1
UPPER EXTREMITIES
LATERAL PROJECTION C.) FIRST CARPOMETACARPAL (CMC)
PP: Hand rest on radial surface (for 2nd-3rd digits) & JOINT
ulnar surface (for 4th-5th digits)
RP: PIP joint ROBERT METHOD
CR: ┴ AP PROJECTION
SS: Lateral projection of affected digit PP: Shoulder, elbow & wrist on same plane
(prevent carpal bones elevation & closing 1st CMC
PA OBLIQUE PROJECTION joint); arm internally rotated; hand hyperextended;
PP: Hand pronated; lateral rotation (for 4th & 5th); dorsal aspect of thumb against IR
medial rotation (2nd & 3rd) RP: 1st CMC joint
RP: PIP joint CR: ┴; 10-15o proximally (Lewis Method); 15o
CR: ┴ proximally (Rafert-Long Method)
SS: PA oblique projection of affected digit SS: 1st CMC joint
ER: To demonstrate arthritic changes; fractures; 1st
B.) THUMB (1st Digit) CMC joint displacement; Bennett’s fracture
Angulation Rationale: To project soft tissue of the
AP PROJECTION hand away from 1st CMC joint; help open joint
PP: Hand in extreme internal rotation space
RP: 1st MCP joint
CR: ┴ BURMAN METHOD
SS: AP projection of thumb AP PROJECTION
PP: Hand hyperextended; opposite hand hold the
PA PROJECTION hyperextended hand or bandage loop around digits;
PP: Hand in lateral position; dorsal surface of hand rotated internally; thumb abducted
thumb // to IR RP: 1st CMC joint
RP: 1st MCP joint CR: 45otoward the elbow
CR: ┴ SS: Magnified 1st CMC joint
SS: Magnified PA projection of thumb ER: To provide a clearer image of 1st CMC than
standard AP
LATERAL PROJECTION
PP: Hand in its natural arched position; palmar FOLIO METHOD/SKIER’S THUMB
surface down PA PROJECTION
RP: 1st MCP joint PP: Hands rested on medial aspect; distal portion of
CR: ┴ both thumbs wrap around by a rubber band; thumb
SS: Lateral projection of thumb in PA plane
RP: b/n level of MCP joints of both hands
PA OBLIQUE PROJECTION CR: ┴
PP: Hand in slight ulnar deviation; thumb abducted SS: 1st CMC joint; bilateral MCP joints & MCP
RP: 1st MCP joint angles
CR: ┴ ER: Useful for diagnosis of ulnar collateral
SS: PA oblique projection of thumb ligament (UCL) rupture\
2
UPPER EXTREMITIES
D.) HAND TANGENTIAL OBLIQUE PROJECTION
Kallen Recommendation
PA PROJECTION PP: Hand in PA position; hand rotated 40-45o
PP: Hand palmar surface down; spread finger toward ulnar surface & 40-45oforward; MCP joints
slightly flexed 75-80o; hand dorsum resting on IR
RP: 3rd MCP joint RP: MCP joint of interest
CR: ┴ CR: ┴
SS: PA oblique projection of the hand ER: To demonstrate metacarpal head fractures
AP Projection:
Hand cannot be extended because of injury LATERAL PROJECTION
and pathologic conditions In Extension
For metacarpal bones and MCP joints PP: Hand in lateral position; digits extended; ulnar
aspect down (lateromedial projection); radial aspect
PA OBLIQUE PROJECTION down (mediolateral projection; more difficult to
PP: Hand pronated; palmar surface down; MCP assume); thumb 90o to palm
joints 45o to IR; 45o foam wedge RP: 2nd MCP joint
RP: 3rd MCP joint CR: ┴
CR: ┴ SS: Lateral projection of the hand in extension
SS: PA oblique projection of the hand ER: To localize foreign bodies and metacarpal
ER: To investigate fractures and pathologic fracture displacement
conditions Fan Lateral Position: Eliminates superimposition
Foam Wedge: For interphalangeal joints of all phalanges (except proximal phalanges)
Fingertips Touching The Cassette: For
metacarpal bones LEWIS METHOD
Index Finger Elevation: PP: Hand rotated 5o posteriorly from true lateral
Use of radiolucent material position (removes superimposition of 2nd-4th
Opens joint spaces metacarpals); thumb extended;
Reduces the degree of foreshortening of RP: Midshaft of 5th metacarpal
phalanges CR: ┴
ER: To better demonstrate fractures of 5th
REVERSE OBLIQUE PROJECTION metacarpal
Lane-Kennedy-Kuschner Recommendations
PP: Hand rotated 45o internally LATERAL PROJECTION
RP: 3rd MCP joint In Flexion
CR: ┴ PP: Hand in natural arch position; digits relaxed
ER: To demonstrate severe metacarpal deformities RP: 2nd MCP joint
fractures CR: ┴
SS: Lateral projection of the hand in flexion
ER: To demonstrate anterior or posterior
displacement in fractures of metacarpals
3
UPPER EXTREMITIES
NORGAARD METHOD LATERAL PROJECTION
AP OBLIQUE PROJECTION Lateromedial
PP: Hand supinated; medial aspect against IR; 45o PP: Elbow flexed 90o; hand & forearm in lateral
sponge support position; ulnar surface against IR; radial surface
RP: b/n level of 5th MCP joints of both hands against IR (for comparison)
CR: ┴ RP: Midcarpal area
SS: AP oblique projection of both hands CR: ┴
ER: To diagnose rheumatoid arthritis SS: Proximal metacarpals & distal radius & ulna;
trapezium & scaphoid (more anterior)
E.) WRIST ER: To demonstrate anterior or posterior
displacement in fractures
PA PROJECTION
PP: Hand slightly arch (places wrist in close contact Burman & et al. Suggestions
with IR) PP: Wrist in palmar flexion (rotates the scaphoid in
RP: Midcarpal area dorsovolar position)
CR: ┴ RP: Scaphoid
SS: Slightly oblique rotation of ulna (AP should be CR: ┴
taken if ulna is under examination) SS: Lateral position of the scaphoid
Daffner-Emmerling-Buterbaugh Foille
Recommendation First to describe carpe bossu (carpal boss), a
PP: Hand slightly arch (places wrist in close contact small bony growth occurring on the dorsal
with IR) surface of the 3rd CMC joint
RP: Midcarpal area Best demonstrated in a lateral position of
CR: 30o toward the elbow; 30o toward the fingertips wrist in palmar flexion
SS: Elongated scaphoid & capitate (toward the
elbow); elongated capitate only (toward the PA OBLIQUE PROJECTION
fingertips) Lateral Rotation
ER: To better demonstrate the scaphoid & capitate PP: Palmar surface against IR; hand pronated &
rotated 45olaterally; wrist ulnar deviation (for
AP PROJECTION scaphoid only)
PP: Hand supinated; digits elevated (places wrist in RP: Midcarpal area
close contact with IR) CR: ┴
RP: Midcarpal area SS: Carpals on the lateral side (Scaphoid &
CR: ┴ Trapezium)
SS: Carpal interspaces better demonstrated; no
rotation of ulna AP OBLIQUE PROJECTION
Medial Rotation
PP: Dorsal surface against IR; hand supinated &
rotated 45omedially
RP: Midcarpal area
4
UPPER EXTREMITIES
CR: ┴ RAFERT-LONG METHOD
SS: Carpals on the medial side (Pisiform, PA & PA AXIAL PROJECTIONS
Triquetrum & Hamate) In Ulnar Deviation
PP: Hand pronated; wrist in extreme ulnar
PA PROJECTION deviation
In Ulnar Deviation RP: Scaphoid
PP: Hand pronated; wrist in extreme ulnar CR: ┴; 10o; 20o; 30ocephalad
deviation SS: Scaphoid with minimal superimposition
RP: Scaphoid ER: To diagnose scaphoid fractures
CR: ┴; 10-15o proximally/distally (clear
delineation) CLEMENTS-NAKAYAMA METHOD
SS: Scaphoid; opens carpal interspaces on lateral PA AXIAL OBLIQUE PROJECTION
side PP: Palmar surface against 45o sponge; hand in
ER: To correctscaphoid foreshortening ulnar deviation; rotate elbow end of IR & arm 20o
away from CR (unable to achieve ulnar deviation)
PA PROJECTION RP: Anatomical snuffbox
In Radial Deviation CR: 45o distally
PP: Hand pronated; wrist in extreme radial SS: Trapezium
deviation ER: To demonstrate trapezium fractures
RP: Midcarpal area
CR: ┴ LENTINO METHOD
SS: Opens carpal interspaces on medial side TANGENTIAL PROJECTION
PP: Hand palm upward; hand 90o to forearm
STECHER METHOD RP: 1.5 in. (3.8 cm) proximal to wrist joint
PA AXIAL PROJECTION CR: 45ocaudad
VARIATIONS: SS: Carpal bridge
IR elevated 20o ER: To demonstrate fractures of scaphoid, lunate
CR 20o toward elbow dislocation, dorsum of wrist calcifications and
CR 20o toward digits foreign bodies & dorsal aspect of carpal bones chip
o Fracture line that angles fractures
superoinferiorly
Close the fist GAYNOR-HART METHOD
RP: Scaphoid TANGENTIAL PROJECTION
CR: ┴ PP: Wrist hyperextended; hand rotated slight
SS: Scaphoid toward the radial side (to prevent superimposition
ER (20o Angulation): of hamate & pisiform shadows); digits grasp w/
To place scaphoid at right angles to the CR opposite hand
To project scaphoid w/o self- RP: 1 in. distal to 3rd MCP base
superimposition CR: 25-30o to long axis of hand
Bridgman Method: Stecher Method with ulnar SS: Carpal canal/tunnel (Carpal sulcus+Flexor
deviation retinaculum)
5
UPPER EXTREMITIES
ER: Hand Pronation:
To demonstrate carpal tunnel syndrome It crosses the radius over the ulna at its
To demonstrate fractures of hook of hamate, proximal third
pisiform & trapezium It rotates the humerus medially
8
UPPER EXTREMITIES
LATERAL PROJECTION
Lateromedial Recumbent
PP:
Supine: arm abducted slightly; forearm
rotated medially; dorsal aspect of hand
against patient’s side; humeral epicondyles
┴ to IR; elbow flexed slightly (for comfort)
Lateral Recumbent: place IR closed to
axilla; elbow flexed (unless
contraindicated); thumb surface of hand up
RP: Midshaft or distal humerus (lateral recumbent)
CR: ┴
SS: Distal humerus
ER (lateral recumbent): For patient with known or
suspected fracture
THE END
“BOARD EXAM is a matter of PREPARATION. If
you FAIL to prepare, you PREPARE to fail”
03/18/14