Radiographic anatomy of the wrist.

Wrist
• The following projections may be taken to demonstrate all the carpal bones.

• PA wrist
• Lateral
• Ulnar deviation (for scaphoid)
• Radial deviation
• Carpal canal

• Wrist (Routine)
• PA
• P A oblique
• Lateral

• Alternate Projection
• AP wrist

• 18 × 24 cm cassette or alternatively within the field of view of a DDR detector

 PA wrist
Clinical Indications
• Fractures of distal radius or ulna
• Isolated fractures of radial or ulnar styloid processes.
• Fractures of individual carpal bones
• Pathologic processes, such as osteomyelitis and arthritis

Part Position
• Align and center long axis of hand and wrist to IR, with carpal area centered to CR.
• With hand pronated, hand is slightly moved to place wrist and carpal area in close contact with IR.

Centering Point
• CR perpendicular to the IR, directed to the mid carpal area

Essential image characteristics

• The image should demonstrate the proximal 2/3 of the metacarpals, the carpal bones, and the distal 1/3 of the
radius and ulna.
• There should be no rotation of the wrist joint.
PA wrist (Cont…)
PA wrist (Cont…)
 Wrist- Lateral
Clinical Indications
• Fractures or dislocations of the distal radius or ulna, specifically AP dislocations of
Barton’s, Colles’, or Smith’s fractures
• Osteoarthritis of the trapezium and first CMC joint.

Position of patient and image receptor

• 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.
• The hand is adjusted to ensure that the radial and ulnar styloid processes are
superimposed.
• The hand and wrist may be immobilized using non-opaque pads and sandbags.

Direction and location of the X-ray beam

• The collimated vertical beam is centred over the radial styloid process.
Wrist- Lateral (Cont…)
 Wrist- Lateral (Cont…)
Essential image characteristics
• The image should include the distal end of the radius and ulna and the
proximal end of the metacarpals.
• The image should demonstrate clearly any subluxation or dislocation of
the carpal bones.
Wrist- Lateral (Cont…)
AP Wrist- Alternate
 Oblique (anterior oblique)- Wrist
Indications
• Pathologic processes, such as osteomyelitis and arthritis.
• To confirm the presence of a suspected fracture not demonstrated in the AP and
lateral projections.

• Direction and location of X-ray beam

• The collimated vertical beam is centred midway between the radial and ulnar
styloid processes.

• Essential image characteristics

• exposure should provide adequate penetration to visualize the carpal bones.
• The image should demonstrate the proximal 2/3 of the metacarpals, the carpal
bones and the distal 1/3 of the radius and ulna.
Oblique (anterior oblique)- Wrist
 PA-ulnar deviation.

WARNING: If patient has possible wrist trauma, do not attempt this position
until a routine wrist series has been completed and evaluated to rule out possible
fracture of distal forearm or wrist or both.

• Position of patient and image receptor

• Position wrist as for a PA projection; palm down and hand and wrist aligned
with center of long axis of IR with scaphoid centered to CR.

• Without moving forearm, gently evert hand as far as patient can tolerate
without lifting or rotating distal forearm.

Centering Point
• CR perpendicular to IR, directed to midcarpal area
 PA-ulnar deviation (Cont…)
• Essential image characteristics
• The image should include the distal end of the radius
and ulna and the proximal end of the metacarpals.

• The joint space around the scaphoid should be

demonstrated clearly.
PA-ulnar deviation (Cont…)
PA-ulnar deviation (Cont…)
 Anterior oblique – ulnar deviation
WARNING: If patient has possible wrist trauma, do not attempt this position until a routine wrist
series has been completed and evaluated to rule out possible fracture of distal forearm or wrist or
both.

Clinical Indications
• Fractures of distal radius or ulna
• Isolated fractures of radial or ulnar styloid processes.
• Fractures of individual carpal bones
• Pathologic processes, such as osteomyelitis and arthritis

Patient and IR Position

• Align and center hand and wrist to IR.
• From pronated position, rotate wrist and hand laterally 45°.
• For stability, place a 45° support under thumb side of hand to support hand and wrist in a 45°
oblique position or partially flex fingers to arch hand so that fingertips rest lightly on IR
 Anterior oblique – ulnar deviation (Cont…)
Direction and location of X-ray beam
• The collimated vertical beam is centred midway between the radial and
ulnar styloid processes.

Essential image characteristics

• The image should include the distal end of the radius and ulna and the
proximal end of the metacarpals.
• The scaphoid should be seen clearly, with its long axis parallel to the
detector.
Anterior oblique- ulnar deviation
 CARPAL BRIDGE—TANGENTIAL PROJECTION:
WRIST
WARNING: If patient has possible wrist trauma, do not attempt this position until a
routine wrist series has been completed and evaluated to rule out possible fracture of
distal forearm or wrist or both.

Clinical Indications
• Calcification or other pathology of the dorsal aspect of the carpal bones

Position of patient and image receptor

• The patient is standing facing away from the table.
• The detector is placed level with the edge of the tabletop.
• The palm of the hand is pressed onto the detector, with the wrist joint dorsiflexed to
approximately 135°.
• The fingers are curled around under the table to assist in immobilisation.
 CARPAL BRIDGE—TANGENTIAL PROJECTION: WRIST
CR
• Angle CR 45° to the long axis of the forearm.
• Direct CR to a midpoint of the distal forearm about 4 cm proximal to wrist
joint..

Essential image characteristics

• The image should include the distal end of the radius and ulna and the
proximal end of the metacarpals.
• The joint space around the scaphoid should be demonstrated clearly.
CARPAL BRIDGE—TANGENTIAL PROJECTION: WRIST
CARPAL BRIDGE—TANGENTIAL PROJECTION: WRIST
 CARPAL CANAL (TUNNEL)— TANGENTIAL, INFEROSUPERIOR
PROJECTION: WRIST
WARNING: If patient has possible wrist trauma, do not attempt this position until a routine
wrist series has been completed and evaluated to rule out possible fracture of distal forearm or
wrist or both.

• Clinical Indications
• Rule out abnormal calcification and bony changes in the carpal sulcus that may impinge on
the median nerve, as with carpal tunnel syndrome
• Possible fractures of the hamulus process of the hamate, pisiform, and trapezium

Position of patient and image receptor

• The patient is seated alongside the table.
• The detector is placed on top of a plastic block approximately 8 cm high.
• The lower end of the forearm rests against the edge of the block, with the wrist adducted and
dorsiflexed to 135°.
• This position is assisted using a traction bandage held by the patient’s other hand.
 CARPAL CANAL (TUNNEL)— TANGENTIAL,
INFEROSUPERIOR PROJECTION: WRIST
Direction and location of X-ray beam
• Direct CR to the center of the palm.

Essential image characteristics

• The image should demonstrate clearly;
• Pisiform
• Hook of the hamate medially
• Tubercle of the scaphoid
• Tubercle of the trapezium laterally.
CARPAL CANAL (TUNNEL)— TANGENTIAL, INFEROSUPERIOR
PROJECTION: WRIST
CARPAL CANAL (TUNNEL)— TANGENTIAL,
INFEROSUPERIOR PROJECTION: WRIST
 Forearm- AP
Clinical Indications
• Fractures and dislocations of the radius or ulna
• Pathologic processes such as osteomyelitis or arthritis

• 24 × 30 cm CR cassette.

Position of patient and image receptor

• The patient is seated alongside the table, with the affected side nearest to the table.
• The arm is abducted and the elbow joint is fully extended, with the supinated forearm resting on
the table.
• The shoulder is lowered to the same level as the elbow joint.
• The image receptor is placed under the forearm to include the wrist joint and the elbow joint.
• The arm is adjusted such that the radial and ulnar styloid processes and the medial and lateral
epicondyles are equidistant from the image receptor.
• The lower end of the humerus and the hand may be immobilized using sandbags.
 Forearm- AP (Cont…)
Direction and location of X-ray beam
• The collimated vertical beam is centred in the midline of the forearm to a
point midway between the wrist and elbow joints.

Essential image characteristics

• Both the elbow and the wrist joint must be demonstrated on the radiograph.
• Both joints should be seen in the true AP position, with the radial and ulnar
styloid processes and the epicondyles of the humerus equidistant from the
image receptor.
Forearm- AP (Cont…)
Forearm- AP (Cont…)
 Forearm- Lateral
Position of patient and image receptor
• From the AP position, the elbow is flexed to 90°.
• The humerus is internally rotated to 90° to bring the medial aspect of
the upper arm, elbow, forearm, wrist and hand into contact with the
table.
• The image receptor is placed under the forearm to include the wrist
joint and the elbow joint.
• The arm is adjusted such that the radial and ulnar styloid processes
and the medial and lateral epicondyles are superimposed.
• The lower end of the humerus and the hand may be immobilized using
sandbags.
 Forearm- Lateral (Cont…)
Direction and location of X-ray beam
• The collimated vertical beam is centred in the midline of the forearm
to a point midway between the wrist and elbow joints.

Essential image characteristics

• Both the elbow and the wrist joint must be demonstrated on the image.
• Both joints should be seen in the true lateral position, with the radial
and ulnar styloid processes and the epicondyles of the humerus
superimposed.
Forearm- Lateral (Cont…)
Galeazzi #: # of distal radius + Disloc of distal Ulnar
 Forearm- Lateral (Cont…)
• Notes
• In trauma cases, it may be impossible to move the arm into
the positions described, and a modified technique may need
to be employed to ensure that diagnostic images are
obtained.

• If the limb cannot be moved through 90°, then a horizontal

beam should be used.
• Both joints should be included on each image.
• No attempt should be made to rotate the patient’s hand.
 Elbow-Lateral
• Position of patient and image receptor
• The patient is seated alongside the table, with the affected side nearest to the table.

• The elbow is flexed to 90° and the palm of the hand is rotated so that it is at 90° to
the tabletop.

• The shoulder is lowered or the height of the table increased so that it is on the same
plane as the elbow and wrist, such that the medial aspect of the entire arm is in
contact with the tabletop.

• The image receptor is placed under the patient’s elbow, with its center to the elbow
joint and its short axis parallel to the forearm.

• The limb may be immobilized using sandbags.

 Elbow-Lateral (Cont…)
Direction and location of X-ray beam
• The collimated vertical beam is centred over the lateral epicondyle of the
humerus.

Essential image characteristics

• The epicondyles should be superimposed.

• The image should demonstrate the distal 1/3 of humerus and the proximal
1/3 of the radius and ulna.
Elbow-Lateral (Cont…)
Dislocation of the elbow
# Olecranon Process
 Elbow-AP
Position of patient and image receptor
• From the lateral position, the patient’s arm is externally rotated.

• The arm is then extended fully, such that the posterior aspect of the entire limb is in
contact with the tabletop and the palm of the hand is facing upwards.

• The image receptor is positioned under the elbow joint, with its short axis parallel
to the forearm.

• The arm is adjusted such that the medial and lateral epicondyles are equidistant
from the image receptor.

• The limb is may be immobilized using sandbags.

 Elbow-AP
Centering Point
• Direct the CR to the mid-elbow joint

Essential image characteristics

• The central ray must be perpendicular to the humerus to provide a
satisfactory view of the joint space.

• The image should demonstrate the distal 1/3 of humerus and the proximal
1/3 of the radius and ulna.
Elbow-AP (Cont…)
Elbow-AP (Cont…)