1. Wrist
1.1. PA Projection
1.1.1. CR @ midcarpals; perpendicular to IR; 40 in SID
1.1.2. ANATOMY: Carpal bones, midmetacarpals, distal radius and ulna, fat pads & fat stripes
1.1.3. PATHOLOGY: osteomyelitis/arthritis; fractures of distal radius or ulna or carpal bones
1.2. PA Oblique Projection
1.2.1. CR @ midcarpals; perpendicular to IR; 40 in SID
1.2.2. ANATOMY: Trapezium & scaphoid well visualized; distal radius and ulna, midmetacarpals, scaphoid fat pad best visualized
1.2.3. PATHOLOGY: osteomyelitis/arthritis; fractures of distal radius or ulna or individual carpal bones
1.3. Lateral Projection
1.3.1. CR @ midcarpals; perpendicular to IR; 40 in SID
1.3.2. ANATOMY: distal radius or ulna; ulnar head should be superimposed over distal radius in a true lateral; long axis of the hand, wrist, and forearm
1.3.3. PATHOLOGY: fractures/dislocations of the distal radius or ulna, (Barton's, Colles, or Smith's fractures specifically); osteoarthritis almost demonstrated primarily in the trapezium & 1st CMC joint
2. Forearm
2.1. AP Projection
2.1.1. CR @ mid-forearm with patient seated at end of table with hand and arm fully extended and supinated; shoulder, elbow, and wrist joint on same horizontal plane; 40 in SID
2.1.2. ANATOMY: proximal carpals and distal humerus both demonstrated; entire radius and ulna shown with SLIGHT superimposition of radius and ulna, fat pads of wrist and elbow joints
2.1.3. PATHOLOGY: fractures or dislocations of radius or ulna; osteomyelitis/arthritis
2.2. Lateral Projection
2.2.1. CR @ mid-forearm, perpendicular to IR; patient seated at end of table with elbow flexed 90*; shoulder, wrist, and elbow on same horizontal plane; 40 in SID
2.2.2. ANATOMY: entire radius and ulna, proximal row of carpal bones and distal humerus, fat pads and stripes of wrist and elbow joints, the 3 concentric arcs (trochlear sulcus, outer ridges of capitulum/trochlea, and trochlear notch of ulna); humeral epicondyles superimposed and perpendicular to the IR
2.2.3. PATHOLOGY: fractures and dislocations of radius or ulna, osteomyelitis/arthritis
3. Elbow
3.1. AP Projection
3.1.1. CR @ mid-elbow joint, perpendicular to the IR; humeral epicondyles parallel to the IR, hand supinated with shoulder, elbow and wrist on same horizontal plane; 40 in SID
3.1.2. ANATOMY: distal humerus and proximal radius and ulna demonstrated; humeral epicondyles completely parallel to IR; on a true AP with no rotation the radius and ulna will be slightly superimposed on one another
3.1.3. PATHOLOGY: fractures and dislocations of the elbow; osteomyelitis/arthritis
3.2. External (lateral) Oblique Projection
3.2.1. CR @ mid-elbow joint, perpendicular to the IR; patient seated at end of table with arm fully extended and shoulder, elbow and wrist joint on same horizontal plane; intercondylar plane at 45* to IR; 40 in SID
3.2.2. ANATOMY: Oblique of distal humerus and proximal radius and ulna with no superimposition; capitulum, lateral epicondyle, radial head and neck, and radial tubercle should all be visible
3.2.3. PATHOLOGY: fractures and dislocations of the elbow, primarily the radial head and neck; visibility of the radial head, neck, and tuberosity; osteomyelitis/arthritis
3.3. Internal (medial) Oblique Projection
3.3.1. CR @ mid-elbow joint; perpendicular to the IR; patient seated at edge of table with fully extended and shoulder, elbow, and wrist joint on the same horizontal plane and arm supine with hand pronated to create the medial oblique; 40 in. SID
3.3.2. ANATOMY: Oblique view of the distal humerus and proximal radius and ulna is visible; olecranon process should appear seated on olecranon fossa and trochlear notch partially open and visualized; epicondyles at 45* to the IR
3.3.3. PATHOLOGY: fractures and dislocations of the elbow, primarily the coronoid process; certain pathologic processes, such as osteoporosis and arthritis
3.4. Lateral Projection
3.4.1. CR @ mid-elbow joint, perpendicular to the IR with patient seated at the edge of the table with shoulder, wrist, and elbow joint on same horizontal plane; 40 in SID
3.4.2. ANATOMY: lateral projection of the distal humerus and proximal forearm, olecranon process and soft tissues and fat pads of the elbow joint are visible; elbow must be at 90* flexion to be considered true lateral; condyles are perpendicular to the IR and superimposed over each other
3.4.3. PATHOLOGY: fractures and dislocations of the elbow; certain bony pathologic processes, such as osteomyelitis and arthritis; elevated or displaced fat pads of the elbow joint may be visualized
4. Thumb/fingers
4.1. AP/PA Projection
4.1.1. CR @ MCP joint for the 1st digit and at the PIP for digits 2-5; perpendicular to the IR; 40 in SID; patient in a comfortable position and the IR positioned to fit the patients comfort; CR perpendicular to the IR
4.1.2. ANATOMY: distal, middle, and proximal phalanges; distal metacarpal; and associated joints; trapezium must be visible for the 1st digit and corresponding carpal bones for digits 2-5
4.1.3. PATHOLOGY: fractures and dislocations for the distal, middle, and proximal phalanges; distal metacarpal and associated joints; pathologic processes such as osteoporosis and osteoarthritis
4.2. PA Oblique Projection (medial or lateral rotation)
4.2.1. CR @ the MCP joint for the 1st digit and at the PIP joints for digits 2-5; CR perpendicular to the IR with elbow flexed at 90* with hand and wrist both resting on the IR; 40 in SID; finger on wedge block with 45* rotation with the long axis of the part aligned with the long axis of the IR
4.2.2. ANATOMY: oblique view of the distal, middle, and proximal phalanges; distal metacarpal, and associated joints
4.2.3. PATHOLOGY: fractures and dislocations of the distal, middle, and proximal phalanges; distal metacarpal, and associated joints; pathologies such as osteoporosis and osteoarthritis
4.3. Lateromedial/Mediolateral Projection
4.3.1. CR @ PIP joint, and directed perpendicular to the IR; 40 in SID; place hand in lateral position with finger to be examined fully extended and centered to portion of IR being exposed; use a sponge block to support finger and prevent motion
4.3.2. ANATOMY: lateral views of distal, middle, and proximal phalanges; distal metacarpal and associated joints are visible; 2nd digit is preferred to be taken at a mediolateral if the patient can do this position to reduce OID for the finger; finger at a true lateral as indicated by the concave appearance of the anterior surface of the shaft of the phalanges
4.3.3. PATHOLOGY: fractures and dislocations of the distal, middle, and proximal phalanges; distal metacarpal and associated joints; pathologic processes such as osteoporosis and osteoarthritis
5. Hand
5.1. PA Projection
5.1.1. CR @ 3rd MCP joint and directed perpendicular to the IR; hand pronated with palmar surface in contact with IR and fingers spread slightly; center hand and wrist to IR; radiograph mush include carpal bones and distal end of radius and ulna; 40 in SID
5.1.2. ANATOMY: entire hand and wrist and about 1 inch of distal forearm are visible; this projection demonstrates an oblique view of the thumb; all phalanges of each digit should be visible separated slightly will no overlapping
5.1.3. PATHOLOGY: fractures, dislocations or foreign bodies of the phalanges, metacarpals, and all joints of the hand
5.2. PA Oblique Projection
5.2.1. CR @ 3rd MCP joint; rotate entire hand laterally 45* and support with a sponge so that all digits are separated and parallel to IR; 40 in SID
5.2.2. ANATOMY: oblique of the entire hand and wrist and about 1 in. of distal forearm; can skip using the step block when metacarpals are of interest and the digits do not have to be parallel to the IR
5.2.3. PATHOLOGY: fractures and dislocations of the phalanges, metacarpals, and all joints of the hand; osteoporosis and osteoarthritis
5.3. Lateral Projections (Fan and Extension)
5.3.1. CR @ the 2nd MCP joint, fan lateral when phalanges are of interest and extension lateral when metacarpals are of interest; CR perpendicular to the IR; 40 in SID
5.3.2. ANATOMY: entire hand and wrist and about 1 in of distal forearm are visible; in the extension, thumb should be slightly oblique and free of superimposition with joint spaces open
5.3.3. PATHOLOGY: visualization of foreign bodies best seen with extension lateral and anterior and posterior displacement of the metacarpals as well; fractures and dislocations of the phalanges, anterior and posterior displaces fractures of the metacarpals for the fan lateral