Chapter 2

Upper Limb (Extremity)

• Technical factors and radiation protection

Fingers

PA oblique fingers (R)

PA and PA oblique critique

Lateral fingers (R)

Thumb

Lateral finger and AP thumb critique

PA oblique and lateral thumb critique

AP axial (modified Roberts method) (S)

Hand

AP axial thumb and PA hand critique

Lateral (“fan”) (R)

PA oblique hand and “fan” lateral hand critique

AP oblique bilateral (Norgaard/ball-catcher’s) (S)

AP oblique bilateral critique

Wrist

PA and PA oblique critique

Lateral critique

PA axial ulnar deviation (15° and Modified Stecher) (S)

Scaphoid projections (15° and Modified Stecher) critique

PA radial deviation (S)

PA wrist radial deviation critique

Tangential carpal canal (Gaynor-Hart method) (S)

Tangential carpal canal critique

Forearm

AP and lateral critique

Elbow

AP partially flexed critique

AP oblique (medial and lateral) (R)

AP medial and lateral elbow critique

Lateral elbow (R)

Lateral elbow critique

Trauma axial lateral (Coyle method) (S)

Trauma axial lateral (Coyle method) critique

Pediatric Upper Limbs

(R) Routine, (S) Special

Upper Limb (Extremity)^*

Technical Factors

The following technical factors are important for all upper limb procedures to maximize image sharpness.

• 40-44″ (102-113 cm) SID, minimum OID

• Small focal spot

• Nongrid or TT (tabletop), detail (analog) screens

• Digital imaging requires special attention to accurate CR and part centering and close collimation.

• Short exposure time

• Immobilization (when needed)

• Multiple exposures per imaging plate: Multiple images can be placed on the same IP. When doing so, careful collimation and lead masking must be used to prevent pre-exposure or fogging of other images.

• Grid use with digital systems: Grids generally are not used with analog (film-screen) imaging for body parts measuring 10 cm or less. However, with certain digital systems, the grid may or may not be able to be removed from the receptor. In those cases, it is departmental protocol that determines if a grid is left in place or removed. Important: If a grid is used, the anatomy must be centered to it to avoid grid cutoff.

Radiation Protection

Collimation

Close collimation is the most effective practice for preventing unnecessary radiation exposure to the patient.

Patient Shielding

Erect Patients:

Patients seated at the end of the table should always have a shield over radiosensitive organs to prevent exposure from scatter radiation and from the divergent primary beam.

Recumbent Patients:

A good practice to follow for upper limb examinations for patients on a stretcher or table is to always have shielding in place, especially the gonadal region.

PA Fingers^*

Alternative routine: Include entire hand on PA finger projection for possible secondary trauma to other parts of hand (see PA Hand).

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient seated at end of table, elbow flexed 90° (lead shield over lap)

• Pronate hand, separate fingers.

• Center and align long axis of affected finger(s) to portion of IR being exposed.

Central Ray:

CR ⊥, centered to PIP joint

SID:

40-44″ (102-113 cm)

Collimation:

On four sides to area of interest

Fig. 2-1 PA, 2nd digit.

PA Oblique Fingers^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-2 PA oblique, 2nd digit (parallel to IR). Inset: Minimized OID.

Position

• Patient seated, hand on table, elbow flexed 90° (lead shield over lap)

• Align fingers to long axis of portion of IR being exposed.

• Rotate hand 45° medially or laterally (dependent of digit examined), resting against 45° angle support block.

• Separate fingers; ensure that affected finger(s) is (are) parallel to IR.

Central Ray:

CR ⊥, centered to PIP joint

SID:

40-44″ (102-113 cm)

Collimation:

On four sides to area of affected finger(s) and distal aspect of metacarpal

PA Finger

Evaluation Criteria

Anatomy Demonstrated:

• Distal phalanx to distal metacarpal and associated joints

Position:

• Long axis of digit parallel to IR with joints open

• No rotation of digit with symmetric appearance of shafts

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated; no motion

Fig. 2-3 PA finger.

PA Oblique Finger

Evaluation Criteria

Anatomy Demonstrated:

• Distal phalanx to distal metacarpal and associated joints

Position:

• Interphalangeal and MCP joints open

• No superimposition of adjacent digits

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated; no motion

Fig. 2-4 PA oblique finger.

Lateral Fingers^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-5 4th digit.

Fig. 2-6 2nd digit (digit parallel to IR).

Position

• Patient seated, hand on table (lead shield over lap)

• Hand in lateral position, thumb side up for 3rd to 5th digits, thumb side down for 2nd digit

• Align finger to long axis of portion of IR being exposed.

Central Ray:

CR ⊥, centered to PIP joint

SID:

40-44″ (102-113 cm)

Collimation:

On four sides to area of affected finger and distal aspect of metacarpal

AP Thumb^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient standing or seated, hand rotated internally with palm out to bring the posterior surface of thumb in direct contact with IR

• Align thumb to long axis of portion of IR being exposed.

Central Ray:

CR ⊥, centered to lst MP joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely to area of thumb (include entire 1st metacarpal extending to carpals).

Fig. 2-7 AP thumb, CR to 1st MP joint.

Lateral Fingers

Evaluation Criteria

Anatomy Demonstrated:

• Distal phalanx to distal metacarpal and associated joints

Position:

• True lateral: joints are open and concave appearance of anterior surfaces of shaft of phalanges

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue margins and bony trabeculation clearly seen, no motion

Fig. 2-8 Lateral finger.

AP Thumb

Evaluation Criteria

Anatomy Demonstrated:

• Distal phalanx to proximal metacarpal and trapezium

Position:

• Long axis of thumb parallel to IR with joints open

• No rotation of thumb with symmetric appearance of shafts

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated; no motion

Fig. 2-9 AP thumb.

PA Oblique Thumb^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient seated, hand on table, elbow flexed (shield over lap)

• Align thumb to long axis of portion of IR being exposed.

• With hand pronated, abduct thumb slightly. This position tends to naturally rotate thumb into 45° oblique.

Central Ray:

CR ⊥, centered to 1st MCP joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely to area of thumb (include entire 1st metacarpal extending to carpals).

Fig. 2-10 Oblique thumb, CR to 1st MCP joint.

Lateral Thumb^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient seated, hand on table, elbow flexed (shield across lap)

• Align thumb to long axis of portion of IR being exposed.

• With hand pronated and slightly arched, rotate hand medially until thumb is in true lateral position.

Central Ray:

CR ⊥, centered to lst MCP joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely to area of thumb (include entire 1st metacarpal extending to carpals).

Fig. 2-11 Lateral thumb, CR to 1st MCP joint.

PA Oblique Thumb

Evaluation Criteria

Anatomy Demonstrated:

• Distal phalanx to proximal metacarpal and trapezium

Position:

• Long axis of thumb parallel to IR with joints open

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated

Fig. 2-12 PA oblique thumb.

Lateral Thumb

Evaluation Criteria

Anatomy Demonstrated:

• Distal phalanx to proximal metacarpal and trapezium

Position:

• True lateral position

• Interphalangeal and MCP joints open

• Anterior surfaces of first metacarpal and proximal phalanx equally concave shaped; posterior surfaces are relatively straight

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated, no motion

Fig. 2-13 Lateral thumb.

AP Axial Thumb^*

(Modified Roberts)

Note: This is a special projection to better demonstrate the first carpometacarpal joint region.

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-14 AP axial thumb for 1st CMC joint (CR 15° proximally).

Position

• Patient seated or standing, hand rotated internally placing posterior surface of thumb directly on IR

• Align thumb to long axis of portion of IR being exposed.

• Extend fingers and hold back with other hand to prevent superimposing base of thumb and 1st CMC joint region (a key positioning requirement).

Central Ray:

CR angled 15° proximally, centered to 1st CMC joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely to entire thumb, including the trapezium carpal bone.

PA Hand^*

• 24 × 30 cm L.W. (10 × 12″)

or

• 18 × 24 cm L.W. (8 × 10″) smaller hand

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient seated, hand on table, elbow flexed (shield across lap)

• Align long axis of hand and wrist parallel to edge of IR.

• Hand fully pronated, digits slightly separated

Central Ray:

CR ⊥, centered to 3rd MCP joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to outer margins of hand and wrist. Include proximal and distal row of carpals.

Fig. 2-15 PA hand.

AP Axial Thumb (Modified Roberts)

Evaluation Criteria

Anatomy Demonstrated:

• Distal phalanx to proximal metacarpal and trapezium

• Base of 1st metacarpal and trapezium well demonstrated

Position:

• Long axis of thumb parallel to IR with joints open

• No rotation

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated, no motion

Fig. 2-16 AP axial thumb.

PA Hand

Evaluation Criteria

Anatomy Demonstrated:

• Hand/wrist and 1″ (2.5 cm) distal forearm

Position:

• Interphalangeal and MCP joints open

• No rotation of hand with symmetric appearance of shafts of metacarpals and phalanges

• Digits slightly separated

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated, no motion

Fig. 2-17 PA hand.

PA Oblique Hand^*

• 24 × 30 cm L.W. (10 × 12″)

or

• 18 × 24 cm L.W. (8 × 10″) smaller hand

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient seated, hand on table, elbow flexed (shield across lap)

• Rotate entire hand and wrist laterally 45°, support with wedge or step block. Align hand and wrist to IR.

• Ensure that all digits are slightly separated and parallel to IR.

Central Ray:

CR ⊥, centered to 3rd MCP joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to hand and wrist. Include proximal and distal row of carpals.

Fig. 2-18 PA oblique hand (digits parallel to IR).

Lateral Hand (Fan and Extension Lateral)^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Accessory—45° foam step support

• Lead masking with multiple exposures on same IR

Position

• Patient seated, hand on table, elbow flexed (shield across lap)

• Hand in lateral position, thumb side up, digits separated and spread into “fan” position and supported by radiolucent step block or similar type support (Ensure true lateral of metacarpals.)

Central Ray:

CR ⊥, centered to 2nd MCP joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to hand and wrist. Include proximal and distal row of carpals.

Fig. 2-19 “Fan” lateral hand (digits not superimposed).

Fig. 2-20 Alternative: lateral in extension (for possible foreign body and metacarpal injury).

PA Oblique Hand

Evaluation Criteria

Anatomy Demonstrated:

• Hand/wrist and 1″ (2.5 cm) distal forearm

Position:

• Long axis of digits/metacarpals parallel to IR with joints open

• No overlap of midshafts of 3rd to 5th metacarpals

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated

Fig. 2-21 PA oblique hand.

“Fan” Lateral Hand

Evaluation Criteria

Anatomy Demonstrated:

• Hand/wrist and 1″ (2.5 cm) distal forearm

• Interphalangeal and MCP joints open

Position:

• Digits in true lateral position

• Phalanges and metacarpal surfaces symmetric

• Distal radius, ulna, and metacarpals superimposed

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated

Fig. 2-22 “Fan” lateral hand.

AP Oblique Bilateral Hand^*

(Norgaard Method and Ball-Catcher’s)

• 24 × 30 cm (10 × 12″), crosswise or 35 × 43 cm (14 × 17″) crosswise

• Nongrid

• Accessories—two 45° foam sponges for support

Fig. 2-23 AP 45° bilateral oblique. Inset: Ball-catcher’s option.

Position

• Patient seated at end of table, both arms and hands extended with palms up and hands obliqued 45°, medial aspects touching

• Fingers fully extended supported by 45° support blocks

Ball-Catcher’s Option:

• Fingers partially flexed, which visualizes metacarpals and MP joints well but distorts interphalangeal joints

Central Ray:

CR ⊥, centered to midway between 5th MP joints

SID:

40-44″ (102-113 cm)

Collimation:

Collimate to outer margins of hands and wrists. Include proximal and distal row of carpals.

AP Bilateral Oblique Hands (Norgaard Method)

Evaluation Criteria

Anatomy Demonstrated:

• Both hands from carpals to distal phalanges

• Both hands positioned in 45° oblique

Position:

• Midshafts of 2nd to 5th metacarpals not overlapped

• MCP joints open

Fig. 2-24 AP bilateral oblique hand.

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation with MCP joints clearly demonstrated to distal phalanges

PA Wrist^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient seated, arm on table (shield across lap)

• Align hand and wrist parallel to edge of IR.

• Lower shoulder, rest arm on table to ensure no rotation of wrist

• Hand pronated, fingers flexed, and hand arched slightly to place wrist in direct contact with surface of IR

Central Ray:

CR ⊥, centered to midcarpals

SID:

40-44″ (102-113 cm)

Collimation:

Collimate to wrist on four sides; include distal radius and ulna and the midmetacarpal area.

Fig. 2-25 PA wrist.

PA Oblique Wrist^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient seated, arm on table, elbow flexed (shield across lap)

• Align hand and wrist parallel to edge of IR.

• Rotate hand and wrist laterally into 45° oblique position.

• Flex fingers to support hand in this position, or use 45° support sponge (inset).

Central Ray:

CR ⊥, centered to midcarpals

SID:

40-44″ (102-113 cm)

Collimation:

Collimate to wrist on four sides; include distal radius and ulna and the midmetacarpal area.

Fig. 2-26 45° PA oblique wrist.

PA Wrist

Evaluation Criteria

Anatomy Demonstrated:

• Midmetacarpals; carpals; distal radius, ulna, and associated joints

Position:

• True PA is evidenced by symmetry of proximal metacarpals

• Separation of the distal radius and ulna

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation of carpals clearly demonstrated, no motion

Fig. 2-27 PA wrist.

PA Oblique Wrist

Evaluation Criteria

Anatomy Demonstrated:

• Midmetacarpals; carpals; distal radius, ulna, and associated joints

Position:

• Long axis of hand to forearm aligned to IR

• 45° oblique of wrist

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation of carpals clearly demonstrated, no motion

Fig. 2-28 PA oblique wrist.

Lateral Wrist^*

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Patient seated, arm on table, elbow flexed, shoulder dropped to place humerus, forearm, and wrist on same horizontal plane

• Align hand and wrist parallel to edge of IR.

• Place hand and wrist into a true lateral position, use support to maintain this position if needed.

Central Ray:

CR ⊥, centered to midcarpals

SID:

40-44″ (102-113 cm)

Collimation:

Collimate to wrist on four sides; include distal radius and ulna and the midmetacarpal area.

Fig. 2-29 Lateral wrist.

Lateral Wrist

Evaluation Criteria

Anatomy Demonstrated:

• Midmetacarpals; carpals; distal radius, ulna, and associated joints

Position:

• True lateral of wrist

• Ulnar head superimposed distal radius

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation of carpals clearly demonstrated, no motion

• Demonstrate visible fat pads and stripes

Fig. 2-30 Lateral wrist.

PA Axial Wrist—UInar Deviation and Modified Stecher (Scaphoid)^*

Warning: The ulnar deviation view should be attempted only with possible wrist trauma after a routine wrist series rules out gross fractures to wrist or distal forearm. PA axial projection recommended for obscure fractures. If patient can’t ulnar deviate wrist, elevate hand on 20° angle sponge.

Note: See p. 26, 8th ed textbook for joint movement terminology.

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-31 Ulnar deviation, CR 10°–15° angle toward elbow. CR perpendicular to scaphoid.

Fig. 2-32 Modified Stecher method. Elevate hand on 20° sponge, CR ⊥, to IR.

Position

• From PA wrist position, gently evert wrist toward ulnar side as far as patient can tolerate.

Central Ray:

Angle CR 10°–15° proximally toward elbow, centered to scaphoid (thumb side of carpal area). If hand placed on 20° sponge, CR ⊥ to IR.

Note:

A four-projection series with CR at 0°, 10°, 20°, and 30° may be required

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to carpal region.

PA Axial Scaphoid (Ulnar Deviation with 15° and Modified Stecher)

Evaluation Criteria

Anatomy Demonstrated:

• Scaphoid demonstrated clearly without foreshortening or overlap

• Soft tissue and bony trabeculation of scaphoid clearly demonstrated, no motion

Position:

• Ulnar deviation evident.

• Multiple CR angles may best visualize this area.

• No rotation of wrist.

Fig. 2-33 Ulnar deviation with 15° CR angle.

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation of scaphoid clearly demonstrated, no motion

Fig. 2-34 Modified Stecher.

PA Wrist—Radial Deviation^*

Warning: This position should be attempted for possible wrist trauma only after a routine wrist series rules out gross fractures to wrist or distal forearm.

Note: See p. 26, 8th ed textbook, for explanation on wrist joint movement terminology.

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-35 Radial deviation, CR perpendicular. (Demonstrates ulnar side carpals.)

Position

• From PA wrist position, gently invert wrist toward radial side as far as patient can tolerate (shield across lap).

Central Ray:

CR ⊥, to midcarpals

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely to four sides of carpal region (≈7.5 cm or 3″ square).

PA Wrist—Radial Deviation

Evaluation Criteria

Anatomy Demonstrated:

• Ulnar side carpals best visualized

Position:

• Radial deviation evident

• No rotation of wrist

Exposure:

• Soft tissue and bony trabeculation of ulnar aspect of carpal region clearly demonstrated, no motion

• Optimal density and contrast (brightness and contrast for digital images)

Fig. 2-36 PA wrist—radial deviation.

Wrist—Carpal Canal^*

(Gaynor-Hart Tangential Projection)

Warning: This position is sometimes called the “tunnel view” and should be attempted for possible wrist trauma only after a routine wrist series rules out gross fractures to wrist or distal forearm.

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-37 Carpal canal (tunnel) projection (CR 25°–30° to long axis of hand).

Position

• Patient seated, hand on table (shield across lap)

• Hyperextend (dorsiflex) wrist as far as patient can tolerate with patient using other hand to hold fingers back.

• Rotate hand and wrist slightly internally—toward radius (≈5°–10°).

• Work quickly as this may be painful for patient.

Central Ray:

CR 25°–30° to long axis of the palmar surface of hand, centered to ≈1″ (2-3 cm) distal to base of 3rd metacarpal

SID:

40-44″ (102-113 cm)

Collimation:

Collimate to carpal region (≈7.5 cm or 3″ square).

Tangential (Gaynor-Hart) Carpal Canal

Evaluation Criteria

Anatomy Demonstrated:

• Carpals demonstrated in arched arrangement

Position:

• Pisiform and the hamular process separated

• Scaphoid/trapezium in profile

Fig. 2-38 Tangential carpal canal.

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissues and bony trabeculation of carpal canal clearly demonstrated

AP Forearm^*

• 35 × 43 cm L.W. (14 × 17″) or 30 × 35 cm (11 × 14″) for smaller patients

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-39 AP forearm (to include both joints).

Position

• Patient seated at end of table with arm extended and hand supinated (shield across lap)

• Ensure that both wrist and elbow joints are included (use as large an IR as required to include both wrist and elbow joints).

• Have patient lean laterally as needed for a true AP of forearm.

Central Ray:

CR ⊥, centered to midpoint of forearm

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides, include a minimum of 2.5 cm (1″) beyond both wrist and elbow joints.

Lateral Forearm^*

• 35 × 43 cm L.W. (14 × 17″) or 30 × 35 cm (11 × 14″) for smaller patients

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-40 Lateral forearm (to include both joints).

Position

• Patient seated at end of table (shield across lap)

• Elbow should be flexed 90°.

• Hand and wrist must be in a true lateral position (distal radius and ulna should be directly superimposed).

• Ensure that both wrist and elbow joints are included unless contraindicated.

Central Ray:

CR ⊥, centered to midpoint of forearm

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides, include a minimum of 2.5 cm (1″) beyond both wrist and elbow joints.

AP Forearm

Evaluation Criteria

Anatomy Demonstrated:

• Entire radius and ulna

• Entire elbow and proximal carpals

Position:

• Slight superimposition of proximal radius/ulna

• Humeral epicondyles in profile

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissues and bony trabeculation clearly demonstrated

Fig. 2-41 AP forearm.

Lateral Forearm

Evaluation Criteria

Anatomy Demonstrated:

• Entire radius and ulna demonstrated

• Entire elbow and proximal carpals demonstrated

Position:

• True lateral position

• Humeral epicondyles superimposed

• Head of ulna and distal radius are superimposed.

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissues and bony trabeculation of carpal canal clearly demonstrated

Fig. 2-42 Lateral forearm.

AP Elbow^*

• 24 × 30 cm L.W. (10 × 12″)

• Nongrid

• Lead masking with multiple exposures on same IR

Fig. 2-43 AP, fully extended.

Position

• Elbow extended and hand supinated (shield across lap)

• Lean laterally as needed for true AP (palpate epicondyles)

• If elbow cannot be fully extended, take two AP projections as shown (Figs. 2-44 and 2-45) with CR perpendicular to distal humerus on one, and perpendicular to proximal forearm on another.

Central Ray:

CR ⊥, centered to mid-elbow joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to area of interest.

Fig. 2-44 CR, ⊥ to humerus.

Fig. 2-45 CR ⊥ to forearm.

AP Elbow—Fully Extended

Evaluation Criteria

Anatomy Demonstrated:

• Distal humerus

• Proximal radius and ulna

Position:

• Slight superimposition of proximal radius/ulna

• Humeral epicondyles in profile

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissues and bony trabeculation of elbow clearly demonstrated, no motion

Fig. 2-46 AP elbow fully extended.

AP—Partially Flexed Elbow

Fig. 2-47 Humerus parallel to IR.

Fig. 2-48 Forearm parallel to IR.

Evaluation Criteria

Anatomy Demonstrated:

• Distal ⅓ of humerus

• Proximal ⅓ of forearm

Position:

• Slight superimposition of proximal radius/ulna

• Humeral epicondyles in profile

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissue and bony trabeculation clearly demonstrated, no motion

Oblique Elbow (Medial and Lateral Rotation)^*

Medial (internal) oblique best visualizes coronoid process. Lateral (external) oblique best visualizes radial head and neck (most common oblique projection).

• 24 × 30 cm L.W. (10 × 12″)

• Nongrid

Fig. 2-49 Medial (internal) oblique (45°).

Position: Medial Oblique

• Elbow extended, hand pronated

• Palpate epicondyles to check for 45° internal rotation

Lateral Oblique:

Similar position except supinate hand and rotate elbow 40°–45° externally. More difficult for patient; lean entire upper body laterally as needed.

Central Ray:

CR ⊥, centered to mid-elbow joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to area of interest.

Fig. 2-50 Lateral (external) oblique (40°–45°).

Medial (Internal) Oblique Elbow

Evaluation Criteria

Anatomy Demonstrated:

• Proximal radius and ulna

• Medial epicondyle and trochlea

Position:

• Coronoid process in profile

• Radial head/neck superimposed over ulna

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissues and bony trabeculation clearly demonstrated

Fig. 2-51 Medial (internal) oblique elbow.

Lateral (External) Oblique Elbow

Evaluation Criteria

Anatomy Demonstrated:

• Proximal radius and ulna

• Lateral epicondyle and capitulum

Position:

• Radial head, neck, tuberosity free of superimposition

• Humeral epicondyles and capitulum in profile

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissues and bony trabeculation demonstrated; no motion

Fig. 2-52 Lateral (external) oblique elbow.

Lateral Elbow^*

• 24 × 30 cm L.W. (10 × 12″)

• Nongrid

• Lead masking with multiple exposures on same IR

Position

• Elbow flexed 90°, shoulder dropped as needed to rest forearm and humerus flat on table and IR (shield across lap)

• Center elbow to center of IR or to portion of IR being exposed, with forearm aligned parallel to edge of cassette.

• Place hand and wrist in a true lateral position.

Central Ray:

CR ⊥, centered to mid-elbow joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides, include a minimum of ≈5 cm (2″) of forearm and humerus.

Fig. 2-53 Lateral elbow, flexed 90°.

Lateral Elbow

Evaluation Criteria

Anatomy Demonstrated:

• Proximal radius/ulna and distal humerus

• Region of joint fat pads

Position:

• Olecranon process/trochlear notch in profile

• Humeral epicondyles superimposed

• Elbow flexed at 90°

Fig. 2-54 Lateral elbow.

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissues and bony trabeculation clearly demonstrated

Trauma Axial Lateral Elbow^*

(Coyle Method)

Special views to demonstrate radial head and coronoid process

• 24 × 30 cm L.W. (10 × 12″)

• Nongrid

Fig. 2-55 For radial head and neck, elbow flexed 90°.

Fig. 2-56 For coronoid process, elbow flexed 80°.

Position and Central Ray

Radial Head and Neck:

• Elbow flexed 90° if possible, with hand pronated

• Angle CR 45° toward thorax, centered to radial head and neck (CR to enter at mid-elbow joint)

Coronoid Process:

• Elbow flexed only 80°, with hand pronated

• Angle CR 45° away from thorax, centered to coronoid process (CR to enter at mid-elbow joint)

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to area of interest.

Trauma Axial Lateral Elbow

(Coyle Method)

Fig. 2-57 Axial lateral elbow (for radial head, neck, and capitulum).

Fig. 2-58 Axial lateral elbow (for coronoid process and trochlea).

Evaluation Criteria

Anatomy Demonstrated and Position—CR 45° Toward Shoulder:

• Radial head, neck, and capitulum; elbow flexed 90°

Anatomy Demonstrated and Position—CR 45° Away from Shoulder:

• Coronoid process and trochlea

• Coronoid process in profile, elbow flexed 80° (Flexion of more than 80° will obscure coronoid process)

Exposure:

• Optimal density and contrast (brightness and contrast for digital images)

• Soft tissues and bony trabeculation clearly demonstrated; no motion

Pediatric AP Upper Limb^*

With possible trauma, handle limb very gently with minimal movement. Take a single exposure to rule out gross fractures before additional radiographs are taken.

• IR size determined by patient age and size

• TT (tabletop IR) or image receptor

Fig. 2-59 AP, upper limb.

Position

• Supine position, arm abducted away from body, lead shield over pelvic area

• Include entire limb unless a specific joint or bone is indicated.

• Immobilize with clear flexible-type retention band and sandbags, or with tape.

• Use parental assistance only if necessary, provide lead gloves and apron.

Central Ray:

CR ⊥, centered to midlimb

SID:

40-44″ (102-113 cm)

Collimation:

On four sides to area of interest

Pediatric Lateral Upper Limb^*

• IR size determined by patient age and size

• TT (detail screens) or DR image receptor

Fig. 2-60 Lateral, upper limb.

Position

• Supine position with arm abducted away from body, lead shield over pelvic area

• Include entire limb unless a specific joint or bone is indicated.

• Immobilize with clear flexible-type retention band and sandbags or with tape.

• Flex elbow and rotate entire arm into a lateral position.

• Use parental assistance only if necessary, provide lead gloves and apron.

Central Ray:

CR ⊥, centered to midlimb

SID:

40-44″ (102-113 cm)

Collimation:

On four sides to area of interest

^*Bontrager Textbook, 8th ed, pp. 136 and 137.

^*Bontrager Textbook, 8th ed, p. 141.

^*Bontrager Textbook, 8th ed, p. 142.

^*Bontrager Textbook, 8th ed, p. 143.

^*Bontrager Textbook, 8th ed, p. 144.

^*Bontrager Textbook, 8th ed, p. 145.

^*Bontrager Textbook, 8th ed, p. 146.

^*Bontrager Textbook, 8th ed, p. 147.

^*Bontrager Textbook, 8th ed, p. 149.

^*Bontrager Textbook, 8th ed, p. 150.

^*Bontrager Textbook, 8th ed, p. 151.

^*Bontrager Textbook, 8th ed, p. 153.

^*Bontrager Textbook, 8th ed, p. 154.

^*Bontrager Textbook, 8th ed, p. 155.

^*Bontrager Textbook, 8th ed, p. 156.

^*Bontrager Textbook, 8th ed, pp. 157 and 158.

^*Bontrager Textbook, 8th ed, p. 159.

^*Bontrager Textbook, 8th ed, p. 160.

^*Bontrager Textbook, 8th ed, p. 162.

^*Bontrager Textbook, 8th ed, p. 163.

^*Bontrager Textbook, 8th ed, pp. 164 and 165.

^*Bontrager Textbook, 8th ed, pp. 166 and 167.

^*Bontrager Textbook, 8th ed, p. 168.

^*Bontrager Textbook, 8th ed, p. 170.

^*Bontrager Textbook, 8th ed, p. 635.

^*Bontrager Textbook, 8th ed, p. 635.