it all about basic x ray views of scaphoid and wrist positioning and

1. BASIC VIEWS OF
SCAPHOID AND WRIST
MAAJID MOHI UD DIN MALIK
LECTURER COPMS ADESH UNIVERSITY
BATHINDA,PUNJAB

2. Postero-anterior – ulnar deviation
Imaging of the carpal bones is most commonly
undertaken to demonstrate the scaphoid. The
projections may also be used to demonstrate
other carpal bones, as indicated below. Four
projections may be taken to demonstrate all the
carpal bones using a 24 X 30-cm cassette, each
quarter being used in turn, with the other three-
quarters masked off using lead rubber. For
scaphoid fractures, three projections are
normally taken: Postero-anterior, anterior
oblique and lateral.

3. Position of patient andcassette
→The patient is seated alongside the table
with the affected side nearest the table.
→The arm is extended across the table with
the elbow flexed and the forearm pronated.
→If possible, the shoulder, elbow and wrist
should be at the level of the tabletop.

4. CONT…
→The wrist is positioned over one-quarter of
the cassette and the hand is adducted (ulnar
deviation).
→Ensure that the radial and ulnar styloid
processes are equidistant from the cassette.
→The hand and lower forearm are
immobilized using sandbags

5. DIRECTION AND CENTRING OF THE X-RAY
BEAM
The vertical central ray is centred
midway between the radial and ulnar
styloid processes.

6. ESSENTIAL IMAGE CHARACTERISTICS
The image should include the distal end of
the radius and ulna and the proximal end of
the metacarpals.
 The joint space around the scaphoid should
be demonstrated clearly.

7. Antero-posterior radiograph of wrist

8. POSITION

9. POSITION

10. NORMAL POSTERO-ANTERIOR RADIOGRAPHOF SCAPHOIDIN
ULNAR DEVIATION

11. ANTERIOR OBLIQUE – ULNAR DEVIATION
Position of patient and cassette
From the Postero-anterior position, the hand
and wrist are rotated 45 degrees externally and
placed over an unexposed quarter of the
cassette. The hand should remain adducted in
ulnar deviation.
The hand is supported in position, with a non-
opaque pad placed under the thumb.
The forearm is immobilized using a sandbag.

12. DIRECTION AND CENTRING OF THE X-RAY
BEAM
The vertical central ray is centred
midway between the radial and
ulnar styloid processes.

13. ESSENTIAL IMAGE CHARACTERISTICS
The image should include the distal end of
the radius and ulna and the proximal end of
the metacarpals.
The scaphoid should be seen clearly, with its
long axis parallel to the cassette.

14. ANTERIOR OBLIQUE RADIOGRAPH OF
SCAPHOID

15. POSITION

16. NORMAL ANTERIOR OBLIQUE RADIOGRAPH OF
SCAPHOID

17. POSTERIOR OBLIQUE
Position of patient and cassette
From the anterior oblique position, the hand
and wrist are rotated externally through 90
degrees, such that the posterior aspect of the
hand and wrist are at 45 degrees to the
cassette.
The wrist is placed over an unexposed quarter
of the cassette, with the wrist and hand
supported on a 45-degree non-opaque foam
pad.
The forearm is immobilized using a sandbag.

18. Direction and centring of the X-ray beam
The vertical central ray is
centred over the styloid
process of the ulna.

19. ESSENTIAL IMAGE CHARACTERISTICS
The image should include the distal
end of the radius and ulna and the
proximal end of the metacarpals.
The pisiform should be seen clearly in
profile situated anterior to the
triquetral.
The long axis of the scaphoid should be
seen perpendicular to the cassette.

20. Posterior oblique radiograph of wrist

21. POSITION

22. NORMAL POSTERIOR OBLIQUE RADIOGRAPH
OF WRIST

23. Lateral
Position of patient and cassette
From the posterior oblique position, the hand
and wrist are rotated internally through 45
degrees, such that the medial aspect of the
wrist is in contact with the cassette.
The hand is adjusted to ensure that the radial
and ulnar styloid processes are superimposed.
The hand and wrist are immobilized using
non-opaque pads and sandbags.

24. DIRECTION AND CENTRING OF THE X-RAY
BEAM
The vertical central ray is centred
over the radial styloid process.

25. ESSENTIAL IMAGE CHARACTERISTICS
The image should include the distal end of
the radius and ulna and the proximal end of
the metacarpals.
The image should demonstrate clearly any
subluxation or dislocation of the carpal
bones.

26. RADIOLOGICAL CONSIDERATIONS
Fracture of the waist of the scaphoid may be
very poorly visible, if at all, at presentation. It
carries a high risk of delayed avascular
necrosis of the distal pole, which can cause
severe disability. If suspected clinically, the
patient may be re-examined after 10 days of
immobilization, otherwise a technetium bone
scan or magnetic resonance imaging (MRI)
may offer immediate diagnosis.

27. LATERAL RADIOGRAPH OF WRIST

28. POSTION

29. NORMAL LATERAL RADIOGRAPH OF WRIST

30. BASIC VIEWOF WRIST
Postero-anterior
Position of patient and cassette
 The patient is seated alongside the table, with the
affected side nearest to the table.
 The elbow joint is flexed to 90 degrees and the arm is
abducted, such that the anterior aspect of the
forearm and the palm of the hand rest on the
cassette.
 If the mobility of the patient permits, the shoulder
joint should be at the same height as the forearm.

31. CONT…
The wrist joint is placed on one half of the
cassette and adjusted to include the lower part
of the radius and ulna and the proximal two-
thirds of the metacarpals.
The fingers are flexed slightly to bring the
anterior aspect of the wrist into contact with
the cassette.
The wrist joint is adjusted to ensure that the
radial and ulnar styloid processes are
equidistant from the cassette.
The forearm is immobilized using a sandbag.

32. Direction and centring of the X-ray beam
The vertical central ray is centred to
a point midway between the radial
and ulnar styloid processes.

33. Essential image characteristics
The image should demonstrate the proximal
two-thirds of the metacarpals, the carpal
bones, and the distal third of the radius and
ulna.
There should be no rotation of the wrist
joint.

34. POSITION

35. Normal Postero-anterior radiograph of wrist

36. LATERAL– METHOD 1
Position of patient and cassette
 From the Postero-anterior position, the wrist is
externally rotated through 90 degrees, to bring the
palm of the hand vertical.
 The wrist joint is positioned over the unexposed half
of the cassette to include the lower part of the radius
and ulna and the proximal two-thirds of the
metacarpals.
 The hand is rotated externally slightly further to
ensure that the radial and styloid processes are
superimposed.
 The forearm is immobilized using a sandbag.

37. Direction and centring of the X-ray beam
The vertical central ray is centred
over the styloid process of the
radius.

38. Essential image characteristics
The exposure should provide adequate
penetration to visualize the carpal bones.
 The radial and ulnar styloid processes
should be superimposed.
 The image should demonstrate the
proximal two-thirds of the metacarpals, the
carpal bones, and the distal third of the
radius and ulna.

39. POSITION

40. NORMAL LATERAL RADIOGRAPH OF WRIST,
METHOD 1

41. Lateral – method 2
This projection will ensure that both the radius
and the ulna will be at right-angles, compared
with the Postero-anterior projection.
Position of patient and cassette
From the Postero-anterior position, the
humerus is externally rotated through 90
degrees.
The elbow joint is extended to bring the medial
aspect of the forearm, wrist and hand into
contact with the table.

42. CONT…
The wrist joint is positioned over the
unexposed half of the cassette to include the
lower part of the radius and ulna and the
proximal two-thirds of the metacarpals.
 The hand is rotated externally slightly
further to ensure that the radial and styloid
processes are superimposed.
 The forearm is immobilized using a
sandbag.

43. Direction and centring of the X-ray beam
The vertical central ray is
centred over the styloid process
of the radius.

44. Essential image characteristics
The exposure should provide adequate
penetration to visualize the carpal bones.
The radial and ulnar styloid processes should
be superimposed.
The image should demonstrate the proximal
two-thirds of the metacarpals, the carpal
bones and the distal third of the radius and
ulna.

45. Notes
If the patient’s limb is immobilized in plaster
of Paris, then it may be necessary to modify the
positioning of the patient to obtain accurate
Postero-anterior and lateral projections.
Increased exposure factors will be necessary to
penetrate the plaster, and the resultant image
will be of reduced contrast.
Light-weight plasters constructed from a
polyester knit fabric are radio-lucent and
require exposure factors similar to uncasted
areas.

46. POSITION

47. NORMAL LATERAL RADIOGRAPH OF WRIST,
METHOD 2

48. Postero-anterior radiograph of wrist through conventional plaster

49. Postero-anterior radiograph of wrist through light-weight plaster

50. Oblique (anterior oblique)
Position of patient and cassette
The patient is seated alongside the table,
with the affected side nearest to the table.
The elbow joint is flexed to 90 degrees and
the arm is abducted, such that the anterior
aspect of the forearm and the palm of the
hand rest on the tabletop.

51. CONT…
If the mobility of the patient permits, then the
shoulder joint should be at the same height as
the forearm.
The wrist joint is placed on the cassette and
adjusted to include the lower part of the radius
and ulna and the proximal two-thirds of the
metacarpals.
 The hand is externally rotated through 45
degrees and supported in this position using a
non-opaque pad.
The forearm is immobilized using a sandbag.

52. Direction and centring of the X-ray beam
The vertical central ray is centred
midway between the radial and
ulnar styloid processes.

53. Essential image characteristics
The exposure should provide adequate
penetration to visualize the carpal
bones.
The image should demonstrate the
proximal two-thirds of the
metacarpals, the carpal bones, and the
distal third of the radius and ulna.

54. Radiological considerations
Fracture of the distal radius can be undisplaced,
dorsally angulated (Colles’ fracture) or ventrally
angulated (Smith’s fracture). The importance of
Smith’s fracture lies in the fact that it is less
stable than Colles’ fracture.
Dislocations of the carpus are uncommon, but
again they carry potential for serious disability.
One manifestation of lunate dislocation is an
increased gap between it and the scaphoid,
which will be missed if the wrist is rotated on
the posteroanterior projection.

55. POSTION

56. Normal anterior oblique radiograph of wrist

57. To changethe projectionof the ulna, the armmust be rotatedas shown in
the three photographs above