4. X-RAY PA VIEW - WRIST JOINT
Part Position: Forearm pronated,
with a loosely closed fist and the
wrist flat on the film.
CR: To the midcarpal region.
Collimation: To the wrist,
approximately 6 inches
6. PA view
A correctly positioned PA view will show
the extensor carpi ulnaris groove radial
the midportion of the ulnar styloid.
7. NEUTRAL ULNAR VARIANCE
• As a rule, the radial styloid
process rises 9 to 12 mm above
the articular surface of the distal
ulna. This distance is also known
as the radial length
8. • The joint spaces of the wrist have a
width of 2 mm or less. Only the
radiocarpal joint is slightly wider. The
carpometacarpal joints are slightly
narrower than the midcarpal joints
9. ARCS
• The first arc is a smooth curve outlining
the proximal convexities of the scaphoid,
lunate and triquetrum.
• The second arc traces the distal concave
surfaces of the same bones.
• third arc follows the main proximal
curvatures of the capitate and hamate.
10. VULNERABLE ZONE OF WRIST
• The “vulnerable zone”
of the carpus is
represented by
shaded areas.
• Most fractures,
fracture-dislocations,
and dislocations of
the carpal bones
occur within it.
11. PA VIEW
The PA view is
especially useful
for assessing fractures
12. WRIST: PA ULNAR FLEXION
PROJECTION
Part Position: Forearm
pronated with the wrist
moved into ulnar deviation
and placed flat on the film.
CR: To the midcarpal region.
Collimation: To the wrist,
approximately 6 inches
14. • This view enhances
visualization of scaphoid and
radial styloid fractures by
distracting the fracture line,
which may not be visible on
the neutral study.
ulnar flexion the scaphoid fracture becomes wider and
more apparent.
15. WRIST: MEDIAL
OBLIQUE PROJECTION
• Part Position: Forearm
semipronated so the dorsum of
the wrist is 45° to the film
• CR: To the midcarpal area
• Collimation: To the wrist,
approximately 6 inches.
17. For scaphoid, because it shows to
advantage the waist and tubercle,
which are common sites of
fracture that can be obscured on
other views.
Also offers additional views of the
thumb and distal forearm.
A longitudinal fracture is present within
the trapezium, which was not visible on the PA view in a
patient suspected clinically of a scaphoid fracture
18. WRIST: LATERAL PROJECTION
• Part Position: Forearm is in
true lateral position.
• CR: To the midcarpal area.
• Collimation: To the wrist,
approximately 6 inches.
19. NORMAL ANATOMY
• 7. Capitate.
• 8. Scaphoid.
• 9. Pisiform.
• 10. Trapezium.
• 11. Base, first metacarpal.
• 12. Fat line, pronator
quadratus (arrow).
1. Posterior lip, radius.
2. Anterior lip, radius.
3. Styloid process, ulna.
4. Shaft of the radius.
5. Shaft of the ulna.
6. Lunate
20. Only on a good
positioned lateral view
one can see the volar
edges of respectively
scaphoid, pisiform and
capitate separately
21. • The relationships of
the carpal bones to
each other, the
radiocarpal joint
(especially the
lunate), and the
distal radius after
trauma are best
analyzed on this
view.
lunate is tilted and dislocated ventrally relative to the
radius and capitate (arrow).
# of the distal radius is marked by a break in the cortex (arrow).
The distal segment of the radius is angulated dorsally
22. REVIEW
VIEW Advantage
PA view • for assessing fractures
Medial oblique • Best for scaphoid – waist & tubercule
Lateral • relationships of the carpal bones
• Trauma to distal radius
PA Ulnar flexion • enhances visualization of scaphoid and radial
styloid fractures
23. NEGATIVE AND POSITIVE ULNAR
VARIANCE.(A) Negative ulnar variance.
The articular surface of the
ulna
projects 5 mm proximal to
the site of radiolunate
articulation.
(B) Positive ulnar variance.
The articular surface
of the ulna projects 8 mm
distal to the site of
radiolunate articulation
26. BARTONS FRACTURE
The fracture line in
the coronal plane
extends from the
dorsal margin of
the distal radius
into the
radiocarpal
articulation.
27. HUTCHINSON FRACTURE
• The fracture line in the
sagittal plane extends
through the radial
margin of the radial
styloid process into the
radiocarpal articulation
28. SMITH FRACTURE.
• typical appearance
of Smith fracture.
Volar displacement
of the distal
fragment is clearly
evident on the
lateral view.
29. HAND: PA PROJECTION
• Part Position: Hand is placed
palm down on the film with the
fingers extended.
• CR: Third metacarpal head.
• Collimation: To hand size.
31. HAND: OBLIQUE PROJECTION
• Part Position: Hand is semi pronated to 45°
to the film.
• For stability, the fingers are flexed to touch
the film and to be projected free from each
other or they may be placed on a foam
rubber positioning aid.
• CR: Between the second and third
metacarpal heads.
• Collimation: To hand size
33. FINGERS: PA, OBLIQUE, AND
LATERAL PROJECTIONS
• Part Position: (a) Posteroanterior: hand
prone, with affected finger centered.
• (b) Oblique: hand semiprone to 45° with
the film; the exposed finger is extended,
with the other fingers slightly flexed and
spread apart.
• (c) Lateral: hand in true lateral position,
affected finger is extended, with the
remaining fingers flexed.
• CR: At the proximal interphalangeal joint.
• Collimation: To include only the affected
digit
35. THUMB: AP AND LATERAL
PROJECTIONS
• Part Position: (a) AP (Robert’s
projection): the hand is rotated
internally until the posterior surface of
the thumb contacts the film.
• (b) Lateral: the hand is placed prone
and the thumb is brought to a lateral
position. This is assisted by slightly
flexing of the metacarpophalangeal
joints.
• CR: Through the first
metacarpophalangeal joint.
• Collimation: To thumb size
37. ANTERO-POSTERIOR OBLIQUE BOTH
HANDS (BALL CATCHER’S OR
NORGAARD PROJECTION)
• 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
• CR - The collimated vertical beam is
centred to a point midway between
the hands at the level of the 5th
metacarpophalangeal joints (MCPJ).
38. • This projection may be
used in the diagnosis of
rheumatoid arthritis. It can
also be used to
demonstrate fractures of
the base of the 5th
metacarpals.
Radiograph of hand in ball catcher’s position showing severe
erosive disease.
39. SCAPHOID (CARPAL BONES)
POSTERO-ANTERIOR – ULNAR DEVIATION
• The wrist is positioned over the centre of
the image receptor and the hand is
adducted (ulnar deviation).
• CR - The collimated vertical beam is
centred midway between the radial and
ulnar styloid processes.
41. AXIS OF THE CARPAL BONES
• Scaphoid axis
• The true axis of the scaphoid is the line through the midpoints of its proximal and
distal poles.
42. LUNATE AXIS
• The axis of the lunate runs through the
midpoints of the convex proximal and
concave distal joint surfaces and can
best be drawn by finding the
perpendicular to a line joining the distal
palmar and dorsal borders of the bone
• More than 80 degree – instability of
wrist
43. CAPITATE AXIS
• The capitate axis joins the
midportion of the proximal
convexity of the third
metacarpal and that of the
proximal surface of the
capitate.
• > 30 degree angle-
indicates instability of the
wrist.
44. SCAPHOID (CARPAL BONES)
ANTERIOR OBLIQUE – ULNAR DEVIATION
• From the postero-anterior position, the
hand and wrist are rotated 45° externally
and placed over the image detector.
• The hand should remain adducted in
ulnar deviation.
• CR -The collimated vertical beam is
centred midway between the radial and
ulnar styloid processes.
45. POSTERIOR OBLIQUE VIEW-
SCAPHOID
• The wrist is placed over the centre of the
detector with the wrist and hand supported
on a 45° non-opaque foam pad.
• CR - The collimated vertical beam is
centred over the styloid process of the
ulna.
47. SCAPHOID – LATERAL VIEW
• From the posterior oblique position, the
hand and wrist are rotated internally
through 45°, such that the medial aspect
of the wrist is in contact with the image
detector.
• CR - The collimated vertical beam is
centred over the radial styloid process.
49. CARPAL TUNNEL
• The palm of the hand is pressed onto
the detector, with the wrist joint
dorsiflexed to approximately 135.
• CR- The collimated vertical beam is
centred between the pisiform and the
hook of the hamate medially and the
tubercle of the scaphoid and the ridge
of the trapezium laterally.
50.
51.
52. STRESS VIEWS
• In the AP or PA position the
patient stresses the thumb
with the contralateral hand
using the contralateral
thumb as the fulcrum.
• Gamekeeper thumb is an
avulsion or rupture of the
ulnar collateral ligament
(UCL) of the thumb
54. DISI OR DORSIFLEXION
INSTABILITY.
• DISI is short for dorsal
intercalated segmental
instability.
The intercalated segment
is the proximal carpal row
identified by the lunate.
• in DISI or dorsiflexion
instability the lunate is
angulated dorsally.
55.
56. VISI OR VOLAR FLEXION INSTABILITY
• Volar intercalated
segmental
instability or palmar
flexion instability is
when the lunate is
tilted palmarly too
much.
57.
58. REVIEW
View Importance
Ball catchers view For R.A and # of 5th metacarpal
oblique The oblique film is especially useful in depicting
fractures of the metacarpals and dislocations of the
finger joints.
PA, Oblique, and Lateral Projections Phalanx bone detail, which can be achieved only by
performing all three views for the digit examined
Thumb Ap and lateral view For thumb, the base of the first metacarpal and its
joint
Burman x-ray first
metacarpotrapezial
Stress view Game keepers thumb
68. SIGNET RING SIGN
• Rotary subluxation of the scaphoid
can be recognized by the cortical
ring shadow (arrow) that appears
projecting over the scaphoid
69. • On the lateral radiograph of the wrist,
lunate dislocation is evident from the
break in the longitudinal alignment of
the third metacarpal and the capitate
over the distal radial surface at the site
of the lunate, which is volarly rotated
and displaced.
• (B) Dorsovolar projection shows a
disrupted arc II at the site of the lunate,
indicating malalignment. Note also the
triangular appearance of the lunate, a
finding virtually pathognomonic of
dislocation of this bone
Lunate dislocation
70. PERILUNATE DISLOCATION
• Lateral radiograph of the wrist
demonstrates perilunate dislocation
characterized by displacement of the
capitate dorsal to the lunate.
• On the dorsovolar projection perilunate
dislocation is evident from the
overlapping proximal and distal carpal
rows and the resulting disruption of
arcs II and III.
71. TRANSSCAPHOID PERILUNATE
DISLOCATION• Dorsovolar radiograph of the wrist in
ulnar deviation clearly shows a scaphoid
fracture (arrow), but the disruptions in
the distal carpal arcs are unclear as to
the type of dislocation.
• Lateral tomogram demonstrates that
the capitate is displaced dorsal to the
lunate, which remains in articulation
with the distal radius—the classic
appearance of perilunate dislocation.
