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