Week 5: Upper Extremity

Essential Projections for Hand Radiography

• Standard collimation includes a radiation field of 1 inch (2.5 cm) on all sides of the hand, extending 1 inch (2.5 cm) proximal to the ulnar styloid.

PA Hand Projection

• Patient position involves sitting at the radiographic table, adjusting height to rest the forearm on the table.
• Palmar surface placed on the IR
• Forearm should be on the table
• Digits should be extended and separated to prevent soft tissue overlap
• The third MCP joint must be centered to the IR in the part position.
• CR is perpendicular to the third MCP joint.

PA Oblique Hand Projection

• The CR is perpendicular to the third MCP joint.
• Forearm and palmar surface are on the table.
• Palm is rotated away from the IR until the MCP joint forms a degree angle of 45.
• Digits should be supported with sponge or parallel to the IR
• Support demonstrates IP joints and prevents foreshortening of phalanges.
• MCP joints must be centered in the center of IR

Lateral Hand Projection

• Forearm is on the table.
• Elbow is flexed 90 degrees.
• Hand rests on medial surface (thumb side up).
• Known as the lateromedial projection
• Radial and ulnar styloids must be superimposed and perpendicular to the IR.
• Perform with the palmar surface perpendicular to IR
• Digits 2 to 5 are extended (superimposing the phalanges).
• With the first digit abducted to right angle to the palm
• Ensure the MCP joints are centered to the IR.
• CR is perpendicular to the second MCP joint

Fan Lateral Hand Projection

• Forearm is on the table with the elbow flexed at 90 degrees.
• Hand is resting on its medial surface (thumb side up).
• Known as the lateromedial projection
• Ensures radial and ulnar styloids are superimposed and perpendicular to the IR.
• Perform with the palmar surface perpendicular to the IR.
• Ensure the digits are fanned with phalanges individually separated
• Ensure that MCP joints are centered to the IR.
• CR is perpendicular to the second MCP joint

PA Hand Evaluation Criteria

• Look for evidence of proper collimation.
• Ensure the anatomy from the fingertips to the distal radius and ulna are visible
• Slight separation of digits without soft tissue overlap must be present
• No rotation should be visible
• Metacarpal and phalangeal bodies must have equal concavity on both sides
• Soft tissue amounts should be equal on both sides of phalanges.
• If visualized, fingernails must be in the center of each distal phalanx
• Equal distance should appear between the metacarpal heads
• MCP and IP joints must appear open, indicating a flat hand on the IR
• Bony trabecular detail and surrounding soft tissues must be visible

PA Oblique Hand Evaluation Criteria

• Ensure that there is evidence of collimation
• Look for anatomy from fingertips to distal radius and ulna
• Note that digits are separated slightly and have no soft tissue overlap
• Look for 45 degree rotation of anatomy
• Metacarpal bodies 2-5 should show amounts of decreasing separation, with the second and third metacarpals having the greatest separation
• Partial superimposition of the 3rd, 4th and 5th metacarpal heads and bases is a must
• MCP joints must be open
• Open IP joints should be present when the digits are positioned parallel to the IR
• Observe bony trabecular detail and surrounding soft tissues

Lateral Hand Evaluation Criteria

• Observe: proper collimation, anatomy visibility from fingertips to distal radius and ulna, and extended digits.
• Ensure the hand is in in a true lateral position
• Note that superimposed phalanges are each seen individually in the fan lateral view
• Then ensure superimposed metacarpals and distal radius with ulna.
• Thumb should be free of motion and superimposition.
• Bony trabecular detail and surrounding soft tissues must be present

AP Oblique Norgaard Method

• Involves that patient to be in ball-catcher’s position
• Patient needs be seated at end of table
• Hands need to be placed on a 45 degree angle from the IP
• CR must be perpendicular to point midway to both hands at the level of MCP joints
• Structures shown include a 45 degree oblique projection of both hands
• Used for detection of rheumatoid arthritis
• Check for proper collimation and side marker placed clear indicating the anatomy of interest
• Ensure visualization of both hands in their entirety and metacarpal heads and proximal phalangeal bases free of superimposition

Essential Wrist Projections

• PA
• Lateral
• PA oblique
• PA projection in ulnar deviation position
• Scaphoid; PA axial (Stecher method)
• Carpal canal, Tangential (Gaynor-Hart method)

Wrist Essential Projections

• Position patient at the end of the radiographic table
• Align shoulder, elbow, and wrist joints in the same plane
• Achieve collimation using a radiation field 2.5 inches (6 cm) proximal and distal to the wrist joint and 1 inch (2.5 cm) on the sides

PA Wrist Projection

• Upper extremity rests on the table
• Position the entire upper extremity in the same plane.
• Flex the elbow 90 degrees.
• Place the wrist in the center of the IR.
• Slightly flex the digits to place the wrist closer to the IR.
• CR is directed perpendicular to the midcarpal area.

Lateral Wrist Projection

• Upper extremity rests on the table
• Position the entire upper extremity in the same plane.
• Flex the elbow at 90 degrees.
• Forearm and wrist rests on the medial surface (lateromedial projection)
• Radial and ulna styloid need to superimposed and perpendicular to the IR.
• CR is directed perpendicular to the wrist joint.

PA Oblique Wrist

• Position the upper extremity as previously described for other wrist projections.
• From the lateral position, rotate the palmar surface toward the IR until the wrist forms a 45-degree angle with the IR.
• From pronated position, the palmar surface is rotated to face away from IR until wrist forms same angle with IR.
• Support the wrist with a 45-degree wedge sponge.
• Direct the CR perpendicular to the midcarpal area, distal to the radius

PA Projection in Ulnar Deviation

• Upper extremity rests on the table (axilla must be in contact), placing the entire arm in the same plane.
• Elbow must be flexed at 90 degrees.
• Wrist must be placed in the center of IR.
• Flex digits slightly to place the wrist closer to the IR.
• Without moving forearm, rotate the hand outward until the wrist is in extreme ulnar deviation.
• Direct the CR perpendicular to scaphoid.

PA Axial Scaphoid (Stecher Method)

• Place upper extremity resting on the table (axilla in contact) to place entire upper extremity in the same plane.
• Wrist must be placed at the center of the IR.
• Adjust the IR, ensuring finger end is elevated at a 20-degree angle with support.
• The wrist may be placed in ulnar deviation for this projection.
• CR is perpendicular to the table and enters at scaphoid, and can be angled at 20 degree towards the elbow if there is no available support for the IR

Tangential Carpal Tunnel (Gaynor-Hart Method)

• Forearm rests on the table and the arm is aligned parallel to the long axis of the table.
• Hyperextend the wrist to place long axis of hand as vertical as possible
• IR needs to be centered at the joint level of the radial styloid.
• Digits need to be grasped with the opposite hand to maintain extended position
• Gently rotate the hand towards the radial side.
• CR is angled to 25-30 degrees toward the palm of the hand (elbow)
• Enters approx. 1 inch (2.5 cm) distal to the base of the third metacarpal.
• Radiation field to 1 inch (2.5 cm) on the three sides of the shadow of the wrist must be collimated.

Evaluation Criteria for PA Wrist

• Evidence of proper collimation.
• Visible distal radius and ulna, carpals, and proximal half of the metacarpals.
• Digits can't have excessive flexion that overlap and obscure the metacarpals.
• No rotation radius ulna
• Visualization of an Open radioulnar joint space
• Presence of bony trabecular detail and surrounding soft tissues.

Evalution Criteria for Lateral Wrist

• Demonstrate the evidence of proper collimation
• Exhibit the distal radius and ulna, carpals, and proximal half of metacarpals in the image
• Depicts a superimposed distal radius and ulna.
• Notes of superimposed metacarpals
• Display the bony trabecular detail and soft tissue of the wrist.

PA Oblique Wrist Evaluation

• Ensure proper collimation.
• Distal radius and ulna, carpals, and proximal half of metacarpals must be seen and easily identifiable.
• Look for 45-degree rotation of the anatomy.
• Note that Slight interosseous space between the third, fourth, and fifth metacarpal bodies, as well as slight overlap of the distal radius and ulna
• With carpals located on lateral side of wrist.
• Confirm the trapezium and distal half of the scaphoid without superimposition and open trapeziotrapezoid and scaphotrapezial joint space.
• Confirm the bony trabecular detail and soft tissues.

Ulnar Deviation PA Projection Criteria

• Ensure proper collimation
• Verify radius/ulna, carpals, and proximal metacarpals seen
• Adjacent articulations of scaphoid viewed open
• Rule out rotation
• Verify max ulnar deviation is detected and detail of trabecular bone

Evalution Criteria for PA Axial Scaphoid

• Must demonstrate proper collimation.
• Verify distal radius and ulna, carpals, as well as proximal half of Metacarpals can be viewed in image
• adjacent sides of the scaphoid can be viewed opened
• No rotation detected
• Note presence detail in the bony trabecular

Tangential Carpal Tunnel Evalution

• Perform test to ensure that the collimation is precise
• Carpal bones must be organized arching
• Pisiform bone and detail has been set free
• Hook of the Hamate bone can be extracted
• Bony and inner soft tissued details are both extracted

Anatomy of Forearm

• Forearm consists of two long bones: the ulna and radius.
• Ulna is on the medial side
• Radius is on the lateral side

Anatomy of Ulna

• Olecranon process is proximal and posterior.
• Coronoid process is proximal and anterior.
• Styloid process is distal.

Radial Anatomy

• Radial head is proximal.
• Radial tuberosity is proximal.

Elbow Joint

• It is a proper joint constituted of radioulnar, humeroulnar and humeroradial joints
• These joints are encased in one single capsule

Anatomy: Humerous

• It's a long bone that is located at the upper arm
• Its head articulates with scapula( shoulder joint)
• End is responsible for elbow joint

Proximal Humorous

• Constituted of head, anatomic neck, surgical neck, greater tubercle and lesser tubercle

Distal Humorous

• Constituted of Medial epicondyle, Lateral epicondyle, Trochlea, Capitulum, Coronoid fossa, and the Olecranon fossa ( posterior).

Patient Preparation Guidelines for Upper Extremity Radiography

• Remove artifacts from the anatomy of interest, such as watches, rings, and bracelets
• For humerus examinations, female patients should remove their bra and put on a gown

General Patient Position Guidelines to Perform Upper Extremity Radiography

• Images of forearm and elbow are taken with ambulatory patients seated at the end of the x-ray table with the upper limb in the same plane as the shoulder.
• Patient's affected extremity is required to stay in contact with the IR positioned so they can get an exact shot of a shoulder.
• For nonambulatory patients- alter to allow correct shot of anatomy of patient in bed or in a supine position

General Patient Guidelines for Humerous Imaging

• Obtain shot of humerus from patients that sit, recline or stay standing at the radiographic machine.

Guidelines for SID on Humerous Imaging

• Most common and recommended IR sizes and radiation field parameters for forearm, elbow, and humerus procedures is required when imaging.
• Try to use as much of the area required and collimate in as much as the area isn' t in close usage.
• Always set the source to area in question being extracted

Importance of ID Markers in Radiography

• Right and left side must always be correctly noted on the extracted image.
• Never digitally annotate for position the correct side on set of scans, correct side

Radiation Protection Guidelines

• Always cover the reproductive organs
• Collimate correctly so the correct factors always protect the patient as always.

Guidelines for Patients

• Demonstrate/Explain procedures to patients
• Give constant feedback to maintain correct positioning of area to be extracted.
• Suspend respiration upon exposure

Essential projections: Elbow

• Includes AP
• Includes Lateral
• Includes AP oblique (medial rotation position, ,lateral Rotation position)
• includes Partial Flexion that will make it distal/ proximal
• includes Axiolateral, or Coyle Method

Essential Elbow: Patient Position

• Seat the patient nearest radiographic machine as possible to get more details.
• Make necessary ajustments so as to align the hummerus and elbow joint can be viewed.
• Direct at radiation for 3 inches at a level proximated at 8 cm, also put beam approximately cm to sides

AP Elbow

• Place upper arm at posterior plane for contact
• Elbow in extension position and hand in supinated position
• Area in question needs to be centered or at the middle of IR.
• Make humerous parallel side with the IR
• Direct radiation Perpendicularly to the elbow

Lateral Elbow

• The extremity needs to in line where long side is in contact.
• Make the elbow is bent into 90' corner and the elbow has been set exactly in middle.
• Forearm has been recline to ulnar side to maintain
• Set the elbow and all area surrounding, so that the radiation is directly given at it.
• humerous position perpendicular to it
• CR and the sides must have adequate exposure in this process.

AP Oblique Elbow- Medial Rotation Position

• Put elbow in extended position
• Set elbow right to the IR or middle center of it
• Internally pronate hand and center it at the surface
• Direct perpencidular CR right in elbow

AP Oblique Elbow-Rotational Position

• Extent arm so elbow is in place
• set elbow to the to the exact spot where there's
• Have all areas that need to be marked to be touched at where they need to be at.
• perpenciular CR aimed in same place

AP Elbow-Distal Humerus-Partial Flexion Position

• Can be performed so it replaces the AP projection of arm from not exending the joint at right position.
• Extract all sides that radius may superimpose and all radius joints.
• CR perpendicular the side that contains the elbow

Evaluation Criteria for AP Forearm

• Document and note all the precise areas.
• Verify all key parts from the radius can be seen or can be noticed from the distal points.
• Rule out elongations or foreshortenings
• elbow area open for observation

Review of Lateral: Forearm

• Verify at full side the elbow and the wrist
• Radius and ulna that superimpose must be checked correctly with all area sides extracted.
• humerous side all must be marked to the anterior position
• make elbow 90' position too

Evaluation of Criteria- Elbow

• rule out all rotation errors/ make humerous perpendicular to area all needs to be in perfect equal side
• area surrounding joint to be extract
• no deviation

Coyle Evaluation- Radius

• Open joints, elbows fully bent at 90' degree view
• neck area free of super impostiiton
• The tube needs to be aligned correctly at every axis
• the bony view of the sides

AP - Evaluate

• The tube position needs to correct with the bony alignment
• radius is not superimpose