Radiography of the Hand

Fracture terminology
o Longitudinal
o Spiral
o Simple
o Compound
Very serious
Parts of fracture have gone through the skin
o Oblique
o Comminuted
Multiple fragments
o Impacted
Common in elderly
Pushing the bone back against itself
A lot in humerus and femur
o Compression
In thoracic or lumbar spine
Kyphosis- hunch back
Fracture frequency
o Distal phalanx most commonly fractured site in hand of
adults and children
of all hand related FX
tuft- bony part at the very end of the finger
o Metacarpals are 2nd-1st digit (thumb) 3rd
Parts of the hand
o 14 phalanges
o 9 interphalangeal joints (IP joints)
o 5 metacarpals
o 5 metacarphalangeal (MCP) joints
Thumb is always lateral side

Anatomy of the hand

o Phalanges labeled medial to
lateral
o Proximal then lateral to
medial then go to distal row
by lateral to medial
o S.C.T.P.T.C.H
o Know joint names
Diarthrodial joint
because they are
freely moveable
Metacarpalmetapheal
joint

PA Hand
o Affected side closet to table with arm flexed 90 degrees
with elbow bent
Helps minimize angulation and rotation at the hand
and wrist
o 100 ss (extremity) receptor or CR plate
o Usually 60-65 kVp
o Shield shield appropriate for adults
Full apron for children
o Hand fully pronanted with digits extended
o CR perpendicular to 3rd MCP joint
o Collimation from tufts to proximal carpal row
Include part of radius and ulna (1 inch)
o Anatomy demonstrated
Interphalangeal and MCP joints
Base of 3-5 metacarpals best seen free of
superimposition
All soft tissue
Include carpals and 1 of distal radius/ulna
1st digit seen in PA oblique position
PA Oblique
o Hand rotated 45 degree laterally
o Fingers in extension or slightly flexed per protocols
o CR perpendicular at 3rd MCP joint

 Near knuckle
o +3 kVp because you need to penetrate because you start
to superimpose
o You want to see carpal and metacarpal of thumb and 1st
phalange

o Assessment:
Base of 1st and 2nd metacarpals seen free of
superimposition, as well as 1st carpometacarpal joint
Base of 3-5 metacarpals seen with slight
superimposition
Sesamoid frequently seen medial to 1st metacarpal
head
Fan lateral hand
o Most commonly performed lateral
o Medial aspect closest to receptor
o Digits separated as much as possible
o CR is perpendicular to 2nd MCP joint
o Get individual laterals of 4 digits
o Increase kVp by 10
o Provides whether the fraction is in the anterior or posterior
part of the anatomy
Lateral with flexion relaxed lateral
o Evaluate anterior vs posterior metacarpals FXs
o Truest lateral of metacarpals
o Less painful for painful
o Always perform for post reduction radiographs
o CR is perpendicular to 2nd MCP joint
o Fan and relaxed lateral= +6 kVp
Full extension lateral
o Used to demonstrate suspected soft tissue foreign bodies
o Provides optimal superimposition of phalanges
o CR is perpendicular to MCP joint
o Usually recommend with soft tissue exposure (1/2 mAs)
for analog imaging only
AP oblique ball-catchers/norgaard
o Performed bilaterally so you can compare right and left
o Use 100 ss analong receptor
o R/O early arthritic changes and base of proximal phalanges
o Rheumatoid arthritic- joints are deteriorated and very
painful
Decrease kVp 6-10 depending on severity
o CR is right between two hands

Traumatic hand protocol

o 2 AP approach
o Do AP of phalanges parallel
o Do AP of metacarpals parallel
AP thumb
o Affected hand is hyper pronanted
to place the dorsal aspect of
thumb in contact with receptor
o CR is parallel to MCP joint
Make sure you get to
bottom on hand to make
sure you include scaphoid
o 60 kVp
o Attempt to free the base of the
carpometacarpal region of soft
tissue superimposition
o Must include carpometacarpal
articulation
o Hyperpronante until thumb is in
superimposition
o Have them take their other hand
and pull the hand being x-rayed
back
o Make sure they dont over rotate
the thumb
PA Oblique thumb
o Place hand in true PA position with 1st digit separated from
other digits
o Thumb is naturally obliqued 45 degree when hand is
pronanted
o CR is perpendicular to MCP Joint
Lateral thumb
o Rotate digit into lateral position by arching fingers
o CR is perpendicular to MCP Joint
Bennetts FX
o Primary intrarticular type associated with the 1st digit
o A fracture dislocation- base of 1st MC- 1st CM joint
o Make sure it is healed so they dont get severe arthritis
o Fracture of the proximal end of the 1st metacarpal with
dorsal and lateral dislocation of the distal segment
Avulsion fracture is a bone fracture, which occurs when a fragment of bone tears
away from the main mass of bone as a result of physical trauma. This can occur at
the ligament due to the application forces external to the body (such as a fall or

pull) or at the tendon due to a muscular contraction that is stronger than the forces
holding the bone together
Rolando FX
o A comminuted (has multiple fragments) Bennetts
o Intra-articular type with many fragments
o Much more difficult to treat then regular Bennetts because of multiple
fragments
Roberts projection
o Useful in assessment of Bennetts vs Rolando FX
o 1st digit is positioned same as routine AP thumb
o Incorporates a 15 degree angle proximally/to the elbow
o Uses distortion to help differentiate possible fragments
Digits 2-5
o PA- PA oblique and lateral positions are performed
o Positioning criteria is same as PA, PA oblique hand and lateral thumb
o For all digits (2-5) CR is perpendicular proximal interphalangeal joint
(PIP)
Has to be here so there is no beam divergence/ no distortion
As beam emerges from tube and spreads out laterally it starts to
come out an angle so when you center at a certain joint then there
is less distortion
Boxers FX
o Metacarpals are 2nd most frequently fractured area of the hand
o Boxers is the most common FX of the 5th metacarpal
o It is a transverse FX through the neck of the metacarpal, with volar
(anterior) displacement
Exposure consideration with fracture appliances
o Most common appliance for hand injury is an immobilization cast
o Can be plaster or Waterproof
o Plaster= 2x > mAs
If it still has moisture in it then you must 2x the mass plus 10%
more kVp
o Waterproof= +3 kVp
Closed reduction vs open reduction/internal fixation (ORIF)
o Post reduction protocols
o Closed reduction-simple realignment w/o SX, apply pressure
o Internal fixation- put screws, etc or need SX