Chapter 4 Upper limb

Digits (2nd-5th): PA projections - IR

8x10 inch lengthwise or crosswise for two or more images on one IR

First Digit (Thumb): AP, PA, lateral, and PA oblique projections - structures shown

AP, PA, lateral and PA oblique projections of the thumb

Digits (2nd-5th): PA oblique projection (lateral rotation) - position of pt

end of table

First carpometacarpal joint: AP projection (folio method): position of pt

end of table

First digit (thumb): AP projection - position of patient

end of table with arm internally rotated

First digit (thumb): Lateral projection - position of pt

end of table with relaxed hand placed on IR

Digits that cannot be extended can be

examined in small sections

First carpometacarpal joint: AP projection: roll of tape between metacarpals and rubber band holding distal aspects of thumbs visible referred to as

folio method

First carpometacarpal joint: AP projection (Robert method) - IR

8 x 10 inch lengthwise

Hand: PA projection: IR

8x10 for hand of average size or 10x12 crosswise for two images

First carpometacarpal joint: AP projection (folio method): IR

8x10 inch crosswise

First carpometacarpal joint: AP projection (burman method): IR

8x10 inch lengthwise

Hand: Lateral projection (lateromedial in flexion) - IR

8x10 inch lengthwise

Hand: Lateral projection (mediolateral or lateromedial-extension or fan lateral) - IR

8x10 inch lengthwise for hand of average size or 10x12 inch crosswise for two images

Hand: PA oblique projection (lateral rotation) - IR

8x10 inch lengthwise or 10x12 inch crosswise for two images

Digits (2nd-5th): Lateral projections (lateromedial or mediolateral) - IR

8x10 inch lengthwise or crosswise for two or more images

Digits (2nd-5th): PA oblique projection (lateral rotation) - IR

8x10 inch lengthwise or crosswise for two or more images

First Digit (Thumb): AP, PA, lateral, and PA oblique projections - IR

8x10 inch lengthwise or crosswise for two or more images

First carpometacarpal joint: AP projection: when hyperextension of the wrist is referred to as

Burman method

First Digit (Thumb): AP, PA, lateral, and PA oblique projections - collimation

1 inch on all sides of the digit including 1 inch proximal to the CMC joint

Digits (2nd-5th): Lateral projections (lateromedial or mediolateral) - collimation

1 inch on all sides of the digit, including 1 inch proximal to the MCP joint

Digits (2nd-5th): PA oblique projection (lateral rotation) - collimation

1 inch on all sides of the digit, including 1 inch proximal to the MCP joint

Digits (2nd-5th): PA projections - collimation

1 inch on all sides of the digit, including 1 inch proximal to the MCP joint

Hand: PA projection - collimation

1 inch on all sides of the hand, including 1 inch proximal to the ulnar styloid

recommended using a tangential oblique projection to show the metacarpal head fractures. From the PA hand position, the MCP joints are flexed 75-80 degrees with the dorsum of the digits resting on the IR. The hand is rotated 40-45 degrees toward the ulnar surface. Then the hand is rotated 40-45 degrees forward until the affected MCP joint is projected beyond its proximal phalanx. The perpendicular central ray is directed tangentially to enter the MCP joint of interest.

Kallen

recommended the inclusion of a reverse oblique projection to show sever metacarpal deformities or fractures better. Have patient rotate hand 45 degrees medially from the palm down position

Lane et al

Hand: Lateral projection (mediolateral or lateromedial-extension or fan lateral) - collimation

1 inch on all sides of the shadow of the hand and thumb, including 1 inch proximal to the ulnar styloid process

Hand: PA oblique projection (lateral rotation) - collimation

1 inch on all sides, including 1 inch proximal to the ulnar styloid

Hand: PA oblique projection (lateral rotation) - structures shown

PA oblique projection of bones and soft tissues of the hand. Used for investigating fractures and pathologic conditions

Hand: AP oblique projection (Norgaard method) - IR

10x12 crosswise

First carpometacarpal joint: AP projection - maximum internal rotation referred to as

Robert method

Digits (2nd-5th): PA oblique projection (lateral rotation): Some radiographers rotate the _______ digit

second - medially from the prone position so that the part is closer to the IR for improved recorded detail and increased visibility of certain fractures

Hand: PA projection - position of patient

set at end of table and adjust the patient's height so that the forearm is resting on the table

First carpometacarpal joint: AP projection (burman method): SID

the recommended distance is 18 inches, this produces magnified image that creates a greater field of view of the concavoconvex aspect of this joint

Hand: AP oblique projection (Norgaard method) - structures shown

the resulting image shows an AP 45 degree oblique projection of both hands. The radiologic change significant in making the diagnosis of rheumatoid arthritis is a symmetric, very slight, indistinct outline of the bone corresponding to the insertion of the joint capsule dorsoradial on the proximal end of the first phalanx of the four fingers. In addition, associated demineralization of the bone structure is always present in the area directly below the contour effect.

Hand: Lateral projection (lateromedial in flexion) - structures shown

this projection produces a lateral image of the bony structures and soft tissues of the hand in their normally flexed position. It also shows anterior or posterior displacement in fractures of the metacarpals

First carpometacarpal joint: AP projection (burman method): CR

through the first CMC joint at a 45 degree angle toward the elbow

Digits (2nd-5th): PA projections - Position of pt

End of table

First carpometacarpal joint: AP projection (burman method): structures shown

a magnified concavoconvex outline of the first CMC joint

First carpometacarpal joint: AP projection (folio method): CR

perpendicular to a point midway between both hands at the level of the MCP joints

Digits (2nd-5th): PA oblique projection (lateral rotation) - structures shown

resultant image shows a PA oblique projection of the bones and soft tissue of affected digit

First carpometacarpal joint: AP projection (burman method): position of pt

seat pt at end of table so that the forearm can be adjusted to lie approx. parallel with the long axis of the IR

First digit (thumb): PA oblique projection - position of pt

seat pt at end of table with palm of hand resting on IR

Hand: AP oblique projection (Norgaard method) - position of pt

seat pt at end of table. Norgaard recommended that both hands be radiographed in the half-supinated position for comparison

First carpometacarpal joint: AP projection (Robert method)- position of pt

seat the pt sideways at the end of the table. The pt should be positioned low enough to place the shoulder, elbow, and wrist on the same plane. The entire limb must be on the same plane to prevent elevation of carpal bones and closing of the first CMC joint

First carpometacarpal joint: AP projection (folio method): structures shown

the MCP joints and MCP angles bilaterally

First digit (thumb): PA projection - position of part

-If a PA projection of the first CMC joint and first digit is to be performed, place the hand in the lateral position. Rest elevated and abducted thumb on a radiographic support, or hold it up with radiolucent stick. Adjust the hand to place dorsal surface of digit parallel with IR. This position magnifies the part. -center the MCP joint to the center of the IR

First Digit (Thumb): oblique - evaluation criteria

-proper rotation of phalanges, soft tissue, and first metacarpal -area from distal tip of thumb to the trapezium -open IP and MCP joint spaces

described a special exposure technique for imaging early rheumatoid arthritis

Clements and Nakayama

Digits (2nd-5th): PA projections - structures shown

PA projection of the appropriate digit

When joint injury is suspected,

an AP projection is recommended instead of a PA projection

First carpometacarpal joint: AP projection (lewis modification) - CR

angled 10-15 degrees proximally along the long axis of the thumb and entering the first MCP joint

Digits (2nd-5th): Lateral projections (lateromedial or mediolateral) - position of pt

end of table

Hand: AP oblique projection (Norgaard method) -Hand: AP oblique projection (Norgaard method) - CR

perpendicular to a point midway between both hands at the level of the MCP joints for either of the two patient positions

Digits (2nd-5th): PA projections - CR

perpendicular to the PIP joint of the affected digit

Hand: Lateral projection (mediolateral or lateromedial-extension or fan lateral) - structures shown

the image, which shows a lateral projection of the hand in extension, is the customary position for localizing foreign bodies and metacarpal fracture displacement. The exposure technique depends on the foreign body. The fan lateral superimposes the metacarpals but shows almost all of the individual phalanges. The most proximal portions of the proximal phalanges remain superimposed

Digits (2nd-5th): Lateral projections (lateromedial or mediolateral) - evaluation criteria

-entire digit in true lateral position (fingernail in profile, concave anterior surfaces, no rotation of phalanges) -no obstruction of the proximal phalanx or MCP joint by adjacent digits -open IP joint spaces -soft tissue and bony trabeculation

Digits (2nd-5th): PA oblique projection (lateral rotation) - evaluation criteria

-entire digit rotated at a 45-degree angle, including distal portion of the adjoining metacarpal -no superimposition of the adjacent digits over the proximal phalanx or CP joint -open IP and MCP joint spaces -soft tissue and bony trabeculation

Digits (2nd-5th): Lateral projections (lateromedial or mediolateral) - position of part

-Because lateral digit positions are difficult to hold, tell patient how the digit is adjusted on the IR and demonstrate. Let pt assume most comfortable arm position -ask pt to extend digit to be examined. Close rest of digits into fist and hold them in complete flexion with the thumb -support elbow on sandbag or other suitable support when elbow must be elevated -have pt's hand rest on the lateral, or radial, surface for the second or third digit or on the medial, or ulnar, surface for the 4th or 5th digit -Center IR to the PIP joint -Rest the 2nd and 5th digits directly to the IR, but for an accurate image of the bones and joints, elevate the 3rd and 4th digits and place their long axes parallel with the plane of the IR -immobilize the extended digit by placing a strip of adhesive tape, a tongue depressor, or other support against the palmar surface. Pt can hold with opposite hand

First carpometacarpal joint: AP projection (Long and Rafert modification)- CR

-angled 15 degrees proximally along the long axis of the thumb and entering the first CMC joint -collimation to include entire thumb

Hand: AP oblique projection (Norgaard method) - evaluation criteria

-both hands from the carpal area to the tips of the digits -metacarpal heads and proximal phalangeal bases free of superimposition -useful level of density over the heads of the metacarpals

Hand: Lateral projection (lateromedial in flexion) - position of part

-center the IR to the mcp joints, and adjust it so that its midline is parallel with the long axis of the hand and forearm -with the pt relaxing the digits to maintain the natural arch of the hand, arrange the digits so that they are perfectly superimposed -have the pt hold the thumb parallel with the IR, or, if necessary, immobilize the thumb with tape or a sponge

Digits (2nd-5th): PA projections - evaluation criteria

-concavity of the phalangeal shafts and an equal amount of soft tissue on both sides of the phalanges -open IP and MCP joint spaces without overlap of bones -soft tissue and bony trabeculation

First digit (thumb): AP projection - position of part

-demonstrate how to avoid motion or rotation with the hand. By adjusting the body position on the chair, the pt can place hand in correct position with the least amount of strain on arm -put pt's hand in position of extreme medial rotation. Have pt hold the extended digits back with tape or opposite hand. Rest thumb on IR. If elbow is elevated place support under it and have pt rest the opposite forearm against table for support -place 5th metacarpal back far enough to avoid superimposition -Lewis suggested directing the central ray 10-15 degrees along the long axis of the thumb toward the wrist to show the 1st metacarpal free of the soft tissue of the palm

Hand: PA oblique projection (lateral rotation) - position of pt

-end of table -adjust pt's height to rest forearm on table

First digit (thumb): PA projection - position of pt

-end of table with hand resting on medial surface

Hand: Lateral projection (mediolateral or lateromedial-extension or fan lateral) - position of part

-extend pt's digits and adjust the first digit at a right angle to palm -place the palmar surface perpendicular to the IR -center the IR to the MCP joints, and adjust the midline to be parallel with the long axis of the hand and forearm. If the hand is resting on the ulnar surface, immobilization of the thumb may be necessary -the two extended digit positions result in superimposition of the phalanges. A modification of the lateral hand is the fan lateral position, which eliminates superimposition of all but the proximal phalanges. For the fan lateral position, place the digits on a sponge wedge Abduct the thumb and place it on the radiolucent sponge for support

First carpometacarpal joint: AP projection (Robert method) - position of part

-extend the limb straight out on the table -rotate the arm internally to place the posterior aspect of the thumb on the IR with the thumbnail down -place the thumb in the center of the IR -hyperextend the hand so that the soft tissue over the ulnar aspect does not obscure the first CMC joint. Ensure that the thumb is not oblique -Long and Rafert stated that the pt may hold back fingers with other hand -steady the hand on a sponge

Hand: AP oblique projection (Norgaard method) - Norgaard stated that ________ screens should be used to show high resolution. ____ kVp is recommended to obtain necessary contrast.

-extremely fine-grain intensifying -low (60-65)

First carpometacarpal joint: AP projection (robert method) - evaluation criteria

-first CMC joint free of superimposition of the hand or other bony elements -first metacarpal with the base in convex profile -trapezium

First Digit (Thumb): lateral - evaluation criteria

-first digit in a true lateral projection -no rotation of the phalanges -area from distal tip of thumb to trapezium -open IP and MCP joints

First carpometacarpal joint: AP projection (burman method): evaluation criteria

-first metacarpal -trapezium in concave profile -base of first metacarpal in convex profile -first CMC joint, unobscured by adjacent carpals

Hand: Lateral projection (mediolateral or lateromedial-extension or fan lateral) - evaluation criteria

-hand is in a true lateral --superimposted phalanges (individually shown on a fan lateral) --superimposed metacarpals --superimposted distal radius and ulna -extended digits -thumb free of motion and superimposition -each one outlined through the superimposed shadows of the metacarpals

Hand: AP oblique projection (Norgaard method) - position of part

-have the pt place the palms of both hands together. Center the MCP joints on the medial aspect of both hands to the IR. Both hands should be in the lateral position -place two 45 degree radiolucent sponges against the posterior aspect of each hand -rotate the pt's hands to a half-supinated position until the dorsal surface of each hand rests against each 45 degree sponge support -extend the pt's fingers, and abduct the thumbs slightly to avoid superimposing them over the second MCP joint -the original method of positioning the hand is often modified. The pt is positioned similar to the method described except that the fingers are cupped as though the pt were going to catch a ball. Comparable diagnostic information is provided using either position

Hand: PA oblique projection (lateral rotation) - evaluation criteria the following should be clearly shown

-minimal overlap of the third-fourth and fourth-fifth metacarpal shafts -slight overlap of the metacarpal bases and heads -separation of the second and third metacarpals -open IP and MCP joints -digits separated slightly with no overlap of their soft tissues -all anatomy distal to the distal radius and ulna

First Digit (Thumb): AP and PA thumb - evaluation criteria

-no rotation -area from distal tip of thumb to the trapezium -open IP and MCP joint spaces without overlap of bones -overlap of soft tissue profiled of the palm over the mid-shaft of the first metacarpal -PA thumb projection magnified compared with AP projection

Hand: PA projection - evaluation criteria the following should be clearly shown

-no rotation of hand -equal concavity of the metacarpal and phalangeal shafts on both sides -equal amount of soft tissue on both sides of the phalanges -equal distance between between the metacarpal heads -open MCP and IP joints -slightly separate digits -all anatomy distal to the radius and ulna

First carpometacarpal joint: AP projection (folio method): evaluation criteria the following should be clearly shown

-no rotation of the thumbs -first metacarpals -diagnostic image of the first MCP joint -rubber band and medical tape in correct position -thumbs centered to the center of the image

Digits (2nd-5th): PA projections - position of part

-place extended digit with palmar surface down -separate digits slightly and center digit under examination to midline portion of IR -center the PIP joint to the IR

First digit (thumb): Lateral projection - position of part

-place hand in its natural arched position with palmar surface down and fingers flexed or resting on sponge -place midline of the IR parallel with long axis of digit. Center IR to the MCP joint -adjust the arching of hand until true lateral position of thumb is obtained

First carpometacarpal joint: AP projection (folio method): position of part

-place pt's hands on the cassette resting them on their medial aspects -tightly wrap a rubber bad around the distal portion of both thumbs and place a roll of medical tape between the bodies of the first metacarpals -ensure thumbs remain in the PA plane by keeping the thumbnails parallel to the cassette -before exposure, instruct pt to pull thumbs apart and hold

First carpometacarpal joint: AP projection (burman method): position of part

-place the IR under the wrist, and center the first CMC joint to the center of the IR -hyperextend the hand, and have the pt hold the position with the opposite hand or with a bandage looped around the digits -rotate the hand internally, and abduct the thumb so that it is flat on the IR

Digits (2nd-5th): PA oblique projection (lateral rotation) - position of part

-place the pt's forearm on the table with the hand pronated -center the IR at the level of the PIP joint -rotate hand laterally until the digits separate and supported on a 45 degree foam edge. The wedge supports the digits in a position parallel with the IR plane so that the IP joint spaces are open

Hand: PA projection - position of part

-rest patient's forearm on the table place hand with palmar surface down -center IR to MCP joints -spread fingers slightly -ask pt to relax hand to avoid motion. prevent involuntary movement with the use of adhesive tape or positioning sponges. A sandbag may be placed over distal forearm

Hand: PA oblique projection (lateral rotation) - position of part

-rest pt's forearm on table with hand pronated and palm resting on IR -adjust the obliquity of the hand so that the MCP joints form an angle of approx. 45 degrees with the IR -use a 45 degree foam wedge to support the fingers in the extended position to show the iP joints -when examining the metacarpals, obtains a PA oblique projection of the hand by rotating the pt's hand laterally (externally) from the pronated position until the fingertips touch the IR -if it is possible to obtain the correct position with all fingertips resting on the Ir, elevate the index finger and thumb on a suitable radiolucent material. Elevation opens the joint spaces and reduces the degree of foreshortening of the phalanges. -for either approach, center the IR to the MCP joints

Hand: Lateral projection (lateromedial in flexion) - position of pt

-seat pt at end of table -ask pt to rest the forearm on the table, and place the hand of the IR with the ulnar aspect down

Hand: Lateral projection (mediolateral or lateromedial-extension or fan lateral) - position of pt

-seat pt at end of table with the forearm in contact with the table and the and in the lateral position with the ulnar aspect down -alternatively, place the radial side of the wrist against the IR. This position is more difficult for the pt to assume -If elbow is elevated, support with sandbags

Hand: Lateral projection (lateromedial in flexion) - evaluation criteria

-superimposed phalanges and metacarpal -superimposed distal radius and ulna -flexed digits -no motion or superimposition of the first digit -radiographic density similar to frontal and oblique hand images, which requires increased exposure factors to compensate for greater hand thickness -clear outline of each bone through the superimposed shadows of the other metacarpals

First digit (thumb): PA oblique projection - position of part

-with thumb abducted, place the palmar surface of hand in contact with IR. Ulnar deviate hand slightly. This positions the thumb in oblique position. -center the IR to the MCP joint

To show fractures of the fifth metacarpal better, _____ recommended rotating the hand 5 degrees posteriorly from the true lateral position. this positioning removes the superimposition of the second-4th metacarpals. The thumb is extended as much as possible, and the hand is allowed to become hollow by relaxation. The central ray is angled so that it passes parallel to the extended thumb and enters the midshaft of the fifth metacarpal

Lewis

described a positioning variation to place the second through fifth metacarpals parallel to the IR resulting in a true PA projection

Lewis

Hand: AP oblique projection - referred to as

Norgaard method, sometimes referred to as the ball-catcher's position, assists in detecting early radiologic changes in the dorsoradial aspects of the second through 5th proximal phalangeal bases, needed to diagnose rheumatoid arthritis

Digits (2nd-5th): Lateral projections (lateromedial or mediolateral) - structures shown

lateral projection of the affected digit

First carpometacarpal joint: AP projection (Robert method)- central ray

perpendicular entering at the first CMC joint

First Digit (Thumb): AP, PA, lateral, and PA oblique projections - CR

perpendicular to the MCP joint

Hand: Lateral projection (lateromedial in flexion) - CR

perpendicular to the MCP joint, entering the MCP joint of the second digit

Digits (2nd-5th): Lateral projections (lateromedial or mediolateral) - CR

perpendicular to the PIP joint of the affected digit

Digits (2nd-5th): PA oblique projection (lateral rotation) - CR

perpendicular to the PIP joint of the affected digit

Hand: Lateral projection (mediolateral or lateromedial-extension or fan lateral) - CR

perpendicular to the second MCP joint

Hand: PA oblique projection (lateral rotation) - CR

perpendicular to the third MCP joint

Hand: PA projection - CR

perpendicular to the third MCP joint

First carpometacarpal joint: AP projection (robert method) - structures shown

projection shows the first CMC joint free of superimposition of the soft tissues of the hand