Radiography of the Heart lungs hand wrist.pdf

04/09/2024 Radiography of the Heart and Lungs Projection: PA Patient position: standing infront- VGD/VCH-anterior thorax dependent Comfort and part position: - both UE (upper extremities)-raised-flexed-elbows-dorsum o...

04/09/2024 Radiography of the Heart and Lungs Projection: PA Patient position: standing infront- VGD/VCH-anterior thorax dependent Comfort and part position: - both UE (upper extremities)-raised-flexed-elbows-dorsum of hands in contact-hips-rotated forward to draw the scapula laterally and prevent superimposition with the lungs - both LE (lower extremities) extended- separated and weight distributed equally - shoulders-depressed to prevent clavicles to superimpose with lung apices - chin-raised-top of the VGD (vertical grid device) - MSP (mid sagittal plane)-coincide-MP (midpoint) of IR (image receptor) - Establish-RP (reference point) -T7 (inferior border of scapulae) by palpation IR size and placement: - Cassette 14X17-VGD/VCH-longitudinal-MP (midpoint)-coincide-RP (reference point) - Upper border of the IR-approximately 1 ½ -2 inches from shoulder level CRD (Central Ray Direction)- perpendicular- at 72”- SID-RP (reference point)-exits-MP (midpoint)- IR (image receptor)/cassette 1  04/09/2024 Objective: - To demo. thoracic viscera, the air-filled trachea, well expanded lungs, diaphragmatic dome, heart and aortic knob Note: - Exposure-end of second full suspended inspiration/inhalation to allow the lungs to expand, widen intercostal spaces, depress the diaphragm, and make the costophrenic angles/sulci sharp - Collimate x-ray beam to cassette size - Use ID marker (R/L) - Gonadal shield Additional note: - Vascular markings are prominent at the end of full expiration/exhalation - For certain conditions, such as pneumothorax and the presence of a foreign body, radiographs are sometimes made at the end of full inspiration and expiration - 10 posterior ribs should be visible - For cardiac studies, patient is given a bolus of barium sulfate and instructed take a deep breath and to swallow upon instruction by the technologist. This will outline the posterior heart and aorta. - Grid technique is used for opaque areas (foreign body) within the lung fields - Chest x-ray can be done in seating/ bedside radiography - Chest x-ray is primarily done in upright to prevent pulmonary engorgement/dilatation 2  04/09/2024 Added projections: Lateral projection: (upright-standing) Patient position: - Standing-Left/right lateral position-infront of VGD/VCH Comfort position: - Both UE-raised-flexed at elbows-placed on top of head with hands grasping the elbows to avoid superimposition - Both LE-extended-wt. distributed equally Part position: - thorax-adjusted in lateral - MCP-coincide with MP of IR/cassette - Chin is raised - Establish the RP at T7 - Avoid body rotation IR size/placement: - 14X17-placed in VGD/VCH-longitudinal with MP-coincide with MCP-level of T7 - Upper edge of IR is approx. 1 ½ -2” from shoulder level CRD- Perpendicular-at 72”-distance-towards-MCP-at T7-exits at –MP- of IR 3  04/09/2024 Objective: - To demo the lateral image of the lungs - For left lateral position- it will demonstrate the heart, aorta, left sided pulmonary lesions - For right lateral position- it will demonstrate right sided pulmonary lesions - Lateral projection demonstrate interlobar fissures, differentiate lobes, and anterior/posterior location of tumor Note: - Exposure is made at the end of second full suspended inspiration/inhalation - Collimate x-ray beam to cassette size - Use ID marker (R/L) - Observe gonadal shielding Added note: - Use IV stand to support weak patients - Avoid patient to lean, it will distort the lung image - Use left lateral position for demonstration of heart - For cardiac studies, same principle is applied in PA projection - The procedure can be done in seating or recumbent position 4  04/09/2024 - For recumbent position Patient position: - Patient to assume either left/right lateral position on top of RT Comfort position: - both UE raised, flexed at elbows and FA (forearm) placed against the head - both LE flexed at knees with sandbag/pillow placed in between knees and ankles for support Part position: - thorax in lateral position - MCP-coincide with MP of IR - RP at level of T7 - Avoid body rotation IR size/placement: - 14X17-placed inside the BD (Bucky Diaphragm/tray)-longitudinal with MP-coincide with RP - Upper edge of IR approx. 1 ½ -2” from shoulder level CRD: - Perpendicular- 72”-SID-MCP-level-T7-exit at MP of IR 5  04/09/2024 PA OBLIQUE PROJECTION: Patient position: - Stand infront-VGD/VCH-anterior thorax dependent - Adjusted either in RAO/LAO position Comfort position: - Dependent UE flex-elbow-dorsum of hand-in contact with hip - Opposite UE raised-grasp the top edge of VGD - Both LE extended-wt. distributed equally Part position: - Body obliquity-approx. 45 degrees - Midline-body-coincide-MP-IR - RP-T7 - Chin is raised IR size/placement: - 14x17-VGD/VCH-longitudinal-MP-coincide-RP - Top edge of IR- 1 ½ -2”-from shoulder level CRD: Perpendicular-72” SID-midline-body-level- T7-exit-MP-IR 6  04/09/2024 Objective: - To demo the oblique image of the heart and lungs - For LAO position: - right lung field (side farther from the IR) is demonstrated - the trachea and it bifurcation (the carina) and the entire right branch of the bronchial tree - heart, descending aorta and arch of the aorta - For RAO position: - the left lung field (side farther from the l R) is demonstrated - trachea and - the entire left branch of the bronchial tree - gives the best image of the left atrium, the anterior portion of the apex of the left ventricle, and the right retrocardiac space Note: - Exposure is made at the end of second full suspended inspiration/inhalation - Collimate x-ray beam to cassette size - Use ID marker (R/L) - Observe gonadal shielding Added note: - For cardiac studies- body obliquity is 55-60 degrees - PA BOLIQUE PROJECTION can be done in recumbent 7  04/09/2024 AP OBLIQUE PROJECTION: Patient position: - Stand infront-VGD/VCH-posterior thorax dependent - Adjusted either in RPO/LPO position Comfort position: - Dependent UE-raised- flex at elbow- hand-in contact with the head - Opposite UE flexed at elbows-dorsum of hand- in contact with hip - Both LE extended-wt. distributed equally Part position: Body obliquity-approx. 45 degrees - Midline of body-coincide with MP of IR - RP-T7 - Chin is raised IR size/placement: - 14X17-placed in the VGD/VCH-longitudinal- MP-coincide with-RP - Top edge of IR- 1 ½ -2”-from shoulder level CRD: Perpendicular-72” SID-midline of the body- level-T7 (3” below jugular notch)-exit-MP-IR 8  04/09/2024 Objective: - similar with PA OBLIQUE PROJECTION, however, elevated side usually appear shorter because of magnification of the diaphragm - heart and great vessels also cast magnified shadows as a result of being farther from the IR Note: - Exposure is made at the end of second full suspended inspiration/inhalation - Collimate x-ray beam to cassette size - Use ID marker (R/L) - Observe gonadal shielding Added note: - RPO position corresponds with LAO position while LPO position corresponds with RAO position The side of interest in APO is usually the dependent side - AP OBLIQUE PROJECTION can be done is recumbent 9  04/09/2024 AP PROJECTION - This projection is done if the patient is too ill to be positioned in upright Patient position: - Supine on top of RT Comfort position: - Both UE extended-abducted-hands pronated - Both LE extended-sandbag placed under ankles for support Part position: - MSP-coincide with midline of RT/coincide with MP of IR - Shoulders on same transverse plane - RP-T7 IR size/placement: - 14X17-inside BD-longitudinal-MP-coincide- MSP-level of T7 CRD: - Perpendicular-72”SID-MSP-level of T7 (3” below jugular notch)-exit at MP of IR 10  04/09/2024 Objective: - Similar with PA projection except that heart and great vessels are magnified and engorged - Lung fields appear shorter due to abdominal compression - Clavicles are projected higher - Ribs in horizontal appearance Note: - Exposure is made at the end of second full suspended inspiration/inhalation - Collimate x-ray beam to cassette size - Use ID marker (R/L) - Observe gonadal shielding Added note: - Resnick recommendation- AP axial projection to free the basal part of the lungs from superimpositions - this projection also differentiates middle lobe and lingular processes from lower lobe disease - CRD- 30 degrees caudal- 40”SID-MSP-level of midsternal region 11  04/09/2024 DEMONSTRATION OF AIR-FLUID LEVEL IN THE LUNGS AP/PA projection: Right/Left lateral decubitus position Patient position: - Right/Left lateral decubitus position-top-RT Comfort position: - both UE raised, flexed at elbows and FA (forearm) placed against the head - both LE flexed at knees with sandbag/pillow placed in between knees and ankles for support Part position: - thorax in lateral position - MCP-perpendicular with RT - MSP-coincide with MP of IR/cassette - RP at level of T7 - Avoid body rotation - Radiolucent support (2-3” thick) placed under the dependent side to elevate 12  04/09/2024 IR size/placement: - 14X17-placed-top-RT-vertical-in contact with either posterior/anterior surface of the body- longitudinal with MP-coincide with RP; back part supported - Upper edge of IR approx. 1 ½ -2” from shoulder level CRD: - Horizontal- 72”-SID-MCP-level-T7-exit at MP of IR for AP and 3” below jugular notch for PA Objective: - To demo change in position of fluid and free air in the pleural cavity Note: - Exposure is made at the end of second full suspended inspiration/inhalation - Collimate x-ray beam to cassette size - Use ID marker (R/L) - Observe gonadal shielding 13  04/09/2024 Added note: - Wait for 5 minutes before making an exposure to allow the fluid to settle down and for air to rise - For fluid level- place the part of interest dependent - For air level- place the part of interest elevated - Ekimsky recommendation: Patient to assume the conventional CXR or AP projection in upright and to lean laterally at 45 degrees to demonstrate pleural effusion LATERAL PROJECTION: Ventral/Dorsal decubitus position Patient position: - supine/prone on top of RT Comfort position: Both UE extended upward-hands placed over the head - Both LE extended-sandbag placed under ankles for support 14  04/09/2024 Part position: - MSP-perpendicular with RT - MCP-coincide with MP of IR - Shoulders on same transverse plane - RP-T7 - Radiolucent support (2-3”) thick-placed under the thorax to elevate IR size/placement: - 14X17-placed on top of RT-vertical- longitudinal-MP-coincide-MCP-level of T7 - back part-supported CRD: - Horizontal-72”SID-MCP-level of T7 (for ventral decubitus)- exit at MP of IR - Horizontal-72”SID-MCP-level of 3-4” below jugular notch (for dorsal decubitus)-exit at MP of IR Objective: - To demo. change in the position of fluid and reveals pulmonary area that are obscured by the fluid 15  04/09/2024 Note: - Exposure is made at the end of second full suspended inspiration/inhalation - Collimate x-ray beam to cassette size - Use ID marker (R/L) - Observe gonadal shielding Added note: - Wait for 5 minutes before making an exposure to allow the fluid to settle down and for air to rise APICOGRAPHY - Special examination of the lung apices to confirm the existence of TB previously diagnosed in the conventional PA projection of the chest (CXR) Conventional Projection: AP AXIAL (Lindblom method) Patient position: - Standing in front of VGD/VCH-posterior thorax dependent - Comfort and Part position: - Both UE-flex-elbow-dorsum of hand-in contact-hips - Patient-make 1 step (1 foot-30.5cm) forward without bending the knees-lean 16  04/09/2024 backward-posterior thorax-in contact with VGD - Patient assume-lordotic position - MSP-coincide-MP-IR - RP- mid sternum IR size/placement: - 14X17-placed in VGD/VCH-longitudinal-MP- level-mid sternum - Top edge-3”from shoulder level CRD: - Perpendicular-72”SID-MSP-level-midsternum- exit-MP-IR Objective: - Demo. Apices of lungs and interlobar effusions Note: conventional- this means that you have to follow the basic protocol of exposure, x-ray beam limitation, use of ID marker, and gonadal shielding Added note: - For AP oblique lordotic position, rotate the body approximately 30 degrees with the affected side dependent and centered to the MP of IR. 17  04/09/2024 PA AXIAL PROJ. Nb. The same with the conventional PA projection of the chest except CRD: for inspiratory phase of exposure- 10-15 degrees cranial-72”SID-MSP-level-T3-exit MP-IR - For expiratory phase of exposure- Perpendicular- 72”-SID-MSP-level-T3 - 10X12-cassette-VGD-crosswise-MP-level-T3 - Objective: demo apices above the clavicles - Note: conventional- this means that you have to follow the basic protocol of exposure, x-ray beam limitation, use of ID marker, and gonadal shielding AP AXIALPROJ. Patient position: -Standing-in front-VGD-posterior thorax dependent Comfort position: -Both UE-flex-elbow-dorsum-hand-in contact-hips - Both LE-extended-wt. distributed equally Part position: - MSP-coincide-with MP of IR - RP-T2 - Shoulder on same plane 18  04/09/2024 IR size/placement: - 10X12-VGD-crosswise with MP-coincide-at T2 CRD: 15-20 degrees cranial-72”-MSP-level-T2-exit- MP-IR Objective: Demo the apices lying below the clavicles Note: AP AXIAL is preferred for hypersthenic patients to separate clavicles with apices PA AXIAL PROJ. (FLEICHNER METHOD) Patient Position: Stand- in front-VGD/VCH-anterior thorax-dependent Comfort position: both UE flex-elbow-dorsum of hand-in contact with hip Part position: patient to lean backward assume lordotic pos’n Anterior thorax 45 degrees from-VGD MSP-coincide-MP-IR RP-T4 19  04/09/2024 IR size/placement: 14X17-VGD-longitudinal-MP- level-T4 CRD: Perpendicular-72”SID-MSP-level-T4-exit MP- IR Objective: demo apices and interlobar effusion Note: conventional Added note: to demo minimal mitral disease direct CR 30 caudal-level-T4 Carrera Method (AP AXIAL)- same with CXR raquirements in AP except CRD-30 cranial-T4 FELSON method-same with CXR except CRD-45 caudal-T4 (PA AXIAL) 20  04/09/2024 Radiography of the Hand 1. PA PROJ. (DORSOPALMAR) Indications Fracture: Bennett’s Boxer’s BD Cancer Patient Pos’n: seated lateral-beside RT Comfort: unaffected UE-raised-flex-elbow-hand- lap both LE: flex knee-feet-floor Part: arm-affected side-top RT-flex-elbow-90 deg- hand pronated digits-separated-equal LA-hand-parallel-LA-IR RP-3rd MCPJ immobilize-tape-positioning sponge draw head from tube 21  04/09/2024 IR: 8x10/10x12-top RT-LA-parallel-LA-hand MP-coincide-RP-3rd MCPJ consider masking technique CRD: Perp-36-40”-RP-3rd MCPJ-exit-MP-IR Objective: Demo carpals, metacarpals, interarticulations of hand, distal radius and ulna, thumb in oblique Note: conventional Note: AP proj to demo MCP joint/metacarpals for injured hand 2. PAO (lateral rotation) Patient Pos’n: seated lateral-beside RT Comfort: unaffected UE-raised-flex-elbow-hand-lap both LE: flex knee-feet-floor Part: arm-affected side-top RT-flex-elbow-90 deg-hand pronated-rotate lateral MCPJ-45 deg 45 deg foam wedge-support extended digits-demo interphalangeal joints finger tips-in contact-IR-demo metacarpals LA-hand-parallel-LA-IR RP-3rd MCPJ immobilize-tape-positioning sponge draw head from tube 22  04/09/2024 IR: 8x10/10x12-top RT-LA-parallel-LA-hand MP-coincide-RP-3rd MCPJ consider masking technique CRD: Perp-36-40”-RP-3rd MCPJ-exit-MP-IR Objective: oblique image of hand Note: conventional Note: Lane, Kennedy, Kuschner rec: reverse oblique proj-hand rotated 45 deg medial from pronated hand- demo severe metacarpal deformity/fx Kallen rec: from PA-MCPJ flex-75-80 deg-dorsum-digits- in contact-IR-rotate 40-45 deg towards ulna and rotated 40-45 deg forward until affected MCPJ-projected beyond-proximal phalanx CRD-Perp and tangential-affected MCPJ ADDED. LATERAL PROJ (mediolateral/lateromedial) Patient Pos’n: seated lateral-beside RT Comfort: unaffected UE-raised-flex-elbow-hand-lap both LE: flex knee-feet-floor Part: arm-affected side-top RT-flex-elbow-90 deg-ulnar surface/radial-IR digits extended and thumb abducted at right angle-LA- hand/palm palm-perp-IR LA-hand-parallel-LA-IR RP-2nd MCPJ immobilize-tape-positioning sponge draw head from tube 23  04/09/2024 IR: 8x10/10x12-top RT-LA-parallel-LA-hand MP-coincide-RP-2nd MCPJ consider masking technique CRD: Perp-36-40”-RP-2nd MCPJ-exit-MP-IR Objective: lateral image of hand-localize FB, metacarpal fracture displacement Note: conventional Added note: for fan lateral-use a sponge wedge to separate the digits assuming a fan-shape to demo individual lateral image of digits except proximal part LEWIS REC: to better demo fractures of 5th metacarpals- rotate hand 5 deg posterior from lateral-thumb extended-CRD is parallel-thumb-level mid shaft of 5th metacarpal ADDED. LATERAL PROJ (lateromedial in flexion) Patient Pos’n: seated lateral-beside RT Comfort: unaffected UE-raised-flex-elbow-hand-lap both LE: flex knee-feet-floor Part: arm-affected side-top RT-flex-elbow-90 deg-ulnar surface-IR hand in lateral and assume normal arch thumb-parallel-LA-IR RP-2nd MCPJ immobilize-tape-positioning sponge draw head from tube 24  04/09/2024 ADDED. NORGAARD METHOD (Ball Catcher’s position) detect early radiologic changes to diagnose rheumatoid arthritis reqts.-fine grain IS. For high resolution (60-65kVp) Stapczynski rec of this procedure to demo fx of 5th metacarpal -conventional seating/comfort part: both UE-top-RT-dorsum-hand-in-contact-suinated -hands –assume- ball catcher’s pos’n/ 2 (45 deg foam wedge)-placed-under dorsum-hands-digits extended RP-midway bet both MCPJ IR- 10x12/11/14-top-RT-CW-MP-RP CRD-perp (v)-36-40”-RP-MP-IR Radiography of the WRIST Indications: Fracture, BD, Dislocation 25  04/09/2024 1. PA projection pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT-flex elbow 90 degrees-hand pronated arch hand-MCPJ-place wrist-in contact-IR RP: mid carpal area IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp-36-40”-SID-RP-MP-IR PA projection Note: this gives a slightly oblique rotation to the ulna - if ulna is under examination, an AP projection should be taken. Eval criteria: To demonstrate Distal radius and ulna, carpals, and proximal half of metacarpals No rotation in carpals, metacarpals, or radius Soft tissue and bony trabeculation No excessive flexion to overlap and obscure metacarpals with digits 26  04/09/2024 PA projection modification Daffner, Emmerling, and Buterbaugh all the same with Pa-EXCEPT CRD: 300 towards elbow Obj: elongates the scaphoid and capitate CRD: 300 towards fingertips Obj: elongates only the capitate Added: AP projection pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top -hand and arm supinated Elevate digits – support – wrist - IR RP: mid carpal area IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp-36-40”-SID-RP-MP-IR 27  04/09/2024 AP projection Note: carpal interspaces are better demonstrated Eval criteria: To demonstrate Distal radius and ulna, carpals, and proximal half of the metacarpals No rotation of the carpals, metacarpals, radius, and ulna Well-demonstrated soft tissue and bony trabeculation No overlapping or obscuring of the metacarpals as a result of excessive flexion 2. Lat projection (Lateromedial) pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT-flex elbow 90 degrees-hand lateral and wrist in true lateral RP: mid carpal area IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp-36-40”-SID-RP-MP-IR 28  04/09/2024 Lateral projection Note: This position can also be used to demonstrate anterior or posterior displacement in fractures. Eval criteria: To demonstrate Distal radius and ulna, carpals, and proximal half of metacarpals Superimposed distal radius and ulna Superimposed metacarpals Radiographic density similar to PA or AP and oblique radiographs, which requires increased exposure factors to compensate for greater part thickness Added: Lateral projection (Mediolateral) An image obtained with the radial surface against the IR is shown for comparison. pt position: should lean forward to assume the position 29  04/09/2024 Lateral projection modification Burman et. al. If the lateral position of the scaphoid should be obtained, wrist should be in palmar flexion ✓ this action rotates the bone anteriorly into a dorso-volar position. ✓ this is valuable only when sufficient flexion is permitted. Lateral projection modification Fiolle first to describe a small bony growth occurring on the dorsal surface of the third CMCJ ‘carpe bossu’ (carpal boss) and found that it is demonstrated best in a lateral position with the wrist in palmar flexion 30  04/09/2024 Added: PA Oblique projection: Lateral rotation pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT-flex elbow 90 degrees-axilla in contact – RT –place wrist-in contact-IR Prone – rotate laterally – 450 with IR plane Note: use foam wedge – If ff-up will be done RP: scaphoid If POI is scaphoid, with ulnar deviation IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp midcarpal-36-40”-SID-just distal to radius Added: PA Oblique projection: Lateral rotation Note: demonstrates the carpals on the lateral side of the wrist, particularly the trapezium and the scaphoid. Eval criteria: To demonstrate A well demonstrated scaphoid and trapezium Distal radius and ulna, carpal and proximal half of metacarpals Usually, adequate amount of obliquity in the following circumstances: ✓ Slight interosseus space between the third-fourth and fourth-fifth metacarpal shafts ✓ Slight overlap of the distal radius and ulna Soft tissue and bony trabeculation 31  04/09/2024 Added: AP Oblique projection: Medial rotation pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT- FA rest on RT - place wrist-in contact-IR supine – rotate medially –semi-supinated - 450 with IR plane Note: use foam wedge – If ff-up will be done RP: midway medial and lateral borders – midcarpal area IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp midcarpal-36-40”-SID-RP Added: AP Oblique projection: Medial rotation Note: separates the pisiform from the adjacent carpal bones. It also gives a more distinct radiograph of the triquetrum and hamate Eval criteria: To demonstrate Carpals on medial side of wrist Triquetrum, hamate, and pisiform free of superimposition and in profile Distal radius and ulna, carpals and proximal half of metacarpals Radiographic quality soft tissue and bony trabeculation 32  04/09/2024 Added: PA PROJECTION: Ulnar deviation pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT- FA rest on RT - place wrist-in contact-IR PA proj pos’n – wrist in extreme ulnar deviation RP: scaphoid IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp – scaphoid - 36-40”-SID-RP Note: clear delineation – CR 100 to 150 prox or distal Added: PA PROJECTION: Ulnar deviation Note: corrects foreshortening of the scaphoid, which occurs with a perpendicular central ray. It also opens the spaces between the adjacent carpals Eval criteria: To demonstrate Scaphoid with adjacent articulation open No rotation of wrist Extreme ulnar deviation, as revealed by the angle formed between longitudinal axes of the forearm compared with the longitudinal axes of the metacarpals Soft tissue and bony trabeculation 33  04/09/2024 Added: PA PROJECTION: Radial deviation pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT- FA rest on RT - place wrist-in contact-IR PA proj pos’n – wrist in extreme radial deviation RP: midcarpal IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp – midcarpal - 36-40”-SID-RP Added: PA PROJECTION: Radial deviation Note: opens the interspaces between the carpals on the medial side of the wrist Eval criteria: To demonstrate ▪ Carpal and their articulations on the ▪ medial ide of the wrist ▪ No rotation of wrist ▪ Extreme radial deviation, as revealed ▪ by the angle formed between longitudinal axes of forearm compared to the longitudinal axes of the metacarpals ▪ Soft tissue and bony trabeculation 34  04/09/2024 Scaphoid PA AXIAL PROJECTION: STECHER METHOD pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT- FA rest on RT – axilla on RT - wrist-centered and in contact-IR PA proj pos’n – one end of IR – support – 200 elevated (phalangeal end) RP: scaphoid IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp – RT - scaphoid - 36-40”-SID-RP 35  04/09/2024 PA AXIAL PROJECTION: STECHER METHOD Note: places the scaphoid at right angles to the CR so that it is projected without self-superimposition Eval criteria: To demonstrate Scaphoid No rotation of carpals, metacarpals, radius, or ulna Distal radius and ulna, carpals, and proximal half of the metacarpals Soft tissue and bony trabeculation PA AXIAL PROJECTION: STECHER METHOD Variations IR and wrist - horizontal – CR 200 toward elbow Superoinferior FRACTURE line demo: wrist angled inferiorly or CR angled towards the digits Clench fist: elevates distal end of scaphoid (parallel with IR) & widens fracture line – (PA wrist; no CR angulation) 36  04/09/2024 PA AXIAL PROJECTION: STECHER METHOD Variations PA AXIAL PROJECTION: BRIDGMAN METHOD All the same as Stecher method EXCEPT: With ulnar deviation 37  04/09/2024 Scaphoid series The series is performed after routine wrist radiographs do not identify a fracture PA and PA AXIAL PROJECTION: Ulnar deviation RAFERT-LONG METHOD pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT- FA rest on RT –- wrist- centered and in contact-IR PA proj pos’n of wrist – extreme ulnar deviation RP: scaphoid IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: SERIES: Perp (00), 100, 200, and 300 cephalad 38  04/09/2024 PA and PA AXIAL PROJECTION: Ulnar deviation RAFERT-LONG METHOD Note: scaphoid is demonstrated with minimal superimposition Eval criteria: To demonstrate No rotation of the wrist Scaphoid with adjacent articular areas open Extreme ulnar deviation Trapezium 39  04/09/2024 PA AXIAL OBLIQUE PROJECTION CLEMENTS-NAKAYAMA METHOD pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT- FA rest on RT –- hand in contact- IR – lateral – 450 sponge wedge on palmar surf wrist – lat – resting on ulnar – center of IR – ulnar deviation ***LA of IR and FA & wrist align with CR and rotate 20 0 away from CR (if ulnar deviation not possible) RP: scaphoid IR: 8x10/10x12-top-RT-longitudinal-MP-RP CRD: 450 distal to anatomic snuffbox of wrist PA AXIAL OBLIQUE PROJECTION CLEMENTS-NAKAYAMA METHOD Note: demonstrates the trapezium and its articulations with the adjacent carpal bones. The articulation of the trapezium and scaphoid is not demonstrated on this image. Eval criteria: Trapezium projected free of the other carpal bones with the exception of the articulation with the scaphoid 40  04/09/2024 PA AXIAL OBLIQUE PROJECTION CLEMENTS-NAKAYAMA METHOD Carpal Bridge 41  04/09/2024 TANGENTIAL PROJECTION pt position: Conventional lateral seating/stand -edge RT – allow manipulation of arm / XRT PART: affected limb-top RT- hand – palm upward on IR – hand at right angle to FA or elevate FA on sandbags – wrist flexed at right angle - IR in vertical position RP: anatomic snuffbox – pass through trapezium IR: 8x10-top-RT-longitudinal-MP-RP CRD: 1 ½ inch prox to wrist - 450 caudal TANGENTIAL PROJECTION Note: for demonstration of fractures of the scaphoid, lunate dislocations, calcifications and foreign bodies in the dorsum of the wrist, and chip fractures of the dorsal aspect of the carpal bones. Eval criteria: Dorsal aspect of the wrist Carpals Dorsal surface of the carpals free of superimposition by the metacarpal bases 42  04/09/2024 TANGENTIAL PROJECTION TANGENTIAL PROJECTION 43  04/09/2024 Carpal Canal TANGENTIAL PROJECTION GAYNOR-HART METHOD: inferosuperior pt position: Conventional lateral seating-edge RT – FA parallel with LA of RT PART: affected limb-top RT- hand – hyperextend wrist – level of radial styloid process Radiolucent pad – ¾ inch – under lower FA – rotate hand slightly toward radial side (prevent superimpo of shadows of hamate and pisiform) Pt – grasp digits w/ opp hand or use a suitable device to hold wrist in extended pos’n RP: 1 in distal to bass of 3rd MC IR: 8x10-top-RT- LW -MP-RP CRD: 25 to 30 degrees - towards palm of hand – LA of hand - RP 44  04/09/2024 TANGENTIAL PROJECTION GAYNOR-HART METHOD: inferosuperior Note: shows the palmar aspect of the trapezium, the tubercle of the trapezium, and the scaphoid, capitate, hook of hamate, triquetrum, and entire pisiform TANGENTIAL PROJECTION GAYNOR-HART METHOD: superoinferior (modification) pt position: Stand -edge RT – allow manipulation of arm PART: affected limb-top RT- hand – dorsiflex wrist as much as tolerable – lean forward level – carpal canal tangent to IR RP: midpoint of wrist IR: 8x10-top-RT- LW -MP-RP CRD: tangential to carpal canal – midpoint of wrist or angled toward the hand 20 – 35 degree from LA of FA 45  04/09/2024 TANGENTIAL PROJECTION GAYNOR-HART METHOD: superoinferior (modification) Note: shows the palmar aspect of the trapezium, the tubercle of the trapezium, and the scaphoid, capitate, hook of hamate, triquetrum, and entire pisiform TANGENTIAL PROJECTION GAYNOR-HART METHOD: superoinferior (modification) When dorsiflexion of the wrist is limited, Marshall I suggested placing a 45-degree angle sponge under the palmar surface of the hand. This slightly elevates the wrist to place the carpal canal tangent to the central ray. A slight degree of magnification exists because of the increased object-to-image receptor distance (OID) 46 04/09/2024 47 04/09/2024 48 04/09/2024 49  04/09/2024 Radiography of the Wrist Indications Fracture: BD Dislocation 50  04/09/2024 PROJECTIONS: 1. PA pt position: Conventional lateral seating/comfort position-edge RT PART: affected limb-top RT-flex elbow 90 degrees-hand pronated FA-parallel-LA-RT arch hand-MCPJ-place wrist-in contact-IR RP-mid carpal area IR: 8x10/10x12-top-RT-longitudinal/CW-MP-RP CRD: Perp-36-40”-SID-RP-MP-IR 51