Anatomy of upper limb, Radiographic anatomy ,positioning of upper limb,image characteristics and technical paarmeters

1. Rituraj Mishra
Radiological Technologist
Gandaki Medical College and
Teaching Hospital

3. • Phalanges
• Metacarpals
• Carpals
• Radius
• Ulna
• Humerus
• Scapula
• Clavicle

5. • 27 Bones
– Phalanges - 14
– Metacarpals - 5
– Carpals - 8

6. 14 bones
Fingers
– Proximal
– Middle
– Distal
Thumb
-Proximal
-Distal

7. • 1
• 2
• 3
• 4
• 5
• Thumb
• Index
• Middle
• Ring
• Little

8.  Interphalangeal
Metacarpophalangeal
Carpometacarpal joint
Distal Interphalangeal
Proximal
Interphalangeal
Trapeziometacarpal

9.  5 bones
• Three parts
– Head
– Body
– Base

10. 8 bones

11. • She
• Looks
• Too
• Preety
• Try
• To
• Catch
• Her
Alternative mnemonic
• Some
• Lovers
• Try
• Positions
• That
• They
• Can’t
• Handle

12. • Radiocarpal
• Intercarpal

13. • Radial Styloid Process
• Ulnar Styloid Process
• Distal Radioulnar Jt.

15. A.
B.
C.
D.
E.
F.
G.
H.

16. Tuft
2nd DIP Jt.
2nd PIP Jt.
2nd MP Jt.
IP Jt.
1st MP Jt.
CM Jt.
Radiocarpal Jt.

17. Trapezoid
Scaphoid
Pisiform

18. Indications
Position of the patient and cassette
Direction and centering of x-ray beam
Image characteristics
Technical parameters
-kVp
-mAS
-FFD
-Grid

19. Remove rings, watches, and other radiopaque objects.
 Seat the patient at the side or end of the table and place the cassette at a
location and angle that allows the patient to be in the most comfortable position.
 Direct the central ray (CR) at a right angle to the midpoint of the cassette.
 When performing a bilateral examination of hands or wrists, separately
radiograph each side.
 Shield the patient’s gonads from scattered radiation.
 Use close collimation. This technique is recommended for all upper-limb
radiographs.
 When placing multiple exposures on one cassette, the side of the unexposed
cassette should always be covered with lead.
 Use right or left markers and any other vital identification markers when
appropriate.

20. • Routine projections
– PA
– Lateral
– Medial Oblique
– Lateral Oblique

21. Pain
Swelling
Tenderness
Dislocations
Fractures
To locate Foreign objects(Lateral view)

22. Fingers (2 – 5)
 Cassette Size: 24x30cm
 Cassette Orientation: Landscape.
 All three images projections of fingers can fit on one film.
 Central Ray: Perpendicular to Cassette
 Centering Point: PIP(Proximal interphalangeal) joint
 Collimation: To include distal tip of finger and distal carpal bones
 Positioning:
PA:
• Place hand flat with the palmar surface down.
• Separate digits slightly.
Oblique:
• Rotate palm 45 degrees toward IR until digits are resting on support.
Lateral:
• Place hand in lateral position (thumb side up) with finger to be examined
fully extended and centered to portion of IR being exposed.
• Ensure that long axis of finger is parallel to IR.

23. kVp:50-55
mAs:3-5
FFD:100cm
Grid: No

24. PA

28. The image should include the fingertip and
distal third of metacarpal bone.

29. • Immobilize
– Sandbags
– Tape

30. • Routine projections
– AP or, PA
– Oblique
– Lateral

31. Positioning of the thumb is unique because its axis differs from that of the other digits. Basic
views of the thumb include Anteroposterior (AP), Posteroanterior (PA), Oblique, and Lateral.
Stress views of the first Metacarpo-phalangeal (MCP) Joint may be required for evaluation of
injuries of the ligaments of this joint.
Cassette Size: 24x30cm.
Cassette Orientation: Landscape.
 All three thumb images can fit on one film.
FFD: 100cm.
Centering Point: MCP.
Central Ray: Perpendicular to Cassette.
Collimation: To include distal tip of thumb and distal carpal bones.
Positioning:
(AP): Rotate the Hand Medially to make the Thumb in True AP Projection.
(PA): Place hand in lateral position with little finger on cassette.
(Oblique): Place hand flat with the palmar surface down. This orientate the thumb to an
oblique position
(Lateral): Flex all Fingers and make the Lateral aspect of thumb resting on the cassette with.

32. AP

36. Evaluation criteria of Thumb projections
1. The area from the distal tip of the thumb to the trapezium should be clearly
demonstrated.
2. There should be no rotation, and concavity of the phalangeal and metacarpal
shafts should be demonstrated with equal amounts of soft tissue on both sides of
the phalanges.
3. The first CMC joint should be free of superimposition of the hand or other bony
elements.
4. The first metacarpal and trapezium should be clearly demonstrated.
5. There should be open interphalangeal and MCP joint spaces.
6. The soft tissue and bony trabeculation should be clearly present.

37. • Routine projections
– PA
– PA OBLIQUE
• Non-routine projections
 Lateral for Foreign Body
Posterior oblique(Ball
catcher’s or, Norgaard
Projection.)

38. • Routine projections
– PA
– PA Oblique

39.  Cassette Size: 24x30cm
 Cassette Orientation: Landscape (Crosswise).
 FFD: 100cm
 Central Ray: Perpendicular to cassette
 Centering Point: Entering hand at 3rd MCP Jt.
 Collimation: To include entire hand and Distal Forearm.
 Positioning:
 PA : Place affected hand/finger palmar side down on
cassette.
 OBLIQUE: Place affected hand/finger palmar side
down on a 45º sponge/angle thumb side raised.
 LATERAL : Place affected hand with thumb raised.
 To properly visualize the phalanges the fingers should be
positioned in a fan like arrangement.

42. Evaluation criteria
 The entire hand, wrist, and about 2.5
cm of the distal forearm should be
visible.
 MCP and interphalangeal joints
should appear open.
 No rotation of hand.
 The digits should be separated
slightly with soft tissues and should not
be overlapping.
PA HAND

43. Evaluation criteria
 Entire hand, wrist, and about 2.5 cm of
the distal forearm should be visible in
oblique view.
 MCP and interphalangeal joints should
be open.
A 45° oblique is evidenced by the
following: Midshafts of third, fourth, and
fifth metacarpals should not overlap; some
overlap of the 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.
HAND OBLIQUE

44. Evaluation Criteria
 Entire hand, wrist, and about 2.5 cm of
the distal forearm should be visible.
 Fingers should appear equally separated,
with phalanges in the lateral position and
joint spaces open.
 Thumb should appear in a slightly
oblique position completely free of
superimposition, with joint spaces open.
 Hand and wrist should be in a true-
lateral position evidenced by the
following:
1. Distal radius and ulna superimposed.
2. metacarpals are superimposed.
HAND LATERAL

46. INDICATIONS
 Rheumatoid arthritis
 Fracture of base of the fifth metacarpal

47.  Patient is seated alongside the table. However, if this is
not possible due to patient’s condition, the patient is
seated facing the table.
 Both forearms are supinated and placed on the table
with dorsal surface of the hand in contact with
cassette.
 From this position ,both hands are rotated
internally(medially) 45degs into ball catching position.
 Cassette is adjusted such that ROI lies in close contact
with cassette.

48. The vertical central ray is centered to a
point midway between the hands at the
level of the fifth metacarpo-phalangeal
joints.

49. The image should demonstrate all
phalanges, including the soft tissue of
fingertips ,the carpal and metacarpal
bones, and distal end of radius and ulna.

50. kVp:55-60
mAs:5-7
FFD:100cm
Grid: No

51. • Routine projections
 PA (Ulnar Flexion)
 Lateral
• (Scaphoid Series)
– PA (Ulnar deviation)
– Anterior oblique(ulnar deviation)
– Posterior oblique
– Lateral

52. • Routine projections
– PA (Ulnar Flexion)
– Lateral

53. Radiographic Positioning of the WRIST
Cassette Size: 24x30cm
Cassette Orientation: Landscape (Crosswise).
• All three Wrist images can usually fit on one film.
FFD: 100cm
Central Ray: Perpendicular to the cassette.
Centering Point:
PA: Midway between the radial and ulnar styloid processes.
OBLIQUE: Radial Styloid Process.
LATERAL: Radial Styloid Process.
Collimation: To include the distal 1/3 of the forearm and metacarpal bones.
Positioning:
PA: Forearm resting with anterior aspect on the table, with cassette under wrist.
OBLIQUE:
• Forearm resting with anterior aspect on the table, with cassette under wrist.
• Rotate wrist 45º with thumb side raised and rest on sponge if required.
LATERAL:
• Forearm resting with ulnar side on the table, with cassette under wrist.

54. Centering; Midway between radial and
ulnar styloid process

55. Centering: Radial
styloid process

57. Evaluation criteria for PA
wrist:
 True PA is evidenced by
the following: 1. separation
of the distal radius and ulna
is present, except for
possible minimal
superimposition at the distal
radioulnar joint.
 Soft tissue and bony
trabeculation should be
visible.
PA WRIST

58. Evaluation criteria
 Distal radius and ulna,
carpals, and at least the
midmetacarpal area should be
visible.
 True-lateral position is
evidenced by the following:
1. Ulnar head should be
superimposed over distal
radius.
2. proximal second through
fifth metacarpals all should
appear aligned and
superimposed.
 Soft tissue and bony
trabeculation should be visible.
WRIST LATERAL

59. – PA (Ulnar deviation)
– Anterior oblique(ulnar
deviation)
– Posterior oblique
– Lateral

60. INDICATIONS
 Demonstrate scaphoid
 Scaphoid fracture

61. The patient is seated alongside the table
with affected side nearest the table.
Ensure the radial and ulnar styloid process
are equidistant from cassette.
The hand lower forearm are immobilized
using sandbags.

62. The vertical central ray is centered midway
between radial and ulnar styloid process.

63. The image should include distal end of
radius and ulna and proximal end of
metacarpals.
The joint space should be demonstrated
clearly.

64. kVp:55-60
mAs:5-7
FFD:100cm
Grid: No

65. Direction and centering of X-ray beam
- The vertical central ray is centred midway
between the radial and ulnar styloid
process.
Image characteristics
- The scaphoid series should be seen
clearly, with its long axis parallel to the
cassette.

66. Direction and centering of X-ray beam
- The vertical central ray is centred ulnar
styloid process.
Image characteristics
- The scaphoid series should be seen
clearly, with its long axis perpendicular to
the cassette.

67. Direction and centering of X-ray beam
- The vertical central ray is centred radial
styloid process.
Image characteristics
- The image should include distal end of
radius and ulna and proximal end of
metacarpals.

69.  Casted
– Regular film
– Lower mAs 10 times
 Wet cast
– Add 15 to the kV
 Dry cast
– Add 10 to the kV
 Fiberglass
– Add 5 to the kV
• No cast
– Extremity film
– 10mAs @ 60kV

74. Medial Epicondyle
Coronoid Process
Shaft (Ulna)
Ulnar Head
Ulnar Styloid
Process
Lateral
Epicondyle
Radial Head
Radial
Tuberosity
Shaft (Radius)
Distal
Radioulnar Jt.
Radial Styloid
Process

75. Lateral epicondyle
Capitulum
Proximal radioulnar
jt.
Radial head
Radial neck
Radial tuberosity
Olecranon fossa
Medial
epicondyle
Trochlea
Coronoid
process

76. Coronoid Process
Radial head
Radial neck
Condyles
Trochlear notch
Olecranon
process
Radial notch

77. • Routine
projections
–AP
–Lateral

78. Cassette Size: 35 x 35 cm or 35 x 43 cm depending on
Patient size.
Cassette Orientation: Portrait
FFD: 100cm.
Central Ray: Perpendicular to cassette.
Centering Point: Midshafts of forearm.
Collimation: To include both wrist and elbow within field.
Positioning:
AP : Posterior aspect of Forearm on cassette with both wrist
and elbow in AP position.
LATERAL:
 Medial side of Forearm on cassette with both wrist and
elbow in lateral position.
 Elbow flexed at 90.

79. AP

82. AP FOREARM
Evaluation criteria
1.The entire radius and ulna should
be visible, with pertinent soft
tissues.
2. The wrist and distal humerus
(Elbow) should be clearly
demonstrated.
3. No rotation as evidenced by
humeral Epicondyle visualized in
profile with slight superimposition
of the radial head, neck, and
tuberosity over the proximal ulna.
4.Similar radiographic densities of
the proximal and distal forearm.

83. LATERAL FOREARM
Evaluation criteria
1. No rotation as evidenced by:
 Superimposition of the radius
and ulna at their distal end.
 Superimposition by the radial
head over the Coronoid process.
 Radial tuberosity facing
anteriorly.
 Superimposed humeral
Epicondyle.
2.Elbow should be flexed
90degree.
3. soft tissues and bony
trabeculation should be visible.

84. • Routine projections
– AP
– Lateral
• Non-routine
– Obliques medial
(internal) rotation
and lateral (external)
rotation.

85. • Routine
projections
–AP
–Lateral

86. Cassette Size: 24x30cm.
Cassette Orientation: Landscape.
FFD: 100cm.
Central Ray: Perpendicular to Cassette.
Centering Point: Elbow Joint.
Collimation: To include Distal third of humerus and proximal third of forearm.
Positioning:
AP:
• Elbow as close to straight as the patient is able, with posterior aspect on cassette.
• Humerus and forearm should both be in contact with the cassette in order to
ensure a open joint space.
OBLIQUE:
• Elbow as close to straight as the pt is able, with posterior aspect on cassette.
• Rotate entire arm laterally as far as pt will tolerate.
• Humerus and forearm should both be in contact with the cassette.
LATERAL:
• Elbow flexed at 900, with wrist in lateral orientation.
• Forearm, Humerus and cassette all parallel.

87. AP