the CR location is correct. • CR and center of collimation field should be at the first MCP joint.
AP Projection: Thumb - Critique
Anatomy Demonstrated: • Distal and proximal phalanges, first metacarpal, trapezium, and associated joints are visible. • Interphalangeal and metacarpophalangeal joints should appear open. Position: • Long axis of thumb should be aligned with side border of IR. • No rotation, as evidenced by the concave sides of the phalanges and by equal amounts of soft tissue appearing on each side of the phalanges, should be present. Interphalangeal joint should appear open, indicating that thumb was fully extended and correct CR location was used. • CR and center of collimation field should be at the first MCp joint.
PA Oblique: Thumb - Critique
Anatomy Demonstrated: • Distal and proximal phalanges, first metacarpal, trapezium, and associated joints are visualized in a 45° oblique position. Position: • Long axis of thumb should be aligned with side border of IR. • Interphalangeal and metacarpophalangeal joints should appear open if the phalanges are parallel to the IR and if the CR location is correct. • CR and center of collimation field should be at first MCp joint.
AP Projection: Elbow (Partial Extension) - Critique
Anatomy Demonstrated: • Distal humerus is best visualized on "humerus parallel" projection, and proximal radius and ulna are best visualized on "forearm parallel" projection. • Note: Structures in elbow joint region are partially obscured and slightly distorted, depending on amount of elbow flexion possible. Position: • Long axis of arm should be aligned with side border of IR. • No rotation is evidenced by the epicondyles seen in profile and radial head and neck separated or only slightly superimposed over ulna on forearm parallel projection. • CR and center of collimation field should be to the midelbow joint.
AP Projection: Elbow (Full Extension) - Critique
Anatomy Demonstrated: • Distal humerus, elbow joint space, and proximal radius and ulna are visible. Position: • Long axis of arm should be aligned with long axis of IR. • No rotation is evidenced by the appearance of bilateral epicondyles seen in profile and radial head, neck, and tubercles separated or only slightly superimposed by ulna. • Olecranon process should be seated in the olecranon fossa with fully extended arm • Elbow joint space appears open with fully extended arm and proper CR centering. • CR and center of collimation field should be to the midelbow joint.
Lateral - Lateromedial Projection: Wrist - Critique
Anatomy Demonstrated: • Distal radius and ulna, carpals, and at least the midmetacarpal area are visible. Position: • Long axis of the hand, wrist, and forearm should be aligned with long axis of IR. • True lateral position is evidenced by the following: ulnar head should be superimposed over distal radius; proximal second through fifth metacarpals all should appear aligned and superimposed. • CR and center of collimation field should be to midcarpal region
PA Scaphoid - Hand and Ulnar Deviation: Wrist (Modified Stecher Method) - Critique
Anatomy Demonstrated: • Distal radius and ulna, carpals, and proximal metacarpals are visible. • Carpals are visible, with adjacent interspaces more open on the lateral (radial) side of the wrist. • Scaphoid is shown, without foreshortening or superimposition of adjoining carpals. Position: • Long axis of wrist and forearm should be aligned with side border of IR. • Ulnar deviation is evidenced by only minimal, if any, superimposition of distal scaphoid. • No rotation of wrist is evidenced by the appearance of distal radius and ulna with no or only minimal superimposition of distal radioulnar joint. • CR and center of collimation field should be to scaphoid.
PA Projection - Radial Deviation: Wrist - Critique
Anatomy Demonstrated: • Distal radius and ulna, carpals, and proximal metacarpals are visible. • Carpals are visible, with adjacent interspaces more open on the medial (ulnar) side of the wrist. Position: • Long axis of the forearm is aligned with the side border of IR • Extreme radial deviation is evidenced by the angle of the long axis of the metacarpals to that of the radius and ulna and the space between the triquetrum/pisiform and the styloid process of the ulna. • No rotation of the wrist is evidenced by the appearance of the distal radius and ulna. • CR and center of the collimation field should be to the midcarpal area.
PA and PA Axial Scaphoid - with Ulnar Deviation: Wrist - Critique
Anatomy Demonstrated: • Distal radius and ulna, carpals, and proximal metacarpals are visible. • Scaphoid should be demonstrated clearly without foreshortening, with adjacent carpal interspaces open (evidence of CR angle). Position: • Long axis of wrist and forearm should be aligned with side border of IR. • Ulnar deviation should be evident by the angle of the long axis of the metacarpals to that of the radius and ulna. • No rotation of wrist is evidenced by appearance of distal radius and ulna, with minimal superimposition of distal radioulnar joint. • CR and center of collimation field should be to the scaphoid.
PA Oblique Projection-Lateral Rotation: Wrist - Critique
Anatomy Demonstrated: • Distal radius, ulna, carpals, and at least to midmetacarpal area are visible. • Trapezium and scaphoid should be well visualized, with only slight superimposition of other carpals on their medial aspects. Position: • Long axis of the hand, wrist, and forearm should be aligned with IR. • True 45° oblique of the wrist is evidenced by the following: ulnar head partially superimposed by distal radius; proximal third through fifth metacarpals (metacarpal bases) should appear mostly superimposed. • CR and center of collimation field should be to midcarpal area.
PA Projection: Fingers - Critique
Anatomy Demonstrated: • Distal, middle, and proximal phalanges; distal metacarpal; and associated joints. Position: • Long axis of finger should be aligned with and parallel to side border of IR. • No rotation of fingers is evidenced by symmetric appearance of both sides or concavities of the shafts of the phalanges and distal metacarpals. • The amount of tissue on each side of the phalanges should appear equal. • Fingers should be separated with no overlapping of soft tissues. • Interphalangeal joints should appear open, indicating that hand was fully pronated and the correct CR position was used. • CR and midpoint of collimation field should be to the PIP joint.
'Fan' Lateral - Lateromedial Projection: Hand - Critique
Anatomy Demonstrated: • Entire hand and wrist and about 2.5 cm (1 inch) of distal forearm are visible. Position: • Long axis of hand and wrist should be aligned with long axis of IR. • Fingers should appear equally separated, with phalanges in the lateral position and joint spaces open, indicating that fingers were parallel to IR. • Thumb should appear in slightly oblique position completely free of superimposition, with joint spaces open. • Hand and wrist should be in a true lateral position, as evidenced by the following: distal radius and ulna are superimposed; metacarpals are superimposed. • CR and center of collimation field should be at second MCp joint.
Lateral in Extension - Lateromedial Projection: Hand - Critique
Anatomy Demonstrated: • Entire hand and wrist and about 2.5 cm (1 inch) of distal forearm are visible. • Thumb should appear in slightly oblique position and free of superimposition with joint spaces open. Position: • Long axis of the hand and the wrist is aligned with long axis of the IR. • Hand and wrist should be in true lateral position, as evidenced by the following: distal radius and ulna are superimposed; metacarpals and phalanges are superimposed. • CR and center of collimation field should be at second to fifth MCp joints.
PA Stress Thumb Projection (Folio Method) - Critique
Anatomy Demonstrated: • Entire thumbs from first metacarpals to distal phalanges. • Demonstrates metacarpophalangeal angles and joint spaces at MCP joints. Position: • No rotation of thumbs as evidenced by symmetric appearance of concavities of shafts of first metacarpals and phalanges. • Distal phalanges should appear to be pulled together, indicating that tension was applied. • MCP and IP joints should appear open, indicating that thumbs were parallel to IR and perpendicular to CR. • CR and center of collimation field should be midway between the two MCp joints
Lateral - Lateromedial Projection: Elbow - Critique
Anatomy Demonstrated: • Lateral projection of distal humerus and proximal forearm, olecranon process, and soft tissues and fat pads of the elbow joint are visible. Position: • Long axis of the forearm should be aligned with long axis of IR, with the elbow joint flexed 90°. • About one-half of radial head should be superimposed by the coronoid process, and olecranon process should be visualized in profile. • True lateral view is indicated by three concentric arcs of the trochlear sulcus, double ridges of the capitulum and trochlea, and the trochlear notch of the ulna. In addition, superimposition of the humeral epicondyles occurs. • CR and center of collimation field should be midpoint of the elbow joint.
Lateral - Lateromedial Projection: Forearm - Critique
Anatomy Demonstrated: • Lateral projection of entire radius and ulna, proximal row of carpal bones, elbow, and distal end of the humerus are visible as well as pertinent soft tissue, such as fat pads and stripes of the wrist and elbow joints. Position: • Long axis of forearm should be aligned with long axis of IR. • Elbow should be flexed 90°. • No rotation as evidenced by head of ulna being superimposed over the radius, and humeral epicondyles should be superimposed. • Radial head should superimpose coronoid process, with radial tuberosity demonstrated. • CR and center of collimation field should be to midpoint of the radius and ulna.
Lateral (lateromedial or mediolateral) Projection: Finger - Critique
Anatomy Demonstrated: • Lateral views of distal, middle, and proximal phalanges; distal metacarpal; and associated joints are visible. Position: • Long axis of finger should be aligned with the side border of IR. • Finger should be in true lateral position, as indicated by the concave appearance of the anterior surface of the shaft of the phalanges. • Interphalangeal and metacarpophalangeal joint spaces should be open, indicating correct CR location and that the phalanges are parallel to the IR. • CR and center of collimation field should be to the pip joint.
PA (AP) Projection: Wrist - Critique
Anatomy Demonstrated: • Midmetacarpals and proximal metacarpals; carpals; distal radius, ulna, and associated joints; and pertinent soft tissues of the wrist joint, such as fat pads and fat stripes, are visible. • All the intercarpal spaces do not appear open because of irregular shapes that result in overlapping. Position: • Long axis of the hand, wrist, and forearm is aligned with IR. • True PA is evidenced by the following: equal concavity shapes are on each side of the shafts of the proximal metacarpals; near-equal distances exist among the proximal metacarpals; separation of the distal radius and ulna is present except for possible minimal superimposition at the distal radioulnar joint. • CR and center of collimation field should be to the midcarpal area.
AP Oblique Projection - Lateral (External) Rotation: Elbow - Critique
Anatomy Demonstrated: • Oblique projection of distal humerus and proximal radius and ulna is visible. Position: • Long axis of arm should be aligned with side border of IR. • Correct 45° lateral oblique should visualize radial head, neck, and tuberosity, free of superimposition by ulna. • Lateral epicondyle and capitulum should appear elongated and in profile. • CR and center of collimation field should be to mid-elbow joint.
PA Oblique Projection: Hand - Critique
Anatomy Demonstrated: • Oblique projection of the entire hand and wrist and about 2.4 cm (1 inch) of distal forearm are visible. Position: • Long axis of hand and wrist should be aligned with IR. • 45° oblique is evidenced by the following: midshafts of metacarpals should not overlap; some overlap of distal heads of third, fourth, and fifth metacarpals but no overlap of distal second and third metacarpals should occur; excessive overlap of metacarpals indicates over-rotation, and too much separation indicates under-rotation. • MCP and IP joints are open without foreshortening of midphalanges or distal phalanges, indicating that fingers are parallel to IR. • CR and center of collimation field should be at third MCp joint.
PA Projection: Hand - Critique
Anatomy Demonstrated: • PA projection of entire hand and wrist and about 2.5 cm (1 inch) of distal forearm are visible. • PA projection of hand demonstrates oblique view of the thumb. Position: • Long axis of hand and wrist aligned with long axis of IR. • No rotation of hand, as evidenced by symmetric appearance of both sides or concavities of shafts of metacarpals and phalanges of digits 2 through 5 and the appearance of equal amounts of soft tissue on each side of phalanges 2 through 5. • Digits should be separated slightly with soft tissues not overlapping. • MCP and IP joints should appear open, indicating correct CR location and that hand was fully pronated. • CR and center of collimation field should be to third MCp joint.
Carpal Canal (Tunnel) - Tangential, Inferosuperior Projection: Wrist (Gaynor-Hart Method) - Critique
Anatomy Demonstrated: • The carpals are demonstrated in a tunnel-like, arched arrangement. Position: • The pisiform and the hamulus process should be separated and visible in profile without superimposition. • The rounded palmar aspects of the capitate and the scaphoid should be visualized in profile as well as the aspect of the trapezium that articulates with the first metacarpal. • CR and center of collimation field should be to midpoint of the carpal canal.
Trauma Axial Laterals - Axial Lateromedial Projections: Elbow - Critique
For Radial Head: • Joint space between radial head and capitulum should be open and clear. • Radial head, neck, and tuberosity should be in profile and free of superimposition except for a small part of the coronoid process. • Distal humerus and epicondyles appear distorted because of 45° angle. For Coronoid Process: • Distal (anterior) portion of the coronoid appears elongated but in profile. • Joint space between coronoid process and trochlea should be open and clear. • Radial head and neck should be superimposed by ulna. • Optimal exposure factors should visualize clearly the coronoid process in profile. Bony margins of superimposed radial head and neck should be visualized faintly through proximal ulna.
Acute Flexion Projections: Elbow - Critique
Four-sided collimation borders should be visible with CR and center of collimation field midway between epicondyles. Proximal Humerus: • Forearm and humerus should be directly superimposed. • Medial and lateral epicondyles and parts of trochlea, capitulum, and olecranon process all should be seen in profile. • Optimal exposure should visualize distal humerus and olecranon process through superimposed structures. • Soft tissue detail is not readily visible on either projection.
Lateral - Lateromedial Projection: Forearm
IR Size: Large Patient Position: WES, elbow 90`, seated at table end Part Position: elbow flexed to 90`, fingers extended, true lateral wrist CR: Perpendicular to IR, mid-forearm Collimated: include 1-1.5 in of proximal carpal bones and distal humerus Clinical Use: Fractures and dislocations of the radius or ulna, pathologies (osteomyelitis or arthritis) NOTE: if muscling is large in the forearm place support under hand to align distal radius and ulna
AP Projection: Forearm
IR Size: Large Patient Position: WES, seated at table end Part Position: supinated hand with fully extended elbow CR: Perpendicular to IR, mid-forearm Collimated: include minimum of 1-1.5 in of proximal carpal bones and distal humerus Clinical Use: Fractures and dislocations of the radius or ulna, pathologies (osteomyelitis and arthritis)
PA Projection: Hand
IR Size: Medium Patient Position: 90` elbow, seated at table end Part Position:pronated hand, spread fingers slightly CR: Perpendicular to IR, 3rd MCP joint Collimation: 2.5cm around soft tissue and 2.5cm distal wrist Clinical Use: Fractures, dislocations, pathology (osteoporosis/osteoarthritis)
Lateral - Lateromedial Projection: Elbow
IR Size: Medium Patient Position: WES, 90` elbow, Seated at table end Part Position: rotate hand into true lateral position, thumb side up CR: Perpendicular to IR, mid-elbow (4cm medial to easily palpated posterior surface of olecranon process) Collimated: Distal humerus and proximal forearm, olecranon process and soft tissues and fat pads of the elbow joint Clinical Use: Fractures and Dislocations of the elbow, certain bony pathologies (osteomyelitis and arthritis), elevated or displaced fat pads NOTE: Soft tissue pathologies may require less flexion but these should only be performed when specifically indicated
AP Projection: Elbow (Full Extension)
IR Size: Medium Patient Position: WES, seated at table end Part Position: supinated hand, fully extended elbow CR: Perpendicular to IR, mid-elbow joint line (2cm distal to elbow joint line) Collimated: distal humerus, elbow joint space ad proximal radius and ulna Clinical Use: Fractures and dislocations of the elbow, pathologies (osteomyelitis and arthritis)
AP Oblique Bilateral Projection: Hand (Norgarrd Method/Ball Catchers Method)
IR Size: Medium Patient Position: elbow 90`, seated at table end Part Position: Supinate hands and medial aspect of hands together at center of IR, internally rotate to 45` and place foam wedge under both hands, extend fingers if possible, abduct thumbs to avoid superimposition CR: Perpendicular to IR, midpoint between both hands at level of 5th MCP joints Collimation: 2.5cm beyond soft tissue, 2.5cm of distal wrist Clinical Use: early evidence of rheumatoid arthritis at 2nd through 5th phalanges and MCP joints, for comparison of bony structures and 5th digit metacarpal base fractures
PA Oblique Projection: Hand
IR Size: Medium Patient Position: elbow 90`, seated at table end Part Position: pronated hand on IR, rotate hand laterally 45` and support with foam wedge CR: Perpendicular to IR, 3rd MCP joint Collimation: 2.5 cm beyond soft tissue and 2.5cm of distal wrist Clinical Use: Fractures, dislocations of phalanges and metacarpals and all joints, pathology (osteoporosis/osteoarthritis)
'Fan' Lateral - Lateromedial Projection: Hand
IR Size: Medium Patient Position: elbow 90`, seated at table end Part Position: rotate hand and wrist into lateral position with thumb up, spread fingers and thumb into a fan CR:Perpendicular to IR 2nd MCP Joint Collimation: 2.5 cm beyond soft tissue, 2.5 cm of distal wrist Clinical Use: anterior/posterior displaced Fractures and dislocations of metacarpals, pathology (osteoporosis/osteoarthritis) NOTE: Preferred if the phalanges are of interest
Lateral in Extension - Lateromedial Projection: Hand
IR Size: Medium Patient Position: elbow 90`, seated at table end Part Position: rotate hand and wrist into true lateral, 2nd to 5th metacarpals superimposed, use support block to keep flinger extended CR: Perpendicular to IR, 2nd to 5th MCP joint Collimation: 2.5 cm beyond soft tissue, 2.5 cm of distal wrist Clinical Use: localization of foreign bodies of the hand and fingers, also demonstrates anterior/posterior displacement fractures of metacarpals
Acute Flexion Projections: Elbow
IR Size: Medium, 2 Projections Patient Position: Seated at table end, acute flexion of elbow joint Part Position: acutely flex forearm and fingers resting on shoulder, palpate humeral epicondyles and ensure that they are parallel and no rotation CR: Distal Humerus - perpendicular to IR and humerus, midway between epicondyles Proximal forearm - Perpendicular to FOREARM (angle CR as needed), approximately 2 in proximal or superior to olecranon process Collimated: mid-Forearm Clinical Use: Trauma, fractures and moderate dislocations of the elbow
AP Projection: Elbow (Partial Extension)
IR Size: Medium; 2 Projections Patient Position: WES, seated at table end Part Position: Projection 1: arm extended, forearm parallel to IR Projection 2: arm extended, humerus parallel to IR CR: Perpendicular to IR, mid-elbow joint (2cm distal to elbow joint line) Collimated: Projection 1: Proximal Radius and ulna Projection 2: Distal Humerus Clinical Use: Fractures and dislocations of the elbow, pathologies (osteomyelitis and arthritis) NOTE: if elbow cannot be extended past 90` then angle CR 10` to 15` into elbow joint OR if flexed more than 90` then use Acute Flexion Projection (jones Method)
Radial Head Laterals - Lateromedial Projections: Elbow
IR Size: Small Patient Position: WES, 90˚elbow, seated at table end Part Position: 90˚ elbow Position 1: Hand supinated (external rotation) Position 2: Hand lateral Position 3: Hand pronated (partial internal rotation) Position 4: Hand with maximum internal rotation - thumb in AP view CR: Perpendicular, radial head - approximately 2 to 3 cm distal to lateral epicondyle Clinical Use: Occult fractures of the radial head or neck
Trauma Axial Laterals - Axial Lateromedial Projections: Elbow
IR Size: Small Patient Position: WES, elbow 90`, seated at table end Part Position 1 - Radial Head: 90` flexed elbow, hand pronated CR 1: angle 45` toward shoulder, midelbow Part Position 2 - Coronoid Process: ONLY 80` flexed elbow, hand pronated CR 2: angle 45` from shoulder, midelbow Collimated: 1 inch beyond elbow crease Clinical Use: fractures or dislocations of the elbow, particularly the radial head and coronoid process NOTE: Increase exposure factors by 4 to 6kV from lateral elbow due to angled CR
PA Scaphoid - Hand and Ulnar Deviation: Wrist (Modified Stecher Method)
IR Size: Small Patient Position: WES, elbow 90`, seated at table end Part Position: place pronated everted hand on 20` angle sponge CR: Perpendicular to IR, center by scaphoid by the butt of the hand Collimated:, evert hand without moving forearm as far as the patient can go Clinical Use: Fractures to scaphoid NOTE: Do not use for trauma
PA Projection - Radial Deviation: Wrist
IR Size: Small Patient Position: WES, elbow 90`, seated at table end Part Position: pronate hand then invert hand as far as possible CR: perpendicular to IR, midcarpal area Collimated: Distal radius and ulna, carpals and proximal metacarpals, carpal interspaces are visible Clinical Use: fracture of caral bones on ulnar side of the wrist, especially lunate, triquetrum, pisiform, and hamate NOTE: Do not use for trauma
PA and PA Axial Scaphoid - with Ulnar Deviation: Wrist
IR Size: Small Patient Position: WES, elbow 90`, seated at table end Part Position: pronated hand, evert hand without moving forearm as far the patient can go CR: angle CR 10` to 15` proximally, center by scaphoid by the butt of the hand Collimated: Distal radius and ulna, carpals and proximal metacarpals, scaphoid demonstrated clearly, carpal interspaces are open Clinical Use: Fractures of scaphoid NOTE: Obscre fractures of scaphoid may require 4 projections at 0`, 10`, 20` and 30` called Rafart and Long NOTE: Do not use for trauma
Carpal Canal (Tunnel) - Tangential, Inferosuperior Projection: Wrist (Gaynor-Hart Method)
IR Size: Small Patient Position: WES, elbow 90`, seated at table end Part Position: pronated hand, hyperextend wrist (dorsiflex) as far as possible and support with band so long axis of metacarpals and fingers are near vertical CR: angle 25` to 30` toward wrist, 2 to 3cm distal to the base of the third metacarpal Collimated: Carpals are demonstrated in a tunnel-like arched arrangement Clinical Use: Rule out abnormal calcification and bony changes in the carpal sulcus that may impinge on the median nerve (Carpal Tunnel) NOTE: DO not use for trauma
PA Oblique Projection-Lateral Rotation: Wrist
IR Size: Small Patient Position: WES. elbow 90`, seated at table end Part Position: pronate hand then laterally rotate to 45`, support with 45` wedge sponge CR: Perpendicular to IR, midcarpal area Collimated: distal radius and ulna and midcarpal area, base of metacarpals Clinical Use: fractures of distal radius or ulna, isolated fractures of radial or ulnar styloid processes and fractures of carpal bones, Pathology (osteoporosis/osteoarthritis) NOTE: Do not use for trauma
PA (AP) Projection: Wrist
IR Size: Small Patient Position: elbow 90`, WES, seated at table end, Part Position: hand pronated, arch fingers to bring wrist into contact with IR, center over carpals CR: Perpendicular to IR, midcarpal area Collimated: Perpendicular to IR, midcarpal area Clinical Use: fractures of distal radius or ulna, isolated fractures of radial or ulnar styloid processes and fractures of carpal bones, Pathology (osteoporosis/osteoarthritis) NOTE: AP may be used to put wrist and carpals in close contact with IR to demonstrate intercarpal spaces and wrist joint, good for vizualization of the carpal bones
PA Oblique Projection - Medial or Lateral Rotation: Fingers
IR Size: Small Patient Position: elbow 90`, seated at table end Part Position: 45` foam wedge, finger extended, finger isolate CR: Perpendicular to IR, PIP joint Collimation: 45` of distal, middle and proximal phalanges, distal metacarpals and associated joints Clinical Use: Fractures, Dislocation, Pathology (osteoporosis/osteoarthritis) NOTE: 2nd digit use mediolateral
PA Oblique: Thumb
IR Size: Small Patient Position: elbow 90`, seated at table end Part Position: Pronate hand, abducted thumb slightly, natural 45` on thumb CR: Perpendicular to IR, 1st MCP joint Collimation: Distal and proximal phalanges, first metacarpal, trapezium and associated joints Clinical Use: Fractures, dislocations, pathology (osteoporosis/osteoarthritis)
Lateral (lateromedial or mediolateral) Projection: Finger
IR Size: Small Patient Position: elbow 90`, seated at table end Part Position: finger extended, finger isolate, use block to hold extended finger CR: Perpendicular to IR, PIP Joint Collimation: Lateral distal, middle and proximal phalanges, distal metacarpals and associated joints Clinical Use: Fractures, Dislocations, Pathology (osteoporosis/osteoarthritis) NOTE: 2nd digit use mediolateral
PA Projection: Fingers
IR Size: Small Patient Position: elbow 90`, seated at table end Part Position: hand pronated, fingers extended, finger isolated CR: Perpendicular to IR, Proximal Interphaangeal Joint Collimation: Distal middle and proximal phalanges, distal metacarpals and associated joints Clinical Use: Fractures, Dislocation, Pathology (osteoporosis/osteoarthritis)
Lateral Position: Thumb
IR Size: Small Patient Position: elbow 90`, seated at table end Part Position: pronate hand and abducted thumb, hand and fingers slightly arched, rotate slightly until thumb is in a true lateral CR: Perpendicular to IR, 1st MCP Joint Collimation: Distal and proximal phalanges, first metacarpal, trapezium and associated joints Clinical Use:Fractures, dislocations, pathology (osteoporosis/osteoarthritis)
AP Axial Projection (Modified Robert's Method): Thumb
IR Size: Small Patient Position: seated at table end Part Position: rotate arm internally until posterior aspect of thumb rests on IR CR: 15` proximally (toward wrist), 1st CMC Joint Collimation: AP thumb, CMC joint Clinical Use: Fractures, Dislocations, pathology NOTE: Demonstrates the base of the first metacarpal for ruling out of Benett's Fracture, Demonstrates dislocation of the first CMC joint
AP Projection: Thumb
IR Size: Small Patient Position: seated at table end, arm extended in front, hand medially rotated with supinated thumb Part Position: supinated thumb, thumb fully extended until posterior surface is in contact with IR CR: Perpendicular to IR, 1st MCP Joint Collimation: Distal and proximal phalanges, first metacarpal, trapezium and associate joints (IP and MCP joints should be open) Clinical Use: Fractures, dislocations, pathology (osteoporosis/osteoarthritis) NOTE: Exception - PA if patient cannot supinate thumb, support thumb on block that is high enough so there is no rotation in thumb
Carpal Bridge - Tangential Projection: Wrist
IR Size: Small Patient Position: standing Part Position: flex hand to 90`and place dorsal side down CR: angle 45` toward hand, center at midpoint of the distal forearm about 4cm proximal to wrist Collimated: tangential view of scaphoid, lunate and triquetrum, outline of captitate and trapezium superimposed Clinical Use: Calcification or other pathology of the dorsal aspect of the carpal bones NOTE: Do not use for trauma
PA Stress Thumb Projection (Folio Method)
IR Size: Small landscape Patient Position: seated at table end, both hands extended and pronated on IR Part Position: position thumbs parallel to each other on a raised block, place spacer between proximal thumbs and a rubber band around distal thumbs, pull thumbs apart before exposure CR:Perpendicular to IR, midway between MCP joints Collimation: second metacarpals and entire thumbs, CMC joint to distal phalanges Clinical Use: Sprain or tearing of ulnar collateral ligament of thumb at MCP joint as a result of acute hyperextension of thumb, also referred to as 'skier's thumb'
Lateral - Lateromedial Projection: Wrist
IR: Small Patient Position: WES, elbow 90`, seated at table end Part Position: Adjust wrist into a true lateral with fingers extended, use a block to support CR: Perpendicular to IR, midcarpal area Collimated: Distal radius and ulna and midmetacarpal Clinical Use: Fractures, dislocations of the distal radius and ulna, Specifically anteroposterior dislocations of Barton's, Colle's or Smith's fractures NOTE: Do not use for trauma
