1. Upper Limb

2. Evaluation Criteria Structures shown Position/projection
Collimation/central ray
Exposure criteria
Acceptable and unacceptable upper limb images based on errors i.e.:
Motion
Collimation
Positioning
Exposure factors
Side markers and patient demographic information
Radiation Protection
Every time a radiographer completes an image, an evaluation must be made to determine whether the image is diagnostically optimal for the radiologist to provide an accurate diagnosis. A radiologist should NEVER have to return an image for repeat if proper evaluation of the image is done by the radiographer.
Here are five basic criteria for radiographic evaluations and critique. These should be used every time a radiographic image is performed.

3. Introduction PA Hand <Image #5>
The upper limb consists of 30 bones ranging in size from some of the smallest bones in the body located in the wrist to one of the longest in the upper arm (humerus). In addition to the bones and their processes, the upper limb contain a significant number of joints or articulations that are very important to the radiographer.
This video will concentrate on the routine positions/projections of the upper limb from the fingers to the humerus. Some alternate positions and projections will also be presented. Routine positions/projections for the fingers and thumb are:
Finger: PA or AP, Oblique and Lateral
Thumb: AP or PA Oblique and Lateral
PA Hand

4. PA, PA oblique and lateral digits 2-5
Finger Imaging Basics
<Images 4, 10, 15>
The most common indication for finger imaging examinations is trauma. Joint diseases such as arthritis or gout may also be visualized on finger images. Structures demonstrated on the image include all three phalanges and most or all of the metacarpal of the affected finger except the lateral is not seen. The criteria presented for digits 2-5 are the same for each.
PA, PA oblique and lateral digits 2-5

5. Finger Imaging Criteria
Technical Considerations
Detail IR
Non-grid (table top)
kVp range: 55-60
SID: 40 inches (100 cm)
IR size 8x10 inch (18x24 cm) or 10x 12 inch (24X30 cm)
Patient Position
PA, oblique and lateral finger (2-5 digits)
Patient is seated at the end of the radiographic table with all potential artifacts from the part.
Part Position
PA finger (2-5 digits)
Pronate the patient’s hand and wrist to place them flat on the IR
fingers slightly spread apart
Oblique finger (2-5 digits)
Begin with the hand pronated and rotate the finger 45 degrees
Fingers should be spread slightly to avoid superimposition with the other fingers
Lateral finger (2-5 digits)
Place the hand at a 90 degree angle to the IR, ulna side down
Affected finger is in a fully extended lateral position
Finger is parallel to the IR
Flex all remaining fingers
Central Ray (CR)
CR is perpendicular to the metacarpophalangeal joint of the affected finger.
PA oblique finger (2-5 digits)
Perpendicular to the proximal interphalangeal joint.
Patient Instructions
“Breathe normally and don’t move.”
Evaluation Criteria
PA finger (2-5 digits )
Phalanges should not be rotated
Distal, middle, and proximal phalanges should be included on the image
Distal end of the metacarpal should be included on the image
Markers are present on the image indicating R or L
Affected finger must not be superimposed on the other fingers
Phalanx of interest should be seen in profile
Distal, middle, and proximal phalanges should be included
Metacarpals will not be completely visualized
Additional Information
This same position of the hand and wrist give an oblique view of the thumb
Some imaging department protocols require that the entire metacarpal be included.
Some imaging department protocols require that a PA image of the entire hand be included as routine for fingers or thumb.
In cases of trauma where a PA would not yield a satisfactory image, the fingers can be imaged in the AP position
If only the distal end of the finger is affected, it is not necessary to demonstrate the entire metacarpal, the CR may be directed to the proximal interphalangeal joint (Again, this is dependent on departmental protocols.)
Always indicate on the image which finger is represented
A 45 degree foam wedge (sponge) is helpful to maintain position
For the 2nd digit (index finger) to reduce the object IR distance the finger can be rotated medially instead of laterally
If only the distal end of the finger is affected it is not necessary to demonstrate the entire metacarpal, the CR may be directed to the proximal interphalangeal joint (Again, this is dependent on departmental protocols.)
Immobilization is highly recommended for lateral imaging of fingers
For imaging of the 2nd digit, a reduced object to IR distance may be obtained by placing the radial side of the hand closest to the IR
Click each button for more information about imaging the finger.
Technical Considerations
Evaluation Criteria
Additional Information

6. Knowledge Check <Images #16 & 17> Label the anatomy:
Distal phalanx, Distal interphalangeal (DIP) joint, Middle phalanx, Proximal interphalangeal (PIP) joint, Proximal phalanx, Metacarpal phalangeal (MP) joint

7. Thumb Imaging Basics <Images 18 and 19 (top)>
The most common indication for thumb imaging is trauma. Although the routine positions are the same as other digits (fingers), the thumb has several unique features that require positioning modifications. Structures demonstrated on the image include both phalanges and most or all of the metacarpal. The thumb can be imaged in either the AP or PA position/projection as indicated in these images. PA position/projection has significant OID and should be used only if the patient cannot maintain the position for an AP.
<Images 20 and 21>
These images show the positions of the PA oblique thumb and the lateral thumb

8. Thumb Imaging Criteria
<Images 22, 5 and 24>
Technical Considerations
Detail IR
Non-grid (table top)
kVp range: 55-60
FFD-SID: 40 inches (100 cm)
IR size 8x10 inch (18x24 cm) or 10x 12 inch (24X30 cm)
Patient Position
Patient is seated at the end of the radiographic table with all potential artifacts removed from the part.
Part Position
AP: rotate the hand internally until the posterior surface of the thumb is flat on the IR
Oblique: pronate the hand and place the hand and thumb flat on the IR (same as PA hand position)
Lateral: begin with the hand pronated and rotate the thumb toward the radial side and flex fingers until the digit is in a true lateral position
Central Ray (CR)
CR is perpendicular to the first metacarpophalangeal joint (MP joint).
Patient Instructions
“Breathe normally and don’t move.”
Evaluation Criteria
Distal and proximal phalanges should be included
Distal end of the first metacarpal should be visualized
Some department protocols may require the entire metacarpal to be visualized
Markers are present on the image indicating R or L
Additional Information
When only the tip of the distal phalange is injured, the PA thumb is sometimes substituted for the AP
Click each button for more information about imaging the thumb.
Technical Considerations
Evaluation Criteria
Additional Information

9. Knowledge Check
Which hand position provides an oblique position of the thumb?
A. Lateral
B. Oblique
C. PA
D. Tangential

10. Hand Imaging Basics PA PA oblique Lateral <Image #25>
The most common indications for hand examinations are trauma and joint diseases such as arthritis or gout. Structures demonstrated on the images include all of the phalanges, the metacarpals, the carpals, and joints of the hand and wrist. The criteria presented are for PA, PA oblique, and the lateral hand, all routine positions in the hand series.
Note: Are there different images that can be used that don’t demonstrate the marker on every image?-DS

11. Hand Imaging Criteria
Technical Considerations
Detail IR
Non-grid (table top)
kVp range: 55-60
FFD-SID: 40 inches (100 cm)
IR size 10x 12 inch (24X30 cm)
Patient Position
Patient is seated at the end of the radiographic table with all potential artifacts removed from the part.
Part Position
PA hand:
Pronate the hand and wrist to place them flat on the IR
Fingers extended and slightly spread
Lateral hand position:
Place the hand and wrist at a 90 degree angle to the IR
Ulnar side down
Fingers should be spread in a fan-like manner
Thumb should be projecting away from the palm of the hand and parallel to the IR
PA oblique hand:
Pronate the hand and wrist
Rotate the radial side of the wrist 45 degrees from the IR
Keep fingers parallel to the IR and slightly spread to prevent superimposition of bones on the image
Central Ray (CR)
CR for the PA and PA oblique perpendicular to the 3rd metacarpophalangeal joint.
CR for the lateral hand perpendicular to the 2nd metacarpophalangeal joint
Patient Instructions
“Breathe normally and don’t move.”
Evaluation Criteria
All phalanges, metacarpals, and carpals should be included on the image.
Phalanges and metacarpals should not be rotated.
Joint spaces of the hand should be open.
Thumb should be in an oblique position.
One half to one inch (1-3 cm) of the distal radius and ulna should be visualized.
Metacarpals should be superimposed on each other.
Fingers two through five should be seen in profile.
Thumb should be in the PA position.
All phalanges, metacarpals, and carpals should be included.
Thumb should be in the oblique position.
One-half to 1 inch (1-3 cm) of the distal radius and ulna should be visualized.
Little or no overlap of the metacarpals should be evident on the image.
Additional Information
The hand should be immobilized with tape or sand bags if motion is a potential problem.
An AP projection may be substituted if the hand cannot be flattened or the fingers extended because the diverging x-ray beam will assist in opening the joint spaces.
An AP projection better demonstrates the bases of the metacarpals.
Patient motion is very common on this position immobilization of the hand is recommended.
Some department protocols require the fingers to be fully extended and superimposed.
A 45 degree sponge may be used to support the hand to obtain the correct hand angle.
Click each button for more information about the imaging the hand.
Guidelines
Evaluation Criteria
Additional Information

12. Knowledge Check (Images #5 and answers 5-1) Label the anatomy:
4th distal phalange, 2nd middle phalange, 1st metacarpal, 5th proximal phalange, Metacarpals, Carpals, Ulna, Radius.

13. Wrist Imaging Basics <Image 27>
The most common indication for a wrist examination is trauma to the hand and/or fingers. Structures demonstrated on the image include all eight carpals and portions of the proximal metacarpals, distal radius, and ulna. The criteria presented are for PA, PA oblique, and the lateral wrist (routine positions in a wrist series).
Note- Are there better images that can be used that don’t show the wrist positioned with a field of view at an angle with relationship to the IR?-DS

14. Wrist Imaging Criteria
Technical Considerations
Detail IR
Non-grid (table top)
kVp range: 55-60
SID: 40 inches (100 cm)
IR size 10x 12 inch (24X30 cm)
Patient Position
Patient is seated at the end of the radiographic table with all potential artifacts removed from the part.
Part Position
PA wrist:
Pronate the hand and wrist to place them flat on the IR
Flex the fingers by curling them into a fist
Carpals will then be parallel to the IR
Lateral wrist position:
Extend the fingers and place the hand and wrist at a 90 degree angle to the IR
Ulnar side down
Fingers should be spread in a fan-like manner
Elbow should be flexed at a 90 degree angle
PA oblique wrist,
Pronate the hand and wrist
Rotate the radial side of the wrist 45 degrees from the IR
Fingers and wrist is extended
Central Ray (CR)
CR perpendicular to the mid-carpals
Patient Instructions
“Breathe normally and don’t move.”
Evaluation Criteria
All eight carpals should be included
One to 2 inches (3-5 cm) of the metacarpals and distal radius/ulna should be included on the image
Carpals should be mostly superimposed on each other
Distal radius and ulna should be superimposed
Scaphoid should be projected anteriorly
PA oblique wrist:
One to 2 inches (3-5 cm) of the metacarpals and the distal radius/ulna should be included on the image
Scaphoid and trapezium should be well demonstrated
Additional Information
Curl the fingers into a fist to place the carpals parallel to the IR
Lateral wrist:
The lateral position of the wrist may be used to demonstrate widening of the wrist joint due to fracture of dislocation by taking two images—one with the wrist in maximum flexion and one with the wrist in hyperextension
A 45 degree sponge may be used to support the wrist and to obtain the correct part angulation
The less common semi supination oblique position is sometimes take to better demonstrate the pisiform, hamate, and triquetrum
Click each button for more information about imaging the wrist.
Technical Considerations
Evaluation Criteria
Additional Information

15. Knowledge Check <Images 29 (answers image #28)>
Label the anatomy:
1st digit thumb, Trapezium, Trapezoid, Scaphoid, Lunate and Radius

16. Knowledge Check <Image 33>
What is this position of the wrist called?
Stecher method
Gaynor-Hart method (tangential)
Clements/Nakayama method

17. Forearm Imaging Basics
<Images #34 & 35>
The most common reason for the imaging the forearm is again, trauma. Structures demonstrated on the images include the entire radius and ulna, including portions of the wrist and elbow. The criteria presented are for AP and lateral, the routine positions/projections for the forearm.

18. Forearm Imaging Criteria
Technical Considerations
Detail IR
Non-grid (table top)
kVp range: 60-65
FFD-SID: 40 inches (100 cm)
IR size 10x 12 inch (24X30 cm)
Patient Position
Patient is seated at the end of the radiographic table with all potential artifacts removed from the part.
Part Position
AP Forearm:
Hand is supinated
Center the long axis of the forearm to the IR
Attempt to get both the wrist and elbow flat on the IR
The entire upper limb from the shoulder to the hand should lie in the same horizontal plane
Parallel to the IR
Lateral Forearm position:
Flex the elbow 90 degrees
Place the hand, wrist, and elbow in a true lateral position
Resting on the ulnar surface
Patient may need to lean forward to place the entire upper limb in the same plane
Central Ray (CR)
CR perpendicular to the mid-forearm
Patient Instructions
“Breathe normally and don’t move.”
Evaluation Criteria
AP forearm:
Both the wrist and elbow joints should be present on the image
Radius and ulna should have only slight superimposition at both the proximal and distal ends
Lateral forearm position:
Radius and ulna should be mostly superimposed
Both wrist and elbow joints should be present on the image
Additional Information
The PA projection is never performed because the radius and ulna cross over each other in this position
If both elbow and wrist joins cannot be demonstrated on a single image, a separate AP of one joint should be performed
Lateral forearm:
If both elbow and wrist joints cannot be demonstrated on a single image, a separate lateral of one joint should be performed
Never turn the IR.
Make sure the wrist on the AP and lateral are on the same end of the IR not on opposite ends of the IR
Click each button for more information about imaging the forearm.
Technical Considerations
Evaluation Criteria
Additional Information

19. Knowledge Check <Images #36, 37>
Label the following anatomy: medial epicondyle, lateral epicondyle, epiphysis, radial head, radial neck, radial tuberosity, ulnar body, radial body, ulnar styloid process, radial styloid process, (Answers image #37)

20. Elbow Imaging Basics <Images # 40, 41, 42, & 44>
Trauma is the most common reason for obtaining radiographic images of the elbow. Structures shown on the image include the elbow joint, proximal radius/ulna, and distal humerus. The criteria presented are for the routine positions/projections of the elbow, including AP, lateral, and oblique views of the elbow.

21. Elbow Imaging Criteria
Technical Considerations
Detail IR
Non-grid (table top)
kVp range: 60-65
FFD-SID: 40 inches (100 cm)
IR size 10x 12 inch (24X30 cm)
Patient Position
Patient is seated at the end of the radiographic table with all potential artifacts removed from the part.
Part Position
AP Elbow:
Hand is supinated
Both humerus and forearm flat on the IR
Fully extend the elbow
Place the epicondylar line parallel to the IR
Lateral Elbow:
Flex the elbow 90 degrees
Place both the humerus and forearm flat on the IR, the shoulder and elbow must be in the same plane
Parallel to the IR
Place the hand, wrist, and elbow in a true lateral position
Epicondylar line perpendicular to the IR
Medial (Internal) Oblique Elbow:
Pronate the hand until the elbow joint is rotate medially 45 degrees
Lateral (External) Oblique Elbow:
Supinate the hand until the elbow joint is rotate laterally 45 degrees
Central Ray (CR)
CR perpendicular to the elbow joint
Patient Instructions
“Breathe normally and don’t move.”
Evaluation Criteria
Joint space should be open and centered to the IR
Radius and ulna should be slightly superimposed at the radial tuberosity
Epicondyles should not be rotated
Lateral Elbow position:
Humerus and radius/ulna should form a 90 degree angle
Epicondyles should be superimposed
Medial (Internal) Oblique:
Radius and ulna should be substantially superimposed with the coronoid process visualized in profile
Lateral (External) Oblique:
Radius and ulna should be free from superimposition of each other with the radial tuberosity, head, and neck clearly demonstrated on the image
Additional Information
For patients who are unable to fully extend the elbow, the trauma AP projection of the elbow should be substituted.
It is essential that the elbow be flexed 90 degrees because this give the best visualization of the fat pad which offer clues to possible elbow fractures
Oblique (Internal and External) Elbow
In cases of acute injury, trauma obliques should be substituted
Click each button for more information about imaging the elbow.
Technical Considerations
Evaluation Criteria
Additional Information

22. Knowledge Check <Images 45, 45-1> Label the following anatomy:
Radial head, Radial neck, Ulna, Anterior fat pad, Humeral epicondyles, Coronoid process, Olecranon process,
<Images 46, 47>
2. Label the following anatomy:
Medial epicondyle, Trochlea, Proximal ulna, Lateral epicondyle, Capitulum, Radial head, Radial neck, Radial tuberosity

23. Humerus Imaging Basics
<images 49 and 49>
Trauma is the primary reason for imaging the humerus. Bony tumors and cysts are occasionally visualized on long bones such as the humerus. Structures demonstrated on humerus images include the entire humerus and a portion of the elbow and shoulder joints. The criteria presented are for the routine positions/projections of the humerus, which are the AP and lateral views.
Note- image # 49 does not match the radiographic image.-DS

24. AP and Lateral Humerus Criteria
Technical Considerations
Grid
kVp range: 70-80
SID: 40 inches (100 cm)
IR size 14x 17 (45 x 54 cm)
Patient Position
Supine or upright, depending on patient condition, with the posterior surface of the body against the IR
All potential artifacts removed from the upper arm
Part Position
AP Humerus:
Hand is supinated
Fully extend the elbow and place the epicondylar line parallel to the IR
Align the long axis of the humerus to the long axis of the IR
Be certain to include ½ to 1 inch (1-3 cm) of both the elbow and the shoulder joints
Patient may be turned slightly toward the affected side to reduce object-IR distance
Lateral Humerus position:
Flex the elbow and rotate the arm medially to place the epicondylar line perpendicular to the IR
Be certain to include ½ to 1 inch (1-3 cm) of both the elbow and should joints
The patient may be turned slightly toward the affected side to reduce object-IR distance
Central Ray (CR)
CR perpendicular to the mid-shaft of the humerus
Patient Instructions
“Breathe normally and don’t move.”
Evaluation Criteria
Both the elbow and shoulder joints should be present on the image
Greater tubercle should be demonstrated in profile on the lateral aspect of the humerus
Lateral position:
Both elbow and shoulder joints should be present on the image
Epicondyles should be superimposed
Lesser tubercle should be demonstrated in profile on the medial aspect of the humerus
Additional Information
AP and Lateral Humerus:
For upper arm measuring less that 12 cm, these projections can be performed without a grid
If acute trauma is evident or suspected, the AP humerus is taken in whatever position the arm is presented
Do not attempt to rotate the arm of a patient with injuries to the humerus
If both elbow and shoulder joints cannot be demonstrated on a single IR, a separate AP and lateral of one joint should be performed
Some departmental protocols allow follow-up images to include only the joint closest to the site of injury
Click each button for more information about imaging the humerus.
Technical Considerations
Evaluation Criteria
Additional Information

25. Knowledge Check <Images #52, 51>
Label the following anatomy: acromion process, greater tubercle, body of humerus, lateral epicondyle, medial epicondyle, (answers Image #50)

26. Summary
This video presented the routine positions/projections of the upper limb. Not all the positions or projects are shown here. There are many more that are used for trauma and diagnosis of other pathologies of the bones of the upper limb. When you know the routine projections and positions, the alternate positions and projections are easier to perform. A knowledge of radiographic anatomy presented is of primary importance when performing images of the upper limb.