Upper Limb Plain Radiology: DR. MITESH J. PATEL(M.S ORTHO)

PLAIN RADIOLOGY
UPPER LIMB
DR. Mitesh J. Patel
Orthopaedics Resident
HOU:DR. Rohit B.Shah
GCS Medical College And Hospital,
Ahmedabad

DORSI-PALMAR
•
•
POSITION: The forearm is
pronated and placed on
the table with the palmer
surface of the hand in
contact with the Image
receptor.
BEAM: The collimated
ver cal beam is centred
over the head of the 3rd
metacarpal

ANTERIOR OBLIQUE (DP OBLIQUE)
•
•
POSITION: From the basic
postero-anterior posi on, the
hand is externally rotated 45°
with the ﬁngers extended.
The ﬁngers should be
separated slightly and the
hand supported on a 45°
non-opaque pad.
ver cal beam is centred over
the head of the 5th
metacarpal.

LATERAL
•
•
POSITION: From the
postero-anterior (DP)
posi on, the hand is
externally rotated 90°.
The palm of the hand is
perpendicular to the
image receptor
over the head of the 2nd
metacarpal.

USE: The lateral view is
used primarily to assess for
foreign bodies and/or
displacement of fractures/
disloca ons.

BALL CATCHER’S OR NORGAARD
PROJECTION
•
•
POSITION:Both forearms
are supinated and placed
on the table with the
dorsal surface of the
hands in contact with the
image receptor.
From this posi on both
hands are rotated
internally (medially) 45°
into a ‘ball catching’
posi on.
•BEAM: The collimated ver cal beam is centred to a point
midway between the hands at the level of the 5th
metacarpophalangeal joints.

USE: The ball-catcher view is o en done to inves gate signs
of rheumatoid arthri s.
Normal radiograph of hands in
‘ball catcher’s’ posi on.
Radiograph of hand in ball
catcher’s posi on showing severe
Erosive disease.

FINGERS
DORSI-PALMAR
•
•
•
POSITION: The pa ent is
posi oned seated
alongside the table as for
a postero-anterior
projec on of the hand.
The forearm is
pronated with the
anterior (palmer) aspect
of the finger(s) in contact
with the image receptor.
The finger(s) are
extended and separated.
• BEAM: The collimated ver cal beam is centred over the proximal
interphalangeal joint of the affected and adjacent finger.

LATERAL INDEX AND MIDDLE FINGERS
•
•
POSITION: The index
finger is fully extended
and the middle finger
slightly flexed to avoid
superimposi on.
BEAM :The collimated
ver cal central ray is
centred over the
proximal interphalangeal
joint of the affected
finger.

LATERAL RING AND LITTLE FINGERS
• POSITION: The affected finger is
extended and the remaining fingers
are fully flexed into the palm of the
hand and held there by the thumb
in order to prevent superimposi on.
•BEAM: The collimated ver cal
beam is centred over the proximal
interphalangeal joint of the
affected finger.

•
•
USE: Scleroderma
(one cause of
Raynaud’s disease)
causes was ng and
calcifica on of the
so ssue of the
finger pulp.
Chip fracture of the
base of the dorsal
aspect of the distal
phalanx is
associated with
avulsion of the
inser on of the
extensor digitorum
tendon, leading to
the mallet finger
deformity.
Lateral radiograph of
middle finger showing a
fracture of the middle
phalanx.
Lateral radiograph of li le
finger showing disloca on
of the distal
interphalangeal joint.

THUMB
LATERAL
•
•
POSITION:The thumb is
ﬂexed slightly and the
palm of the hand is
placed on the image
receptor.
over the 1st MCPJ.

THUMB
ANTERO-POSTERIOR (AP)
•
•
POSITION: The pa ent
leans forward, lowering
the shoulder so that the
1st metacarpal is
parallel to the tabletop.
ver cal central ray is
centred over the 1st
MCPJ.

THUMB
POSTERO-ANTERIOR
•
•
POSITION:With the hand
in the postero-anterior
posi on, the palm of the
hand is rotated through
90° to bring the medial
aspect of the hand in
contact with the table
and the palm ver cal.
BEAM:The collimated
over the base of the 1st
metacarpal.

•USE: Fracture of the base of the 1st metacarpal
through the joint surface may be associated with
disloca on due to the pull of the abductor and
extensor tendons of the thumb. This is known as
Benne ’s fracture and may cause func onal
impairment and early degenera ve disease if not
corrected.
In contrast, a fracture that does not transgress
the ar cular surface does not dislocate and does not
have the same signiﬁcance
(Rolando fracture).

SCAPHOID (CARPAL BONES)
Postero-anterior – ulnar devia on
•
•
POSITION: The wrist is
posi oned over the
centre of the image
receptor and the hand is
adducted (ulnar
devia on).
midway between the
radial and ulnar styloid
processes.

SCAPHOID
ANTERIOR OBLIQUE – ULNAR DEVIATION
•
•
POSITION: From the
postero-anterior posi on,
the hand and wrist are
rotated 45° externally
and placed over the
image detector.
midway between the
processes.

LATERAL
•
•
POSITION: From the
posterior oblique
posi on, the hand and
wrist are rotated
internally through 45°,
such that the medial
aspect of the wrist is in
contact with the image
detector.
over the radial Styloid
process.

RADIOLOGICAL CONSIDERATIONS:
• Fracture of the waist of the
scaphoid may be very poorly
visualised, or may go unno ced, at
presenta on.
• These fractures carry a high risk
of delayed avascular necrosis
of the distal pole, which can cause
severe disability.
If suspected clinically, the pa ent
may be re-examined a er
10 days of immobilisa on,
otherwise a magne c resonance
imaging scan (MRI) may oﬀer
immediate diagnosis
Normal lateral radiograph of wrist.

CARPAL TUNNEL VIEW
•
•
Axial – method 1: The
palm of the hand is
pressed onto the
detector, with the wrist
joint dorsiﬂexed to
approximately135°.
Axial – method 2: The
lower end of the forearm
rests against the edge of
the block, with the wrist
adducted and dorsiﬂexed
to 135°.
Axial – method 1
Axial – method 2

BEAM : The collimated ver cal central ray is centred between
the pisiform and the hook of the hamate medially and the
tubercle of the scaphoid and the ridge of the trapezium
laterally.
RADIOLOGICAL
CONSIDERATION: To
demonstrate the medial and
lateral prominences and the
concavity.
Also Hook of hamate,
pisiform and trapezium
fractures

WRIST
Postero-anterior
•
•
POSITION: The elbow
joint is ﬂexed to 90° and
the arm abducted such
that the anterior aspect
of the forearm and the
palm of the hand rest
on the image receptor.
BEAM: The ver cal
central ray is centred to
a point midway
between the radial and
ulnar styloid processes.

WRIST- LATERAL
•
•
•
POSITION: From the
postero-anterior posi on
the wrist is externally
rotated through 90° to
bring the palm of the
hand ver cal.
The hand is rotated
externally slightly further
to ensure that the radial
and styloid processes are
superimposed.
BEAM: The ver cal
central ray is centred
over the styloid process
of the radius.

WRIST OBLIQUE
•
•
POSITION: The hand is
externally rotated
through 45° and
supported in this
posi on using a non-
opaque pad.
midway between the
processes.

• Fracture of the distal radius can be
undisplaced, dorsally angulated (Colles’
fracture) or ventrally angulated (Smith’s
fracture).
• Disloca ons of the carpus are
uncommon, but again they carry
poten al for serious disability.
• One manifesta on of lunate
disloca on is an increased gap between
it and the scaphoid, which will be missed
if the wrist is rotated on the postero-
anterior projec on.

FOREARM
Antero-posterior
•
•
POSITION: The arm is
abducted and the elbow
joint is fully extended,
with the supinated
forearm res ng on the
table.
in the midline of the
forearm to a point
midway between the
wrist and elbow joints.

Forearm
Lateral
•
•
POSITION: From the
antero-posterior posi on,
the elbow is ﬂexed to 90°.
The humerus is internally
rotated to 90° to bring
the medial aspect of the
upper arm, elbow,
forearm, wrist and hand
into contact with the
table.
in the midline of the
forearm to a point
midway between the
wrist and elbow joints.

•
Radiological considera ons:
• When two or more bones such as the
radius and ulna form a ring, fracture of
one of the bones is o en associated
with fracture or disloca on elsewhere
in the ring, especially if the fracture is
displaced or the bone ends overlap.
• In Galeazzi fracture there is a fracture
of the radius with disloca on of the
distal ulna, while in Monteggia fracture
there is fracture of the ulna with
disloca on of the head of the radius.
In forearm fracture, therefore, both
ends of both bones, as well as the
proximal and distal radio-ulnar joints,
must be demonstrated.

LATERAL
•
•
POSITION: The elbow is
ﬂexed to 90°and the
palm of the hand is
rotated so that it is at
90° to the tabletop.
over the lateral
Epicondyle of the
humerus.

ANTERO-POSTERIOR
•
•
POSITION: From the
lateral posi on, the
pa ent’s arm is
externally rotated.Then
arm is then extended
fully.
BEAM:The collimated
through the joint space
2.5 cm distal to the
point midway between
the medial and lateral
epicondyles of the
humerus.

AXIAL
•
•
•
POSITION: The elbow is fully ﬂexed, and
the palm of the hand is facing the
upwards. The forearm is fully supinated.
BEAM: A]For the proximal ends of the
radius and ulna and the radiohumeral
joint to a point on the posterior aspect
of the upper arm 5 cm proximal to the
olecranon process.
B] For the lower end of the humerus
and the olecranon process of the ulna
to a point at right-angles to the upper
arm 5 cm proximal to the olecranon
process.

HUMERUS – SUPRACONDYLAR
FRACTURE- LATERAL
•
•
POSITION: An image
receptor is supported
between the pa ent’s
trunk and elbow, with
the medial aspect of the
elbow in contact with the
image detector.
beam is angled so that
the beam is directed
sha of the humerus and
centred to the lateral
epicondyle.

Antero-posterior
•
•
POSITION: From the lateral
posi on, the pa ent’s
upper body is rotated
towards the aﬀected side.
BEAM: central ray is
directed at right-angles to
the humerus to a point
midway between the
epicondyles of the humerus
without ﬁrst passing
through the forearm.

HUMERUS – SHAFT
ANTERO-POSTERIOR
•
•
POSITION: The pa ent sits or stands with
their back in contact with the image
receptor. The pa ent is rotated towards
the aﬀected side to bring the posterior
aspect of the shoulder, upper arm and
elbow into contact with the image
receptor.
BEAM: The ver cal collimated X-ray
beam is centred to a point midway
between the shoulder and elbow joints
at rightangles to the image receptor.

LATERAL
•
•
POSITION: From the anterior posi on,
the pa ent is rotated through 90°
un l the lateral aspect of the injured
arm is in contact with the image
receptor.
BEAM:The horizontal collimated X-ray
beam is centred to a point midway
between the shoulder and elbow
joints at rightangles to the sha .

HUMERUS – INTERTUBEROUS
SULCUS (BICIPITAL GROOVE)
•
•
•
•
POSITION: The pa ent lies supine on
the X-ray table.
The image receptor is supported
ver cally above the shoulder.
The arm is rested on the tabletop
with the palm of the hand facing the
pa ent’s side and the line joining the
epicondyles of the humerus at 45° to
the table.
BEAM: The horizontal collimated X-ray
beam is directed cranially and centred
to the anterior part of the head of the
humerus.

HUMERUS NECK
Antero-posterior
•
•
POSITION: The pa ent is rotated
towards the aﬀected side to bring
the posterior aspect of the injured
shoulder into contact with the
midline of the image receptor.
BEAM: The collimated X-ray beam
is directed at right-angles to the
humerus and centred to the head
of the humerus.

Supero-inferior [Axial]
•
•
POSITION: The pa ent is seated
at one end of the table, with the
trunk leaning towards the table,
the arm of the side being
examined in its maximum
abduc on, and the elbow
res ng on the table.
BEAM:The collimated ver cal X-
ray beam is directed to the
acromion process of the scapula.

ANTERO-POSTERIOR
•
•
stands with the aﬀected
shoulder against the
image receptor and is
externally rotated 15° to
bring the shoulder under
examina on closer to
the image receptor.
horizontal beam is
directed to the palpable
coracoid process of the
scapula.

• External rota on of the humerus
shows the greater tuberosity in profile
and the humeral head has a ‘walking
s ck appearance.
• Internal rota on of the humerus
demonstrates the lesser tuberosity in
profile and the humeral head has a
‘lightbulb’appearance.
• A posterior disloca on is difficult to
detect on an AP and a second
projec on should always be
obtained in trauma.

Supero-inferior (axial)
•
•
•
POSITION: The image receptor
is placed on the tabletop, and
the arm under examina on is
abducted over the table.
BEAM: The collimated ver cal
beam is centred over the mid
glenohumeral joint.
INDICATION: Used for
assessing subluxa on or
disloca on as well as bankart
lesion.

Infero-superior (reverse axial)
•
•
lies supine, with the
arm of the aﬀected side
abducted and supinated.
horizontal beam is
centred towards the
axilla with minimum
angula on towards the
trunk.

Radiograph of infero-superior
shoulder showing posterior
disloca on.
Radiograph of infero-
superior shoulder

Apical oblique
(Garth projec on)
•
•
POSITION: The pa ent is
posi oned erect. The
pa ent is then rotated
toward the aﬀected side
so they a ain a 45°
posterior oblique
posi on.
horizontal beam is
centred to the image
receptor and a 45°
caudal tube angula on is
employed.

Anterior oblique (‘Y’
projec on)
•
•
POSITION:The pa ent stands or sits
with the lateral aspect of the injured
arm against the image receptor and is
adjusted so that the axilla is in the
centre of the receptor.
• The unaﬀected shoulder is raised to
make the angle between the trunk and
the receptor approximately 60°. A line
joining the medial and lateral borders
of the scapula is now at right-angles to
the receptor.
BEAM: The collimated horizontal beam
is centred towards the medial border
of the scapula and centred to the head
of the humerus.

• This is a useful projec on for
diﬀeren a ng the direc on of a
disloca on but is less useful for
demonstra ng associated
fractures.

Infero-superior modiﬁed (West
Point projec on)
• POSITION: The pa ent
lies prone on the X-ray
table with the head
turned away from the
aﬀected side. The
humerus is abducted
90°. The forearm then
hangs over the side of
the X-ray table.

Infero-superior modiﬁed (West
Point projec on)
•
•
BEAM: The beam is
centred such that is
passes through
glenohumeral joint and
exits the shoulder at a
point just medial to the
deltoid muscle.
USED TO: Demonstrates
the anterior aspect of the
glenoid rim and is useful
for detec ng Bankart
lesions.

Antero-posterior modified (Stryker
projec on)
•
•
POSITION: The arm of the
affected side is extended
fully and the elbow then
flexed to allow the hand
to rest on the pa ent’s
head.
ver cal beam is angled
10° cranially and centred
through the centre of the
axilla to the head of the
humerus.

Radiograph of Stryker projec on
demonstra ng a Hill–Sachs
lesion
Radiological considera on:
• This projec on is highly
eﬀec ve in demonstra ng a
Hills–Sachs deformity.

GLENOHUMERAL JOINT
Grashey projec on
• POSITION:The pa ent
shoulder against the
image receptor and the
torso is rotated
approximately 35-45°
toward the aﬀected side
to bring the plane of the
glenoid fossa
receptor.

horizontal beam is
centred just below the
palpable coracoid process
of the scapula.
Radiological
considera ons:
Useful in joint instability and
for narrowing seen in arthri s

OUTLET PROJECTIONS (calciﬁed
tendons) Antero-posterior 25°↓
•
•
POSITION:The pa ent
shoulder and rotated 15°
to bring the plane of the
scapula parallel with the
image receptor.
BEAM:The collimated
central ray is angled 25°
caudally and centred to
the upper border of the
head of the humerus and
to the centre of the
receptor.

Radiological
considera ons:
• This projec on is useful for
demonstra ng the inser on
of the infraspinatus muscle
and the subacromial space in
cases of impingment or
calciﬁed tendons.
Radiograph of AP 25°↓
projec on, showing small
calciﬁca on in
the subacromial space.

LATERAL OBLIQUE 15°↓
•
•
POSITION: • The pa ent
stands or sits facing the
image receptor, with the
lateral aspect of the aﬀected
arm in contact. The aﬀected
arm is extended backwards,
with the dorsum of the hand
res ng on the back of
pa ent’s waist.
BEAM:The collimated
horizontal beam is angled
10–15° caudally and centred
just below the ACJ.

Radiological
considera ons
• The projec on may
show subacromial
abnormali es such as
osteophytes, which
may cause impingment.

ACROMIOCLAVICULAR JOINTS
ANTERO-POSTERIOR[ZANCA VIEW]
•
•
POSITION: The shoulder being examined is
placed in contact with the receptor, and
the pa ent is then rotated approximately
15° towards the side being examined to
bring the ACJ space at right-angles to the
image receptor with the acromion process
central to the ﬁeld.
BEAM:The collimated horizontal beam is
centred to the palpable lateral end of the
clavicle at the ACJ. To avoid
superimposi on of the joint on the spine
of the scapula, the central ray can be
angled 15–25° cranially before centring to
the joint.

AP radiography of ACJ showing
subluxa on.
Normal AP radiograph of ACJ
Radiological considera ons
• The normal joint is variable
(3–8 mm) in width. The normal
diﬀerence between the sides
should be less than 2–3 mm.

CLAVICLE
Postero-anterior
•
•
POSITION: The pa ent sits or
stands facing an erect image
receptor. The pa ent’s head is
turned away from the side being
examined and the aﬀected
shoulder rotated slightly forward
to allow the aﬀected clavicle to
be brought into close contact
with the image receptor.
BEAM: The collimated horizontal
beam is centred to the middle of
the clavicle.

PA radiograph of clavicle
showing comminuted
fracture.
Normal PA radiograph of
clavicle.

STERNOCLAVICULAR JOINTS
SERENDIPITY/ROCKWOOD VIEW
•
•
Serendipity View "some mes
called Rockwood view"
obtained to demonstrates
sternoclavicular joints and
medial 1/3 of the clavicles for
fractures or disloca on.
As Medial clavicular fractures
and SC joint injuries may be
diﬃcult to appreciate on
standard views because of the
overlap of the clavicle with
the sternum and the ﬁrst rib.

NORMAL ROCKWOOD (SERENDIPITY) VIEW OF THE
STERNOCLAVICULAR (SC) JOINT.

SCAPULA
Antero-posterior
•
•
POSITION:The pa ent stands
with the aﬀected shoulder
against the ver cal stand and
rotated slightly to bring the
plane of the scapula parallel with
the receptor. The arm is slightly
abducted away from the body
and medially rotated.
BEAM:The collimated horizontal
beam is centred 2.5 cm inferior
and medial to the head of the
humerus.

AP radiograph of scapula showing
a fracture through the neck of the
glenoid
•
•
Radiological
considera ons
There are o en underlying
rib fractures in pa ents who
have suﬀered trauma to the
scapula. These may lead to a
pneumo-thorax.
It is therefore important that
exposure and image
processing factors are
manipulated to ensure lung
markings can be clearly seen.

Anterior oblique (lateral)
Y-VIEW
•
•
POSITION: The arm is
either adducted across the
body or abducted with the
elbow ﬂexed to allow the
back of the hand to rest on
the hip.
horizontal beam is centred
to the midpoint of the
medial border of the
scapula and to the middle
of the receptor.

Normal lateral
radiograph of scapula.

CORACOID PROCESS
•
•
POSITION:The shoulder of
the affected side is flexed to
above-shoulder level and
the elbow flexed, allowing
the hand to rest on the
pa ent’s head.
horizontal beam is centred at
right-angles to the image
receptor and centred to the
axilla of the affected side.

Upper Limb Plain Radiology: DR. MITESH J. PATEL(M.S ORTHO)

Upper Limb Plain Radiology: DR. MITESH J. PATEL(M.S ORTHO)

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