UPPER EXTREMETIES

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Questions and Answers

What is the angle of the Rafert/Long Modification when performing an AP projection of the 1st carpometacarpal joint?

20 degrees

10 degrees

15 degrees (correct)

0 degrees

Which method provides a clearer image of the 1st carpometacarpal joint compared to a standard AP projection?

Robert Method (correct)

Folio Method

Lewis Modification

Rafert/Long Modification

What is a common clinical presentation managed by imaging of the 1st Carpometacarpal joint?

Tendonitis

UCL sprain

Carpal tunnel syndrome

Fractures (correct)

What does the Folio Method specifically address during its procedure?

UCL of the thumb Signup and view all the answers

Which option describes the purpose of performing an external rotation (ER) during imaging of the 1st CMC joint?

To protect soft tissue around the joint Signup and view all the answers

Which modification uses an arm internally rotated and the hand hyperextended?

Robert Method Signup and view all the answers

What is the primary purpose of the Lewis Modification during imaging of the 1st CMC joint?

To angulate for clearer joint spaces Signup and view all the answers

Which of the following conditions can be diagnosed using the AP projection methods outlined for the 1st CMC joint?

Bennett's Fracture Signup and view all the answers

What is the angulation used in the Rafert/Long Modification for the 1st carpometacarpal joint projection?

15 degrees Signup and view all the answers

Which position is utilized in the Folio Method for imaging Skiers' Thumb?

Thumbs wrapped around by a rubber band Signup and view all the answers

During which projection method is the hand rested on its medial aspect?

Folio Method Signup and view all the answers

What is a common reason for performing external rotation (ER) during the imaging of the 1st CMC joint?

To protect soft tissues away from the joint Signup and view all the answers

What is the primary diagnostic purpose of assessing both bilateral MCP joint and metacarpal angles in the context of UCL ruptures?

To determine the alignment and integrity of the UCL Signup and view all the answers

During the Robert Method for imaging the 1st carpometacarpal joint, what position should the arm be in?

Internally rotated with the hand hyperextended Signup and view all the answers

Which condition is specifically associated with the diagnosis of Skiers' Thumb?

UCL rupture of the thumb Signup and view all the answers

What is the main modification applied in the Folio Method for imaging the thumb?

Wrapping both distal portions of the thumbs with a rubber band Signup and view all the answers

What effect does the Rafert/Long Modification have on the imaging of the 1st carpometacarpal joint?

It provides a clearer outline of the joint by modifying the angle Signup and view all the answers

Which projection method is recommended when the patient cannot extend their digits?

AP projection Signup and view all the answers

What position is the hand in for the PA oblique projection of the thumb?

Slight ulnar deviation Signup and view all the answers

What is the primary purpose of the lateral projection of the thumb?

To visualize the 1st MCP joint Signup and view all the answers

Which projection method requires the hand positioned in lateral position for the thumb assessment?

PA projection Signup and view all the answers

How is the hand positioned for the AP projection of the 1st digit when assessing for joint injury?

In extreme internal rotation Signup and view all the answers

What is the hand position for the PA oblique projection of the thumb?

Hand in slight ulnar deviation Signup and view all the answers

Which projection is typically used when the patient cannot fully extend their digits?

AP projection Signup and view all the answers

What is the angle of CR for the Lewis method during the AP projection of the thumb?

10-15° toward the wrist Signup and view all the answers

Which projection emphasizes recorded detail for the 2nd and 3rd digits?

PA projection Signup and view all the answers

What is the primary focus of the lateral projection of the thumb?

To show superimposition of the trapezium Signup and view all the answers

What projection is recommended when the patient cannot extend their digits?

AP projection Signup and view all the answers

In which projection is the hand placed in slight ulnar deviation with the thumb abducted?

PA oblique projection Signup and view all the answers

What is the purpose of the PA oblique projection of the thumb?

To obtain a magnified image of the thumb Signup and view all the answers

What is the angle of the central ray (CR) in the Lewis method during the AP projection of the thumb?

10-15° Signup and view all the answers

Which projection emphasizes recorded detail in the 2nd and 3rd digits?

PA projection Signup and view all the answers

What projection method should be used when a patient cannot extend their digits?

AP projection Signup and view all the answers

Which projection emphasizes a clearer view of the first metacarpophalangeal joint?

AP projection Signup and view all the answers

In which projection is the hand positioned in slight ulnar deviation while the thumb is abducted?

PA oblique projection Signup and view all the answers

Which projection is performed with the hand in extreme internal rotation for assessing suspected joint injury?

AP projection Signup and view all the answers

What should be the angulation of the central ray for the Lewis method during the AP projection of the thumb?

10-15° toward the wrist Signup and view all the answers

Which projection is primarily used when assessing for suspected joint injury in the thumb?

AP projection Signup and view all the answers

What is the angle of the central ray (CR) in the Lewis method during the AP projection of the thumb?

10-15 degrees Signup and view all the answers

In which situation is the AP projection recommended as an alternative to the PA projection?

When the patient cannot extend their digits Signup and view all the answers

What is the position of the hand during the PA oblique projection of the thumb?

Slight ulnar deviation with thumb abducted Signup and view all the answers

Which digit(s) benefit from increased recorded detail during specific projections?

2nd and 3rd digits Signup and view all the answers

What is the recommended angle for the central ray during the AP projection of the thumb using the Lewis method?

10-15° towards the wrist Signup and view all the answers

Which projection method is used when a patient is unable to extend their digits?

AP projection Signup and view all the answers

In which position is the hand placed for the lateral projection of the thumb?

Palmar surface down in an arched position Signup and view all the answers

What is the angle of rotation for a PA oblique projection of the thumb?

45° laterally Signup and view all the answers

Which of the following is NOT a benefit of the PA projection for the 2nd and 3rd digits?

Reduction of magnification Signup and view all the answers

What is the purpose of the AP projection of the thumb?

To obtain a clear image of the 1st metacarpophalangeal joint for suspected joint injury Signup and view all the answers

During which projection is the hand placed in a lateral position, with the dorsal surface of the thumb parallel to the image receptor?

PA projection Signup and view all the answers

Which projection is recommended for patients who cannot extend their digits?

AP projection Signup and view all the answers

What should be the angle of the central ray (CR) when using the Lewis method for the AP projection of the thumb?

10-15° toward the wrist Signup and view all the answers

Which projection emphasizes recorded detail for the 2nd and 3rd digits?

PA vs. PA oblique projection Signup and view all the answers

Which projection method is specifically used to evaluate erosive changes associated with rheumatoid arthritis?

Brewerton Signup and view all the answers

What angle is recommended for the hand when performing the AP axial projection for rheumatoid arthritis evaluation?

60° Signup and view all the answers

Which projection is specifically aimed at demonstrating fractures of the base of the 5th metacarpal?

Stapczynski AP oblique projection Signup and view all the answers

What is the primary purpose of the Norgaard method in hand imaging?

Early diagnosis of rheumatoid arthritis Signup and view all the answers

During which projection is the hand placed in a semi-supinated position?

AP oblique hands Signup and view all the answers

What is the primary purpose of the PA oblique projection of the hand?

To investigate fractures of the metacarpals Signup and view all the answers

What is the correct positioning for the lateral projection of the hand in extension?

Digits extended with the ulnar aspect down Signup and view all the answers

Which projection is specifically recommended to detect early rheumatoid arthritis?

Clements-Nakayama projection Signup and view all the answers

What angle is recommended for the MCP joint during the PA oblique projection?

45° to IR Signup and view all the answers

Which projection is characterized by the hand being rotated 40-45° towards the ulnar surface?

Tangential oblique projection Signup and view all the answers

What is the primary focus of the lateral projection for the 5th metacarpophalangeal joint?

To assess for fractures in the midshaft of the metacarpal Signup and view all the answers

What advantage does the Lewis recommendation provide during the lateral projection?

Reduction of superimposition among metacarpals Signup and view all the answers

In which projection is the hand placed in a true lateral position with the thumb extended?

Lewis projection Signup and view all the answers

What is the primary purpose of the PA Oblique Projection with lateral rotation of the hand?

To open joint spaces and reduce foreshortening of phalanges Signup and view all the answers

Which projection would be used to investigate fractures of the metacarpals?

Lateral Projection in Flexion Signup and view all the answers

In what scenario would the 45º foam wedge be utilized?

When the fingertips are to touch the cassette Signup and view all the answers

What is the angle of rotation required for the Tangential Oblique Projection?

75-80 degrees at the MCP joint Signup and view all the answers

Which projection method is recommended for detecting early Rheumatoid Arthritis?

Clements-Nakayama Projection Signup and view all the answers

What is a key clinical indication for using the Reverse Oblique Projection?

Demonstrating severe metacarpal deformities Signup and view all the answers

What disadvantage is associated with the Lateral Projection of the hand in extension?

Superimposition of phalanges Signup and view all the answers

What is the recommended hand position for the Fan Lateral projection?

Hand in natural arch with digits relaxed Signup and view all the answers

Which projection is primarily utilized for detecting erosive changes associated with rheumatoid arthritis?

Brewerton Signup and view all the answers

What is the recommended position for the hand when performing the AP oblique projection to assess fractures of the 5th metacarpal?

Medially rotated Signup and view all the answers

Which method is recommended for assessing the age of bone using PA projection of the left hand?

Greulich & Pyle Signup and view all the answers

Which projection method is recommended for detecting foreign bodies or displacement fractures in the hand?

Fan lateral Signup and view all the answers

What angle is used for the hand in relation to the IR during the Brewerton projection?

60° Signup and view all the answers

What is the primary purpose of the AP oblique projection for both hands?

To demonstrate fractures of the base of the 5th metacarpal Signup and view all the answers

Which projection method is used for the early detection of rheumatoid arthritis?

Norgaard Method Signup and view all the answers

In the context of the Brewerton projection, what is the relationship of the hand to the image receptor (IR)?

60° angle Signup and view all the answers

What is the recommended projection to assess the 5th metacarpal fracture according to Stapczynski?

AP oblique projection Signup and view all the answers

Which method uses a PA projection of the left hand with computer software for bone aging?

Greulich & Pyle Method Signup and view all the answers

What is the primary purpose of performing a PA projection of the hand?

To investigate fractures and pathologic conditions Signup and view all the answers

Which projection uses MCP joints positioned at a 45° angle to the imaging receptor?

PA Oblique Projection (Lateral Rotation) Signup and view all the answers

What is a characteristic feature of the Clements-Nakayama projection?

It is primarily used to detect early Rheumatoid Arthritis Signup and view all the answers

In the fan lateral projection of the hand, what is the principal advantage?

Localization of foreign bodies and metacarpal fractures Signup and view all the answers

Which projection method employs the usage of an angled foam wedge for finger positioning?

45º Foam Wedge Projection Signup and view all the answers

What is the positioning of the hand during a PA Oblique projection?

Palmar surface down and rotated laterally Signup and view all the answers

What does the lateral projection of the hand primarily localize?

Foreign bodies and metacarpal fracture displacement Signup and view all the answers

Which aspect is demonstrated by the reverse oblique projection of the hand?

Medial rotation of the hand Signup and view all the answers

What projection method is primarily recommended for detecting erosive changes associated with rheumatoid arthritis?

Ball catchers projection Signup and view all the answers

Which projection is best suited for demonstrating fractures at the base of the 5th metacarpal?

AP oblique projection Signup and view all the answers

What is the angle of rotation recommended for a PA projection of the left hand using the Greulich & Pyle method?

45 degrees Signup and view all the answers

In which projection is the hand placed in a semi-supinated position?

AP oblique hands projection Signup and view all the answers

Which projection method emphasizes early detection and diagnosis of rheumatoid arthritis?

Norgaard Method Signup and view all the answers

What is the purpose of the Clements-Nakayama projection?

To diagnose early Rheumatoid Arthritis Signup and view all the answers

In the PA Oblique Projection, which joint should be at a 45° angle to the image receptor?

MCP joint Signup and view all the answers

Which projection is particularly helpful for demonstrating fractures of the metacarpal head?

Fan Lateral Projection Signup and view all the answers

What is the orientation of the hand for the lateral projection in extension?

Radial aspect down with digits extended Signup and view all the answers

Which recommendation is followed for the Lewis modification during lateral hand projection?

Hand rotated 5° posteriorly Signup and view all the answers

What is the position of the hand for the Norgaard Method AP oblique projection?

Both hands supinated Signup and view all the answers

Which projection is described as showing joints spaces by reducing the degree of foreshortening of phalanges?

Interphalangeal Joint Projection Signup and view all the answers

What is the primary use of the Reverse Oblique Projection?

For severe metacarpal deformities assessment Signup and view all the answers

What is the correct position of the hand for the AP projection of the forearm when the hand is supinated?

Hand supinated Signup and view all the answers

Which projection technique involves the radius crossing over the ulna?

AP projection with hand pronated Signup and view all the answers

What is the recommended elbow position for the lateral projection of the forearm?

Elbow flexed at 90° Signup and view all the answers

Which anatomical landmarks are key to consider when obtaining the lateral projection of the forearm?

Olecranon process and humeral epicondyle Signup and view all the answers

What is the result of obtaining an AP projection of the forearm with the hand in a pronated position?

Distorted view of forearm anatomy Signup and view all the answers

What is the main feature of the AP projection with the hand supinated?

Humeral epicondyle parallel to the image receptor Signup and view all the answers

Which projection involves the radius crossing over the ulna?

AP projection with hand pronated Signup and view all the answers

During the lateral projection of the forearm, how should the elbow be positioned?

Flexed at 90 degrees Signup and view all the answers

What distortion occurs in the AP of the elbow joint?

Proximal row of carpals is slightly distorted Signup and view all the answers

Which anatomical feature is not included in the lateral projection of the forearm?

Radial tuberosity Signup and view all the answers

What is a characteristic of the AP projection with the hand pronated?

The radius crosses over the ulna. Signup and view all the answers

Which of the following should be true concerning the lateral projection of the forearm?

The elbow must be flexed at exactly 90°. Signup and view all the answers

During the AP projection of the forearm with the hand supinated, which anatomical alignment is key?

Humeral epicondyle in line with the image receptor. Signup and view all the answers

What anatomical structures may appear distorted in the AP projection of the elbow joint?

Proximal row of carpals may appear slightly distorted. Signup and view all the answers

What is the necessary orientation of the hand for the AP projection of the forearm?

The hand must be placed in full supination. Signup and view all the answers

Which imaging method is preferred to demonstrate a fracture of the scaphoid?

Lentino Method Signup and view all the answers

What projection technique is utilized to assess carpal canal tunnel syndrome?

Gaynor-Hart Method Signup and view all the answers

During which method does the wrist need to be hyperextended and rotated toward the radial side?

Gaynor-Hart Method Signup and view all the answers

What is the primary focus of the Lentino Method in radiography?

Demonstration of lunate dislocation Signup and view all the answers

Which positioning method involves elevating the forearm using sandbags?

Modified tangential projection Signup and view all the answers

What is the primary advantage of using a PA projection when imaging the wrist area?

Opens the radio-ulnar joint space and elongates the scaphoid Signup and view all the answers

During which projection is the wrist placed in close contact with the imaging receptor while the hand is elevated?

AP projection Signup and view all the answers

What is the ideal positioning for the elbow when performing a lateral projection of the wrist?

Flexed at 90 degrees Signup and view all the answers

Which projection is specifically better for examining fractures in the wrist such as Colle's or Smith's fractures?

Lateral projection Signup and view all the answers

Which of the following conditions is NOT demonstrated by the AP projection of the wrist?

Fractures of the trapezium Signup and view all the answers

What is the primary purpose of performing the PA axial projection with ulnar deviation for the scaphoid?

To achieve better visualization of scaphoid fractures Signup and view all the answers

During the Clements-Nakayama method, what positioning adjustment is made if the patient cannot perform ulnar deviation?

The IR is moved 20 degrees towards the patient's shoulder Signup and view all the answers

Which projection provides the clearest delineation of the scaphoid without foreshortening?

Stecher method Signup and view all the answers

What is the recommended positioning of the hand during the PA oblique projection of the wrist when focusing on the medial carpals?

Hand is supinated and rotated 45 degrees medially Signup and view all the answers

For the visualization of the trapezium, which method is suggested for enhancing the articular surface evaluation?

Clements-Nakayama method Signup and view all the answers

In the Rafert-Long method for scaphoid imaging, what celestial angle is recommended for the central ray?

20 degrees cephalad Signup and view all the answers

Which imaging technique is used to visualize the anatomical snuffbox while assessing the trapezium?

Clements-Nakayama method Signup and view all the answers

What is the correct wrist positioning for the PA projection aimed at the scaphoid to avoid self-superimposition?

Wrist in extreme ulnar deviation Signup and view all the answers

Which approach is specifically designed to demonstrate a fracture line that angles superoinferiorly in the scaphoid?

Stecher method Signup and view all the answers

During imaging of the carpal canal, what is the effect of placing the wrist in extension?

Improves visualization of the pisiform Signup and view all the answers

What is the optimal hand position for an AP projection of the wrist?

Hand supinated with digits elevated Signup and view all the answers

Which aspect is demonstrated more effectively in the PA projection of the wrist?

Carpal interspaces Signup and view all the answers

What should be the elbow flexion angle when performing a lateral projection of the wrist?

90 degrees Signup and view all the answers

During which projection is the arm positioned 30 degrees toward the elbow?

PA Projection Signup and view all the answers

Which wrist projection is recommended to demonstrate anterior or posterior displacement in a fracture?

Lateral Projection Signup and view all the answers

What is the preferred angle of the central ray (CR) for the Gaynor-Hart method?

25-30 degrees Signup and view all the answers

Which of the following conditions can be examined using the Lentino Method?

Scaphoid fracture Signup and view all the answers

In the Alternative Method suggested for the aspect when the wrist is too painful, what is the wrist position?

In flexion Signup and view all the answers

What aspect of the wrist is emphasized when using the Templeton & Zim method?

Carpal sulcus anatomy Signup and view all the answers

Which method involves placing a sponge under the palmar surface to achieve the desired wrist angle?

Mequillen-Martensen method Signup and view all the answers

What is the function of ulnar deviation during the PA projection of the scaphoid?

To correct foreshortening of the scaphoid Signup and view all the answers

Which carpal bone is primarily visualized in the PA oblique projection with medial rotation?

Pisiform Signup and view all the answers

What is the purpose of the Stecher Method in scaphoid imaging?

To elevate the IR and avoid self-superimposition Signup and view all the answers

Which projection is suggested for viewing the trapezium and its articular surface?

Clements-Nakayama method Signup and view all the answers

For which specific reason is ulnar deviation used in the Rafert-Long method?

To demonstrate minimal superimposition of the scaphoid Signup and view all the answers

What is a key characteristic of the PA axial projection during scaphoid imaging?

CR angulation is necessary to avoid self-superimposition Signup and view all the answers

What is the recommended position for the hand during the PA oblique projection for the scaphoid?

Wrist in palmar flexion and hand pronated Signup and view all the answers

What is the primary outcome of using the Bridgman method in scaphoid projection?

Provide an open joint interspace at the lateral side Signup and view all the answers

Which positioning adjustment is made for patients unable to perform ulnar deviation in trapezium imaging?

Elbow rotated 20 degrees away from the CR Signup and view all the answers

During the PA projection with radial deviation, what anatomical area is primarily opened?

Carpal interspaces on the medial side Signup and view all the answers

What is the correct positioning of the elbow for the DEB projection?

Elbow flexed 30 degrees Signup and view all the answers

Which projection is specifically designed to better demonstrate carpal interspaces?

AP Projection Signup and view all the answers

What characteristic is important for executing the PA projection of the wrist?

Wrist in close contact with the imaging receptor Signup and view all the answers

In the lateral projection of the wrist, what position should the hand be in?

Ulnar surface against IR Signup and view all the answers

Which of the following projections elongates the scaphoid and capitate bones?

PA Projection Signup and view all the answers

What is the angulation of the central ray (CR) in the Lentino Method when performing a carpal bridge projection?

45 degrees Signup and view all the answers

Which condition can be diagnosed using the Gaynor-Hart Method?

Carpal canal tunnel syndrome (CTS) Signup and view all the answers

In the Templeton & Zim method, what wrist position is required?

Dorsiflexed Signup and view all the answers

What is the purpose of elevating the forearm on sandbags in the modified tangential projection?

To reduce pain during the procedure Signup and view all the answers

What specific angulation is employed in the Gaynor-Hart Method?

25-30 degrees Signup and view all the answers

What is the main purpose of performing the PA oblique projection with lateral rotation?

To open carpal interspaces on the lateral side Signup and view all the answers

Which projection method elevates the IR by 20 degrees to avoid foreshortening of the scaphoid?

Stecher method Signup and view all the answers

In the PA axial projection (ulnar deviation), what is the orientation of the wrist?

Wrist in extreme ulnar deviation Signup and view all the answers

What do the variations of the Clements-Nakayama method primarily allow for?

Accommodating the patient's inability to perform ulnar deviation Signup and view all the answers

Which feature is NOT associated with the PA oblique projection for the scaphoid?

Wrist dorsal surface against the image receptor Signup and view all the answers

What describes the positioning during the PA projection for radial deviation?

Wrist in radial deviation Signup and view all the answers

What does the Rafert-Long method include when diagnosing scaphoid fractures?

Multiple angles of central ray application Signup and view all the answers

Which carpal bone is specifically visualized using the Clements-Nakayama method?

Trapezium Signup and view all the answers

Which projection uses an IR position that is parallel to the CR when elevating it towards the elbow?

Stecher method Signup and view all the answers

What is the correct position for the AP projection of the humerus when the patient is upright?

Arm slightly abducted, hand supinated Signup and view all the answers

Which statement accurately describes the positioning for the lateral projection of the humerus in a recumbent position?

Forearm medially rotated with the dorsal aspect of the hand against the patient's side Signup and view all the answers

In the lateromedial projection of the humerus, what must the elbow position be?

Flexed at 90 degrees with the hand palmar on the hip Signup and view all the answers

For a patient with a suspected humeral fracture, which projection involves the patient's hand holding the broken arm?

(Mediolateral) Upright Signup and view all the answers

What is the primary positioning requirement for the AP projection of the humerus in a recumbent posture?

Unaffected arm elevated, hand supinated Signup and view all the answers

During the lateromedial projection for the distal humerus, how should the IR be positioned?

Between the axilla and the affected arm Signup and view all the answers

What is the appropriate hand position for the lateral projection of the humerus when in a recumbent position?

Dorsal aspect resting on the patient's thigh Signup and view all the answers

What is a key requirement for conducting the lateral projection of the humerus when the patient is upright?

Elbow flexed at 90 degrees Signup and view all the answers

What is the correct arm position for an AP projection of the humerus in the upright position?

Arm slightly abducted Signup and view all the answers

In the lateral projection of the humerus in an upright position, how should the elbow be positioned?

Flexed at 90° Signup and view all the answers

Which hand position is required for the lateral projection of the humerus in the recumbent position?

Dorsal aspect of the hand placed on the patient's side Signup and view all the answers

What should the positioning of the forearm be for the lateromedial view in the recumbent position?

Medially rotated Signup and view all the answers

For a patient with a suspected fracture, where should the image receptor (IR) be placed during the lateral recumbent position?

Between the axilla and the affected arm Signup and view all the answers

What is the correct positioning of the hand for the AP projection of the humerus in a recumbent posture?

Supinated with the hand elevated Signup and view all the answers

What is required for the humeral epicondyle's alignment during the lateral projection of the humerus?

It must be parallel to the IR without elbow flexion Signup and view all the answers

When imaging the proximal humerus in an upright position, what is the expected positioning of the hand?

Palmar placed on the hip Signup and view all the answers

What is the required position of the arm during an AP projection of the humerus when the patient is upright?

Arm slightly abducted Signup and view all the answers

During a lateral projection (lateromedial) of the humerus in the upright position, how should the elbow be positioned?

Elbow flexed at 90° Signup and view all the answers

What hand position is required for the lateral recumbent projection of the distal humerus?

Dorsal aspect of the hand against the thigh Signup and view all the answers

For a patient in a recumbent position undergoing an AP projection of the humerus, what should the position of the unaffected arm be?

Elevated above the head Signup and view all the answers

In what position should the forearm be during a lateral recumbent projection of the humerus?

Medially rotated Signup and view all the answers

What is the position of the hand during the AP projection of the humerus when the patient is upright?

Supinated Signup and view all the answers

When performing a lateromedial projection of the humerus in the recumbent position, what must be ensured about the elbow?

The elbow is extended without any flexion Signup and view all the answers

What specific hand position is used for an upright (mediolateral) projection of the humerus?

Hand placed on the hip Signup and view all the answers

What is the positioning of the arm for the AP projection in the upright position?

Arm slightly abducted Signup and view all the answers

Which positioning is required for the lateral recumbent projection of the distal humerus?

Elbow fully flexed with thumb surface up Signup and view all the answers

What is correct about the hand position for the lateral projection in the upright position?

Palmar aspect placed on the hip Signup and view all the answers

Which projection requires that the forearm be medially rotated and the dorsal aspect of the hand placed on the patient's side?

Lateral Projection (Lateromedial) Recumbent Signup and view all the answers

What is the primary positioning of the arm for the AP projection in the recumbent position?

Unaffected arm elevated and hand supinated Signup and view all the answers

In the (Mediolateral) upright projection, how should the patient's hand be positioned?

Holding the affected arm Signup and view all the answers

Which of these options best describes the elbow position for the lateral projection of the humerus in the upright position?

Flexed at 90 degrees Signup and view all the answers

What positioning requirement is unique to the lateral projection of the distal humerus?

Thumb surface must be positioned upwards Signup and view all the answers

What is the hand position for the AP projection of the humerus in the upright position?

Hand supinated Signup and view all the answers

Which projection requires the elbow to be flexed at 90 degrees?

Lateral Projection (Lateromedial) Upright Signup and view all the answers

For a recumbent lateral projection of the humerus, what is the placement of the forearm?

Medially rotated Signup and view all the answers

During the upright mediolateral projection, what is a key requirement concerning the patient's hand?

Patient's hand holding the affected arm Signup and view all the answers

What is the correct positioning for the AP projection of the humerus when the patient is supine?

Affected arm elevated and hand supinated Signup and view all the answers

What should be done with the elbow for the lateromedial recumbent projection of the distal humerus?

Elbow flexed Signup and view all the answers

Which of the following describes the hand placement for the recumbent lateral projection of the humerus?

Dorsal aspect placed on the side Signup and view all the answers

In the upright lateral projection of the humerus, how should the arm be rotated?

Internally rotated Signup and view all the answers

What is the correct hand positioning for the AP projection when the patient is upright?

Hand supinated Signup and view all the answers

During the Lateral (Lateromedial) projection upright, how should the elbow be positioned?

Flexed at 90° Signup and view all the answers

In the recumbent Lateral (Lateromedial) projection of the humerus, how is the hand positioned?

Dorsal aspect placed on patient's side Signup and view all the answers

What is the position of the arm for an AP projection in a recumbent posture?

Affected arm elevated Signup and view all the answers

For a lateromedial recumbent projection, how should the elbow be positioned?

Flexed Signup and view all the answers

Which projection requires the patient's arm to be holding the broken limb?

Mediolateral (Upright) Signup and view all the answers

In the lateromedial recumbent projection for the distal humerus, how is the IR positioned?

Between the axilla and the affected arm Signup and view all the answers

What is the arm's position in the AP projection while in a recumbent posture?

Slightly abducted with hand supinated Signup and view all the answers

What is the position of the arm during an upright AP projection of the humerus?

Arm slightly abducted Signup and view all the answers

In a lateromedial upright projection of the humerus, how is the elbow positioned?

Elbow flexed 90° Signup and view all the answers

What hand position is required for a lateral recumbent projection of the humerus?

Dorsal aspect against the patient's thigh Signup and view all the answers

Which of the following describes the required positioning for an AP recumbent projection of the humerus?

Patient supine with the unaffected arm elevated Signup and view all the answers

What is the position of the forearm during a lateral recumbent projection of the distal humerus?

Medially rotated Signup and view all the answers

For a (mediolateral) upright projection, what is the patient required to do with their hand?

Hold the broken arm Signup and view all the answers

During a lateral (lateromedial) recumbent projection of the humerus, how should the elbow be flexed?

Elbow flexed at 90° Signup and view all the answers

What position should be obtained for the forearm in a lateral recumbent projection?

Dorsal side on the patient’s side Signup and view all the answers

Which projection method is primarily used to assess for suspected joint injury in the thumb?

Lewis Method Signup and view all the answers

What is the central ray angulation used in the Rafert/Long Modification for imaging the 1st carpometacarpal joint?

15 degrees Signup and view all the answers

During which projection method is the hand positioned in slight ulnar deviation with the thumb abducted?

PA oblique projection Signup and view all the answers

Which condition is specifically targeted during imaging with the Folio Method?

Skiers' Thumb Signup and view all the answers

Which of the following modifications uses an arm positioned in external rotation during imaging of the 1st carpometacarpal joint?

Rafert/Long Modification Signup and view all the answers

What is the primary purpose of the Lewis Method during the imaging of the thumb?

To emphasize the first metacarpophalangeal joint for clearer imaging Signup and view all the answers

In which projection is the hand placed in slight ulnar deviation with the thumb abducted?

Folio Method Signup and view all the answers

What positioning is typically utilized during the Robert Method for imaging the 1st carpometacarpal joint?

Arm internally rotated and hand hyperextended Signup and view all the answers

Which projection method is mainly recommended when a patient is unable to fully extend their digits?

Lewis Method Signup and view all the answers

What is the recommended angle for the central ray during the Rafert/Long Modification?

15 degrees Signup and view all the answers

What is the primary focus of the Robert Method during imaging of the 1st carpometacarpal joint?

Providing clearer imaging for joint injuries Signup and view all the answers

Which projection method is best suited for visualizing the metacarpophalangeal (MCP) joints in cases of UCL ruptures?

AP projection Signup and view all the answers

During the PA oblique projection, what is the preferred positioning of the hand?

Hand pronated with slight ulnar deviation Signup and view all the answers

Which projection method addresses the need for assessing the 1st carpometacarpal joint when the patient cannot extend their digits?

Lewis Method Signup and view all the answers

What is the primary purpose of the lateral projection during thumb imaging?

To provide a clear view of the thumb's alignment and joint structure Signup and view all the answers

What is the primary purpose of the Rafert/Long Modification in thumb imaging?

To achieve a clearer image of the 1st carpometacarpal joint Signup and view all the answers

During which projection method is the hand specifically placed in slight ulnar deviation?

Folio Method Signup and view all the answers

What is the angle of the central ray (CR) in the Lewis method during the AP projection of the thumb?

15 degrees Signup and view all the answers

Which projection method emphasizes recorded detail for the 2nd and 3rd digits?

PA projection Signup and view all the answers

What is a common reason for performing external rotation (ER) during the imaging of the 1st CMC joint?

To improve the visual clarity of joint space Signup and view all the answers

What is the purpose of the Rafert/Long Modification during imaging of the 1st carpometacarpal joint?

To enhance the visibility of the joint space Signup and view all the answers

In which projection method is the hand positioned in slight ulnar deviation while the thumb is abducted?

Folio Method Signup and view all the answers

Which projection method is recommended when the patient cannot fully extend their digits?

AP projection Signup and view all the answers

What should be the angulation of the central ray for the Lewis method during the AP projection of the thumb?

15 degrees Signup and view all the answers

Which projection method primarily focuses on the first metacarpophalangeal joint?

Rafert/Long Modification Signup and view all the answers

What is the hand position for the PA oblique projection of the thumb?

Slight ulnar deviation with the thumb abducted Signup and view all the answers

Which projection emphasizes a clearer view of the first metacarpophalangeal joint?

AP projection Signup and view all the answers

What should be the angulation of the central ray for the Lewis method during the AP projection of the thumb?

20 degrees towards the wrist Signup and view all the answers

During which projection method is the hand rested on its medial aspect?

Rafert/Long Modification Signup and view all the answers

Which projection method is recommended when the patient cannot extend their digits?

AP projection Signup and view all the answers

Which projection is primarily recommended when assessing for suspected joint injury in the thumb?

Lewis Method Signup and view all the answers

What is the primary purpose of the lateral projection of the thumb?

Providing a clearer view of fractures Signup and view all the answers

During the Robert Method, what position should the arm be in for imaging the 1st carpometacarpal joint?

Internally rotated Signup and view all the answers

What is the purpose of the PA oblique projection of the thumb?

To visualize the joint spaces effectively Signup and view all the answers

What is the typical angle of the central ray for the Lewis method during the AP projection of the thumb?

15 degrees Signup and view all the answers

What is the effect of the Rafert/Long Modification on the imaging of the 1st carpometacarpal joint?

It provides a clearer view of the joint contour. Signup and view all the answers

Which projection method is recommended when assessing for joint injuries in the thumb?

Lateral projection Signup and view all the answers

In which position should the hand be for the Folio Method when imaging Skiers' Thumb?

Cupped shape with fingers extended Signup and view all the answers

What is the primary reason for performing external rotation during imaging of the 1st CMC joint?

To visualize bone alignment accurately. Signup and view all the answers

What is the recommended central ray angle for the Lewis method during the AP projection of the thumb?

25 degrees cephalad Signup and view all the answers

What angle is used for the coronoid process during a radial-lateral projection of the elbow?

45 degrees Signup and view all the answers

Which position is required for the PA axial projection of the distal humerus?

Arm resting vertically against the IR Signup and view all the answers

What is the required hand position for the PA axial projection of the proximal forearm?

Hand supinated Signup and view all the answers

During an AP oblique projection with internal rotation, what should be the angle between the forearm and the humerus?

75 degrees Signup and view all the answers

Which projection is specifically indicated for visualizing the radial head, neck, and capitulum of the elbow?

AP Oblique Projection (Lateral Rotation) Signup and view all the answers

What is the correct hand position for the AP oblique projection with medial rotation of the elbow?

Hand pronated Signup and view all the answers

In performing the Jones Method for acute flexion of the elbow, what is the position of the elbow?

Fully flexed Signup and view all the answers

Which projection is recommended for visualizing the radial head in varying degrees of rotation?

Lateral Projection (latero-medial) Signup and view all the answers

For a suspected soft tissue injury in the elbow, what degree of flexion should be used?

30-35 degrees Signup and view all the answers

What anatomical feature is free of the radial head in the AP oblique projection?

Coronoid Process Signup and view all the answers

What is seen in the elevated/displaced fat pads associated with an elbow fracture and dislocation?

Posterior fat pads Signup and view all the answers

Which method utilizes a 45-degree medial rotation for the elbow projection?

AP Oblique Projection (medial rotation) Signup and view all the answers

What should be the position of the elbow and hand for the trauma axial lateral projection?

Elbow flexed 90 degrees, hand supinated Signup and view all the answers

What is the correct angle of the central ray for a PA axial projection of the distal humerus?

75 degrees Signup and view all the answers

Which position is required to best demonstrate the ulna's coronoid process using the AP oblique projection?

Internal rotation Signup and view all the answers

In a PA axial projection for the proximal forearm, the arm should be positioned at what angle from the forearm?

45-50 degrees Signup and view all the answers

What degree of flexion is required at the elbow for a lateral projection?

90 degrees Signup and view all the answers

To properly visualize the radial head in the lateral view, the elbow should be positioned at what angle?

90 degrees Signup and view all the answers

What is the correct hand position for an AP Projection of the elbow?

Hand supinated Signup and view all the answers

Which projection is used for imaging the distal humerus when the patient cannot fully extend their elbow?

AP projection (Partial flexion) Signup and view all the answers

What is the purpose of the COYLE Method in elbow imaging?

To provide an axiolateral projection with the elbow flexed Signup and view all the answers

In the AP Oblique Projection (medial rotation), how should the elbow be positioned?

Fully extended and medially rotated Signup and view all the answers

Which projection is specifically indicated for a suspected injury involving soft tissue of the elbow?

AP Projection (partial flexion) Signup and view all the answers

For assessing the radial head, which series should be performed?

Lateral Projection (latero-medial) Signup and view all the answers

What positioning should be used to visualize the olecranon process more clearly in acute flexion?

Fully flexed Signup and view all the answers

What characteristic indicates the presence of a fracture when the fat pad is displaced in elbow imaging?

Elevated or displaced fat pads Signup and view all the answers

What is the angle at which the mid-elbow joint is positioned for optimal imaging?

45 degrees cephalad Signup and view all the answers

Which projection is best for demonstrating the radial head, neck, and capitulum?

AP Oblique Projection (External Rotation) Signup and view all the answers

What is the recommended position and angle for imaging the coronoid process during an AP oblique projection?

Medial rotation at 45 degrees Signup and view all the answers

What projection method is advised for detecting obscured calcifications in the ulnar sulcus?

Rafert Long Modification Signup and view all the answers

In the PA Axial Projection of the proximal forearm, what is the angle of the arm relative to the forearm?

45-50 degrees Signup and view all the answers

What is the required position of the hand for an AP Oblique Projection with medial rotation of the elbow?

Hand pronated Signup and view all the answers

In the Jones Method for acute flexion of the elbow, what is the particular position of the elbow?

Completely flexed Signup and view all the answers

What view is analyzed to assess the presence of elevated or displaced fat pads in the elbow?

Lateral Projection Signup and view all the answers

Which projection requires the elbow to be flexed to 30-35 degrees to assess suspected soft tissue injury?

Partial Flexion Projection Signup and view all the answers

For a radial head series, what is the required position of the hand for the supinated lateral projection?

Hand supinated Signup and view all the answers

In the COYLE method for axiolateral projection, what degree of elbow flexion is required?

Fully flexed at 90 degrees Signup and view all the answers

What is the hand placement for the AP Projection in partial flexion when assessing the proximal forearm?

Dorsal surface on IR Signup and view all the answers

What is the primary focus of the Radial Head Varying Degrees of Rotation projection?

Positioning the radial head relative to rotation Signup and view all the answers

What is the position of the arm when performing a PA axial projection of the distal humerus?

Vertical against the IR Signup and view all the answers

Which projection best demonstrates the radial head, neck, and capitulum?

AP oblique projection with external rotation Signup and view all the answers

What angle should the CR be positioned at for imaging the coronoid process during an AP oblique projection?

45 degrees cephalad Signup and view all the answers

During which projection is the humerus positioned at 45-50 degrees from the forearm?

PA axial projection of the proximal forearm Signup and view all the answers

What is the recommended flexion angle for the lateral projection when demonstrating the elbow?

90 degrees Signup and view all the answers

What is the hand position required for the AP Oblique Projection with medial rotation?

Hand pronated, elbow fully extended Signup and view all the answers

Which projection is indicated for a suspected soft tissue injury of the elbow?

Elbow flexed at 30-35 degrees Signup and view all the answers

What should be done to visualize the Radial Head clearly during trauma imaging?

Use the Greenspan Norman Method Signup and view all the answers

In which projection is the elbow flexed to 90 degrees with the hand in a lateral position?

Lateral Projection Signup and view all the answers

When performing an AP Projection for the distal humerus with partial flexion, what position is required for the hand?

Hand supinated, elbow partially flexed Signup and view all the answers

What is the primary purpose of the COYLE Method in elbow imaging?

To obtain an axiolateral view of the radial head Signup and view all the answers

What angle should the elbow be positioned for the AP Oblique Projection with lateral rotation?

45 degrees laterally Signup and view all the answers

What does the presence of elevated or displaced fat pads indicate in an elbow examination?

Fracture or dislocation Signup and view all the answers

What is the required angle of the central ray (CR) for the PA axial projection of the distal humerus?

75 degrees Signup and view all the answers

Which projection method is best for demonstrating the coronoid process and the trochlea?

AP Projection (Internal Rotation) Signup and view all the answers

What position should the arm be in for the PA axial projection of the proximal forearm?

Resting on the forearm Signup and view all the answers

In the context of imaging for tennis elbow, which projection is most relevant?

PA Axial Projection (distal humerus) Signup and view all the answers

For a patient unable to fully extend their elbow during imaging, which projection method is appropriate?

Lateral Projection Signup and view all the answers

What is the correct hand position for the AP projection of the elbow on a supinated hand?

Supinated with elbow extended Signup and view all the answers

In which projection is the elbow flexed at 90 degrees and the humeral epicondyle positioned to the image receptor?

Lateral Projection Signup and view all the answers

For the AP Oblique Projection with medial rotation, which feature of the ulna must be free of the radial head?

Coronoid Process Signup and view all the answers

What angle of rotation is required for the lateral rotation in the AP Oblique Projection of the elbow?

45 degrees Signup and view all the answers

Which projection series is utilized for evaluating the radial head with various degrees of rotation?

Radial Head Series Signup and view all the answers

In the case of a suspected acute elbow flexion injury, which projection method is recommended?

Jones Method Signup and view all the answers

Which projection is described as having a hand positioned pronated and the elbow flexed at 90 degrees?

Lateral Projection (latero-medial) Signup and view all the answers

What positioning of the forearm is required during the AP Projection (partial flexion) of the distal humerus?

Dorsal surface placed on image receptor Signup and view all the answers

Study Notes

1st Carpometacarpal Joint (CMC) AP Projection

Robert Method: Shoulder, elbow, and wrist aligned on the same plane; prevents carpal bone elevation and closing of the 1st CMC joint; arm internally rotated, hand hyperextended, dorsal aspect of thumb against the IR.
Rafert/Long Modification: Similar to Robert Method, but with the hand rotated proximally towards the wrist by 15 degrees.
Lewis Modification: Similar to Robert Method, but with the hand rotated 10-15 degrees towards the wrist.

1st CMC Joint

Robert Method (A)
Rafert/Long Modification (B)
Lewis Modification (C)
Indications: Identifying arthritic changes, fractures, displacement of the 1st CMC joint, Bennett's fracture, and Rolando fracture (transverse fracture at the metacarpal base).
ER (External Rotation): Essential for protecting soft tissues of the hand, opening up joint spaces, and improving visualization.

1st Metacarpophalangeal Joint (MCP) AP Projection

Provides a clearer image of the 1st CMC joint compared to the standard AP projection.
Magnifies the 1st CMC joint, showcasing:
- Concavoconvex outline of the 1st CMC joint
- Trapezium in concave profile
- Base of the 1st metacarpal in convex profile

1st MCP Joint PA Projection

Folio Method (Skier's Thumb):
- Hand placed on its medial aspect with distal portion of both thumbs secured by a rubber band.
- Thumb positioned in a true PA plane.

Skier's Thumb

Refers to a sprain or tear of the UCL (Ulnar Collateral Ligament) of the thumb.

Diagnosis of UCL Rupture

Bilateral MCP joint and metacarpal angles: Comparing the angles between the MCP joint and the metacarpal on both hands aids in diagnosing UCL rupture.
Level of MCP joint: Measuring the level of the MCP joint on both hands helps determine any disparity and potential ligament damage.

1st Carpometacarpal Joint AP Projection

Robert Method positions the shoulder, elbow, and wrist on the same plane.
Robert Method prevents carpal bone elevation and closing of the 1st CMC joint.
Robert Method involves internal rotation of the arm, hyperextension of the hand, with the dorsal aspect of the thumb against the IR.
Rafert/Long Modification involves an additional 15-degree proximal angulation toward the wrist.
Lewis Modification involves a 10-15-degree angulation.

1st CMC Joint

Robert Method A
Rafert/Long Modification B involves a 15-degree angulation.
Lewis Modification C involves a 10-15-degree angulation.
Potential findings include arthritic changes, fractures, 1st CMC joint displacement, Bennett's fracture, and Rolando fracture.
Angulation rationale of the projection is to protect the soft tissue of the hand and open joint spaces.

1st MCP Joint AP Projection

This projection provides a clearer image of the 1st CMC joint than the normal AP projection.
The projection magnifies the concavoconvex outline of the 1st CMC joint.
The projection displays the trapezium in a concave profile and the base of the 1st metacarpal in a convex profile.

1st MCP Joint PA Projection

Folio Method (Skier's Thumb) PA Projection: the hand is rested on the medial aspect, with the distal portion of both thumbs wrapped around by a rubber band.
Folio Method positions the thumb in a plane PA.
Skier's Thumb refers to a sprain or tear of the UCL of the thumb.

Diagnosis of UCL Rupture

Diagnosis involves comparing the MCP joint and metacarpal angles bilaterally.
Diagnosis compares the angles between the levels of the MCP joints of both hands.

1st Carpometacarpal Joint (CMC)

Robert Method for AP projection aligns shoulder, elbow, and wrist.
Rafert/Long Modification to Robert Method: rotates the hand 15 degrees proximally towards the wrist.
Lewis Modification to Robert Method: rotates the hand 10-15 degrees.
1st CMC joint AP projections are useful for identifying:
- Arthritic changes
- Fractures
- 1st CMC joint displacement
- Bennett's fracture and Rolando fracture (transverse fracture of metacarpal base).
External Rotation (ER) rationale: open joint spaces and protect hand soft tissue.

1st Metacarpophalangeal Joint (MCP)

AP projection of the 1st MCP provides a clearer image of the 1st CMC joint compared to a standard AP projection.
The AP projection magnifies the 1st CMC joint, showing the concavoconvex outline with the trapezium in concave profile and the base of the 1st metacarpal in convex profile.

1st MCP Joint - PA Projection

Folio Method (PA projection):
- Hand rests on the medial aspect.
- Distal portions of both thumbs are wrapped by a rubber band.
- Thumb is in a plane PA.

Skier's Thumb

Skier's thumb: Sprain or tear of the ulnar collateral ligament (UCL) of the thumb.
Diagnosis of UCL rupture: involves comparing the bilateral MCP joint and metacarpal angles between both hands.

1st Carpometacarpal Joint (CMC) AP Projection

Robert Method: Positions the shoulder, elbow, and wrist on the same plane to prevent carpal bone elevation and joint closure. The arm is internally rotated, hand hyperextended, and the thumb's dorsal aspect is against the internal rotation.
Rafert/Long Modification: A 15-degree proximal tilt towards the wrist from the Robert Method.
Lewis Modification: A 10-15 degree tilt from the Robert Method.

1st CMC Joint AP Projection Variations

Robert Method (A): Standard AP projection of the 1st CMC joint.
Rafert/Long Modification (B): 15-degree proximal tilt for a better view.
Lewis Modification (C): 10-15 degree tilt for an alternative view.

Indications for 1st CMC Joint Projections

Arthritic changes: Detection of joint space narrowing or bony spurs.
Fractures: Identify fractures of the trapezium, base of the first metacarpal, or Bennett's/Rolando's fractures.
1st CMC joint displacement: Assess for subluxation or dislocation of the joint.
Bennett's Fracture: A fracture of the base of the first metacarpal.
Rolando Fracture: A transverse fracture of the metacarpal base.

Rationale For External Rotation (ER)

Soft tissue protection: ER protects the soft tissues of the hand from the 1st CMC joint by creating space.
Open joint spaces: ER allows for clearer visualization of the joint spaces.

1st Metacarpophalangeal (MCP) Joint AP Projection

Clearer Image: Provides a clearer view of the 1st CMC joint compared to a standard AP projection.
Magnified 1st CMC Joint: Offers a magnified image of the joint, highlighting the trapezium and base of the first metacarpal.
Concavoconvex outline: Displays the concave profile of the trapezium and the convex profile of the base of the first metacarpal.

1st MCP Joint PA Projection (Folio Method)

Hand Position: The hand is rested on its medial aspect with the thumbs wrapped around by a rubber band.
Thumb Position: The thumb is positioned in a plane parallel to the PA direction.
Indication: Used for diagnosing skier's thumb injuries.

Skier's Thumb

Definition: A sprain or tear of the ulnar collateral ligament (UCL) of the thumb.

Diagnosis of UCL Rupture

Bilateral MCP joint and metacarpal angles: Comparison of the MCP joint angles on both hands.
Level of MCP joints: Assessment of the alignment of the MCP joints on both hands.

Digits (2nd to 5th) Projection

PA projection: Standard view for digits 2-5.
PA oblique (lateral rotation): Rotate the hand 45 degrees laterally.
PA oblique (medial rotation): Rotate the hand 45 degrees medially.
Lateral (Lateromedial/mediolateral): Used for the 4th and 5th digits.
2nd and 3rd digits: These projections allow for increased detail and can reveal other fractures which may be missed in other views.
Alternative to PA projection:
- AP projection: Used when the patient cannot extend their digits.
  - Uses a small dental film.
  - Helpful for suspected joint injuries.
- Foreign bodies: This projection can be used to identify foreign bodies in the digits.

1st digit (Thumb) - AP Projection

AP projection: Used for suspected joint injuries.
- Hand is in extreme internal rotation to align the 1st MCP joint for an AP view.
- Method:
  - Lewis method: Use a 10-15 degree cephalic angle towards the wrist to ensure the thumb is clear of the palm.

1st digit (Thumb) - Other Projections

PA projection: Hand is in a lateral position with the dorsal surface of the thumb parallel to the image receptor, allowing for visualization of the 1st MCP joint.
PA Oblique projection: The hand is in slight ulnar deviation with the thumb abducted, providing a PA oblique projection of the thumb.
Lateral projection: Hand is in a natural arched position with the palmar surface down, showing the 1st MCP joint in profile.

1st Digit - Image Examples:

Figure 4-41: AP view of the 1st digit showing the distal phalanx, interphalangeal joint, proximal phalanx, metacarpophalangeal joint, 1st metacarpal, and carpometacarpal joint.
Figure 4-42: PA view of the 1st digit.
Figure 4-43: Lateral view of the 1st digit.
Figure 4-44: PA oblique view of the 1st digit.
Figure 4-37: AP view of the 1st digit.
Figure 4-38: PA view of the 1st digit using a cotton swab.
Figure 4-40: PA oblique view of the 1st digit.
Figure 4-39: Lateral view of the 1st digit.

### Digits 2nd to 5th Projections

PA projection: Standard projection of the digits 2nd - 5th, used to visualize the bones and joints.
PA Oblique Projections are used to assess the digits 2nd to 5th in more detail, with two types to consider:
- Lateral Rotation: Rotate the hand 45° laterally for better visualization.
- Medial Rotation: Rotate the hand 45° medially for a different view.
Lateral (Lateromedial/mediolateral) projection is used to further assess the 4th and 5th digit and provide a view of the bones from the side.
2nd and 3rd Digit Projections: These projections offer increased detail and are used to identify injuries that are not easily seen on other projections.
Alternative Projections when Hand Extension is Limited: For individuals with limited hand extension, use an AP projection instead of PA. Use a small dental film to image the joint.
- This is particularly useful for suspected joint injuries and identifying foreign bodies.

1st Digit (Thumb) Projections

AP Projection
- This projection is specifically used to visualize the 1st metacarpophalangeal joint (MCPJ) and assess any potential injuries.
  - It involves placing the hand in extreme internal rotation to align the joint.
  - The Lewis method, placing a 10-15° CR (Central Ray) towards the wrist, is employed for optimal visualization.
PA Projection
- The hand is placed in a lateral position with the thumb's dorsal surface parallel to the image receptor(IR) in this projection.
- This projection is especially beneficial for visualizing the 1st MCPJ and offers a magnified view of the thumb.
PA Oblique Projection
- Utilized for assessing the 1st MCPJ, the hand is positioned with slight ulnar deviation and the thumb abducted.
- PA oblique projection focuses on the thumb.
Lateral Projection
- This projection is obtained with the hand in a natural arched position, with the palmar surface down.
- This particular projection offers maximum detail of the 1st MCPJ, the lateral portion of the thumb, and provides a view of the trapezium.

Image Descriptions

Fig. 4-41: AP projection of the first digit, illustrating the distal and proximal phalanges, the interphalangeal joint, the metacarpophalangeal joint, the 1st metacarpal, and the carpometacarpal joint.
Fig. 4-42: PA projection of the first digit.
Fig. 4-43: Lateral projection of the first digit.
Fig. 4-44: PA oblique projection of the first digit.
Fig. 4-37: AP projection of the first digit.
Fig. 4-38: PA projection of the first digit (utilizing a cotton swab for a specific purpose).
Fig. 4-40: PA oblique projection of the first digit.
Fig. 4-39: Lateral projection of the first digit.

Digits (2nd to 5th) Projection

PA projection is used to image digits 2 - 5.
PA oblique projection for digits 2 - 5, can be performed with 45° lateral or medial rotation.
Lateral (Lateromedial/mediolateral) projection used for imaging 4th and 5th digits.
The 2nd and 3rd digits are best imaged with the PA projection to maximize recorded detail and help identify other fractures.
Alternative to PA projection:
- AP projection: can be used if pt can’t extend digits.
  - Small dental film may be used in the process.
  - Consider AP for suspected joint injury.
- Use AP or PA for foreign body identification

1st digit (Thumb)

AP Projection: used for suspected joint injury, especially at the 1st MCP joint.
Hand should be in extreme internal rotation with CR directed 10-15° towards the wrist, this allows for clear visualization of the 1st MCP joint and prevents soft-tissue obscuration.
PA projection: Hand should be in lateral position with the dorsal surface of the thumb parallel to the imaging receptor. Keep distance between the thumb and IR.
PA Oblique Projection: Hand should be slightly ulnar deviated with the thumb abducted.
Lateral Projection: Hand should be in a natural arched position with the palmar surface down. This helps to enhance the visualization of the 1st MCP joint, the lateral portions of the thumb, and minimizes the superimposition of the trapezium.

Image Information

Fig. 4-41, 4-37: Shows AP projection of the first digit.
Fig. 4-42, 4-38: Shows PA Projection of the first digit.
Fig. 4-43, 4-39: Shows Lateral Projection of the first digit.
Fig. 4-40: Shows PA Oblique Projection of the first digit.

Digits (2nd to 5th) Projection

PA projection: Standard projection for digits 2-5
PA Oblique Projection: Used for digits 2-5, with the hand rotated 45 degrees medially or laterally
Lateral Projection: Best for visualizing 4th and 5th digits, provides better detail for 2nd and 3rd digits.
Alternative to PA projection:
- AP projection: Used when patient cannot extend digits, utilizes a small dental film, helpful for suspected joint injuries.
- Foreign body projections: Can be used to visualize foreign bodies.

1st Digit (Thumb) Projection

AP Projection: Used for suspected joint injuries.
- Hand in extreme internal rotation: 1st MCP joint is aligned parallel to IR.
- Method: Lewis method involves 10-15 degree cephalic angulation towards the wrist for clear visualization.
PA Projection:
- Hand in lateral position: Thumb is aligned with dorsal surface parallel to IR.
- Results in magnification of the thumb.
PA Oblique Projection:
- Hand in slight ulnar deviation, thumb abducted: 1st MCP is aligned parallel to IR.
Lateral Projection:
- Hand in neutral, arched position: Palmar surface down, enhances visualization of 1st MCP joint and lateral portion of the thumb, but trapezium will be superimposed.

Image Examples

- **Fig. 4-41 AP first digit**:  Shows distal phalanx, interphalangeal joint, proximal phalanx, metacarpophalangeal joint, 1st metacarpal and carpometacarpal joint.
- **Fig. 4-42 PA first digit**:  Includes additional images for various projections of the thumb.
- **Fig. 4-43 Lateral first digit**:  Images for various projections of the thumb.
- **Fig. 4-44 PA oblique first digit**:  Images for various projections of the thumb.
- **Fig. 4-37 AP first digit**:  Images for various projections of the thumb.
- **Fig. 4-38 PA first digit (cotton swab)**:  Images for various projections of the thumb.
- **Fig. 4-40 PA oblique first digit**:  Images for various projections of the thumb.
- **Fig. 4-39 Lateral first digit**:  Images for various projections of the thumb.

Digits (2nd to 5th) Projections

PA projection, PA oblique (45° laterally and medially), lateral (lateromedial/mediolateral) projections are used for imaging digits 2-5
Lateral projections are best for imaging 4th and 5th digits
PA and oblique projections are preferred for 2nd and 3rd digits to capture more detail and identify other potential fractures
Alternative to PA projection:
- AP projection is used when the patient cannot extend their digits
  - Small dental film is used
  - This projection is suitable for suspected joint injuries
Foreign bodies can also be visualized using this projection

1st Digit (Thumb) Projections

AP projection specifically targets the 1st MCP Joint (thumb)
- Hand is positioned in extreme internal rotation
- Lewis method (10-15° CR toward the wrist) ensures the thumb is free of soft tissue
PA projection helps to visualize the 1st MCP Joint and other aspects of the thumb
- Hand is placed laterally with the dorsal surface of the thumb parallel to the image receptor
- The thumb is magnified in this projection
PA Oblique projection focuses on the 1st metacarpophalangeal joint
- Hand is positioned in slight ulnar deviation with the thumb abducted
Lateral projection provides a magnified view of the 1st MCP joint and the lateral portion of the thumb
- The hand should be in a natural arched position with the palmar surface facing down
- The trapezium will be superimposed on the image

Key Anatomical Structures

AP projection visuals: distal phalanx, interphalangeal joint, proximal phalanx, metacarpophalangeal joint, 1st metacarpal, carpometacarpal joint
PA projection visuals: 1st MCP Jt, thumb, trapezium
PA Oblique projection visuals: 1st MCP Jt
Lateral projection visuals: 1st MCP Jt, lateral portion of thumb, trapezium

Digits Projection (2nd to 5th)

PA projection is a standard view for digits 2nd to 5th.
PA oblique projection with lateral rotation (45°) provides detail of the 4th and 5th digit.
PA oblique projection with medial rotation (45°) provides detail of the 2nd and 3rd digit.
Lateral projection is used for the 4th and 5th digit.
Lateral projection provides increased detail for the 2nd and 3rd digit and is preferred for other injuries.
AP projection is an alternative for PA projection when the patient cannot extend their digits.
AP projection requires a small dental film and is used for suspected joint injuries.
AP projection can be used to visualize foreign bodies.

1st Digit (Thumb)

AP Projection
- Used for suspected joint injury.
- The projection requires the hand to be in extreme internal rotation with the thumb free of soft tissue of the palm.
- This projection primarily targets the 1st MCP joint.
- Lewis technique (10-15° CR toward wrist) can be utilized to maximize visualization of the 1st MCP joint and minimize soft tissue interference.
PA Projection
- Hand in lateral position with the dorsal surface of the thumb parallel to the IR.
- The 1st MCP joint and thumb are visualized in this projection.
- The thumb may be magnified in this view.
PA Oblique Projection
- Hand is placed in slight ulnar deviation with the thumb abducted.
- This projection targets the 1st MCP joint and provides an oblique view of the thumb.
Lateral Projection
- Hand is positioned in natural arched position with the palmar surface down.
- Primarily used for visualization of the 1st MCP joint, lateral portions of the thumb, but also shows the trapezium.

Image

Fig. 4-41 AP first digit.- Visualizes distal phalanx, interphalangeal joint, proximal phalanx, metacarpophalangeal joint, 1st metacarpal and carpometacarpal joint.
Fig. 4-42 PA first digit.- - Fig. 4-43 Lateral first digit.- - Fig. 4-44 PA oblique first digit.- - Fig. 4-37 AP first digit.- - Fig. 4-38 PA first digit (cotton swab).- - Fig. 4-40 PA oblique first digit.- - Fig. 4-39 Lateral first digit. - These images show various views of the thumb and related structures.

Digits (2nd to 5th) Projection

PA projection is a standard view for 2nd to 5th digits
PA oblique (Lateral Rotation) uses 45° lateral rotation for improved visualization
PA oblique (Medial Rotation) uses 45° medial rotation for better detail
Lateral (Lateromedial/mediolateral) projection is ideal for 4th and 5th digits
2nd and 3rd digit PA projections provide increased detail and are useful for other fractures
Alternative to PA projection is AP projection:
- Used when patients cannot extend their digits
- Requires a small dental film and can be used for suspected joint injuries
- Also helpful for visualizing foreign bodies

1st Digit (Thumb) AP Projection

AP Projection is used for suspected joint injuries
Hand in extreme internal rotation positions the 1st MCP joint and allows for an AP projection of the thumb
Lewis Method uses a 10-15° CR towards the wrist to ensure the thumb is clear of the palm
PA Projection requires the hand to be in a lateral position with the dorsal surface of the thumb parallel to the IR
PA Oblique Projection requires slight ulnar deviation and thumb abduction for the 1st MCP joint
Lateral Projection positions the hand in a natural arched position with the palmar surface down for optimal visualization of the 1st MCP joint and the lateral portion of the thumb
Superimposition of the trapezium may occur in lateral projection
Fig. 4-41 shows an AP view of the first digit, including:
- Distal phalanx
- Interphalangeal joint
- Proximal phalanx
- Metacarpophalangeal joint
- 1st metacarpal
- Carpometacarpal joint
Fig. 4-42 shows a PA projection of the first digit.
Fig. 4-43 shows a lateral projection of the first digit.
Fig. 4-44 shows a PA oblique projection of the first digit.
Fig. 4-37 shows an AP projection of the first digit.
Fig. 4-38 shows a PA projection of the first digit, utilizing a cotton swab.
Fig. 4-40 shows a PA oblique projection of the first digit.
Fig. 4-39 shows a lateral projection of the first digit.

Hand Palmar Surface

Hand projections with the palmar surface facing down are essential for various hand examinations.
The AP projection is commonly used, except in cases of injury or pathology.

Clements-Nakayama Projection

This specific projection is specifically designed for the early detection of Rheumatoid Arthritis.

PA Oblique Projection (Lateral Rotation)

The hand is pronated and rotated laterally.
The palmar surface faces down, with the MCP joints positioned at a 45-degree angle to the image receptor (IR).

PA Projections of the Hand

These projections are used to visualize specific anatomical structures like the carpals, metacarpals, and the 2nd-5th phalanges.

Thumb PA Oblique

This projection focuses on the thumb anatomy.

Interphalangeal Joint Projection

This projection aims to open joint spaces for clear visualization, minimizing the foreshortening of the phalanges.
A 45-degree foam wedge elevates the index finger, ensuring proper alignment of finger tips with the cassette.

PA ProT Hand

This projection focuses on the 2nd-5th fingers in the PA view.

Metacarpal Bones

The MCP joint is crucial for the investigation of fractures or pathological conditions.

Reverse Oblique Projection (Lane, kennedy & Kushner)

This projection is achieved through medial rotation of the hand.

Tangential Oblique Projection (Ikällen Recommendation)

From the hand's PA position, rotate the hand 40-45° toward the ulnar surface.
The MCP joint is positioned at 75-80° with the dorsum of digits resting on the IR.

Hand Rotation for MCP Joint Visualization

Rotate the hand 45° medially (internally) to visualize the MCP joint of interest, especially for severe metacarpal deformities.

Lateral Projection

The lateral projection of the hand can be done in extension or flexion.
Extension lateral projection is a standard technique, with the thumb positioned at 90° to the palm and the ulnar aspect facing down.
Lateromedial projection involves positioning the radial aspect down, which is technically more challenging.
Mediolateral projection is another option, with the radial aspect facing the IR.

2nd and 5th MCP Joint Projections

The lateral projection in extension is used to localize foreign bodies, assess metacarpal fracture displacement, and visualize the 2nd MCP joint.
The 5th MCP joint requires a latero-medial projection positioning for optimal visualization.
The mediolateral projection, with the radial surface of the hand facing the IR, is crucial for specific evaluations.

Fan Lateral Projection

This technique modifies the lateral hand projection.

Latero-medial Projection in Flexion

The hand assumes a natural arch with relaxed digits, creating a "C" shape.
This projection is especially beneficial for the 2nd MCP joint, eliminating superimposition of phalanges (except the proximal) and offering clarity for fractures.

LEWIS Recommendation

The hand is positioned in the lateral projection, with a 5° posterior rotation to remove superimposition.
This minimizes the superimposition of the 2nd-4th metacarpals while the thumb remains extended.

5th Metacarpal Midshaft

This projection is designed for better visualization of fractures in the 5th metacarpal midshaft, including Boxer's Fractures.

Norgaard Method AP Oblique Projection (Medial Rotation)

The hand is supinated and medially rotated, with the medial aspect resting on the IR.
A 45-degree sponge support is used for proper hand alignment.
This technique compares the 5th MCP Joints of both hands.

Stapczynski Recommended Projection

This AP oblique projection helps identify fractures at the base of the 5th metacarpal.

Brewerton Projection

This AP axial projection assesses erosive changes at the base and head of the 1st metacarpal at a 60 degree angle.

Rheumatoid Arthritis Projections

Various projections, including the Norgaard method, ball catcher's position, Brewerton, and Clements-Nakayama, are useful for diagnosing Rheumatoid Arthritis.

Projections for 5th Metacarpal Fractures

Lewis recommendation (5° rotation) and Stapczynski (AP oblique) projections are particularly helpful in identifying 5th metacarpal fractures.

Lateral Projections for Foreign Bodies and Fracture Displacement

Lateral projections of the hand effectively reveal the presence of foreign bodies and allow for the assessment of fracture displacement.

Fan Lateral and Lateral in Flexion Projections

The fan lateral projection further enhances laterality.
The lateral projection in flexion minimizes superimposition of phalanges, offering detailed visualization.

Early Detection and Diagnosis of Rheumatoid Arthritis

Specific projections, like those in Figures 4-65-67, contribute to early diagnosis and detection of RA.

Ball Catcher's Position

The ball catcher's position, shown in Figure 4-67 and 4-68, is crucial for examining the hand in AP oblique projections for the detection of Rheumatoid Arthritis.

Hand Projections

Hand palmer surface faces down with fingers slightly spread.
AP projection - use this if a PA projection is not possible due to a pathologic or injury.

### Clements-Nakayama

Detects early Rheumatoid Arthritis
Uses AP projection.

PA Oblique Projection (Lateral Rotation)

Hand is pronated and rotated laterally.
Palmar surface down.
MCP joints are at a 45° angle to the image receptor.

Projections for:

Carpals
Metacarpals
2nd-5th phalanges

Thumb - PA Oblique

Interphalangeal Joint

Used for metacarpal bones.
Opens joint spaces.
Reduces phalange foreshortening.

45° Foam wedge

Fingertips touch the cassette.
Index finger is elevated.

PA ProT Hand Projection

2nd-5th PA projection.
Shows the metacarpal bones and the MCP joints.

Metacarpal Bones

Used to investigate fracture and pathologic conditions.

Reverse Oblique Projection (Lane, Kennedy & Kushner)

Hand is in a medial rotation.

Tangential Oblique Projection (Ikällen Recommendation)

Hand is in an PA projection.
MCP joints are at 75-80° angle.
The dorsum of the digits rest on the IR.
The hand is rotated 40-45° towards the ulnar surface.
Used for severe metacarpal deformities.
Used to demonstrate metacarpal head fractures.

Lateral Projection

Includes extension, lateromedial, Fan Lateral (Lewis recommendation), and flexion (mediolateral)
Extension
- Hand is in a lateral position with digits extended.
- Thumb is 90° to the palm.
- Ulnar aspect faces down.
Lateromedial
- Radial aspect faces down.
- Difficult to perform.
Medio lateral

2nd MCP Jt

Lateral Projection in Extension
- Cons: Superimposition of phalanges.
- Pros: Localizes foreign bodies and metacarpal fracture displacement.

5th MCP Jt

Extension, Latero-medial
- Mediolateral projection.
- Used for the medio-atrical region.

Fan Lateral (modification of the lateral hand)

Flexion (Latero Medial)

Hand in a natural arch.
Digits relaxed.
C-shaped hand.

2nd MCP Jt

Lateral projection of the hand in flexion.
Superimposition of phalanges.

Lewis Recommendation

Hand starts in a true lateral position then rotates 5° posteriorly to remove superimposition of the 2nd-4th metacarpals.
Thumb is extended.
Used to demonstrate the midshaft of the 5th metacarpal.

To Better Demonstrate Fracture of 5th Metacarpal

Boxer's Fx (Bar Room)
Norgaard Method AP Oblique Projection (Medial rotation) Ball catcher's position
- Both hands are supinated and medially rotated.
- The medial aspect faces the IR.
- 45° sponge support.
- Shows the level of the 5th MCP joints of both hands.
Stapczynski AP Oblique Projection
- Shows fractures of the base of the 5th metacarpal.

Brewerton

Unilateral ball catcher projection.
Used to evaluate erosive changes.
AP axial projection.
Shows the base to head of the 1st metacarpal.
Hand is at a 60° angle to the IR.

Rheumatoid Arthritis

Greulich & Pyle
- Bone aging method.
- PA projection of the left hand.
- Uses a computer software to calculate bone age.

Projections for Rheumatoid Arthritis

Norgaard Method
Ball Catcher's Position
Brewerton
Clements Nakayama (AP Projection).

Projections for 5th (pinky) metacarpal FX

Lewis Recommendation
Stapczynski (AP oblique)

Lateral Projection

Evaluates foreign bodies and displacement of fractures.

Early Detection and Diagnosis of Rheumatoid Arthritis

AP oblique hands in a semi-supinated position.
Ball Catcher's Position.

To see where the indistinct area occurs:

Ball Catcher's Position.

Hand Projections

Hand Projections involve various positions and angles to visualize different anatomical structures and pathologies.

Positions and Projections

Palmar Surface Down: The hand is placed with the palm facing downwards.
AP Projection: Anterior-posterior projection, where the X-ray beam enters the anterior aspect and exits the posterior aspect.
PA Projection: Posterior-anterior projection, where the X-ray beam enters the posterior aspect and exits the anterior aspect. PA projections of the hand are often avoided due to potential pathologic conditions.
Clements-Nakayama Projection: A specific projection used to detect early rheumatoid arthritis.
PA Oblique Projection (Lateral Rotation): The hand is pronated (palm down), rotated laterally with the MCP joints at a 45-degree angle to the image receptor. This view is used to visualize the carpals, metacarpals and phalanges.
Thumb PA Oblique: A specific projection for visualizing the thumb.
Interphalangeal Joint: Uses a 45-degree foam wedge to open the joint spaces and reduce foreshortening of the phalanges.
PA ProT Hand: A projection that focuses on the PA view of the 2nd to 5th phalanges.
Reverse Oblique Projection (Lane, Kennedy & Kushner): Involves medial rotation of the hand for specific imaging needs.
Tangential Oblique Projection (Ikällen Recommendation): The hand is positioned in PA, but the MCP joint is angled 75-80 degrees with the dorsum resting on the image receptor. The hand is then rotated 40-45 degrees towards the ulnar side.
Lateral Projection: The hand is positioned laterally, with several variations:
- Extension: The digits are extended, with the thumb at a 90-degree angle to the palm.
- Lateromedial: The radial aspect of the hand is placed down on the cassette.
- Mediolateral: The ulnar aspect of the hand is placed down on the cassette.
Fan Lateral: A modification of the lateral projection for specific purposes.
Flexion (Lateromedial): The hand is placed in a natural arch with the digits relaxed, forming a "C" shape.
Norgaard Method (AP Oblique Projection, Medial Rotation): Both hands are supinated and medially rotated with the medial aspect against the image receptor, using a 45-degree sponge support. This method is often used for the 5th MCP joint.
Stapczynski Recommended Projection: An AP oblique projection designed to visualize fractures at the base of the 5th metacarpal.

Specific Conditions and Projections

Rheumatoid Arthritis:
- Norgaard Method
- Ball Catchers Position
- Brewerton Projection
- Clements Nakayama (AP Projection).
5th Metacarpal Fracture (Pinky):
- Lewis Recommendation (Lateral Projection with 5-degree rotation)
- Stapczynski (AP Oblique).
Boxer’s Fracture (Bar Room Fracture): A fracture of the 5th metacarpal, often sustained when a fist strikes a hard object.
Metacarpal Head Fractures (Knuckles): Tangential Oblique Projections are often used.
Fractures of the Metacarpals: Lateral projections in flexion help demonstrate anterior or posterior displacement.
Foreign Bodies: Lateral and extension projections are used to localize foreign bodies.

Additional Information

Grewlich & Pyle Bone Aging Method: A technique using the PA projection of the left hand with specialized software to estimate bone age.
Langerhans cells (Histiocytosis): Cells that play a role in immune response, and are sometimes involved in histiocytosis, a rare disorder where these cells accumulate abnormally.

Hand Projections

Hand Palmar Surface Down: Fingers slightly spread for a clear image.
AP Projection: PA is not possible due to potential injury or pathological conditions.
Clements-Nakayama: A special projection specifically for detecting early Rheumatoid Arthritis.
PA Oblique Projection (Lateral Rotation): Hand pronated and rotated laterally, with the palmar surface down and the MCP joint at 45° to the image receptor.
PA of Carpals, Metacarpals, and 2nd-5th Phalanges: Used to visualize these structures.
Thumb - PA Oblique: Special projection for the thumb.
Interphalangeal Joint: Opens joint spaces and reduces foreshortening of phalanges when imaging metacarpal bones.
45° Foam Wedge: Used to elevate the index finger and ensure fingertips touch the cassette during certain projections.
PA ProT Hand: Used to obtain a PA view of the 2nd to 5th digits.
Metacarpal Bones: Projections are done to investigate fractures and pathological conditions.
Reverse Oblique Projection (Lane, Kennedy & Kushner): Hand is rotated medially.
Tangential Oblique Projection (Ikällen Recommendation): Hand in a PA position, MCP joint at 75-80°, dorsum of digits rest on the image receptor, and rotated 40-45° toward the ulnar surface.
Hand Rotate 45° medially (internally): Used to visualize the MCP joint of interest, particularly for severe metacarpal deformities.
Demonstrate Metacarpal Head Fractures (Knuckles): Tangential oblique projection is helpful.
Lateral Projection: Includes Extension, Lateromedial, Fan Lateral (Lewis Recommendation), and Flexion (Mediolateral) variations.

Lateral Projection Variations

Extension: Hand in lateral position with digits extended and thumb 90° to the palm, ulnar aspect down.
Lateromedial: Radial aspect down, often difficult to perform.
MedioLateral: Frequently used.

Hand Projections: Special Considerations

2nd MCP Joint: Lateral projection can be beneficial, but superimposition of phalanges remains a concern.
5th MCP Joint: Latero-medial projection in extension provides a good visual.
Fan Lateral: Modified lateral projection.
Flexion (Latero Medial): Hand in a natural arch with digits relaxed, forming a "C" shape.
LEWIS Recommendation: Hand from true lateral position, rotated 5° posteriorly to reduce superimposition of 2nd-4th metacarpals, thumb extended.

Specific Projections

Norgaard Method AP Oblique Projection (Medial Rotation) "Ball Catcher's Position": Both hands supinated/medially rotated, medial aspect against the IR, with a 45° sponge support. Important for visualizing between levels 1 of the 5th MCP Joint of both hands.
Stapczynski Recommended AP Oblique Projection: Used to demonstrate fractures at the base of the 5th metacarpal.
Brewerton - Unilateral "Ball Catcher": AP axial projection to evaluate erosive changes at the base and head of the 1st metacarpal, with the hand at a 60° angle to the image receptor.

Rheumatoid Arthritis

GReulich & Pyle Method: Bone aging method using PA projection of the left hand with software to calculate bone age.
Projections for Rheumatoid Arthritis:
- Norgaard Method
- Ball Catcher's
- Brewerton
- Clements Nakayama (AP Projections)

Fractures

5th (Pinky) Metacarpal Fracture Projections:
- LEWIS Recommendation - 5° rotation (Lateral)
- Stapczynski (AP oblique)
Lateral Projection: Useful for demonstrating foreign bodies and displaced fractures.
Boxer's Fracture "Bar Room" Fracture: A common fracture of the 5th metacarpal.

Important Figures

Fig. 4-61 Fan lateral hand.
Fig. 4-64 Lateral hand in flexion.
Fig. 4-65 Lateral hand in flexion.
Fig. 4-66 AP oblique hands, semi-supinated position.
Fig. 4-67 Ball-catcher's position.
Fig. 4-68 A, AP oblique hands, ball-catcher's position, showing where indistinct area occurs (arrows); B, ball-catcher position.

Early Detection

Early detection and diagnosis of Rheumatoid Arthritis: Specific projections are critical for early diagnosis.

Forearm Projections

AP Projection involves positioning the hand supinated or pronated.
Hand Supinated - patient leans laterally and humeral epicondyle is internally rotated.
Hand Pronated - hand is pronated, resulting in an oblique projection of the forearm. The radius crosses the ulna and the humerus rotates medially.
Lateral Projection - also known as Lateromedial. - the elbow is flexed at 90 degrees, with the forearm and hand in a true lateral position. The humeral epicondyle is internally rotated.
AP Of Elbow Joint - centers the beam to the midpoint of the forearm capturing the radius, ulna, and proximal row of carpals. The proximal row of carpals may appear slightly distorted.

Image Descriptions

Figure 4-104 - AP forearm
Figure 4-105 - AP forearm with hand supinated
Figure 4-106 - AP forearm with hand pronated (incorrect)
Figure 4-108 - Lateral forearm
Figure 4-109- Lateral forearm.
Some of these figures depict various bony landmarks of the forearm including:
- Olecranon process
- Humeral epicondyle
- Coronoid process
- Radial head
- Radial tuberosity
- Ulnar body
- Radial body
- Ulnar styloid process

Forearm Projections

AP and Lateral projections are used to visualize the forearm
Hand Supination and Pronation are essential for AP projections
Hand Supinated: Humeral Epicondyle is in Internal Rotation (IR)
Hand Pronated: Humerus rotates medially
Lateral Projection: Lateromedial view, Elbow Flexed 90°, Forearm and hand in true lateral position with Humeral Epicondyle in IR
AP of Elbow Joint: Midpoint of forearm, radius and ulna, proximal row of carpals may be slightly distorted

Image Descriptions

Figure 4-104 is an AP Forearm projection
Figure 4-105 is an AP Forearm projection with hand supinated
Figure 4-106 is an incorrect AP Forearm projection with hand pronated
Figure 4-108 is a Lateral Forearm projection
Figure 4-109 is a Lateral Forearm projection
Key Anatomical structures: Olecranon process, Humeral epicondyle, Coronoid process, Radial head, Radial tuberosity, Ulnar body, Radial body, and Ulnar styloid process.

Forearm Projection

AP projection of the forearm can be performed with the hand supinated or pronated.
When supinated, the patient leans laterally and the humeral epicondyle is internally rotated (IR).
When pronated, the forearm is in an oblique projection with the radius crossing the ulna and the humerus rotating medially.
Lateral projection of the forearm is performed with the elbow at 90 degrees and the forearm and hand in true lateral position.
The humeral epicondyle should be internally rotated.
AP projection of the elbow joint includes the midpoint of the forearm, radius and ulna, and proximally the carpal bones.

Key Anatomical Structures

Olecranon Process: bony projection at the back of the elbow
Humeral Epicondyle: bony prominence on the lateral side of the humerus
Coronoid Process: bony projection at the front of the ulna
Radial Head: rounded proximal end of the radius
Radial Tuberosity: bony prominence on the medial side of the radius
Ulnar Body: central shaft of the ulna
Radial Body: central shaft of the radius
Ulnar Styloid Process: bony prominence on the medial side of the ulna

Lateral Position Palmar Flexion

Positions the wrist in palmar flexion
Rotates the scaphoid into a dorsovolar position
Shows the scaphoid in a lateral position
Additional structures are also visible

CARPE BOSSU

A bony growth occurring on the dorsal side of the 3rd CMC joint

PA Oblique Projection (Lateral Rotation)

Hand pronated and rotated 45 degrees laterally
Places the palmar surface of the wrist against the image receptor
Shows the carpals on the lateral side: thumb, trapezium, and scaphoid

PA Oblique Projection (Medial Rotation)

Hand supinated and rotated 45 degrees medially
Places the dorsal surface of the wrist against the image receptor
Shows the carpals on the medial side: hamate, pisiform, and triquetrum

PA Projection (Ulnar Deviation)

Hand is pronated
Wrist in extreme ulnar deviation
Used to project and capture the scaphoid without foreshortening
Corrects the typical foreshortening of the scaphoid

PA Projection (Radial Deviation)

Hand pronated
Wrist in radial deviation
Opens up the interspaces between the carpal bones on the medial side

SCAPHOID (Cephalad)

Stecher Method: original PA axial projection with 20 degree IR elevation
Scaphoid is visualized without foreshortening
Several variations exist with the same goal: visualizing the scaphoid without superimposition
Close/clenched fist projection: Stecher method with ulnar deviation
Bridgman suggested a PA axial projection with ulnar deviation

SCAPHOID Series

Rafert-Long method: PA axial projection with hand in extreme ulnar deviation
Series involves 10, 20, and 30 degree cephalad angles to minimize scaphoid superimposition and help diagnose scaphoid fractures

TRAPEZIUM (Greater Multangular)

PA Axial Oblique method (Clements-Nakayama method): Palmar surface against 45 degree foam wedge
Hand in ulnar deviation
Used to demonstrate trapezium fractures and evaluate the articular surface

Wrist Projection

PA Projection: Slightly arched hand placed in close contact with the image receptor
Shows the midcarpal area and a slightly oblique view of the ulna
DAFFNER, EMMERLING & BUTERBAUGH: recommended PA projection with 30 degrees toward the elbow
AP Projection: Hand supinated and digits elevated
Lateral Projection: Elbow flexed 90 degrees to rotate ulna (laterally), best to demonstrate anterior or posterior displacement of fractures

Carpal Bridge

Lentino Method (Tangential Projection): Palm upward, hand 90 degrees to forearm, wrist flexed 90 degrees
CR at 45 degrees, 1.5 inches proximal to the wrist
Used to assess scaphoid fractures, lunate dislocation, and calcification of the wrist dorsum
Modified tangential projection: Elevated forearm on sandbags, wrist flexed 90 degrees

Carpal Canal

Gaynor-Hart Method (Tangential Projection): Wrist hyperextended, hand rotated slightly toward radial side
CR at 25-30 degrees to the long axis of the hand
Used to assess carpal canal tunnel syndrome, fractures of the hook of the hamate, and triquetrum/pisiform
Templeton & Zim: Dorsiflexed wrist, carpal canal tangent to the image receptor
M3 (Mequillen-Martensen) suggested using a CR parallel to the palmar surface when the wrist can't extend to within 15 degrees of vertical
Marshall suggested using a 45 degree angle sponge under the palmar surface for a slight magnification of the carpal canal

Carpal Canal Projections

Gaynor-Hart
Zim & Templeton

Wrist Projection

Midcarpal Projection (or) Wrist Projection (between 2 Styloid Processes): Captures a PA image of the carpals, with a slightly oblique view of the ulna.
Midcarpal - PA Projection
- Hand slightly arched and placed in close contact with the IR.
- Elongates the scaphoid and capitate.
- Better for ulnar examination.
- 30 degrees toward the elbow (DEB 30 degrees EIF-fingers cap)
  - 30 degrees toward the fingertips with the elbow at 30 degrees.
  - Focuses on scaphoid and capitate.
Midcarpal - AP Projection
- Hand supinated and digits elevated, wrist in close contact with the IR.
- Better demonstrates the carpal interspaces.
- No rotation of the ulna.
Lateral Projection
- Elbow flexed 90 degrees, hand & forearm in lateral position with ulnar surface against IR.
- Captures the midcarpal area, lateral metacarpals, distal radius and ulna.
- Utilizes a dorsovolar position of the scaphoid.
- Helpful for visualizing anterior or posterior displacement in fractures, including:
  - Colle's Fracture (Bayonet, DinnerFork)
  - Smith Fracture (Reverse Colles)
  - Barton's Fracture
  - Hutchinson's Fracture (Chauffer)
Lateral Position with Palmar Flexion (Burman et al)
- Additional structures visible with the wrist in palmar flexion.
- Rotates the scaphoid into a dorsovolar position, allowing for a better visualization of its lateral aspect.
- Demonstrates Carpal Boss
Foille
- First to describe Carpal Boss - a bony growth found on the dorsal side of the 3rd CMC Joint.

PA Oblique Projections

Lateral Rotation (PA Oblique)
- Hand pronated and rotated 45 degrees laterally.
- Palmar surface of wrist on IR.
- Emphasizes the lateral side of the carpals, including the thumb, trapezium and scaphoid.
- Best for visualizing the scaphoid.
- Often used with ulnar deviation.
Medial Rotation (PA Oblique)
- Hand supinated and rotated 45 degrees medially.
- Wrist dorsal surface against IR.
- Highlights the medial side of the carpals: Hamate, pisiform, triquetrum.

PA Projection (Ulnar Deviation)

Scaphoid Projection
- Hand pronated, wrist in extreme ulnar deviation.
- Emphasizes the scaphoid for clear delineation, often at a 10-15 degree angle.
- Helps correct foreshortening of the scaphoid.
- Opens joint spaces on the lateral side.

PA Projection (Radial Deviation)

Hand pronated, wrist in radial deviation.
Focuses on the midcarpal area and opens carpal interspaces on the medial side.

Scaphoid (and) Cephalad

Stecher Method (PA Axial Projection): Original method
- IR elevated 20 degrees.
- Prevents foreshortening of the scaphoid and superimposition.
- Scaphoid positioned at a right angle to the CR.
Other variations (but same result as original):
- CR 20 degrees toward the elbow
- CR 20 degrees toward digits
- Demonstrates fractures that angle superoinferiorly (from up to down).
Close/Clenched Fist (PA projection)
- Bridgman method (Stecher with ulnar deviation).
- Open joint interspace on the lateral side.
- Emphasizes the scaphoid.
Bridgman (PA axial projection with ulnar deviation)
- Wrist in ulnar deviation.

Scaphoid Series

Rafert-Long Method (PA Axial Projection)
- Hand pronated, wrist in extreme ulnar deviation.
- 10, 20, and 30 degrees cephalad.
- Minimizes superimposition on the scaphoid.
- Used to diagnose scaphoid fractures.
PA Axial Projection (Ulnar Deviation)
- Four-image, multiple angle central ray series.
- Helpful for difficult to diagnose scaphoid fractures when the wrist's position is uncertain after a routine radiograph.

Trapezium (or) Greater Multangular (MSP CR)

Clements-Nakayama Method (PA Axial Oblique)
- Palmar surface against a 45 degree foam wedge, with the hand in ulnar deviation.
- 45 degrees distally.
- Focuses on the anatomical snuff box and the trapezium.
- Demonstrates trapezium fractures.
- Useful for evaluating trapezium articular surface, especially in osteoarthritis.
- If ulnar deviation is not possible, rotate the elbow end of the IR and arm 20 degrees away from the CR.
Variations of the Clements:
- Holly - Hand on a recommended sponge.

Carpal Bridge

Lentino Method (Tangential Projection)
- Hand palm upward, hand 90 degrees to the forearm, wrist at 90 degrees flexion
- 45 degree CR, 1.5 inches proximal to the wrist.
- Demonstrates:
  - Scaphoid fractures.
  - Lunate dislocation.
  - Calcification of the wrist dorsum.
  - Foreign bodies.
  - Chip fractures on the dorsal aspect of carpal bones.
Alternative Method (Modified Tangential Projection)
- Elevate forearm on sandbags, wrist flexed 90 degrees, IR vertical.

Carpal Canal

Gaynor-Hart Method (Tangential Projection)
- Wrist hyperextended, hand slightly rotated toward the radial side.
- 25-30 degrees angle to the long axis of the hand.
- Focus on the palm of the hand, approximately 1 inch distal to the 3rd MCP base.
- Demonstrates:
  - Carpal tunnel syndrome (CTS).
  - Fractures of the hook of the hamate (Colfer's wrist).
  - Triquetrum.
  - Pisiform.
Templeton & Zim
- Wrist dorsiflexed, lean forward to place carpal canal tangent to IR.
- 20-35 degree angle from the long axis of the forearm.
- Focus on the midpoint of the wrist.
- Emphasizes the carpal sulcus and flexor retinaculum for CTS assessment.
(M3) Mequillen-Martensen (Suggested)
- If wrist cannot extend within 15 degrees of vertical, orient the CR parallel to the palmar surface.
Marshall (Suggested)
- Place a 45 degree angle sponge under the palmar surface for wrist with limited dorsiflexion.
- Increases the magnification of the carpal canal.

Carpal Canal Projections

Gaynor-Hart
Zim & Templeton

Wrist Projection

PA Projection of the midcarpal area - demonstrates the carpals in a PA projection, slightly oblique projection of the ulna, open radio-ulnar joint space, elongated scaphoid and capitate.
AP Projection of the midcarpal area - demonstrates better visualization of the carpal interspaces, better for ulnar examination
Lateral Projection - demonstrates the lateral metacarpals, distal radius and ulna, scaphoid and trapezium, good for demonstrating anterior or posterior displacement in case of a fracture, for Colle's Fx, Smith Fx, Barton's Fx, and Hutchinsion's Fx
Lateral Position Palmar flexion - recommended by Burman et al., rotates the scaphoid into a dorsovolar position, lateral position of the scaphoid
CARPE BOSSU - bony growth on the dorsal surface of the 3rd CMC joint, first described by Foille.

PA Oblique Projection

Lateral Rotation - shows the scaphoid, trapezium and thumb, carpals on the lateral side of the wrist
Medial Rotation - shows the hamate, pisiform, and triquetrum, carpals on the medial side of the wrist

PA projection (ulnar deviation)

Scaphoid projection - hands pronated, wrist in extreme ulnar deviation, used to correct foreshortening of the scaphoid, opens joint spaces on the lateral side

PA Projection (radial deviation)

Hands pronated, wrist in radial deviation, shows open carpal interspaces on the medial side.

SCAPHOID (and) Cephalad

Original method: Stecher Method (PA axial projection) - IR elevated 20 degrees, scaphoid with 20 degrees angulation of the IR, scaphoid perpendicular to the CR, scaphoid parallel to the IR
Other variations - CR 20 degrees toward the elbow, CR 20 degrees toward digits, demonstrate a fracture line angling superoinferiorly
Close/clenched the fist (PA projection) - Bridgman method is the Stecher method with ulnar deviation, open joint interspace at the lateral side, demonstrates scaphoid

SCAPHOID Series

Rafert-Long method (PA axial projection) - hand pronated, wrist in extreme ulnar deviation, 10, 20, and 30 degrees cephalad, minimizes superimposition of the scaphoid

TRAPEZIUM (or) Greater Multangular MSP CR

Clements-Nakayama method PA axial oblique method- palmar surface against a 45-degree foam wedge (hand in ulnar deviation), 45 degrees distally, demonstrates trapezium fractures, evaluation of the trapezium articular surface
Variations of clements - Holly - Hand on recommended sponge.

Carpal Bridge

Lentino Method (tangential projection) - hand palm upward, hand 90 degrees to the forearm, 45 degrees CR, 1.5 inches proximal to the wrist
Alternative Method - modified tangential projection, elevate the forearm on sandbags, wrist flexed 90 degrees.

Carpal Canal

Gaynor-Hart Method (tangential projection) - wrist hyperextended, rotate hand slightly toward the radial side, 25-30 degrees to the long axis of the hand, approx. 1 inch distal to the 3rd MCP base
Templeton & Zim - dorsiflex the wrist, lean forward, 20-35 degrees from the long axis of the forearm, midpoint of the wrist
(M3) Mequillen-Martensen suggested - wrist can't extend to within 15 degrees of vertical, CR parallel to the palmar surface
Marshall suggested - place a 45 degrees angle sponge under the palmar surface

Carpal canal projections

Gaynor-Hart
Zim & Templeton

Upright Humerus Projections

AP Projection
- Patient in erect or seated upright position
- Arm slightly abducted
- Hand supinated
- Humeral epicondyle parallel to the image receptor (IR)
Lateral (Lateromedial) Projection
- Patient in erect or seated upright position
- Arm rotated internally
- Elbow flexed 90 degrees
- Hand placed palmar on the hip
- Humeral epicondyle perpendicular to the IR
(Mediolateral) Projection
- Performed in a RAO or LAO position
- Patient's hand holds affected arm

Recumbent Humerus Projections

AP Projection (HH & 6T)
- Patient supine
- Unaffected arm elevated
- Hand supinated
- Humeral epicondyle parallel to the IR
Lateral (Lateromedial) Projection (HH & LT)
- Patient positioned supine
- Forearm medially rotated
- Dorsal aspect of hand placed on patient's side
- Humeral epicondyle perpendicular to the IR (without bending the elbow)

Recumbent Distal Humerus Projections

Lateromedial Recumbent or Lateral Recumbent Projection
- IR placed between the axilla (armpit) and the affected arm
- Elbow flexed
- Thumb surface of hand pointing upwards

Humerus Projections for Patients with a Suspected Fracture

- Lateral recumbent position is ideal for demonstrating the distal lateral humerus

Upright Humerus Projections

AP Projection:
- Patient stands or sits upright
- Arm slightly abducted
- Hand supinated
- Humeral epicondyle parallel to image receptor (IR)
Lateral Projection:
- Patient stands or sits upright
- Arm rotated internally
- Elbow flexed 90 degrees
- Hand placed on hip, palm down
- Humeral epicondyle perpendicular to IR
Mediolateral Projection:
- Patient stands or sits upright
- Patient uses their hand on the injured side to support the arm
- Performed with a Right Anterior Oblique (RAO) or Left Anterior Oblique (LAO) position

Recumbent Humerus Projections

AP Projection:
- Patient lies supine
- Unaffected arm is elevated
- Hand is supinated
- Humeral epicondyle is parallel to IR
- May be performed as part of a Hand and Forearm (HH) or Shoulder and 6th Thoracic Vertebra (6T) series
Lateral Projection:
- Patient lies supine (HH & LT)
- Forearm is rotated medially
- Back of hand is placed on the patient's side
- Humeral epicondyle is perpendicular to IR without flexing the elbow
- Performed as part of a Hand and Forearm (HH) or Shoulder and 6th Thoracic Vertebra (6T) series

Distal Humerus Projections

Lateromedial or Lateral Recumbent:
- Image receptor (IR) is placed between the axilla and the affected arm
- Elbow is flexed
- Thumb surface of hand is pointing upward

Distal Humerus Considerations

Suspected Fracture: Carefully position the patient for proper visualization of the distal humerus.

Humerus Projections - Upright

AP Projection (Upright)
- Patient is erect or seated upright
- Arm slightly abducted
- Hand supinated
- Humeral epicondyle parallel to IR
Lateral Projection (Lateromedial) Upright
- Patient is erect or seated upright
- Arm rotated internally
- Elbow Flexed 90°
- Hand palmar placed on hip
- Humeral epicondyle perpendicular to IR
(Mediolateral) UPRIGHT
- RAO / LAO position
- Patient's hand holding the broken arm

Humerus Projections - Recumbent

AP Projection HH & 6T
- Patient is supine
- Unaffected arm elevated
- Hand supinated
- Humeral epicondyle parallel to IR
Lateral Projection (lateromedial) HH & LT
- Patient is supine
- Forearm medially rotated
- Dorsal aspect of hand placed on patient's side
- Humeral epicondyle perpendicular to IR (without flexing the elbow)

Distal Humerus Projections

Lateromedial Recumbent / Lateral recumbent
- Place the IR between the axilla and the affected arm
- Elbow Flexed
- Thumb surface up

General Notes

Images of humerus projections can be found in Figures 4-147, 4-149, 4-151, 4-152, and 4-153.
Specific positioning details of the humerus projections are summarized in the table provided.

Humerus Projection

Upright: The patient can be upright or seated.
Recumbent: The patient lies supine during the exam
Distal Humerus: The patient can be positioned in a recumbent position for the distal humerus.

AP Projection

Upright: The patient's arm should be slightly abducted (moved away from the body) and the hand should be supinated (palm facing up). The humeral epicondyle should be parallel to the image receptor (IR).
Recumbent: The unaffected arm should be elevated and the hand supinated. The humeral epicondyle should be parallel to the IR.

Lateral Projection

Upright: The arm should be internally rotated and the elbow flexed at 90 degrees. The hand should be placed on the hip with the palm facing the body. The humeral epicondyle should be perpendicular to the IR..
Recumbent: The forearm should be medially rotated and the dorsal aspect of the hand should be placed on the patient's side. The epicondyle will be perpendicular to the IR without bending the elbow.

Mediolateral Projection

The patient's arm should be raised so that the injured arm is closest to the IR and the hand should be touching the injured area.

Distal Humerus Lateromedial Projection

The IR should be positioned between the axilla and the affected arm, the elbow should be flexed, and the thumb surface should be facing up.

Humerus Projection

The humerus can be imaged in upright or recumbent positions.
The upright and recumbent positions are used for proximal humerus projections.
Lateral recumbent positioning is used for the distal humerus.

Upright Positions

Upright AP projections require the patient to be either erect or seated with the arm slightly abducted and the hand supinated.
The humeral epicondyle should be parallel to the image receptor (IR).
The upright Lateral projection (lateromedial) requires the patient to be erect or seated, with the arm internally rotated.
The elbow should be flexed at 90 degrees with the hand placed palmar-side down on the hip.
The humeral epicondyle should be perpendicular to the IR.
The upright Mediolateral projection, requires a RAO or LAO position.
The patient's hand will be used to support the broken arm.

Recumbent Positions

Recumbent AP projections are taken with the patient supine, and the unaffected arm elevated.
The hand should be supinated, and the humeral epicondyle should be parallel to the IR.
Recumbent lateral (lateromedial) projections are taken with the patient supine.
The forearm should be medially rotated with the dorsal aspect of the hand placed on the patient's side.
The humeral epicondyle should be perpendicular to the IR without flexing the elbow.

Distal Humerus Positioning

For distal humerus projections, the patient will be placed in a lateral recumbent position.
The image receptor is placed between the axilla and the affected arm.
The elbow will be flexed, and the thumb surface should be facing up.

Specific Positioning for Suspected Fractures

When imaging a suspected fracture, additional considerations should be made for patient positioning.
Ensure the patient’s broken arm is supported by the broken arm or other assistive devices.
The positioning should reflect the patient’s overall comfort and mobility.

Upright Projections Summary

AP (Upright): Erect/ seated upright, arm slightly abducted, hand supinated, humeral epicondyle parallel to IR.
Lateral (Lateromedial) Upright: Erect/ seated upright, arm internally rotated, elbow flexed 90 degrees, hand palmar placed on hip, humeral epicondyle perpendicular to IR.
(Mediolateral) UPRIGHT: RAO/ LAO, patient's hand holding the broken arm.

Recumbent Projections Summary

AP (Recumbent): Supine, unaffected arm elevated, hand supinated, humeral epicondyle parallel to IR.
Lateral (lateromedial) (Recumbent): Supine, forearm medially rotated, dorsal aspect of hand placed on patient's side, humeral epicondyle perpendicular to IR without flexing the elbow.
Distal Humerus (Lateromedial Recumbent/ Lateral recumbent): Place IR between axilla and affected arm, elbow flexed, thumb surface up.

Humerus Projection - Upright

AP Projection:
- Patient is upright (standing or seated)
- Arm slightly abducted
- Hand is supinated
- Humeral epicondyle is parallel to the image receptor
Lateral Projection:
- Patient is upright (standing or seated)
- Arm is rotated internally
- Elbow is flexed 90 degrees
- Hand is placed palmar on the hip
- Humeral epicondyle is perpendicular to the image receptor
Mediolateral Projection:
- Patient is in a RAO or LAO position
- Patient’s hand is holding the broken arm

Humerus Projection - Recumbent

AP Projection:
- Patient is supine
- Unaffected arm is elevated
- Hand is supinated
- Humeral epicondyle parallel to the image receptor
Lateral Projection:
- Supine position with forearm medially rotated
- Dorsal aspect of hand placed on the patient's side
- Humeral epicondyle perpendicular to the image receptor (without flexing the elbow)

Distal Humerus Projection

Lateromedial Recumbent / Lateral Recumbent:
- Image receptor placed between the axilla and the affected arm
- Elbow is flexed
- Thumb surface is facing upward

Humerus Projection for Suspected Fracture

Use the appropriate projection and position based on the suspicion of a fracture.
Ensure proper positioning to visualize the area of interest for the most accurate diagnosis.

Humerus Projection

Upright and recumbent positions are used for humerus imaging.
AP and lateral projections are common for the humerus.

Upright Humerus Projections

AP projection: Arm slightly abducted, hand supinated, and humeral epicondyle parallel to IR.
Lateral projection: Arm rotated internally, elbow flexed 90°, hand placed palmar on the hip, and humeral epicondyle perpendicular to IR.
Mediolateral projection: Patient's hand holds the broken arm, performed in RAO or LAO position.

Recumbent Humerus Projections

AP projection: Patient supine, unaffected arm elevated, hand supinated, and humeral epicondyle parallel to IR.
Lateral projection: Patient supine, forearm medially rotated, dorsal aspect of hand placed on the patient's side.
Distal humerus (Lateromedial / Lateral recumbent): IR placed between axilla and affected arm, elbow flexed, and thumb surface up. This positioning is used when a fracture is suspected.

Positioning Considerations

The positioning for these projections is crucial to obtain optimal images of the humerus.
Ensure proper alignment of the humerus relative to the IR to demonstrate anatomical structures accurately.
Maintaining the correct degree of rotation and positioning of the arm and hand is essential for clear visualization of the bone.

1st Carpometacarpal Joint Imaging

Rafert/Long Modification: 15 degrees of angulation is used to provide a clearer view of the joint.
Folio Method: Addresses the specific needs of Skiers' Thumb by positioning the hand in supination with the thumb abducted and extended.
External Rotation (ER): Used to visualize the joint space and provide a more magnified view of the joint.
Lewis Modification: Primarily used for visualizing the trapezium and scaphoid bones, enhancing detail of the joint.
Skiers' Thumb: Involves a tear of the ulnar collateral ligament (UCL) of the thumb.

Imaging Projections of the Thumb

AP Projection: The hand is placed in a neutral position with the thumb abducted and extended.
PA Oblique Projection: The hand is positioned with the dorsal surface of the thumb parallel to the image receptor.
Lateral Projection: Used to clearly visualize the joint spaces and the sesamoid bones.
Lewis Method: Uses a 15-degree angle of the central ray (CR) for a more detailed view of the joint.
PA Projection: Provides a clear view of the 2nd and 3rd digits due to the central ray angulation.

Hand Imaging

PA Oblique Projection: The hand is placed in slight ulnar deviation with the thumb abducted.
Fan Lateral Projection: The hand is positioned with the dorsal surface resting on the image receptor.
Reverse Oblique Projection: Reveals the styloid process of the ulna, the triquetrum, and the pisiform bone.
Brewerton Projection: Uses a 45-degree angle between the hand and the image receptor.
Clements-Nakayama Projection: Employs a PA projection with computer software for determining bone aging.
Norgaard Method: Utilizes a PA projection of the hand for assessing bone age in children.
AP Oblique/Reverse Oblique Projection: Utilizes a 45-degree angle between the hand and the image receptor.
Lateral Projection of Hand in Extension: Provides a clear overview of the carpal bones and their articulations.
Tangential Oblique Projection: Used for visualizing the carpal bones and their articulations.
PA projection: Recommended for assessing the anatomy of the hand, including the carpal bones and articulations.
Greulich & Pyle Method: Involves a PA projection of the left hand with computer software for bone aging.
Lateral Projection (True Lateral): Place the hand in a true lateral position with the thumb extended.
Reverse Oblique Projection: Used to further investigate areas like the styloid process of the ulna, the triquetrum, and the pisiform bones.

1st CMC Joint Projections

Rafert/Long Modification: 15 degree angle for visualizing the 1st CMC joint.
Folio Method: Addresses positioning for Skiers' Thumb by hyperextending the thumb and rotating the hand.
External Rotation (ER): Used to optimize visualization of the 1st CMC joint by separating the joint spaces.
Lewis Modification: Hand is internally rotated and hyperextended, used for better visualization of the joint.
Robert Method: Arm is placed in a pronated position.
Skiers' Thumb: A common clinical presentation managed by imaging the 1st CMC joint; it involves a sprain or tear of the UCL.

Thumb Projections

PA oblique projection: Hand is placed in a lateral position, with the dorsal surface of the thumb parallel to the image receptor.
Lateral Projection: Primarily used to assess the joint space of the 1st CMC joint.
AP Projection: Hand is placed on its medial aspect and the CR is angled.
Lewis Method: Used for AP projection, focusing on the 2nd and 3rd digits. CR angled 15 degrees.
PA projection: Recommended when the patient cannot fully extend their digits.
Reverse Oblique Projection: The hand is placed with slight ulnar deviation and the thumb is abducted, primarily to assess the 1st CMC joint.

Hand Projections

AP Projection: Hand is placed flat.
Brewerton Projection: Hand is positioned at a 30-degree angle to the image receptor, used for evaluating rheumatoid arthritis.
Clements-Nakayama Projection: Evaluates the carpal bones by positioning the hand with the MCP joint at a 45-degree angle to the IR.
Fan Lateral (fan projection): Hand is positioned with slight ulnar deviation and the thumb abducted.
Greulich & Pyle Bone Age Evaluation: Uses a PA projection of the left hand with computer software.
Lateral Projection: Used to assess the 5th metacarpophalangeal joint, with the hand in a true lateral position.
Norgaard Method: Used for assessing fractures of the 5th metacarpal, employing a semi-supinated hand position.
PA Oblique Projection: Recommended for detecting early rheumatoid arthritis, using a 45° rotation.
Reverse Oblique Projection: Hand is placed with slight ulnar deviation and thumb abducted, focuses on the 1st CMC joint.
Tangential Oblique Projection: Used for visualizing the carpal bones, employing a 45-degree rotation.

Rafert/Long Modification

Rafert/Long Modification uses a 15-degree angle.
Provides a clearer image of the 1st carpometacarpal joint compared to the standard AP projection.

Folio Method

Folio Method specifically addresses the need for visualizing the scaphoid and trapezium in a straight, non-overlapped position.
Utilized for imaging Skiers' Thumb.

External Rotation (ER)

External rotation (ER) of the arm is used to position the thumb joint in a more open position for enhanced visualization.

Lewis Modification

Lewis Modification is utilized to optimize the visualization of the first metacarpophalangeal joint.

Robert Method

The Robert Method involves placing the arm in a neutral position.

Skiers' Thumb

A tear of the ulnar collateral ligament of the thumb.

PA Oblique Projection

The thumb is positioned with the dorsal surface of the thumb perpendicular to the imaging receptor for the PA oblique projection.
The hand is positioned in slight ulnar deviation with the thumb abducted.

Lateral Projection

Uses a lateral position with the thumb extended.

AP Projection

The hand is positioned with the thumb flexed 45 degrees for the AP projection of the 1st digit.
The central ray (CR) is angled 15 degrees towards the radial side for the Lewis method.

Norgaard Method

Method for assessing carpometacarpal joint stability and alignment.

Brewerton Projection

The hand is positioned at a 45-degree angle to the IR with the palm facing downward.

Clements-Nakayama Projection

Employs the use of an angled foam wedge to position the index finger in a 45-degree angle.

PA Oblique Projection of the Hand

The hand is positioned with the palm facing the image receptor with the thumb abducted and the MCP joints positioned at a 45-degree angle to the imaging receptor.

Lateral Projection of the Hand in Extension

The hand is positioned in a true lateral position, with the thumb extended.

Fan Lateral Projection

Places the hand in a lateral position with the thumb extended.

Tangential Oblique Projection

The hand is rotated 40-45° towards the ulnar surface.
Used to assess fractures of the 5th metacarpal
Requires a 45º foam wedge.

Reverse Oblique Projection

Used to assess fractures of the distal end of the radius.

Greulich & Pyle Method

Uses a PA projection of the left hand with computer software for bone aging.

PA Projection of the Hand

The hand is positioned in a semi-supinated position with the fingers extended.

AP Axial Projection

The hand is positioned at a 45-degree angle to the IR, with the palm facing downward.
Used for assessing rheumatoid arthritis.

1st CMC Joint Angulation

The Rafert/Long Modification utilizes a 15-degree angulation for the AP projection of the 1st CMC joint.
The Rafert/Long Modification emphasizes the magnified outline of the 1st CMC joint.
Folio Method specifically addresses the need for a clearer image of the 1st CMC joint compared to a standard AP projection.
The Folio method uses a position where the thumb is extended and the hand is relaxed.

Skiers' Thumb

Skiers' Thumb involves a UCL rupture.
The Folio Method is commonly used to image Skiers' Thumb.

1st CMC Joint Imaging Techniques

The Lewis Modification is specifically designed to improve visualization of the joint space and surrounding soft tissues.
External Rotation (ER) during imaging is to visualize the scaphoid and trapezium.
The Robert method involves placing the arm in a pronated position for the AP projection.
The Lewis Modification involves internal rotation of the arm and hyperextension of the hand.

General Thumb Imaging

The PA oblique projection of the thumb positions the hand so that the dorsal aspect of the thumb is parallel to the image receptor.
The lateral projection of the thumb is particularly useful for visualizing fractures and other injuries.
The lateral projection of the thumb is performed with the hand in a true lateral position.
The AP projection of the thumb is often used as an alternative to the PA projection when the patient is unable to extend their digits.
The AP oblique projection of the thumb is typically used to assess the first metacarpophalangeal joint (MCP).

Hand Projection Methods

The Norgaard method helps in assessing the alignment of the hand.
The Brewerton projection is specifically designed to assess rheumatoid arthritis in the hand.
The Clements-Nakayama is used specifically for assessing the carpal bones of the hand.
The Clements-Nakayama projection requires the hand to be abducted.
The PA oblique projection of the hand is recommended for evaluating the MCP joint.
Reverse Oblique Projection is used to investigate fractures of the metacarpals.
- The Reverse Oblique Projection places the hand in a semi-supinated position.
The Tangential Oblique Projection is used for assessing the 5th metacarpal fracture.
Norgaard method involves positioning the hand in a semi-supinated position.
The lateral projection of the hand in extension is commonly used to assess soft tissues and bony structures.
The Greulich & Pyle method is used for assessing the age of bone using a PA projection of the left hand.

Projection Specifics

The lateral projection is used for assessing the 5th metacarpophalangeal joint and demonstrating fractures and dislocations.
The Fan Lateral Projection utilizes the dorsal aspect of the hand being positioned against the IR.
The Brewerton Projection involves placing the hand in a semi-supinated position with the central ray (CR) directed towards the MCP joints at a 45-degree angle.
The AP oblique projection for assessing fractures of the 5th metacarpal involves positioning the hand in a 40-45° ulnar deviation.
The PA Oblique Projection with lateral rotation of the hand is used to visualize the 5th metacarpal and associated soft tissues.
The PA projection of the left hand with computer software is utilized in the Greulich & Pyle method for bone aging.

Projection of the Hand Applications

The PA projection of the hand assesses fractures and dislocations.
The Tangential Oblique Projection is used to detect early rheumatoid arthritis.
The Brewerton Projection utilizes a 30° angle between the hand and the IR.
The AP projection of the hand can be used to detect rheumatoid arthritis and fractures in the hand.
The AP axial projection is recommended for evaluating rheumatoid arthritis.

Rafert/Long Modification

Angulation of 15 degrees
Provides a clearer image of the 1st carpometacarpal joint compared to a standard AP projection

1st Carpometacarpal Joint

Commonly imaged for diagnosing Skiers' Thumb, a common clinical presentation
The Folio Method specifically addresses this condition

External Rotation (ER)

Used to open up the joint space for better visualization
Provides a clearer view of the 1st metacarpophalangeal joint

Lewis Modification

Uses internally rotated arm and hyperextended hand
Emphasizes the magnified outline of the 1st carpometacarpal joint
Useful for diagnosing UCL ruptures

Folio Method

Hand is positioned in a lateral position
Used for imaging Skiers' Thumb
Specifically modifies the positioning of the thumb to emphasize the joint

Robert Method

Arm is placed in a pronated position
Used for imaging the 1st carpometacarpal joint
The hand is extended and the thumb is abducted

PA Oblique Projection (Thumb)

Hand is positioned in slight ulnar deviation with the thumb abducted
Used to assess the 1st carpometacarpal joint for suspected joint injury

Lateral Projection (Thumb)

Hand is positioned in a lateral position with the dorsal surface parallel to the image receptor
Demonstrates the joint space and soft tissues surrounding the thumb
Used for assessing joint injury

AP Projection (Thumb)

Hand is placed on its medial aspect
Used to visualize the joint space and soft tissues of the thumb
Useful for assessing erosive changes associated with rheumatoid arthritis

2nd & 3rd Digital Recording

PA projection emphasizes recorded detail for the 2nd and 3rd digits
Provides a clearer view of the joints and surrounding structures of these digits

Norgaard Method

Used for assessing the age of bone
Utilizes a PA projection of the left hand with computer software

Stapczynski Method

Uses a 45-degree angle for the MCP joint
Recommended for assessing fractures of the base of the 5th metacarpal

Reverse Oblique Projection

Hand is rotated 40-45° towards the ulnar surface
Useful for investigating metacarpal fractures

Brewerton Projection

Hand is placed in a semi-supinated position with the ulnar border of the hand on the image receptor
Used for detecting early rheumatoid arthritis and erosive changes

Clements-Nakayama Projection

Also termed the fan lateral projection
Hand is positioned in a lateral position with the thumb extended
Primarily used to assess fractures of the 5th metacarpal

Lateral Projection (Hand)

Hand is positioned in a true lateral position with the thumb extended
Used for assessing the 5th metacarpophalangeal joint

PA Oblique Projection (Hand)

Hand is rotated 45 degrees towards the ulnar surface
Used for investigating fractures of the metacarpals

Angled Foam Wedge

Used for finger positioning during the PA oblique projection of the hand

Greulich & Pyle Method

Uses a PA projection of the left hand for bone aging analysis

Tangential Oblique Projection

Requires an angle of 45 degrees
Used for investigating metacarpal fractures

AP Axial Projection

Hand is positioned at a 45-degree angle to the image receptor
Used to evaluate erosive changes associated with rheumatoid arthritis

1st Carpometacarpal Joint Imaging

Rafert/Long Modification utilizes a 15-degree angulation of the central ray (CR) to enhance visualization of the 1st CMC joint.
This modification, compared to a standard AP projection, provides a clearer image of the 1st CMC joint.
Skiers' Thumb is a common clinical presentation managed by imaging of the 1st CMC joint, involving a UCL rupture.
Folio Method specifically addresses the issue of the thumb being flexed during the procedure, ensuring proper positioning.
External Rotation (ER) during imaging of the 1st CMC joint is performed to align the joint parallel with the image receptor.
Lewis Modification uses an internally rotated arm and a hyperextended hand.
The primary purpose of the Lewis Modification is to open up the joint space and improve visualization of the joint.
UCL rupture, osteoarthritis, and De Quervain's tenosynovitis are conditions that can be diagnosed using the AP projection methods outlined for the 1st CMC joint.
Folio Method utilizes the position where the patient's thumb is abducted and the hand is in a radial deviation position for imaging Skiers' Thumb.
The Robert Method involves positioning the arm in a pronated position.
Skiers' Thumb is specifically associated with a tear of the ulnar collateral ligament (UCL) of the thumb's 1st CMC joint.
Folio Method utilizes a modification of the hand position, specifically a radial deviation with thumb abduction, for imaging the thumb.
Rafert/Long Modification enhances the visualization of the 1st CMC joint by angling the central ray (CR) at 15 degrees.
PA Oblique projection is recommended when the patient cannot fully extend their digits, emphasizing the magnified outline of the 1st CMC joint.
The Lewis Modification is commonly employed to address a patient's inability to fully extend their digits, providing a clearer view of the joint space.
During the PA Oblique projection of the thumb, the hand is positioned with the thumb abducted and the fingers extended.
Lateral projection of the thumb focuses primarily on assessing the joint space, cartilage, and bone alignment.
Lateral projection requires the hand to be positioned in a lateral position, specifically with the thumb extended.
AP projection of the 1st digit necessitates the positioning of the hand with the thumb abducted and the fingers extended.
In the PA Oblique projection, the hand is positioned with the thumb abducted and the fingers extended.
PA Oblique projection is employed as an alternative when the patient cannot fully extend their digits.
During the Lewis method in the AP projection of the thumb, the central ray (CR) is angled at 15 degrees.
PA projection of the thumb focuses on emphasizing the details of the 2nd and 3rd digits.
Lateral projection focuses on the joint space and bone alignment of the thumb.
PA Oblique projection is recommended when the patient cannot extend their digits due to pain, swelling, or injury.
PA Oblique projection involves positioning the hand in slight ulnar deviation with the thumb abducted.
PA Oblique projection is used for a clear visualization of the trapezium, scaphoid, and 1st metacarpal relationship.
Lewis method employs a 15-degree angulation of the central ray during the AP projection of the thumb.
AP projection is primarily used when investigating suspected joint injury in the thumb.
The Lewis method involves a 15-degree angulation of the central ray (CR).
AP projection serves as an alternative to the PA projection when the patient experiences discomfort or limitations.
PA Oblique projection positions the hand with the thumb abducted and the fingers extended, maximizing the detail of the 1st CMC joint.
PA projection benefits the second and third digits by maximizing the visibility of their structures.
Lewis method involves a 15-degree angulation of the central ray (CR) during the AP projection of the thumb.
PA Oblique projection is recommended as an alternative when the patient experiences discomfort or limitations.
Lateral projection is performed by positioning the hand in a lateral position with the dorsal surface of the thumb parallel to the image receptor.
PA Oblique projection is recommended when patients experience difficulty extending their digits.
Lewis method, during the AP projection of the thumb, involves angling the central ray (CR) at 15 degrees.
PA projection emphasizes the detailed features of the 2nd and 3rd digits.
PA axial projection is specifically employed to evaluate erosive changes associated with rheumatoid arthritis in the hands.
AP axial projection recommends positioning the hand with the MCP joints at a 45-degree angle to the image receptor to show the joint space clearly.
Norgaard method focuses primarily on demonstrating fractures at the base of the 5th metacarpal.
Norgaard method positions the hand in a semi-supinated position, with slight radial deviation.
PA oblique projection utilizes a hand in a semi-supinated position with the thumb extended to better visualize the 1st CMC joint.
Lateral projection of the hand in extension involves positioning the hand with the thumb abducted and extended.
PA oblique projection at a 45-degree angle is recommended for detecting early rheumatoid arthritis.
PA oblique projection positions the MCP joint at a 45° angle to the image receptor, enhancing visualization.
Tangential Oblique Projection is characterized by the hand being rotated 40-45° towards the ulnar surface, aiming at assessing fractures at the base of the 5th metacarpal.
Lateral projection for the 5th metacarpophalangeal joint focuses specifically on the joint space.
Lewis recommendation involves placing the hand in a true lateral position, with the thumb extended, which ultimately reduces the amount of superimposition.
PA Oblique Projection with lateral rotation aims to visualize fractures of the metacarpals by allowing for better visualization of the joint space and bone alignment.
45º foam wedge is used to position the patient's hand in a 45-degree angle to facilitate the PA oblique projection.
Tangential Oblique Projection necessitates a rotation of the hand towards the ulnar surface with the thumb extended.
PA Oblique Projection is recommended for early detection of rheumatoid arthritis, highlighting the fine details of the hand's joints.
Reverse Oblique Projection is often utilized to investigate suspected bone fractures or injuries.
Lateral Projection of the hand in extension suffers from a limitation due to the potential for overlapping structures, making interpretations sometimes challenging.
Fan Lateral Projection involves positioning the hand in a fan-like lateral position with the fingers extended, resulting in a clear image of the entire hand.
PA axial projection is primarily employed for evaluating erosive changes associated with rheumatoid arthritis.
AP oblique projection involves positioning the hand with the ulnar border against the image receptor and the thumb abducted, used for assessing fractures of the 5th metacarpal.
Greulich & Pyle method uses a PA projection of the left hand with computer software for bone aging, commonly used in pediatric patients to assess bone maturity based on skeletal development.
PA projection serves to evaluate the overall structure and alignment of the hand bones and joints.
PA oblique projection positions the MCP joints at a 45-degree angle to the image receptor.
Clements-Nakayama projection is a specific projection method aimed at visualizing the carpal bones and their relationships with each other, particularly useful in evaluating carpal instability and fracture patterns.
Fan Lateral projection provides a clear image of the entire hand without superimposition of structures, which is particularly helpful for assessing multiple bones simultaneously.
PA Oblique Projection employs the use of an angled foam wedge to position the fingers properly during the procedure.
PA Oblique projection positions the hand with the ulnar border against the image receptor.
Lateral projection of the hand primarily localizes the bones in the hand.
Reverse Oblique Projection demonstrates the relationship between the carpal components and the radius.
PA axial projection is primarily recommended for detecting erosive changes associated with rheumatoid arthritis.
Norgaard method is best suited for demonstrating fractures at the base of the 5th metacarpal.
Greulich & Pyle method involves a 45-degree rotation of the left hand towards the ulnar side.
PA oblique projection necessitates a semi-supinated position of the hand, with the thumb extended.
PA Oblique Projection emphasizes the early detection and diagnosis of rheumatoid arthritis by visualizing the joints.
Clements-Nakayama projection is specifically designed for visualizing the carpal bones in a single projection.

1st Carpometacarpal Joint Projections

Rafert/Long Modification uses a 15-degree angle for clear visualization of the 1st CMC joint, providing a sharper image than standard AP.
Folio Method specifically addresses Skiers' Thumb by positioning the hand in ulnar deviation with the thumb abducted.
External Rotation (ER) during 1st CMC imaging optimizes visualization of the joint space, particularly useful for diagnosing UCL ruptures.
Robert Method requires the arm to be internally rotated for optimal 1st CMC joint imaging.
Skiers' Thumb is a common clinical presentation managed with 1st CMC imaging, involves a tear of the ulnar collateral ligament (UCL).
Folio Method specifically addresses Skiers' Thumb with hand positioning in ulnar deviation, thumb abducted.
Rafert/Long Modification at 15 degrees specifically amplifies the 1st CMC joint outline.
Lewis Modification emphasizes joint space visualization and clarifies the relationship of the trapezium to the 1st metacarpal.

Thumb Projections

PA Oblique projection positions the hand with the dorsum of the thumb parallel to the IR, showcasing the thumb's lateral aspect.
Lateral projection of the thumb focuses on the articulation between the 1st metacarpal and trapezium, highlighting joint space.
AP projection of the thumb, with the hand resting on its medial aspect, is typically used when the patient cannot extend their digits.
Lewis Method uses a 15° CR angle for the AP projection of the thumb, emphasizing detail of the 2nd and 3rd digits.
PA Oblique projection aligns the thumb perpendicular to the IR, visualizing the joint space between the 1st metacarpal and trapezium.
Lewis Method uses a 15° CR angle for the AP projection, enhancing 2nd and 3rd digit detail while maximizing joint space visualization.

Hand Projections

PA Oblique projection of the hand positions the MCP joints at 45° to the IR, best demonstrating fractures at the base of the 5th metacarpal.
Lateral projection of the hand in extension, with the dorsal surface of the hand parallel to the IR, is useful for visualizing the carpal bones, metacarpals, and phalanges.
PA Oblique projection of the hand, with the hand rotated 40-45° towards ulnar surface, best demonstrates early rheumatoid arthritis changes.
Reverse Oblique Projection of the hand emphasizes visualization of the 5th metacarpal base and proximal phalanx, aiding in fracture detection.
Fan Lateral projection of the hand, with the dorsal surface parallel to the IR but with the elbow at 90° with the ulnar side of the arm resting on the table, is useful for evaluating the hand.
Brewerton Projection position the hand at a 45° angle to the IR, with the dorsal aspect of the 5th metacarpal touching the cassette.
Clements-Nakayama projection, a modification of the PA oblique, aims to improve visualization of the scapholunate joint.
Lateral projection of the hand with the wrist in slight ulnar deviation, enhances visualization of the carpal bones and is useful for identifying arthritis.
Norgaard Method utilizes a PA projection of the left hand with computer software for bone aging assessments, particularly useful for diagnosing skeletal maturity.
PA projection of the hand, where the hand is placed in a semi-supinated position, is ideal for visualizing the carpal bones.
PA Oblique projection of the hand, with the MCP joints angled at 45° to the IR, is indicated for examining fractures at the base of the 5th metacarpal.
Clements-Nakayama Projection prioritizes visualization of the scapholunate joint, aiding in detecting injuries or instability in this area.
Fan Lateral projection of the hand, with the hand placed flat, wrist facing toward the IR, and the ulnar side resting on the table, minimizes distortion and enhances detail of the carpal bones, particularly useful for detecting subtle fractures or other abnormalities.

1st Carpometacarpal Joint Imaging

The Rafert/Long Modification for an AP projection of the 1st CMC joint uses a 15-degree angle.
The Folio Method provides a clearer image compared to a standard AP projection.
Skiers' Thumb is a common clinical presentation managed by imaging of the 1st CMC joint.
The Folio Method addresses flexion and extension of the thumb during its procedure.
External rotation (ER) is used to maximize visualization of the 1st CMC joint.
The Robert Method uses an internally rotated arm and the hand hyperextended.
The Lewis Modification focuses on improving visualization of the 1st CMC joint.
De Quervain's Tenosynovitis can be diagnosed using AP projection methods for the 1st CMC joint.
The Folio Method utilizes the thumb in an extended position for imaging Skiers' Thumb.
The Rafert/Long Modification angled at 15 degrees improves visualization of the 1st CMC joint.
The Folio Method emphasizes a magnified outline of the 1st CMC joint.
Skiers' Thumb involves rupture of the ulnar collateral ligament (UCL) of the 1st CMC joint.
During the Rafert/Long Modification, the hand is rested on its medial aspect.
ER is used to reduce superimposition of the scaphoid and trapezium.
Assessing bilateral MCP joint and metacarpal angles helps diagnose UCL ruptures.
The arm should be in a supinated position during the Robert Method.

Thumb Imaging
- Skiers' Thumb is a common condition associated with UCL rupture of the 1st CMC joint.
- The Folio Method utilizes a hyperextended thumb for imaging.
- The Rafert/Long Modification improves visualization of the 1st CMC joint.
- The PA oblique projection is recommended when the patient cannot extend their digits.
- The hand is positioned in palmar aspect during the PA oblique projection of the thumb.
- The lateral projection assesses joint space and soft tissue of the thumb.
- The lateral projection requires the hand in a lateral position.
- The hand is placed in a neutral position for the AP projection of the 1st digit.
- The hand is positioned in palmar aspect for the PA oblique projection of the thumb.
- The PA oblique projection is typically used when patients cannot fully extend their digits.
- The angle of CR for the Lewis method is 15 degrees.
- The PA projection emphasizes detail for the 2nd and 3rd digits.
- The lateral projection focuses on evaluating the soft tissues and joint space.
- The PA oblique projection is recommended when the patient cannot extend their digits.
- The PA oblique projection utilizes ulnar deviation with thumb abduction.
- The PA oblique projection helps visualize the joint space and soft tissues.
- The angle of CR for the Lewis method is 15 degrees.
- The PA projection emphasizes detail for the 2nd and 3rd digits.
- The PA oblique projection is used when patients cannot extend their digits.
- The PA projection offers a clearer view of the first metacarpophalangeal joint.
- The PA oblique projection requires ulnar deviation and thumb abduction.
- The PA projection is performed with the hand in extreme internal rotation.
- The central ray should be angled 15 degrees.
- The PA projection is used for suspected joint injury in the thumb.
- The angle of CR for the Lewis method is 15 degrees.
- The AP projection is recommended as an alternative to the PA projection when the patient cannot extend their digits.
- The hand is positioned palmar aspect for the PA oblique projection.
- The 2nd and 3rd digits benefit from increased recorded detail during specific projections.
- The central ray angle is 15 degrees for the Lewis method.
- The PA oblique projection is used when patients cannot extend their digits.
- The hand is placed in a lateral position with the thumb extended for the lateral projection of the thumb.
- The angle of rotation for the PA oblique projection is 45 degrees.
- The PA projection does not enhance visualization of the 1st carpometacarpal joint.
- The AP projection is used to assess the alignment and integrity of the thumb.
- The lateral projection positions the hand in a lateral position.
- The PA oblique projection is recommended for patients who cannot extend their digits.
- The central ray angle for the Lewis method is 15 degrees.
- The PA projection emphasizes detail for the 2nd and 3rd digits.
- The PA projection evaluates erosive changes associated with rheumatoid arthritis.
- The hand is angled 20-25 degrees during the AP axial projection for rheumatoid arthritis evaluation.
- The AP axial projection demonstrates fractures of the base of the 5th metacarpal.

Hand Imaging

The Norgaard method utilizes AP projection for bone age assessment.
The hand is in a semi-supinated position during the PA oblique projection.
For the lateral projection of the hand in extension, the dorsal surface of the hand is placed on the image receptor.
The PA oblique projection is specifically recommended for detecting early rheumatoid arthritis.
The MCP joint is angled 45° to the image receptor during the PA oblique projection.
The reverse oblique projection involves 40-45° ulnar rotation of the hand.
The lateral projection of the 5th metacarpophalangeal joint focuses on joint space and soft tissue visualization.
The Lewis Recommendation improves visualization of the carpometacarpal joint during the lateral projection.
The hand is placed in a true lateral position for the lateral projection of the hand with thumb extended.
The PA oblique projection with lateral rotation is used to assess metacarpal fractures.
The 45º foam wedge is used for the PA oblique projection of the hand.
The Tangential Oblique Projection requires 45° rotation.
The PA oblique projection is recommended for detecting early rheumatoid arthritis.
The Reverse Oblique Projection is used for fracture assessment of the 5th metacarpal.
The lateral projection of the hand in extension has limited visibility of the carpal bones.
For the Fan Lateral projection, the dorsal aspect of the hand is placed on the IR.
The PA Oblique Projection is used for detecting erosive changes associated with rheumatoid arthritis.
The hand is positioned 45° towards the ulnar side when performing the AP oblique projection for fracture assessment of the 5th metacarpal.
The Greulich & Pyle method assesses bone age using a PA projection of the left hand.
The PA projection of the hand is recommended for the detection of foreign bodies or displacement fractures.
The hand is placed perpendicular to the image receptor during the Brewerton projection.
The AP oblique projection for both hands is used to assess the 5th metacarpal.
The PA oblique projection is recommended for the early detection of rheumatoid arthritis.
The hand is placed parallel to the image receptor during the Brewerton projection.
The PA oblique projection of the hand is recommended for the assessment of the 5th metacarpal fracture.
The Greulich & Pyle method utilizes software analysis of a PA projection of the left hand for bone aging assessment.
The PA projection of the hand is used to evaluate alignment and integrity of the bones.
The Clements-Nakayama projection features MCP joints positioned at a 45° angle.
The Fan Lateral projection offers improved visualization of the carpal bones.
The PA Oblique Projection utilizes an angled foam wedge for positioning.
The hand is positioned 45 degrees towards the ulnar side during the PA oblique projection.
The lateral projection primarily localizes the soft tissues and joint spaces of the hand.
The reverse oblique projection demonstrates the lateral aspect of the hand.
The PA oblique projection is primarily recommended for detecting erosive changes associated with rheumatoid arthritis.
The AP oblique projection is best suited for demonstrating fractures at the base of the 5th metacarpal.
The Greulich & Pyle method utilizes a 45° rotation for the hand in the PA projection.
The hand is positioned semi-supinated during the PA oblique projection.
The PA oblique projection is emphasized for early detection and diagnosis of rheumatoid arthritis.
The Clements-Nakayama projection is used to assess carpal alignment and integrity.

Elbow Projections

AP Projection: Hand supinated, elbow extended, humeral epicondyle parallel to the IR.
Lateral Projection: Elbow flexed 90 degrees, hand in lateral position, humeral epicondyle to IR.
Suspected injury soft tissue Elbow: Elbow flexed 30-35 degrees.
FX & Dislocation of elbow: Elevated/displaced fat pads.
Posterior Fat pads seen: FX Jerced elbow (nursemaid).
AP Oblique Projection (medial rotation): Hand pronated, elbow fully extended, rotated 45 degrees medially from IR.
Coronoid Process: (ulna) free of radial head.
Trochlea: (humerus) (medial side)
AP Oblique Projection (lateral rotation): Hand supinated, elbow fully extended. Rotate elbow 45 degrees laterally to IR. Thumb and index finger touching the table.
Radial Head - Neck (lateral).
Capitulum: (humerus).

Alternatives

Lateral Elbow
AP Projection (partial flexion): Distal humerus.
AP projection (Partial flexion): Proximal forearm.

Patient Unable to Fully Extend Elbow:

Distal Humerus

AP Projection (Partial flexion): Hand supinated, elbow partially flexed, distal humerus placed on IR.

Proximal Forearm

AP Projection (Partial flexion): Dorsal surface of forearm placed on IR. Hand supinated, elbow partially flexed.

Acute Flexion - For FX & moderate Dislocation of Elbow

Distal Humerus

Jones Method (Acute flexion): Elbow fully flexed.
1. AP projection: Superimposed (AP arm, PA forearm).
2. PA projection: Superimposed bones of arm and forearm.
Olecranon process: More open elbow joint.

Proximal Forearm

2. PA projection (Acute flexion): Elbow fully flexed.

Radial Head Series

Lateral Projection (latero-medial): Flexed elbow 90 degrees, elbow in lateral position.
- 1. Hand supinated
- 2. Hand in lateral
- 3. Hand pronated
- 4. Hand internally rotated
Radial Head: 1 inch distal to Lateral epic.

Radial Head Varying Degrees of Rotation

Radial head facing Anteriorly: Supinated lateral.
Radial Head Facing Posteriorly: Pronated, internally rotated.

Radial Head Clearly Projected -> Elbow Trauma

Greenspan Norman Method: 45 degrees medially toward the shoulder.
Radial Head Holly Method: AP Projection of radial head.

Trauma Axial Lateral Projection Elbow

COYLE Method (axiolateral projection):
- Seated:
  - Hand pronated, radial head, elbow flexed 90 degrees.
  - Radial-Lateral: 45 degrees toward the shoulder.
  - Mid-elbow joint: 45 degrees cephalad, coronoid process medial.
- Supine:
  - IR vertical: Humeral epicondyles // to IR.
  - Hand facing anteriorly, coronal process, 80 degrees to elbow.
  - Radial Head - 90 degrees to elbow.
  - 45 degrees cephalad: Coronoid process, 45 degrees caudad.

CR & UT

Seated:
- Seat: 45 degrees toward shoulder.
- Lateral: 90 degrees flexion.
- Medial: 80 degrees flexion.
- Radial head: 90 degrees to elbow.
- Coronoid process: 90 degrees to elbow.
Supine:
- Sup: -45 degrees to CR.
- -45 degrees to CR.

Patient Can't Fully Extend Elbow For AP Med / Lal Oblique Traumatic Elbow Injury

Distal Humerus

PA Axial Projection (distal humerus):
- Seated, arm rested vertically against IR.
- Rest forearm // IR, hand supinated.
- Humerus, 75 degrees, forearm 15 degrees to CR.
- Ulnar Sulcus: groove b/n medial epicondyle & trochlea
- Rafert Long: AP oblique projection (distal humerus)
  - Demo of ulnar sulcus for ulnar nerve.
- Demo of: Epicondyles, trochlea, ulnar sulcus, olecranon fossa (humerus posterior).
- For Radiohumeral bursitis (Tennis Elbow): Lateral epicondylitic.
- To detect obscured calcifications in the ulnar sulcus.

Olecranon Process (proximal vina)

PA Axial Projection (proximal forearm): Seated, rest forearm // to IR.
- Humerus (arm): 45-50 degrees from forearm.
- Hand supinated: 20 degrees toward the wrist.
- Dorsum of olecranon process: Curved extremity and articular margin of the olecranon process.

Best Ways to Demonstrate Coronoid (ulna) & Trochlea:

AP Oblique Projection (Internal Rotation): (medial rotation).

Best Way to Demonstrate Radial Head, Neck & Capitulum:

AP Oblique Projection (external rotation): (lateral rotation).

Elbow Projection

AP Projection
- Hand supinated, elbow extended
- Humeral epicondyle // IR.
Lateral Projection
- Elbow flexed 90 degrees
- Hand in lateral position, humeral epicondyle to IR.
Suspected injury soft tissue Elbow
- Elbow flexed 30-35 degrees (partial flexion)
FX + D of elbow
- Elevated/displaced fat pads
- Posterior Fat pads seen: FX Jerced elbow (nursemaid)
AP Oblique Projection (medial rotation)
- Hand pronated, elbow fully extended
- Medially rotated 45 degrees from IR.
- Coronoid Process: (ulna) Free of radial head
- Trochlea: (humerus) (medial side)
AP Oblique Projection (lateral rotation)
- Hand supinated, elbow fully extended
- Rotate elbow 45 degrees laterally to IR.
- Thumb and index finger touching the table (1st or 2nd digit)
- Radial Head - Neck (lateral)
- Capitulum: (humerus)

Alternatives

Lateral Elbow
AP Projection (partial flexion)
- Distal humerus
- Proximal forearm

Pt can't fully Extend Elbow:

Distal Humerus

AP Projection (Partial flexion)
- Hand supinated, elbow partially flexed
- Distal humerus placed on IR.

Proximal Forearm

AP Projection (Partial flexion)
- Dorsal surface of forearm placed on IR.
- Hand supinated, elbow partially flexed.

Acute Flexion - FOR FX & moderate Dislocation of Elbow

Distal Humerus

Jones Method (Acute flexion): Elbow fully flexed
- 1.AP projection: Superimposed (AP arm, PA forearm)
- 2.PA projection: Superimposed bones of arm and forearm
- Olecranon process: More open elbow joint

Proximal Forearm

2.PA projection (Acute flexion): Elbow fully flexed

Radial Head Series

Lateral Projection (latero-medial): Flexed elbow 90 degrees, elbow in lateral position
- 1.Hand supinated
- 2.Hand in lateral
- 3.Hand pronated
- 4.Hand internally rotated
- Radial Head: 1 inch distal to Lateral epi.

Radial Head Varying Degrees Of Rotation

Radial head facing Anteriorly: Supinated lateral
Radial Head Facing Posteriorly: Pronated, internally rotated

Radial Head Clearly Projected -> Elbow Trauma

Greenspan Norman Method: 45 degrees medially toward the shoulder
Radial Head Holly Method: AP Projection of radial head

Trauma Axial Lateral Projection Elbow

COYLE Method (axiolateral projection): Seated
- Hand pronated, radial head, elbow flexed 90 degrees
- Radial-Lateral: 45 degrees toward the shoulder
- Mid-elbow joint: 45 degrees cephalad, coronoid process medial
Supine:
- IR vertical: Humeral epicondyles // to IR
- Hand facing anteriorly, coronal process, 80 degrees to elbow
- Radial Head - 90 degrees to elbow
- 45 degrees cephalad: Coronoid process, 45 degrees caudad

CR UT

Seated
- Seat: 45 degrees toward shoulder
- Lateral: 90 degrees flexion
- Medial: 80 degrees flexion
- Radial head: 90 degrees to elbow
- Coronoid process: 90 degrees to elbow
Supine:
- Sup: -45 degrees to CR
- -45 degrees to CR

Pt Can't Fully Extend Elbow For AP Med / Lal Oblique Traumatic Elbow Injury

Distal Humerus

PA Axial Projection (distal humerus): Seated, arm rested vertically against IR. Rest forearm // IR, hand supinated
- Humerus, 75 degrees, forearm 15 degrees to CR.
- Ulnar Sulcus: groove b/n medial epicondyle & trochlea
- Rafert Long: AP oblique projection (distal humerus)
  - Demo of ulnar sulcus for ulnar nerve.
- Demo of: Epicondyles, trochlea, ulnar sulcus, olecranon fossa (humerus posterior)
- For Radiohumeral bursitis (Tennis Elbow): Lateral epicondylitic
- To detect obscured calcifications in the ulnar sulcus.

Olecranon Process (proximal vina)

PA Axial Projection (proximal forearm): Seated, rest forearm // to IR
- Humerus (arm): 45-50 degrees from forearm
- Hand supinated: 20 degrees toward the wrist
- Dorsum of olecranon process: Curved extremity and articular margin of the olecranon process.

Best Ways to Demonstrate Coronoid (ulna) & Trochlea:

AP Oblique Projection (Internal Rotation): (medial rotation)

Best Way to Demonstrate Radial Head, Neck & Capitulum:

AP Oblique Projection (external rotation): (lateral rotation)

Elbow Projections

AP Projection: Used for the elbow joint with the hand supinated and the elbow extended. The humeral epicondyle should be parallel to the image receptor (IR).
Lateral Projection: Used to view the elbow joint with the elbow flexed 90 degrees, the hand in lateral position. The humerus epicondyle is aligned with the IR.
Suspected injury soft tissue Elbow: To see if the elbow is injured, the elbow is flexed 30-35 degrees (partial flexion) with a lateral projection.
FX + D of elbow: Fat pads are elevated or displaced in a fracture or dislocation of the elbow.
Posterior Fat pads seen: This indicates a "Jerced elbow" (nursemaid's elbow) also known as a radial head subluxation
AP Oblique Projection (medial rotation): Used to view the coronoid process and the trochlea. The hand is pronated, the elbow is extended, and the elbow is medially rotated 45 degrees from the IR.
- Coronoid Process: (ulna) should be clear of the radial head
- Trochlea: (humerus) on the medial side
AP Oblique Projection (lateral rotation): Used to view the radial head and neck, and the capitulum. The hand is supinated, the elbow is extended. Rotate the elbow laterally 45 degrees from the IR. The thumb and index finger should be touching the table.
- Radial Head - Located laterally
- Capitulum: (humerus)

Alternatives

Lateral Elbow: Can be used to assess the joint
AP Projection (partial flexion): Used to view the distal humerus
AP projection (Partial flexion): Used to view the proximal forearm

Pt can't fully Extend Elbow: Distal Humerus

AP Projection (Partial flexion): The hand is supinated, the elbow is partially flexed, and the distal humerus is placed on the IR.

Pt can't fully Extend Elbow: Proximal Forearm

AP Projection (Partial flexion): The dorsal surface of the forearm is placed on the IR. The hand is supinated, the elbow is partially flexed.

Acute Flexion - FOR FX & moderate Dislocation of Elbow: Distal Humerus

Jones Method (Acute flexion): The elbow is fully flexed.
- 1.AP projection: Superimposes the AP arm and PA forearm
- 2.PA projection: Superimposes the bones of the arm and forearm.
- Olecranon process: Makes the elbow joint more open

Acute Flexion - FOR FX & moderate Dislocation of Elbow: Proximal Forearm

2.PA projection (Acute flexion): With the elbow fully flexed.

Radial Head Series

Lateral Projection (latero-medial): The elbow is flexed 90 degrees and positioned laterally.
- 1.Hand supinated
- 2.Hand in lateral
- 3.Hand pronated
- 4.Hand internally rotated
- Radial Head: 1 inch distal on the Lateral epicondyle

Radial Head Varying Degrees Of Rotation

Radial head facing Anteriorly: Supinated lateral
Radial Head Facing Posteriorly: Pronated, internally rotated

Radial Head Clearly Projected -> Elbow Trauma

Greenspan Norman Method: The elbow is rotated 45 degrees medially towards the shoulder.
Radial Head Holly Method: AP Projection of the radial head

Trauma Axial Lateral Projection Elbow

COYLE Method (axiolateral projection): Patient is seated with:
- Hand pronated, radial head, elbow flexed 90 degrees.
- Radial-Lateral: Rotate 45 degrees toward the shoulder.
- Mid-elbow joint: Rotate 45 degrees cephalad, the coronoid process should be medial.
Supine:
- IR vertical: Humeral epicondyles // to IR
- Hand facing anteriorly, coronal process, 80 degrees to elbow
- Radial Head - 90 degrees to elbow
- 45 degrees cephalad: Coronoid process, 45 degrees caudad.

CR UT

Seated
- Seat: 45 degrees toward shoulder
- Lateral: 90 degrees flexion
- Medial: 80 degrees flexion
- Radial head: 90 degrees to elbow
- Coronoid process: 90 degrees to elbow
Supine:
- Sup: -45 degrees to CR
- -45 degrees to CR

Pt Can't Fully Extend Elbow For AP Med / Lal Oblique Traumatic Elbow Injury: Distal Humerus

PA Axial Projection (distal humerus): Patient is seated, arm rested vertically against IR. Rest forearm // IR, hand supinated.
- Humerus, 75 degrees, forearm 15 degrees to CR.
- Ulnar Sulcus: the groove between the medial epicondyle & trochlea
- Rafert Long: AP oblique projection (distal humerus) used for the ulnar nerve
  - Demo of: Epicondyles, trochlea, ulnar sulcus, olecranon fossa (humerus posterior)
- For Radiohumeral bursitis (Tennis Elbow): Used for lateral epicondylitic
- To detect obscured calcifications in the ulnar sulcus.

Pt Can't Fully Extend Elbow For AP Med / Lal Oblique Traumatic Elbow Injury: Olecranon Process (proximal vina)

PA Axial Projection (proximal forearm): Patient seated, rest forearm // to IR
- Humerus (arm): 45-50 degrees from forearm
- Hand supinated: 20 degrees toward the wrist
- Dorsum of olecranon process: Used to view the curved extremity and articular margin of the olecranon process.

Best Ways to Demonstrate Coronoid (ulna) & Trochlea:

AP Oblique Projection (Internal Rotation): (medial rotation)

Best Way to Demonstrate Radial Head, Neck & Capitulum:

AP Oblique Projection (external rotation): (lateral rotation)

Elbow Projections

AP Projection: Hand supinated, elbow extended. The humeral epicondyle should be parallel to the image receptor.
Lateral Projection: Elbow flexed 90 degrees, hand in lateral position. The humeral epicondyle should be parallel to the image receptor.
Suspected Injury Soft Tissue Elbow: Elbow flexed 30-35 degrees (partial flexion).
FX + D of elbow: Elevate the affected area.
Posterior Fat pads seen: May indicate a fractured elbow (nursemaid's elbow).
AP Oblique Projection (medial rotation): Hand pronated, elbow fully extended, medially rotated 45 degrees from Internal Rotation.
Coronoid Process: (ulna) This projection should allow for visualisation of the coronoid process free of the radial head.
Trochlea: (humerus) (medial side) This projection should allow for better visualization of the trochlea.
AP Oblique Projection (lateral rotation): Hand supinated, elbow fully extended. Rotate elbow 45 degrees laterally to Internal Rotation. Thumb and index finger touching the table (1st or 2nd digit).
Radial Head - Neck (lateral). This projection should allow for better visualization of the radial head and neck.
Capitulum: (humerus). This projection should allow for better visualization of the capitulum.

Alternatives

Lateral Elbow.
AP Projection (partial flexion): Distal humerus.
AP projection (Partial flexion): Proximal forearm.

Pt can't fully Extend Elbow

Distal Humerus

AP Projection (Partial flexion): Hand supinated, elbow partially flexed, distal humerus placed on IR.

Proximal Forearm

AP Projection (Partial flexion): Dorsal surface of forearm placed on IR. Hand supinated, elbow partially flexed.

Acute Flexion - FOR FX & moderate Dislocation of Elbow

Distal Humerus

Jones Method (Acute flexion): Elbow fully flexed.
- 1. AP projection: Superimposed (AP arm, PA forearm).
- 2. PA projection: Superimposed bones of arm and forearm.
- Olecranon process: Allows for a more open view of the elbow joint.

Proximal Forearm

2. PA projection (Acute flexion): Elbow fully flexed.

Radial Head Series

Lateral Projection (latero-medial): Flexed elbow 90 degrees, elbow in lateral position.
- 1.Hand supinated
- 2.Hand in lateral
- 3.Hand pronated
- 4.Hand internally rotated
- Radial Head: 1 inch distal to Lateral epicondyle.
Radial Head Varying Degrees Of Rotation
Radial head facing Anteriorly: Supinated lateral.
Radial Head Facing Posteriorly: Pronated, internally rotated.

Radial Head Clearly Projected -> Elbow Trauma

Greenspan Norman Method: 45 degrees medially toward the shoulder.
Radial Head Holly Method: AP Projection of radial head.

Trauma Axial Lateral Projection Elbow

COYLE Method (axiolateral projection): Seated
- Hand pronated, radial head, elbow flexed 90 degrees.
- Radial-Lateral: 45 degrees toward the shoulder.
- Mid-elbow joint: 45 degrees cephalad, coronoid process medial.
Supine:
- IR vertical: Humeral epicondyles // to IR.
- Hand facing anteriorly, coronal process, 80 degrees to elbow.
- Radial Head - 90 degrees to elbow.
- 45 degrees cephalad: Coronoid process, 45 degrees caudad.

CR UT

Seated
- Seat: 45 degrees toward shoulder.
- Lateral: 90 degrees flexion.
- Medial: 80 degrees flexion.
- Radial head: 90 degrees to elbow.
- Coronoid process: 90 degrees to elbow.
Supine:
- Sup: -45 degrees to CR.
- -45 degrees to CR.

Pt Can't Fully Extend Elbow For AP Med / Lal Oblique Traumatic Elbow Injury

Distal Humerus

PA Axial Projection (distal humerus): Seated, arm rested vertically against IR. Rest forearm // IR, hand supinated.
- Humerus, 75 degrees, forearm 15 degrees to CR.
- Ulnar Sulcus: groove b/n medial epicondyle & trochlea
- Rafert Long: AP oblique projection (distal humerus)
  - Demo of ulnar sulcus for ulnar nerve.
- Demo of: Epicondyles, trochlea, ulnar sulcus, olecranon fossa (humerus posterior).
- For Radiohumeral bursitis (Tennis Elbow): Lateral epicondylitic.
- To detect obscured calcifications in the ulnar sulcus.

Olecranon Process (proximal vina)

PA Axial Projection (proximal forearm): Seated, rest forearm // to IR.
- Humerus (arm): 45-50 degrees from forearm.
- Hand supinated: 20 degrees toward the wrist.
- Dorsum of olecranon process: Curved extremity and articular margin of the olecranon process.

Best Ways to Demonstrate Coronoid (ulna) & Trochlea:

AP Oblique Projection (Internal Rotation): (medial rotation).

Best Way to Demonstrate Radial Head, Neck & Capitulum:

AP Oblique Projection (external rotation): (lateral rotation).

Elbow Projections

AP Projection: Shows the humeral epicondyle when the hand is supinated and the elbow is extended.
Lateral Projection: Views the elbow when it is flexed 90 degrees, with the hand in lateral position. The humeral epicondyle should be aligned with the IR.
Suspected injury soft tissue Elbow: Use partial flexion of the elbow (30-35 degrees) for better visibility.
FX + D of elbow: Look for elevated or displaced fat pads, indicative of a fracture or dislocation.
Posterior Fat pads seen: This may suggest a "Nursemaid's elbow" (jerked elbow) injury.

AP Oblique Projections

AP Oblique Projection (medial rotation): Hand pronated, elbow extended, rotated 45 degrees medially from the IR. This shows the coronoid process of the ulna, free of the radial head.
AP Oblique Projection (lateral rotation): Hand supinated, elbow extended, rotated 45 degrees laterally from the IR. This demonstrates the radial head and neck, along with the capitulum of the humerus.

Alternatives to Standard Projections

Lateral Elbow: Another useful projection for elbow evaluation.
AP Projection (partial flexion): Used for visualizing the distal humerus or proximal forearm.

Patient Unable to Fully Extend Elbow

Distal Humerus

AP Projection (Partial flexion): Hand supinated, elbow partially flexed, distal humerus placed on the IR.

Proximal Forearm

AP Projection (Partial flexion): Dorsal surface of the forearm placed on the IR. Hand supinated, elbow partially flexed.

Acute Flexion (for FX & moderate Dislocation)

Distal Humerus

Jones Method (Acute flexion):
- AP projection: Superimposes the AP arm and PA forearm.
- PA projection: Superimposes the bones of the arm and forearm.
- Olecranon process: Provides a more open view of the elbow joint.

Proximal Forearm

PA projection (Acute flexion): Elbow fully flexed.

Radial Head Series

Lateral Projection (latero-medial):
- Flexed elbow 90 degrees, elbow in lateral position.
- 1.Hand supinated
- 2.Hand in lateral
- 3.Hand pronated
- 4.Hand internally rotated
- Radial Head: Located 1 inch distal to the lateral epicondyle

Radial Head Varying Degrees of Rotation

Radial head facing Anteriorly: Achieved with supinated lateral projection
Radial Head Facing Posteriorly: Achieved with pronated, internally rotated projection.

Radial Head Clearly Projected Following Elbow Trauma

Greenspan Norman Method: Used to clearly visualize the radial head.
Radial Head Holly Method: AP Projection of the radial head for better visualization.

Trauma Axial Lateral Projection Elbow

COYLE Method (axiolateral projection):
- Seated
  - Hand pronated, elbow flexed 90 degrees.
  - Radial-Lateral: CR angled 45 degrees toward the shoulder.
  - Mid-elbow joint: CR angled 45 degrees cephalad, visualizing the coronoid process medially.
- Supine
  - IR vertical: Humeral epicondyles parallel to the IR.
  - Hand facing anteriorly: Coronoid process is at 80 degrees to the elbow.
  - Radial Head: 90 degrees to the elbow.
  - 45 degrees cephalad: Visualizes coronoid process, with 45 degrees caudad.

CR Angulation for Trauma Axial Lateral Projection

Seated:
- Seat: Angled 45 degrees towards the shoulder.
- Lateral: Elbow flexed 90 degrees.
- Medial: Elbow flexed 80 degrees.
- Radial head: CR angled 90 degrees to the elbow.
- Coronoid process: CR angled 90 degrees to the elbow.
Supine:
- CR angled -45 degrees.

Patient Cannot Fully Extend Elbow (Traumatic Elbow Injury)

Distal Humerus

PA Axial Projection (distal humerus):
- Seated: Arm rested vertically against the IR. Forearm parallel to the IR, hand supinated.
- Humerus: 75 degrees, forearm 15 degrees to CR.
- Ulnar Sulcus: Demonstrates the groove between the medial epicondyle and the trochlea.
- Rafert Long: AP oblique projection of the distal humerus.
  - Used to assess the ulnar nerve.
- Demonstrates: Epicondyles, trochlea, ulnar sulcus, and the olecranon fossa (posterior humerus).
- Used to assess: Radiohumeral bursitis (Tennis Elbow). Also used to visualize obscured calcifications in the ulnar sulcus.

Olecranon Process (proximal ulna)

PA Axial Projection (proximal forearm):
- Seated
- Forearm: Rest parallel to the IR.
- Humerus: Angled 45-50 degrees from the forearm.
- Hand Supinated: Angled 20 degrees toward the wrist.
- Shows: The curved extremity and articular margin of the olecranon process.

Best Way to Visualize Coronoid (ulna) and Trochlea

AP Oblique Projection (Internal Rotation): (Medial rotation)

Best Way to Visualize Radial Head, Neck, and Capitulum

AP Oblique Projection (External Rotation): (Lateral rotation)

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Description

This quiz covers the various techniques used for imaging the 1st carpometacarpal joint (CMC), including the Robert Method and its modifications. It highlights the importance of proper hand positioning and external rotation in identifying arthritic changes and fractures. Test your knowledge on the correct protocols and indications for CMC joint imaging.

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Questions and Answers

What is the angle of the Rafert/Long Modification when performing an AP projection of the 1st carpometacarpal joint?

Which method provides a clearer image of the 1st carpometacarpal joint compared to a standard AP projection?

What is a common clinical presentation managed by imaging of the 1st Carpometacarpal joint?

What does the Folio Method specifically address during its procedure?

Which option describes the purpose of performing an external rotation (ER) during imaging of the 1st CMC joint?

Which modification uses an arm internally rotated and the hand hyperextended?

What is the primary purpose of the Lewis Modification during imaging of the 1st CMC joint?

Which of the following conditions can be diagnosed using the AP projection methods outlined for the 1st CMC joint?

What is the angulation used in the Rafert/Long Modification for the 1st carpometacarpal joint projection?

Which position is utilized in the Folio Method for imaging Skiers' Thumb?

During which projection method is the hand rested on its medial aspect?

What is a common reason for performing external rotation (ER) during the imaging of the 1st CMC joint?

What is the primary diagnostic purpose of assessing both bilateral MCP joint and metacarpal angles in the context of UCL ruptures?

During the Robert Method for imaging the 1st carpometacarpal joint, what position should the arm be in?

Which condition is specifically associated with the diagnosis of Skiers' Thumb?

What is the main modification applied in the Folio Method for imaging the thumb?

What effect does the Rafert/Long Modification have on the imaging of the 1st carpometacarpal joint?

Which projection method is recommended when the patient cannot extend their digits?

What position is the hand in for the PA oblique projection of the thumb?

What is the primary purpose of the lateral projection of the thumb?

Which projection method requires the hand positioned in lateral position for the thumb assessment?

How is the hand positioned for the AP projection of the 1st digit when assessing for joint injury?

What is the hand position for the PA oblique projection of the thumb?

Which projection is typically used when the patient cannot fully extend their digits?

What is the angle of CR for the Lewis method during the AP projection of the thumb?

Which projection emphasizes recorded detail for the 2nd and 3rd digits?

What is the primary focus of the lateral projection of the thumb?

What projection is recommended when the patient cannot extend their digits?

In which projection is the hand placed in slight ulnar deviation with the thumb abducted?

What is the purpose of the PA oblique projection of the thumb?

What is the angle of the central ray (CR) in the Lewis method during the AP projection of the thumb?

Which projection emphasizes recorded detail in the 2nd and 3rd digits?

What projection method should be used when a patient cannot extend their digits?

Which projection emphasizes a clearer view of the first metacarpophalangeal joint?

In which projection is the hand positioned in slight ulnar deviation while the thumb is abducted?

Which projection is performed with the hand in extreme internal rotation for assessing suspected joint injury?

What should be the angulation of the central ray for the Lewis method during the AP projection of the thumb?

Which projection is primarily used when assessing for suspected joint injury in the thumb?

What is the angle of the central ray (CR) in the Lewis method during the AP projection of the thumb?

In which situation is the AP projection recommended as an alternative to the PA projection?

What is the position of the hand during the PA oblique projection of the thumb?

Which digit(s) benefit from increased recorded detail during specific projections?

What is the recommended angle for the central ray during the AP projection of the thumb using the Lewis method?

Which projection method is used when a patient is unable to extend their digits?

In which position is the hand placed for the lateral projection of the thumb?

What is the angle of rotation for a PA oblique projection of the thumb?

Which of the following is NOT a benefit of the PA projection for the 2nd and 3rd digits?

What is the purpose of the AP projection of the thumb?

During which projection is the hand placed in a lateral position, with the dorsal surface of the thumb parallel to the image receptor?

Which projection is recommended for patients who cannot extend their digits?

What should be the angle of the central ray (CR) when using the Lewis method for the AP projection of the thumb?

Which projection emphasizes recorded detail for the 2nd and 3rd digits?

Which projection method is specifically used to evaluate erosive changes associated with rheumatoid arthritis?

What angle is recommended for the hand when performing the AP axial projection for rheumatoid arthritis evaluation?

Which projection is specifically aimed at demonstrating fractures of the base of the 5th metacarpal?

What is the primary purpose of the Norgaard method in hand imaging?

During which projection is the hand placed in a semi-supinated position?

What is the primary purpose of the PA oblique projection of the hand?

What is the correct positioning for the lateral projection of the hand in extension?

Which projection is specifically recommended to detect early rheumatoid arthritis?

What angle is recommended for the MCP joint during the PA oblique projection?

Which projection is characterized by the hand being rotated 40-45° towards the ulnar surface?

What is the primary focus of the lateral projection for the 5th metacarpophalangeal joint?

What advantage does the Lewis recommendation provide during the lateral projection?

In which projection is the hand placed in a true lateral position with the thumb extended?

What is the primary purpose of the PA Oblique Projection with lateral rotation of the hand?

Which projection would be used to investigate fractures of the metacarpals?

In what scenario would the 45º foam wedge be utilized?

What is the angle of rotation required for the Tangential Oblique Projection?

Which projection method is recommended for detecting early Rheumatoid Arthritis?

What is a key clinical indication for using the Reverse Oblique Projection?

What disadvantage is associated with the Lateral Projection of the hand in extension?

What is the recommended hand position for the Fan Lateral projection?

Which projection is primarily utilized for detecting erosive changes associated with rheumatoid arthritis?

What is the recommended position for the hand when performing the AP oblique projection to assess fractures of the 5th metacarpal?

Which method is recommended for assessing the age of bone using PA projection of the left hand?