Radiographic Procedures And Techniques For Upper Limb

Learning objective

Interpret radiology and imaging request forms for the patients Conduct x-ray examinations of the upper and lower axial and appendicular muscular skeletal system Conduct x-ray examinations of the vertebral( cervical Thoracic and lumber) as per radiographic drill Evaluate resultant image for quality check Communicate resultant image to the required destination

Apply radiographic drill concept in performing radiography of the axial and appendicular muscular skeletal system

a. Interpret radiology and imaging request forms for the patients

A radiology request form is a document used by healthcare providers to formally request imaging studies, such as X-rays, MRIs, or CT scans, for a patient.

It includes

Essential patient information it include, name of the patient, patient hospital reg no, gender, age, LMP, dept/ward Relevant clinical history it may include provisional diagnosis Examination requested,

Referring Physician Information

Date

This form helps ensure that the appropriate imaging is conducted and assists radiologists in understanding the context of the request for accurate interpretation

Request Form

The radiographer checks the request form to ensure the examination is justified according to:

◾ ionizing radiation regulations;

◾ department protocols, making sure that the form contains all the required details, i.e. patient demographics, examination requested, authorised signature for the examination and rationale for the examination.

◾ An explanation of the examination requested is provided.

• Conduct x-ray examination of the upper and lower limbs as per radiographic drill

HAND

ANATOMY

The skeleton of the hand includes the bones of the carpus the bones of the metacarpus and the phalanges.

EQUIPMENT AND ACCESORIES

X-RAY MACHINE

IMMOBILAZERS(SAND BAG/FOAM PADS)

CASSETTE- 18X24CM/24X30CM

ANATOMICAL MARKER

PROCESSING UNIT

BASIC PROJECTIONS

• Two projections are routinely taken, a dorsi-palmar (DP) and

an anterior oblique (DP oblique)

DORSI-PALMAR

• Position of patient

The patient is seated alongside the table with the affected arm nearest to the table.

• The forearm is pronated and placed on the table with the palmer surface of the hand in contact with the image receptor/cassette.
• The fingers are separated and extended but relaxed to ensure that they remain in contact with the image receptor/cassette.
• The wrist is adjusted so that the radial and ulna styloid processes are equidistant from the image receptor.
• A sandbag is placed over the lower forearm for immobilisation.

DIRECTION AND LOCATION OF X-RAY BEAM

• The collimated vertical beam is centered over the head of the 3rd metacarpal
• Radiation protection/dose
• Careful technique and close collimation will assist in reducing the patient dose.

Essential image characteristics (Figs above )

• The image should demonstrate all the phalanges, including the soft tissue of the fingertips, the carpal and metacarpal bones and the distal end of the radius and ulna.
• The interphalangeal and metacarpo-phalangeal and carpometacarpal joints should be demonstrated clearly.
• No rotation of the hand.

ANTERIOR OBLIQUE (DP OBLIQUE)

Position of patient

• From the basic postero-anterior position, the hand is externally rotated 45° with the fingers extended.
• The fingers should be separated slightly and the hand supported on a 45° non-opaque pad.
• A sandbag is placed over the lower end of the forearm for immobilisation

DIRECTION AND LOCATION OF THE X-RAY BEAM

• The collimated vertical beam is centred over the head of the 5th metacarpal.
• The tube is then angled so that the central ray passes through the head of the 3rd metacarpal, enabling a reduction in the size of the field.

Essential image characteristics (Figs above)

• The image should demonstrate all the phalanges, including the soft tissue of the fingertips, the carpal and metacarpal bones and the distal end of the radius and ulna.
• The correct degree of rotation has been achieved when the heads of the 1st and 2nd metacarpals are seen separated whilst those of the 4th and 5th are just superimposed.

Over-rotation of the hand

DP oblique hand

• DP oblique hand demonstrating over-rotation.
• The 3rd, 4th and 5th metacarpals are superimposed.

A repeat X-ray is required.

LATERAL

• Position of patient
• From the postero-anterior (DP) position, the hand is externally rotated 90°.
• The palm of the hand is perpendicular to the image receptor,with the fingers extended and the thumb abducted and supported parallel to the image receptor on a non-opaque pad.
• The radial and ulnar styloid processes are superimposed

DIRECTION AND LOCATION OF THE X-RAY BEAM

• The collimated vertical beam is centred over the head of the 2nd metacarpal

Essential image characteristics (Fig. above)

The image should include the fingertips, including soft tissue,and the radial and ulnar styloid processes.

The heads of the metacarpals should be superimposed. The thumb should be demonstrated clearly without superimposition of other structures.

DORSI-PALMAR BOTH HANDS

Position of patient

• Ideally, the patient is seated alongside the table. However, if this is not possible due to the patient’s condition, the patient may be seated facing the table.
• Both forearms are pronated and placed on the table with the palmer surface of the hands in contact with the image receptor.
• The fingers are separated and extended but relaxed to ensure that they remain in contact with the image receptor

• The wrists are adjusted so that the radial and ulna styloid processes are equidistant from the image receptor.

• A sandbag is placed over the lower forearms for immobilisation.

DIRECTION AND LOCATION OF THE X-RAY BEAM

• The collimated vertical beam is centred over a point midway between the interphalangeal joints of both thumbs.

Essential image characteristics(Figs bove)

• The image should demonstrate all the phalanges, including the soft tissue of the fingertips, the carpal and metacarpal bones and the distal end of the radius and ulna.
• The exposure factors selected must produce an accurate EI and optimally demonstrate joint detail

ANTERO-POSTERIOR OBLIQUE BOTH

HANDS (BALL CATCHER’S OR NORGAARD PROJECTION)

Ideally the patient is seated alongside the table. However, if this is not possible, due to the patient’s condition, the patient may be seated facing the table .

• Both forearms are supinated and placed on the table with the dorsal surface of the hands in contact with the image receptor.
• From this position both hands are rotated internally (medially) 45° into a ‘ball catching’ position

Radiographic Procedures And Techniques For Upper Limb

• The fingers and thumbs are separated and extended but relaxed to ensure that they remain in contact with the image receptor.
• The hands may be supported using 45° non-opaque pads.
• A sandbag is placed over the lower forearms for immobilisation.

DIRECTION AND LOCATION OF X-RAY BEAM

• The collimated vertical beam is centred to a point midway between the hands at the level of the 5th metacarpophalangeal joints (MCPJ).

Essential image characteristics (Figs above )

• The image should demonstrate all the phalanges, including the soft tissue of the finger tips, the carpal and metacarpal bones and the distal end of the radius and ulna.
• The exposure factors selected must produce an accurate EI and optimally demonstrate joint detail.
• The heads of the metacarpals should not be superimposed.

RADIATION PROTECTION

If it has been necessary to position the patient facing the table it is essential to provide radiation protection for the lower limbs and gonads.

This may be achieved by placing a lead-rubber sheet on the table underneath the image receptor to attenuate the primary beam

FINGERS

• Basic projections

Two projections are routinely taken, a postero-anterior and a lateral.

The adjacent finger is routinely imaged unless the injury is very localised, e.g. a crush injury to the distal phalanx.

DORSI-PALMAR (DP)

Position of patient

• The patient is positioned seated alongside the table as for a postero-anterior projection of the hand.
• The forearm is pronated with the anterior (palmer) aspect of the finger(s) in contact with the image receptor.
• The finger(s) are extended and separated.
• A sandbag may be placed across the dorsal surface of the wrist for immobilisation.

DIRECTION AND LOCATION OF X-RAY BEAM

The collimated vertical beam is centred over the proximal interphalangeal joint of the affected and adjacent finger.

LATERAL INDEX AND MIDDLE FINGERS

Position of patient and image receptor

• The patient is seated alongside the table with the arm abducted and medially rotated to bring the lateral aspect of the index finger into contact with the image detector.
• The raised forearm is supported.
• The index finger is fully extended and the middle finger slightly flexed to avoid superimposition.
• The middle finger is supported on a non-opaque pad.
• The remaining fingers are fully flexed into the palm of the hand and held there by the thumb.

DIRECTION AND LOCATION OF X-RAY BEAM

• The collimated vertical central ray is centred over the proximal interphalangeal joint of the affected finger.

LATERAL RING AND LITTLE FINGERS

Position of patient and image receptor

• The patient is seated alongside the table with the palm of the hand at right-angles to the table and the medial aspect of the little finger in contact with the image receptor.
• The affected finger is extended and the remaining fingers are fully flexed into the palm of the hand and held there by the thumb in order to prevent superimposition.
• It may be necessary to support the ring finger on a nonopaque pad to ensure that it is parallel to the image receptor

DIRECTION AND LOCATION OF X-RAY BEAM

• The collimated vertical beam is centred over the proximal interphalangeal joint of the affected finger.