Upper Extremity

1 Upper Extremity




FINGERS


• PA (dorsipalmar)

• Lateral

THUMB


• AP

• Lateral

• AP alternative position (trauma)

HAND


• PA (dorsipalmar)

• PA oblique

• Lateral

• AP oblique (ball catcher’s)

WRIST


• PA

• PA oblique

• Lateral

SCAPHOID


• PA

• PA oblique

• AP oblique

• Possible scaphoid fracture (alternative ‘banana projection’)

FOREARM


• AP

• Lateral

ELBOW


• AP

• Lateral

• Modified projections

RADIAL HEAD


• Alternative projection

HUMERUS


• AP

• Lateral


FINGERS





image

Projection: PA (DORSIPALMAR)


Centring Point: To the proximal interphalangeal joint





image

Second finger



image

Fifth finger


Projection: LATERAL


Centring Point: To the proximal interphalangeal joint



Points to consider



Technique




image Metacarpophalangeal joint must be included


image Always include another finger to aid identification


image AP – the fingers must be placed flat upon the cassette


image Lateral – non-opaque pad can be used to help extend the finger


image Lateral – trauma – try not to let the finger flex too much




image


Radiological assessment




image Avulsion #s are common – look for soft tissue swelling


image Mallet finger – direct blow plus avulsion of extensor tendon


image Dislocation – proximal interphalangeal joint – sporting injury


image Joint spaces should be uniform – approximately 1 mm in width


image Transverse # – result of hyperextension of the finger



PA (dorsipalmar) – affected finger




• Patient seated, affected side towards the X-ray table


• Forearm placed on table


• Palmar aspect of fingers placed on the cassette


• Fingers extended and separated slightly



Collimation


To include: PROXIMALLY: Full length of metacarpal


DISTALLY: Terminal phalanx


LATERALLY: Soft tissue borders


Include adjacent finger to aid identification



Lateral – index and middle fingers




• Hand rotated medially until the lateral aspect of the index finger is in contact with the cassette


• Index and middle fingers are extended and separated


• Remaining fingers are flexed


• Forearm may be raised on pads and supported – middle finger may be supported with a non-opaque pad



Lateral – little and ring fingers




• Hand rotated laterally so that the medial aspect of the little finger is in contact with the cassette


• Little and ring fingers are extended and separated


• Ring finger may be supported on a non-opaque pad and parallel to the cassette


• Remaining fingers are flexed



Collimation


To include: PROXIMALLY: Proximal phalanx


DISTALLY: Terminal phalanx


LATERALLY: Soft tissue borders



THUMB





image

Projection: AP


Centring Point: To the metacarpophalangeal joint





image

Projection: LATERAL


Centring Point: To the metacarpophalangeal joint



Points to consider



Technique




image AP – condyles must be equidistant from the cassette


image Lateral – condyles must be superimposed


image ?Trauma – consider alternative AP (trauma) projection


image Underpenetration of proximal thumb due to thenar pad




image


Radiological assessment




image Radiograph can appear normal – look for soft tissue swelling


image Avulsion #s may be present


image Bennett’s # – # dislocation – result of forced abduction


image Skier’s (gamekeeper’s) thumb – acute sprain or rupture – ulnar collateral ligament



AP




• Patient seated, affected side towards the X-ray table


• Thumb, elbow and shoulder at the same height (desirable but not essential)


• The hand and forearm are extended


• Hand rotated medially so that the posterior aspect of the thumb is in contact with the cassette



Collimation


To include: PROXIMALLY: Carpometacarpal joint


DISTALLY: Terminal phalanx


LATERALLY: Soft tissue borders


MEDIALLY: Soft tissue borders



Lateral




• Patient seated


• Hand prone, the palm is then rotated medially and supported on a non-opaque pad until the thumb is lateral, fingers form fist to support position or use non-opaque pad where indicated


• Lateral aspect of the thumb is in contact with the cassette and is then slightly flexed



Collimation


To include: PROXIMALLY: Carpometacarpal joint


DISTALLY: Terminal phalanx


LATERALLY: Soft tissue borders


MEDIALLY: Soft tissue borders



THUMB





image

Projection: AP ALTERNATIVE POSITION (TRAUMA)


Centring Point: To the metacarpophalangeal joint



Points to consider



Technique




image Use if injury to base of first metacarpal is suspected


image Where indicated support the thumb on a non-opaque pad


image Must include the carpometacarpal joint


image Increase SID to reduce the magnification


image Thumb must be parallel to the cassette



Radiological assessment




image Check the first carpometacarpal joint is included


image A magnified image unless an increased SID is used


image Bennett’s # – unlikely thumb will be parallel to the cassette



AP alternative position (trauma)




• Medial border of the hand, placed in contact with the cassette


• Palmar aspect 90°


• Thumb is extended and where indicated placed on a non-opaque pad




image

If the patient’s thumb is in a cast, the patient standing often enables the thumb to be more easily placed parallel to the cassette.



Collimation


To include: PROXIMALLY: Carpometacarpal joint


DISTALLY: Terminal phalanx


LATERALLY: Soft tissue borders


MEDIALLY: Soft tissue borders



HAND





image

Projection: PA (DORSIPALMAR)


Centring Point: To the head of the third metacarpal





image

Projection: PA OBLIQUE


Centring Point: To the head of the third metacarpal



Points to consider



Technique




image Include the whole of the hand, including carpal bones and distal radius/ulna


image ?Injury confined to distal digit – limit image to that digit


image If you identify an injury – proceed to a lateral


image PA oblique – better general assessment if fingers parallel


image PA oblique – avoid over-rotation – obscure metacarpals




image


Radiological assessment




image #s metacarpal neck – usually the result of a direct blow


image Common site for #s – head of the fifth metacarpal – Boxer’s #


image Look for vertical # through the base with dislocation of joint


image Secondary ossification centres appear at age 2–3 years


image PA poor at showing #s of the articular surface of the metacarpal heads



PA (dorsipalmar)




• Patient seated, affected side towards the X-ray table


• Palmar aspect placed on the cassette


• Fingers are extended and slightly separated



Collimation


To include: PROXIMALLY: Distal radius and ulna


DISTALLY: Terminal phalanx


LATERALLY: Soft tissue borders


MEDIALLY: Soft tissue borders



PA oblique




• From the PA position the hand is rotated onto the lateral side to form an angle of 45° and where indicated supported on a non-opaque pad


• Fingers slightly flexed and separated


• Fingertips in contact with the cassette



Collimation


To include: PROXIMALLY: Distal radius and ulna


DISTALLY: Terminal phalanx


LATERALLY: Soft tissue borders


MEDIALLY: Soft tissue borders



HAND





image

Projection: LATERAL


Centring Point: To the head of the second metacarpal





image

Projection: AP OBLIQUE (BALL CATCHER’s)


Centring Point: Midway between both hands at the level of the head of the fifth metacarpal



Points to consider



Technique




image Lateral – where indicated support the thumb on a non-opaque pad

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Mar 6, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Upper Extremity

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