Chapter 4 upper extremities
lateral
What projection is shown
True or False. The hand should be pronated for the lateral projection.
False (The hand should be in the lateral position with the thumb side up.)
PA, Axial stecher
Fig. 4-23 demonstrates the _____________________ projection (_____________________ method).
With which of the following structures of the distal humerus does the radial head articulate? a. Trochlea b. Capitulum c. Lateral epicondyle d. Medial epicondyle
b. capitulum
5. What group of bones articulates with the bases of metacarpal bones?
carpals
Bones in the wrist
carpals
List the names of the three groups of bones that com- prise the hand and wrist and indicate the quantity of bones in that group in each upper limb.
carpals, metacarpals, phalanges
Write the name of each fossa found on the distal humerus, and indicate on which surface each is located.
coronoid fossa, radial fossa, olecranon fossa
Palpable landmarks on each side of distal humerus
epicondyles
What type of movement for Elbow joint (humeroulnar and humeroradial) joints
flexion, extension
Raised process on proximal, lateral humerus
greater tubercle
Carpal bone with hooklike process
hamate
Essential projection: PA with Ulnar rotation wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
PA—ulnar deviation position 2.5 inches (6 cm) proximal and distal to the wrist joint and 1inch (2.5cm) on the sides Seated at end of table, affected upper limb in same plane and resting on table; anterior surface of wrist on IR; fingers flexed loosely; hand turned toward ulna as much as possible Styloid processes of radius and ulna parallel with IR; long axis of hand turned toward ulna Perpendicular to scaphoid
Which two bony processes are located on the proximal end of the ulna? a. Ulnar head and styloid process b. Ulnar head and coronoid process c. Olecranon process and styloid process d. Olecranon process and coronoid process
D.
Essential projection: thumb AP Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
Demonstrate how to avoid motion or rotation with the hand. • Put the patient's hand in a position of extreme medial rotation. Have the patient hold the extended digits back with tape or the opposite hand. Rest the thumb on the IR. If the elbow is elevated, place a support under it and have the patient rest the opposite forearm against the table for support • Center the long axis of the thumb parallel with the long axis of the IR. . Place the fifth metacarpal back far enough to avoid superimposition. • Lewis1 suggested directing the central ray 10 to 15 degrees along the long axis of the thumb toward the wrist to show the first metacarpal free of the soft tissue of the palm. Center the MCP joint to the center of the IR. Central ray • Perpendicular to the MCP joint for AP, PA, lateral, and oblique projections Collimation • 1 inch (2.5 cm) on all sides of the digit, including 1 inch (2.5 cm) proximal to the CMC joint
Capitulum
round, marblelike structure
For the PA oblique projection when the scaphoid is of primary interest, the scaphoid can sometimes be better demonstrated if the patient deviates the hand and wrist toward the ________________
ulna
List the names of the two bones that comprise the forearm, and indicate which bone is lateral and which bone is medial.
ulna- medial radius- lateral
Essential projection: tangential Gaynor Hart method Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
1 inch (2.5 cm) on the three sides of the shadow of the wrist n Seated at end of table, affected upper limb in same plane and resting on table; anterior surface of wrist on IR; hand hyperextended to place palm vertical n Styloid processes of radius and ulna parallel with IR n Angled 25 to 30 degrees to long axis of hand; enters 1 inch (2.5 cm) distal to third metacarpal base
Essential projection: Lateral hand (Flexion) Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
1 inch (2.5cm) on all sides of the hand and thumb, including 1 inch (2.5cm) proximal to ulnar styloid Seated at end of table, affected upper limb resting on table; from PA oblique, rolled laterally until in a lateral position resting on ulnar surface; fingers extended and superimposed; thumb abducted Styloid processes of radius and ulna superimposed and perpendicular to IR; long axis of hand aligned with long axis of IR Perpendicular to second MCP joint
Essential projection: Lateral hand (fan lateral) Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
1 inch (2.5cm) on all sides of the hand and thumb, including 1inch (2.5cm) proximal to ulnar styloid Seated at end of table, affected upper limb resting on table; from PA oblique, rolled laterally until in a lateral position resting on ulnar surface; fingers extended and positioned spread apart ("fanshape"); thumb abducted Styloid processes of radius and ulna superimposed and perpendicular to IR; long axis of hand aligned with long axis of IR Perpendicular to second MCP joint
List the essential projections for the hand, and describe the positioning steps used for each, as follows: Essential projection: PA hand Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
1 inch (2.5cm) on all sides of the hand including 1 inch (2.5cm) proximal to ulnar styloid Seated at end of table, affected upper limb resting on table; hand pronated, fingers extended and spread slightly apart Long axis of hand aligned with long axis of IR Perpendicular to third MCP joint
Essential projection: PA Oblique hand Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
1 inch (2.5cm) on all sides of the hand, including 1 inch (2.5cm) proximal to ulnar styloid Seated at end of table, affected upper limb resting on table; from PA, rotate hand laterally to a 45-degree angle with IR; fingers extended and spread slightly apart—radiolucent sponge provides support Long axis of hand aligned with long axis of IR Perpendicular to third MCP joint
Essential projection: Lateral forearm Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
2 inches (5 cm) distal to the wrist and proximal to the elbow and 1 inch (2.5 cm) on the sides n Seated at end of table, affected upper limb in same plane and resting on table; medial surface of forearm on IR; elbow flexed 90 degrees n Styloid processes of radius and ulna and humeral epicondyles superimposed and perpendicular to IR; long axis of forearm aligned with IR long axis n Perpendicular; enters midforearm
Essential projection: AP forearm Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
2 inches (5 cm) distal to the wrist and proximal to the elbow and 1 inch (2.5 cm) on the sides n Seated at end of table, affected upper limb in same plane and resting on table; posterior surface of forearm on IR n Styloid processes of radius and ulna and humeral epicondyles parallel with IR; long axis of forearm aligned with IR long axis n Perpendicular; enters midforearm
Essential projection: lateral wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
2.5 inches (6 cm) proximal and distal to the wrist joint and 1inch (2.5cm) on palmar and dorsal surfaces Seated at end of table, affected upper limb in same plane and resting on table; from PA oblique, rolled laterally until in a lateral position resting on ulnar surface Styloid processes of radius and ulna superimposed and perpendicular to IR; long axis of wrist aligned with long axis of IR Perpendicular to wrist joint
Essential projection: Scaphoid PA axial wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
2.5 inches (6 cm) proximal and distal to the wrist joint and 1inch (2.5cm) on the sides Seated at end of table, affected upper limb in same plane and resting on table; anterior surface of wrist on IR; fingers flexed loosely; IR at distal end of wrist elevated 20 degrees Styloid processes of radius and ulna parallel with IR; long axis of wrist aligned with IR long axis Perpendicular; enters scaphoid (or 20 degrees towards elbow if IR is flat)
Essential projection: PA wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
2.5 inches (6 cm) proximal and distal to the wrist joint and 1inch (2.5cm) on the sides Seated at end of table, affected upper limb in same plane and resting on table; anterior surface of wrist resting on IR; fingers loosely flexed Styloid processes of radius and ulna parallel with IR plane; long axis of wrist aligned with long axis of IR Perpendicular to midcarpals
Essential projection: PA oblique wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
2.5 inches (6cm) proximal and distal to the wrist joint and 1inch (2.5cm) on the sides Seated at end of table, affected upper limb in same plane and resting on table; from PA, rolled laterally 45 degrees Styloid processes of radius and ulna at 45-degree angle to IR; long axis of wrist aligned with long axis of IR Perpendicular to midcarpals; enters just distal to radius
How many degrees from the PA position should a finger be rotated for PA oblique projection?
45degrees
trochlea
A spool-like structure
What type of movement for Metacarpophalangeal joints
Adduction, flexion, extension, adduction, circumduction
Essential projection: Lateral finger Size of collimated field Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
Before making the final adjustment of the digit position, place the IR so that the midline of its unmasked portion is parallel with the long axis of the digit. Center the IR to the PIP joint. • Rest the second and fifth digits directly on the IR, but for an accurate image of the bones and joints, elevate the third and fourth digits and place their long axes parallel with the plane of the IR. A radiolucent sponge may be used to support the digits. • Immobilize the extended digit by placing a strip of adhesive tape, a tongue depressor, or other support against its palmar surface. The patient can hold the support with the opposite hand. • Adjust the anterior or posterior rotation of the hand to obtain a true lateral position of the digit. • Shield gonads. 1:113 Central ray • Perpendicular to the PIP joint of the affected digit Collimation • 1 inch (2.5 cm) on all sides of the digit, including 1 inch (2.5 cm) proximal to the MCP joint
medial condyle
Bony prominence; easily palpated
coronoid fossa
Depression; located on the anterior surface
olecranon fossa
Depression; located on the posterior surface
What type of movement for Interphalangeal Joints
Extension and flexion
What type of movement for Intercarpal joints
Gliding
What type of movement for Radiocarpal joints
Gliding
What is the disadvantage of using the substitute projection mentioned above?
Increased OID and magnification, resulting in a loss of recorded detail
A. Olecranon process B. Trochlear notch C. Radial head D. Radial neck E. Radial tuberosity F. Body of radius G. Radial styloid process H. Coronoid process of ulna I. Body of ulna J. Ulnar head K. Ulnar styloid process
Label the parts
a.Distal phalanx of the second digit B. Middle phalanx of the second digit C. Proximal phalanx of the second digit D. Second metacarpophalangeal joint E. Radius F. Ulna G. Distal interphalangeal joint of the third digit H. Proximal interphalangeal joint of the third digit I. Phalanges J. Metacarpals K. Carpals
Label the parts
A. Distal phalanx B. Interphalangeal joint C. Proximal phalanx D. Metacarpophalangeal joint E. First metacarpal F. Carpometacarpal joint
Label the parts
A. Hamate B. Capitate C. Trapezoid D. Trapezium E. Scaphoid F. Lunate G. Pisiform H. Triquetrum
Label the parts
A. Head B. Greater tubercle C. Lesser tubercle D. Body E. Medial epicondyle F. Trochlea G. Coronoid fossa H. Lateral epicondyle I. Capitulum
Label the parts
a.Proximal interphalangeal (PIP) joint of the fifth digit, right hand b.Fifthmetacarpophalangeal(MCP)joint,righthand c.Carpals, right wrist d.Distalinterphalangeal(DIP)jointofthethirddigit, right hand e. Interphalangeal (IP) joint of the first digit, right hand f.Metacarpophalangeal (MCP) joint of the first digit, right hand g.First metacarpal, right hand h.Carpometacarpal (CMC) joint of the first digit, right hand i.Radius (right) j.Ulna (right)
Label the parts
A. Distal phalanx B. Distal interphalangeal joint C. Middle phalanx D. Proximal interphalangeal joint E. Proximal phalanx F. Metacarpophalangeal joint G. Head of metacarpal PA projection
Label the parts and name the projection
What projection of the thumb may be substituted if the patient is unable to maintain the required position for the AP projection?
PA
Essential projection: Oblique finger Size of collimated field Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
Place the patient's forearm on the table with the hand pronated and the palm resting on the IR. • Center the IR at the level of the PIP joint. • Rotate the hand laterally until the digits are separated and supported on a 45-degree foam wedge. The wedge supports the digits in a position parallel with the IR plane so that the IP joint spaces are open. Central ray • Perpendicular to the PIP joint of the affected digit Collimation • 1 inch (2.5 cm) on all sides of the digit, including 1 inch (2.5 cm) proximal to the MCP joint
What type of movement for Distal radioulnar joints
Rotational (around a single axis)
What type of movement for Proximal radioulnar joints
Rotational (around a single axis)
Identify each carpal bone by listing its name
Scaphoid Lunate Triquetrum Pisiform Trapezium Trapazoid Capitate Hamate
How many proximal, middle, and distal phalanges are found in one hand? a. Proximal: ______ b. Middle: _______ c. Distal: _______
a. 5 b. 4 c. 5
When using a wedge to elevate the IR (as shown in Fig. 4-23), how should the central ray be directed toward the wrist? a. Perpendicularly b. At a 10-degree angle toward the elbow c. At a 20-degree angle toward the elbow d. At a 30-degree angle toward the elbow
a. Perpendicularly
For the AP projection of the forearm, how should the elbow be positioned? a. Fully extended b. Flexed 45 degrees c. Flexed 90 degrees
a. fully extended
Which kinds of movements do the interphalangeal joints allow? a. Gliding and sliding b. Flexion and extension c. Rotational movements around a single axis
a. gliding and sliding
What is the most distal portion of each metacarpal? a. Head b. Base c. Tubercle
a. head
For the lateral projection of the wrist, which surface of the wrist should be in contact with the IR? a. Medial b. Lateral c. Anterior d. Posterior
a. medial
On which hand surface should the hand be rested when performing the lateral projection image of the fourth or fifth digit? a. Medial (ulnar) b. Lateral (radial) c. Anterior (palmar) d. Posterior (ventral)
a. medial (ulnar)
With which of the following structures of the distal humerus does the trochlear notch articulate? a. Trochlea b. Capitulum c. Lateral epicondyle d. Medial epicondyle
a. trochlea
On which bone is the trochlear notch located? a. Ulna b. Radius c. Humerus
a. ulna
What other name refers to the radiocarpal joint?
articular disk
How far from horizontal should the IR be inclined toward the elbow? a. 10 degrees b. 20 degrees c. 30 degrees
b. 20 degree
Which bone classification are the metacarpals? a. Flat b. Long c. Short d. Irregular
b.long
Which of the following types of upper limb joints are formed in part by the bases of the metacarpals? a. Interphalangeal b. Carpometacarpal c. Metacarpophalangeal
b. carpometacarpal
Which joint is the most distal joint in the upper limb? a. Carpometacarpal b. Distal interphalangeal c. Metacarpophalangeal d. Proximal interphalangeal
b. distal interphalangeal
From the following list, circle the three articulations that form the complete elbow joint. a. Radiocarpal b. Humeroulnar c. Humeroradial d. Scapulohumeral e. Distal radioulnar f. Proximal radioulnar
b. humeroradial c. humeroradial f. proximal radioulnar
With reference to the capitulum, where is the trochlea located? a. Lateral b. Medial c. Distal d. Proximal
b. medial
With reference to the plane of the IR, how should the long axis of the hand be positioned? a. Angled b. Vertical c. Parallel
b. vertical
With reference to the long axis of the hand, how much should the central ray be angled? a. 5 to 10 degrees b. 15 to 20 degrees c. 25 to 30 degrees
c. 25 to 30 degrees
How much should the wrist be rotated for the PA oblique projection? a. 25 degrees b. 35 degrees c. 45 degrees
c. 45 degree
For the lateral projection of the forearm, how should the elbow be positioned? a. Fully extended b. Flexed 45 degrees c. Flexed 90 degrees d. Rotated medially 45 degrees
c. Flexed 90 degrees
Which two groups of joints of the hand and digits should be demonstrated open on the image of the PA projection of the hand? a. Intercarpal and interphalangeal b. Intercarpal and carpophalangeal c. Metacarpophalangeal and interphalangeal d. Metacarpophalangeal and carpophalangeal
c. Metacarpophalangeal and interphalangeal
Which joint do the radial notch of the ulna and the head of the radius form? a. Humeroulnar b. Humeroradial c. Distal radioulnar d. Proximal radioulnar
c. distal radioulnar
For the lateral projection of the wrist, how should the elbow be positioned? a. Fully extended b. Flexed 45 degrees c. Flexed 90 degrees
c. flexed 90 degrees
Which bones articulate with the heads of the meta- carpal bones? a. Carpals b. Distal phalanges c. Proximal phalanges
c. proximal phalanges
Which carpal bone is of primary interest with this position? a. Lunate b. Capitate c. Scaphoid
c. scapoid
Which bone classification are the carpal bones? a. Flat b. Long c. Short d. Irregular
c. short
Which of the following is located on the proximal ulna? a. Ulnar notch b. Humeral notch c. Trochlear notch
c. trochlear notch
To delineate a fracture line better with a PA projection of the wrist in ulnar deviation, how many degrees and in which direction may the central ray be directed? a. 10 to 15 degrees medially or laterally b. 20 to 25 degrees medially or laterally c. 10 to 15 degrees proximally or distally d. 20 to 25 degrees proximally or distally
c.10 to 15 degrees proximally or distally
If no wedge is used to angle the IR, how should the central ray be directed toward the wrist? a. Perpendicularly b. At a 10-degree angle toward the elbow c. At a 20-degree angle toward the elbow d. At a 30-degree angle toward the elbow
c.At a 20-degree angle toward the elbow
How are the metacarpals identified? a. Letters A to E from medial (little finger side) to lateral (thumb side) b. Letters A to E from lateral (thumb side) to medial (little finger side) c. Numbered 1 through 5 from lateral (thumb side) to medial (little finger side) d. Numbered 1 through 5 from medial (little finger side) to lateral (thumb side)
c.Numbered 1 through 5 from lateral (thumb side) to medial (little finger side)
Carpal that articulates with third metacarpal
capitate
Portion of distal humerus that articulates with radial head
capitulum
Process located on anterior, proximal ulna
coronoid
Which projection of the hand should demonstrate superimposed phalanges? a. PA b. PA oblique c. Lateral, in fan lateral position d. Lateral, in extension
d. lateral, in extension
Which joint do the head of the ulna and the ulnar notch of the radius form? a. Humeroulnar b. Humeroradial c. Distal radioulnar d. Proximal radioulnar
d. proximal radioulnar
End of bone on which ulnar head is
distal
On which end of the radius (proximal or distal) is the styloid process located?
distal
On which end of the ulna (proximal or distal) is the styloid process located?
distal
For lateral projections of the third or fourth digit, why should the affected digit be positioned so that its long axis is parallel with the IR?
for an accurate image
Depression on posterior surface of distal humerus, olecranon
fossa
What part of a metacarpal bone (base or head) forms part of each metacarpophalangeal joint?
head
Write the name of each articulation of the humerus.
humeroulnar, humeroradial
Upper arm bone
humerous
IP portion of DIP abbreviation
interphalangeal
Carpal between scaphoid and triquetrum
lunate
Bones in the palm of the hand
metacarpals
Flexing the fingers for the PA projection of the wrist decreases ___________________________ and increases ________________
oid, recorded detail
Prominent process on proximal ulna
olecranon
Finger bones
phalanges
End of bone on which radial head is located
proximal
On which end of the radius (proximal or distal) is the radial head located?
proximal
On which end of the ulna (proximal or distal) is the olecranon process located?
proximal
Lateral bone of forearm
radius
If the hand is pronated for the AP projection of the forearm, the image will demonstrate the:
radius and ulna crossed over each other
Distal process on radius and ulna
styloid
For the PA oblique projection of the third digit, what is the advantage of placing the patient's fingers on a 45-degree foam wedge?
supports the digits in a position parallel w the IR
For the PA oblique projection of the second digit, what is the advantage of rotating the second digit medially compared with the advantage of rotating the digit laterally?
the part is closer to the IR for improved recorded detail and increased visibility of certain fractures
Medial to trapezium
trapazoid
All thumb images should include the ______________ carpal within the collimated field.
trapezium
Prominence on anterior surface of distal, medial humerus located
trochlea
Essential projection: thumb first metacarpal joint (Roberts method) Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Extend the limb straight out on the radiographic table. • Rotate the arm internally to place the posterior aspect of the thumb on the IR with the thumbnail down (Fig. 4-45, B). • 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 • Perpendicular entering at the first CMC joint Central ray angulation choices to show first CMC joint. A, Robert method, 0 degrees to CMC joint. B, Long-Rafert modification, 15 degrees proximal to CMC joint. C, Lewis modification, 10 to 15 degrees proximal to MCP joint. Long and Rafert modification • Angled 15 degrees proximally along the long axis of the thumb and entering the first CMC joint • Collimation to include the entire thumb Lewis modification • Angled 10 to 15 degrees proximally along the long axis of the thumb and entering the first MCP joint NOTE: Angulation of the central ray serves two purposes: (1) It may help project the soft tissue of the hand away from the first CMC joint, and (2) it can help open the joint space when the space is not shown with a perpendicular central ray.
Essential projection: AP projection wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Have the patient rest the forearm on the table, with the arm and hand supinated. • Place the IR under the wrist, and center it to the carpals. • Elevate the digits on a suitable support to place the wrist in close contact with the IR. • Have the patient lean laterally to prevent rotation of the wrist Central ray • Perpendicular to the midcarpal area Structures shown The carpal interspaces are better shown in the AP image than in the PA image. Because of the oblique direction of the interspaces, they are more closely parallel with the divergence of the x-ray beam
List the essential projections for the carpal canal, and describe the positioning steps used for each, as follows: Essential projection: (_______________________) method Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Hyperextend the wrist, and center the IR to the joint at the level of the radial styloid process. • For support, place a radiolucent pad approximately image inch (1.9 cm) thick under the lower forearm. • Adjust the position of the hand to make its long axis as vertical as possible. • To prevent superimposition of the shadows of the hamate and pisiform bones, rotate the hand slightly toward the radial side. • Have the patient grasp the digits with the opposite hand, or use a suitable device to hold the wrist in the extended position Central ray • Directed to the palm of the hand at a point approximately 1 inch (2.5 cm) distal to the base of the third metacarpal and at an angle of 25 to 30 degrees to the long axis of the hand • When the wrist cannot be extended to within 15 degrees of vertical, McQuillen Martensen1 suggested that the central ray first be aligned parallel to the palmar surface, then angled an additional 15 degrees toward the palm. Collimation • 1 inch (2.5 cm) on the three sides of the shadow of the wrist Structures shown This image of the carpal canal (carpal tunnel) shows the palmar aspect of the trapezium; the tubercle of the trapezium; and the scaphoid, capitate, hook of hamate, triquetrum, and entire pisiform (Fig. 4-101).
Essential projection: AP oblique wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Place the IR under the wrist and center it at the dorsal surface of the wrist. • Rotate the wrist medially (internally) until it forms a semisupinated position of approximately 45 degrees to the IR Central ray • Perpendicular to the midcarpal area; it enters the anterior surface of the wrist midway between its medial and lateral borders Structures shown This position separates the pisiform from adjacent carpal bones. It also provides a more distinct radiograph of the triquetrum and hamate
Essential projection: thumb first metacarpal joint (Burman method) Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Place the IR under the wrist, and center the first CMC joint to the center of the IR. • Hyperextend the hand, and have the patient 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 Hyperextended hand and abducted thumb position for AP of first CMC joint: Burman method. Central ray • Through the first CMC joint at a 45-degree angle toward the elbow
Essential projection: PA finger Size of collimated field Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Place the extended digit with the palmar surface down on the unmasked portion of the IR. • Separate the digits slightly, and center the digit under examination to the midline portion of the IR. • Center the PIP joint to the IR Central ray • Perpendicular to the PIP joint of the affected digit Collimation • 1 inch (2.5 cm) on all sides of the digit, including 1 inch (2.5 cm) proximal to the MCP joint
Essential projection: thumb lateral Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Place the hand in its natural arched position with the palmar surface down and fingers flexed or resting on a sponge. • Place the midline of the IR parallel with the long axis of the digit. Center the IR to the MCP joint. • Adjust the arching of the hand until a true lateral position of the thumb is obtained
Essential projection: thumb first metacarpal joint (folio method) Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Place the patient's hands on the cassette, resting them on their medial aspects. • Tightly wrap a rubber band around the distal portion of both thumbs and place a roll of medical tape between the bodies of the first metacarpals. • Ensure the thumbs remain in the PA plane by keeping the thumbnails parallel to the cassette Hands and thumbs in position for PA first MCP joints: Folio method. Note roll of tape between thumbs. • Before exposure, instruct the patient to pull the thumbs apart and hold. Central ray • Perpendicular to a point midway between both hands at the level of the MCP joints NOTE: To avoid motion, have the correct technical factors set on the generator and be ready to make the exposure before instructing the patient to pull the thumbs apart
Essential projection: Trapezium PA axial oblique wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Place the wrist in the lateral position, resting on the ulnar surface over the center of the IR. • Place a 45-degree sponge wedge against the anterior surface, and rotate the hand to come in contact with the sponge. • If the patient is able to achieve ulnar deviation, adjust the IR so that the long axis of the IR and the forearm align with the central ray • If the patient is unable to achieve ulnar deviation comfortably, align the straight wrist to the IR, and rotate the elbow end of the IR and arm 20 degrees away from the central ray Central ray • Angled 45 degrees distally to enter the anatomic snuffbox of the wrist and pass through the trapezium Structures shown The image clearly shows the trapezium and its articulations with adjacent carpal bone
Essential projection: PA with radial rotation wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Position the wrist on the IR for a PA projection. • Without moving the forearm, turn the hand medially until the wrist is in extreme radial deviation Central ray • Perpendicular to midcarpal area Structures shown Radial deviation opens the interspaces between the carpals on the medial side of the wrist
Essential projection: Scaphoid series PA and PA axial wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• Seat the patient at the end of the radiographic table with the arm and axilla in contact with the table. • Rest the forearm on the table. Place one end of the IR on a support, and adjust the IR so that the finger end of the IR is elevated 20 degrees • Adjust the wrist on the IR for a PA projection, and center the wrist to the IR. • Bridgman2 suggested positioning the wrist in ulnar deviation for this radiograph. • Shield gonads. Central ray • Perpendicular to the table and directed to enter the scaphoid Collimation • 2.5 inches (6 cm) proximal and distal to the wrist joint and 1 inch (2.5 cm) on the sides Structures shown The 20-degree angulation of the wrist places the scaphoid at right angles to the central ray, so that it is projected with minimal superimposition
Essential projection: carpal bridge tangential wrist Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• The originators1 of this projection recommended that the hand lie palm upward on the IR with the hand at right angle to the forearm (Fig. 4-96). image • When the wrist is too painful to be adjusted in the position just described, a similar image can be obtained by elevating the forearm on sandbags or other suitable support. Then with the wrist flexed in right-angle position, place the IR in the vertical position (Fig. 4-97). image • Shield gonads. Central ray • Directed to a point about image inches (3.8 cm) proximal to the wrist joint at a caudal angle of 45 degrees Structures shown The carpal bridge is shown on the image in Figs. 4-98 and 4-99. The originators recommended this procedure to show fractures of the scaphoid, lunate dislocations, calcifications and foreign bodies in the dorsum of the wrist, and chip fractures of the dorsal aspect of the carpal bones.
Essential projection: thumb PA oblique Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• With the thumb abducted, place the palmar surface of the hand in contact with the IR. Ulnar deviate the hand slightly. This relatively normal placement positions the thumb in the oblique position. • Align the longitudinal axis of the thumb with the long axis of the IR. Center the IR to the MCP joint
Essential projection: thumb PA Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:
• With the thumb abducted, place the palmar surface of the hand in contact with the IR. Ulnar deviate the hand slightly. This relatively normal placement positions the thumb in the oblique position. • Align the longitudinal axis of the thumb with the long axis of the IR. Center the IR to the MCP joint
