RADIOGRAPHY OF UPPER

LIMB
Presented by:Prativa Khanal
BSc.MIT 1st year
National Medical College and Teaching Hospital
UPPER LIMB RADIOGRAPHY INCLUDES
MAINLY
• Hands
• Wrist joint
• Forearm
• Elbow
• Shoulder
• Scapula
• Clavicle
INDICATIONS
• Trauma
• Pathology
1.Scurvy –deficiency of vit. C(wrist jt.)
2.Rickets-deficiency of vit. D(wrist jt.)
3.Diseases of joints- RA, OA,
4.Hyperparathyroidism (phalanges)
5.Diseases of bones- OM, Tumors
• Foreign body
• Dislocation
• Subluxation
PATIENT PREPARATION
• Check request form,identify and verify patient
• Remove jewelry,metal objects or clothing that might interfere
with the x-ray images
• Technique must be explained to the patient with
demonstration
HAND
Consists of 27 bones: -
• 8 carpal bones
• 5 metacarpal bones
• 14 phalanges
RADIOGRAPHY OF Hand
Basic views:
• Dorsi-palmar
• Lateral
• AP Oblique( ball catcher view)
PA VIEW ( Dorsi-palmar View)

Positioning
• Patient is asked to sit on a stool
• The arm is flexed at elbow joint
• Hand is placed over the cassette in
prone position
• The fingers are well extended and
separated from each other
Direction and location of x-ray beam: collimated vertical beam is
centred over the head of 3rd metacarpal
Technical factors
• Exposure: 50-55KVp
3-5mAs
• Detector size:18x24 cm
• SID: 100cm
• Grid:NO
Image characteristics
• The image should demonstrate all the
phalanges, including the soft tissue of
the fingertips, the carpal and
metacarpal bones and the distal end of
the radius and ulna
• The interphalangeal and metacarpo
phalangeal and carpometacarpal
joints should be demonstrated clearly
LATERAL VIEW:
Positioning:
• From PA position hand is rotated 90 ° outwards
with ulnar aspect down so that palm of hand
makes an angle of 90 ° with the cassette
• Fingers are fully extended

Direction and location of x-ray beam: collimated

vertical beam is directed perpendicular to the
head of 2nd metacarpal
Image characteristics
• Hand should be in true lateral position
• Fingers should be well extended
• Thumb should be free of motion and
superimposition
• Distal radius and ulna should be
superimposed
Anterior oblique(DP OBLIQUE)
POSITIONING: -
• From the basic postero-anterior position, the
hand is externally rotated 45° with the fingers
extended
• The fingers should be separated slightly and the
hand supported on a 45° non-opaque pad
• In this view metacarpals are well demonstrated
but not the joint spaces
Image characteristics
• The image should demonstrate all the
phalanges, including the soft tissue of the
fingertips, the carpal and metacarpal bones
and the distal end of the radius and ulna
• The correct degree of rotation has been
achieved when the heads of the 1st and 2nd
metacarpals are seen separated whilst those of
the 4th and 5th are just superimposed
AP OBLIQUE (Ball catcher’s view):
POSITIONING: -
• Patient is asked to place the palm of both
hand together in lateral position
• Hands are rotated outwards at 45° in ball
catching position
• Fingers are well extended and thumb is
abducted to avoid superimposition over fingers
Direction and location of x-ray beam: central ray is directed
midway between the line joining the metacarpo-phalangeal joint
• The image should demonstrate
all the phalanges, including the
soft tissue of the finger tips, the
carpal and metacarpal bones
and the distal end of the radius
and ulna
• The heads of the metacarpals
should not be superimposed
Fingers
Dorsi-palmar (DP)
Patient positioning
• The patient is positioned seated alongside the table as for a
postero-anterior projection of the hand
• The forearm is pronated with the anterior
(palmer) aspect of the fingers in contact with
the image receptor
• The fingers are extended and separated
Direction and location of X-ray beam:The collimated vertical
beam is centred over the proximal interphalangeal joint of the
affected and adjacent finger
Essential image characteristics
• It is necessary to include adjacent fingers, i.e. the 2nd
and 3rdor 4th and 5th to aid in identifying the relevant
anatomy
Lateral index and middle fingers
Patient positioning
• The patient is seated alongside the table with the arm abducted and
medially rotated to bring the lateral aspect of the index finger into contact
with the image detector
• The index finger is fully extended and the middle
finger slightly flexed to avoid superimposition

Direction and location of X-ray beam-The collimated vertical central ray is

centred over the proximal interphalangeal joint of the affected finger
 Image characteristics
• The image should include the fingertip and the distal 3rd of
the metacarpal bone
Lateral ring and little finger
Patient positioning
Same as PA and the medial aspect of the little finger in contact with the
image receptor
• The affected finger is extended and the remaining
fingers are fully flexed into the palm of the hand and
held there by the thumb in order to prevent
superimposition
Direction and location of X-ray beam
• The collimated vertical beam is centred over the proximal interphalangeal
joint of the affected finger
 Image characteristics
• The image should include the tip of the finger
and the distal 3rd of the metacarpal bone
Thumb-lateral
Patient positioning
• Same as basic DP
• The thumb is flexed slightly and the palm of the hand is placed
on the image receptor
• The palm of the hand is raised slightly with the fingers
partially flexed and may be supported on a non-opaque pad,
such that the lateral aspect of the thumb is in contact with the image
receptor
Direction and location of X-ray beam
The collimated vertical beam is centred over the 1st MCPJ
Image characteristics
• The image should include the fingertip and the
distal 1/3 of the metacarpal bone
• Where there is a possibility of injury to the base
of the 1st metacarpal, the carpo-metacarpal joint
must be included on the image
Antero-posterior (AP)

Patient positioning
• The patient is seated facing away from the table with the arm
extended backwards and medially rotated at the shoulder.
• The hand may be slightly rotated to ensure that the 2nd, 3rd and
4rth metacarpals are not superimposed on the base of
the 1st metacarpal
• The patient leans forward, lowering the shoulder
so thatthe 1st metacarpal is parallel to the tabletop
• The image receptor is placed under the wrist and
thumb and oriented to the long axis of the metacarpal
Direction and location of X-ray beam
• The collimated vertical central ray is centred over the 1st MCPJ
Image characteristics
• The image should include the fingertip and the distal
1/3 of the metacarpal bone
• carpo-metacarpal joint must be included on the image
 WRIST JOINT
ANATOMY: -
• Synovial joint of ellipsoid variety
• Bones participating :-
- Head of radius
- 8 carpal bones
• Basic projection
- PA
- LAT
• SPECIAL PROJECTION
- PA OBLIQUE
- AP OBLIQUE
- PA with ulnar deviation
- PA with radial deviation
-Axial
POSTERO-ANTERIOR
Positioning
• Ask patient to be seat at the end of table and Flex the elbow so
that the forearm is at rt. angled to the humerus
• Hand is placed in prone position
• Fingers are flexed so that the wrist is in proper
contact with the cassette
TECHNICAL FACTORS
Direction and centring of the X-ray beam
• The vertical central ray is centred to a point midway between
the radial and ulnar styloid processes
Exposure: 50-55KVp
3-5 mAs
Detector size:18x24 cm
SID: 100cm
Grid:NO
IMAGE CHARACTERISTICS
• The image should demonstrate the
proximal 2/3 of the metacarpals, the
carpal bones, and the distal 1/3 of the
radius and ulna
• There should be no rotation of
the wrist joint
Lateral
POSITIONING: -
• From PA position forearm is rotated at 90° so that palm of hand
faces the body
• Center the cassette to the carpal bones and
adjust the forearm and hand so that the
wrist is in true lateral position
Direction and centring of the X-ray beam: vertical ray is
directed perpendicular to the styloid process of radius
Image characteristics
• Distal radius, ulna and proximal half of metacarpal
should be included
• Distal radius and ulna should be superimposed
• Metacarpals should be superimposed
ANTERIOR OBLIQUE-VIEW
POSITIONING:
• From lateral position wrist is rotated medially so that it makes
an angle of 45° with the cassette
Direction and location of X-ray beam
• The collimated vertical beam is centred
midway between the radial and ulnar styloid
processes
Image characteristics
• Scaphoid should be well demonstrated
• Proximal half of metacarpals, distal end of radius and ulna
should be included
Scaphoid(carpal bones)
Postero-anterior-ulnar deviation
POSITIONING: -
• From PA position patient is asked to rotate the
wrist towards ulna until it is in extreme ulnar
deviation
Direction and location of X-ray beam : collimated vertical
beam is centred midway between the radial and ulnar styloid
process
Image characteristics
• The image should include the distal end
of the radius and ulna and the proximal
end of the metacarpals
• The joint space around the scaphoid
should be demonstrated clearly
Anterior oblique-ulnar deviation

Position of patient and image receptor

• From the postero-anterior position, the hand and wrist are
rotated 45° externally and placed over the IR
• The hand should remain adducted in ulnar
deviation
• The hand is supported in position, with a
non-opaque pad placed under the thumb
• The forearm may be immobilised using a sandbag
Direction and location of X-ray beam
• The collimated vertical beam is
centred midway between the radial
and ulnar styloid processes
Essential image characteristics
• The image should include the distal
end of the radius and ulna and the
proximal end of the metacarpals
• The scaphoid should be seen clearly,
with its long axis parallel to the IR
Posterior oblique
Positioning
• From the anterior oblique position, the hand
and wrist are rotated externally through 90°,
such that the posterior aspect of the hand and
wrist are at 45° to the IR
• The wrist is placed over the centre of the IR
with the wrist and hand supported on a 45° non-opaque foam pad
Direction and location of X-ray beam
• The collimated vertical beam is centred over the styloid process of the ulna
Image characteristics
• The image should include the
distal end of the radius and ulna
and the proximal
• The pisiform should be seen
clearly in profile situated anterior
to the triquetral
• The long axis of the scaphoid
should be seen perpendicular to
the long edge of the IR
CARPAL TUNNEL-Axial
Positioning
• Ask Patient to seat at the end of the table
• Extend the forearm and place the hand in PA
position.
• Hand is dorsally flexed or hyper extended.
• Rotate the hand slightly towards the radial side to
avoid the superimposition of Hamate and pisiform
Direction and location of X-ray beam : collimated vertical beam is angled
20 –25°towards wrist joint 1” distal to the base of 3rd metacarpal
Image characteristics
• The image should demonstrate
clearly the pisiform and the
hook of the hamate medially
and the tubercle of the scaphoid
and the tubercle of the trapezium
laterally
SUPEROINFERIOR VIEW
Positioning
• Patient is asked to stand with his back towards
The table
• Hand is placed in prone position over the cassette
• Patient is asked to dorsi-flex the wrist as much as
Possible
Direction and location of X-ray beam:is directed 1.5”proximal to
the wrist at an angle of 45° towards the wrist joint
Image characteristics
• The image should include the distal
end of the radius and ulna and the
proximal end of the metacarpals
• The joint space around the scaphoid
should be demonstrated clearly
Forearm-AP
Positioning
• The patient is seated alongside the table, with the affected side nearest to
the table
• The arm is abducted and the elbow joint is fully
extended, with the supinated forearm resting on
the table
• The shoulder is lowered to the same level as the
elbow joint
• The image receptor is placed under the forearm to
include the wrist joint and the elbow joint
Direction and location of X-ray beam
• The collimated vertical beam is centred in the midline of the
forearm to a point midway between the wrist and elbow joint
Image characteristics
• Both joints should be seen in the true antero-posterior
position, with the radial and ulnar styloid processes and
the epicondyles of the humerus equidistant from
the image receptor
LATERAL
POSITIONING:
• From AP position forearm is flexed at elbow joint at an
angle of 90°
• Forearm is adjusted in true lateral position so that
radius and ulna should be superimposed. The thumb
side of hand must be upward
Direction and location of X-ray beam
• The collimated vertical beam is centred in the midline
of the forearm to a point midway between the wrist
and elbow join
Image characteristics
• Both the elbow and the wrist joint must be
demonstrated on the image
• Both joints should be seen in the true lateral
position,with the radial and ulnar styloid
processes and the epicondyles of the
humerus superimposed
ELBOW JOINT
• The elbow joint includes proximal radio ulnar articulation as well
as articulation between humerus,radius and ulna
• Hinge type of Synovial joint
• Bones participating are:
Capitulum→head of radius
Trochlea →Trochlear notch of ulna
LATERAL
POSITIONING:
• Ask patient to seat low enough to place the elbow and the
shoulder at the same level
• Flex the forearm at 90° so that the elbow joint can be placed in
true lateral position
Direction and location of X-ray beam
• The collimated vertical beam is centred
over the lateral epicondyle of humerus
Technical factors
• Exposure: 50-60KVp
3-5 mAs
• Detector size:18x24 cm
• SID: 100cm
• Grid:NO
Image characteristics
• Medial epicondyle should superimposed over
the anterior third of the distal humerus
• Olecranon process should visible in profile
• Superimposition of trochlear groove and
medial lip of trochlea with capitellum
• Radial tuberosity should anterior with slight
superimposition of the radial head over the
cronoid process
AP
POSITIONING: -
• Extend the elbow and supinate the hand
• Ask the patient to lean laterally so that both humeral epicondyles
are In same plane
Direction and location of X-ray beam
• The collimated vertical beam is centred
through the joint space 2.5 cm distal to the
point midway between the medial and lateral
epicondylesof the humerus
Image characteristics

• Image should include distal 1/3 of

humerus and proximal 1/3 of radius and
ulna
• Trochlea and capitulum should seen in
profile
 MEDIAL OBLIQUE VIEW
POSITIONING:
• From AP position hand is rotated medially
till the palm of hand is pronated
• Adjust the elbow to place the anterior
surface of elbow at 45° to the film
Image characteristics
• Coronoid process should be in profile.
• Radial head and neck should superimpose
the ulna
• Olecranon process should be seen within
LATERAL OBLIQUE VIEW:
POSITIONING:
• From AP position the forearm is rotated
laterally so that posterior surface of elbow
makes an angle of 45° with the cassette
IMAGE CHARACTERISTICS
• Elbow joint should be open
• Radial head, neck and tuberosity should be
free of superimposition.
Axial – upper arm in contact
POSITIONING
• The patient is seated alongside the table, with the affected side nearest to
the table
• The elbow is fully flexed, and the palm of the hand is facing the shoulder
• The posterior aspect of the upper arm is
placed on the image receptor, with the arm
parallel to the long axis of the IR
• The patient’s trunk is adjusted in order to
bring the medial and lateral epicondyles of the
humerus equidistant to the IR
Image characteristics
• There should be no rotation
• Forearm and humerus should be
superimposed
• Olecranon process and distal humerus
should be visualised
• Soft tissue outside the olecranon process
should be seen
Axial forearm in contact
POSITION OF PATIENT AND IMAGE RECEPTOR
• The patient is seated alongside the table, with the affected
side nearest to the table
• The elbow is fully flexed, and the palm of the
hand is facing the upwards
• The forearm is fully supinated, with the
posterior aspect of the forearm resting on the
IR and the arm parallel to the long axis of the image detector
Image characteristics
• There should be no rotation
• Forearm and humerus should
be superimposed
• Outline of ulnar groove should
be seen
LATERAL HEAD OF RADIUS
Projections of elbow
Image characteristics
• The elbow joint should be seen in the true lateral position
in each projection
• Sufficient detail of bony trabeculae should be demonstrated
to enable fine fractures
Humerus
BASIC PROJECTION
-AP
-LAT

• ADDITIONAL PROJECTION
-Trans-thoracic lateral
AP
POSITIONING
• Patient is made standing in erect position
• Opposite shoulder is slightly raised on sandbag to place
the affected arm in close contact with the cassette
• Elbow is fully extended and hand is placed in supine
position
Direction and location of X-ray beam- central ray passes through
the mid point of humerus
Technical factors
• Exposure:60-70KVp
10-15mAs
• Detector size:35x43cm
• SID:100cm
• Grid:No
Image characteristics
• Elbow and shoulder joint should
be included
• Humerus should be in true AP
position
Lateral
Positioning
• From AP position forearm is rotated medially till the
epicondyles become perpendicular to the cassette
Image characteristics
• Elbow and shoulder joint should be included
• Humerus should be in true lateral position:
1. Epicondyles should be superimposed
2. Lesser tubercle should be in profile
3. Greater tubercle is superimposed over humeral
head
TRANSTHORACIC LATERAL VIEW (LAWRENS
METHOD)
POSITIONING
• Patient is asked to stand in front of a vertical cassette holder
with injured side touching the cassette
• Uninjured arm is raised and kept over
head
• Humeral epicondyle should be perpendicular
to the IR
• Cassette is centered to the neck of humerus
• Direction and location of x-ray beam; collimated horizontal beam
is centred through the axilla at the level of surgical neck of
humerus
• Image characteristics
• Proximal portion of humerus should be
included
• Humerus should be in lateral position
• Unaffected humerus and shoulder should
not superimpose the area of interest
REFRENCES
• Clark’s positioning in radiography
• Various internet sites
Questions
• Write down the positioning of hand?
• What is ball catcher view?
• What are the indications for upper limb radiography?
• Describe the basic projection of humerus?
• What radiograph will you perform when there is supracondylar
fracture?
THANK YOU…