UPPER EXTREMITIES

PP = Part Position 9.) Dislocation/Luxation

RP = Reference Point  Bone is displace from a joint
CR = Central Ray 10.) Subluxation
SS = Structure Shown  Partial dislocation
ER = Examination Rationale 11.) Rolando Fx
┴ = Perpendicular  Comminuted fx of 1st MCP base
// = Parallel 12.) Bennett’s Fx
b/n = between  Transverse fx of 1st MCP base
13.) Boxer’s Fx
TRAUMA & FRACTURE TERMINOLOGY  4th-5th metacarpal neck fx
1.) Fracture 14.) Colles’ Fx/Dinnerfork/Bayonet
 A break in a bone  Fx of distal radius w/ posterior/dorsal
2.) Simple/Closed Fx displament
 Does not break through the skin 15.) Smith Fx/Reverse Colles’
3.) Compound/Open Fx  Fx of distal radius w/ anterior/palmar
 Portion of the bone protrudes through the displacement
skin 16.) Barton’s Fx
4.) Incomplete/Partial Fx  Fx of posterior lip of distal radius
 Does not traverse through entire bone 17.) Baseball/Mallet Fx
 Torus/Buckle Fx: buckle in the cortex with  Fx of distal phalanx
no complete break 18.) Hutchinson’s/Chaeffeur’s Fx
 Greenstick Fx/Willow Stick/Hickory  Intraarticular fx of the radial styloid process
Stick: fracture is on one side only 19.) Monteggia’s Fx
(commonly in children)  Fx of proximal half of the ulna with radial
5.) Complete Fx head dislocation
 Break is complete & bone is broken into two 20.) Nursemaid’s/Jerked Elbow
pieces  Partial dislocation of the radial head of a
 Transverse Fx: near right angle to long axis child
of the bone
 Oblique Fx: at an oblique angle to the bone\ A.) DIGITS (2nd-5th)
 Spiral Fx: bone is twisted apart & spirals
around the long axis of bone PA PROJECTION
6.) Comminuted Fx PP: Palmar surface down; separate the digits
 Bone is splintered or crushed (two or more slightly
fragments) RP: PIP joint
7.) Impacted Fx CR: ┴
 One fragment is firmly driven into the other SS: PA projection of affected digit
8.) Avulson Fx AP Projection: For suspected joint injury
 A fragment of bone is separated or pulled
away

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 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\

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 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

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 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)

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 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

Mcquillen Martensen Suggestion LATERAL PROJECTION

 For wrist that cannot be extended to w/in 15o PP: Elbow flexed 90o; forearm & hand in true
of vertical lateral; thumb must be up; humeral epicondyle ┴ to
 CR aligned // to palmar surface IR
 Angled an additional 15o toward the palm RP: Midshaft
CR: ┴
SUPEROINFERIOR PROJECTION SS: Elbow joints; radius & ulna; carpal bones
PP: Dorsiflex the wrist; lean forward (to place (proximal row)
carpal canal tangent to IR)  Superimposed radius & ulna at their distal
RP: Midpoint of the wrist end
CR: ┴  Superimposed radial head over the coronoid
SS: Carpal canal/tunnel process
ER: Taken when patient cannot assume/maintain  Superimposed humeral epicondyles
Gaynor-Hart Method  Radial tuberosity facing anteriorly

Marshall Suggestion G.) ELBOW

 For limited dorsiflexion of the wrist
 Placed 45o sponge under palmar surface of AP PROJECTION
the hand PP: Elbow extended; hand supinated; patient lean
o Slightly elevates the wrist to place laterally; humeral epicondyles & anterior surface of
the carpal canal tangent to CR elbow // to IR
 With slight degree of magnification due to RP: Elbow joint
increased OID CR: ┴
SS: Elbow joints; distal arm & proximal forearm
F.) FOREARM  Radial head, neck & tuberosity slightly
superimposed over the proximal ulna
AP PROJECTION
PP: Hand supinated; patient lean laterally; humeral LATERAL PROJECTION
epicondyles // to IR Lateromedial
RP: Midshaft PP: Elbow flexed 90o; elbow flexed 30-35o
CR: ┴ (suspected elbow injury); hand in lateral position;
SS: Elbow joints; radius & ulna; distorted carpal humeral epicondyles ┴ to IR
bones (proximal row) RP: Elbow joint
 Slight superimposition of radial head, neck CR: ┴
& tuberosity over the proximal ulna SS: Elbow joints; distal arm & proximal forearm
 Superimposed humeral epicondyles
6
 UPPER EXTREMITIES
 Radial tuberosity facing anteiorly ER (2 AP Projections): For patient cannot
 Radial head partially superimposing completely extend the elbow
coronoid process JONES METHOD
 Olecranon process in profile AP PROJECTION
Griswold (Elbow flexing 90o): 2 reasons Acute Flexion
 Olecranon process seen in profile Distal Humerus
 Elbow fat pads are least compressed PP: Elbow fully (acutely) flexed
RP: 2 in. superior to olecranon process
AP OBLIQUE PROJECTION CR: ┴ to humerus
Medial Rotation SS: Olecranon process
PP: Hand pronated or medially rotated 45o; anterior Proximal Forearm
surface of elbow 45o to IR PP: Elbow fully (acutely) flexed
RP: Elbow joint RP: 2 in. distal to olecranon process
CR: ┴ CR: ┴ to flexed forearm
SS: Coronoid process in profile; trochlea & medial SS: Elbow joint more open
epicondyle
RADIAL HEAD SERIES
AP OBLIQUE PROJECTION LATERAL PROJECTION
Lateral Rotation Four-Position Series
PP: Hand laterally rotated 45o; 1st & 2nd digits PP: Elbow flexed 90o; elbow joint in lateral
touching the table; posterior surface of elbow 45o to position; four exposures: 1.) hand supinated 2.)
IR hand in lateral 3.) hand pronated 4.) hand internally
RP: Elbow joint rotated
CR: ┴ RP: Elbow joint
SS: Radial head & neck in profile; capitulum CR: ┴
SS: Radial head in varying degrees of rotation
AP PROJECTIONS  Radial tuberosity facing anteriorly (1st & 2nd
In Partial Flexion exposures)
Distal Humerus  Radial tuberosity facing posterior (3rd & 4th
PP: Hand supinated; elbow partially flexed exposures)
RP: Elbow joint
CR: ┴ to humerus COYLE METHOD
SS: Distal humerus when elbow cannot be fully AXIOLATERAL PROJECTION
extended PP:
Proximal Forearm  Seated: hand pronated
PP: Hand supinated; dorsal surface of forearm  Supine (trauma): distal humerus elevated;
against IR; elbow partially flexed IR vertical; humeral epicondyles ┴ to IR;
RP: Elbow joint palmar aspect of hand facing anteriorly
CR: ┴ to forearm  Elbow flexed 90o (radial head) or 80o
SS: Proximal forearm (coronoid process);
RP: Midelbow joint
7
 UPPER EXTREMITIES

CR: H.) HUMERUS

 o
Seated: 45 toward the shoulder (radial
head); 45o away from the shoulder (coronoid AP PROJECTION
process) Upright
 Supine: horizontal; 45o cephalad (radial PP: Erect/seated-upright (more comfortable); arm
head); 45o caudad (coronoid process) abducted slightly; hand supinated; humeral
SS: Open elbow joint b/n radial head & capitulum epicondyles // to IR
or coronoid process & trochlea RP: Midshaft
ER: CR: ┴
 To demonstrate pathologic processes or SS: Humeral head & greater tubercle in profile
trauma in the area of radial head & coronoid
process LATERAL PROJECTION
 Cannot fully extend elbow for medial & Lateromedial Upright
lateral oblique PP: Erect/seated-upright (more comfortable); arm
rotated internally; elbow flexed approximately 90o;
PA AXIAL PROJECTION palmar aspect of hand against hip; humeral
PP: Seated; arm rested vertically against IR; epicondyles ┴ to IR
forearm // to IR; humerus 75o from forearm or RP: Midshaft
15o from CR; hand supinated CR: ┴
RP: Ulnar sulcus SS: Lesser tubercle in profile; greater tubercle
CR: ┴ superimposed over humeral head
SS: Epicondyles; trochlea; ulnar sulcus (groove b/n Mediolateral Upright
medial epicondyle & trochlea); olecranon fossa PP: RAO/LAO; patient’s hand holding the broken
ER: arm
 Used in radiohumeral bursitis (tennis elbow) RP: Midshaft
 To detect otherwise obscured calcification CR: ┴
located in the ulnar sulcus SS: Lesser tubercle in profile; greater tubercle
Rafert-Long: AP oblique distal humerus for superimposed over humeral head
demonstration of ulnar sulcus ER: For patients with broken humerus

PA AXIAL PROJECTION AP PROJECTION

PP: Seated; arm 45-50o from vertical; hand Recumbent
supinated PP: Supine; unaffected shoulder elevated; hand
RP: Olecranon process supinated; humeral epicondyles // to IR
CR: ┴ or 20o toward the wrist RP: Midshaft
SS: Dorsum of olecranon process (┴); curved CR: ┴
extremity & articular margin of olecranon process SS: Humeral head & greater tubercle in profile
(20o)

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