UPPER

EXTREMITIES
PP = Part Position  A fragment of bone is separated or
RP = Reference Point pulled away
CR = Central Ray
SS = Structure Shown 9.) Dislocation/Luxation
ER = Examination Rationale  Bone is displace from a joint
┴ = Perpendicular 10.) Subluxation
// = Parallel  Partial dislocation
b/n = between 11.) Rolando Fx
 Comminuted fx of 1st MCP base
TRAUMA & FRACTURE 12.) Bennett’s Fx
TERMINOLOGY
 Transverse fx of 1st MCP base
1.) Fracture
13.) Boxer’s Fx
 A break in a bone
 4th-5th metacarpal neck fx
2.) Simple/Closed Fx
14.) Colles’ Fx/Dinnerfork/Bayonet
 Does not break through the skin
 Fx of distal radius w/
3.) Compound/Open Fx posterior/dorsal
 Portion of the bone protrudes displament
through the skin
15.) Smith Fx/Reverse Colles’
4.) Incomplete/Partial Fx  Fx of distal radius w/
 Does not traverse through entire bone anterior/palmar
 Torus/Buckle Fx: buckle in the displacement
cortex with no complete break 16.) Barton’s Fx
 Greenstick Fx/Willow  Fx of posterior lip of distal radius
Stick/Hickory Stick: fracture
is on one side only (commonly
17.) Baseball/Mallet Fx
in children)  Fx of distal phalanx
5.) Complete Fx 18.) Hutchinson’s/Chaeffeur’s Fx
 Break is complete & bone is broken  Intraarticular fx of the radial styloid
into two pieces process
 Transverse Fx: near right angle to 19.) Monteggia’s Fx
long axis of the bone  Fx of proximal half of the ulna
 Oblique Fx: at an oblique angle to the with radial head dislocation
bone\ 20.) Nursemaid’s/Jerked Elbow
 Spiral Fx: bone is twisted apart &  Partial dislocation of the
spirals around the long axis of radial head of a child
bone
6.) Comminuted Fx
 Bone is splintered or crushed (two
or more fragments)
7.) Impacted Fx
 One fragment is firmly driven into the
other

DIGITS (2nd-5th)
8.) Avulson Fx
OUTLINE
 UPPER
EXTREMITIES
• PA PROJECTION RP: PIP joint
• LATERAL PROJECTION CR: ┴
SS: PA oblique projection of affected digit
– LATEROMEDIAL
– MEDIOLATERAL
• PA OBLIQUE PROJECTION
– LATERAL ROTATION
• STREET METHOD
– MEDIAL ROTATION

PA PROJECTION
PP: Palmar surface down; separate the
digits slightly
RP: PIP joint AP PROJECTION
CR: ┴ Recommended for suspected joint injury
SS: PA projection of affected digit
DENTAL FILM
Can be used to examine small section of digit
that cannot be extended

THUMB (1st Digit)

OUTLINE
• AP PROJECTION
• PA PROJECTION
• LATERAL PROJECTION
• PA OBLIQUE PROJECTION
LATERAL PROJECTION
(LATEROMEDIAL/MEDIOLATERAL) AP PROJECTION
PP: Hand rest on radial surface (for 2nd-3rd PP: Hand in extreme internal rotation
digits) & ulnar surface (for 4th-5th digits) RP: 1st MCP joint
RP: PIP joint CR: ┴
CR: ┴ SS: AP projection of thumb
SS: Lateral projection of affected digit

PA OBLIQUE PROJECTION PA PROJECTION

PP: Hand pronated; lateral rotation (for 4th & PP: Hand in lateral position; dorsal
5th); medial rotation (2nd & 3rd) surface of thumb // to IR
 UPPER
EXTREMITIES
RP: 1st MCP joint (CMC) JOINT
CR: ┴ OUTLINE
SS: Magnified PA projection of thumb 1ST CARPOMETACARPAL JOINT
• ROBERT METHOD
(AP PROJECTION)
• LONG-RAFERT METHOD
(AP AXIAL PROJECTION)
• LEWIS METHOD
(AP AXIAL PROJECTION)
• BURMAN METHOD
(AP PROJECTION)

PA OBLIQUE PROJECTION 1ST METACARPOPHALANGEAL JOINT

PP: Hand in slight ulnar deviation; thumb • FOLIO METHOD
abducted (BILATERAL PA PROJECTION)
RP: 1st MCP joint
CR: ┴ ROBERT METHOD
SS: PA oblique projection of thumb AP PROJECTION
PP: Shoulder, elbow & wrist on same
plane (prevent carpal bones elevation &
closing 1st CMC joint); arm internally
rotated; hand hyperextended; dorsal aspect
of thumb against IR
RP: 1st CMC joint
CR: ┴
ER: Used to demonstrate
• Arthritic changes
• Fractures
LATERAL PROJECTION • 1st CMC joint displacement
PP: Hand in its natural arched position; • Bennett’s fracture
palmar surface down RAFERT-LONG METHOD
RP: 1st CMC joint
RP: 1st MCP joint
CR: 15o proximally
CR: ┴
LEWIS METHOD
SS: Lateral projection of thumb RP: 1st MCP joint
CR: 10-15o proximally

ROBERT RAFERT-LONG

LEWIS
FIRST
CARPOMETACARPAL BURMAN METHOD
 UPPER
EXTREMITIES
AP PROJECTION OUTLINE
PP: Hand hyperextended; opposite hand • PA PROJECTION
hold the hyperextended hand or bandage • PA OBLIQUE PROJECTION
loop around digits; hand rotated internally; – LATERAL ROTATION
thumb abducted • LATERAL PROJECTION
RP: 1st CMC joint – EXTENSION
CR: 45otoward the elbow – FLEXION
SS: Magnified concavo convex of 1st CMC – FAN LATERAL
joint • NORGAARD METHOD
ER: To provide a clearer image of 1st CMC (BILATERAL AP OBLIQUE
than standard AP PROJECTION)

PA PROJECTION
PP: Hand palmar surface down; spread finger
slightly
RP: 3rd MCP joint
CR: ┴
SS: PA oblique projection of the thumb
AP Projection:
 Hand cannot be extended because of
FOLIO METHOD/SKIER’S injury and pathologic conditions
THUMB PA PROJECTION  For metacarpal bones and MCP joints
PP: Hands rested on medial aspect; distal
portion of both thumbs wrap around by a
rubber band; thumb in PA plane
RP: b/n level of MCP joints of both hands
CR: ┴
SS: 1st CMC joint; bilateral MCP joints &
MCP angles
ER: Useful for diagnosis of
ulnar collateral ligament PA OBLIQUE PROJECTION
(UCL) rupture PP: Hand pronated; palmar surface down;
MCP joints 45o to IR; 45o foam wedge
RP: 3rd MCP joint
CR: ┴
SS: PA oblique projection of the hand
ER: To investigate fractures and
pathologic conditions
Foam Wedge: For interphalangeal joints
Fingertips Touching The Cassette: For
metacarpal bones
Index Finger Elevation:
 Use of radiolucent material
 Opens joint spaces
 Reduces the degree of
foreshortening of phalanges
HAND
 UPPER
EXTREMITIES

REVERSE OBLIQUE PROJECTION

LATERAL PROJECTION
Lane-Kennedy-Kuschner In Flexion
Recommendations PP: Hand rotated 45o PP: Hand in natural arch position; digits
internally relaxed
RP: 3rd MCP joint
RP: 2nd MCP joint
CR: ┴
CR: ┴
ER: To demonstrate severe metacarpal
SS: Lateral projection of the hand in flexion
deformities fractures
ER: To demonstrate anterior rposterior
displacement in fractures of metacarpals
TANGENTIAL OBLIQUE
PROJECTION
Kallen Recommendation
PP: Hand in PA position; hand rotated 40-
45o toward ulnar surface & 40-45oforward;
MCP joints flexed 75-80o; hand dorsum
resting on IR
RP: MCP joint of interest
CR: ┴
ER: To demonstrate metacarpal head fractures
LATERAL PROJECTION
Fan Lateral
PP: • Seated position
LATERAL PROJECTION • Place digits on radiolucent sponge wedge for
In Extension support
PP: Hand in lateral position; digits extended; RP: 2nd MCP joint
ulnar aspect down (lateromedial projection); CR: ┴
radial aspect down (mediolateral projection; SS: Individual phalanges (except proximal)
more difficult to assume); thumb 90o to palm • Superimposed MC
RP: 2nd MCP joint ER: Eliminates superimposition of all phalanges
CR: ┴ (except proximal phalanges)
SS: Lateral projection of the hand in extension
ER: To localize foreign bodies and
metacarpal fracture displacement
Fan Lateral Position: Eliminates
superimposition of all phalanges (except
proximal phalanges)

NORGAARD METHOD
AP OBLIQUE PROJECTION
 UPPER
EXTREMITIES
PP: Hand supinated; medial aspect against IR; PA PROJECTION
45o sponge support PP: Hand slightly arch (places wrist in close
RP: b/n level of 5th MCP joints of both hands contact with IR)
CR: ┴ RP: Midcarpal area
SS: AP oblique projection of both hands CR: ┴
ER: To diagnose rheumatoid arthritis SS: Slightly oblique rotation of ulna (AP
should be taken if ulna is under examination)
: Open radioulnar (wrist) joint space

WRIST DAFFNER-EMMERLING-BUTERBAUGH
OUTLINE
PP: Hand slightly arch (places wrist in close
• PA PROJECTION
contact with IR)
• AP PROJECTION RP: Midcarpal area
• LATERAL PROJECTION CR: 30o toward the elbow; 30o toward the
• PA OBLIQUE PROJECTION fingertips
– LATERAL ROTATION
SS: Elongated scaphoid & capitate
• AP OBLIQUE PROJECTION
(toward the elbow)
– MEDIAL ROTATION
• PA WITH ULNAR DEVIATION : Elongated capitate only
• PA WITH RADIAL DEVIATION (toward the fingertips)
• STECHER METHOD ER: To better demonstrate the scaphoid &
capitate
(PA AXIAL PROJECTION)
• RAFERT-LONG METHOD
(PA & PA AXIAL PROJECTION)
AP PROJECTION
– SCAPHOID SERIES
PP: Hand supinated; digits elevated (places
• CLEMENTS-NAKAYAMAY METHOD
wrist in close contact with IR)
(PA AXIAL OBLIQUE PROJECTION)
RP: Midcarpal area
• LENTINO METHOD
(TANGENTIAL PROJECTION) CR: ┴
– FOR CARPAL BRIDGE SS: Carpal interspaces better demonstrated;
• GAYNOR-HART METHOD no rotation of ulna
(TANGENTIAL PROJECTION)
– FOR CARPAL CANAL
• SUPEROINFERIOR PROJECTION

LATERAL PROJECTION
 UPPER
EXTREMITIES
Lateromedial PP: Palmar surface against IR; hand
PP: Elbow flexed 90o; hand & pronated & rotated 45o laterally; wrist ulnar
forearm in lateral position; ulnar deviation (for scaphoid only)
surface against IR; radial surface RP: Midcarpal area
against IR (for comparison) CR: ┴
RP: Midcarpal area SS: Carpals on the lateral side
CR: ┴ (Scaphoid & Trapezium)
SS: Proximal metacarpals & distal radius &
ulna; trapezium & scaphoid (more anterior)
ER: To demonstrate anterior or posterior
displacement in fractures

AP OBLIQUE PROJECTION
Medial Rotation
PP: Dorsal surface against IR; hand
supinated & rotated 45o medially
Burman & et al. Suggestions RP: Midcarpal area
PP: Wrist in palmar flexion (rotates the CR: ┴
scaphoid in dorsovolar position) SS: Carpals on the medial side
RP: Scaphoid (Pisiform, Triquetrum & Hamate)
CR: ┴
SS: Lateral position of the scaphoid

PA PROJECTION
Foille
In Ulnar Deviation
 First to describe carpe bossu PP: Hand pronated; wrist in extreme ulnar
(carpal boss), a small bony deviation
growth occurring on the dorsal
RP: Scaphoid
surface of the 3rd CMC joint
CR: ┴; 10 - 15 o proximally/distally (clear
 Best demonstrated in a lateral
delineation)
position of wrist in palmar
SS: Scaphoid; opens carpal interspaces on
flexion
lateral side
ER: To correctscaphoid foreshortening

PA OBLIQUE PROJECTION PA PROJECTION

Lateral Rotation
 UPPER
EXTREMITIES
In Radial Deviation PA & PA AXIAL PROJECTIONS
PP: Hand pronated; wrist in extreme radial Scaphoid Series
deviation In Ulnar Deviation
RP: Midcarpal area PP: Hand pronated; wrist in extreme ulnar
CR: ┴ deviation
SS: Opens carpal interspaces on medial side RP: Scaphoid
CR: ┴; 10o; 20o; 30o cephalad
SS: Scaphoid with minimal superimposition
ER: To diagnose scaphoid fractures

STECHER METHOD
PA AXIAL PROJECTION
VARIATIONS:
• IR elevated 20 o CLEMENTS-NAKAYAMA METHOD
• CR 20 o toward elbow PA AXIAL OBLIQUE PROJECTION
PP: Palmar surface against 45o sponge;
• CR 20 o toward digits
hand in ulnar deviation; rotate elbow end
o Fracture line that angles
of IR & arm 20o away from CR (unable to
superoinferiorly
achieve ulnar deviation)
• Clench the fist
RP: Anatomical snuffbox
RP: Scaphoid
CR: 45o distally
CR: ┴
SS: Trapezium
SS: Scaphoid
ER: To demonstrate trapezoid fractures
ER (20 o Angulation):
• To place scaphoid at right angles to the CR
• To project scaphoid w/o self superimposition alignment with
Bridgman Method: ulnar deviation.

Stecher Method with ulnar deviation

alignment without
ulnar deviation.

RAFERT-LONG METHOD
 UPPER
EXTREMITIES
LENTINO METHOD
TANGENTIAL PROJECTION
PP: Hand palm upward; hand 90o to forearm
RP: 1.5in proximal to wrist joint
CR: 45o caudad
SS: Carpal bridge
ER: To demonstrate:
• Fractures of scaphoid
• Lunate dislocation
SUPEROINFERIOR PROJECTION
• Dorsum of wrist
PP: Dorsiflex the wrist; lean forward (to place
calcifications carpal canal tangent to IR)
• Foreign bodies RP: Midpoint of the wrist
• Chip fractures (dorsal aspect of carpal CR: ┴
bones) SS: Carpal canal/tunnel
ER: Taken when patient cannot
assume/maintain Gaynor-Hart Method
Marshall Suggestion
• For limited dorsiflexion of the wrist
• Placed 45 o sponge under palmar surface of
the hand
o Slightly elevates the wrist to place the
carpal canal tangent to CR
If the wrist is too • With slight degree of magnification due to
painful
increased OID

GAYNOR-HART METHOD
TANGENTIAL PROJECTION
PP: Wrist hyperextended; hand rotated slight
toward the radial side (to prevent
superimposition of hamate & pisiform
shadows); digits grasp w/ opposite hand
RP: 1 in. distal to 3rd MCP base
CR: 20-30o to long axis of hand
SS: Carpal canal/tunnel (Carpal sulcus+Flexor
retinaculum)
ER:
FOREARM
OUTLINE
• To demonstrate carpal tunnel syndrome
• AP PROJECTION
• To demonstrate fractures of hook of hamate,
pisiform & trapezium • LATERALPROJECTION
Mcquillen Martensen Suggestion – LATEROMEDIAL
• For wrist that cannot be extended to w/in 15o
of vertical
• CR aligned // to palmar surface
• Angled an additional 15o toward the palm
 UPPER
EXTREMITIES
AP PROJECTION
ELBOW
PP: Hand supinated; patient lean laterally;
humeral epicondyles // to IR OUTLINE
RP: Midshaft • AP PROJECTION
CR: ┴ • LATERALPROJECTION
SS: Elbow joints; radius & ulna; distorted – LATEROMEDIAL
carpal bones (proximal row) • AP OBLIQUE PROJECTION
• Slight superimposition of radial head, neck – MEDIAL ROTATION
& tuberosity over the proximal ulna – LATERAL ROTATION
Hand Pronation: • AP PROJECTION
• It crosses the radius over the ulna at its – IN PARTIAL FLEXION
proximal third – DISTAL HUMERUS
• It rotates the humerus medially – PROXIMAL FOREARM
• JONES METHOD
(AP PROJECTION)
– ACUTE FLEXION
– DISTAL HUMERUS
– PROXIMAL FOREARM
• RADIAL HEAD SERIES
– LATERAL PROJECTION
– FOUR-POSITION SERIES
• COYLE METHOD
LATERALPROJECTION – AXIOLATERAL PROJECTION
Lateromedial • PA AXIAL PROJECTION
PP: Elbow flexed 90o ; forearm & hand in true – DISTAL HUMERUS
lateral; thumb must be up; humeral • PA AXIAL PROJECTION
epicondyle ┴ to IR – OLECRANON PROCESS
RP: Midshaft
CR: ┴
SS: Elbow joints; radius & ulna; carpal bones
(proximal row) AP PROJECTION
• Superimposed radius & ulna at their distal PP: Elbow extended; hand supinated; patient
end lean laterally; humeral epicondyles & anterior
surface of elbow // to IR
• Superimposed radial head over the coronoid
RP: Elbow joint
process
CR: ┴
• Superimposed humeral epicondyles
SS: Elbow joints; distal arm & proximal
• Radial tuberosity facing anteriorly forearm
• Radial head, neck & tuberosity slightly
superimposed over the proximal ulna
 UPPER
EXTREMITIES
LATERAL PROJECTION
Lateromedial AP OBLIQUE PROJECTION
PP: Elbow flexed 90o ; elbow flexed 30-35o Lateral Rotation
(suspected elbow injury); hand in lateral PP: Hand laterally rotated 45o ; 1st & 2nd digits
position; humeral epicondyles ┴ to IR touching the table; posterior surface of elbow
RP: Elbow joint 45o to IR
CR: ┴ RP: Elbow joint
SS: Elbow joints; distal arm & proximal CR: ┴
forearm SS: Radial head & neck in profile; capitulum
• Superimposed humeral epicondyles
• Radial tuberosity facing anteiorly
• Radial head partially superimposing
coronoid process
• Olecranon process in profile
Griswold (Elbow flexing 90o)
2 reasons:
• Olecranon process seen in profile AP PROJECTIONS
• Elbow fat pads are least compressed In Partial Flexion
Distal Humerus
PP: Hand supinated; elbow partially flexed
RP: Elbow joint
CR: ┴ to humerus
SS: Distal humerus when elbow cannot be fully
extended

AP OBLIQUE PROJECTION
Medial Rotation
PP: Hand pronated or medially rotated 45o;
anterior surface of elbow 45o to IR
RP: Elbow joint
CR: ┴ Proximal Forearm
SS: Coronoid process in profile; trochlea PP: Hand supinated; dorsal surface of forearm
against IR; elbow partially flexed
RP: Elbow joint
CR: ┴ to forearm
SS: Proximal forearm
ER (2 AP Projections): For patient cannot
completely extend the elbow
 UPPER
EXTREMITIES

JONES METHOD
Hand
AP PROJECTION supinated
Acute Flexion painful
Distal Humerus
PP: Elbow fully (acutely) flexed
RP: 2 in. superior to olecranon process
Hand
CR: ┴ to humerus lateral
SS: Olecranon process

Hand
pronated
painful

Hand
Proximal Forearm internally
PP: Elbow fully (acutely) flexed painful
RP: 2 in. distal to olecranon process
CR: ┴ to flexed forearm GREENSPAN AND NORMAN
SS: Elbow joint more open CR: 45o medially
SS: radial head can be projected more clearly
with reduced superimposition

RADIAL HEAD SERIES

LATERAL PROJECTION COYLE METHOD
Four-Position Series AXIOLATERAL PROJECTION
PP: Elbow flexed 90o; elbow joint in lateral PP:
position; four exposures: • Seated: hand pronated
1.) hand supinated • Supine (trauma): distal humerus elevated;
2.) hand in lateral IR vertical; humeral epicondyles ┴ to IR;
3.) hand pronated palmar aspect of hand facing anteriorly
4.) hand internally rotated • Elbow flexed 90o (radial head) or 80o
RP: Elbow joint (coronoid process);
CR: ┴ RP: Midelbow joint
SS: Radial head in varying degrees of rotation CR:
• Radial head facing anteriorly (1st & 2nd • Seated: 45o toward the shoulder (radial
exposures) head); 45o away from the shoulder (coronoid
• Radial head facing posterior (3rd & 4th process)
exposures) • Supine: horizontal; 45o cephalad (radial
head); 45o caudad (coronoid process)
 UPPER
EXTREMITIES
SS: Open elbow joint b/n radial head &
capitulum or coronoid process & trochlea PA AXIAL PROJECTION
ER: Olecranon Process
• To demonstrate pathologic processes or PP: Seated; arm 45-50o from vertical; hand
trauma in the area of radial head & coronoid supinated
process RP: Olecranon process
• Cannot fully extend elbow for medial & CR: ┴ or 20o toward the wrist
lateral oblique SS: Dorsum of olecranon process (┴); curved
extremity & articular margin of olecranon
process (20o)

HUMERUS
OUTLINE
PA AXIAL PROJECTION
• AP PROJECTION
Distal Humerus
– UPRIGHT
PP: Seated; arm rested vertically against IR;
• LATERALPROJECTION
forearm // to IR; humerus 75o from forearm or
15o from CR; hand supinated – LATEROMEDIAL UPRIGHT
RP: Ulnar sulcus – MEDIOLATERAL UPRIGHT
CR: ┴ • AP PROJECTION
SS: Epicondyles; trochlea; ulnar sulcus (groove – RECUMBENT
b/n medial epicondyle & trochlea); olecranon • LATERAL PROJECTION
fossa – LATEROMEDIAL RECUMBENT
ER:
• Used in radiohumeral bursitis (tennis
elbow) AP PROJECTION
• To detect otherwise obscured calcification Upright
located in the ulnar sulcus PP: Erect/seated-upright (more comfortable);
Rafert-Long arm abducted slightly; hand supinated; humeral
AP oblique distal humerus for demonstration of epicondyles // to IR
ulnar sulcus RP: Midshaft
CR: ┴
SS: Humeral head & greater tubercle in profile
 UPPER
EXTREMITIES
LATERAL PROJECTION LATERAL PROJECTION
Lateromedial Upright Lateromedial Recumbent
PP: Erect/seated-upright (more comfortable); PP:
arm rotated internally; elbow flexed • Supine: arm abducted slightly; forearm
approximately 90o; palmar aspect of hand rotated medially; dorsal aspect of hand
against hip; humeral epicondyles ┴ to IR
against patient’s side; humeral epicondyles
RP: Midshaft
┴ to IR; elbow flexed slightly (for comfort)
CR: ┴
• Lateral Recumbent: place IR closed to
SS: Lesser tubercle in profile; greater tubercle
axilla; elbow flexed (unless contraindicated);
superimposed over humeral head 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

Mediolateral Upright
PP: RAO/LAO; patient’s hand holding the
broken arm
RP: Midshaft
CR: ┴
SS: Lesser tubercle in profile; greater tubercle
superimposed over humeral head
ER: For patients with broken humerus
“PROJECT your dreams and POSITION
yourself to make a clear VIEW of your future”

AP PROJECTION
Recumbent
PP: Supine; unaffected shoulder elevated; hand
supinated; humeral epicondyles // to IR
RP: Midshaft
CR: ┴
SS: Humeral head & greater tubercle in profile