Film Critique 1 st year class 4 th class Fingers-Wrist PA The most readily identifiable bony structures are the posterior aspects of the metacarpophalangeal (MCP) joints. Also know as the "knuckles". Note that there are two interphalangeal (IP) joints in each finger (proximal and distal, abbreviated to "PIP" and "DIP"), but only one interphalangeal (IP) joint in the thumb. This reflects the number of phalanges in each. Bony Landmarks Distal phalanx Distal interphalangeal joint Middle phalanx Proximal interphalangeal joint Proximal phalanx DIP PIP Metacarpophalangeal joint Carpometacarpals joint MCP CMC IP Trapezium PA Rt Hand In the posteroanterior (PA) view is of the hand and wrist. Since the human thumb is "rotated" 90 with respect to the fingers, this radiograph gives an oblique view of the thumb, (In some people its a lateral) but a PA view of all the other structures. Thumb/1 st digit Standard views * AP (PA) * PA Oblique *Lateral * AP Lt 1 st Finger PA Lt 1 st Finger Oblique Rt 1 st finger Oblique vs Lateral Oblique right 1 st fingerLateral right 1 st finger Lateral Lateral Rt 1 st Finger Lateral Rt 1 st finger Structures shown All projections demonstrates the 1 st carpometacarpal (CMC) joint free of superimposition of the soft tissues of the hand Check rotation * Must have the area from the distal tip of the 1 st phalanx to the Trapezium on the film Open interphalangeal (IP) and metacarpophalangeal (MCP) joint spaces (we center to the MCP) All soft tissue and bony trabeculation Open joint spaces Open Closed 2 nd -5th fingers Standard views *PA (AP) *PA 45 DEGREE OBLIQUE *LATERAL PA PA Left 5 th finger Oblique left 5 th finger Lateral Left 5 th finger LT Do you know your collimator? Structures Shown *All projections of the 2 nd -5th fingers: entire digit from tip (distal phalanx)to distal portion of the adjoining metacarpal (some sites like the whole metacarpal or even some carpals !!!) Check rotation (can you see the finger nail) is there equal soft tissue on both sides of the finger No soft tissue overlap from adjacent digits Open IP and MCP joint spaces (we center to the PIP Standard views of Hand *posteroanterior (PA) *lateral (with fingers fanned) *PA 45 degree oblique HOMEHOME | LEARNING MODULE HOME | RADIOLOGY MODULE HOMELEARNING MODULE HOME RADIOLOGY MODULE HOME H ome W rist and hand module S elf-tests Radiographsme ist and hand module lf-tests p revious | 1 of 8 | nexteviousnext PA RT Hand RT PA RT Hand Structure shown: PA hand: No rotation of hand Open MCP and IP joints Slightly separate digits with no soft tissue overlap *The area from the distal phalanges, metacarpals, carpals to the distal radius and ulna Soft tissue and bony trabeculation Lateral Left Hand Poor positioning Structure shown: Lateral hand: Hand is in a true lateral position (superimposed metacarpals) Superimposed distal radius and ulna Thumb free of motion and superimposition Posteroanterior oblique (oblique) Either with or without the aid of a foam (radiolucent) support, the patient holds the hand at about 45 with respect to the cassette, and fans the fingers so there is minimal overlap in the final radiograph. Note that in this view, the all-important scaphoid bone is not well isolated from the other carpal bones Oblique with sponge To much rotation R Oblique Right hand Too much Overlap ( Navicular) Oblique Rt Hand RT Boxers FX The 5th Oblique Rt Hand Structures Shown PA oblique projection of the bones and soft tissue of the hand Minimal overlap of the 3-4 and 4-5 metacarpal shafts Slight overlap of the metacarpal bases and heads (but separation of the second and third metacarpals) Open interphalangeal and MCP joints Digits separated slightly with no overlap of soft tissues All anatomy distal to the distal radius and ulna Soft tissue and bony trabeculation Obliques To much R Oblique Right Hand Wrist views *PA PA in ulnar deviation *45 degree oblique *Lateral *PA Axial-Stecher method (Navicular) PA wrist :PA projection of the carpals, distal radius and slightly oblique rotation of ulna, and proximal metacarpals *The area from the proximal metacarpals, carpals to the distal ulna and radius on the film No rotation in the carpals, metacarpals or radius Open radioulnar joint space Soft tissue and bony trabeculation No excessive flexion of hand to overlap and obscure metacarpals with digits Structures shown: Bridgemans viewPA RT Oblique Lt Wrist Oblique wrist: The carpals on the lateral side of the wrist, particularly the trapezium and the scaphoid (**the most common fracture and dislocated bones of the wrist) *Distal radius and ulna, carpals and proximal half of metacarpals on the film Open trapeziotrapezoid and scaphotrapezial joints spaces Rotation: slight overlap of distal radius and ulna Soft tissue and bony trabeculation Structures shown: Lateral Lt wrist Structures shown: Lateral projection of proximal metacarpals, carpals and the distal radius and ulna superimposed Remember to have the elbow flexed at 90 degrees Almost always could roll the wrist back more (away from the patient)! Stecher Method PA wrist (no deviation) with a CR or film angled 20 degrees toward the elbow Stecher Lt wrist Modified Stecher method (Bridgman) Wrist is PA in ulnar deviation With CR angled 20 degrees toward the elbow entering at the scaphoid CR 20 degrees