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Upper Limb Radiography Positioning Principles and Techniques

Learn about essential positioning and technical points for upper limb radiography, focusing on optimal contrast, shielding, and immobilization techniques.

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Upper Limb Radiography Positioning Principles and Techniques

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  1. RAD 222 Sunday (time 9-12) *20 marks final exam Sunday 10-2-1434 SARAH ALLITHEY sallithey@ksu.edu.sa

  2. Technical Points Positioning principles for upper limb , kV should be lower to medium (50 – 70) KVp with short exposure time. No secondary radiation grid used(only if the part to be x-rayed is greater than 10- 13 cm (as in the case of shoulder) Grid A series of thin lead strips designed to absorb scatter radiation, typically mounted above where the cassette lies in the bucky. A Bucky is a component of x-ray units that holds the x-ray film cassette and moves the grid during x-ray exposure*image FFD is generally 40 inches (100 cm) at a small focus for improved image geometric sharpness (therefore, improved bony details)*image 2

  3. Optimal contrast and density will allow visualization of bony cortical margins soft tissue structures. Close collimation is necessary to reduce patient’s absorbed dose and improve contrast through reducing irradiated area’s dimensions. Radiation protection has to be well observed, using the special gonad shields over pelvic region, or the lead apron as necessary

  4. Immobilization Radiodensity (or radiopacity) refers to the relative inability of particularly X-rays, to pass through a particular material. Radiolucency indicates greater transparency or "transradiancy" to X-ray photons Materials that inhibit the passage of x-ray are called radiodense, while those that allow radiation to pass more freely are referred to as radiolucent. radiolucent. radiodense

  5. PA Projection Fingers: Basic * Film Size: 8x10 in. (18x24 cm) crosswise SHIELDING: Place lead shield over patient’s lap • * Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand and forearm resting on table. • Part Position:all fingers extended and separated from each other. Sand bag over the lower forearm for immobilization Separate other fingers from affected finger. • Distance: 100 cm or 40 in. • CR: Perpendicular to film . • CP: directed to Proximal Interphalangeal joint (PIPj) . • Collimation: collimate on four sides to area of interest.

  6. PA Projection ,2nd finger(index) of the left hand CP (PIPj) Structure shown: distal , middle, proximal, phalanges,distal metacarpal, and associated joints.

  7. The Fingers: Lateral Projection Basic Film Size: 8x10 in. (18x24 cm) crosswise. SHIELDING: Place lead shield over patient’s lap to shield gonads Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand and wrist resting on cassette with fingers extended. Part Position: hand medially rotated, the lateral aspect of index on the film, middle and other fingers flexed, sandbag over the lower forearm. • Distance:100 cm or 40 in • C R: Perpendicular to film. • CP: directed to Proximal Interphalangeal (PIP) joint. • Collimation: collimate on four sides to area of interest.

  8. Lateral projection,2nd finger(index) of the left hand Structure shown: Lateral view of the distal , middle, proximal, phalanges,distal metacarpal, and associated joints are visible.

  9. Oblique Projection fingers Basic Film Size: 8x10 in.(18x24 cm) crosswise. • SHIELDING: Place lead shield over patient’s lap to shield gonads. • Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand and wrist resting on cassette with fingers extended. • Part Position: Place hand with fingers fully extended against 45 foam wedge block, placing hand on in a 45 lateral oblique (thumb side up). • Distance:100 cm or 40 in. • C R: Perpendicular to film. • CP: directed to Proximal Interphalangeal (PIP) joint. • Collimation: Collimate on four sides to area of interest.

  10. Oblique Projection 4th finger of the left hand Cp:(PIP) joint Structure shown: 45 oblique view of the distal , middle, proximal, phalanges,distal metacarpal, and associated joints.

  11. The Thumb AP Projection: Basic • Film Size: HD18x24 cm ( 8x10 in)crosswise . • SHIELDING:P lace lead shield over patient’s lap to shield gonads. • * Patient Position: Patient sits at end of the couch, shoulder at couch level, hand and wrist and forearm extended , arm with hand rotated internally to Supinate thumb for AP projection. • Part Position: Internally rotate hand with fingers extended until posterior surface of thumb is in contact with film or posterior aspect of thumb rests supinated on the film, hand and wrist immobilized. • Distance: 100 cm or 40 in. • C P: 1st MP joint (1stMetacarpophalangeal joint) . • C R: perpendicular to film. • Collimation: collimate on four sides to area of interest. NB/ * PA thumb not recommended as image will suffer magnification and, therefore, distortion due to the greater OFD PA (only if Pt cannot position for AP).

  12. The Thumb AP Projection of the left hand C P: 1st MP joint trapezium Structure shown: distal and proximal phalanges,distal 1st metacarpal, trapezium and associated joints. are visible. Interphalangeal And Metacarpophalangeal joint should appear open

  13. Oblique (Thumb only): Basic Film Size: 8x10 in. (18x24 cm)crosswise. * SHIELDING: Place lead shield over patient’s lap to shield gonads Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand and wrist resting .on cassette Part Position: Abduct thumb slightly with palmar surface of hand in contact with cassette (this will naturally place thumb into a 45 oblique position). • Distance: 100 cm or 40 in. • * CP: directed to 1st MP joint.(1st Metacarpophalangeal joint) • C R: CR perpendicular to film. • Collimation: collimate on four sides to area of interest.

  14. Oblique right Thumb CP: 1st MP joint Structure shown: distal and proximal phalanges, 1st metacarpal, trapezium, and associated joints. are visible. Interphalangeal And Metacarpophalangeal joint should appear open.

  15. 3. Lateral Thumb : Basic • Film Size: 8x10 in. (18x24 cm) crosswise. • * SHIELDING: Place lead shield over patient’s lap to shield gonads • * Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand resting on cassette, palm down. • Part Position: start with hand pronated and thumb abducted with fingers and hand medially rotate slightly until thumb is in a true lateral position. (may need to provide sponge or other support under fingers of hand). or palm raised on pad (or fingers slightly arched) so that thumb is in true lateral, hand and wrist immobilized. Entire lateral aspect of thumb should be in direct contact with cassette. Distance: 100 cm or 40 in. C R: perpendicular to film. C P:directed to 1st MP joint. Collimation: collimate on four sides to area of interest

  16. Lateral of right thumb Structure shown: distal and proximal phalanges, 1st metacarpal, trapezium (superimposed) and associated joints. are visualized in the lat position. Interphalangeal and metacarpophalangeal joint should appear open.

  17. The Hand PA Basic: Film Size: 10x12 in. (24x30 cm) crosswise. * SHIELDING: Place lead shield over patient’s lap to shield gonads. * Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand and forearm resting on table. Part Position: Pronate hand with palmar surface on the cassette spread the fingers slightly. Ask the patient to be relax to avoid motion. Distance: 100 cm or 40 in. CR: perpendicular to film. CP: directed to 3rd MP joint. Collimation: collimate on four sides to area of interest.

  18. PA of the left hand CP: directed to 3rd MP joint Structure shown: PA projection of entire hand and wrist and about 1 in (2.5cm) of distal forearm are visible. Note that PA projection of hand demonstrated oblique view of the thumb.

  19. A. ThumbB. IndexC. Middle fingerD. Ring fingerE. Little finger I-V. Metacarpal bones 1,4. Distal phalanx2. Middle phalanx3,5. Proximal phalanx6. Sesamoid bones7. Distal interphalangeal joint (DIP)8. Proximal interphalangeal joint (PIP)9. Metacarpophalangeal joint (V.)10. Carpometacarpal joints 11. Trapezium12. Trapezoid13. Capitate14. Hamate15. Scaphoid16. Lunate17. Triquetrum18. Pisiform 19. Radius20. Ulna

  20. PA Oblique Hand: Basic *Film Size: HD 24x30 cm 10x12 in. crosswise. *SHIELDING: Place lead shield over patient’s lap to shield gonads. Patient Position: Patient sits at the end of the couch, elbow flexed 90, hand and .forearm resting on table top. Part Position: Pronate hand and then rotate entire hand and wrist laterally 45. Or Pronate hand and then rotate entire hand and wrist laterally 45, then Support hand with radiolucent wedge with digits separated from each others and digits parallel to IR • For oblique Hand, use support block to place digits parallel to IR and to prevent foreshortening of phalanges and obscuring of interphalangeal joint. • *Distance:100 cm or 40 in. • *CR: perpendicular to film. • *CP: directed to 3rd MP joint. • Collimation: collimate on four sides to area of interest.

  21. Oblique view of the right hand Structure shown: oblique projection of entire hand and wrist and about 1 in (2.5cm) of distal forearm are visible.

  22. Lateral Hand Basic * Film Size: 8x10 in. (18x24 cm) lengthwise. * SHIELDING: Place lead shield over patient’s lap to shield gonads. * Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand and forearm resting on table. * Part Position: Place hand in lateral position (thumb away from fingers to avoid superimposition) the fingers are fully extended. The Ulnar aspect of hand down. • Distance: 100 cm or 40 in. • CR: perpendicular to film. • CP: 2nd M.P.J. (or head of 2nd M.C.) • .Collimation: collimate on four sides to area of interest.

  23. Lateral view of the right hand CP: 2nd M.P.J. Structure shown: entire hand and wrist and about 1 in (2.5cm) of distal forearm are visible. Thumb should appear slightly obliqued and free of superimposition with joint space open.

  24. APO (Ball catcher’s) (Special) Film Size: HD 24x30 cm 10x12 in crosswise. *SHIELDING: Place lead shield over patient’s lap to shield gonads. Patient Position :Patient sits at end of couch, with both hands extended. Part position: Both hands to be exposed in a single exposure for purpose of comparison, hands rotated internally 45(cupped as if catching a ball) and supported on 45 sponge blocks. Abduct both thumbs to avoid superimposition. • *Distance: 100 cm or 40 in. • * CR: perpendicular to film. • CP:Midway between the hands at levels of heads of the 5th M.P.Js. • Collimation: collimate on four sides to area of interest.

  25. APO view Structure shown: both hands from the carpal area to tips of digits in 45 oblique position are visible.

  26. MnemonicforLearningCarpals She Likes To Play Lunate Scaphoid Triquetrum Pisiform Hamate Trapezium Capitate Trapezoid Try To Catch Her Right Palm Click R Button for Slideshow

  27. PA Wrist: Basic Film Size: HD 8x10 in. (18x24 cm) crosswise. *SHIELDING: Place lead shield over patient’s lap to shield gonads. *Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand and wrist resting on table, palm down. Part Position: Palm down, small pad under M.P.Js to maintain the wrist in close contact with film (or hand slightly arched for same purpose), middle part of forearm immobilized. • Distance: 100 cm or 40 in. • C R: perpendicular to film. • *CP: Midcarpal area (midway between Ulna and radial styloid processes). • Collimation: collimate on four sides to area of interest.

  28. PA of the left wrist Structure shown: midmetacarpals and proximal metacarpals, carpal ,distal radius , ulna, and associated joints, and pertinent soft tissue, such as fat pads and fat stripes of the wrist joint are visible. but Intercarpal joints not well shown open because irregular shape result overlapping.

  29. I-V: Metacarpals Trapezium Trapezoid Capitate 4. Head of Capitate 5. Hamate 6. Hook of Hamate 7. Scaphoid 8. Lunate 9. Triquetrum 10. Pisiform 11. Styloid process of radius 12. Head of ulna 13. Styloid process of ulna 14. Radio carpal joint 15. Distal Radioulnar joint

  30. Oblique wrist: Basic • Film Size: 8x10 in. (18x24 cm) crosswise. • * SHIELDING: Place lead shield over patient’s lap to shield gonads. • Patient Position: Patient seated at end of table with elbow flexed about 90 degree with hand and wrist resting on cassette , palm down. • Part Position: from pronate position , rotate wrist and hand laterally 45 degree. • For stability, place 45 degree support under thumb side of hand to support hand and wrist in a45 degree oblique position or partially flex fingers to arch hand so the fingertips rest lightly on cassette . Ask the patient to be relax to avoid motion. • Distance: 100 cm or 40 in. • C R: perpendicular to film. • * CP: (Midcarpal area). • Collimation: collimate on four sides to area of interest.

  31. Oblique view of the left wrist trapezium scaphoid Structure shown: distal radius , ulna, carpal, and at least to midmetacarpal area are visible. The trapezium and scaphoid should be well visualized.

  32. Lateral wrist: Basic Film Size: HD 8x10 in. (18x24 cm) crosswise. *SHIELDING: Place lead shield over patient’s lap to shield gonads. Patient Position: Patient seated at end of table , elbow flexed 90 with hand and forearm rested on table top. Part Position: Hand and wrist in true lateral (styloid processes must superimpose), back of hand supported. Ask the patient to be relax to avoid motion. Distance:100 cm or 40 in. C R: perpendicular to film. C P: (Midcarpal area). Collimation: collimate on four sides to area of interest.

  33. Lateral view of the left wrist C P: (Midcarpal area) Structure shown: distal radius , ulna, carpal, and at least midmetacarpals area are visible.

  34. PA Scaphoid(ulnar deviation) Special Film Size: HD 8x10 in. (18x24 cm) crosswise. * SHIELDING: Place lead shield over patient’s lap to shield gonads. * Patient Position: Patient sits at the end of the couch, elbow flexed 90, hand and forearm resting on table top. Part Position:Pronate hand and then from the PA hand, the hand is deviated towards the ulna as far as patient can tolerate without lifting or obliquingdistal forearm. and immobilized (ulnar deviation) Distance: 100 cm or 40 in. C R: 10 - 15 proximally to film center (along the long axis of forearm). * CP: To the Scaphoid (2 cm or 3/4in distal and medial to radial styloid process). Collimation: collimate on four sides to area of interest.

  35. Ulnar deviation of the left wrist Structure shown: distal radius , ulna, carpals, and proximal metacarpals are visible. scaphoid should be demonstrated clearly (without foreshorting ,with adjacent carpal interspaces open

  36. PA Scaphoid (radial deviation) (Special) * Film Size: HD 8x10 in. (18x24 cm) crosswise. * SHIELDING: Place lead shield over patient’s lap to shield gonads. * Patient Position: Patient sits at the end of the couch, elbow flexed 90, hand and forearm resting on table top. Part Position: From the PA wrist, (hand is moved gently towards the thumb side) as far as possible (radial deviation) . Ask the patient to be relax to avoid motion • Distance: 100cm or 40 in. • CR: 90 to film center. • C P: Midcarpal area (midway between ulnar and radial styloids). • Collimation: collimate on four sides to area of interest.

  37. Radial deviation of the left wrist Structure shown: distal radius, ulna, carpals, and proximal metacarpals are visible. The carpals are visible ,with adjacent interspaces more open on the medial (ulna) side of the wrist.

  38. carpal tunnel (Tangential (axial) ( inferosuperior) - Gaynor-Hart Method (special) Film Size: HD 8x10 in. (18x24 cm) crosswise. * SHIELDING: Place lead shield over patient’s lap to shield gonads. *Patient Position: wrist and hand hyperextended (dorsiflexed) by grasping the fingers with the other hand until the metacarpals are roughly 90 to the forearm. Part Position: entire hand and wrist then internally rotated 10 (toward the radius). Ask the patient to be relax to avoid motion Distance:100cm or 40 in. C R: 25 - 30 to the long axis of the hand. C P :Metacarpal area (Center of palm), 3 cm distal to base of 3rd MC. Collimation: Collimate on four sides to area of interest.

  39. carpal tunnel (Tangential (axial) of the left wrist Structure shown: carpal, are demonstrated in a tunnel like, arched arrangement.

  40. Carpal tunnel (alternative positions) S Patient stands with his back to the couch, palm pressing on the film. A lead apron should be put on the patient's back, with CR 90 axially (tangentially) to CP. Film placed on surface of a plastic block against which the forearm is supported, wrist is dorsiflexed roughly 135 with ulnar deviation using traction by bandage round the palm, CR 90 axially tangentially) to CP.

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