RADIOGRAPHIC TECHNIQUE OF UPPER LIMB BY SAGAR CHAULAGAIN

RADIOGRAPHIC TECHNIQUE
OF UPPER LIMB
SAGAR CHAULAGAIN
BSCMIT 1sT YEAR
ROLL NO:-157
MMC , IOM
1

CONTENTS:-
• INTRODUCTION
• RADIOGRAPHY OF HAND
• RADIOGRAPHY OF WRIST
• RADIOGRAPHY OF FOREARM
• RADIOGRAPHY OF ELBOW
• RADIOGRAQPHY OF ARM
2

INTRODUCTION TO RADIOGRAPHIC
TECHNIQUE OF UPPER LIMB
• Upper limb radiography is the radiological investigation of the
shoulder girdle, humerus, radius, ulna, carpals, metacarpals and
phalanges of the hand.
• It is often utilized in the context of trauma to rule out fractures
and dislocations.
3

General terms
• Radiograph and radiography:-
radiograph is an image of a patient’s anatomic parts, as produced by the
action of x-rays on an image receptor and radiography is the process and
procedures of producing a radiograph.
• Image receptor (IR):
The device that captures the radiographic image that exits the patient; refers
to both film-screen cassettes and digital acquisition devices
• Central ray (CR):
Refers to the center-most portion of the x-ray beam emitted from the x-ray
tube; the portion of the x-ray beam that has the least divergence.
4

Terms Related to Movements of upper limbs
• Flexion versus extension:-
Flexion decreases the angle of the joint and Extension increases the angle as
the body part moves from a flexed to a straightened position
• Ulnar deviation versus radial deviation of wrist:-
Ulnar deviation is to turn or bend the hand and wrist from the natural position
toward the ulnar side, and radial deviation is toward the radial side of the
wrist.
• Abduction versus adduction:-
Abduction is the lateral movement of the arm or leg away from the body and
Adduction is a movement of arm or leg toward the body, to draw toward a
center or medial line
5

• Supination versus pronation:-
Supination is a rotational movement of the hand into the anatomic position
(palm up in supine position or forward in erect position). Pronation is a
rotation of the hand into the opposite of the anatomic position (palm down or
back).
• Elevation versus depression:-
Elevation is a lifting, raising, or moving of a part superiorly. Depression is a
letting down, lowering, or moving of a part inferiorly.
6
Terms Related to Movements of upper limbs

Radiographic anatomy:-
• The 27 bones on each hand and wrist are divided into three groups:
1. Phalanges (fingers and thumb) 14
2. Metacarpals (palm) 5
3. Carpals (wrist) 8
The most distal bones of the hand are the phalanges, which constitute the
digits (fingers and thumb). The second group of bones is the metacarpals ;
these bones make up the palm of each hand. The third group of bones, the
carpals, consists of the bones of the wrist.
8
Radiography of Hand and Wrist

• Each finger and thumb is called a digit, and each digit consists
of two or three separate small bones called phalanges.
• The digits are numbered, starting with the thumb as 1 and
ending with the little finger as 5.
• Each of the four fingers or digits (2, 3, 4, and 5) is composed of
three phalanges—proximal, middle, and distal and The thumb,
or first digit, has two phalanges—proximal and distal.
• Each phalanx consists of three parts: a distal head, a body, and
base.
9

• The thumb has only two phalanges and two joints, the joint B/W
phalanges is called the interphalangeal (IP) joint and The joint
B/W the first metacarpal and the proximal phalanx of the thumb is
called the first metacarpophalangeal (MCP) joint.
• Each of the second through fifth digits has three phalanges, and
they have three joints each. Starting from the most distal portion
of each digit, the joints are the distal interphalangeal (DIP) joint
followed by the proximal interphalangeal (PIP) joint, and, most
proximally, the metacarpophalangeal (MCP) joint.
10

• Metacarpals are also numbered in the same way as the digits are,
with the first metacarpal being on the thumb.
• metacarpal is composed of three parts, similar to the phalanges.
Distally, the rounded portion is the head, The middle portion,
body (shaft) and The base is the expanded proximal end, which
articulates with associated carpals.
• The metacarpals articulate with the phalanges at their distal ends
by metacarpophalangeal (MCP) joints and at the proximal end it
articulate with the respective carpals and by carpometacarpal
(CMC) joints.
11

12

• The third group of bones of the hand and wrist are the carpals,
the bones of the wrist.
• There are the eight carpal bones which are divided into two rows
of four each.
13
Proximal
row:-
Scaphoid
(boat-shaped
bone)
The lunate
(moon-
shaped)
triquetrum
(pyramidal
shape)
The pisiform
(pea-shaped)
Distal
row :-
trapezium
(irregularly
shaped )
Trapezoid
(wedge-
shaped)
Capitate hamate

Radiography of Hand and Wrist 14

Projections and clinical indications for fingers
Clinical indications Routine projections
 Fractures and dislocations of the
phalanges, metacarpal and associated
joints.
 Pathologic processes, such as
osteoporosis and osteoarthritis.
 PA
 PA Oblique
 Lateral
15

Patient Position:-
• Seat patient at end of table, with elbow flexed about
90° and with hand and forearm resting on the table.
• Pronate hand with fingers extended.
• Center and align long axis of affected finger with long
axis of IR.
• Separate adjoining fingers from affected finger.
CR:-
• CR perpendicular to IR, directed to PIP joint.
16
PA projection of fingers:-

Evaluation Criteria
• Anatomy should be demonstrated of Distal, middle, and proximal
phalanges; distal metacarpal; and associated joints.
• No rotation of fingers is evidenced by symmetric appearance of both sides
or concavities of the shafts of the phalanges and distal metacarpals.
• The amount of tissue on each side of the phalanges should appear equal.
• Fingers should be separated with no overlapping of soft tissues.
• Interphalangeal joints should appear open, indicating that hand was fully
pronated and the correct CR position was used.
17
PA projection of fingers:-

Patient position
• Only difference in the positioning is that fingers are
extended against 45° foam wedge block by placing hand in
a 45° lateral oblique (thumb side up).
• Position hand on cassette so that the long axis of the finger
is aligned with the long axis of the IR.
• Separate fingers and carefully place finger that is being
examined against block, so it is supported in a 45° oblique
and parallel to IR.
18
PA oblique projection of fingers:-

CR:-
Note :-
Second digit also may be taken in a 45° medial oblique
(thumb side down) with thumb and other fingers flexed to
prevent superimposition. This position places the part closer
to the IR for improved definition but may be more painful
for the patient.
19
PA oblique projection of fingers:-

Lateral (Lateromedial/Mediolateral)
projections of fingers:-
Patient Position:-
• Hand should be Placed in lateral position (thumb side
up) with finger to be examined fully extended and
centered to portion of IR being exposed.
• Align and center the finger to long axis of IR and to CR ,
Use sponge block or other radiolucent device to support
finger and prevent motion and Flex unaffected fingers.
CR:-
20

Lateral (Lateromedial/Mediolateral)
projections of fingers:-
• For second digit, a mediolateral is advised if the
patient can assume this position. Place the second digit
in contact with IR. (Definition is improved with less
object image receptor distance (OID).
21

Projections and clinical indications for thumb 22
Clinical indications Projections
 Fractures and dislocations of the distal
and proximal phalanges, distal
metacarpal, and associated joints
 Pathologic processes, such as
osteoporosis and osteoarthritis.
 AP
 PA oblique
 Lateral
 Bennett’s fracture.  AP, Modified Robert’s method
 skier’s thumb injury (ulnar collateral
ligament injury)
 PA stress (Folio method) projection

AP projection of thumb:-
Patient Position:-
• Seat patient facing table, arms extended in front, with
hand rotated internally until posterior surface of thumb
is in contact with IR.
• Immobilize other fingers with tape to isolate thumb if
necessary.
• Align thumb with long axis of the IR and Center first MCP
joint to CR and to center of IR.
CR:-
CR perpendicular to IR, directed to first MCP joint
23

Exception—PA (Only if Patient Cannot Position
for Previous AP)
• Place hand in near-lateral position and rest thumb
on sponge support block that is high enough so that
thumb is not rotated but is in position for a true PA
projection
NOTE: As a rule, the PA is not advisable because it
results in loss of definition caused by increased OID.
24

Evaluation Criteria
• Anatomy should be Demonstrated phalanges, first
metacarpal, trapezium, and associated joints.
• Interphalangeal and metacarpophalangeal joints should
appear open.
• No rotation, as evidenced by the concave sides of the
phalanges and by equal amounts of soft tissue appearing
on each side of the phalanges, should be present.
• Interphalangeal joint should appear open, indicating
that thumb was fully extended and correct CR location
was used.
25

PA oblique projection of thumb:-
Patient Position:-
• Seat patient at end of table, with elbow flexed about 90°
with hand resting on IR.
• Abduct thumb slightly with palmar surface of hand in contact
with IR. (This action naturally places thumb in a 45° oblique)
• Align long axis of thumb with long axis of IR and Center first
MCP joint to CR and to center of IR.
CR:-
26

Lateral projection of thumb:-
Patient Position:-
• Patient should be seated at end of table, with elbow flexed
about 90°with hand resting on IR, palm down.
• Start with hand pronated and thumb abducted, with fingers
and hand slightly arched; then rotate hand slightly medial
until thumb is in true lateral position.
• Align long axis of thumb with long axis of the IR and Center
first MCP joint to CR and to center of IR.
CR:-
27

AP axial projection of thumb (modified
Robert’s method)
• This special projection demonstrates fractures or
dislocations of the first CMC joint.
• It is used to demonstrate base of first metacarpal for
ruling out Bennett’s fracture.
• patient position is same as AP projection of thumb.
• CR is directed 15° proximally (toward wrist), entering at
the first CMC joint
NOTE: This projection was first described by M. Robert in 1936 to
demonstrate the first CMC joint with the use of a perpendicular CR.
The projection was later modified to include a 15° proximal CR angle.
28

AP axial projection of thumb (modified
Robert’s method)
• Evaluation Criteria:-
• Anatomy should be demonstrated of an AP projection of
the thumb and first CMC joint without superimposition.
• Base of first metacarpal and trapezium should be well
visualized.
• No rotation, as evidenced by the symmetric appearance of
both concave sides of the phalanges and by the equal
amounts of soft tissue that appear on each side of the
phalanges.
• First CMC and MCP joints should appear open.
29

PA Stress thumb projection (folio method)
• It is use to diagnose Sprain or tearing of ulnar collateral ligament of
thumb at MCP joint as a result of acute hyperextension of thumb
(skier’s thumb injury.)
Patient Position:-
• Seat patient at end of table with both hands extended and pronated
on IR.
• Position both hands side by side to center of IR, rotated laterally into
± 45° oblique position, resulting in true PA projection of both thumbs.
• Place supports as needed under both wrist and proximal thumb
regions to prevent motion. Ensure that hands are rotated enough to
place thumbs parallel to IR for true PA projection of both thumbs.
• Place round spacer, such as a roll of medical tape, between proximal
thumb regions; wrap rubber bands around distal thumbs as shown.
• Immediately before exposure, ask patient to pull thumbs apart firmly
and hold.
30

• CR perpendicular to IR directed to midway between MCP joints.
• Anatomy should be demonstrated of Entire thumbs from first
metacarpals to distal phalanges, metacarpophalangeal angles
and joint spaces at MCP joints.
• No rotation of thumbs as evidenced by symmetric appearance
of concavities of shafts of first metacarpals and phalanges.
• Distal phalanges should appear to be pulled together, indicating
that tension was applied.
• MCP and IP joints should appear open, indicating that thumbs
were parallel to IR and perpendicular to CR.
• CR and center of collimation field should be midway between
the two MCP joints.
31
PA Stress thumb projection (folio method)

Projections and clinical indications for hand
 Fractures, dislocations of the phalanges,
metacarpals, and all joints of the hand
 Pathologic processes such as osteoporosis
and osteoarthritis.
 PA(DP)
 PA oblique
 Lateral
 Foreign bodies  Lateral
 fractures of the base of the 5th
metacarpals, rheumatoid arthritis
 AP oblique bilateral (Norgaard method)
32

PA (DP) Projection for Hand:-
Patient Position:-
• Seat patient at end of table with elbow flexed about
90° and hand and forearm resting on table.
• Pronate hand with palmar surface in contact with IR;
spread fingers slightly.
• Align long axis of hand and forearm with long axis of IR
and Center hand and wrist to IR
CR:-
• CR perpendicular to IR, directed to the base of third
MCP joint
33

PA Projection for Hand:-
Evaluation Criteria
• Anatomy should be demonstrated of entire hand and
wrist and about 2.5 cm (1 inch) of distal forearm are
visible.
• Long axis of hand and wrist should be aligned with
long axis of IR and there should be No rotation.
• Digits should be separated slightly with soft tissues
not overlapping.
• MCP and IP joints should appear open, indicating
correct CR location and that hand was fully
pronated.
• Optimal density and contrast with no motion should
be present.
34

PA Oblique projection of hand:-
Patient position:-
• from PA position of hand rotate entire hand and wrist
laterally 45° and support with radiolucent wedge or step
block, so that all digits are separated and parallel to IR.
• Note:-If the metacarpals only are of interest, the image can
be taken with thumb and fingertips touching IR.
CR:-
• The collimated vertical beam is centered over the head of
5th metacarpal
• The tube is then angled so that CR passes through the head
of 3rd metacarpal
35

PA Oblique projection of hand:-
Evaluation criteria :-
• anatomy should be demonstrated of Oblique projection of
the entire hand and wrist and about 1 inch of distal forearm.
• 45° oblique is evidenced by the following: midshafts of
metacarpals should not overlap; some overlap of distal
heads of third, fourth, and fifth metacarpals but no overlap
of distal second and third metacarpals should occur.
• excessive overlap of metacarpals indicates over-rotation,
and too much separation indicates under-rotation.
• MCP and IP joints are open without foreshortening of mid-
phalanges or distal phalanges, indicating that fingers are
parallel to IR.
36

Lateral projection of hand
Patient position:-
• From the postero-anterior (DP) position, the hand is externally
rotated 90°.
• The palm of the hand is perpendicular to the image receptor,
with the fingers extended and the thumb abducted and
supported parallel to the image receptor on a non-opaque pad.
• The radial and ulnar styloid processes are superimposed
CR:-
The collimated vertical beam is centred over the head of the 2nd
metacarpal.
37

Lateral projection of hand
Evaluation Criteria:-
• The image should include the fingertips,
including soft tissue, and the radial and ulnar
styloid processes.
• The heads of the metacarpals should be
superimposed.
• The thumb should be demonstrated clearly
without superimposition of other structure.
• Notes • If the projection is undertaken to identify the position
of a foreign body, the kilovoltage should be reduced to
improve radiographic contrast and a metal marker is used to
demonstrate the site of entry of the foreign body.
38

Antero-posterior oblique both hands (ball
catcher’s or Norgaard projection)
Patient position:-
• Patient should seated facing the table with both
forearm supinated keeping dorsal surface of the hands
in contact with the IR.
• From this position both hands are rotated medially 45°
into a ‘ball catching’ position.
CR:-
• The collimated vertical beam is centred to a point
midway between the hands at the level of the 5th
metacarpophalangeal joints (MCPJ).
39

Antero-posterior oblique both hands (ball
catcher’s or Norgaard projection)
• Anatomy should be demonstrated of both
hands from the carpal area to the tips of
digits in 45° oblique position .
• 45°oblique as evidenced by the
following: midshafts of second through
fifth metacarpals and base of phalanges
should not overlap; MCP joints should be
open; no superimposition of the thumb
and second digit should occur.
40

Projections and clinical indications for wrist
 Fractures of distal radius or ulna, styloid
processes and carpal bones
 osteomyelitis and arthritis.
 PA
 PA Oblique
 Lateral
 Barton’s, Colles’, or Smith’s fractures
 Osteoarthritis in the trapezium and first CMC.
 lateral
 Fractures of carpal bones  PA, PA Oblique & CR angle ulnar deviation
 Lateral
 PA with radial deviation
 carpal tunnel syndrome.
 fractures of the hamulus process of the
hamate, pisiform, and trapezium
 Carpal canal infero-superior
 Carpal canal supero-inferior
41

PA Projection of wrist:-
Patient position:-
• Ask patient to be seat at the end of table and flex the
elbow so that the forearm is at rt. angled to the
humerus.
• Hand is placed in prone position.
• Fingers are flexed so that the wrist is in proper
contact with the cassette.
CR:-
• CR perpendicular to IR, directed to midway
between styloid process of radius and ulna .
42

AP Projection of wrist:-
• Alternative AP projection of wrist may be
taken, with hand slightly arched to place
wrist and carpals in close contact with IR,
to demonstrate intercarpal spaces and
wrist joint better and to place the
intercarpal spaces more parallel to the
divergent rays
• This wrist projection is good for
visualizing the carpals if the patient can
assume this position easily.
43

PA Projection of wrist:-
Evaluation Criteria :-
• Anatomy should be demonstrated of metacarpals; carpals;
distal radius, ulna, and associated joints; and pertinent soft
tissues of the wrist joint, such as fat pads and fat stripes.
• All the intercarpal spaces do not appear open because of
irregular shapes that result in overlapping.
• True PA is evidenced by the following: equal concavity
shapes are on each side of the shafts of the proximal
metacarpals; near-equal distances exist among the proximal
metacarpals; separation of the distal radius and ulna is
present except for possible minimal superimposition at the
distal radioulnar joint.
44

Lateral projection of wrist:-
• Patient position :-
• From PA position forearm is rotated at 90º so that palm
of hand faces the body.
• Center the cassette to the carpal bones and adjust the
forearm and hand so that the wrist is in true lateral
position.
CR:-
• CR is directed perpendicular to the styloid process of
radius.
45

Lateral projection of wrist:-
Evaluation Criteria :-
• Anatomy should be demonstrated of distal radius
and ulna, carpals, and metacarpal
• True lateral position is evidenced by the
following: ulnar head should be superimposed
over distal radius; proximal second through fifth
metacarpals all should appear aligned and
superimposed.
46

PA oblique projection of wrist:-
• From lateral position wrist is rotated medially so
that it makes an angle of 45º with the cassette.
• CR should passes through styloid process of ulna.
• Scaphoid should be well demonstrated.
• Proximal half of metacarpals, distal end of radius
and ulna should be included.
• True 45° oblique of the wrist is evidenced by
ulnar head partially superimposed by distal
radius and proximal third through fifth
metacarpal bases should appear mostly
superimposed. •
47

PA with ulnar deviation projection of wrist:-
• Help to find the Possible fractures of the scaphoid.
• From PA position patient is asked to rotate the wrist
towards ulna until it is in extreme ulnar deviation.
• CR:- passes midway between radial and ulnar styloid
process.
• Scaphoid should be demonstrated clearly without
foreshortening, with adjacent carpal interspaces
open
• No rotation of wrist is evidenced by appearance of
distal radius and ulna, with minimal superimposition
of distal radioulnar joint.
48

PA with radial deviation projection of wrist:-
• Help to find the Possible fractures of the carpal
bones on the ulnar side of the wrist.
• From PA position wrist joint is turned medially
towards radius until the wrist joint is in extreme
flexion.
• CR:- passes midway between radial and ulnar
styloid process.
• Carpals and their articulations on the medial side
of the wrist should be well demonstrated.
• space between the triquetrum/pisiform and the
styloid process of the ulna should well visualized.
49

Anterior oblique – ulnar deviation of wrist:-
• From the PA position, the hand
and wrist are rotated 45°
externally with hand remains
adducted in ulnar deviation.
• CR is centred midway between the
radial and ulnar styloid processes.
• the scaphoid should be seen
clearly, with its long axis parallel
to the detector.
50

Posterior oblique of scaphoid
• From the anterior oblique position, the hand
and wrist are rotated externally through 90°,
such that the posterior aspect of the hand
and wrist are at 45° to the image detector.
• The collimated vertical beam is centred over
the styloid process of the ulna.
• 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 long edge of the image
detector
51

Postero-anterior – ulnar deviation and 30°
cranial angle
• The patient and image receptor are
positioned as for the postero-anterior
scaphoid with ulnar deviation
• The collimated vertical beam is angled
30° and centred to the scaphoid.
• this projection elongates the scaphoid and
with ulnar deviation demonstrates the
space surrounding the scaphoid.
52

Carpel tunnel Tangential, infero-superior
projection (Gaynor-Hart method):-
Patient Position:-
• Seat patient at end of table, with wrist and hand on IR and
palm down.
• Align hand and wrist with long axis of the IR.
• Ask patient to dorsiflex wrist as far as possible by the use of
a piece of tape or band and gently but firmly
hyperextending the wrist until the long axis of the
metacarpals and the fingers are as near 90° to forearm as
possible (without lifting the wrist and forearm from the IR).
• Rotate entire hand and wrist about 10° internally to
prevent superimposition of pisiform and hamate.
53

Carpel tunnel Tangential, infero-superior
projection (Gaynor-Hart method):-
CR :-
• Angle CR 25°to 30°to the long axis of the hand and direct to
a point 1 inch distal to the base of third metacarpal.
• Anatomy of the carpals should be demonstrated in a tunnel-
like, arched arrangement.
• The pisiform and the hamulus process should be separated
and visible in profile without superimposition.
• The rounded palmar aspects of the capitate and the scaphoid
should be visualized in profile as well as the aspect of the
trapezium that articulates with the first metacarpal.
54

Radiographic anatomy of forearm:-
• Forearm consists of two bones namely radius (on the lateral or
thumb side) and ulna (on the medial side).
• The radius and ulna articulate with each other at the proximal
radioulnar joint and at the distal radioulnar joint, These two
joints allow for the rotational movement of the wrist and hand.
• Small conical projections, called styloid processes, are located
at the extreme distal ends of both the radius and the ulna.
• The head of the ulna is located near the wrist at the distal end
of the ulna.
• The head of the radius is located at the proximal end of the
radius near the elbow joint
55

 Fractures and dislocations of the
radius or ulna.
 Pathologic processes such as
osteomyelitis or arthritis
 AP
 Lateral
56
Projections and clinical indications for forearm

AP Projection of forearm:-
Patient position:-
• Seat patient at end of table, with hand and arm fully extended and
palm up (supinated).
• Drop shoulder to place entire upper limb on same horizontal plane.
• Align and center forearm to long axis of IR, ensuring that both wrist
and elbow joints are included.
CR:-
• The collimated vertical beam is centred in the midline of the
forearm to a point midway between the wrist and elbow joints
57

AP Projection of forearm:-
• Anatomy should be demonstrated of AP projection of the
entire radius and ulna is shown, with a minimum of proximal
row carpals and distal humerus and pertinent soft tissues, such
as fat pads and stripes of the wrist and elbow joints.
• Long axis of forearm should be aligned with long axis of IR, No
rotation is evidenced by humeral epicondyles visualized in
profile, with radial head, neck, and tuberosity slightly
superimposed by the ulna.
• Wrist and elbow joint spaces are only partially open because of
beam divergence.
58

Lateral projection of forearm:-
Patient Position
• Seat patient at end of table, with elbow flexed to 90°.
• Drop shoulder to place entire upper limb on same
horizontal plane then Align and center forearm to long
axis of IR
• Rotate hand and wrist into true lateral position, and
support hand to prevent motion.
• To make best use of the anode heel effect, place elbow at
cathode end of x-ray beam
CR:-
• is centred midway between the wrist and elbow joints.
59

Lateral projection of forearm:-
• Anatomy should be demonstrated of Lateral projection of
entire radius and ulna, proximal row of carpal bones, elbow,
and distal end of the humerus are visible as well as
pertinent soft tissue, such as fat pads and stripes of the
wrist and elbow joints.
• No rotation as evidenced by head of ulna being
superimposed over the radius, and humeral epicondyles
should be superimposed.
• Radial head should superimpose coronoid process, with
radial tuberosity demonstrated.
60

Radiographic anatomy of elbow joint:-
• The elbow joint generally is
considered a ginglymus (hinge)-type
synovial joint with flexion and
extension movements between the
humerus and the ulna and radius.
• elbow joint includes three joints
enclosed in one articular capsule
they are, hinge joints between the
humerus and ulna and the humerus
and radius, the proximal radioulnar
joint (trochoidal, or pivot-type)
61

Projections and clinical indications for elbow
 Fractures, dislocations and pathologic of elbow  AP, Lateral
 Fracture or pathologic on radial head, neck and
capitulum of humerus.
 AP obliques-Lateral (external) rotation
 Fracture or pathologic on coronoid process of
ulna and trochlea
 AP obliques-Medial (internal) rotation
 to visualize distal humerus and the proximal
radius and ulna
 Acute flexion (Jones method)
 to visualize radial head and coronoid process.  Trauma axial laterals (Coyle method)
 Occult fractures of the radial head or neck  Radial head laterals
62

Fully extended AP Projection of elbow:-
Patient Position
• Seat patient at end of table, with elbow fully extended, if
possible.
• Extend elbow, supinate hand, and align arm and forearm with
long axis of IR.
• Center elbow joint to center of IR.
• Ask patient to lean laterally as necessary for true AP projection.
CR:-
• CR perpendicular to IR, directed to mid-elbow joint, which is
approximately 2 cm distal to midpoint of a line between
epicondyles.
63

Fully extended AP Projection of elbow:-
• Anatomy should be demonstrated of Distal humerus,
elbow joint space, and proximal radius and ulna.
• No rotation is evidenced by the appearance of
bilateral epicondyles seen in profile and radial
head, neck, and tubercles separated or only slightly
superimposed by ulna.
• Olecranon process should be seated in the
olecranon fossa and elbow joint space appears open
with fully extended arm.
64

Partially flexed AP Projection of elbow:-
• Obtain two AP projections—one with forearm parallel to IR (if the
main area of interest is the proximal end of the radius and ulna)
and one with humerus parallel to IR (If the main area of interest is
the distal end of the humerus).
65

AP oblique projection of elbow :-
lateral(external) rotation
Patient position:-
• From the AP position rotate laterally the entire arm so that
the distal humerus and the anterior surface of the elbow
joint are approximately 45° to IR.
CR:-
• Should be perpendicular to IR, directed to mid-elbow joint
(a point approximately 2 cm distal to midpoint of line
between the epicondyles.
Evaluation criteria:-
• Correct 45° lateral oblique should visualize radial head,
neck, and tuberosity, free of superimposition by ulna with
Lateral epicondyle and capitulum should appear elongated
in profile.
66

AP oblique projection of elbow :-
Medial (internal rotation)
Patient position:-
• Seat patient in natural palm-down position and rotate arm as needed
until distal humerus and anterior surface of elbow are rotated 45°.
CR:-
• perpendicular to IR, directed to mid-elbow joint (approximately 2 cm
distal to midway between epicondyles).
Evaluation criteria:-
• Correct 45° medial oblique should visualize coronoid process of the
ulna in profile, Radial head and neck should be superimposed and
centered over the proximal ulna.
• Medial epicondyle and trochlea should appear elongated and
Olecranon process should appear seated in olecranon fossa.
67

Lateral projection of elbow:-
Patient position:-
• The patient is seated alongside the table with
shoulder on the same plane as the elbow and wrist.
• The elbow is flexed to 90° and the palm of the hand is
rotated so that it is at 90° to the tabletop.
CR:-
• The collimated vertical beam is centred over the
lateral epicondyle of the humerus.
68

Lateral projection of elbow:-
• Anatomy should be demonstrated of Lateral projection of
distal humerus and proximal forearm, olecranon process,
and soft tissues and fat pads of the elbow joint .
• About one-half of radial head should be superimposed by
the coronoid process, and olecranon process should be
visualized in profile.
• True lateral view is indicated by three concentric arcs of
the trochlear sulcus, double ridges of the capitulum and
trochlea, and the trochlear notch of the ulna. In addition,
superimposition of the humeral epicondyles occurs.
69

Acute flexion projection of elbow:-
(Jones method)
Patient Position:-
• Seat patient at end of table, with acutely flexed arm
resting on IR.
• Align and center humerus to long axis of IR, with
forearm acutely flexed and fingertips resting on shoulder
• Adjust IR to center of elbow joint region.
CR
• Distal humerus:- CR perpendicular to IR and humerus,
directed to a point midway between epicondyles
• Proximal forearm:- CR perpendicular to forearm (angling
CR as needed), directed to a point approximately 2inch
proximal or superior to olecranon process.
70

Acute flexion projection of elbow:-
(Jones method)
• Evaluation Criteria
• Distal Humerus: Forearm and humerus
should be directly superimposed, Medial and
lateral epicondyles and parts of trochlea,
capitulum, and olecranon process all should
be seen in profile.
• proximal Forearm: Proximal ulna and radius,
including outline of radial head and neck,
should be visible through superimposed distal
humerus.
71

Trauma axial lateral projection of elbow:-
(Coyle method)
Patient Position and CR:-
• Seat patient at the end of the table for the erect
position or supine on the table
• For Radial Head Elbow should flexed 90° if
possible; hand pronated and CR directed at 45°
angle toward shoulder, centered to radial head.
• For Coronoid Process Elbow should flexed only
80° from extended position (because >80° may
obscure coronoid process) and hand pronated CR
angled 45° from shoulder, into mid-elbow joint.
72

(Coyle method)
• For Radial Head:
• Joint space between radial head and capitulum
should be open and clear.
• Radial head, neck, and tuberosity should be in
profile and free of superimposition except for a
small part of the coronoid process.
• Distal humerus and epicondyles appear distorted
because of 45° angle.
73

(Coyle method)
• For Coronoid Process:
• Distal (anterior) portion of the coronoid appears elongated.
• Joint space between coronoid process and trochlea should
be open and clear.
• Radial head and neck should be superimposed by ulna.
• Optimal exposure factors should visualize clearly the
coronoid process in profile. Bony margins of superimposed
radial head and neck should be visualized faintly through
proximal ulna.
74

Radial head lateral projection of elbow:-
• Patient Position
• Seat patient at end of table, with arm
flexed 90º
• Center radial head area to center of IR.
• Take four projections, the only difference
among the four being rotation of the hand
and wrist from
1. Supinate hand (palm up)
2. Place hand in true lateral position (thumb up).
3. Pronate hand (palm down).
4. Internally rotate hand (thumb down)
75

CR:-
• CR perpendicular to IR, directed to radial head (approximately 2 to 3
cm [1 inch] distal to lateral epicondyle)
• Elbow should be flexed 90° in true lateral position, as evidenced by
direct superimposition of epicondyles.
• Radial head and neck should be partially superimposed by ulna but
completely visualized in profile in various projections.
76

• Radial tuberosity should be visualized
in various positions and degrees of
profile as follows:-
(1) Fig slightly anterior
(2) Fig not in profile, superimposed
over radial shaft
(3) Fig slightly posterior
(4) Fig seen posteriorly, adjacent to
ulna when hand and wrist are at
maximum internal rotation.
77

Ulnar groove-axial
• POSITIONING:-
• The affected elbow is fully flexed with the posterior
aspect of the upper arm in contact with the tabletop.
• With the elbow still fully flexed, the arm is externally
rotated through 45°
• CR:-
• perpendicular over the medial epicondyle of the
humerus
78

Ulnar groove-axial
• Evaulation criteria:-
• Should show ulnar groove.
79

Radiographic anatomy of humerus:- 80
• The proximal part of humerus articulates with shoulder girdle.
• The proximal end consists head, Just below the head is narrow
constricted anatomic neck and The constriction of the body just
below the tubercle is called surgical neck which is the site of many
fractures.
• distal end of the humerus is the humeral condyle. The articular
portion of the humeral condyle is divided into two parts: the
trochlea (medial condyle) and the capitulum ( lateral condyle)
• The medial and lateral epicondyles are superior to the condyle and
easily palpated.
• On the anterior surface ,superior to the trochlea, a shallow
depression called the coronoid fossa present and a relatively small
radial fossa is located lateral to the coronoid fossa.

Projections and clinical indications for humerus
 Fracture and dislocation of the humerus.
 Pathologic processes including
osteoporosis.
 AP
 AP rotational lateral
 Horizontal beam lateral
 Fractures of the diaphysis of the humerus  AP
 Transthoracic lateral
81

AP Projection of humerus :-
Patient Position:-
• Position patient erect or supine. Adjust the height of the cassette
so that shoulder and elbow joints are equidistant from ends of IR.
• Rotate body toward affected side as needed to bring shoulder and
proximal humerus in contact with cassette.
• Align humerus with long axis of IR ,extend hand and forearm as far
as patient can tolerate.
• Abduct arm slightly and gently supinate hand so that epicondyles
of elbow are parallel and equidistant from IR.
CR :-
• CR perpendicular to IR, directed to midpoint of humerus
82

AP Projection of humerus :-
• Evaluation Criteria
• Anatomy should be demonstrated of AP projection shows
the entire humerus, including the shoulder and elbow
joints.
• True AP projection is evidenced at proximal humerus by
the following: greater tubercle is seen in profile laterally;
humeral head is partially seen in profile medially, with
minimal superimposition of the glenoid cavity. •
• Distal humerus: lateral and medial epicondyles both are
visualized in profile.
83

AP rotational lateral projection of humerus:-
Patient position:-
• Position patient erect or supine as for
lateromedial or mediolateral projection
• From AP position forearm is rotated
medially till the epicondyles become
perpendicular to the cassette.
CR:-
• CR perpendicular to IR, directed to
midpoint of humerus
84

AP rotational lateral projection of humerus:-
Evaluation Criteria
• Anatomy should be demonstrated of Lateral
projection of the entire humerus, including
elbow and shoulder joints.
• True lateral projection is evidenced by the
following: epicondyles are directly
superimposed; lesser tubercle is shown in
profile medially, partially superimposed by
lower portion of glenoid cavity.
85

Horizontal beam lateral projection of
humerus:-
• With patient recumbent, perform image as a
horizontal beam lateral, placing support under
the arm.
• Flex elbow if possible, but do not attempt to
rotate arm; projection should be 90° from AP.
• Gently place cassette between arm and thorax
(top of IR to axilla).
• CR perpendicular to midpoint of distal two-thirds
of humerus
86

Horizontal beam lateral projection of
humerus:-
• Respiration:- Suspend respiration during
exposure. (This step is important in preventing
movement of the image receptor during the
exposure).
Evaluation Criteria
• Anatomy should be demonstrated of Lateral
projection of the mid humerus and distal
humerus, including the elbow joint.
• The distal two-thirds of the humerus should be
well visualized
87

Transthoracic lateral projection of humerus:-
• Patient Position
• Place patient in an erect or supine position in lateral
position with side of interest closest to IR.
• Raise opposite arm and place hand over top of head;
elevate shoulder as much as possible to prevent
superimposition of affected shoulder.
• Center neck of affected humerus and center of IR to CR.
CR:-
• Passes through the axilla at the level of surgical neck of
humerus.
88

Transthoracic lateral projection of humerus:-
Evaluation criteria :-
• Proximal portion of humerus should be
included.
• Humerus should be in lateral position.
• Unaffected humerus and shoulder should
not superimpose the area of interest.
89

Precautions and Radiation Protection
• There should be correct identification of patient.
• The radiopaque substance must be removed from the site to be examined
for example watch, bracelets, ring etc.
• Collimation should be accurate.
• Follow the ALARA Principle.
• Shield radiosensitive tissues outside region of interest.
• An upper limb with a cast requires an increase in exposure. This increase
depends on the thickness and type of cast
90

Technical factor used in upper limb
radiography:- 91
Body part KVp mAs Grid IR Size SID
Digits 50-55 1-5 No 8 × 10 inch 100 cm
Hand 55-60 3-5 No 10 × 12 inch 100 cm
wrist 55-60 3-5 No 8 × 10 inch 100 cm
forearm 60-65 3-5 No 11× 14 inch 100 cm
Elbow 60-65 3-5 No 10 × 12 inch 100 cm
Humerus 60-70 10-15 yes 14× 17 inch 100 cm
Transthoracic view of
humerus
70-80 35-45 Yes 14 × 17 inch 100 cm

References:-
TEXTBOOK OF RADIOGRAPHIC POSITIONING AND RELATED ANATOMY
by Kenneth L. Bontrager, MA John P. Lampignano, MEd,
RT(R)(CT)_8th edition.
CLARK’S POSITIONING IN RADIOGRAPHY by A. STEWART WHITLEY ■
GAIL JEFFERSON ■ KEN HOLMES CHARLES SLOANE ■ CRAIG
ANDERSON ■ GRAHAM HOADLEY -13th edition
92

RADIOGRAPHIC TECHNIQUE OF UPPER LIMB BY SAGAR CHAULAGAIN

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