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Basics of Hand and Finger Radiography

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Title: Fingers, Hand & Wrist, Intro to QA Author: Russ Wilson Last modified by: madar Created Date: 9/6/2002 10:49:27 PM Document presentation format – PowerPoint PPT presentation

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Title: Basics of Hand and Finger Radiography


1
Basics of Hand and Finger Radiography
  • Routine views for fingers include
  • an A-P (thumb) or P-A ( fingers) view
  • an oblique view
  • a lateral view
  • The digit must be parallel to the film for all
    projections.

2
12.2 Thumb A-P
  • Measure A-P at Metacarpal-Phalangeal Joint
  • Protection Coat Lead Apron
  • SID 40 Table Top
  • Film 1/3 of 10 x 8 Extremity or Detail Cassette

3
Thumb A-P
  • Using Lead Blockers, cover 2/3 of the 10 x 8
    Fine or Extremity Cassette
  • Center Beam to the uncovered portion of cassette.
  • Ask patient to internally rotate arm and place
    thumb on uncovered portion of cassette.

4
Thumb A-P
  • The palm is rolled back to clear the thumb.The
    palm should not cover the metacarpal or
    trapezium.
  • If overlap is unavoidable, angle tube 10 to 15
    degrees cephalad.
  • Horizontal CR metacarpal-phalangeal joint.

5
Thumb A-P
  • Vertical CR long axis of thumb.
  • Collimation top to bottom Tuff of thumb to
    trapezium.
  • Collimation side to side skin of thumb
  • Breathing Instruction Hold still
  • Make exposure and let patient relax

6
Thumb A-P Film
  • Thumb should be in a true A-P position. When
    positioning view look at the thumb nail as a
    reference.
  • Should see from tip of thumb to trapezium. Note
    the soft tissue overlapping the proximal
    metacarpal. A tube angle would have improved
    image.

7
12.2 Thumb P-A Oblique
  • Measure A-P at M-P joint
  • Protection Coat apron
  • SID 40 table top
  • No tube angle
  • Film middle 1/3 of 10 x 8 Extremity Cassette
  • Special equipment two lead blockers

8
Thumb P-A Oblique
  • Center beam to uncovered portion of the cassette
  • Ask patient to place hand on cassette with palm
    flat on film. The thumb is abducted away from
    other fingers.
  • Horizontal CR M-P joint
  • Vertical CR long axis of the thumb.

9
Thumb P-A Oblique
  • Collimation top to bottom Tuff of thumb to
    trapezium
  • Collimation side to side skin of thumb
  • Patient Instructions Remain still
  • Make exposure and let patient relax.

10
Thumb P-A Oblique Film
  • Joint spaces should be open.
  • Entire thumb on film
  • Ideally should see from tip of thumb to trapezium

11
12.2Thumb Lateral
  • Measure lateral at M-P Joint
  • Protection Coat Apron
  • SID 40 Table Top
  • No tube angle
  • Film remaining 1/3 of the 10 x 8 Extremity or
    Fine Cassette
  • Special equipment angle sponge

12
Thumb Lateral
  • Measure lateral at M-P Joint
  • Protection Coat Apron
  • SID 40 Table Top
  • No tube angle
  • Film remaining 1/3 of the 10 x 8 Extremity or
    Fine Cassette
  • Special equipment angle sponge

13
Thumb Lateral
  • Cover 2/3 of cassette with lead blockers. Center
    beam to remaining 1/3 of cassette.
  • Sponge is placed on covered portion of the
    cassette.
  • Patient is asked to place palm on sponge with
    thumb on unexposed portion of film.

14
Thumb Lateral Film
  • The thumb should be in true lateral position.
  • Joint spaces open
  • Must see from tip of thumb to trapezium.
  • Lateral view is best view for marker.

15
Thumb Series Film
  • Joint spaces open
  • Must see from tip of thumb to trapezium.
  • Lateral view is best view for marker.

16
Better Thumb Series
  • Fracture at base of 1st metacarpal seen with tube
    angle is to move soft tissue of palm on A-P view.
  • The trapezium is seen on all three views.

17
12.3 Finger P-A
  • Measure P-A at PIP joint
  • Protection Coat apron
  • SID 40 Table Top
  • Film 1/3 of 10 x 8 detail, fine or extremity
    cassette
  • Special equipment Lead Blockers

18
Finger P-A
  • Cover 2/3 of cassette with lead blockers
  • Center beam to uncovered portion of cassette.
  • Patient asked to place affected finger on
    uncovered portion of cassette. The palm and
    finger flat on film.

19
Finger P-A
  • Horizontal CR PIP joint
  • Vertical CR long axis of finger
  • Collimation top to bottom Tip of affected finger
    to M-P joint.
  • Collimation side to side slightly larger than
    skin of finger
  • Patient instructions remain still
  • Make exposure and let patient relax

20
Finger P-A
  • Include entire finger from tip to M-P Joint
  • Joint spaces must be open.
  • With crooked or bent finger, A-P may be helpful,

21
12.3Finger Oblique View
  • Measure A-P at PIP joint
  • Protection Coat apron
  • SID 40 table top
  • No tube angle
  • Film middle 1/3 of 10 x 8 cassette. Cover
    remainder of cassette with lead blockers.
  • Special Equipment 45 degree sponge or step sponge

22
Finger Oblique View
  • Place sponge on cassette.
  • Ask patient to place hand on sponge with ulnar
    side to film. Hand will be at a 45 degree angle
    to film.
  • Make sure that the affected finger is parallel to
    film. The step sponge is designed to keep finger
    parallel to film.

23
Finger Oblique View
  • Center the affected finger to unexposed portion
    of film.
  • Horizontal CR PIP of the affected finger
  • Vertical CR long axis of affected finger
  • Ask patient to remain still while making
    exposure.

24
Finger Oblique View
  • Must see from tip of finger to M-P Joint.
  • All joint spaces must be open.
  • Affected finger will be in oblique position,

25
12.3 Finger Lateral View
  • Measure Lateral at PIP of affected finger
  • Protection Coat Apron
  • SID 40 table top
  • No tube angle
  • Film remaining 1/3 of 10 x 8 Extremity Cassette

26
Index Finger Lateral
  • Index finger Radial side of hand next to film
    with index finger extended. Other fingers bent
    out of the view.
  • Horizontal CR PIP of index finger
  • Vertical CR long axis of finger

27
Finger Lateral
  • Collimation top to bottom tip of affected finger
    to M-P joint
  • Collimation side to side slightly larger than
    skin of finger
  • Patient Instruction Remain still
  • Make exposure and let patient relax

28
Third Finger Lateral
  • Third finger Radial side of hand next to film
    with third finger extended and resting on sponge.
    Other fingers bent out of the view.
  • Horizontal CR PIP of third finger
  • Vertical CR long axis of finger

29
Fourth Finger Lateral
  • Fourth finger Ulnar side of hand next to film
    with fourth finger extended and resting on
    sponge. Other fingers bent out of the view.
  • Horizontal CR PIP of fourth finger
  • Vertical CR long axis of finger

30
Fifth Finger Lateral
  • Fifth finger Ulnar side of hand next to film
    with fifth finger extended and resting on sponge.
    Other fingers bent out of the view.
  • Horizontal CR PIP of fifth finger
  • Vertical CR long axis of finger

31
Finger Lateral
  • Joint spaces must be open. They will not be open
    if finger is not parallel to film.
  • Must see from tip of the affected finger to the
    Metacarpal-Phalangeal Joint.

32
Finger Series
  • Joint spaces must be open. They will not be open
    if finger is not parallel to film.
  • Must see from tip of the affected finger to the
    Metacarpal-Phalangeal Joint.

33
12.4 Hand P-A
  • Measure A-P at 3rd M-P joint
  • Protection Coat Apron
  • SID 40 table top
  • No tube angle
  • Film 1/2 of 12 x 10 or 30 cm x 24 cm Extremity
    Cassette

34
Hand P-A
  • Cover 1/2 of cassette with Lead Blocker
  • Center beam to uncovered half of cassette.
  • Ask patient to place hand flat on cassette.
    Fingers are spread slightly.
  • Horizontal CR third M-P joint

35
Hand P-A
  • Vertical CR long axis of hand
  • Collimation top to bottom tips of fingers to 1
    of distal ulna and radius
  • Collimation side to side skin of hand and
    fingers
  • Instruction patient to remain still.
  • Make exposure and let patient relax

36
Hand P-A
  • View should include all fingers, metacarpals,
    carpal bone and one inch of the distal ulna and
    radius.
  • Fingers are spread slightly to avoid superimposed
    soft tissues.

37
12.5 Hand P-A Oblique
  • Measure A-P at metacarpal-phalangeal joints
  • Protection Lead Apron
  • SID 40 Table Top
  • No Tube Angle
  • Film 1/2 of 12 x 10 or 30 cm x 24 cm detail or
    extremity cassette

38
Hand P-A Oblique
  • The unexposed portion of the film used for the
    P-A hand will be used.
  • Using a special stepped sponge or other suitable
    sponge, place hand with ulna side to the film.
  • Hand should form a 30 to 45 degree angle with
    fingers parallel to film.

39
Hand P-A Oblique
  • Horizontal CR through the metacarpal - phalangeal
    joints.
  • Vertical CR between the second and third MP
    Joints
  • Collimation top to bottom Tips of fingers to 1
    of distal radius
  • Collimation side to side skin of hand and fingers

40
Hand P-A Oblique
  • Make sure that all fingers are within the
    collimated field. Need to also include the distal
    ulna and radius.
  • Ask patient to remain still and make the
    exposure.
  • Let patient relax

41
Hand P-A Oblique
  • The P-A and Oblique hand views are taken on the
    same film.
  • Make sure that all joints in the phalanges are
    open.
  • Distal ulna and radius should be seen
  • All soft tissue of the hand should be imaged.

42
12.6 Hand Lateral
  • Measure Lateral at Metacarpal Phalanges Joints
  • Protection Coat Apron
  • SID 40 Table Top
  • Film 8 x 10 Extremity or detail Cassette
  • Special Equipment Lateral Hand Sponge

43
Hand Lateral
  • Hand placed in a lateral position with ulna to
    film.
  • Lateral hand sponge placed next to hand. Patient
    will spread fingers so each finger will rest on
    the appropriate step of sponge.
  • Or

44
Hand Lateral
  • Hand placed on film in lateral position with ulna
    to film.
  • Patient makes the OK sign with fingers. Keep
    each finger parallel to film.
  • Horizontal CR 2nd MP joint.

45
Hand Lateral
  • Vertical CR long axis of hand.
  • Collimation to include all fingers and distal
    one inch of forearm.
  • Instructions Hold still
  • Make exposure and let patient relax.

46
Hand Lateral Film
  • Hand and wrist should be in lateral position.
  • Distal forearm and metacarpal will be
    superimposed
  • Fingers spread with joint spaces open.
  • To avoid over exposing the fingers, a 3 point
    filter was used.

47
Wrist Radiography
  • Examinations tailored to the history and mode of
    injury.
  • Routine views are P-A, Oblique Lateral
  • If scaphoid injury is suspected add the Ulna
    deviation and/or P-A scaphoid.
  • If ligament problem is suspected, the A-P
    clinched fist view is taken.

48
Wrist Radiography
  • When there is a possibility of a fracture of the
    distal radius, an A-P and A-P oblique view may be
    very helpful.

49
Distal Radius Fracture
  • P-A A-P
  • The A-P provides a better view of the distal
    radius

50
Surgical repair of fractured scaphoid
51
12.7 Wrist P-A
  • Measure A-P through carpal bones
  • Protection Coat Apron
  • SID 40 Non-Bucky
  • Film 1/4 or 1/3 of a 10x12 Extremity or Detail
    Cassette. Dividing cassette into quarters is
    recommended.

52
Wrist P-A
  • Cover unused portions of cassette with lead
    shields. Center beam to 1/4 of cassettes
    uncovered.
  • Ask patient to rest wrist in P-A position on
    cassette.
  • Ask patient to cup fingers to move carpal bones
    closer to the film.

53
Wrist P-A
  • Horizontal CR Just distal to radius or through
    the first row of carpal bones.
  • Vertical CR long axis of wrist ( mid way between
    ulna and radius and third metacarpal).

54
Wrist P-A
  • Collimation top to bottom less than 1/4 of the
    10 x 12 or from carpal to metacarpal
    articulations to include distal ulna and radius.
  • Collimation side to side soft tissue of wrist
  • Ask patient to hold still and make exposure.

55
Wrist P-A Film
  • Must include all carpal bones and wrist soft
    tissue.
  • Articulations with metacarpals and distal ulna
    and radius must be seen.
  • Dont cut off too much of the distal ulna and
    radius.

56
12.8 Wrist P-A Oblique
  • Measure A-P at carpal bones
  • Protection Lead Apron
  • SID 40 table top
  • No Tube Angle
  • Film 1/4 of the 24cm x 30cm detail or fine
    cassette
  • Accessories Sponge and Lead Blockers

57
Wrist P-A Oblique
  • Cover the exposed quarter of cassette. Uncover
    the next quadrant of the cassette.
  • Center beam to this section of the cassette.
  • Ask patient to place wrist in this section.The
    wrist is rotated to a 35 - 45 degree oblique with
    ulna resting on film.

58
Wrist P-A Oblique
  • The thumb may be extended to rest on the film for
    support.
  • The wrist can be placed on a sponge with the
    fingers wrapped over the end of the sponge.
  • Horizontal CR first row of carpal bones or
    slightly distal to the radius.

59
Wrist P-A Oblique
  • Vertical CR middle or the wrist or aligned
    between the second and third metacarpals and long
    axis of ulna and radius.
  • Collimation side to side soft tissue of wrist
  • Collimation top to bottom must include the
    articulations with metacarpals and distal radius.

60
Wrist P-A Oblique
  • Ask patient to hold perfectly still and make the
    exposure.
  • Note the use of the sponge for positioning. Often
    sponges will make the study less painful.

61
Wrist P-A Oblique Film
  • The trapezium and trapezoid carpal bones should
    be seen clear of superimposition.
  • The scaphoid tuberosity will be seen.
  • This view demonstrates the correct placement of
    the central ray.
  • Adequate visualization of the distal radius is
    achieved.

62
12.9 Wrist Lateral View
  • Measure Lateral through carpal bones
  • Protection Lead apron
  • SID 40 table top
  • No tube angle
  • Film 1/3 or 1/4 of 24 cm x 30 cm or 10 x 12
    detail or extremity cassette

63
Wrist Lateral View
  • The patient is seated or kneeling next to the
    table.
  • The next section of the unexposed portion of the
    cassette is uncovered and the exposed film
    covered by blockers.
  • The beam is centered to the uncovered portion of
    the film.

64
Wrist Lateral View
  • The patient is asked to place their wrist on the
    film.
  • The entire forearm should be in a lateral
    position with the elbow bent 90 degrees.
  • The fingers are cupped or may remain straight
    with the thumb to the side.

65
Wrist Lateral View
  • Horizontal CR the first row of carpal bones or
    about 1 cm distal to the radius.
  • Vertical CR long axis of wrist and forearm/
  • Collimation skin of wrist and to include distal
    radius to metacarpal- carpal joints.

66
Wrist Lateral View
  • The lateral view is the best view to place the
    anatomical marker.
  • Make sure it is within the primary beam.
  • Ask patient to remain still and make exposure.
  • Let patient relax. If no scaphoid film is needed,
    process the film.

67
Wrist Lateral Film
  • The distal ulna and radius should be superimposed
    indicating no rotation.
  • The distal end of the scaphoid and pisiform will
    be superimposed.
  • The first metacarpal should be off to the side.

68
12.10 Wrist P-A for Scaphoid
  • Measure A-P through carpal bones
  • Protection Lead Apron
  • SID 40 Table Top
  • Tube angle 15 to 20 degrees cephalad or sponge
    placed under wrist
  • Film 8 x 10 Detail or Extremity Film

69
Wrist P-A for Scaphoid
  • Sponge and no angle method.
  • A 15 degree sponge is placed on the cassette.
  • Patient places palm of the hand on the sponge.
    The palm will be at a 15 to 20 degree angle to
    the film.

70
Wrist P-A for Scaphoid
  • Tube angle method.
  • Tube is angled 15 to 20 degrees cephalad and
    centered to film.
  • Patient asked to place wrist flat on the film.
  • Tube angle and sponge methods
  • Horizontal CR centered to scaphoid or about 0.5
    distal to the radial styloid process

71
Wrist P-A for Scaphoid
  • Tube angle and Sponge method.
  • Vertical CR centered to scaphoid or mid wrist
  • Collimation soft tissue of wrist
  • Ask patient to remain still and make exposure.

72
Wrist P-A for Scaphoid Film
  • The scaphoid will be elongated making it easier
    to visualize fractures.
  • Joint spaces around scaphoid should be open.
  • Distal ulna and radius must be seen.

73
12.11 Wrist Unlar Flexion for Scaphoid
  • Measure A-P through carpal bones
  • Protection Coat Apron
  • SID 40 Non-Bucky
  • Tube angle 15 to 20 degrees cephalic
  • Film 1/4 of a 10x12 or on a 8 x 10Extremity
    or Detail Cassette.

74
Wrist Ulnar Flexion
  • Cover unused portions of cassette with lead
    shields. Center beam to 1/4 of cassettes
    uncovered.
  • Ask patient to rest wrist in P-A position on
    cassette.
  • Ask patient to unlar flex their wrist as far as
    they can tolerate.

75
Wrist Ulnar Flexion
  • Horizontal CR Through the scaphoid or slightly
    distal to the radius.
  • Vertical CR Through the scaphoid or very
    slightly medial to the long axis of the wrist. If
    patient is small, center to the distal forearm.

76
Wrist Unlar Flexion
  • Collimation top to bottom less than 1/4 of the
    10 x 12 or from carpal to metacarpal
    articulations to include distal ulna and radius.
  • Collimation side to side soft tissue of wrist
  • Ask patient to hold still and make exposure.

77
Wrist Unlar Flexion Film
  • The scapholunate and scaphocapitate spaces should
    be open.
  • If scaphocapitate space is closed, oblique the
    wrist about 15 degrees.
  • Hand must be flat on film to open the
    scaphotrapzium joint space.

78
12.12 Wrist A-P Stress View
  • Measure A-P through carpal bones
  • Protection Coat Apron
  • SID 40 Non-Bucky
  • Film 1/4 of a 10x12 with routine wrist series
    or individual 8 x 10 Extremity or Detail
    Cassette.

79
Wrist A-P Stress
  • Cover used portions of cassette with lead
    shields. Center beam to 1/4 of cassettes
    uncovered.
  • Ask patient to rest wrist in A-P position on
    cassette.
  • Ask patient to form a fist. Make sure that wrist
    is not in a oblique position.

80
Wrist A-P Stress View
  • Horizontal CR Just distal to radius or through
    the first row of carpal bones.
  • Vertical CR long axis of wrist ( mid way between
    ulna and radius and third metacarpal).

81
Wrist A-P Stress View
  • Collimation top to bottom less than 1/4 of the
    10 x 12 or from carpal to metacarpal
    articulations to include distal ulna and radius.
  • Collimation side to side soft tissue of wrist
  • Ask patient to clinch their fist and hold still
    and make exposure.

82
Wrist A-P Stress Film
  • Must include all carpal bones and wrist soft
    tissue.
  • The view is to stress the ligaments in the wrist.
  • The first row of carpal should form a C on the
    normal view.

83
19.1 Quality Assurance and Quality Control
  • Q A is a management tool used to optimize the
    performance of radiography services.
  • If we can optimize the performance of taking
    radiographs and assure that the equipment is
    operating properly, the office will operate more
    efficiently.
  • Your patient will receive better care and lower
    exposure to radiation.

84
Quality Assurance and Quality Control
  • Elements of a QA Program
  • Policies and Procedures that establish standards
    for training, performance and competency of
    staff.
  • Defined administrative accountability and
    standards

85
Quality Assurance and Quality Control
  • Elements of a QA Program
  • A Quality Control Program for x-ray, film
    processing and ancillary equipment.
  • Preventive and corrective maintenance of the
    equipment.
  • Retake or repeat rate analysis to quantity
    competencies and control of radiography.

86
Quality Control in Radiography
  • Definition
  • Standardized test of the equipment at prescribed
    intervals designed to detect slowing evolving
    problems before they cause significant
    deterioration of image quality.

87
Quality Control in Radiography
  • Q C Tests of three Groups of Equipment
  • Dark room, Film Storage and Processing
  • Radiographic Equipment and calibration
  • Accessories including cassettes, grids and
    radiation protection devices.

88
Quality Control in Radiography
  • Costs Associated with a QA Program
  • Training of Staff
  • QC equipment (about 2,000)
  • Lost treatment time if done during patient visit
    times.
  • Costs of physicist or specialist to test
    equipment.

89
Quality Control in Radiography
  • Benefits Associated with a QA Program
  • Reduced repeated films, better throughput and
    lower radiation exposure for your patient.
  • Lower cost from waste of film, processing
    chemicals and hazardous waste.
  • Less wear and tear on equipment.

90
Quality Control in Radiography
  • Benefits Associated with a QA Program
  • Overall reduced service cost on equipment
  • Ability to combine QA with radiation and office
    safety programs to meet regulatory requirements.

91
Four Major Steps of QA
  • Acceptance testing to insure that equipment meets
    specifications.
  • Establishing baseline of equipment performance.
  • Diagnosis of changes in performance of equipment
  • Verification of corrective measures.

92
Retake Analysis
  • Done every three months using a relatively large
    sample of data to see trends in
  • Type of examination being repeated.
  • Reasons for the repeated films.
  • Determine if additional training or review is
    needed.
  • Determine if equipment service might be required.

93
Equipment needed for Q C
  • The Aluminum Step Wedge is used to test the dark
    room safelight and consistency of exposure.

94
Equipment needed for Q C
  • A homogenous phantom. The lead apron may be used
    as a homogenous phantom or a piece of Lucite may
    be used.

95
Equipment needed for Q C
  • Wire mesh test tool used to test cassette screen
    contact.

96
Equipment needed for Q C
  • Thermometer used to measure processor chemical
    temperatures.

97
Equipment needed for Q C
  • Sensitometer used to generate a highly
    reproducible stepwedge for processor quality
    control..

98
Equipment needed for Q C
  • Densitometer used to measure the amount of light
    passing through an exposed film.

99
Darkroom Quality Assurance Rules
  • 1. No food or drink or smoking in the dark room.
  • 2. Daily cleaning of dark room to avoid dust.
  • 3. Daily cleaning of dark room work surfaces.
  • 4. Handle film with clean and dry hands.
  • 5. Check that the safelight is equipped with the
    correct filter and bulb.

100
Darkroom Quality Assurance Rules
  • 6. Keep cassettes and screens clean and free of
    artifacts.
  • 7. Load only one sheet of film in cassettes.
  • 8. Handle film carefully to avoid artifacts. Use
    clean and dry hands and touch only the edges of
    the film.
  • 9. Lock the darkroom door when processing or
    loading film into the cassettes.

101
X-Ray Quality Assurance Rules
  • 1. Measure patient with calipers.
  • 2. Consult technique chart and record factors
    used to take film.
  • 3. Enter correct technical factors in control.
  • 4. Accurate and precise positioning of patient
    and equipment.
  • 5. Collimate beam to area of interest or less
    than films size,whichever is smaller.

102
X-Ray Quality Assurance Rules
  • 6. Give concise and accurate breathing
    instructions to patient and ask patient to remain
    still.
  • 7. Observe patient for compliance with
    instructions before making exposure.
  • 8. Hold exposure button down for complete
    exposure.
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