Upper Extremity
Variations of Stecher Method
1. Hand pronated with CR angled 20 degrees toward elbow 2. Wrist may be angled inferiorly or CR angles 20 degrees toward digits 3. Have patient clench fist (widens fracture line)
Carpal Canal (Gaynor-Hart Method) Tangential Projections
1. Inferosuperior- Hyperextend wrist, rotate hand slightly toward radial side, CR angled 25-30 degrees toward long axis of hand and enters base of 3rd metacarpal; Demonstrates trapezium, scaphoid, capitate, hook of hamate, triquetrum and pisiform 2. Superoinferior- Dorsiflex wrist, CR angled 20-35 degrees toward hand; Magnification exists from increased OID
Bones of Hand and Wrist
27 bones in each hand total- 14 phalanges (long bone), 5 metacarpals (long bones), and 8 carpals (short bones)
PA Wrist- radial flexion
Anatomy includes carpal and carpal interspaces on medial side; Hand pronated and inverted, CR to midcarpal region
PA Wrist
Anatomy includes mid-metacarpals, carpals, distal radius and ulna; Hand pronated, fingers flexed to get carpals closer to IR (reducing OID), CR to midcarpals (found by palpating styloid processes)
PA Wrist- ulnar flexion
Anatomy includes specifically scaphoid as well as the other carpal bones; Hand pronated and everted until wrist is in ulnar deviation, CR to scaphoid
Lateral Elbow
Anatomy of distal humerus to proximal radius and ulna with 3 concentric arcs: 1) trochlear sulcus, 2) capitulum and trochlea, 3) trochlear notch with olecranon process Elbow flexed 90 degrees with thumb up; CR enters at elbow joint
AP Elbow
Anatomy of distal humerus to proximal radius and ulna; Elbow extended and hand supinated until epicondyles are parallel, CR enters at elbow joint
AP Wrist
Anatomy of mid-metacarpals to distal radius and ulna; Hand supinated with digits elevated to place wrist closer to IR, CR to midcarpal region *alternative-opens intercarpal spaces
Lateral Wrist
Anatomy of mid-metacarpals to distal radius and ulna; Wrist rotated (90 degrees) until radius and ulna are superimposed, thumb turned to ceiling, CR to midcarpal region
PA projection of Hand
Anatomy of tufts to distal radius and ulna visible; hand pronated with fingers slightly separated; CR to 3rd MCP joint
PA Oblique Hand
Anatomy of tufts to distal radius and ulna visible; hand rotated 45 degrees, CR to 3rd MCP joint *Minimal superimposition of bases of 4th and 5th metacarpals
Lateral Hand- Extension/Flexion
Anatomy of tufts to distal radius and ulna; metacarpals parallel to flim, CR to 2 MCP joint In flexed, fingers are flexed. In extended, fingers are extended.
Lateral Hand- Fan
Anatomy of tufts to distal radius and ulna; phalanges separated with no superimpostion, CR to 2nd MCP joint *preferred lateral for hand
Olecranon Process- PA Axial
Arm at 45-50 degree angle from vertical position, hand supinated; CR perpendicular to olecranon process and at 20 degree angle to show curved extremity Demonstrates olecranon process and articular margin of olecranon and humerus
Joints of Hand and Wrist
Distal interphalangeal, Proximal interphalangeal, Metacarpophalangeal, Carpometacarpal, Intercarpals, Radiocarpal, Distal radioulnar
AP Elbow- acute flexion Distal Humerus
Elbow fully flexed, IR proximal to epicondylar area of humerus, CR perpendicular 2 inches superior to olecranon process Superimposes bones or arm and forearm, olecranon process clearly shown
PA Elbow- acute flexion Proximal forearm
Elbow fully flexed, elbow joint centered, CR angled to enter 2 inches distal to olecranon process Elbow joint more open
AP Thumb
Hand in extreme medial rotation with posterior thumb on IR, CR to MCP joint *preferred for lower OID (object to image distance)
Lateral 2nd-5th Digits
Hand in fist with affected digit sticking out; for 2nd and 3rd digits rest on lateral surface, for 4th and 5th digits rest on medial side, CR to PIP joint
PA Thumb
Hand on medial side with thumb abducted and supported, CR to MCP joint
Lateral Thumb
Hand on palm side with fingers flexed or on sponge, adjust arch of hand until thumb is in true lateral, CR to MCP joint
Oblique Thumb
Hand on palm side, ulnar deviate slightly, CR to MCP joint
Carpal Bridge- Tangential Projection
Hand palm up on IR with hand at right angle to forearm; CR at caudal angle of 45 degrees and about 1.5 inches proximal to wrist *shows fracture of scaphoid, lunate dislocations, foreign bodies, and chip fractures of dorsal aspect
Stecher Method
Hand pronated on IR with sponge elevating finger end of IR 20 degrees; CR enters scaphoid (most broken bone in wrist)
AP Elbow- partial flexion Proximal Forearm
Posterior forearm on IR, hand supinated, CR to elbow joint Demonstrated proximal forearm when elbow cannot be extended
PA Oblique Wrist
Rotate wrist laterally until 45 degrees to IR, wedge can be placed under wrist, CR to midcarpal area *distinct view of trapezium and scaphoid with scaphoid superimposed on itself
AP Oblique Wrist
Rotate wrist medially until 45 degrees to IR, CR to midcarpal area *separates pisiform and provides more distinct view of triquetrum and hamate
PA 2nd-5th Digits
Same position as PA Hand, more collimation, include knuckle (metacarpal head), centered at PIP joint
Radial Head- Axiolateral Projection Coyle Method
Seated: Pronate hand, flex elbow 90 degrees, CR at 45 degree angle directed toward shoulder and enters mid-elbow; Supine for trauma: IR in vertical postion, elevate distal humerus on sponge, flex elbow 90 degrees; horizontal CR directed 45 degrees cephalad and enters mid-elbow joint *both show open elbow joint between radial head and capitulum
AP Humerus
Upright- Abduct arm slightly, supinate hand, epicondyles parallel, respiration suspended; CR enters midhumerus Recumbent- Elevate unaffected shoulder, supinate hand, extend elbow, epicondyles parallel; CR enters midhumerus *both demonstrate entire length of humerus,
Lateral Humerus
Upright- internally rotate arm, flex elbow 90 degrees, anterior hand on hip, epicondyles perpendicular, respiration suspended; CR enters midhumerus Recumbent- abduct arm, rotate forearm medially to place epicondyles perpendicular, respiration suspended; CR enters midhumerus *both demonstrate entire length of humerus and superimposed epicondyles
Radial Head- lateral projection Four position series
Flex elbow 90 degrees, CR enters elbow joint 1. Hand supinated 2. Hand lateral 3. Hand pronated 4. Hand internally rotated Radial head projects varying degrees of rotation
Distal Humerus - PA Axial
Flex elbow nearly vertical so humerus 75 degrees to forearm, hand supinated; CR perpendicular to ulnar sulcus and enters medial to olecranon process Demonstrates epicondyles, trochlea, ulnar sulcus, and olecranon fossa; diagnoses bursitis
AP Elbow- partial flexion Distal Humerus
Hand supinated, IR under elbow, forearm elevated and supported; CR at humeral condyles Demonstrates distal humerus when elbow cannot be extended
AP Forearm
Anatomy of distal humerus to carpals; Elbow extended and hand supinated until epicondyles are parallel, CR enters midforearm
Lateral Forearm
Anatomy of distal humerus to carpals; Elbow flexed 90 degrees with thumb up and fingers extended, CR enters midforearm
Bones of Forearm
Ulna (long bone) on medial side and Radius (long bone) on lateral side
Elbow Joint
Ulna articulates with trochlea; radius articulates with capitulum
AP 1st Carpometacarpal Joint (Robert Method)
Limb extended and rotated internally, hand hyperextended, posterior thumb on IR, CR to CMC joint