Hand and Wrist Radiographic Projections — Comprehensive Study Notes

General Procedures

• Remove rings, watches, and other radiopaque objects; place them in secure storage during the procedure.

• Seat the patient at the side or end of the table to avoid a strained or uncomfortable position.

• Place the IR at a location and angle that allows the patient to be in the most comfortable position.

• Direct the central ray at a right angle to the midpoint of the IR.

• Radiograph each side separately when performing a bilateral examination of the hands or wrists to prevent distortion, particularly of the joint spaces.

• Shield gonads.

• Use close collimation.

• Use right or left markers and any other identification markers.

Digits (Second–Fifth Digits) PA Projection

• PP: palmar surface down, slightly separated digits.

• RP: PIP Joint.

• CR: Perpendicular.

• SS: PA Projection of affected digit.

• Collimation: $1\text{ inch} (2.5\text{ cm})$ on all sides of the digit, including $1\text{ inch} (2.5\text{ cm})$ proximal to the MCP joint.

• EC:

  • Entire digit from fingertip to distal portion of the adjoining metacarpal.

  • No soft tissue overlap from adjacent digits.

  • No rotation of the digit demonstrated by concavity of the phalangeal bodies and an equal amount of soft tissue on both sides of the phalanges.

  • Open IP and MCP joint spaces.

• NOTE: Digits that cannot be extended can be examined in small sections. When joint injury is suspected, an AP projection instead of a PA projection is recommended.

• Lateral Projection (Lateromedial or Mediolateral)

  • PP: hand rests on lateral/radial surface (2nd and 3rd digits) or medial/ulnar surface (4th or 5th digits).

  • RP: PIP Joint.

  • CR: Perpendicular.

  • SS: Lateral projection of affected digits.

  • EC:

  • Entire digit in a true lateral position.

  • Concave, anterior surfaces of the phalanges.

  • No rotation of the phalanges.

  • No obstruction of the proximal phalanx or MCP joint.

  • Open IP joint spaces.

• PA Oblique Projection (Lateral Rotation)

  • PP: Hand pronated, palmar surface down; hand externally/laterally rotated 45°, may use a 45-degree foam wedge.

  • RP: PIP joint.

  • CR: Perpendicular.

  • SS: PA oblique projection of the affected digit.

  • EC:

  • Entire digit rotated 45 degrees demonstrated by the concavity of the elevated side of the phalangeal bodies.

  • No superimposition.

  • Open IP and MCP joint spaces.

• STREET METHOD

  • Medial Rotation – rotate the second digit medially from the prone position.

  • Advantage: the part is closer to the IR for improved recorded detail and increased visibility of certain fractures.

Digits (2nd–5th) Review of Projections

• 1. PA Projection

• 2. Lateral Projection (Lateromedial or Mediolateral)

• 3. PA Oblique Projection (Lateral Rotation)

• 4. PA Oblique Projection (Medial Rotation – Street Method)

Digits (First Digit – Thumb)

AP Projection

• PP: arm is internally rotated; hand is in extreme internal/medial rotation; thumb posterior surface down.

• RP: 1st MCP Joint.

• CR: Perpendicular.

• SS: AP Projection of the thumb.

• EC:

  • Entire digit with trapezium in profile.

  • No rotation (concave phalangeal and metacarpal bodies).

  • Overlap of soft tissue profile (palm and 1st metacarpal).

  • Open IP and MCP Joint spaces.

AP Projection – Lewis Modification

• CR: 10^\u00B0–15^\u00B0 along the long axis of the thumb toward the wrist.

• Rationale: To show the first metacarpal free of soft tissue of the palm.

PA Projection

• PP: Hand resting on its medial surface.

• PA projection of 1st CMC and 1st Digit – hand in lateral position and dorsal surface of the thumb parallel with the IR.

• RP: 1st MCP Joint.

• CR: Perpendicular.

• SS: Magnified PA Projection of the thumb.

• EC:

  • Entire digit with trapezium in profile.

  • No rotation (concave phalangeal and metacarpal bodies).

  • Overlap of soft tissue profile (palm and 1st metacarpal).

  • Open IP and MCP Joint spaces.

Lateral Projection

• PP: Hand is relaxed and in its natural arched position, palmar surface down.

• RP: 1st MCP Joint.

• CR: Perpendicular.

• SS: Lateral Projection of the thumb.

• EC:

  • Entire digit with trapezium in profile.

  • No Rotation: Concave, anterior surface of the proximal phalanx.

  • Overlap of soft tissue profile (palm and 1st metacarpal).

  • Open IP and MCP Joint spaces.

PA Oblique Projection

• PP: Palmar surface on the IR; Thumb is abducted; Hand in slight ulnar deviation.

• RP: 1st MCP Joint.

• CR: Perpendicular.

• SS: PA Oblique Projection of the thumb.

• EC:

  • Entire digit with trapezium in profile.

  • Proper Rotation: concave, anterior surface of the elevated side of the proximal phalanx.

  • Open IP and MCP Joint spaces.

Projections (1st Digit)

AP Projection (Robert Method)

• PP: Shoulder, elbow, and wrist on the same plane to prevent elevation of the carpal bones and closing of the 1st CMC Joint. Extend the limb straight out on the radiographic table. Arm is internally rotated. Hand is hyperextended so that the soft tissue over the ulnar aspect does not obscure the 1st CMC Joint.

• RP: 1st CMC Joint.

• CR: Perpendicular.

• SS: First CMC joint free of superimposition.

• EC: 1st Metacarpal with the base in convex profile; Trapezium.

• Exam Rationale: To demonstrate arthritic changes, fractures, displacement of the first CMC joint and Bennett fracture.

AP Projection (Long & Rafert Modification)

• PP: Shoulder, elbow, and wrist on the same plane to prevent elevation of the carpal bones and closing of the 1st CMC Joint. Extend the limb straight out on the radiographic table. Arm internally rotated. Hand hyperextended so that the ulnar aspect does not obscure the 1st CMC Joint.

• RP: 1st CMC Joint.

• CR: 15^\u00B0 proximally along the long axis of the thumb entering the 1st CMC joint.

• Collimation: includes the entire thumb.

• SS: First CMC joint free of superimposition.

• EC: 1st Metacarpal with the base in convex profile; Trapezium.

AP Projection (Lewis Modification)

• PP: Shoulder, elbow, and wrist on the same plane to prevent elevation of the carpal bones and closing of the 1st CMC Joint. Extend the limb straight out on the radiographic table. Arm is internally rotated. Hand is hyperextended so that the soft tissue over the ulnar aspect does not obscure the 1st CMC Joint.

• RP: 1st MCP Joint.

• CR: 10^\u00B0–15^\u00B0 proximally along the long axis of the thumb entering the 1st MCP joint.

• SS: First CMC joint free of superimposition.

• EC: First CMC joint free of superimposition.

AP Projection (Burman Method)

• When hyperextension of the wrist is not contraindicated, this projection provides a clearer image of the first CMC joint than is seen on standard AP.

• SID: $18\text{ inches}$; this magnifies the image for a greater field of view of the concavo-convex aspect of this joint.

• PP: Forearm approximately parallel with the long axis of the IR. Hand hyperextended and the position is held by the other hand or with a bandage; hand is rotated internally. Thumb abducted and flat on the IR.

• RP: 1st CMC Joint.

• CR: 45^\u00B0 toward the elbow.

• SS: Magnified concavo-convex outline of the first CMC joint.

• EC: First CMC joint unobscured by adjacent carpals; 1st Metacarpal with the base in convex profile; Trapezium in concave profile.

First CMC Projections Summary

• AP Projection (Robert Method)

• AP Projection Long-Rafert modification

• AP Projection Lewis modification

• AP Projection Burman method

• First Metacarpophalangeal Joint PA Projection (Folio Method)

• 1st Metacarpals with MCP joints Hand PA Projection

• PA Oblique Projection of the first digit (shown with the hand)

• Clements and Nakayama special exposure technique for imaging early rheumatoid arthritis (special notes)

• Lewis positioning variation to align 2nd–5th metacarpals parallel to IR (true PA projection)

• PA Oblique Projection (Lateral Rotation)

  • PP: Palmar surface down; MCP joints about 45° with the IR (foam wedge may be used).

  • Hand laterally rotated.

  • RP: 3rd MCP Joint.

  • CR: Perpendicular.

  • SS: PA Oblique Projection of the hand.

  • EC:

  • Entire hand including the distal radius and ulna.

  • Digits separated with no overlap.

  • 45° rotation of the anatomy shown by minimal overlap of 3rd, 4th, and 5th metacarpal bases and heads; separation of 2nd and 3rd metacarpals.

  • Open IP and MCP joint spaces.

• Reverse Oblique Projection (Lane-Kennedy-Kuschner Recommendation)

  • For better demonstration of severe metacarpal deformities or fractures.

  • PP: Palmar surface down; MCP joints about 45° with the IR; medially rotated.

  • RP: 3rd MCP Joint.

  • CR: Perpendicular.

  • SS: PA Oblique Projection of the hand.

  • EC: Entire hand including the distal radius and ulna; digits separated with no overlap; 45° rotation with minimal overlap of 3rd–5th metacarpal bases and heads; open IP and MCP joint spaces.

• Tangential Oblique Projection (Kallen Recommendation)

  • For demonstration of metacarpal head fracture.

  • PP: Palmar surface down. Hand rotated 40–45° toward the ulnar surface and 40–45° forward. MCP joints flexed 75–80°.

  • RP: MCP Joint of interest.

  • CR: Perpendicular.

  • SS: Tangential PA Oblique Projection of the hand.

  • EC: Entire hand including the distal radius and ulna; digits separated with no overlap; 45° rotation shown by minimal overlap of 3rd, 4th, and 5th metacarpal bases and heads; open IP and MCP joint spaces.

• Lateral Projection (Mediolateral / Lateromedial Extension and Fan Lateral)

  • PP: Hand in lateral position, digits extended, thumb abducted and at 90° to the palm. Lateromedial (ulnar aspect down) or Mediolateral (radial aspect down, more difficult). Fan lateral – digits supported on a sponge wedge.

  • RP: 2nd MCP Joint.

  • CR: Perpendicular.

  • SS: Lateral projection of the hand in extension.

  • EC: Entire digits to distal radius and ulna.

  • Features: Extended digits; true lateral shown by superimposed metacarpals, distal radius and ulna; fan lateral shows individual digits.

• Lateral Projection (Lewis Recommendation)

  • Rationale: For better demonstration of fifth metacarpal fractures.

  • PP: Hand rotated 5° posteriorly from true lateral position to remove superimposition of 2nd to 4th metacarpals.

  • RP: Midshaft of 5th metacarpal.

  • CR: Parallel to the extended thumb.

  • SS: Lateral projection of the hand.

  • EC: Thumb extended; distal radius and ulna, carpals, and proximal half of metacarpals.

• Lateral Projection (Lateromedial in Flexion)

  • Use when a hand injury prevents extending the fingers.

  • PP: Forearm rested on the table; hand’s ulnar aspect down; digits relaxed; natural arch; perfectly superimposed with each other.

  • RP: 2nd MCP Joint.

  • CR: Perpendicular.

  • SS: Lateral projection of the hand in flexion.

  • EC: Distal radius and ulna, carpals, and proximal half of metacarpals; flexed digits; superimposed phalanges and metacarpals; superimposed distal radius and ulna.

Review of Projections (Hand)

• PA Projection

• PA Oblique Projection (Lateral Rotation)

• Reverse Oblique Projection (Lane-Kennedy-Kuschner Recommendation)

• Tangential Projection (Kallen Recommendation)

• Lateral Projection (Mediolateral/Lateromedial Extension and Fan Lateral)

• Lateral Projection (Lewis Recommendation)

• Lateral Projection (Lateromedial in Flexion)

• AP Oblique Projection – Medial Rotation (Norgaard Method)

• Special notes on rheumatoid arthritis imaging (Clements/Nakayama, Lewis variations)

Wrist (Carpal) Imaging

• Collimation: $2.5\text{ inches} (6\text{ cm})$ proximal and distal to the wrist joint and $1\text{ inch} (2.5\text{ cm})$ on the sides.

PA Projection

• PP: Seated; Hand pronated; Digits flexed to place the wrist in contact with the IR.

• SWOLLEN WRIST: ask the patient to flex the wrist slightly.

• RP: Midcarpal Area.

• CR: Perpendicular.

• SS: PA projection of the carpals, distal radius and ulna, and proximal metacarpals.

• EC: Distal radius and ulna, carpals, and proximal half of metacarpals.

• Notes: No excessive flexion of digits to overlap and obscure metacarpal; No rotation in carpals, metacarpals, radius, and ulna; Open radioulnar joint space.

PA Projection (Daffner-Emmerling-Buterbaugh Recommendation)

• PP: Seated; Hand pronated; Digits flexed to place the wrist in contact with the IR.

• SWOLLEN WRIST: flex wrist slightly.

• RP: Midcarpal Area.

• CR: 30^\u00B0 toward the elbow or 30^\u00B0 toward the fingertips.

• SS: 30^0 toward the elbow – elongated scaphoid and capitate; 30^0 toward the fingertips – elongated capitate.

AP Projection

• PP: Seated; Arm and hand supinated; Digits elevated to place the wrist in contact with the IR.

• RP: Midcarpal Area.

• CR: Perpendicular.

• SS: The carpal interspaces are better shown in the AP image than in the PA image; interspaces are more closely parallel with beam divergence.

• EC: Distal radius and ulna, carpals, and proximal half of metacarpals; No excessive flexion of digits; No rotation in carpals, metacarpals, radius, and ulna.

Lateral Projection (Lateromedial)

• PP: Seated; Elbow flexed 90° to rotate the ulna in true lateral position; Ulnar surface down.

• RP: Wrist joint.

• CR: Perpendicular.

• SS: Lateral projection of the proximal metacarpals, carpals, and distal radius and ulna.

• EC: Distal radius and ulna, carpals, and proximal half of metacarpals; Superimposed distal radius and ulna; Superimposed metacarpals.

• Notes: This position can also be used to show anterior or posterior displacement in fractures.

Lateral Projection (Burman Suggestion)

• PP: Wrist in palmar flexion because it rotates the bone anteriorly into a dorsovolar position.

• RP: Wrist joint.

• CR: Perpendicular.

• SS: Lateral projection of the scaphoid.

• EC: Wrist with distal radius and ulna; scaphoid elongated.

• Note: This position is valuable only when sufficient flexion is permitted.

Fiolle – Carpal Boss

• Description: A small bony growth on the dorsal surface of the third CMC joint; best seen in lateral position with wrist in palmar flexion.

PA Oblique Projection (Lateral Rotation)

• PP: Seated; From pronated position, rotate wrist laterally 45°; support with sponge if necessary.

• RP: Midcarpal Area just distal to the radius.

• CR: Perpendicular.

• SS: Trapezium and scaphoid on the lateral side of the wrist.

• EC: Distal radius and ulna, carpals, and proximal half of metacarpals; 45° rotation demonstrated by trapezium and scaphoid without superimposition; open trapeziotrapezoid and scaphotrapezial joint space.

AP Oblique Projection (Medial Rotation)

• PP: Seated; From supinated position, rotate wrist medially 45°.

• RP: Midcarpal Area.

• CR: Perpendicular.

• SS: Pisiform in profile and triquetrum free of superimposition.

• EC: Distal radius and ulna, carpals, and proximal half of metacarpals; 45° rotation shown by pisiform free of superimposition and well visualized triquetrum.

Scaphoid Projections

• Scaphoid (PA Axial Projection – Stecher Method)

  • PP: Place IR on end of table; forearm on table; elevate finger end by ~20°; wrist in PA position.

  • RP: Scaphoid.

  • CR: Perpendicular.

  • SS: Scaphoid.

  • EC: Scaphoid with adjacent articulations open.

• Scaphoid (Rafer-T Long Method)

  • PP: IR on end of table; forearm on table; elevate finger end ~20°; wrist PA with ulnar deviation.

  • RP: Scaphoid.

  • CR: 20^0 toward the elbow.

  • SS: Scaphoid.

  • EC: Scaphoid free of superimposition.

• Scaphoid (Ulnar Deviation)

  • PP: PA projection; hand rolled into extreme ulnar deviation.

  • RP: Scaphoid.

  • CR: Perpendicular to the scaphoid; for foreshortening, direct CR 10^0–15^0 proximally or toward the elbow.

  • EC: Scaphoid with adjacent articulations open.

Trapezium (AP Axial Projection)

• PP: Hand in extreme hyperextension; palmar surface rests on IR.

• RP: Midline of the IR at the level of the trapezium.

• CR: Directed toward the base of the thumb at an angle of 45^0 distally.

• SS: Trapezium.

• EC: Trapezium free of superimposition; base of first metacarpal and trapeziometacarpal joint well visualized.

Carpal Bridge (Tangential Projection)

• PP: Patient standing or seated at the end of the table. Dorsal hand on cassette. Flex wrist as much as possible; support digits.

• RP: $1\frac{1}{2}$ inches ( $3.8\text{ cm}$ ) proximal to the wrist joint.

• CR: 45^0 caudal angle toward a point about $1\frac{1}{2}$ inches ( $3.8\text{ cm}$) proximal to the wrist joint.

• SS: Dorsal aspect of carpals.

• EC: Dorsal carpals free of superimposition; useful for lunate dislocations, midcarpal fractures, and foreign bodies.

Carpal Canal (Gaynor-Hart Method – Tangential Inferosuperior Projection)

• PP: Seated; palmar wrist on cassette; hyperextend wrist as much as possible; use tape to hold digits back; rotate hand slightly toward radial side to prevent superimposition of hamate and pisiform.

• RP: Approximately $1\text{ inch} (2.5\text{ cm})$ distal to the base of the 3rd metacarpal; centered to the palm.

• CR: Directed to the palm of the hand at an angle of 25^0 to 30^0 to the long axis of the hand.

• SS: Carpal canal.

• EC: Pisiform in profile; hamulus of hamate well visualized; trapezium and entire carpal canal demonstrated.

• Carpal Canal (Alternate Projection – Superoinferior)

  • PP: Seated; forearm resting on cassette; hand hyperextended; fingers grasp table edge; hand rotated slightly toward radial side.

  • RP: $1\text{ inch} (2.5\text{ cm})$ distal to base of 3rd metacarpal.

  • CR: Directed from above (superior) at an angle of 25^0 to 30^0 to the long axis of the hand.

  • SS: Carpal canal.

  • EC: Pisiform in profile; hamulus of the hamate visualized; trapezium and entire carpal canal demonstrated.

• Carpal Canal (Gaynor-Hart Modification – Ulnar Deviation)

  • PP: Seated with forearm resting on table; hyperextend the wrist and deviate toward the ulna; fingers extended and held back by tape.

  • RP: $1\text{ inch} (2.5\text{ cm})$ distal to the base of the 3rd metacarpal.

  • CR: 25^0 to 30^0 to the long axis of the hand.

  • SS: Carpal canal.

  • EC: Pisiform in profile; hamulus of hamate visualized; entire canal shown without superimposition.

• SPECIAL NOTES (CARPAL CANAL)

  • The carpal canal projections are used for demonstration of carpal tunnel syndrome, fractures of the hook of hamate, pisiform, trapezium, and anterior dislocation of lunate.

Additional Notes and Techniques

• The various PA, AP, oblique, lateral, and tangential projections are designed to evaluate specific joints and structures within the hand, wrist, and first CMC region.

• Rheumatoid arthritis-focused projections (e.g., Norgaard/ball-catcher position) use low kVp for better contrast and early detection of articular changes; recommended kVp range for this projection is $60\text{–}65\,\text{kVp}$.

• When the MCP joints are under examination and the patient cannot extend the hand flat on the IR, the position can be reversed for an AP projection; this is also used for metacarpals when extension is limited due to injury, pathology, or dressings.

• Special positioning notes (e.g., Lewis modification, Street method, Lane-Kennedy-Kuschner, Stecher, Rafert-Long) are designed to optimize visualization of particular fracture patterns or joint features.

• For the first CMC joint, several targeted projections exist to reveal arthritis, fractures, or displacements, including Robert, Rafert, Lewis, and Burman methods; each uses distinct patient positioning and tube angulation.

• When imaging the carpal canal, the goal is to visualize the carpal tunnel contents and structures like the pisiform, trapezium, and hamate without superimposition.

• Tangential projections (e.g., for trapezium, metacarpal heads) require precise patient positioning with specific joint angles to demonstrate the target anatomy.

Key Terminology Summary

• PA Projection, AP Projection, Lateral Projection, Oblique Projection, Tangential Projection.

• Projections by Digit: 1st digit (thumb) vs. 2nd–5th digits.

• Specific Methods: Robert, Rafert-Long, Lewis, Burman, Norgaard, Stecher, Kallen, Gaylor-Hart, Lane-Kennedy-Kuschner, etc.

• Anatomical terms: MCP joint, PIP joint, IP joint, CMC joint, trapezium, capitate, scaphoid, pisiform, hamate, trapeziometacarpal joint, etc.

• Imaging objectives: joint space visualization, avoidance of overlapping structures, detection of fractures, dislocations, early rheumatoid changes, and carpal tunnel-related pathology.

Quick Reference: Common Angles and Landmarks (selected)

• PA Oblique Projection of the hand: rotation about 45^0; open IP and MCP spaces.

• Street Method for 2nd digit: medial rotation improves detail; part closer to IR.

• First CMC AP/Lewis: 10^0$–$15^0 toward wrist.

• Burman AP projection: 45^0 toward elbow; magnified first CMC visualization.

• Kallen Tangential: about 40^0–45^0 rotation; MCP joints flexed 75°–80°.

• Carpal canal Gaynor-Hart tangential: 25^0$–$30^0 to long axis; 1 inch distal to base of 3rd metacarpal.

• Trapezium AP axial: projection toward base of thumb at 45^0 distally.

• Scaphoid positions: Stecher, Rafert-Long, and ulnar deviation methods with angulations around 20^0–30^0 depending on method.

• Norgaard (ball-catcher) method: 60–65 kVp for RA detection; both hands in half-supinated position; 45° sponge supports.