1. Image Evaluation Chapter 3
Critique of Upper Extremity

2. Hand (PA) ID requirements Marker No preventable artifacts
Contrast & density
? True PA
?long axes of 3rddigit and metacarpal aligned

3. Hand (PA) ? Soft tissue overlap
? IP, MP, & CM joints open and phalanges & metacarpals not foreshortened and thumb is in 45 degree oblique position
? 3rd MP joint in center

4. Hand (medial oblique)
Not enough rotation: midshafts of metacarpals are evenly spaced and metacarpal heads are not superimposed
Too much rotation: 3rd -5th metacarpal midshafts are superimposed

5. Hand ( medial oblique) ? Long axes of 3rd digit and metacarpal aligned
? Soft tissue overlap
? IP, MP joints open and phalanges not foreshortened, thumb may be lateral or oblique
? 3rd MP join in center

6. Hand ( lateromedial) 2nd – 5th superimposed ( palpate knuckles)
If not the 2nd metacarpal is demonstrated anterior to the 3rd – 5th metacarpal and the hand is rotated internally or pronated

7. Hand ( lateromedial) ? Long axes of metacarpals aligned
? IP joints open and phalanges not foreshortened
MP joints in center
Optional Positioning: extension & flexion

8. Wrist ( PA)
? True PA : styloids of radial & ulnar are lateral and medial edges of each bone; radioulnar articulation is open with minimal superimposition of metacarpal bases
Rotation is affected by hand, humerus, & elbow movements

9. Wrist ( PA)
If externally rotated, carpal and metacarpal are superimposed on medial side of wrist
If internally rotated, carpal and metacarpal laterally superimposes and shows more pisiform and hamate

10. Wrist ( PA)
If hand & wrist are rotated, the radioulnar articulation is closed
If humerus & elbow are rotated, ulna placement changes
The ulna & radius cross each other if humerus is not abducted

11. Wrist (PA) ?carpal bones at center of field
Film should include carpal bones, ¼ of distal ulna and radius, and ½ of the proximal metacarpals.

12. Wrist ( medial oblique)
?45 degree medial oblique
?trapezoid & trapezium without superimposition, with trapeziotrapezoidal joint space open
?2nd CM and scaphotrapezium joint spaces demonstrated
?long axes of 3rd metacarpal and radius aligned

13. Wrist (Lateral)
? True lateral – distal end of scaphoid & pisiform & radius with ulna superimposed
?90 degrees
If rotated the distal scaphoid & pisiform relationship changes and the pronator fat stripe is obscured

14. Wrist (lateral)
If rotated externally (hand supinated) distal scaphoid is seen posterior to the pisiform
If rotated internally (hand pronated) distal scaphoid is seen anterior to the pisiform

15. Wrist (Ulnar-flexed) ?ulnar flexed
?scaphoid seen without foreshortening and long axes of 1st metacarpal and radius aligned
If patient can’t flex enough angle 20 degrees

16. Wrist(ulnar-flexed) ?scaphoid in center of field
See carpal bones, radioulnar articulation & proximal 1st – 4th metacarpals on film
Scaphoid is most common fractured carpal bone

17. Forearm (AP) ?long axis of forearm aligned
Forearm midshaft in center of field
wrist radius & ulna, elbow joints & forearm soft tissue seen on film
?distal forearm in true AP- radial styloid is seen in profile laterally & very little superimposition of the metacarpal bases of ulna & radius

18. Forearm (AP) ?proximal forearm in true AP
?radial head & tuberosity superimpose lateral part of proximal ulna. If on film, the medial and lateral humeral epicondyles are seen in profile

19. Forearm ( lateral)
Anode heel effect- density is less at anode end of tube than cathode
So, we need to position which part of forearm at the anode end?
Soft tissue sightings – anterior & posterior fat pads and the supinator fat stripe at the elbow; pronator fat stripe at the wrist

20. Forearm ( lateral) ?long axis of forearm aligned
?midshaft of forearm at center of field
? Wrist, radius & ulna & elbow joints and forearm soft tissue on film

21. Forearm ( lateral) Proximal forearm & distal humerus positioning:
Elbow flexed 90 degrees – poor elbow positioning obscures fat pads that we need to see for diagnosis
The radial tuberosity is superimposed by the radius and is not seen in profile
Distal humerus in true lateral position

22. Elbow ( AP) ? True AP projection
Medial & lateral humeral epicondyles are seen in profile
Detecting elbow rotation(1)epicondyles no seen in profile(2)radial head & tuberosity are seen with more than slight superimposition of the ulna(3)coronoid is seen in profile

23. Elbow (AP)
?radial tuberosity medially in profile & eliminates crossing of the radius & ulna
Capitulum-radius joint is open
When patient can’t extend elbow; ap proximal forearm& ap distal humerus

24. Elbow (medial & lateral oblique)
?capitulum-radial joint open
?elbow joint at center of field
?elbow joint, ¼ proximal forearm, distal humerus on film
Medial oblique: 45 degrees medially
Coronoid process, trochlear notch & medial aspect of trochlea in profile
Trochlear-coronoid joint is open with superimposition of radial head & neck over ulna

25. Elbow(medial & lateral oblique)
Lateral oblique: 45 degrees laterally
?captitulum & radial tuberosity are seen in profile
?radial head, neck, and tuberosity seen without superimposing ulna & radioulnar joint is seen

26. Elbow (lateral)
Posterior fat pad is not usually seen unless there is injury
Displacement of supinator fat stripe could mean fractures of radial head and neck
Change in shape or placement of anterior fat pad may indicated joint effusion & elbow injury

27. Elbow (lateral) ?elbow flexed 90 degrees ? True lateral position
?elbow joint space is open and radial head superimposes coronoid process
? Radial tuberosity superimposed by radius and not seen in profile
?elbow joint in center of field

28. Humerus(AP) ?true AP ?long axis aligned
?midshaft of humerus in center of film
?shoulder and elbow joints & lateral humeral soft tissue on film

29. Humerus (lateral) ?mediolateral ?lateromedial ?long axis aligned
?midshaft in center of field