UPPER

EXTREMITY
Upper Extremity:

1. Hand
2. Forearm
3. Arm
4. Shoulder girdle
1. Hand - consists of 27 bones
- Phalanges (bones of the digits) -
14 bones
- Metacarpals (bones of the palm)
5 bones (knuckles)
- Carpals (bones of the wrist) –
8 bones
Carpal Bones
Proximal row: Synonyms
1. Scaphoid - Navicular
2. Lunate - Semilunar
3. Triquetrum - Triquetral. cuneiform, or triangular
4. Pisiform - Pisiform

Distal row:
5. Trapezium - Greater multangular
6. Trapezoid - Lesser multangular
7. Capitate - Os magnum
8. Hamate - Unciform
Carpal Sulcus (Canal or Tunnel View)
Scaphoid - boat-shaped bone.
- the largest bone in the proximal row and articulates with the
radius proximally.
- the most frequently fractured carpal bone.
 Pisiform - Pea-shaped.
Lunate - Moon-shaped. - the smallest of the carpal bones.

Trapezoid - Wedge-shaped, also

four-sided, is the smallest bone in
the distal row.
 Hamate - can be easily
distinguished by the hooklike
process called the hamulus.

Capitate - the largest of the carpal

bones.
 Metacarpal Bones
Each metacarpal bone consists of a proximal base, an
intermediate shaft, and a distal head. The heads of the
metacarpals, commonly called “knuckles,” are readily visible in a
clenched fist.
Metacarpals - articulate with the
phalanges at their distal ends (MCP)
joints.
- articulate with the
respective carpals proximally (CMC)
joints.

The 5 metacarpals
articulate with specific
carpals as follows:
• 1st MC w/ Trapezium
• 2nd MC w/ Trapezoid
• 3rd MC w/ Capitate
• 4th & 5th MC w/
Hamate
 Phalanges
Each of the 4 fingers (digits 2, 3, 4, and 5)
is composed of three phalanges - proximal,
middle, and distal.
The thumb, or first digit (Pollex), has two
phalanges - proximal and distal.

Each phalanx consists of 3 parts: a distal

rounded Head, a Body (shaft), and an expanded
Base, similar to that of the metacarpals.
2. Forearm
- Radius
-Ulna

3. Arm - Humerus
Clinical Indications
1. Carpal tunnel syndrome - is a common painful disorder of the wrist and hand
that results from compression of the median nerve as it passes through the center
of the wrist.

2. Joint effusion - refers to accumulated fluid (synovial or hemorrhagic) in

the joint cavity. It is a sign of an underlying condition, such as fracture,
dislocation, soft tissue damage, or inflammation.
3. Skier’s thumb - refers to a sprain or tear of the ulnar collateral
ligament of the thumb, near the MCP joint of the hyperextended thumb.
The sprain or tear may result from an injury such as falling on an
outstretched arm and hand, which causes the thumb to be bent back
toward the arm.
4. Gout - Hereditary form of arthritis where uric acid is
deposited in joints.
5. Osteoarthritis or Degenerative Joint Disease - Form of arthritis
marked by progressive cartilage deterioration in synovial joints and
vertebrae.
6. Dislocation - (Luxation) occurs when the bone is displaced from a joint, or
when the articular contact of bones that make up a joint is completely lost.
The most common dislocations encountered in trauma involve the
shoulder, fingers or thumb, patella, and hip.

Subluxation - Partial dislocation.

7. Sprain is a forced wrenching or twisting of a joint that results in a partial
rupture or tearing of supporting ligaments, without dislocation.
Severe swelling and discoloration resulting from haemorrhage of
ruptured blood vessels frequently accompany a severe sprain. Symptoms are
similar to those of fractures. Radiographs aid in differentiating a sprain from
a fracture.
8. Fracture - is a break in the structure of bone caused by a force (direct or
indirect).
Greenstick fracture – also known as Hickory or Willow Stick fracture.
Different Types of
Upper Limb
Fractures

1. Boxer’s fracture -
Transverse fracture that
extends through the
metacarpal neck.
- most commonly
seen in the 5th metacarpal.
2. Colles’ fracture - Transverse
fracture of the distal radius in
which the distal fragment is
displaced posteriorly.
3. Smith’s fracture (Goyrand
fracture) - Reverse of Colles’
fracture, or transverse fracture
of the distal radius with the
distal fragment displaced
anteriorly.
4. Barton’s fracture - Fracture and dislocation of the posterior lip
of the distal radius involving the wrist joint.
5. Bennett’s fracture - Fracture of the base of the 1st metacarpal
bone, extending into the carpometacarpal joint, complicated by
subluxation with some posterior displacement.
6. Rolando fracture - is a three part or comminuted intra-articular
fracture-dislocation of the base of thumb (proximal 1st metacarpal).
Bennett’s fracture Rolando fracture
7. Galeazzi fracture – fracture of the radial shaft which is
associated with dislocation of the distal radioulnar joint (DRUJ).
8. Monteggia fracture - comprise of a fracture of the ulnar shaft
and dislocation of the radial head.
9. Chauffeur fractures (Hutchinson’s fractures or Backfire
fractures) are intraarticular fracture of the radial styloid process.
10. Essex-Lopresti fracture - dislocations comprise of a
comminuted fracture of the radial head accompanied by dislocation
of the distal radio-ulnar joint.
11. Baseball (Mallet) fracture - This fracture of the distal
phalanx is caused by a ball striking the end of an extended finger.
The distal interphalangeal (DIP) joint is partially flexed and an
avulsion fracture is frequently present at the posterior base of
the distal phalanx.
12. Tuft / Burst fracture -This comminuted fracture of the
distal phalanx may be caused by a crushing blow to the distal
finger or thumb.
 HAND
1. PA PROJECTION
2. PA OBLIQUE PROJECTION
3. LATERAL PROJECTION
4. AP OBLIQUE PROJECTION (NORGAARD METHOD)
 AP PROJECTION
ROBERT METHOD
Radiographic projection of the first CMC joint.
C.R.
Robert method
-Perpendicular entering at the first CMC joint.

Long and Rafert modification

- Angled 15 degrees proximally along the long
axis of the thumb and entering the first CMC
joint.
Lewis modification
- Angled 10 to 15 degrees proximally along
the long axis of the thumb and entering the
first MCP joint.
 PA STRESS THUMB PROJECTION
FOLIO METHOD
- Sprain or tearing of ulnar collateral ligament of thumb at MCP joint as a result of acute
hyperextension of thumb; also referred to as a “skier’s thumb” injury

Position of part
- Both hands rotated laterally side by side to
place thumbs parallel to IR (cassette) for true
PA projection of both thumbs.

- Place round spacer, such as a roll of medical

tape, between proximal thumb regions; wrap
rubber bands around distal
thumbs.
- Immediately before exposure, ask patient to
pull thumbs apart firmly and hold.

Central Ray
perpendicular to IR directed to midway between MCP joints.
Structures shown
- Entire both thumbs from first metacarpals to distal phalanges.
- Demonstrates metacarpophalangeal angles and joint spaces at MCP joints.
PA PROJECTION

Position of part
- Patient's forearm on the table with the
palmar surface on top of the IR .
- Center the IR to the MCP joints.
- Spread the fingers slightly

C.R.
-Perpendicular to the 3rd MCP joint.
Structures Shown
- PA projections of the
carpals, metacarpals,
phalanges (except the
thumb), interarticulations
of the hand, and distal
radius and ulna.
PA OBLIQUE PROJECTION
Lateral rotation
Position of part
- Patient's forearm on the table with the hand pronated.
- Oblique the hand Approx. 45 degrees.
- Use a 45-degree foam wedge.
- Center the IR to the MCP joints.

Central ray
- Perpendicular to the 3rd MCP joint.
Structures shown
- PA oblique projection of
the bones and soft tissues of
the hand.
- This supplemental position
is used for investigating
fractures and pathologic
conditions.
LATERAL PROJECTION
Mediolateral or Lateromedial Extension and Fan Lateral

Position of part
- Center the IR to the MCP joint.
- For the fan lateral position, place the digits on a sponge wedge. Abduct the thumb and
place it on the radiolucent sponge for support.

Central ray
- Perpendicular to the 2nd MCP joint.
Structures shown
- Lateral projection of the hand
in extension, is used in localizing
foreign bodies and metacarpal
fracture displacement.
- The fan lateral
superimposes the
metacarpals but
demonstrates almost
all of the individual
phalanges. The most
proximal portions of
the proximal
phalanges remain
superimposed.
LATERAL PROJECTION
Lateromedial in Flexion
Position of part
- Center the IR to the MCP joint.
- Maintain the natural arch of the hand, arrange the digits so that they are perfectly
superimposed.
- Have the patient hold the thumb parallel with the I R.
Central ray
- Perpendicular to the 2nd MCP joints.
Structures shown
- This projection produces a lateral
image of the bony structures and
soft tissues of the hand in their
normally flexed position. It also
demonstrates anterior or posterior
displacement in fractures of the
metacarpals.
AP OBLIQUE PROJECTION
NORGAARD METHOD
Medial Rotation

-Also referred to as the ball-catcher's position

-assists in detecting early radiologic changes needed to diagnose rheumatoid arthritis.

Central ray
- Perpendicular to a point midway between both hands at the level of the MCP joints.
 WRIST
1. PA PROJECTION
2. AP PROJECTION
3. LATERAL PROJECTION
4. PA OBLIQUE PROJECTION
5. AP OBLIQUE PROJECTION
6. PA PROJECTION Ulnar Deviation
7. PA PROJECTION Radial Deviation
8. PA AXIAL PROJECTION (STECHER METHOD)
9. PA AXIAL OBLIQUE PROJECTION (CLEMENTS-NAKAYAMA
METHOD)
10. TANGENTIAL PROJECTION (Carpal Bridge)
11. TANGENTIAL PROJECTIONS (GAYNOR-HART METHOD)
PA PROJECTION
Position of part
- Slightly arch the hand at the MCP joints by flexing the digits to place the wrist in
close contact with the IR

Central ray
- Perpendicular to the midcarpal area.
Structures shown
- A PA projection of the carpals, distal radius and ulna, and proximal metacarpals is
shown. The projection gives a slightly oblique rotation to the ulna. When the ulna is under
examination, an AP projection should be taken.
AP PROJECTION
Position of part
- Place the hand on a supine
position.
- Center the IR to the carpals.
- Elevate the digits on a suitable
support to place the wrist in close
contact with the IR.
- Lean the patient laterally to
prevent rotation of the wrist.

Central ray
- Perpendicular to the midcarpal
area.
Structures shown
- The carpal interspaces are better demonstrated in the AP image than the PA
image. Because of the oblique direction of the interspaces, they are more
closely parallel with the divergence of the x-ray beam
LATERAL PROJECTION
Lateromedial

Position of part
- Center the IR to the carpal,
and adjust the forearm and
hand so that the wrist is in a
true lateral position.

Central ray
- Perpendicular to the wrist
joint.
Structures Shown
- The lateral projection of
the proximal metacarpals,
carpals, and distal radius and
ulna.
- This position can also be
used to demonstrate anterior
or posterior displacement in
fractures.
 Fiolle was the first to describe a small bony growth occurring on the
dorsal surface of the third CMC joint. He termed the condition Carpe Bossu
(Carpal Boss) and found that it is demonstrated best in a lateral position with the
wrist in palmar flexion.
PA OBLIQUE PROJECTION
Lateral rotation
Position of part
- Pronate the hand.
- The center point of IR is under the scaphoid.
- Rotate the wrist laterally (externally) at an angle of approximately 45 degrees.

Central ray
- Perpendicular to the midcarpal area. It enters distal to the radius.
Structures shown
- This projection
demonstrates the carpals
on the lateral side of the
wrist, particularly the
trapezium and the
scaphoid. The scaphoid is
superimposed on itself in
the direct PA projection.
AP OBLIQUE PROJECTION
Medial rotation

Position of part
- Place the hand on a supine position.
- Rotate the wrist medially (internally)
at an angle of 45 degrees.

Central ray
- Perpendicular to the midcarpal area,
midway between its medial and lateral
borders.
Structures shown
- This position separates the pisiform from the adjacent carpal bones. It
also gives a more distinct radiograph of the triquetrum and hamate.

Hamate

Pisiform

Triquetrum
Lunate
PA PROJECTION
Ulnar Deviation

Position of part
- Position the wrist for a PA
projection.
-Turn the hand outward.

Central ray
- Perpendicular to the scaphoid.
- Clear delineation sometimes
requires a central ray angulation
of 10 to 15 degrees proximally
or distally.
Structures shown
- This position corrects foreshortening of the scaphoid, which occurs with a
perpendicular central ray. It also opens the spaces between the adjacent carpals.
PA PROJECTION
Radial Deviation

Position of part
- Position the wrist on the IR for a
PA projection.
-Turn the hand medially .

Central ray
- Perpendicular to the midcarpal
area.
Structures shown
- Radial deviation opens the interspaces between the carpals on the medial side
of the wrist.
 PA AXIAL PROJECTION
STECHER METHOD
Position of part
- Place one end of the IR on a support and
adjust the IR so that it is elevated 20
degrees.
- Adjust the wrist on the IR for a PA
projection, and center the wrist to the IR.

Central ray
-Perpendicular the scaphoid.

- direct the central ray 20 degrees towards

the elbow when placing the IR and wrist
horizontally.
Structures shown
- The 20-degree angulation of the wrist places the scaphoid at right angles to
the central ray so that it is projected without self superimposition.
 PA AXIAL OBLIQUE PROJECTION
CLEMENTS-NAKAYAMA METHOD

- Trapezium should be evaluated to treat the

osteoarthritic patient.

Position of part
- Place the wrist in the lateral position
- Rotate the hand on a 45-degree sponge
wedge.
-The hand is in ulnar deviation.

Central ray
- Angled 45 degrees distally to enter the
anatomic snuffbox of the wrist and pass
through the trapezium
Structures shown
- The image clearly demonstrates
the trapezium and its articulations
with the adjacent carpal bones.
 TANGENTIAL PROJECTION
Carpal Bridge

Position of part
- The hand lie palm upward on the IR with
the hand at right angle to the forearm.
- Similar image can be obtained by elevating
the forearm on sandbags. Then with the
wrist flexed in right angle position, place
the IR in the vertical position.

Central ray
- Directed to a point about 1.5 inches
proximal to the wrist joint at a caudal angle
of 45 degrees.
Structures shown
- The carpal bridge is demonstrated on the image. This procedure is for the
demonstration of fractures of the scaphoid, lunate dislocations, calcifications and
foreign bodies in the dorsum of the wrist, and chip fractures of the dorsal aspect
of the carpal bones.

Lunate
Scaphoid
Capitate
Triquetrum

Trapezium
 TANGENTIAL PROJECTIONS
GAYNOR-HART METHOD
Position of part
- Hyperextend the wrist, and center the IR
to the joint at the level of the radial styloid
process.
- Rotate the hand slightly toward the radial
side.
- Have the patient grasp the digits with the
opposite hand.

Central ray
- Directed at a point approximately 1 inch
(2.5 cm) distal to the base of the third
metacarpal at an angle of 25 to 30
degrees.
Structures shown
- This image of the carpal canal (carpal tunnel ) shows the palmar aspect of the
trapezium, the tubercle of the trapezium, and the scaphoid, capitate, hook of
hamate, triquetrum, and entire pisiform.
 Superoinferior

- Have the patient dorsiflex the wrist as much

as tolerable and lean forward to place the
carpal canal tangent to the IR.

Central ray
- Tangential to the carpal canal at the
level of the midpoint of the wrist
- Angled toward the hand approximately 20
to 35 degrees from the long axis of the
forearm.
 Forearm

1. AP PROJECTION
2. LATERAL PROJECTION
 AP PROJECTION

Position of part
- Supinate the hand and forearm.
- Pronation of the hand crosses
the radius over the ulna at its
proximal third and rotates the
humerus medially, resulting in an
oblique projection of the forearm.

Central ray
- Perpendicular to the midpoint of
the forearm.
Structures shown
- An AP projection of the
forearm demonstrates the
elbow joint, the radius and
ulna, and the proximal row
of carpal bones.
 LATERAL PROJECTION
Lateromedial
Position of part
-Flex the elbow 90 degrees.
- Adjust the limb in a true lateral
position
- Make sure that the entire joint of
interest is included.

Central ray
- Perpendicular to the midpoint of the
forearm.
Structures shown
- The lateral projection demonstrates the bones of the forearm, the elbow
joint, and the proximal row of carpal bones.
 ELBOW
1.AP PROJECTION
2. LATERAL PROJECTION
3. AP OBLIQUE PROJECTION Medial rotation
4. AP OBLIQUE PROJECTION Lateral rotation
5. AP PROJECTION of Distal Humerus Partial flexion
6. AP PROJECTION of Proximal Forearm Partial flexion
7. (Jones Method) AP PROJECTION of Distal Humerus Acute
flexion
8. LATERAL PROJECTION of Radial Head Lateromedial Rotation
Four-position series
9. (Coyle Method) AXIAL LATEROMEDIAL PROJECTIONS
10. PA AXIAL PROJECTION
11. PA AXIAL PROJECTION (Olecranon Process)
AP PROJECTION
Position of part
- Extend the elbow, supinate the hand, and center the IR to the elbow joint.

Central ray
- Perpendicular to the elbow joint.
Structures shown
- An AP projection of the
elbow joint, distal arm,
and proximal forearm is
presented.
 LATERAL PROJECTION
Lateromedial

Position of part
- Flex the elbow 90 degrees and
adjust the hand in the lateral
position and ensure that the humeral
epicondyles are perpendicular to the
plane of the IR.

Central Ray
- Perpendicular to the elbow joint.
Structures shown
The lateral projection
demonstrates the elbow joint,
distal arm, and proximal
forearm.

The importance of 90 degrees

flexion of the elbow accdng to
Griswold:

1. The olecranon process can

be seen in profile.
2. The elbow fat pads are the least compressed. It must be realized that in partial
or complete extension the olecranon process elevates the posterior elbow fat pad
and simulates joint pathology.
AP OBLIQUE PROJECTION
Medial rotation

Position of part
- Extend the limb in position for an AP projection.
- Internally rotate or pronate the hand, and adjust the elbow at an angle of 45 degrees.

Central ray
- Perpendicular to the elbow joint.
Structures shown
- The image shows an oblique
projection of the elbow with
the coronoid process projected
free of superimposition.
AP OBLIQUE PROJECTION
Lateral rotation
Position of part
- Extend the patient's arm in position for an AP projection.
- Rotate the hand externally at an angle of 45-degree angle.

Central ray
- Perpendicular to the elbow joint.
Structures shown
- The image shows an oblique
projection of the elbow with the
radial head and neck projected
free of superimposition of the
ulna.
AP PROJECTION
of Distal Humerus
Partial flexion
Position of part
- If possible, supinate the hand. Place the IR under the elbow, and center it to the
condyloid area of the humerus.

Central ray
- Perpendicular to the humerus, traversing the elbow joint.
Structures shown
- This projection shows
the distal humerus when
the elbow cannot be fully
extended.
AP PROJECTION
of Proximal Forearm
Partial flexion
Position of part
- Seat the patient high enough to permit the dorsal surface of the forearm to
rest on the table.

Central ray
- Perpendicular to the elbow joint and long axis of the forearm.
Structures shown

- This projection demonstrates

the proximal forearm when
the elbow cannot be fully
extended.
 Jones Method
AP PROJECTION
of Distal Humerus
Acute flexion

Position of part
- Center the IR proximal to the
epicondylar area of the humerus. The
long axis of the arm and forearm
should be parallel with the long axis of
the IR.

Central ray
- Perpendicular to the humerus
approximately 2 inches (5 cm) superior
to the olecranon process.
Structures shown
- This position superimposes the bones of the forearm and arm. The olecranon
process should be clearly demonstrated.
 PA PROJECTION
of Proximal Forearm
Acute flexion

Central ray
- Perpendicular to the flexed
forearm, entering approximately
2 inches (5 cm) distal to the
olecranon process.
Structures shown
- The superimposed bones
of the arm and forearm
are outlined. The elbow
joint should be more
open than for
projections of the distal
humerus.

- Proximal ulna and

radius, including outline
of radial head and neck,
should be visible
through superimposed
distal humerus.
 LATERAL
PROJECTION
of Radial Head
Lateromedial Rotation
Four-position series

1. Lateral elbow. With hand 2. Lateral elbow. With hand

supinated as much as possible. in lateral position.

Central ray
-Perpendicular to
the elbow joint

3. Lateral elbow. With hand 4. Lateral elbow. With hand

pronated. internally rotated.
Structures shown
- The radial head is projected in varying degrees of rotation.

1. Lateral elbow. With hand 2. Lateral elbow. With hand

supinated as much as possible. in lateral position.

3. Lateral elbow. With hand 4. Lateral elbow. With hand

pronated. internally rotated.
 AXIAL LATEROMEDIAL
PROJECTIONS
COYLE METHOD
These are special projections
taken for pathologic processes or trauma
to the area of the radial head or the
coronoid process of ulna.
These are effective projections
when patient cannot extend elbow fully
for medial or lateral oblique projections
of the elbow.

Part Position 1—Radial Head

- Elbow flexed 90° if possible; hand
pronated.
Central Ray
- directed at 45° angle toward shoulder,
centered to radial head (mid-elbow
joint).
Structure Shown
Radial head, neck, and tuberosity should be in profile and free of
superimposition except for a small part of the coronoid process.
Part Position 2—Coronoid Process
- Elbow flexed only 80° from extended
position (because >80° may obscure
coronoid process) and hand pronated.

Central Ray
- angled 45° from shoulder, into
midelbow joint.
Structure Shown
Distal (anterior) portion of the coronoid appears elongated but in profile.
PA AXIAL PROJECTION

Position of part
- Rest the patient’s forearm on the table
-Flex the elbow and place the arm in a
nearly vertical position (humerus at an
angle of approximately 75 degrees from the
forearm).
- Supinate the hand to prevent rotation of
the humerus and ulna.

Central ray
- Perpendicular to the ulnar sulcus, entering
at a point just medial to the olecranon
process.
Structures shown
- This projection demonstrates the epicondyles, trochlea, ulnar sulcus (groove between
the medial epicondyle and the trochlea), and olecranon fossa.

- The projection is used in radiohumeral bursitis (tennis elbow) to detect otherwise

obscured calcifications located in the ulnar sulcus.
PA AXIAL PROJECTION
( Olecranon Process)

Position of part
- Adjust the arm at an angle of 45 to
50 degrees from the vertical position.
-Supinate the hand.

Central ray
- Perpendicular to the olecranon
process at 20-degrees angle towards
the wrist.
Structures shown
- The projection demonstrates the olecranon process and the articular margin
of the olecranon and humerus.
 HUMERUS

1. AP PROJECTION
2. LATERAL PROJECTION
 AP PROJECTION

Position of part
- Adjust the height of the IR to place its
upper margin about 1.5 inches above
the head of the humerus.
- Abduct the arm slightly, and supinate
the hand.
- Epicondyles should be parallel with
the IR.

Central ray
- Perpendicular to the midportion of
the humerus.
Structures shown
- The AP projection demonstrates the entire length of the humerus. The accuracy
of the position is shown by the epicondyles.
 LATERAL PROJECTION
Lateromedial

Position of part
- 1. Internally rotate the arm, flex the
elbow approximately 90 degrees, and
place the patient's anterior hand on the
Hip.
- Epicondyles should be perpendicular
with the IR.

-2. Rotate the forearm medially, and rest

the posterior aspect of the hand against
the patient's side.

Central ray
- Perpendicular to the mid portion of the
Humerus.
Structures shown
- The lateral projection
demonstrates the entire length of
the humerus.
- A true lateral image is confirmed
by superimposed epicondyles.
4. Shoulder Girdle
- Clavicle
- Scapula
Clinical Indications
1. Shoulder dislocation - occurs as traumatic removal of humeral head from
the glenoid cavity. 95% of shoulder dislocations are anterior, in which the
humeral head is projected anterior to the glenoid cavity.
2. Acromioclavicular (AC) dislocation - refers to an injury in which the distal
clavicle usually is displaced superiorly. This injury most commonly is caused
by a fall.
3. Hill-Sachs defect - is a compression fracture of the articular surface of
the posterolateral aspect of the humeral head that often is associated with an
anterior dislocation of the humeral head.

4. Idiopathic chronic adhesive capsulitis (frozen shoulder) - is a disability of

the shoulder joint that is caused by chronic inflammation in and around the joint.
It is characterized by pain and limitation of motion. (Idiopathic means “of
unknown cause.”)
 Shoulder
1. AP PROJECTION W/ EXTERNAL, NEUTRAL AND INTERNAL ROTATION
2. TRANSTHORACIC LATERAL PROJECTION (LAWRENCE METHOD)
3. INFEROSUPERIOR AXIAL PROJECTION (LAWRENCE METHOD)
4. INFEROSUPERIOR AXIAL PROJECTION (RAFERT MODIFICATION)
5. INFEROSUPERIOR AXIAL PROJECTION (WEST POINT METHOD)
6. INFEROSUPERIOR AXIAL PROJECTION (CLEMENTS MODIFICATION)
7. SUPEROINFERIOR AXIAL PROJECTION
8. AP AXIAL PROJECTION
9. SCAPULAR Y - PA OBLIQUE PROJECTION
10. AP OBLIQUE PROJECTION (GRASHEY METHOD)
11. TANGENTIAL PROJECTION (NEER METHOD) Supraspinatus "Outlet“
12. AP AXIAL PROJECTION (STRYKER NOTCH METHOD)
13. AP OBLIQUE PROJECTION (APPLE METHOD)
14. TANGENTIAL PROJECTION (FISK MODIFICATION)
Intertubercular Groove
15. AP PROJECTION (BLACKED-HEALY METHOD) Subscapular Insertion
16. AP PROJECTION Bilateral (PEARSON METHOD)
Acromioclavicular Articulations
17. AP AXIAL PROJECTION (ALEXANDER METHOD)
18. PA AXIAL OBLIQUE PROJECTION (ALEXANDER METHOD)
Shoulder
1. EXTERNAL ROTATION – hand in Supine
position.
Epicondyles are parallel with the plane of
the IR.

2. NEUTRAL ROTATION - The palm of the

hand placed against the hip.
Epicondyles at an angle of about 45
degrees with the plane of the IR.

3. INTERNAL ROTATION - The posterior

aspect of the hand placed against the hip.
Epicondyles perpendicular to the plane of
the IR.

Central ray
- Perpendicular to a point 1 inch inferior
to the coracoid process.
Structure Shown
EXTERNAL ROTATION
- The greater tubercle is seen laterally in
profile.
- The lesser tubercle is located anteriorly,
just medial to the greater tubercle.

NEUTRAL ROTATION
- Places the greater tubercle anteriorly
but still lateral to the lesser tubercle.

INTERNAL ROTATION
- The lesser tubercle is seen in profile
medially.
TRANSTHORACIC LATERAL PROJECTION
LAWRENCE METHOD
- The Lawrence method is used when trauma
exists and the arm cannot be rotated or abducted
because of an injury.

Position of part
-Raise the uninjured arm, rest the forearm on the
head, and elevate the shoulder as much as
possible.
- Midcoronal plane must be perpendicular to the
IR.
-Center the IR to the surgical neck area of the
affected humerus.

Central ray
- Perpendicular to the IR at the level of the
surgical neck.
- If the patient cannot elevate the unaffected
shoulder, angle the central ray 10 to 15 degrees
cephalad.
Structures shown
- A lateral image of the shoulder and proximal humerus is projected through the
thorax.
INFEROSUPERIOR AXIAL PROJECTION
LAWRENCE METHOD
Position of part
- Abduct the arm of the affected side
at right angles to the long axis of the
body.
- Keep the humerus in external
rotation.
- Have the patient turn the head away
from the side being examined. place
the IR on edge against the shoulder.

Central ray
- Horizontally through the axilla to the
Acromioclavicular joint.
- The degree of medial angulation is
often between 15 and 30 degrees.
INFEROSUPERIOR AXIAL PROJECTION
RAFERT MODIFICATION
- Anterior dislocation of the humeral head, called the Hill-Sachs defect can
be seen through the exaggerated external rotation of the arm.

- With the patient in position exactly as for the Lawrence method, externally
rotate the extended arm until the hand forms a 45-degree oblique. The
thumb will be pointing downward .

Central ray
- Horizontal and angled approximately 15
degrees medially, entering the axilla and
passing through the acromioclavicular
joint.
Structures shown

-An inferosuperior axial image shows the

proximal humerus, the scapulohumeral
joint, the lateral portion of the coracoid
process, and the acromioclavicular
articulation.

Lawrence method

.
- A HillSachs compression fracture on
the posterolateral humeral head may be
seen using the Rafert modification

Rafert modification showing a Hill-Sachs defect

INFEROSUPERIOR AXIAL PROJECTION
WEST POINT METHOD
Position of part
- Abduct the arm of the affected side
90 degrees.
- Place a vertically supported IR
against the superior aspect of the
shoulder.

Central ray
- Directed at a dual angle of 25
degrees anteriorly from the
horizontal and 25 degrees medially.
-The central ray enters approximately
5 inches inferior and 1.5 inch medial
to the acromial edge and exit the
glenoid cavity.
Structures shown
- The resulting image shows bony abnormalities of the anterior inferior rim of
the glenoid in patients with instability of the shoulder.
INFEROSUPERIOR AXIAL
PROJECTION
CLEMENTS MODIFICATION
Position of part
- The patient must be in lateral recumbent
position lying, on the unaffected side.
- Abduct the affected arm 90 degrees.
- Place the IR against the superior aspect of
the patient's shoulder.

Central ray
1. Horizontal to the midcoronal plane,
passing through the midaxillary region of
the shoulder.

2. Angled 5 to 15 degrees medially when

the patient cannot abduct the arm a full
90 degrees.
SUPEROINFERIOR AXIAL PROJECTION
Position of part
- Lean the patient laterally over the IR until the shoulder joint is over the midpoint of
the IR.
- Flex the patient's elbow 90 degrees, and place the hand in the prone position.
-Tilt the head toward the unaffected shoulder.

Central ray
- Angled 5 to 15 degrees through the shoulder joint and toward the elbow.
Structures shown
- A superoinferior axial image shows the joint relationship of the proximal end of
the humerus and the glenoid cavity.

- The acromioclavicular articulation, the outer portion of the coracoid process,

and the points of insertion of the subcapularis muscle ( at body of scapula) and
teres minor muscle ( at inferior axillary border) are demonstrated.
 AP AXIAL PROJECTION
Position of the Patient
- Supine or Upright position

Central ray
- Directed through the scapulohumeral
joint at a cephalic angle of 35 degrees.

Structures shown
- The axial image shows the relationship
of the head of the humerus to the
glenoid cavity.
- This is useful in diagnosing cases of
posterior dislocation.
Scapular Y
PA OBLIQUE PROJECTION
RAO or LAO position
- described by Rubin, Gray, and Green

Position of part
- Rotate the patient so that the midcoronal
plane forms an angle of 45 to 60 degrees
to the IR.
- The scapula must place perpendicular to
the IR.
-Center the IR at the level of the
scapulohumeral joint.

Central ray
- Perpendicular to the scapulohumeral
joint.
Structures shown
- The scapular Y is demonstrated on
an oblique image of the shoulder.
- In the normal shoulder the humeral
head is directly superimposed over
the junction of the Y.
- In anterior dislocations, the humeral
head is beneath the coracoid process.

- In posterior dislocations, it is
projected beneath the acromion
process.

Remember “CAAP”
Coracoid-Anterior /
Acromion-Posterior
Glenoid Cavity
AP OBLIQUE PROJECTION
GRASHEY METHOD

Position of part
- Center the IR to the scapulohumeral joint.
-Rotate the body approximately 35 to 45
degrees toward the affected side.
-Abduct the arm slightly and place palm of
the hand on the abdomen.

Central ray
- Perpendicular to the glenoid cavity at a
point 2 inches medial and 2 inches inferior
to the superolateral border of the
shoulder.
Structures shown
- The joint space between the humeral head and the glenoid
cavity (scapulohumeral joint) is shown.
Supraspinatus "Outlet"
TANGENTIAL PROJECTION
NEER METHOD
- Useful in demonstrating tangentially the
Coracoacromial Arch or Outlet to diagnose
shoulder impingement.

Position of part
-Rotate the patient's unaffected side away from the
IR (45 to 60 degrees).
-Place the scapula perpendicular to the IR.

Central ray
- Angled 10 to 15 degree caudad, entering the
superior aspect of the humeral head.
 Supraspinatus Outlet
Structures shown

- The tangential outlet image

demonstrates the posterior
surface of the acromion and
the acromioclavicular joint
identified as the superior
border of the coracoacromial
outlet.
Proximal Humerus
AP AXIAL PROJECTION
STRYKER " NOTCH “ METHOD

Demonstrates Hill-Sachs defects

Position of part
-Flex the arm slightly beyond 90 degrees
and place the palm of the hand on top
of the head.
-The body of the humerus must be
vertical and parallel to the midsagittal
plane of the body.

Central ray
- Angled 10 degrees cephalad, entering
the coracoid process.
Structures shown
The resulting image will show the posterosuperior and posterolateral
areas of the humeral head.

Patient with a small Hill-Sachs defect

Glenoid Cavity
AP OBLIQUE PROJECTION - APPLE METHOD
RPO or LPO position
Uses weighted abduction to demonstrates a loss of articular cartilage in the scapulohumeral joint.

Position of part
- Center the IR to the scapulohumeral joint.
- Rotate the body approximately 35 degrees to 45 degrees toward the affected side.
- The posterior surface of affected side is closest to the IR.
- The scapula should be positioned parallel to the plane of the IR.
- The patient should hold a 1 pound weight and abduct the arm 90 degrees from the midline of the body.
Central ray
- Perpendicular to the IR at the level of the coracoid process.
Structures shown
The scapulohumeral joint or Glenoid Cavity.
Glenoid Cavity
AP AXIAL OBLIQUE PROJECTION - GARTH METHOD
Position of part
- Center the IR to the glenohumeral joint.
-Rotate the body approximatel y 45 degrees toward the affected side. The posterior surface
of the affected side is closest to the I R .
- Flex the elbow of the affected arm and place arm across the chest.
Central ray
- Angled 45 degree caudad through the scapulohumeral joint.
Structures shown
- The scapulohumeral joint,
humeral head, coracoid process,
and scapular head and neck are
shown.

- Demonstrates acute shoulder

trauma, posterior scapulohumeral
dislocations, glenoid fractures,
Hill-Sachs lesions, and soft tissue
calcifications.
 - Impacted - Anterior dislocation - Posterior dislocation,
fracture of (most common), humerus projected
humeral head humerus projected superiorly
but no major inferiorly.
scapulohumeral
dislocation.
 Intertubercular Groove
TANGENTIAL PROJECTION - FISK MODIFICATION

Position of part
- With the patient supine, palpate
the anterior surface of the shoulder
to locate the intertubercular
groove.
-Patient's hand in supine position.
-Place the IR against the superior
surface of the shoulder.

Central ray
- Angled 10 to 15 degrees posterior
(downward from horizontal) to the
long axis of the humerus for the
supine position.
Fisk Modification

- Patient standing at the end

of the radiographic table.
-Flex the elbow and lean
forward to place the posterior
surface of the forearm on the
table.
-Place the vertical humerus at
an angle of 10 to 15 degrees.

Central Ray
- Perpendicular to the IR.
Structures shown
The tangential image profiles the intertubercular groove free from
superimposition of the surrounding shoulder structures.
Subscapular Insertion
AP PROJECTION - BLACKED-HEALY METHOD
Position of part
- The unaffected shoulder may be elevated approximately 15 degrees.
- Abduct the affected arm to the long axis of the body.
- Flex the elbow and rotate the arm internally by pronating the hand.

Central ray
- Perpendicular to the shoulder joint, entering the coracoid process.
Structures shown
- This method provides an
image of the insertion of
the subscapularis at the
lesser tubercle.

Subscapularis insertion

Lesser tubercle
Acromioclavicular Articulations
AP PROJECTION
Bilateral
PEARSON METHOD
Two exposures:
1. The patient is standing
upright without weights
attached.
2. The patient has equal
weights (5 to 8 lb) affixed to
each wrist

Central ray
- Perpendicular to the midline
of the body at the level of the
acromioclavicular joints.
Structures shown
- Bilateral images of the acromioclavicular joints are demonstrated . This projection
is used to demontrates dislocation, separation, and function of the joints.
AP AXIAL PROJECTION
ALEXANDER METHOD
- Demonstrates acromioclavicular
subluxation or dislocation.

Position of part
- Adjust the patient's position to
center the coracoid process to the
IR.

Central ray
- Directed to the coracoid process
at a cephalic angle of 15 degrees.

This angulation projects the ACJ

above the acromion.
Structures shown
- The resulting image will show the ACJ or acromioclavicular joint projected
slightly superiorly.
PA AXIAL OBLIQUE PROJECTION
ALEXANDER METHOD
Position of part
- Rotate the patient so the midcoronal plane forms an angle of 45 to 60 degrees from
the IR to place the scapula perpendicular to the IR.

Central ray
- Directed through the acromioclavicular joint at an angle of 15 degrees caudad.
Structures shown
- The PA axjal oblique image demonstrates the acromioclavicular joint and the
relationship of the bones of the shoulder.
 CLAVICLE

1. AP PROJECTION
2. AP AXIAL PROJECTION - Lordotic position
3. TANGENTIAL PROJECTION
4. TANGENTIAL PROJECTION (TARRANT METHOD)
AP PROJECTION

-Place the patient in the

supine or upright position.

Position of part
- Center the clavicle to the IR.

Central ray
- Perpendicular to the
midshaft of the Clavicle.
Structures shown
- This projection demonstrates a frontal image of the clavicle.
PA PROJECTION
- The PA projection is most useful when improved recorded detail is
desired. The advantage of the PA projection is that the clavicle is closer
to the image receptor.
AP AXIAL PROJECTION
Lordotic position

Position of part
- Lean backward in a position of extreme
lordosis, and rest the neck and shoulder
against the vertical grid device. The neck
will be in extreme flexion.
- Center the clavicle to the center of the IR.
Central ray
- Directed to enter the midshaft of the
clavicle.
- For the standing lordotic position, 0 to
15 degrees is recommended.
- For the supine position, 15 to 30
degrees is recommended.
Structures shown
An axial image of the clavicle is projected above the ribs.
TANGENTIAL PROJECTION
Position of part
- Depress the shoulder to place the clavicle in a horizontal plane
- Have the patient turn the head away from the side being examined.
- Place the IR on edge at the top of the shoulder.
Central ray
- Perpendicular to the plane of the IR at an angle of 25 to 40 degrees so that the central
ray will pass between the clavicle and the chest wall.
Structures shown
- An inferosuperior image of the clavicle is demonstrated, projected free of superimposition.
TANGENTIAL PROJECTION
TARRANT METHOD
Position of part
- Center the IR to the projected
clavicle area, and have the
patient hold the IR in position.
-Lean slightly forward.

Central ray
- Directed anterior and inferior to
the midshaft of the clavicle at a
25 to 35 degree angle.
Structures shown
- The clavicle above the thoracic cage is demonstrated.
 SCAPULA
1. AP PROJECTION
2. LATERAL PROJECTION RAO or LAO body position
3. PA OBLIQUE PROJECTION (LORENZ AND LILIENFELD METHODS)
4. AP AXIAL PROJECTION
5. TANGENTIAL PROJECTION (LAQUERRIERE-PIERQUIN METHOD)
AP PROJECTION
Position of part
- Abduct the arm to a right angle
with the body to draw the scapula
laterally. Then flex the elbow, and
support the hand in a comfortable
position.
-Position the top of the IR 2 inches
above the top of the shoulder.

Central ray
- Perpendicular to the mid scapular
area at a point approximately 2
inches inferior to the coracoid
process.
Structures shown
- An AP projection of the
scapula is demontrated.
LATERAL PROJECTION
RAO or LAO body position
Position of part
- Adjust the patient in an RAO or LAO
position, with the affected scapula
centered to the grid. The average
patient require a 45 to 60 degree
rotation.
- Flex the elbow and place the back of
the hand on the posterior thorax.

Central ray
- Perpendicular to the midmedial
border of the protruding scapula.
Structures shown
A lateral image of the
scapula is demonstrated by
this projection.
Position of Part
Have patient reach across front
of chest and grasp opposite
shoulder.
PA OBLIQUE PROJECTION
LORENZ AND LILIENFELD METHODS
RAO or LAO position
Position of part
- With the patient in the lateral position,
upright or recumbent, center the scapula
to the midline of the grid device.
Lorenz method
- Adjust the arm of the affected side at a
right angle to the long axis of the body,
flex the elbow, and rest the hand against
the patient's head.
-Rotate the body slightly forward.

LiIienfeld method
- Extend the arm of the affected side
obliquely upward, and have the patient rest
the hand on his or her head.
- Rotate the body slightly forward.
Central ray
Lorenz method
- Perpendicular to the IR,
between the chest wall and the
mid area of the protruding
scapula.

Structures shown
An oblique image of the scapula
is shown. The degree of obliquity
depends on the position of the
arm.

Lilienfeld method
Coracoid Process
AP AXIAL PROJECTION
- Place the patient in the supine position with the arms along the sides of the body.
Position of part
- Center the affected coracoid process to the midline of the grid.
- Abduct the arm of the affected side slightly, and supinate the hand.

Central ray
- Directed to enter the coracoid process at an angle of 15 to 45 degrees cephalad.
Structures shown
- A slightly elongated inferosuperior image of the coracoid process is illustrated.
TANGENTIAL PROJECTION
LAQUERRIERE-PIERQUIN METHOD
Position of part
- Center the shoulder to the midline of the grid.
-Turn the head away from the shoulder being examined.

Central ray
Directed through the posterosuperior region of the shoulder at an angle of 45 degrees
caudad.
Structures shown
- The spine of the scapula is shown in profile and is free of bony superimposition,
except for the lateral end of the clavicle.

Scapular spine