Chapter 4: Upper Limb (Positioning)

Exposure Factors for upper limbs

1. Lower to medium kVp

2. Short exposure time (less chance of motion)

3. Small focal spot (better spatial resoluiton)

4. Adequate mAs for sufficient density (brightness)

PA Fingers (Digits 2-5)

Projection: PA

Position: PA Pronate

SID: 40"

IR: 8X10 (lengthwise or crosswise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at the end of table, with elbow

flexed about 90° and with hand and forearm

resting on the table

Part Position: Pronate hand with fingers

Center and align long axis of affected finger with

long axis of IR

Separate adjoining fingers from affected finger

CR: Perpendicular to IR, directed to Proximal Interphalangeal

Joint

Collimation: Collimate to part size

Evaluation Criteria: Should see distal phlanx, distal IP joint,

middle phalanx, proximal IP joint (CR),

proximal phalanx, MCP joint, and a

metacarpal

No rotation of fingers evidenced by

symmetric appearance of of both sides of

or concavities of the shafts of the fingers

and distal metacarpals

PA Oblique Fingers (Digits 2-5)

Projection: PA Oblique

Position: Medial or Lateral Rotation

SID: 40''

IR: 8x10 (lengthwise and crosswise)

Shielding: Yes (Asl LMP)

Patient Position: Seat patient at end of table, with elbow flexed

about 90° with hand and wrist resting on IR

and fingers extended

Part Position: Place hand in a 45° oblique

Position hand on IR so that the long axis of the

finger is aligned with the long axis of the IR

Separate fingers, in a 45° oblique and parallel

to IR

CR: Perpendicular to IR, directed to Proximal Interphalangeal

Joint

Collimation: Collimate to part size

Evaluation Criteria: Should see distal phalanx, distal IP joint,

middle phlanx, proximal IP joint (CR),

proximal phalanx, and MCP joint

Note: The oblique that is done depends on which finger is

being x-rayed so that OID and magnification are

decreased along with better spatial resolution

A pen or pencil may be used to hold affected digit out

so that it isn't superimposed by other digits (let patient

do this b/c they know their pain tolerance)

Lateral Fingers (Digits 2-5)

Projection: Lateromedial/Mediolateral

Position: Lateral

SID: 40''

IR: 8x10 (lengthwise or crosswise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table, with elbow flexed

about 90° with hand and wrist resting on IR

and fingers extended

Part Position: Place hand in lateral position with finger to be

examined fully extended and centered to

portion of IR being exposed

Align and center finger to long axis of IR and to

CR

Ensure that long axis of finger is parallel to IR

CR: Perpendicular to IR and Proximal Interphalnageal Joint

Collimate: To part size

Note: For a second digit, a mediolateral is advised if the patient

can assume the position (decreases OID and

magnification)

Evaluation Criteria: Should see distal phalanx, middle phalanx,

PIP joint (CR) and proximal phalanx

AP Thumb

Projection: AP

Position: AP

SID: 40''

IR: 8x10 (lengthwise or crosswise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient facing table, arms extended in

front, with hand rotated internally to supinate

tumb for AP projection

Part Position: Internally rotate hand with fingers extended until

posterior surface of thumb is in contact with IR

(immobilize other fingers w/ tape to isolate

thumb if necessary)

Align thumb with long axis of IR

Center first metacarpophalngeal joint to CR and

center to IR

CR: Perpendicular to IR and first metacarpophalngeal joint

Collimation: To part size

Evaluation Criteria: Should see distal phalanx, IP joint,

proximal phalanx, MCP joint (CR), 1st

metacarpal, 1st CMC joint, trapezium

PA Oblique Thumb

Projection: PA Oblique

Position: Oblique (medial rotation)

SID: 40''

IR: 8x10 (lengthwise or crosswise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at the end of table with hand

resting on IR

Part Position: Abduct thumb slightly with hand pronated in

contact with IR (naturally places thumb in 45°

oblique position)

Align long axis of thumb with long axis of IR

Center 1st MCP joint to CR and to center of IR

CR: Perpendicular to IR and 1st Metacarpophalangeal Joint

Collimation: To part size

Evaluation Criteria: Should see distal phalanx, IP joint,

proximal phalanx, 1st MCP joint (CR),

sesamoid bone, all of 1st metacarpal, 1st

CMC joint, and all of the trapezium

Lateral Thumb

Position: Lateral

SID: 40''

IR: 8x10 (lengthwise and crosswise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at the end of table, with elbow

flexed about 90° with hand resting on IR,

palm down

Part Position: Start with hand pronated and thumb abducted,

with fingers and hand slightly arched; then

rotate hand slightly medial until tumb is in true

lateral position

Align long axis of thumb with long axis of IR

Entire lateral aspect of thumb sould be in direct

contact with IR

CR: Perpendicular to IR and 1st Metacarpophlangeal Joint

Collimation: To part size

Evaluation Criteria: Should see distal phalanx, IP joint,

proximal phalanx, 1st MCP joint (CR),

sesamoid bone, all of 1st metacarpal,

1st CMC joint, and all of the trapezium

PA Hand

Projection: PA

Position: PA Pronate

SID: 40''

IR: 10x12 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at the end of table, with hand

and forearm extended

Part Position: Pronate hand with palamar surface in contact

with IR; spread fingers slightly

Align long axis of hand and forearm with long

axis of IR; Center hand an wrist

CR: Perpendicular to IR and 3rd Metacarpophalangeal Joint

Collimation: To part size

Evaluation Criteria: PA projection of entire hand and wrist,

should see all 5 phalanges and

metacarpals and all 8 carpals, distal,

middle and proximal phalanx, and the

distal radius and ulna

PA hand demonstrates oblique view of

thumb

PA Oblique Hand

Projection: PA Oblique

Position: Oblique

SID: 40''

IR: 10x12 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table with hand and

forearm extended

Part Position: Pronate hand on IR; center and align long axis

of hand with long axis of IR, digits PARALLEL to IR

Rotate entire hand and wrist laterally 45°

CR: Perpendicular to IR and 3rd Metacarpophalangeal Joint

Collimate: To part size

Evaluation Criteria: Should see all 5 phalanges and

metacarapls, and carpals, distal, middle,

and proximal phalanx, and the distal radius

and ulna; phalnges parallel to IR

Note: Ensure that phalanges are kept straight so that distal

interphalangeal joint spaces are open and visible on

on a radiograph

"Fan" Lateral Hand

Projection: Lateromedial

Position: "Fan" Lateral

Clinical Indications: Fractures and dislocations of the

phalanges, anterior/posterior displaced

fractures, and dislocations of metacarpals

SID: 40''

IR: 10x12 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at the end of table with hand and

forearm extended

Part Position: Align long axis of hand with long axis of IR

Rotate hand and wrist into a lateral position with

thumb side up

Spread fingers and thumb into a "fan" position

Ensure that all digits inlcuding the thumb, are

separated and paralell to IR and that the

metacarpals are not rotated but remain ina true

lateral position

CR: Perpendicular to IR and 2nd Metacarpophlangeal Joint

Collimate: To part size

Evalauation Criteria: Should see all 5 phalanges and

superiposed metacarpals, the distal,

middle and proximal phalanx; Thumb has

a PA position

Extension Lateral Hand

Projection: Lateromedial

Position: Lateral

Clinical Indications: Localization of foreign bodies of the hand

and fingers

SID: 40''

IR: 10x12 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table with hand and

forearm extended

Part Position: Rotate hand and wrist, with thumb side up, into

true lateral position

Extend fingers and thumb and ensure that all

fingers and metacarpals are superimposed

CR: Perpendicular to IR and 2nd to 5th MCP Joints

Collimation: To part size

PA Wrist

Projection: PA

Position: PA

SID: 40"

IR: 8x10 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table with hand and

forearm extended; Shoulder, elbow and wrist

should be on same plane

Part Position: With hand pronated, cup hand slightly to place

wrist and carpal area in close contact with IR

(decreases OID of carpals and IR)

CR: Perpendicular to IR and midcarpal area

Collimate: To part size

Evaluation Criteria: Should see metacarpals, all carpals, and

distal radius and ulna

PA Oblique Wrist

Projection: PA Oblique

Position: Oblique w/ a lateral rotation

SID: 40''

IR: 8x10 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at the end of table with hand and

forearm extended; Shoulder, elbow and wrist

should be on the same plane

Part Position: From pronated position, rotate wrist and hand

laterally 45°; Partially flex fingers to arch hand

so that fingertips rest lightly on IR w/o support

CR: Perpendicular to IR and midcarpal area

Collimation: To part size

Evaluation Criteria: Should see distal radius and ulna,

all carpals (especially trapezium

and scaphoid), and metacarpals

The ulna is thrown out of the way so it is

not superimposed and the 3rd-5th

are superimposed

Lateral Wrist

Projection: Lateromedial

Position: Lateral

SID: 40''

IR: 8x10 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table, with arm and

forearm resting on table and place wrist and

hand on IR in tumb up lateral position;

Shoulder, elbow and wrist on same plane

Part Position: Adjust hand and wrist into a true lateral

position, with fingers comfortable extended

CR: Perpendicualr to IR and midcarpal area

Collimation: To part size

Evaluation Criteria: Distal radius and ulna, superimposed

carpals, midmetacarpal area; Can see

trapezium, scaphoid, and capitate

PA and PA Axial Scaphoid (Ulnar Deviation of Wrist)

Projection: PA and PA Axial

Position: PA w/ ulnar deviation

Clinical Indications: Possible fracture of the scaphoid

SID: 40''

IR: 8x10 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table, with wrist and

hand on IR, palm down, and shoulder, elbow

wrist on same plane

Part Position: Position wrist for a PA projection- palm down

and hand and wrist aligned with center of long

axis of IR, with scaphoid centered to CR

CR: Angle tube 10°-15° to carpals and scaphoid (proximal row

on radial side)

Evaluation Criteria: Distal radius and ulna, carpals and

proximal metacarpals are visible;

Schaphoid should be demonstrated

clearly without foreshortening with

adjacent carpal interspaces open

Stecher Method (Wrist)

Instead of angling tube 10°-15°, the hand is put on a positioning sponge and the tube is centered perpendicuallry

PA Wrist (Radial Deviation)

Projection: PA

Position: PA w/ radial deviation

SID: 40"

IR: 8x10 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table with hand and

forearm extended; Shoulder, elbow, and wrist

Should be on same plane

Part Position: Position wrist for PA projection- palm down with

wrist and hand aligned to the long axis of IR

Without moving forearm, gently move hand

medially as far as patient can tolerate without

lifting or rotating distal forearm

CR: Perpendicular to IR and midcarpal area

Collimation: To part size

Evaluation Criteria: Distal radius and ulna, carpals, and

proximal metacarpals are visible; Carpals

are visible, with adjacent interspaces more

open on ulnar side; The pisiform carpal is

more open

Note: Ulnar deviation is more common than radial deviation

because the scaphoid is the most commonly fractured

bone

Gaynor-Hart Method (Wrist)

Projection: Tangential

Clinical Indications: To see carpal tunnel syndrome

SID: 40''

IR: 8x10 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table, with wrist and

hand on IR palm down

Part Position: Ask patient to hyperextend wrist (dorisflex) 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 metacarpals and the

fingers near vertical (90° to forearm) as

possible

Rotate entire hand and wrist about 10° internally

to prevent superimposition of pisiform and

hamate

CR: Angle CR 25° to 30° to the long axis of the hand and 1 inch

distal to the base of 3rd metacarpal (center of palm of

hand)

Collimate: To part size

Evaluation Criteria: The carpals are demonstarted in a tunnel-

like, arched arrangement(

AP Forearm

Projection: AP

Position: AP SUpinate

SID: 40"

IR: 11x14 (lengthwise) or 14x17 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at the end of table, with hand

arm fully extended and palm supinated

Part Position: Entire humerus and forearm in contact with IR

and on the same plane

Align and center forearm to long axis of IR,

ensuring that both wrist and elbow joints are

included

Instruct patient to lean laterally as neccessary to

place entire wrist, elbow, and forearm in as near

a true frontal position as possible

Check that lateral and medial epicondyles are

paralell to the IR

CR: Perpendicular to IR and mid-forearm

Collimation: To part size

Evaluation Criteria: AP projection of entire radis and ulna is

shown, all carpals, and distal humerus

Lateral Forearm

Projection: Lateromedial

Position: Lateral

SID: 40''

IR: 11x14 (lengthwise) ot 14x17 (lengthwise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table with elbow flexed

90° thumb up

Part Position: Place entire upper limb on same plane

Align and center forearm to long axis of IR and

ensure that both wrist and elbow joints are on

IR

Rotate hand and wrist into true lateral position

and support hand to prevent motion

CR: Perpendicular to IR and mid-forearm

Collimate: To part size

Evaluation Criteria: Lateral projection of entire radius and ulna,

all carpal bones, elbow, and distal end of

humerus

Long axis of forearm centered with long

long axis of IR; Elbow flexed 90°, Head of

ulna superimposed over the radius and

humeral epicondyles should be

superimposed; Head of radius

superimposed over coranoid process

AP Elbow

Projection: AP

Position: AP Supinate

SID: 40''

IR: 10x12 (lengthwise or crosswise)

Shielding: Yes (Ask LMP)

Patient Position: Seat patient at end of table, with elbow fully extended, if possible

Part Position: 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 neccessary for true AP projection

CR: Perpendicular to IR and mid-elbow joint

Evaluation Criteria: Radial head, radius, ulna, coronoid process and tubercle, tochela, olecranon process, medial epicondyle, lateral epicondyle, and distal humerus

AP Elbow (Partial Flexion)

Projection: AP

SID: 40''

IR: 10x12 (lengthwise or crosswise)

Shielding: Yes (ask lmp)

Patient Position: Seat patient at end of table, with elbow partially flexed

Part Position: Obtain two AP projections- one with forearm parallel to IR and one with humerus parallel to IR

CR: Perpendicualr to IR and mid-elbow joint

AP Oblique Elbow (Lateral Rotation)

Projection: AP External Oblique

Postion: Oblique w/ lateral rotation

SID: 40''

IR: 10x12 (lengthwise and crosswise)

Shield: Yes (ask lmp)

Patient Position: Seat patient at the end of table, with arm fully extended and shoulder and elbow on the same plane

Part Position: Align forearm and arm with the long axis of I; Supinate hand and rotate laterally the entire arm so that the distal humerus and and the anterior surface of the elbow joint are approximately 45° to IR

CR: Perpendicular to IR and mid-elbow joint

Evaluation Criteria: Capitulum, lateral epicondyle, radial head, radial neck, radial tubercle, radius and ulna are visualized

Note: External (lateral rotation) oblique best visualizes radial head and neck of the radius and capitulum of humerus

AP Oblique Elbow (Internal Rotation)

Projection: AP Internal Oblique

Position: Oblique w/ medial rotation

SID: 40''

IR: 10x12 (lengthwise or crosswise)

Shield: Yes (ask lmp)

Patient Position: Seat patient at end of table, with arm fully extended and shoulder and elbow on same plane

Part Position: Align arm and forearm with long axis of IR; Pronate hand into a natural palm-down position and rotate arm as needed until distal humerus and anterior surface of elbow are rotated 45°

CR: Perpendicular to IR and mid-elbow joint

Collimate: To part size

Evaluation Criteria: Distal humerus, olecranon fossa, olecranon process, radial head, radius, ulna, coronoid process, trochlear notch, trochela, and medial epicondyle are visualized

Note: Internal (medial rotation) Oblique best visualizes coronoid process of ulna and trochlea in profile

Lateral Elbow

Projection: Lateromedial

Position: Lateral

SID: 40''

IR: 10x12 (lengthwise or crosswise)

Shield: Yes (ask LMP)

Patient Position: Seat patient at end of table, with elbow flexed 90°

Part Position: Align long axis of forearm with long axis of IR; Center elbow joint to CR and to center of IR; Humerus and forearm on same plane; Rotate hand and wrist into trule lateral position, thumb side up

CR: Perpendicular to IR and mid-elbow joint

Collimate: To part size

Evaluation Criteria: Elbow joint flexed 90°; Superimposed humeral epicondyles; Olecranon process shown and humerus superimposed

Coyle Method (Elbow)

Projection: Trauma Axial Lateromedial/Mediolateral

Position: Lateral

Clinical Indications: Fractures of the elbow, particularly the radial head

Patient Position: Seat patient at the end of table for erect position or supine on table for cross table-imaging

Part Position: Elbow flexed 90° if possible; hand lateral; Entire upper limb in contact with IR

CR: Angle 45° towards the patient and radial head, mid-elbow joint (Causes eleongagtion of the radial head on purpose and appears distorted)

Evaluation Criteria: 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