Radiology Clinical II~~~

Upper Extremity ~~~~~

Image Review

The following information is only a personal suggested guideline to follow when

positioning Upper Extremity exams.

For additional information on positioning of these

exams, please reference your Radiographic

Positioning and Related Anatomy Textbook.

Hand & Fingers

PA Finger(s)• SID 40” / TT• Elbow 90° • Hand pronated w/ fgrs extended• CR ┴ to IR• CP to effected digit @ PIP joint• Collimate• Shield

4

Oblique Finger(s)• SID 40” / TT• Elbow 90° • Hand rotated 45° w/ fgrs

extended• CR ┴ to IR• CP to effected digit @ PIP joint• Collimate• Shield

5

Lateral Finger(s)• SID 40” / TT• Elbow 90° • Hand true lat w/ fgrs extended• Use sponge and/or tongue blade• CR ┴ to IR• CP to effected digit @ PIP joint• Collimate• Shield

6

AP OBL LAT

AP/PA Thumb• SID 40” / TT• AP-Thumb nail on cassette• AP-Pull fingers back with opposite hand• PA-Hand in true lat position• PA-Rest thumb on a sponge • CR ┴ to IR• CP 1st MCP joint• Collimate• Shield

8

PA Oblique Thumb• SID 40” / TT• Hand pronated w/ thumb

extended• CR ┴ to IR• CP 1st MCP joint• Collimate• Shield

9

Lateral Thumb• SID 40” / TT• Hand pronated & digits 2-5

slightly arched & deviated toward the ulna

• CR ┴ to IR• CP 1st MCP joint• Collimate• Shield

10

AP OBL LAT

PA Hand• SID 40” / TT• Elbow 90° • Hand pronated w/ fgrs extended• CR ┴ to IR• CP to 3rd MCP joint• Collimate• Shield

12

Oblique Hand• SID 40” / TT• Elbow 90° • Hand rotated 45° w/ fgrs

extended• CR ┴ to IR• CP to 3rd MCP joint• Collimate• Shield

14

Lateral Hand X 3*• SID 40” / TT• Elbow 90° • Hand true lat w/ fgrs separated for Fan*,

extended for Extension*, and relaxed for Flexion*

• Use sponge and/or tongue blade• CR ┴ to IR• CP to 2nd MCP joint• Collimate• Shield

16

Fan Flexion Extension

ThumbRepeatable Error?

Poor Positioning

*Need to separate thumb from other

digits

ThumbRepeatable Error?

Poor Positioning

*Need to get palm out of the way

of the 1st MC

HandRepeatable Error?

Poor Collimation

*Or either wrong centering point or

patient moved

Oblique Hand

Repeatable Error?

Poor Positioning

*Over rotated

Good Image

Oblique Hand

Repeatable Error?

Poor Positioning

*Over rotatedAnd digits are not

separated

Good Image

Fan Lat Hand

Repeatable Error?

Poor Positioning

*Under rotated and digits are not

separated.

Good Image

FingerPathology

Dislocation

*Why 2 views at right angles to

each other are so important!

FingerPathology

Dislocation

FingerPathology

Congenital Abnormality

Thumb Pathology

Attacked by a nail gun

ThumbPathology

TraumaFx

HandPathology

Polydactyl

HandPathology

4th Metacarpal DeformityTurner’s

Syndrome

HandPathology

Rheumatoid Arthritis

HandPathology

Degenerative ArthritisFixation

HandPathology

TraumaSnowblower

HandPathology

TraumaUnknown

HandPathology

TraumaSaw

Who took this X-ray?

Who’s hand is it?

211

10

13121

45

6

7

8

9

3

Wrist

PA Wrist• SID 40” / TT• Elbow 90° • Hand pronated w/ fgrs flexed• CR ┴ to IR• CP to mid-carpals• Collimate• Shield

38

Oblique Wrist• SID 40” / TT• Elbow 90° • Hand rotated 45° outward• CR ┴ to IR• CP to mid-carpals• Collimate• Shield

40

Lateral Wrist• SID 40” / TT• Elbow 90° • Hand true lateral • Use sponge for stability• CR ┴ to IR• CP to mid-carpal joint• Collimate• Shield

42

PA Axial Scaphoid Wrist

“Ulnar Deviation”• SID 40” / TT• Elbow 90°• Hand pronated, then gently deviate

hand toward the ulna• CR < 10°-15° proximally up forearm• CP at the scaphoid• Collimate • Shield

44

PA Scaphoid Wrist“Ulnar Deviation – Modified Stecher Method”• SID 40” / TT• Elbow 90°• Hand pronated onto 20° < sponge,

then gently deviate hand toward the ulna• CR ┴ to IR• CP at the scaphoid• Collimate • Shield

45

Carpal Canal (Tunnel) Wrist

“Gaynor-Heart Method”• SID 40” / TT• Hand hyper-extended/dorsiflexed• Rotate hand 10° internally• CR < 25°to 30°to long axis of hand• CP 2-3cm (1”) distal to the base of

the 3rd metacarpal (center of palm of hand)

• Collimate • Shield

47

A = Trapezium B = ScaphoidC = Capitate D = Hamulus E = Pisiform

Oblique Wrist

Technical Error

Poor Positioning

*Under rotated.

Lateral Wrist

Technical Error

Poor Positioning

*Under rotated.

WristPathology

TraumaPrev Surg.

With new fx and gun

shot

WristPatholog

y

TraumaFx

Fall

WristPathology

TraumaFall

Wrist PathologyTrauma – Fall - Cast Info!!

Wrist Pathology

TraumaUnknown

Fx Scaphoid

AP Forearm• SID 40” / TT• Upper limb extended hand supinated• Shoulder in same plane as forearm• Epicondyles are ll to IR • CR is ┴ to IR• CP Mid-forearm• Collimate • Shield

57

AP Forearm

58

Lateral Forearm• SID 40” / TT• Upper limb flexed 90° in true lat pos• Shoulder in same plane as forearm• Epicondyles are ┴ to IR (may have

to slightly elevate wrist)• CR is ┴ to IR • CP Mid-forearm• Collimate • Shield

60

LateralForearm

Repeatable Error?

Poor Positioning

*Not a true lateral and not

a 90° flexion.

LateralForearm

Repeatable Error?

Poor Positioning

*Not a true lateral and not

a 90° flexion.

LateralForearm

Repeatable Error?

Poor Centering

*Poor image due to poor centering

of the CR.

ForearmPatholo

gy

TraumaUnknown

ForearmPatholo

gy

TraumaFallFx

WristPatholo

gy

Bone grafts

ForearmPatholog

y

TraumaHomemade

FireworkGone bad

Elbow

ABCD

E

I

H

G

F

Elbow

Radial neckRadial Head

Capitulum

Lateral epicondyle

Olecranon

Radial tuberosity

Coronoid process

Trochlea

Medial Epicondyle

Medial Epicondyle

74

1) Trochlear Sulcus

13 2

2) Outer Ridges of:Capitulum & Trochlea

3) Trochlear Notch of the Ulna

Elbow Fat Pad Sign

75Normal Abnormal

AP Elbow• SID 40” / TT• Upper limb extended hand supinated• Shoulder in same plane as forearm• Epicondyles are ll to IR • CR is ┴ to IR• CP Mid-elbow joint• Collimate • Shield

76

External ObliqueAlso called Lateral Oblique

• SID 40” / TT• Upper limb extended hand rotated lat• Shoulder in same plane as forearm• Epicondyles are at a 45°< to IR• CR is ┴ to IR• CP Mid-elbow joint• Collimate • Shield

78

Internal ObliqueAlso called Medial Oblique

• SID 40” / TT• Upper limb extended hand rotated

medially, pronate palm• Shoulder in same plane as forearm• Epicondyles are at a 45°< to IR• CR is ┴ to IR• CP Mid-elbow joint• Collimate • Shield

80

Lateral Elbow• SID 40” / TT• Upper limb flexed 90° in true lat pos• Shoulder in same plane as forearm• Epicondyles are ┴ to IR (may have

to slightly elevate wrist)• CR is ┴ to IR • CP Mid-elbow joint• Collimate • Shield

82

Acute Flexion Elbow X2”Jones Method”

• SID 40” / TT• Shoulder in same plane as humerus• Align humerus to long axis of IR, with

elbow flexed and fingers on shoulder• Ensure no rotation by checking

epicondyles to be equal distance from IR.• *CR is ┴ to Humerus *CR is ┴ to Forearm• CP 2” from Olecranon• Collimate • Shield

86

Trauma Lateral Elbow“Coyle Method”

“For Radial Head”• Upper limb flexed

90° in true lateral position-hand prone

• Shoulder in same plane as forearm

• Epicondyles are ┴ to IR

• CR 45°< toward shoulder

• CP Mid-elbow joint89

“For Coronoid”• Upper limb flexed

80° in lateral position-hand prone

• Shoulder in same plane as forearm

• Epicondyles are ┴ to IR

• CR 45°< from shoulder

• CP Mid-elbow joint

Coyle Method ~ “For Radial Head”

Upper limb flexed 90° and CR 45°< toward shoulder

Upper limb flexed 80° and CR 45°< from shoulder

Coyle Method ~ “For Coronoid”

ElbowTechnical

Error

Poor Positioning

*Not a true AP. Pt probably was

not able to extend arm.

ElbowRepeatable

Error?

Poor Positioning

*Not a true AP. Appears as though the patient placed their palm prone.

ElbowRepeatable Error?

Poor Positioning

*Over rotated Internal Oblique.

ElbowRepeatable

Error?

Poor Positioning

*Not flexed to 90° and arm is rotated. Epicondyles are not

┴ to IR.

ElbowRepeatable

Error?

Poor Positioning

*Not flexed to 90° and shoulder is not

in same plane as elbow. Epicondyles

are not ┴ to IR.

ElbowRepeatable

Error?

Poor Positioning

*Shoulder is not in same plane as

elbow. Epicondyles are not ┴ to IR.

ElbowPatholog

y

TraumaRadial Head

Fx

Elbow PathologyTrauma: Capitulum Fx

Elbow PathologyTrauma: Proximal Ulna Fx

ElbowPatholog

y

TraumaOlecranon

Fx

Elbow PathologyTrauma: Distal Humerus Fx

103

Elbow PathologyOsteomyelitis

104

AP Humerus• SID 40” / Bucky• Pt. is supine or uprt w/ arm extended• Shoulder in same plane as elbow*• Abduct arm slightly & supinate hand• CR ┴ to the IR• CP Mid-humerus• Collimate • Shield - Breast also, if you don’t turn the

tube

105*Epicondyles are ║ to IR

Lateral Humerus• SID 40” / Bucky• Pt. is supine or AP/PA uprt w/ arm extended• Shoulder in same plane as elbow• Internally rotate arm*• CR ┴ to IR• CP Mid-humerus• Collimate • Shield – Breast also, if you don’t turn the

tube

107*Epicondyles are ┴ to IR

AP Humerus

Repeatable Error?

Poor Positioning

*Arm is over rotated. Epicondyles

are not ║ to IR.

AP HumerusRepeatable Error?

Poor Centering

and collimation

AP HumerusRepeatable Error?

Poor centering and

collimation

AP HumerusRepeatable Error?

Poor centering and

collimation

AP HumerusRepeatable Error?

Poor centering

Lateral Humerus

Repeatable Error?

Poor Positioning

Lateral Humerus Repeatable Error?

Poor Positioning

Lateral Humerus Repeatable Error? Poor positioning

Humerus Pathology

TraumaDislocatedHumerus

HumerusPathology

TraumaFX

Also under penetrated.

HumerusPathology

TraumaFX

Remember to remove artifacts.

HumerusPathology

OUCH!Trauma

FX

121

P

Shoulder Girdle

123

AP Clavicle• SID 40” min Bucky/Grid• Pt. AP with arm neutral (puts

epicondyles in 45° to IR)• CR ┴ to IR• CP Mid-clavicle• Shield/Cone• Suspend respiration

125

AP Axial Clavicle• SID 40” min Bucky/Grid• Pt. AP with arm neutral (puts

epicondyles in 45° to IR)• CR < 15°-30° cephalad (15°=Hypersthenic - 30°=Asthenic)• CP Mid-clavicle• Shield/Cone• Suspend respiration

127

AP Bilat A/C Jts• SID 72” min • Pt. AP with arms neutral (puts

epicondyles in 45° to IR)• CR ┴ to the IR• CP Midpoint between A/C Jts (1” above jugular notch)• Shield/Cone• Suspend respiration

Bilat Clavicles– After Delivery

131

AP Scapula• SID 40” min Bucky/Grid• Pt. AP Uprt or Supine, abduct arm

90° and supinate hand• CR ┴ to IR• CP mid-scapula (2” inferior to

coracoid process/ level of axilla• Shield/Cone• Respiration=breathing technique

133

Lateral Scapula• SID 40” min Bucky/Grid• Pt. PA Uprt & rotated 45°-60° toward

affected side w/ arm across chest. Feel for true-lat scapula*

• CR ┴ to IR• CP mid-scapula @ medial border• Shield/Cone• Suspend respiration *A/C jt & Superior Angle ┴ to IR

136

AP Shoulder-Neutral Position• SID 40” min Bucky/Grid• Pt. AP with arm neutral (puts

epicondyles in 45° to IR)• CR ┴ to IR• CP Mid-scapulohumeral jt.• Shield/Cone• Suspend respiration

139

AP Oblique Shoulder(Grashey Method) (Ortho refers to as “True AP”

• SID 40” min Bucky/Grid• Pt. rotated 35°-45° toward affected

side, w/ arm abducted in neutral position*

• CR ┴ to IR• CP scapulohumeral jt.• Shield/Cone• Suspend respiration*Elbow flexed 90° @ some sites

Internal Oblique External Oblique

142

AP External Rotation Shoulder• SID 40” min Bucky/Grid• Arm extended and externally rotated

to put epicondyles ║ to IR• CR ┴ to IR• CP Mid-scapulohumeral jt.• Shield/Cone• Suspend respiration

144

AP Internal Rotation Shoulder• SID 40” min Bucky/Grid• Arm is extended and internally rotated

to put epicondyles ┴ to IR• CR ┴ to IR• CP Mid-scapulohumeral jt.• Shield/Cone• Suspend respiration

146

Scapular “Y” Lateral Shoulder• SID 40” min Bucky/Grid• Pt. PA & rotated 45°-60° toward

affected side, w/ arm in neutral position. Feel for true-lat scapula*

• CR ┴ to IR• CP mid-scapula @ medial border• Shield/Cone• Suspend respiration*A/C jt & Superior Angle ┴ to IR

Outlet Neer Method

CR 10°-15° caudal angle

149

Inferosuperior Axial Shoulder

(Lawrence Method)• SID 40” min TT (XTL)• Pt Supine with arm abducted to 90°• Keep hand in external rotation with

palm up, and support arm if needed• CR medially 25°-30° horizontally• CP to the axilla/humeral head• Shield/Cone/Suspend respiration

151

Superoinferior PA Transaxillary Shoulder

(Hobbs Modification)• SID 40” min TT or Bucky/Grid• With arm raised superiorly above

head, place axilla against IR, with slight 5°-10° anterior oblique.

• CR is ┴ to IR• CP is to the glenohumeral joint• Shield/Cone/Suspend respiration

153

Transthoracic Lateral Shoulder

• SID 40” min Bucky/Grid• Pt. Uprt or Supine with affected side

to IR, & arm in neutral position• Raise opposite arm above head• CR horizontal & ┴ to IR• CP surgical neck of humerus• Shield/Cone/Breathing technique

(Lawrence Method)

Clavicle Repeatable Error?Poor centering

ShoulderRepeatable Error?

Artifact

ShoulderRepeatable Error?

Artifact

ShoulderRepeatable Error?

Artifact

ShoulderRepeatable Error?

Poor marker placement

ShoulderRepeatable Error?

Poor Positioning

and *centering

“Grashey”ShoulderRepeatable Error?

Poor Positioning

Scap-YShoulderRepeatable Error?

Poor Positioning

*under rotated

Scap-YShoulder

Repeatable Error?

Poor Positioning

*Over rotated

Scap-YShoulderRepeatable Error?

Poor Positioning

*Over rotated

AxialShoulder

Repeatable Error?

Poor Positioning

Clipped anatomy

Clavicle PathologyTrauma FX

Axial Shoulder PathologyTraumaFX

ShoulderPathology

Scapular-YTrauma

FX

AP ShoulderPathology

TraumaFX/Dislocation

Scapular-YShoulderPathology

TraumaFX/Dislocation

Shoulder PathologyTraumaDislocationMedially

ShoulderPatholog

y

TraumaDislocation

ShoulderPathology

TraumaFX

Peds Pt

Shoulder PathologyTraumaGSW

~~~ The End ~~~