Image Evaluation – Upper Limb (hand, fingers, thumb, wrist, scaphoid) PDF

Image Evaluation – Upper Limb (hand, fingers, thumb, wrist, scaphoid)  IMAGING PARAMETERS Source Image Distance 110 cm Grid No Focal Spot Small/ Fine Kilovoltage (kV) Range 55 – 65 Patients Preparation Remove...

Image Evaluation – Upper Limb (hand, fingers, thumb, wrist, scaphoid)  IMAGING PARAMETERS Source Image Distance 110 cm Grid No Focal Spot Small/ Fine Kilovoltage (kV) Range 55 – 65 Patients Preparation Remove all opacities around the area of interest. Prepare the x-ray room. Get ready non-opaque sponges, sandbags, Imaging Receptors (IR), anatomical markers etc. Patients Positioning Patient is seated at the end of the table. Elbow extended or flexed as appropriate. Hand and forearm correctly placed on the IR. If patient is erect, anatomy should be correctly placed on the IR. Centering Central Ray perpendicular to the centering point of the specific anatomy. Imaging Receptor Use appropriate IR where applicable Long axis of anatomy should be parallel to long axis of IR and x-ray beam. Clinical Indications Fractures, dislocations, or foreign body of the phalanges, metacarpals and all joints of the hand Pathological processes such as osteoporosis and osteoarthritis Hand 1. Distal Phalanx of the 10. Carpo-metacarpal index finger joint 2. Middle phalanx of the 11. Trapezium index finger 12. Trapezoid 3. Proximal phalanx of the index finger 13. Capitate 4. Distal phalanx of the 14. Hamate thumb 15. Scaphoid 5. Proximal phalanx of the 16. Lunate thumb 17. Pisiform 6. Sesamoid 18. Triquetrum 7. Distal interphalangeal joint of the little finger 19. Radial styloid process 8. Proximal 20. Ulna styloid process interphalangeal joint of the little finger 9. Metacarpophalangeal joint of the little finger PROJECTIONS  Hand – Dorsi-Palmer (DP)/ Postero-Anterior (PA) Projection: Dorsi-Palmer Positioning: Patient seated at the end of the table, hand pronated, palmer surface in contact with IR, separate fingers. Centering: CR perpendicular to the 3rd MCP joint Anatomy Demonstrated: DP projection of the entire hand with about 2.5cm distal forearm should be visible. Image Criteria: Soft tissue outlines of the index to the little phalanges are uniform Equal mid shaft concavity is seen on both sides of the phalanges and MCs of the index to little fingers IP, MCP, CM joints are demonstrated as open spaces Phalanges are demonstrated without foreshortening The thumb demonstrates a 45 degree PA oblique projection No soft tissue overlap from adjacent fingers CR and center of collimation field should be to the MCP joint of the middle finger  Hand – Doris-Palmer/ PA Oblique Projection: Dorsi-Palmer Oblique Positioning: Patient seated at the end of the table, hand pronated, palmer surface in contact with IR, separate fingers. Centering: CR perpendicular to the 3rd MCP joint Anatomy Demonstrated: DPO projection of the entire hand with about 2.5cm distal forearm should be visible. Image Criteria: There is no soft tissue overlap from adjacent fingers Index to little MC midshafts demonstrate more concavity on one side than on the other The thumb and index MC heads are not superimposed The middle to little MC heads are slightly superimposed, and only a small space is presented between the ring and the little MC midshafts IP and MCP joints are demonstrated as open spaces Phalanges are demonstrated without foreshortening The thumb is in a DPO projection The middle MCP joint is at the center of the exposure field  Hand – Lateral Projection: Lateral Positioning: Patient seated at the end of the table, rotate the hand and wrist in a true lateral position with the index to little MCPJ centered to the IR. Extend fingers and abduct thumb Centering: CR perpendicular to the 2nd MCP joint Anatomy Demonstrated: Lateral projection of the entire hand with about 2.5cm distal forearm should be visible. Image Criteria: The hand and wrist should be in a true lateral position The radius and ulna are superimposed Metacarpals and phalanges are superimposed and extended The phalanges not foreshortened Index to little MC midshafts demonstrate more concavity on palmer aspect IP joints are open Thumb demonstrated without superimposition  Thumb – Antero-Posterior (AP) Projection: Lateral Positioning: This can be done erect for better patient comfort. If seated, the patient backs the x-ray table and extends arm until posterior aspect of the thumb is resting on the IR. Align thumb with long axis of IR Rotate the arm internally until the thumb is in true AP position Centering: CR perpendicular to the 1st MCP joint Anatomy Demonstrated: Distal and proximal phalanges, MC of the thumb, trapezium and associated joints should be visible. Image Criteria: Concavity on both sides of the phalanges and MC midshaft is equal There is equal soft tissue on each side of the phalanges IP, MCP, CM joints are open The phalanges not foreshortened MCP joint is at the center of the exposure field Phalanges, MC and CM joints are included  Thumb – Lateral Projection: Antero-Posterior Positioning: Patient seated at the end of the table. The hand pronated and resting on the IR, the thumb is abducted, with the fingers slightly arched. Then rotate the hand slightly until the thumb is in a true lateral position. Centering: CR to the MCPJ of the thumb Anatomy Demonstrated: Distal and proximal phalanges, thumb MC, trapezium and associated joints should be visible in the lateral position Image Criteria: Concave-shaped anterior surface of the proximal phalanx and thumb MC Relatively straight posterior surfaces of the proximal phalanx and thumb MC There is equal soft tissue on each side of the phalanges IP, MCP, CM joints are open The phalanges not foreshortened MCP joint is at the center of the exposure field Phalanges, MC and CM joints are included  Fingers – Dorsi-Palmer/ PA (index to middle fingers) Projection: Dorsi-Palmer/ PA (index to little fingers) Positioning: Patient seated at the end of the table. Hand and forearm resting on the table. Pronate hand with fingers extended. Center and align long axis of affected finger to long axis of IR. Separate adjoining fingers from affected finger. Centering: CR perpendicular to PIP Anatomy Demonstrated: Distal, middle and proximal phalanges, distal metacarpals and associated joints. Image Criteria: Soft tissue width and midshaft concavity are equal on both sides of the phalanges No soft tissue overlap from adjacent digits IP and MCP joints are open The phalanges are not foreshortened The PIP is at the center of the exposure field  Fingers – Lateral Projection: Lateral Positioning (index and middle): The hand is rotated until the lateral aspect of the index finger is in contact with the IR Positioning (little and ring): The hand is placed in the lateral position Unaffected fingers are flexed to avoid superimposition. Align and center finger to long axis of IR Centering: CR perpendicular to PIP Anatomy Demonstrated: Lateral views of the distal, middle and proximal phalanges, distal metacarpals and associated joints. Image Criteria: Soft tissue width and midshaft concavity are unequal on both sides of the phalanges No soft tissue overlap from adjacent digits IP and MCP joints are open The phalanges are not foreshortened The PIP is at the center of the exposure field Review Images Review Images Wrist 1. Proximal metacarpal 14. Triquetrum 2. Carpo-metacarpal joint 15. Pisiform 3. Trapezoid 16. Capitate 4. Trapezium 17. Hamate 5. Scaphotrapezoid and 18. Hook of hamate scaphotrapezium joint space 6. Scaphoid 7. Radial styloid process 8. Radioscaphoid and radiolunate joint 9. Lunate 10. Radius 11. Ulnar 12. Radioulnar joint 13. Ulnar styloid process  PROJECTIONS PA Lateral  Wrist – Dorsi-Palmer (DP) / Postero-Anterior Projection: DP/ PA (Dorsi-Palmer (DP) / Postero-Anterior) The intercarpal, radiocarpal, distal radioulnar and carpometacarpal joint spaces are aligned closely and evenly Positioning: Patient seated at the end of the table with the hand forearm extended. Drop shoulder so that shoulder, elbow and wrist are on the same horizontal plane. Align and center long axis of hand and wrist to IR With hand pronated, arch hand slightly to place wrist and carpal area in close contact to CR. Centering: Midway between the radius and ulna styloid process Anatomy Demonstrated: Mid-metacarpals, and proximal metacarpals; carpals; distal radius and ulna; associated joints. Image Criteria: Radial styloid process is in profile laterally Radioulnar joint is open Superimposition of the metacarpal bases Radioscaphoid and radiolunate joints are closed Second through fifth CM joint spaces are open Scaphoid is slightly foreshortened Long axis of the middle MC and the mid-forearm are aligned Carpal bones are at the center of the exposure field  Wrist – Lateral Projection: Lateral Positioning: Patient seated at the end of the table with arm and forearm resting on the table. Align and center hand and wrist to long axis of IR, adjust hand and wrist to a true lateral position, with fingers extended. Centering: central ray over the radial styloid process Anatomy Demonstrated: Distal radius and ulnar, carpals and at least mid MC area are visible. Image Criteria: Pronator fat stripes are visible Ulnar styloid is demonstrated in profile posteriorly Anterior aspects of the distal scaphoid and pisiform are aligned Thumb is parallel with the forearm Trapezium is demonstrated without superimposition of the first proximal MC Carpal bones are demonstrated at the center of the exposure field Scaphoid  SCAPHOID DP/PA UD 30˚ DP/PA UD  Scaphoid – Dorsi-Palmer with Ulna Deviation (DPUD) Projection: DPUD Positioning: Centering: Anatomy Demonstrated: Distal radius and ulnar, carpals, and proximal metacarpals are visible. Obscure fractures of the scaphoid may require several projections taken with different CR angles. Image Criteria: Scaphoid fat stripe is demonstrated Ulnar styloid is in profile medially Scaphotrapezium and scaphotrapezoidal joint spaces are open Scaphoid is demonstrated without foreshortening Scaphocapitate and scapholunate joints are open Radioscaphoid joint spaces are open Scaphoid is at the end of the exposure field  Scaphoid – DPUD 30 degrees tube angulation (Banana view) Projection: Banana View Positioning: Centering: Anatomy Demonstrated: Distal radius and ulnar, carpals, and proximal metacarpals are visible. Scaphoid should be demonstrated clearly without foreshortening, with adjacent carpal interspaces open. The joint space around the scaphoid should be demonstrated clearly. Image Criteria: This projection gives a true length of the scaphoid The ulnar deviation demonstrates the space surrounding the scaphoid Scapholunate joint space is narrowed Scaphotrapezium and scaphotrapezoidal joint spaces are more widely open compared to DPUD Radioscaphoid joint spaces are more widely open compared to DPUD More superimposition of the lunate and capitate Hamate and triquetral joint spaces are closed Identify these projections and discuss their image criteria