PART 1 (FINGER, THUMB, & HAND) Radiographic Procedures 2: Chapter 4 Upper Limb

Phalanges: Thumb (1st Digit)

1) Thumb - has 2 phalanges - has 2 joints: (IP) Interphalangeal joint - between the proximal and distal phalanges. (MCP) First Metacarpophalangeal joint - between the first metacarpal and the proximal phalanx of the thumb. - in a radiograph, thumbs should include the distal phalanx to the base of the first metacarpal. -thumb side always lateral

Upper Limb

1) hand & wrist 2) forearm 3) arm 4) shoulder girdle

Phalanges: (2nd, 3rd, 4th, & 5th Digits)

2) index 3) middle 4) ring 5) pinky - has 3 phalanges: distal, middle, proximal - has 3 joints: (DIP) Distal Interphalangeal joint - between distal and middle phalanges. (PIP) Proximal Interphalangeal joint - between the middle and proximal phalanges. (MCP) Metacarpophalangeal joint - between the proximal phalanges and metacarpals. - pinky side always medial

Number of bones in the hand & wrist

27 bones in each hand & wrist - 14 phalanges (fingers/thumbs) - 5 metacarpals (palm) - 8 carpals (wrist)

Metacarpals: Palm of Hand

5 metacarpals on each hand Each metacarpal consists of 3 parts: 1) distal rounded head 2) body (shaft) 3) expanded base - has 2 joints: (MCP) Metacarpophalangeal joint - between the proximal phalanges and metacarpals. (CMC) Carpometacarpal joint - between the metacarpals and carpals. Metacarpals articulations with Carpals -Trapezium at base of 1st metacarpal -Trapezoid at base of 2nd metacarpal -Capitate at base of 3rd metacarpal -Hamate at the base of 4th and 5th metacarpals

PROCEDURE: Routine Thumb (AP Projection)

Clinical Indications - fractures and dislocations of the distal, middle, and proximal phalanges; distal, metacarpal and associated joints. - Pathological processes like osteoporosis and osteoarthritis. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 8 in x 10 in (18 cm x 24 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - Accessories: sponge support block - CR perpendicular to IR to first MCP joint Patient Position - seat patient facing table, arms extended in front with hand rotated internally to supinate thumb. Part Position - first, demonstrate the position on yourself so the patient can see how it is done to better understand what is expected. - internally rotate hand with fingers extended until posterior surface of thumb is in contact with IR. - immobilize fingers with tape to isolate the thumb if necessary. - align the thumb with the long axis of the IR. - center first MCP joint to CR and to center of IR. Collimation - collimate on all four sides to area of thumb. - remember the thumb includes the entire first metacarpal and trapezium. *Exception PA if patient cannot position for AP* - place hand in near-lateral position and rest thumb on sponge support block that is high enough so the thumb is not rotated but is in position for a true PA projection. - not recommended as it results in loss of definition caused by increased OID.

PROCEDURE: Special Thumb (AP Axial Projection - Modified Robert Method)

Clinical Indications - base of first metacarpal is demonstrated for ruling out Bennett fracture. - demonstrated fractures, dislocations, or pathology of the base of the first metacarpal and trapezium. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 8 in x 10 in (18 cm x 24 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - CR directed 15 degrees proximally (toward wrist) entering at the first CMC joint - *Lewis modification (CR angle 10 degrees to 15 degrees proximal to MCP joint)* Patient Position - seat patient parallel to end of table, with hand and arm fully extended. Part Position - rotate arm internally until posterior aspect of thumb rests on IR. - place thumb in center of IR parallel to side border of IR and extend fingers. Collimation - collimate on all four sides to area of thumb and first CMC joint.

PROCEDURE: Routine Thumb (PA Oblique Projection - Medial Rotation)

Clinical Indications - fractures and dislocations of the distal, middle, and proximal phalanges; distal, metacarpal and associated joints. - Pathological processes like osteoporosis and osteoarthritis. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 8 in x 10 in (18 cm x 24 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 Patient Position - seat patient at end of table with hand resting on IR. Part Position - Abduct thumb slightly with palmar surface of the hand in contact with IR (with naturally places thumb in a 45 degree oblique position). - Align the thumb with the long axis of the IR. - Center first MCP joint to CR and to center of IR. Collimation - collimate on all four sides to area of thumb. - remember the thumb includes the entire first metacarpal and trapezium. support block - CR perpendicular to IR to first MCP joint Patient Position - seat patient at end of table with hand resting on IR. Part Position - abduct thumb slightly with palmar surface of the hand in contact with IR (with naturally places thumb in a 45 degree oblique position). - align the thumb with the long axis of the IR. - center first MCP joint to CR and to center of IR. Collimation - collimate on all four sides to area of thumb. - remember the thumb includes the entire first metacarpal and trapezium.

PROCEDURE: Fingers (Lateromedial or Mediolateral Projection)

Clinical Indications - fractures and dislocations of the distal, middle, and proximal phalanges; distal, metacarpal and associated joints. - Pathological processes like osteoporosis and osteoarthritis. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 8 in x 10 in (18 cm x 24 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - Accessories: sponge support block - CR perpendicular to IR directed to PIP joint Patient Position - seat patient at end of table with elbow flexed about 90 degrees with hand and wrist resting on the IR and fingers extended. Part Position - with fingers extended against 45 degree foam wedge block , place hand in a 45 degree lateral oblique (thumb side up). - Position hand on IR so that the long axis of the finger is aligned with the long axis of the IR. - Separate finger and carefully place finger that is being examined against block, so it is supported in a 45 degree oblique and parallel to IR. Collimation - collimate on all four sides to area of affected finger and distal aspect of metacarpal

PROCEDURE: Fingers (Pa Oblique Projection - Medial or Lateral Rotation)

Clinical Indications - fractures and dislocations of the distal, middle, and proximal phalanges; distal, metacarpal and associated joints. - Pathological processes like osteoporosis and osteoarthritis. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 8 in x 10 in (18 cm x 24 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - Accessories: wedge block or step wedge sponges - CR perpendicular to IR directed to PIP joint Patient Position - seat patient at end of table with elbow flexed about 90 degrees with hand and wrist resting on the IR and fingers extended. Part Position - place hand in lateral position with finger to be examined fully extended and centered to portion of the IR being exposed. - align and center finger to long axis of IR and to CR - use sponge block or other radiolucent device to support finger and prevent motion. - flex unaffected fingers -ensure that long axis of the finger is parallel to the IR Collimation - collimate on all four sides to area of affected finger and distal aspect of metacarpal

PROCEDURE: Fingers (PA Projection)

Clinical Indications - fractures and dislocations of the distal, middle, and proximal phalanges; distal, metacarpal and associated joints. - Pathological processes like osteoporosis and osteoarthritis. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 8 in x 10 in (18 cm x 24 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - CR perpendicular to IR directed to PIP joint Patient Position - seat patient at end of table with elbow flexed about 90 degrees with hand and forearm resting on the table. Part Position - pronate hand with fingers extended - center and align long axis of affected finger with long axis of IR - separate adjoining fingers from affected finger Collimation - collimate on all four sides to area of affected finger and distal aspect of metacarpal

PROCEDURE: Routine Thumb (Lateral Position)

Clinical Indications - fractures and dislocations of the distal, middle, and proximal phalanges; distal, metacarpal and associated joints. - Pathological processes like osteoporosis and osteoarthritis. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 8 in x 10 in (18 cm x 24 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - CR perpendicular to IR to first MCP joint Patient Position - seat patient at the end of the table, with elbow flexed about 90 degrees with hand resting on IR, palm down. Part Position - start with hand pronated and thumb abducted , with fingers and hand slightly arched. - rotate hand slightly medial until thumb is in true lateral position (you may need a support sponge). - align the thumb with the long axis of the IR. - center first MCP joint to CR and to center of IR. - entire lateral aspect of thumb should be in direct contact with IR. Collimation - collimate on all four sides to area of thumb. - remember the thumb includes the entire first metacarpal and trapezium.

PROCEDURE: Routine Hand ("Fan" Lateral - Lateromedial Projection)

Clinical Indications - fractures and dislocations of the phalanges, anterior/posterior displaced fractures, and dislocations of the metacarpals. - Pathological processes like osteoporosis and osteoarthritis especially in the phalanges. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 10 in x 12 in (24 cm x 30 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 -Accessories: 45 degree foam step support - CR perpendicular to IR directed to 2nd MCP joint *A filter may be used to ensure optimum exposure of phalanges and metacarpals because of differences in part thickness.* Patient Position - seat patient at end of table with hand and forearm extended. Part Position - align long axis of hand with the long axis of the IR. - rotate the entire hand and wrist into lateral position with thumb side up. - Spread fingers and thumb into a "fan" position, and support each digit on radiolucent block. - ensure all the digits are separated and parallel to the IR and that the metacarpals are NOT rotated but remain in true lateral position. Collimation - collimate on all four sides to outer margins of hand and wrist.

PROCEDURE: Routine Hand (PA Oblique Projection)

Clinical Indications - fractures, dislocations, or foreign bodies of the phalanges, metacarpals and all joints of the hand. - Pathological processes like osteoporosis and osteoarthritis. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 10 in x 12 in (24 cm x 30 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - CR perpendicular to IR directed to 3rd MCP joint Patient Position - seat patient at end of table with hand and forearm extended. Part Position - pronate hand on IR - center and align long axis of hand with the long axis of the IR. - rotate the entire hand and wrist laterally 45 degrees and support with radiolucent wedge or step block so that all the digits are separated and parallel to the IR. Collimation - collimate on all four sides to hand and wrist *Exception: for a routine oblique hand, use a support block to place digits parallel to IR. This block prevents foreshortening of phalanges and obscuring of interphalangeal joints. If the metacarpals only are of interest, the image can be taken with the thumb and fingertips touching IR.*

PROCEDURE: Routine Hand (PA Projection)

Clinical Indications - fractures, dislocations, or foreign bodies of the phalanges, metacarpals and all joints of the hand. - Pathological processes like osteoporosis and osteoarthritis. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 10 in x 12 in (24 cm x 30 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - CR perpendicular to IR directed to 3rd MCP joint Patient Position - seat patient at end of table with hand and forearm extended. Part Position - pronate hand with palmar surface in contact with the IR; spread fingers slightly. - align long axis of hand and forearm with long axis of IR. - center hand and wrist to IR. Collimation - collimate on all four sides to outer margins of hand and wrist.

PROCEDURE: Special Hand (AP Axial Projection - Brewerton Method)

Clinical Indications - performed commonly to evaluate for early evidence of rheumatoid arthritis at the 2nd through 5th MCP joints; evident by slight erosion of the head of the metacarpal. - May demonstrate fractures of the base of the 4th and 5th metacarpal. Technical Factors - Minimum SID 40 in (100 cm) - IR size 10 in x 12 in (24 cm x 30 cm) portrait or 14 in x 17 in (35 cm x 43 cm) for bilateral study, landscape; smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - Angle CR 15 degrees proximally, toward ulna, directed to the third MCP joint. Patient Position - seat patient at end of table with hand supinated and flexed. Part Position - supinate hand and place at the center of the IR. - from this position, keeping fingers in contact with the IR, flex the hand to create a 65 degree angle between the dorsum of the hand and IR. - extend fingers and ensure they are relaxed, slightly separated and parallel to IR. - Abduct thumb to avoid superimposition. Collimation -collimate on four sides to outer margins of hand and wrist.

PROCEDURE: Special Thumb (PA Stress Thumb Projection - Folio Method)

Clinical Indications - sprain or tearing of ulnar collateral ligament of thumb at MCP joint as a result of acute hyperextension of thumb; also referred to as a "skier's thumb" injury. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 8 in x 10 in (18 cm x 24 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - CR perpendicular to IR directed to midway between MCP joints. Patient Position - seat patient parallel to end of table, with hand and arm fully extended. Part Position - rotate arm internally until posterior aspect of thumb rests on IR. - place thumb in center of IR parallel to side border of IR and extend fingers. Collimation - collimate on all four sides to area of thumb to include the second metacarpals and entire thumbs, from CMC joints proximally to distal phalanges distally.

PROCEDURE: Alternative Hand (Lateral in Extension & Flexion - Lateromedial Projections)

Clinical Indications - the lateral in either extension or flexion is an alternate to the fan lateral for localization of foreign bodies of the hand and fingers; it also demonstrates anterior or posterior displaced fractures of the metacarpals. - the lateral in a natural flexed position may be less painful for the patient. Technical Factors - Minimum SID 40 in (100 cm) - IR Size 10 in x 12 in (24 cm x 30 cm) portrait or smallest IR available and collimate to area of interest. - Nongrid - kVp range 55 to 65 - CR perpendicular to IR directed to 2nd to 5th MCP joints Patient Position - seat patient at end of table with hand and forearm extended Part Position - rotate hand and wrist, with thumb side up, into true lateral position with 2nd to 5th MCP joints centered to IR and CR. - LATERAL IN EXTENSION: extend fingers and thumb, and support against a radiolucent support block. Ensure all fingers and metacarpals are superimposed directly for true lateral position. - LATERAL IN FLEXION: flex fingers into natural flexed position with thumb lightly touching the first finger, maintaining true lateral position. Collimation - collimate to outer margins of hand and wrist.

PROCEDURE: Fingers

FINGERS - PA Projection - PA Oblique Projection (medial or lateral rotation) - Lateromedial or Mediolateral Projections

PROCEDURES: Fingers, Thumb, & Hand

FINGERS - PA Projection - PA Oblique Projection (medial or lateral rotation) - Lateromedial or Mediolateral Projections THUMB (Routine) - AP Projection - PA Oblique Projection (Medial Rotation) - Lateral Position THUMB (Special) - AP Axial Projection (Modified Robert Method) - PA Stress Thumb Projection (Folio Method) HAND (Routine) - PA Projection - PA Oblique Projection - "Fan" Lateral -Lateromedial Projection HAND (Alternate) - Lateral in Extention - Lateromedial Projection - Lateral in Flexion - Lateromedial Projection HAND (Special) - AP Axial Projection (Brewerton Method)

Joints: Hand

HAND - (DIP) Distal Interphalangeal joint is between distal and middle phalanges. - (PIP) Proximal Interphalangeal joint is between the middle and proximal phalanges. - (MCP) Metacarpophalangeal joint is between the proximal phalanges and metacarpals. - (CMC) Carpometacarpal joint is between the metacarpals and carpals.

Phalanges: Fingers & Thumbs (digits)

Phalanges are the most distal bones of the hand. Each finger and thumb is a "digit" - 5 digits: 1) thumb, 2) index, 3) middle, 4) ring, 5) pinky Each digit consists of two to three separate bones called "phalanges" (singular: phalanx) - 2 phalanges (thumb): proximal and distal - 3 phalanges (2,3,4,5): proximal, middle, distal Each phalanx consists of 3 parts: 1) distal rounded head 2) body (shaft) 3) expanded base

PROCEDURE: Thumb

THUMB (Routine) - AP Projection - PA Oblique Projection (Medial Rotation) - Lateral Position THUMB (Special) - AP Axial Projection (Modified Robert Method) - PA Stress Thumb Projection (Folio Method)

Joints: Hand (DIP) Distal Interphalangeal joint

between distal and middle phalanges Movement: Ginglymus or "hinge"

Joints: Hand (CMC) Carpometacarpal joint

between the metacarpals and carpals Movement: Saddle or "sellar" (1st digit/Thumb) Plane or "gliding" (2nd, 3rd, 4th, & 5th digits)

Joints: Hand (PIP) Proximal Interphalangeal joint

between the middle and proximal phalanges Movement: Ginglymus or "hinge"

Joints: Hand (MCP) Metacarpophalangeal joint

between the proximal phalanges and metacarpals Movement: Ellisoidal or "condyloid"