Radiographic procedures: essential projections of forearm, elbow and humerus
AP Projection: Forearm (collimation)
2 inches (5 cm) distal to the wrist joint and proximal to the elbow joint and I inch (2.5 cm) on the sides
Lateral projection forearm (collimation)
2 inches (5 cm) distal to the wrist joint and proximal to the elbow joint and I inch (2.5 cm) on the sides
AP humerus (collimation)
2 inches distal to the elbow joint and superior to the shoulder and 1 inch on the sides
AP humerus (structures shown)
entire humerus elbow and shoulder joints -humeral epicondyles without rotation -humeral head and greater tubercle in profile
What structure is in profile on the lateral side of the proximal humerus on the AP projection of the humerus?
greater tubercle
What is the Coyle method used for?
images obtained of the radial head and coronoid process on patients who cannot fully extend the elbow for medial and lateral oblique projections
AP elbow- Distal humerus acute flexion (collimation)
include proximal half of forearm and 1 inch beyond the olecranon process and sides of the elbow
Elbow PA - Proximal Forearm acute flexion (collimation)
include proximal half of forearm and 1 inch beyond the olecranon process and sides on the elbow`
What is the CR angle and direction to demonstrate the radial head with the axiolateral projection (Coyle method)?
45 degrees toward the shoulder
What projection is the humeral head and greater tubercle in profile?
AP humerus
What projection will you see radial head fractures?
AP oblique lateral (external)
What if patient cant raise unaffected shoulder in Lawrence method?
Angle CR 10-15 degrees cephalad
What does the Lawrence Method demonstrate?
Relationship between the proximal humerus and scapula
Why is the AP oblique elbow LATERAL rotation more normally done than medial rotation?
no overlap of the radius and ulna in the external/lateral rotation
What is the Lawrence method?
Transthoracic lateral projection
AP elbow proximal forearm partial flexion (central ray)
perpendicular to elbow joint and long axis of forearm
When are you using the distal humerus and proximal forearm partial flexion?
when trying to obtain an AP projection of the elbow but the patient can't extend their arm
Lateral projection of elbow (part position)
- Flex elbow 90 degrees, forearm resting on ulnar surface (lateromedial projection) - center IR to elbow joint - humeral epicondyles perpendicular to IR - adjust hand and wrist to true lateral position
AP oblique elbow lateral rotation (structures shown/evaluation criteria)
- elbow joint is open and centered to central ray -elongated lateral humeral epicondyleA -45 degree rotation lateral: radial head, neck and tuberosity projected free of superimposition of ulna -capitulum
AP oblique elbow medial rotation (structures shown/evaluation criteria)
- elbow joint opened and centered -elongated medial humeral epicondyles -45 degree rotation: coronoid process in profile, free of superimposition - olecranon process within olecranon fossa -trochlea
AP oblique elbow medial rotation (part position)
- extend extremity in same plane with extended elbow - elbow centered to IR -medially/internally rotate upper extremity (not of the hand) -humeral epicondyles 45 degrees from true anatomic position
AP elbow proximal forearm partial flexion (structures shown/evaluation criteria)
- foreshortened distal humerus -proximal forearm when elbow isn't fully extended - proximal radius and ulna without rotation -partially open elbow joint -radial head, neck and tuberosity slightly superimposed over proximal ulna
Trauma Lateral humerus (PA) part position
- patient facing IR - IR approx 1.5 inches above humeral head - align humerus into the mediolateral projection - patient may hold injured arm
AP elbow proximal forearm partial flexion (part position)
- patient standing, leave elbow flexed and rest dorsal surface of forearm on table -supinate hand, center condyles of humerus on IR
Non-trauma lateral humerus (AP) part position
-border of IR 1.5 inches above humeral head -internally rotate humerus, flex elbow 90 degrees and palm of hand on hip -epicondyles should be perpendicular to plane of IR
AP elbow-distal humerus acute flexion (part position)
-center IR proximal to the epicondylar area of the humerus -long axis of forearm should be parallel to IR
Elbow PA proximal forearm acute flexion (part position)
-center of flexed elbow joint to center of IR
Lateral humerus structures shown
-elbow and shoulder joints visible, but slightly distorted -superimposed humeral epicondyles -lesser tubercle in profile on medial aspect
AP oblique elbow lateral rotation (part position)
-elbow centered to IR -rotate hand laterally/externally to place posterior surface of elbow at 45-degree angle - first and second digits will touch table when elbow is sufficiently rotated
AP projection of elbow (part position)
-extend the elbow, supinate hand (prevent rotation of bones of forearm) -elbow centered to middle of IR -patient leans laterally until humeral epicondyles and anterior surface are parallel MAKE SURE SHOULDER JOINT, HUMERUS AND ELBOW ARE ON SAME PLANE
Lateral projection forearm (part position)
-flex elbow 90 degrees and place medial aspect (lateromedial projection) of forearm against the Ir -true lateral position, ensuring the numeral epicondyles and styloid processes are superimposed and perpendicular to IR -the thumb side must be up
AP Elbow - Distal Humerus in Partial Flexion (part position)
-humerus in same plane, posterior surface resting on IR - support elevated forearm - supinate hand, center condyles of humerus to IR
Axiolateral (Coyle) Coronoid Process structures shown
-open joint space between coronoid process and trochlea -coronoid process in profile and elongated
Lateral projection of elbow (structures shown/evaluation criteria)
-shows elbow joint, distal arm and proximal forearm -elbow joint is opened and centered -Olecranon process in profile- true lateral position -elevated fat pads in the soft tissue will present a black shadow
AP Elbow - Distal Humerus in Partial Flexion (structures shown/evaluation criteria)
-structures: distal humerus when elbow can't be extended -no rotation of distal humerus - proximal radius superimposed over the ulna - FORSHORTENED PROXIMAL FOREARM
Elbow PA - Proximal Forearm acute flexion (structures shown/evaluation criteria)
-superimposes proximal forearm and distal humerus - elbow joint will be more open than the projection of the distal humerus
AP elbow Distal humerus acute flexion (structures shown/evaluation criteria)
-superimposes proximal forearm and distal humerus - shows radial head, medial epicondyle, capitulum, trochlea, olecranon process
AP Projection: Forearm (part position)
-supinate hand, extend the elblow and place dorsal surface against the IR -adjust IR so long axis is parallel with forearm -palpate and adjust the numeral epicondyles to be equidistant from the IR
What is the size of the IR for an image of the elbow?
10x12 inches (24x30 cm) lengthwise
What size CR plate is used for a forearm radiograph?
14x17 inches (35x43cm) lengthwise
What can be used in place of AP projection of the elbow if patient cannot completely extend the joint?
2 images separately ; AP elbow distal humerus and proximal forearm partial flexion position
AP projection of elbow (collimation)
3 inches (8 cm) proximal and distal to elbow joint and I inch (2.5 cm) on the sides
Lateral projection of elbow (collimation)
3 inches (8cm) proximal and distal to the elbow joint
AP Elbow - Distal Humerus in Partial Flexion (collimation)
3 inches proximal and distal to elbow joint and 1 inch on the sides
Lawrence method structures shown
A lateral image of shoulder and proximal humerus is projected through thorax
What projection demonstrates the coronoid process free of superimposition?
AP Oblique elbow with internal rotation
How would you know if you have proper rotation in an AP oblique elbow medial rotation?
Coronoid process will be in profile and free of superimposition
T/F: entry of central ray for proximal forearm is higher than distal humerus
FALSE: entry is lower
For a lateral projection of elbow, if their is an injury how much should the elbow be flexed?
Joint should only be flexed 30 to 35 degrees
Which projection of the elbow best demonstrates the olecranon process in profile?
Lateral
What projection shows the lesser tubercle in profile?
Lateral humerus
How do you know there is no rotation in the image of an AP elbow?
Olecranon and coronoid fossae will be equidistant from the epicondyles
When a patient is unable to extend their arm fully for elbow image, what would you do?
Perform 2 AP projections: one with the humerus resting on the IR and another with the forearm parallel/resting on IR
Lawrence method central ray
Perpendicular to IR, entering midcoronal plane at level of surgical neck
AP oblique elbow medial and lateral rotation (central ray)
Perpendicular to elbow joint
AP projection of elbow (central ray)
Perpendicular to elbow joint
Lateral projection of elbow (central ray)
Perpendicular to elbow joint
AP humerus (CR)
Perpendicular to midportion of humerus and centered to IR
AP Projection: Forearm (central ray)
Perpendicular to the midpoint of the forearm
Lateral projection forearm (central ray)
Perpendicular to the midpoint of the forearm
AP Humerus (part position)
Place top border of IR about 1.5˝ (3.8 cm) above humeral head Slightly abduct humerus from body and supinate hand Coronal plane passing through humeral epicondyles placed parallel to IR plane
How would you know if there is proper rotation in an image of an AP oblique elbow lateral rotation?
Radial head, neck and tuberosity are free of superimposition of the ulna
Axiolateral (Coyle) Coronoid Process Central ray (seated & supine)
Seated: angled 45 degrees away from shoulder entering joint at mid-elbow Supine: horizontal directed caudad 45 degrees entering at the mid-elbow joint
AP projection of elbow (structures shown)
Shows elbow joint, distal arm and proximal forearm -elbow space open - not rotation: olecranon and coronoid fossae are equidistant to epicondyles
Axiolateral (Coyle) Radial Head Central ray (seated & supine)
Supine: horizontal CR is directed 45 degrees cephalad to radial head , entering mid elbow joint Seated: angled 45 degrees toward shoulder entering at mid-elbow joint
AP Projection: Forearm (structures shown)
The elbow joint, the radius, ulna and proximal row of slightly distorted carpal bones -open radioulnar space
Lateral projection forearm (structures shown)
The elbow joint, the radius, ulna and the proximal row of superimposed carpal bones -superimposition of radius and ulna at their distal ends, radial head over coronoid process, humeral epicondyles
T/F: if there is pronation of the hand, it results in an oblique projection
True; The radius crosses over the ulna at its proximal end and rotates the humerus medially, resulting in an oblique position
which of the following require the humeral epicondyles to be positioned parallel to the IR? 1. AP forearm 2. AP elbow 3. PA wrist
all of them
Elbow PA - Proximal Forearm Acute Flexion (central ray)
angled perpendicular to flexed forearm, 2 inches distal to olecranon process (same entry spot as distal humerus) **in order for it to be perpendicular, match the head of collimator to the arm**
What type of projection is the Coyle method?
axiolateral projection
What is the Jones method?
complete flexion of distal humerus
Axiolateral (Coyle) Coronoid Process (part position)
elbow flexed 80 degrees hand pronated
Coyle Method Radial Head (part position)
elbow flexed 90 degrees hand pronated
Why is it a PA projection when entering proximal forearm for acute flexion?
it enters the posterior surface (if standing in anatomical position) and goes through the forearm
Axiolateral (Coyle) Radial Head (structures shown)
open elbow joint spaces between radial head and capitulum -radial head, neck, tuberosity in profile and free from superimposition
AP Elbow - Distal Humerus in Partial Flexion (central ray)
perpendicular to humerus, passing through elbow joint
Lateral Humerus Central ray
perpendicular to midportion of humerus and centered to IR
AP elbow- Distal Humerus acute flexion (central ray)
perpendicular to the humerus , approx 2 inches superior/above olecranon process
AP humerus (respiration)
suspended