This image evaluation provides a detailed analysis of a PA hand x-ray image based on standards of HIPAA compliance, marker and patient identification, radiation hygiene, completeness of positioning/projection, artifact identification, image sharpness, accurate part positioning, and judicious exposure technique. While meeting minimum acceptance criteria, the summary identifies areas for improvement, including inclusion of soft tissue, proper marker and technologist identification, collimation on three sides, and centering of the CR. The evaluator recommends accepting the image with corrections.

1. IMAGE EVALUATION:
PA HAND
Nicolette Brennan

2. HIPAA COMPLIANCE
• This image is HIPAA compliant
• There is no information related to patient
identification or to the imaging facility
• This image does not violate patient
confidentiality

3. MARKER & PATIENT ID
• Correct anatomical side marker is visible
• Marker does not superimpose pertinent anatomy
• Side marker is partially visible; however, it should be
placed either medially or laterally adjacent to the
proximal end of the hand
• Radiographer's identification number
(initials/numbers) are not present
• An arrow marker can be used to point to an area of
pain/trauma, but is not present in this image
• Image is displayed correctly, oriented as if the patient
is hanging from the distal phalanges
R
NB

4. RADIATION HYGIENE
• Three sides of beam restriction must be
visible on an image and gonadal shielding
must be provided if the gonads are within 5
cm of the primary beam
• The image does not appear to have adequate
collimation; only 2 sides of beam restriction
(medial & lateral) are present, presenting a
thin white border
• Black border (masking) covers the
collimation
R
NB

5. RADIATION HYGIENE
• There should be visible collimation at
the distal end of the phalanges
• There is evidence of primary gonadal
shielding because there is evidence
of beam restriction on the lateral side
of the part (closest to the gonads)
• The gonads are > 5 cm from the edge
of the primary beam, but secondary
shielding should also be used R
NB

6. COMPLETENESS OF
POSITION/PROJECTION
• Routine Procedures:
• PA Projection
• PA 45 degree Oblique Projection
• "Fan" Lateral Projection (Lateromedial)
PA Hand
PA Oblique
"Fan" Lateral
Projection

7. COMPLETENESS OF
POSITION/PROJECTION
• This image complies with the routine
positions/projections
• All anatomical parts are correctly visualized,
however the collimation could have been
open more to include the soft tissue aspects
of the first distal phalange
R
NB

8. ARTIFACT
IDENTIFICATION
• No preventable physical artifacts are visible
• There are no body parts superimposed that
should not be
• Hospital paraphernalia is not visible
• No patient clothing/belongings visible
• No indwelling artifacts/foreign bodies present
R
NB

9. ARTIFACT
IDENTIFICATION
• There is no excess fog visible or
degrading overall image quality
• No CR/DR artifacts visible in the image
R
NB

10. IMAGE SHARPNESS
• There is no "gross" voluntary motion visible on
the image
• Bony trabecular margins are well visualized
• There is no excessive quantum mottle present in
the image
• No evidence of double (or previous/ghosted)
exposure present
• There are no grid lines, grid artifacts or grid cut-
off visible in the image, as a grid is not routinely
used when imaging a hand R
NB

11. IMAGE SHARPNESS
• Size distortion does not appear to be greater
than expected for this image
• OID should be minimal when imaging a PA
hand. Phalanges should be extended, palm is
flat against IR plate
• CR should be perpendicular to 3rd MCP joint
• CR is slightly off but does not appear to be
>1cm, so there is no evidence of shape
distortion
R
NB

12. ACCURATE PART POSITIONING
• Part is slightly off-centered longitudinally and
transversely to the image media
• CR appears to be slightly off-centered,
however is within 1 cm of the anatomical
part
• CR is adequately aligned with image media
• The CR's alignment does conform to an
accepted IR exposure field recognition
template / field because there are 2 sides of
collimation parallel to the adjacent sides of
the IR
R
NB

13. ACCURATE PART
POSITIONING
According to Kathy McQuillen Martensen’s
Radiographic Image Analysis and Merrill’s
Atlas:
Pronate and extend the hand and fingers, and
place the palmar surface flat against the IR in a
PA projection.
Center hand on IR
Separate fingers, leaving a slight space
between them.
Ensure fingers are fully extended, placing them
parallel with the IR

14. ACCURATE PART
POSITIONING
According to Kathy McQuillen Martensen’s
Radiographic Image Analysis and Merrill’s
Atlas:
Position thumb a small distance from the hand
Center a perpendicular CR to third MCP joint
Open the longitudinal collimation to include
the distal phalanges and 1 inch of the distal
forearm
Transversely collimate to within 0.5 inch of the
first and fifth digits' skin line

15. ACCURATE PART
POSITIONING
According to Kathy McQuillen Martensen’s
Radiographic Image Analysis and Merrill’s
Atlas:
Soft tissue outlines of the second through
fifth phalanges are uniform
Distance between the MC heads is equal
Equal midshaft concavity is seen on both
sides of the phalanges and MCs of the second
through fifth fingers
IP, MCP, and CM joints are demonstrated as
open spaces
Phalanges are demonstrated without
foreshortening
Thumb demonstrates a 45-degree-
oblique projection
Thumb is positioned close to the hand
Third MCP joint is at the center of the
exposure field
Phalanges, MCs, carpals, and 1 inch of
the distal radius and ulna are included
within the exposure field

16. ACCURATE PART POSITIONING
• The anatomical part is correctly positioned based
on positioning criteria
• The hand is pronated with fingers extended
• Fingers are parallel with the IR and are
separated with slight space between them
• CR is slightly off-centered but is within 1 cm
of the anatomical part
• All pertinent anatomy is included within the
collimated field
• However, only 2 sides of collimation are present
with thin white border
R
NB

17. ACCURATE PART POSITIONING
• Soft-tissue outlines of second through fifth
phalanges are uniform
• No rotation as distance between MC heads is
equal
• No tissue overlap from adjacent fingers
• IP, MCP, and CM joints are open
• Phalanges demonstrated without
foreshortening
• Thumb is positioned close to hand, however
distal soft tissue structure is collimated off R
NB

18. JUDICIOUS EXPOSURE
TECHNIQUE
• The most radiolucent structures are the soft
tissue surrounding the bony structure and
the joint spaces they are visible on the image
• The most radiopaque structure is the bony
cortex and it is visible
• The image's scale of contrast is short scale
and appears adequate
• The image's brightness is adequate to
visualize all anatomical structures necessary R
NB

19. JUDICIOUS EXPOSURE
TECHNIQUE
• No EI value is associated with this image and
it is difficult to determine whether the image
was over, under, or adequately exposed
• Upon evaluating this image, I would expect
the EI value to be within normal range
R
NB

20. ACCEPT/REJECT IMAGE
This image meets the minimum established
standards for acceptance criteria – ACCEPT
Required Corrections:
• Include soft tissue structure of the first distal
phalanx
• "Right" marker including technologist's
initials or identification number
• Proper collimation ≥ 3 sides
• Center a perpendicular CR to third MCP joint R
NB

21. REFERENCES
https://radiopaedia.org/cases/hand-annotated-x-rays
Kathy McQuillen Martensen Radiographic Image Analysis and Merrill’s
Atlas