Radiographic Positioning of the Shoulder
Section objectives: Shoulder Series
At the conclusion of this course the student doctor should;
1. Be able to efficiently conduct all parts of a 3 view shoulder series and ancillary views including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2. Be able to identify the significant anatomy demonstrated on each view of the series.
Standard Shoulder Series -3 view series
Internal Rotation
PREPARE THE ROOM
Cassette: black, 8" x 10", LW (flash up)
Tube: 40" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: through coracoid process
Filter/shield: gonad (½ apron), stop primary beam leak beyond the shoulder.
PREPARE THE PATIENT
Position: R or L, patient is fully gowned with no jewelry, hairpins, glasses, etc. Rotate patient approximately 40º so that affected scapula is flat against bucky. Internally rotate the humerus and place the back of the hand against the thigh, or bend elbow 90° and place forearm on abdomen.
Central ray: Direct at coracoid process and center film to this.
Collimation: Open to cassette size (apex of lung should be visible).
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA; Internal Rotation
· Proximal 1/3 of humerus, upper scapula and lateral 2/3 of clavicle should be included with collimation visible on all four sides.
· Coracoid process should be the center of the collimated field.
· This is the lateral view of the proximal humerus as seen by the lesser tubercle in profile medially, and the greater tubercle superimposed over the humeral head.
· Optimum exposure should sharply demonstrate bone and trabeculae. Soft tissue should be seen well enough to visualize calcifications.
· Patient identification and R/L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 7 last updated: May, 99
Radiographic Positioning of the Shoulder
External Rotation
PREPARE THE ROOM
Cassette: black, 8" x
Tube: 40" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: through coracoid process
Filter/shield: gonad (½ apron), stop primary beam leak beyond the shoulder
PREPARE THE PATIENT
Position: R or L, patient is fully gowned with no jewelry, hairpins, glasses, etc. Rotate patient approximately 40º so that affected scapula is flat against bucky. Externally rotate the humerus and place the back of the hand against the thigh, or bend elbow to 90º and externally rotate.
Central ray: Direct at coracoid process and center film to this.
Collimation: Open to cassette size (apex of lung should be visible).
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: External Rotation
· Proximal 1/3 of humerus, upper scapula and lateral 2/3 of clavicle should be included with collimation visible on all four sides.
· Coracoid process should be the center of the collimated field.
· This is the frontal view of the proximal humerus with the greater tubercle seen in profile laterally, and the lesser tubercle superimposed over the humeral head.
· Optimum exposure should sharply demonstrate bone and trabeculae. Soft tissue should be seen well enough to visualize calcifications.
· Patient identification and R/L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 8 last updated: May, 99
Radiographic Positioning of the Shoulder
Baby Arm
PREPARE THE ROOM
Cassette: black, 10" x 12", CW (flash lateral)
Tube: 40" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: through coracoid process
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, patient is fully gowned with no jewelry, hairpins, glasses, etc.
Patient positioned with back flat against bucky. Patient flexes the elbow
to
Central ray: Direct at mid clavicle and center film to this.
Collimation: Open to cassette size (apex of lung should be visible).
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Baby Arm
· Proximal 1/3 of humerus, upper scapula and lateral 2/3 of clavicle should be included with collimation visible on all four sides.
· Coracoid process should be the center of the collimated field.
· This is the frontal view of the proximal humerus with the greater tubercle seen in profile laterally, and the lesser tubercle superimposed over the humeral head.
· Optimum exposure should sharply demonstrate bone and trabeculae. Soft tissue should be seen well enough to visualize calcifications.
· Collimation must include lung apex and C7 to rule out cervical rib.
· Patient identification and R/L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 9 last updated: May, 99
Radiographic Positioning of the Humerus
Section objectives: Humerus Series
At the conclusion of this course the student doctor should;
1. Be able to efficiently conduct all parts of a 2 view humerus series including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2. Be able to identify the significant anatomy demonstrated on each view of the series.
Standard Humerus Series -2 view series
· AP Humerus
· Lateral Humerus
A-P Humerus
PREPARE THE ROOM
Cassette: black/gray, 14" x 17", LW
Tube: 40" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, patient is fully gowned with no jewelry, hairpins, glasses, etc. Patient can be erect or supine. Adjust film so the shoulder and elbow joints are equidistant from the cassette edge. Rotate patient so that the shoulder and proximal humerus are as close to the cassette as possible. Abduct arm slightly and supinate hand until humeral epicondyles are parallel to the film. Arm is in anatomic position.
Central ray: Perpendicular to the film and midpoint of the humerus.
Collimation: Open to full cassette vertically, side-to-side to soft tissue.
Marker: R or L.
EXPOSURE
Patient directions; "Hold still, don't move" - expose.
EVALUATION CRITERIA: A-P Humerus
· The entire humerus including elbow and shoulder joints should be included with collimation margins on all four sides.
A true AP is evidenced by:
· The greater tubercle seen in profile laterally, the humeral head seen in profile medially with only minimal superimposition of the glenoid cavity.
· The outline of the lesser tubercle seen just medial to the greater tubercle, and the lateral and medial epicondyles are seen in profile.
· Optimum exposure should demonstrate bone and soft tissue density.
Radiographic Positioning #5822 10 last updated: May, 99
Radiographic Positioning of the Humerus
Lateral Humerus
PREPARE THE ROOM
Cassette: black/gray, 14" x 17", LW
Tube: 40" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, patient is fully gowned with no jewelry, hairpins, glasses, etc. Patient can be erect or supine (erect may be easier on the patient). If erect, patient should face film, which allows close contact between humerus and the film, flex elbow to
Central ray: Perpendicular to the film and midpoint of the humerus.
Collimation: Open to full cassette vertically, side-to-side to soft tissue.
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Lateral Humerus
· The entire humerus including elbow and shoulder joints should be included with collimation margins on all four sides.
A true lateral is evidenced by:
· The lesser tubercle seen in profile medially partially superimposed by the lower portion of the glenoid cavity.
· The lateral and medial epicondyles are directly superimposed.
· Optimum exposure should demonstrate both bone and soft tissue density.
· Patient identification and R/L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 11 last updated: May, 99
Radiographic Positioning of the Elbow
Section objectives: Elbow Series
At the conclusion of this course the student doctor should;
1. Be able to efficiently conduct all parts of a 4 view elbow series including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2. Be able to identify the significant anatomy demonstrated on each view of the series.
Standard Elbow Series -4 view series
·
AP Elbow Optional Elbow View·
Medial Oblique Elbow · Radial Head - capitellum·
Lateral Elbow·
Tangential ElbowA-P Elbow
PREPARE THE ROOM
Cassette: gray, ½ of 10" x 12" (crosswise)
Tube: 40" FFD, no tube tilt
Technique: 65 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ½ of film with Pb vinyl for use with medial oblique. Patient seated at end of table with arm hilly extended, hand supinated. The elbow joint should be centered in the middle of the uncovered side of the cassette. Proper position will have shoulder at table level, and both humeral epicondyles equidistant from cassette surface
Central ray: Perpendicular to film through cubital fossa Oust distal to elbow crease).
Collimation: Open to hill cassette vertically (1/2 being used), side-to-side to soft tissue.
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: A-P Elbow
Radiographic Positioning #5822 12 last updated: May, 99
Radiographic Positioning of the Elbow
Medial Oblique Elbow
PREPARE THE ROOM
Cassette: gray, ½ of 10" x 12" (crosswise)
Tube: 40" FFD, no tube tilt
Technique: 65 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (72 apron)
PREPARE THE PATIENT
Position: R or L, cover ½ of film with Pb vinyl used for AP elbow. Patient seated at end of table with elbow fully extended, hand pronated. The elbow joint should be centered in the middle of the uncovered side of the cassette. Proper position will have shoulder at table level humeral epicondyles
45º to the cassette surface, and hand pronated.Central ray: Perpendicular to film through the cubital fossa Oust distal to elbow crease).
Collimation: Open to full cassette vertically (1/2 being used), side-to-side to soft tissue.
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Medial Oblique Elbow
· Elbow joint space should be centered on exposed area of film with collimation margins on all four sides.
· The long axis of the arm should be aligned to the long axis of the half of exposed film.
· The medial epicondyle and the trochlea should appear elongated and m partial profile.
· Optimum exposure and penetration with no motion should visualize sharp bone margins.
· Trabecular marking should appear clear and sharp.
· Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.
Radiographic Positioning #5822 13 last updated: May, 99
Radiographic Positioning of the Elbow
Lateral Elbow
PREPARE THE ROOM
Cassette: gray, 34 of 10" x 12", (crosswise)
Tube: 40" FFD, no tube tilt
Technique: 65 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ¼ of film with Pb vinyl to use with tangential elbow. Patient seated at end of table with elbow flexed 90º, thumb pointing to ceiling. The elbow joint should be positioned in the comer of the uncovered cassette. Proper position will have shoulder at table level, both humerus and ulna flat on the cassette with thumb sticking into the air.
Collimation: Perpendicular to film about 1" distal to the lateral epicondyle of the humerus.
Central ray: Open to hill cassette to image as much of the radius and ulna as possible.
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Lateral Elbow
· Elbow joint space should be in the corner on the exposed area of film with collimation margins on all four sides.
· A true lateral is evidenced by three concentric arcs: the trochlear sulcus, the ridge of the capitellum and the trochlear notch of the ulna.
· The olecranon process should be visualized in profile, and part of the radial head will be superimposed by the coronoid process.
· Optimum exposure and penetration with no motion should visualize sharp bone margins.
· Trabecular marking should appear clear and sharp.
· Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.
Radiographic Positioning #5822 14 last updated: May, 99
Radiographic Positioning of the Elbow
Tangential Elbow (Jones)
PREPARE THE ROOM
Cassette: gray, ¼ of 10" x 12", (crosswise)
Tube: 40" FFD, no tube tilt
Technique: 65 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ¼ of film with Pb vinyl used for lateral elbow.
Patient seated at end of table with elbow fully flexed, fingers resting on shoulder. The elbow joint should be positioned in the comer of the
uncovered cassette. Proper position will have shoulder at table level, humerus parallel to film.
Central ray: Perpendicular to film directed to a point that is midway between the condyles.
Collimation: Open to soft tissue.
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Tangential Elbow (Jones)
Radiographic Positioning #5822 15 last updated: May, 99
Radiographic Positioning of the Elbow
Radial Head - Capitellum
PREPARE THE ROOM
Cassette: gray, 8" x 10", CW
Tube: 40" FFD, 45º medial tube tilt
Technique: 65 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover 34 of film with Pb vinyl used with lateral elbow. Patient seated at end of table with elbow flexed, thumb pointing to ceiling. The elbow joint should be positioned in the center of the cassette. Proper position will have shoulder at table level, both humerus and ulna flat on the cassette with thumb sticking into the air.
Central ray: Pointing at the radial head.
Collimation: Open to soft tissue vertically, side-to-side to area of interest.
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Radial Head - Capitellum
· Collimation margins on all four sides.
· The radial head should appear without superimposition by the ulna.
· Optimum exposure and penetration with no motion should visualize sharp bone margins.
· Trabecular marking should appear clear and sharp.
·
Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.
Radiographic Positioning #5822 16 last updated: May, 99
Radiographic Positioning of the Forearm
Section objectives: Forearm Series
At the conclusion of this course the student doctor should;
1. Be able to efficiently conduct all parts of a 2 view forearm series including
2. Be able to identify the significant anatomy demonstrated on each view of the
series.
Standard Forearm Series
-2 view series· A-P Forearm
·
Lateral ForearmA-P Forearm
PREPARE THE ROOM
Cassette: gray, ½ of 11" x 14", LW
Tube: 40" FFD, no tube tilt
Technique: 60 kVp, small focal spot
Measure: through central ray
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ½ of film with Pb vinyl.
Patient seated close to the table with forearm resting on cassette, hand
supinated, with humeral epicondyles equidistant from the film.
Entire arm parallel to film plane.
Central ray: Perpendicular to film directed to midpoint of the forearm.
Collimation: Include elbow joint and proximal carpals if possible, side-to-side to soft tissue.
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: A-P Forearm
· View should demonstrate the elbow joint, the radius and ulna, the proximal row of carpals slightly distorted, and the distal humerus.
· Slight superimposition of the radial head, neck, and tuberosity over the proximal ulna.
· No elongation or foreshortening of the humeral epicondyles.
· Soft tissue densities and bony trabeculation of the proximal and distal forearm.
· Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.
Radiographic Positioning #5822 17 last updated: May, 99
Radiographic Positioning of the Forearm
Lateral Forearm
PREPARE THE ROOM
Cassette: gray, ½ of 11 x 14", LW
Tube: 401t FFD, no tube tilt
Technique: 60 kVp, small focal spot
Measure: through central ray
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ½ of film with Pb vinyl.
Patient seated close to the table with forearm resting on cassette, with shoulder joint and elbow in the same plane. This permits the ulna to rotate to the lateral position.
Flex the elbow 90º , with the thumb directed toward the ceiling.
Central ray: Perpendicular to film directed to midpoint of the forearm.
Collimation: Include elbow joint and proximal carpals if possible, side-to-side to soft tissue.
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Lateral Forearm
· View should demonstrate the elbow joint, the radius and ulna, the proximal row of carpals slightly distorted, and the distal humerus.
· Superimposition by the radial head over the coronoid process.
· Superimposed humeral epicondyles.
· Radial tuberosity facing anteriorly.
· Elbow flexed to 90 degrees.
· Soft tissue densities and bony trabeculation of the proximal and distal forearm.
· Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.
Radiographic Positioning #5822 18 last updated: May, 99
Radiographic Positioning of the Wrist
Section objectives: Wrist Series
At the conclusion of this course the student doctor should;
3. Be able to efficiently conduct all parts of a 4 view wrist series including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
4. Be able to identify the significant anatomy demonstrated on each view of the series.
Standard Wrist Series -4 view series
· PA Wrist
· Medial Oblique Wrist
· Ulnar Deviation Wrist
P-A Wrist
PREPARE THE ROOM
Cassette: gray, ¼ of 10" x 12", CW
Tube: 40" FFD, no tube tilt
Technique: 60 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover 3/4 of film with Pb vinyl.
Patient seated at end of table with wrist resting on cassette, palm down.
Patient should make a loose fist to lower carpal arch to the cassette.
Forearm parallel to film plane.
Central ray: Perpendicular to film directed into the mid-carpal area.
Collimation: Open 2" proximal and distal of wrist, side-to-side to soft tissue.
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: P-A Wrist
·
The distal radius , ulna and all carpals at least to mid-metacarpal area should be visualized, centered to the mid-portion and to the long axis on unmasked area of film, with collimation margins on all four sides.· A true PA is evidenced by equal concavity shapes on each side of shafts of proximal
metacarpals.· The scaphoid fat stripe will be evidenced lateral to the scaphoid and trabecular detail will be evident.
· Patient identification should be clew and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.
Radiographic Positioning #5822 19 last updated: May, 99
Radiographic Positioning of the Wrist
Medial Oblique Wrist (Tea Cup View)
PREPARE THE ROOM
Cassette: gray, ¼ of 10" x 12", CW
Tube: 40" FED, no tube tilt
Technique: 60 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ¾ of film with Pb vinyl.
Patient seated at end of table with little finger resting on the cassette,
thumb side of hand raised to 45º
Central ray: Perpendicular to film directed into the mid-carpal area.
Collimation: Open 2" proximal and distal of wrist, side-to-side to soft tissue.
Marker: R or L
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Medial Oblique Wrist
· The distal radius , ulna and all carpals at least to mid-metacarpal area should be visualized, centered to the mid-portion and to the long axis on unmasked area of film, with collimation margins on all four sides.
· The soft tissue and trabecular detail will be evident.
· The trapezium in its entirety should be well visualized as well as the scaphoid which only has slight superimposition of the other carpals.
·
Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.
Radiographic Positioning #5822 20 last updated: May, 99
Radiographic Positioning of the Wrist
Ulnar Deviation Wrist
PREPARE THE ROOM
Cassette: gray, ¼ of 10" x 12", CW
Tube: 40" FFD, no tube tilt
Technique: 60 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ¼ of film with Pb vinyl.
Patient seated at end of table with wrist resting on the cassette, palm
down. Patient should point fingers toward ulnar side as far as possible,
and make a loose fist to lower the carpal arch to the cassette.
Central ray: Perpendicular to film directed into the mid-carpal area.
Collimation: Open 2" proximal and distal of wrist, side-to-side to soft tissue.
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" expose.
EVALUATION CRITERIA: Ulnar Deviation Wrist
Radiographic Positioning #5822 22 last updated: May, 99
Radiographic Positioning of the Hand
Section objectives: Hand Series
At the conclusion of this course the student doctor should;
1. Be able to efficiently conduct all parts of a 3 view hand series including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2. Be able to identify the significant anatomy demonstrated on each view of the series.
Standard Hand Series -3 view series
· PA Hand
· Medial Oblique Hand
· Lateral Hand
P-A Hand
PREPARE THE ROOM
Cassette: gray, ½ of 10" x 12", CW
Tube: 40" FFD, no tube tilt
Technique: 60 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ½ of film with Pb vinyl for use with the medial oblique.
Patient seated with the hand pronated, wrist in a neutral position.
Patient should have fingers slightly spread.
Central ray: Perpendicular to film directed to the third metacarpophalangeal joint.
Collimation: Open to soft tissues.
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: P-A Hand
Radiographic Positioning #5822 23 last updated: May, 99
Radiographic Positioning of the Hand
Medial Oblique Hand
PREPARE THE ROOM
Cassette: gray, ½ of 10" x 12", CW
Tube: 40" FFD, no tube tilt
Technique: 60 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, cover ½ of film with Pb vinyl for used with the PA.
Patient seated with the ulnar side of the hand in contact with the
cassette and rotated to 45º.
The fingers can support the rotation if a positioning block is not used.
Central ray: Perpendicular to film directed to the third metacarpophalangeal joint.
Collimation: Open to soft tissues.
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Medial Oblique Hand
Radiographic Positioning #5822 24 last updated: May, 99
Radiographic Positioning of the Hand
Lateral Hand
PREPARE THE ROOM
Cassette: gray, 8" x 10", LW
Tube: 40" FFD, no tube tilt
Technique: 60 kVp, small focal spot
Measure: through central ray at appropriate angle
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: R or L, patient seated on the anode end of tube with the ulnar side of the
hand in contact with the cassette. The hand should be in a true lateral so
that metacarpals 2-5 will stack one upon the other.
The fingers should be spread as in the "OK" sign, or placed on the appropriate steps of a positioning wedge.
Central ray: Perpendicular to film directed to the second metacarpophalangeal joint.
Collimation: Open to soft tissues.
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" expose.
EVALUATION CRITERIA: Lateral Hand
Note: A radiographic technique suitable for the fingers will underexpose the metacarpals..
A technique that exposes the metacarpals properly will overexpose the fingers.
Radiographic Positioning #5822 25 last updated: May, 99