04/10/2022

FUTURE RRT HUB

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UPPER EXTREMITIES
PREPARED BY:
MEYNARD Y. CASTRO, RRT
ANATOMY
CT-MRI TECHNOLOGIST

UPPER EXTREMITIES HAND

• HAND • Consists of 27 bones
– PHALANGES
– METACARPALS • Phalanges:
– CARPALS
– Bones of the digits
• FOREARM
(fingers & thumb)
– RADIUS
– ULNA • Metacarpals:
• ARM – Bones of the palm
– HUMERUS
• PECTORAL/SHOULDER • Carpals:
GIRDLE – Bones of the wrist
– CLAVICLE
– SCAPULA

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DIGITS METACARPALS
From lateral to medial • Form the bones of the
• First Digit (thumb) palm
– 2 phalanges (proximal, distal)
• Second digit (index finger) • They are long bones
– 3 phalanges (proximal, – Head, body, base
middle, distal)
• Third digit (middle finger)
• 1st-5th MC (from lateral
– 3 phalanges (proximal, to medial side)
middle, distal)
• 1st MC
• Fourth digit (ring finger)
– 3 phalanges (proximal, – Contains two sesamoids
middle, distal) – Palmar aspect below the
• Fifth digit (small finger) neck
– 3 phalanges (proximal,
middle, distal) Each phalanx has head,
• MC head (knuckles) Each phalanx has head,
body and base body and base

JOINTS OF THE HANDS AND WRIST WRIST (CARPAL) BONES

• INTERPHALANGEAL (IP) • 8 carpal bones
JOINT – for 1st digit only
– b/n phalanges
• Short bones
– Proximal IPJ & Distal IPJ (for • Divided into 2
2nd-5th digits) horizontal rows
• METACARPOPHALANGEAL – Proximal & distal
(MCP) JOINT
– b/n phalanges and • Proximal rows:
metacarpals Scaphoid, lunate,
– 1st-5th MCP joints triquetrum, pisiform
• CARPOMETACARPAL (CMC) • Distal rows: trapezium,
JOINT
– b/n metacarpals and carpals
trapezoid, capitate,
– 1st-5th MCP joints hamate

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WRIST (CARPAL) BONES

From LATERAL to MEDIAL
PROXIMAL ROW
Some
Lovers
Try
Position
-THE END-
DISTAL ROW
That
They
Cannot
Handle

CARPAL SULCUS CARPAL CANAL (TUNNEL)

• Concavity formed from
the anterior or palmar The passageway created
surface of the wrist between the carpal sulcus
• Flexor retinaculum: and flexor retinaculum
– Attaches medially to
pisiform & hook of
hamate
CARPAL TUNNEL
– Attaches laterally to
SYNDROME
tubercles of scaphoid & median nerve
trapezium compression inside the
carpal canal

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CARPAL SULCUS FOREARM

• Two bones
– RADIUS: lateral side
– ULNA: medial side
• They are long bones
– Body & 2 articular ends

ULNA ULNA
• Body: long and slender
PROXIMAL END DISTAL END
• Olecranon and coronoid • Head: rounded process
process: two beak-like on the lateral side
processes
• Ulnar styloid process
• Trochlear/Semilunar
– A conic projection
notch: concave
depression – Posteromedial side of
the head
• Radial notch: depression
on the lateral aspect of
coronoid process

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RADIUS RADIUS

PROXIMAL END DISTAL END

• Head: flat disk-like • Radial styloid process:
• Neck: constricted area conic projection on the
below the radial head lateral surface
• Radial tuberosity • Ulnar notch: depression
– Roughened process on the medial aspect of
– Inferior to neck & on distal ulna
medial side of the body

ARM ARM
• One bone DISTAL END OF HUMERUS
– HUMERUS (HUMERAL CONDYLE)
• A long bone • TROCHLEA: smooth
– Body and two articular elevation on the medial
ends
side
• Proximal humerus:
articulate with the • CAPITULUM: smooth
shoulder girdle elevation on the lateral
• Distal humerus: presents
side
numerous processses and PURPOSE
depressions For articulation

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ARM ARM
DISTAL END OF HUMERUS DISTAL END OF HUMERUS
(HUMERAL CONDYLE) (HUMERAL CONDYLE)
• Lateral epicondyle: • Radial fossa:
above the capitulum – receives the radial head
• Medial epicondyle: (elbow flexed)
above the trochlea – Lateral to coronoid fossa &
proximal to capitulum
• Coronoid fossa
– Receives the coronoid • Olecranon fossa:
process of ulna – Deep depression behind
– Anterior and superior to coronoid fossa
trochlea – Receives olecranon process
(elbow extended)

ARM ARM
PROXIMAL END OF PROXIMAL END OF
HUMERUS HUMERUS
• HEAD: • LESSER TUBERCLE:
– large, smooth and rounded – Located on the anterior
– Lies in oblique plane on surface
superomedial side
– below the anatomical
• ANATOMICAL NECK: neck
– Narrow, constricted area
below the humeral head
• GREATER TUBERCLE
• SURGICAL NECK: – Located on the lateral
surface
– Constriction of the body
below the tubercles – Below the anatomical
– Site of many fractures
neck

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ARM UPPER LIMB ARTICULATIONS

PROXIMAL END OF
HUMERUS
• INTERTUBERCULAR
GROOVE:
– Deep depression
– Separates greater and
lesser tubercles

FAT PADS FAT PADS

• Can be visualized only in
lateral projection
• Anterior fat pads
– Superimposed coronoid
THREE FAT PADS
and radial fat pads
• Supinator fat pads
– Within the coronoid and
– Anterior to and parallel
with the anterior aspect of
radial fossae of anterior
proximal humerus humerus
• Posterior fat pads
– Cover largest area
– Within olecranon fossa of
posterior humerus

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FAT PADS
Significant
radiographically when an
elbow injury causes
effusion and displaces the
TRAUMA AND
fat pads and alter their
shape FRACTURE
NORMAL ELBOW TERMINOLOGY
Posterior fat pads are not
visualized

FRACTURES DESCRIPTION
FRACTURES DESCRIPTION
Dislocation/
Simple/Closed Does not break through the skin Bone is displaced from a joint
Luxation
Compound/Open Portion of the bone protrudes through the skin Subluxation Partial dislocation
Incomplete/Partial Does not traverse through entire bone Rolando Comminuted fracture of 1st MCP base
Torus/Buckle Buckle in the cortex with no complete break Bennett Transverse fracture of 1st MCP base
Greenstick Boxer 4th-5th metacarpal neck fracture
/Willow Stick/ Fracture is on one side only
Colles/Dinnerfork/
Hickory Stick Fracture of distal radius with posterior (dorsal) displacement
Bayonet
Complete Break is complete & bone is broken into two pieces Smith/Reverse
Fracture of distal radius with anterior (palmar) displacement
Transverse Near right angle to long axis of the bone Colles
oblique At an oblique angle to the bone Barton Fracture of the posterior lip of distal radius
Bone is twisted apart & spirals around the long axis of Baseball/Mallet Fracture of distal phalanx
Spiral
bone Hutchinson/
Intraarticular fracture of the radial styloid process
Comminuted Bone is splintered or crushed (two or more fragments) Chaeffeur
impacted One fragment is firmly driven into the other Nursemaid/
Partial dislocation of the radial head of a child
Jerked elbow
Avulsion A fragment of bone is separated or pulled away
Fracture of the proximal half of the ulna with radial head
Monteggia
dislocation

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RADIOGRAPHIC DIGITS (2ND-5TH)

POSITIONING

OUTLINE PA PROJECTION
• PA PROJECTION PP:
• LATERAL PROJECTION • Seated position; palmar
– LATEROMEDIAL surface down
– MEDIOLATERAL • Separate the digits
• PA OBLIQUE PROJECTION slightly
– LATERAL ROTATION RP: PIP joint
– STREET METHOD (MEDIAL ROTATION) CR: ┴
SS: PA projection of
affected digit

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PA PROJECTION PA PROJECTION

AP Projection
Recommended for
suspected joint injury

Dental Film
Can be used to examine
small section of digit that
cannot be extended

PA PROJECTION

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LATERAL PROJECTION
(LATEROMEDIAL/MEDIOLATERAL)
PP:
• Hand rest on
radial/lateral surface
– For 2nd-3rd digits
• Hand rest on
ulnar/medial surface
– for 4th-5th digits
RP: PIP joint
CR: ┴

LATERAL PROJECTION LATERAL PROJECTION

(LATEROMEDIAL/MEDIOLATERAL) (LATEROMEDIAL/MEDIOLATERAL)

SS:
• 2nd and 3rd digits
– Lateral/radial surface
down
• 4th and 5th digits
– Medial/ulnar surface
down

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PA OBLIQUE PROJECTION PA OBLIQUE PROJECTION

(LATERAL ROTATION) (LATERAL ROTATION)
PP: Seated position; hand
pronated; palmar surface
down; hand
externally/laterally rotated
45o 45o foam wedge support
RP: PIP joint Used to open IP joint
spaces
CR: ┴
SS: PA oblique projection
of the affected digit

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STREET METHOD
PA OBLIQUE PROJECTION (MEDIAL ROTATION)
Rotate the 2nd digit
medially/internally from the
prone position

The part is closer to the IR

for improved recorded detail
and increase ability to see
certain fractures

For diagnosis of phalangeal

fractures

THUMB (1ST DIGIT)

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OUTLINE AP PROJECTION

• AP PROJECTION PP: Seated; arm internally

• PA PROJECTION rotated; hand in extreme
• LATERAL PROJECTION internal rotation
• PA OBLIQUE PROJECTION RP: 1st MCP joint
CR: ┴
SS: AP projection of
thumb

LEWIS MODIFICATION PA PROJECTION

PP: Seated position; hand
CR 10-15o along the long resting on its medial
axis of the thumb toward surface; hand in lateral
the wrist position; dorsal surface of
the thumb parallel with
the IR
Used to demonstrate 1st
metacarpal free of soft RP: 1st MCP joint
tissue of the palm CR: ┴
SS: Magnified PA
projection of thumb

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LATERAL PROJECTION PA OBLIQUE PROJECTION

PP: Seated position; hand PP: Seated position;
relaxed; hand in its natural palmar surface of the
arched position; palmar hand against the IR;
surface down thumb abducted; hand in
RP: 1st MCP joint slight ulnar deviation
CR: ┴ RP: 1st MCP joint
SS: Lateral projection of CR: ┴
thumb SS: PA oblique projection
of thumb

THUMB
AP PA LATERAL PA OBLIQUE

FIRST CMC AND MCP

JOINTS

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ROBERT METHOD
OUTLINE (AP PROJECTION)
1ST CARPOMETACARPAL JOINT PP:
• ROBERT METHOD (AP PROJECTION) • Shoulder, elbow & wrist
on same plane
• LONG-RAFERT METHOD (AP AXIAL PROJECTION) – prevent carpal bones
• LEWIS METHOD (AP AXIAL PROJECTION) elevation & closing 1st CMC
joint
• BURMAN METHOD (AP PROJECTION) • Hand hyperextended
– So that soft tissue over the
ulnar aspect does not
1ST METACARPOPHALANGEAL JOINT obscure the 1st CMC joint
• FOLIO METHOD (BILATERAL PA PROJECTION) • Arm internally rotated;
dorsal aspect of thumb
against IR

ROBERT METHOD ROBERT METHOD

(AP PROJECTION) (AP PROJECTION)

ER: Used to demonstrate

• Arthritic changes
RP: 1st CMC joint • Fractures
CR: ┴ • 1st CMC joint
SS: 1st CMC joint displacement
• Bennett’s fracture

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LONG-RAFERT MODIFICATION LEWIS MODIFICATION

RP: 1st MCP joint

CR:
RP: 1st CMC joint • ┴ (Robert)
CR: 15o proximally • 15o proximally (Long-
SS: 1ST CMC joint free of Rafert)
superimposition of the • 10-15o proximally
soft tissue of the hand (Lewus)

ROBERT METHOD
(AP PROJECTION)

ANGULATION RATIONALE
• To project soft tissue of
the hand away from 1st
CMC joint
• Help open joint space

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BURMAN METHOD BURMAN METHOD

(AP PROJECTION) (AP PROJECTION)
PP:
• Seated position; PP:
forearm parallel to long • Hand rotated internally
axis of IR; – Prevent superimposition
• Hand hyperextended; with the trapezium
opposite hand hold the • Thumb abducted
hyperextended hand or – so that it is flat on IR
with a bandage looped RP: 1st CMC joint
around the digits
CR: 45o toward the elbow

BURMAN METHOD FOLIO METHOD/SKIERS THUMB

(AP PROJECTION) (PA PROJECTION)
SS: PP:
• Magnified • Hands rested on medial
concavoconvex outline aspect
of the 1st CMC joint • Distal portion of both
• Base of 1st MC in thumbs wrap around by
convex profile a rubber band
• Trapezium in concave • Thumb in PA plane
profile RP: b/n level of MCP joints
ER: To provide a clearer of both hands
image of 1st CMC than CR: ┴
standard AP

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FOLIO METHOD ULNAR COLLATERAL

(BILATERAL PA PROJECTION) LIGAMENT INJURY

SS: MCP joints and MC

phalangeal angles
bilaterally
ER: Useful for diagnosis of
UCL rupture (Skier's
Thumb)

OUTLINE

• PA PROJECTION
• PA OBLIQUE PROJECTION
– LATERAL ROTATION

HAND • LATERAL PROJECTION

– EXTENSION
– FLEXION
– FAN LATERAL
• NORGAARD METHOD (BILATERAL AP OBLIQUE
PROJECTION)

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PA PROJECTION
PP:
• Seated position
• Hand palmar surface
down on the IR
• Spread the fingers
slightly
RP: 3rd MCP joint
CR: ┴
SS: PAO projection of the
thumb

PA OBLIQUE PROJECTION
AP PROJECTION
(Lateral Rotation)
PP:
• When patient cannot extend the hand enough to • Seated position
place its palmar surface in contact with the IR • Hand pronated
• Used for metacarpals when the hand cannot be • Palmar surface down
extended because of an injury, a pathologic condition • MCP joints 45o to IR
or the use of dressings RP: 3rd MCP joint
• When the MCP joints are under examination CR: ┴
SS: PA oblique projection
of the hand
ER: used to investigate
fractures and pathologic
conditions

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PA OBLIQUE PROJECTION LANE-KENNEDY-KUSCHNER RECOMMENDATION

(Lateral Rotation) (REVERSE OBLIQUE PROJECTION)

Fingertips Touching the

IR:
• For metacarpal bones SS:
• Hand rotated 45o medially (internally) from palm-
Index Finger & Thumb down position
Elevation: RP: 3rd MCP joint
• Opens joint spaces CR: ┴
• Reduces the degree of ER: For better demonstration of severe metacarpal
foreshortening of the deformities or fractures
phalanges

KALLEN RECOMMENDATION LATERAL PROJECTION

(TANGENTIAL OBLIQUE PROJECTION) (LATEROMEDIAL PROJECTION IN EXTENSION)

SS:
• Hand in PA position PP:
• MCP joints flexed 75-80o • Seated position
• Dorsum of the digits resting on IR • Hand in lateral position
• Hand rotated 40-45o toward ulnar surface & 40-45o • Digits extended
forward • Thumb 90o to palm
RP: MCP joint of interest • Ulnar aspect down
CR: ┴
ER: For better demonstration of metacarpal head
fractures

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LATERAL PROJECTION
(MEDIOLATERAL PROJECTION IN EXTENSION) LATERAL PROJECTION

PP: RP: 2nd MCP joint

• Seated position CR: ┴
• Hand in lateral position SS: Lateral projection of
• Digits extended the hand in extension
• Thumb 90o to palm ER: To localize foreign
• Radial aspect down bodies and metacarpal
fracture displacement
– More difficult to assume

LATERAL PROJECTION LATERAL PROJECTION

(FAN LATERAL POSITION) (FAN LATERAL POSITION)

PP:
• Seated position SS:
• Place digits on • Individual phalanges
radiolucent sponge (except proximal)
wedge for support • Superimposed MC
RP: 2nd MCP joint ER: Eliminates
CR: ┴ superimposition of all
SS: phalanges (except
• Individual phalanges proximal phalanges)
(except proximal)
• Superimposed MC

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LATERAL PROJECTION
LEWIS RECOMMENDATION
(Lateromedial In Flexion)
PP: PP:
• Hand rotated 5o posteriorly from true lateral • Seated position
position • Hand in natural arch
– Removes superimposition of 2nd-4th metacarpals position
• Thumb extended • Digits relaxed and
RP: Midshaft of 5th metacarpal superimposed
CR: Parallel to the extended thumb • Thumb parallel to IR
ER: To better demonstrate fractures of the fifth RP: 2nd MCP joint
metacarpal CR: ┴

LATERAL PROJECTION NORGAARD METHOD

(Lateromedial In Flexion) (BILATERAL AP OBLIQUE PROJECTION)
PP:
• Seated position
SS: Lateral projection of • Both hands in half-
the hand in normal flexed supinated position
position • Medial aspect against IR
ER: To demonstrate • Fingers extended
anterior or posterior • Thumb slightly
displacement in fractures abducted
– To avoid superimposition
of metacarpals over the fingers
• Use 45o radiolucent
sponge support

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NORGAARD METHOD
BALL-CATCHER’S POSITION
(AP OBLIQUE PROJECTION)

RP: b/n level of 5th MCP

joints of both hands
CR: ┴
SS: AP oblique projection
of both hands
NOTE: Use fine grain
screen and low kVp (60-
65)

NORGAARD METHOD
(AP OBLIQUE PROJECTION)

ER:
• Assist in detecting early
radiologic changes needed
to diagnose rheumatoid
arthritis
• Demonstration of fractures
of the base of the 5th
metacarpal (Stapczynski
Recommendation)

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