Evaluation criteria Upper Limb

1. Phalanges • Metacarpals • Carpals • Radius • Ulna • Humerus • Scapula • Clavicle

2. 3. • 27 Bones – Phalanges - 14 – Metacarpals - 5 – Carpals - 8
3. 4. 14 bones Fingers – Proximal – Middle – Distal Thumb -Proximal -Distal
4. 5. • 1 • 2 • 3 • 4 • 5 • Thumb • Index • Middle • Ring • Little
5. 6.  Interphalangeal Metacarpophalangeal Carpometacarpal joint Distal
Interphalangeal Proximal Interphalangeal Trapeziometacarpal
6. 7.  5 bones • Three parts – Head – Body – Base
7. 8. 8 bones
8. 9. • She • Looks • Too • Preety • Try • To • Catch • Her Alternative mnemonic • Some •
Lovers • Try • Positions • That • They • Can’t • Handle
9. 10. • Radiocarpal • Intercarpal
10. 11. • Radial Styloid Process • Ulnar Styloid Process • Distal Radioulnar Jt.
11. 12. A. B. C. D. E. F. G. H.
12. 13. Tuft 2nd DIP Jt. 2nd PIP Jt. 2nd MP Jt. IP Jt. 1st MP Jt. CM Jt. Radiocarpal Jt.
13. 14. Trapezoid Scaphoid Pisiform
14. 15. Indications Position of the patient and cassette Direction and centering of x-ray
beam Image characteristics Technical parameters -kVp -mAS -FFD -Grid
15. 16. Remove rings, watches, and other radiopaque objects.  Seat the patient at the side
or end of the table and place the cassette at a location and angle that allows the patient to
be in the most comfortable position.  Direct the central ray (CR) at a right angle to the
midpoint of the cassette.  When performing a bilateral examination of hands or wrists,
separately radiograph each side.  Shield the patient’s gonads from scattered radiation. 
Use close collimation. This technique is recommended for all upper-limb radiographs. 
When placing multiple exposures on one cassette, the side of the unexposed cassette
should always be covered with lead.  Use right or left markers and any other vital
identification markers when appropriate.
16. 17. • Routine projections – PA – Lateral – Medial Oblique – Lateral Oblique
17. 18. Pain Swelling Tenderness Dislocations Fractures To locate Foreign
objects(Lateral view)
18. 19. Fingers (2 – 5)  Cassette Size: 24x30cm  Cassette Orientation: Landscape.  All
three images projections of fingers can fit on one film.  Central Ray: Perpendicular to
Cassette  Centering Point: PIP(Proximal interphalangeal) joint  Collimation: To
include distal tip of finger and distal carpal bones  Positioning: PA: • Place hand flat
with the palmar surface down. • Separate digits slightly. Oblique: • Rotate palm 45
degrees toward IR until digits are resting on support. Lateral: • Place hand in lateral
position (thumb side up) with finger to be examined fully extended and centered to
portion of IR being exposed. • Ensure that long axis of finger is parallel to IR.
19. 20. kVp:50-55 mAs:3-5 FFD:100cm Grid: No
20. 21. PA
21. 22. The image should include the fingertip and distal third of metacarpal bone.
22. 23. • Immobilize – Sandbags – Tape
23. 24. • Routine projections – AP or, PA – Oblique – Lateral
24. 25. Positioning of the thumb is unique because its axis differs from that of the other
digits. Basic views of the thumb include Anteroposterior (AP), Posteroanterior (PA),
Oblique, and Lateral. Stress views of the first Metacarpo-phalangeal (MCP) Joint may be
Evaluation criteria Upper Limb

required for evaluation of injuries of the ligaments of this joint. Cassette Size: 24x30cm.
Cassette Orientation: Landscape.  All three thumb images can fit on one film. FFD:
100cm. Centering Point: MCP. Central Ray: Perpendicular to Cassette. Collimation: To
include distal tip of thumb and distal carpal bones. Positioning: (AP): Rotate the Hand
Medially to make the Thumb in True AP Projection. (PA): Place hand in lateral position
with little finger on cassette. (Oblique): Place hand flat with the palmar surface down.
This orientate the thumb to an oblique position (Lateral): Flex all Fingers and make the
Lateral aspect of thumb resting on the cassette with.
25. 26. AP
26. 27. Evaluation criteria of Thumb projections 1. The area from the distal tip of the thumb
to the trapezium should be clearly demonstrated. 2. There should be no rotation, and
concavity of the phalangeal and metacarpal shafts should be demonstrated with equal
amounts of soft tissue on both sides of the phalanges. 3. The first CMC joint should be
free of superimposition of the hand or other bony elements. 4. The first metacarpal and
trapezium should be clearly demonstrated. 5. There should be open interphalangeal and
MCP joint spaces. 6. The soft tissue and bony trabeculation should be clearly present.
27. 28. • Routine projections – PA – PA OBLIQUE • Non-routine projections  Lateral for
Foreign Body Posterior oblique(Ball catcher’s or, Norgaard Projection.)
28. 29. • Routine projections – PA – PA Oblique
29. 30.  Cassette Size: 24x30cm  Cassette Orientation: Landscape (Crosswise).  FFD:
100cm  Central Ray: Perpendicular to cassette  Centering Point: Entering hand at 3rd
MCP Jt.  Collimation: To include entire hand and Distal Forearm.  Positioning:  PA :
Place affected hand/finger palmar side down on cassette.  OBLIQUE: Place affected
hand/finger palmar side down on a 45º sponge/angle thumb side raised.  LATERAL :
Place affected hand with thumb raised.  To properly visualize the phalanges the fingers
should be positioned in a fan like arrangement.
30. 31. Evaluation criteria  The entire hand, wrist, and about 2.5 cm of the distal forearm
should be visible.  MCP and interphalangeal joints should appear open.  No rotation
of hand.  The digits should be separated slightly with soft tissues and should not be
overlapping. PA HAND
31. 32. Evaluation criteria  Entire hand, wrist, and about 2.5 cm of the distal forearm should
be visible in oblique view.  MCP and interphalangeal joints should be open. A 45°
oblique is evidenced by the following: Midshafts of third, fourth, and fifth metacarpals
should not overlap; some overlap of the distal heads of third, fourth, and fifth metacarpals
but no overlap of distal second and third metacarpals should occur; excessive overlap of
metacarpals indicates over rotation, and too much separation indicates under rotation.
HAND OBLIQUE
32. 33. Evaluation Criteria  Entire hand, wrist, and about 2.5 cm of the distal forearm
should be visible.  Fingers should appear equally separated, with phalanges in the
lateral position and joint spaces open.  Thumb should appear in a slightly oblique
position completely free of superimposition, with joint spaces open.  Hand and wrist
should be in a true- lateral position evidenced by the following: 1. Distal radius and ulna
superimposed. 2. metacarpals are superimposed. HAND LATERAL
33. 34. INDICATIONS  Rheumatoid arthritis  Fracture of base of the fifth metacarpal
Evaluation criteria Upper Limb

34. 35.  Patient is seated alongside the table. However, if this is not possible due to patient’s
condition, the patient is seated facing the table.  Both forearms are supinated and placed
on the table with dorsal surface of the hand in contact with cassette.  From this
position ,both hands are rotated internally(medially) 45degs into ball catching position. 
Cassette is adjusted such that ROI lies in close contact with cassette.
35. 36. The vertical central ray is centered to a point midway between the hands at the level
of the fifth metacarpo-phalangeal joints.
36. 37. The image should demonstrate all phalanges, including the soft tissue of fingertips
,the carpal and metacarpal bones, and distal end of radius and ulna.
37. 38. kVp:55-60 mAs:5-7 FFD:100cm Grid: No
38. 39. • Routine projections  PA (Ulnar Flexion)  Lateral • (Scaphoid Series) – PA
(Ulnar deviation) – Anterior oblique(ulnar deviation) – Posterior oblique – Lateral
39. 40. • Routine projections – PA (Ulnar Flexion) – Lateral
40. 41. Radiographic Positioning of the WRIST Cassette Size: 24x30cm Cassette
Orientation: Landscape (Crosswise). • All three Wrist images can usually fit on one film.
FFD: 100cm Central Ray: Perpendicular to the cassette. Centering Point: PA: Midway
between the radial and ulnar styloid processes. OBLIQUE: Radial Styloid Process.
LATERAL: Radial Styloid Process. Collimation: To include the distal 1/3 of the forearm
and metacarpal bones. Positioning: PA: Forearm resting with anterior aspect on the table,
with cassette under wrist. OBLIQUE: • Forearm resting with anterior aspect on the table,
with cassette under wrist. • Rotate wrist 45º with thumb side raised and rest on sponge if
required. LATERAL: • Forearm resting with ulnar side on the table, with cassette under
wrist.
41. 42. Centering; Midway between radial and ulnar styloid process
42. 43. Centering: Radial styloid process
43. 44. Evaluation criteria for PA wrist:  True PA is evidenced by the following: 1.
separation of the distal radius and ulna is present, except for possible minimal
superimposition at the distal radioulnar joint.  Soft tissue and bony trabeculation should
be visible. PA WRIST
44. 45. Evaluation criteria  Distal radius and ulna, carpals, and at least the midmetacarpal
area should be visible.  True-lateral position is evidenced by the following: 1. Ulnar
head should be superimposed over distal radius. 2. proximal second through fifth
metacarpals all should appear aligned and superimposed.  Soft tissue and bony
trabeculation should be visible. WRIST LATERAL
45. 46. – PA (Ulnar deviation) – Anterior oblique(ulnar deviation) – Posterior oblique –
Lateral
46. 47. INDICATIONS  Demonstrate scaphoid  Scaphoid fracture
47. 48. The patient is seated alongside the table with affected side nearest the table.
Ensure the radial and ulnar styloid process are equidistant from cassette. The hand
lower forearm are immobilized using sandbags.
48. 49. The vertical central ray is centered midway between radial and ulnar styloid
process.
49. 50. The image should include distal end of radius and ulna and proximal end of
metacarpals. The joint space should be demonstrated clearly.
50. 51. kVp:55-60 mAs:5-7 FFD:100cm Grid: No
Evaluation criteria Upper Limb

51. 52. Direction and centering of X-ray beam - The vertical central ray is centred midway
between the radial and ulnar styloid process. Image characteristics - The scaphoid series
should be seen clearly, with its long axis parallel to the cassette.
52. 53. Direction and centering of X-ray beam - The vertical central ray is centred ulnar
styloid process. Image characteristics - The scaphoid series should be seen clearly, with
its long axis perpendicular to the cassette.
53. 54. Direction and centering of X-ray beam - The vertical central ray is centred radial
styloid process. Image characteristics - The image should include distal end of radius
and ulna and proximal end of metacarpals.
54. 55.  Casted – Regular film – Lower mAs 10 times  Wet cast – Add 15 to the kV  Dry
cast – Add 10 to the kV  Fiberglass – Add 5 to the kV • No cast – Extremity film –
10mAs @ 60kV
55. 56. Medial Epicondyle Coronoid Process Shaft (Ulna) Ulnar Head Ulnar Styloid Process
Lateral Epicondyle Radial Head Radial Tuberosity Shaft (Radius) Distal Radioulnar Jt.
Radial Styloid Process
56. 57. Lateral epicondyle Capitulum Proximal radioulnar jt. Radial head Radial neck Radial
tuberosity Olecranon fossa Medial epicondyle Trochlea Coronoid process
57. 58. Coronoid Process Radial head Radial neck Condyles Trochlear notch Olecranon
process Radial notch
58. 59. • Routine projections –AP –Lateral
59. 60. Cassette Size: 35 x 35 cm or 35 x 43 cm depending on Patient size.
Cassette Orientation: Portrait FFD: 100cm. Central Ray: Perpendicular to cassette.
Centering Point: Midshafts of forearm.
Collimation: To include both wrist and elbow within field.
Positioning:
AP : Posterior aspect of Forearm on cassette with both wrist and elbow in AP position.
LATERAL:
 Medial side of Forearm on cassette with both wrist and elbow in lateral position.
 Elbow flexed at 90.
60. 61. AP
61. 62. AP FOREARM Evaluation criteria
1. The entire radius and ulna should be visible, with pertinent soft tissues.
2. The wrist and distal humerus (Elbow) should be clearly demonstrated.
3. No rotation as evidenced by humeral Epicondyle visualized in profile with slight
superimposition of the radial head, neck, and tuberosity over the proximal ulna.
4. Similar radiographic densities of the proximal and distal forearm.
62. 63. LATERAL FOREARM Evaluation criteria
63. 1. No rotation as evidenced by:
 Superimposition of the radius and ulna at their distal end.
 Superimposition by the radial head over the Coronoid process.
 Radial tuberosity facing anteriorly.
 Superimposed humeral Epicondyle.
2.Elbow should be flexed 90degree.
3. soft tissues and bony trabeculation should be visible.
64. 64. • Routine projections – AP – Lateral
Evaluation criteria Upper Limb

• Non-routine – Obliques medial (internal) rotation and lateral (external) rotation.

65. 65. • Routine projections –AP –Lateral
66. 66. Cassette Size: 24x30cm. Cassette Orientation: Landscape. FFD: 100cm. Central Ray:
Perpendicular to Cassette. Centering Point: Elbow Joint. Collimation: To include Distal
third of humerus and proximal third of forearm. Positioning: AP: • Elbow as close to
straight as the patient is able, with posterior aspect on cassette. • Humerus and forearm
should both be in contact with the cassette in order to ensure a open joint space.
OBLIQUE: • Elbow as close to straight as the pt is able, with posterior aspect on cassette.
• Rotate entire arm laterally as far as pt will tolerate. • Humerus and forearm should both
be in contact with the cassette. LATERAL: • Elbow flexed at 900, with wrist in lateral
orientation. • Forearm, Humerus and cassette all parallel.
67. 67. AP