Correctly positioned “fan” lateral of the
hand.
Correctly positioned PA & Oblique of the hand.
The lateral projection lacks complete superimposition
of the radius and ulna. However, the lateral passes
the minimal muster standard as being okay!
1 is the________________________________
2 is the________________________________
3 is the________________________________
4 is the________________________________
5 is the________________________________
6 is the________________________________
7 is the________________________________
8 is the________________________________
Question: Is 7 medial or lateral?
Use your textbook to label this image.
Hint: #2 is medial & #7 is the lateral epicondyle.
Correctly positioned PA hand. Note the
following:
This is an adult hand with a commonly
positioned sesmoid bone located at the
metacarpophalangeal joint.
Notice that virtually all of the joint spaces
show degenerative changes, which are
commensurate with the aging process.
Compare this image to that of a younger
individual.
Also, look closely at the phalanges for
signs of degenerative changes.
Finally, I suppose someone should have
removed the bracelet!
PA CXR with clipping of the Apicies. The
four D-min densities
(2 on each side of the chest) are likely due
to EKG attachments.
Lots of abdomen visible on this image,
which is why the apices were clipped.
You think?
Correct positioning of the forearm.
Note surgical reduction plate
attachment on Ulna.
Correctly positioned PA, oblique & lateral wrist.
Correctly positioned AP with good superimposition of the humeral epicondyles.
Is the elbow flexed more than it should be? A tad, you say.
Slightly rotated (to the right) PA CXR. Otherwise, good PA. A= Aortic arch;
B = Costophrenic angle; C = Apicies
Attempt at a lateral forearm – I think
Probably limited due to trauma, or at least
we hope so. Note partially flexed elbow,
and lack of superimposition of humeral
epicondyles.
AP Abdomen with intestinal tube
inserted via the nostril. Intestinal
tubes may be used to prevent or
relieve postoperative distention or
to deflate or decompress an
obstructed small bowel.
PA, Oblique & slightly rotated lateral of the wrist. Also, what is your
opinion regarding CR centering relative to the carpal bones?
“Rigid” lateral showing fracture reduction
plate on the first metacarpal. Question:
does this lateral appear a bit different
from what you may consider a traditional
lateral? Note the anterior placement of
the 5th metacarpal relative to the other
metacarpals. This projection sure does
demonstrate the 5th metacarpal well from
the lateral perspective don’t you agree.
AP External Rotation
AP Internal Rotation
The AP external rotation position shows the greater tuberosity to be in profile, which
gives the humeral head a less than round appearance. The AP internal rotation
position shows the greater and lesser tuberosities to be superimposed resulting in a
more rounded appearance of the humeral head. Over external rotation will diminish
the visual prominence of the greater tuberosity. By the way, which of these images
were taken employing a grid?
Identification:
1 is_____________________________
2 is_____________________________
3 is_____________________________
4 is_____________________________
5 is_____________________________
6 is_____________________________
7 is_____________________________
8 is_____________________________
9 is_____________________________
10 is____________________________
Never lower tillies pants . . .
Lateral CXR: Note the position
of the posterior ribs. Are they
superimposed?
Which - A or B- is the left
hemidiaphragm and Why?
A
B
Which metacarpal
fracture contains
the reduction plate?
How would you
improve upon the
lateral projection?
Is this an adult or
pediatric patient?
How do you know?
Is the fracture old or
relatively new? How
do you know?
Which projection does this image
represent? Does the image
include all of the appropriate
anatomy?
A is the____________________
B is the ____________________
D
C is the ____________________
D is the____________________
This image represents: A) External AP rotation, B) AP Scapula,
C) Internal AP rotation, D) Wanna be Y view E) AP Clavicle C R 150 cephalic
Appears to be a relatively good fan lateral.
However, it is unnecessary to allow the
index finger to touch the first digit ad this
often causes distortion to the mid-phalanx
joint. I suppose the fifth digit could have
been extended out more. What do you
think?
Good example of a routine finger series. However, the white arrow is pointing to the
distal end of the 3rd phalanx. Is the joint space superimposed? Look closely at the
tip of the arrow and ask yourself how many surfaces of the distal end do I see?
Based on the position of the white line, can you offer a critique relative to CR
centering? Also, is this an internal or external rotation? Finally, what does the
sternal end of the clavicle suggest to you given the position of the SC joint?
For the sake of uniformity, it is
probably best to mark the RIGHT
side in abdomen and CXRs. Was
this abdomen taken AP or PA and
how do you know? Does this
upright fulfill the criteria for an
adequate upright image?
Do you think the object in the
circle is internally located? Hint:
there is a similar object next to the
LT. marker. Remember,
coincidence does increase one’s
suspicions.
Identify:
1 is__________________________
2 is__________________________
3 is__________________________
4 is__________________________
5 is__________________________
6 is__________________________
7 is__________________________
Is this an RAO or an LAO?
Routine PA and oblique of the hand. Does the 5th digit appear swollen
(endematous)? Perhaps that is why the radiographer could not straighten the 5th
digit, which is also the reason why the distal end of the 1st phalanx appears distorted!
So is there a fracture at this sight? Probably not, but who knows? Remember, x-ray
images are intended to take the mystery out of interpreting injuries – not add to it.
Another ho hummie example of a correctly positioned wrist series. The lateral is
superb!
The metallic objects causing the increase in photoelectric absorption suggest the
presence of clasps associated with a shoulder harness to restrain upper arm
movement. Within the circle I see patterns of increase density, which has the
appearance of subcutaneous air arising from a penetrating wound. The arrow is
pointing to what appears to be a separation in the skin. On the other hand, was this
image taken with the patient taken laying on a foam filled object with the cassette
beneath the object? Strange D-mins appear throughout the humeral soft tissue.
Another mystery for Sherlock and his side kick. Was this an external rotation?
A
B
C
Another ho hummie routine wrist series. Wonderful lateral, but is the AP a true AP,
or is it somewhere in between? Beats my pair of Jacks!
This strange-looking stuff situated within the circle is more subcutaneous air from a
penetrating wound, or is it the pillow placed beneath the patients head? By the
way, is the an internal or external rotation from the AP position?
Try to keep the mysteries to a minimum!
Is this an AP or a lateral projection of
the humerus? The answer lies in
locating the epicondyles of the distal
humerus and the appearance of the
proximal humerus.
Did you notice the fracture at the midhumerus? Is it relatively new or old and
once again, how do you know?
More Identification – Oh ________!
1 is_______________________________
2 is_______________________________
3 is_______________________________
4 is_______________________________
5 is_______________________________
6 is_______________________________
7(the arrow) is________________________
8 (another arrow) is____________________
The projection is______________________
On your initial inspection of this
image, you will think the image
has one or more of the
characteristics of a post mortem
chest. A closer look reveals air in
the trachea and Rt. and Lt. main
stem bronchi. There is air in both
costo-phrenic angles, so the
gutters are clear The dotted line
runs parallel with the anterior
pects, which are present
bilaterally (arrow on right side). So
what you are viewing represents
significant fluid accumulation
bilaterally. From a technique
standpoint, does this image
demonstrate the anatomy one
expects to see on a CXR?
External or internal rotation? Is this an AP or lateral
projection of the shoulder?
This would appear to be an attempt at a
fan lateral of the hand. There is definite
flexion of the wrist. Otherwise, who
knows. Just make sure that you
recognize the difference between the
good, the bad and the ugly! I believe this
is an ugly and it gives one the impression
that the radiographer may not understand
what she/he is about.
More identification:
1 is___________________
2 is___________________
3 is___________________
4 is___________________
5 is___________________
6 is___________________
7 is___________________
8 is___________________
Note: instructors at USA and the ARRT Registry love to ask students to identify
structures in just about any bone joint.
If this is a clavicle image, is the CR angled 150 cephalic? If the image is an AP
shoulder, is the humerus internally or externally rotated?
This is a
good
example of
an erect
abdomen.
Routine forearm: Provide a
critique of the lateral.
Is the humeral head internally or
externally rotated. Look at the
humeral epicondyles. Is the
humerus over rotated? I think so.
Good example of a properly positioned routine elbow.
A reasonably good “Y” View”
-contour of the scapula projects as the
letter Y
- downward stem of the Y is projected by
body of the scapula;
- upper forks are projected by the coracoid
process anteriorly and by the spine and
acromion posteriorly;
- glenoid is located at the junction of the
stem;
- normally, humeral head is at the center of
the arms.
w/ posterior shoulder dislocation, head lies
posterior to glenoid & in anterior
dislocations it is anterior to glenoid;
- even though AP view may suggest
posterior dislocation, a Y view x-ray will
confirm the diagnosis
- note: that axillary view is best true
lateral view of shoulder, but is likely to
prove to painful for the patient in cases of
fracture or dislocation!
1 is___________________, 2 is__________________, 3 is_______________
The white dotted line parallels which osseous structure?
A
B
Remember: intraluminal gas is usually normal, unless excessive. Extraluminal
gas patterns are always abnormal. Both images demonstrate intraluminal gas
patterns.
Good example of an AP
humerus.
Note the position of the greater
tuberosity and the humeral
epicondyles.
A
In comparing image A to B, is
B identified correctly as the
AP Axial view?
How do you know?
The answer lies in the
difference between the shape
of the clavicles.
B
Note: B is correctly identified.
1 is_______________________
2 is_______________________
3. is______________________
4 is_______________________
5 is_______________________
6 is_______________________
7 is_______________________
Question: was this image taken
prone or supine?
This is an___________________________ position.
Provide a critique of this image noting
the position of the distal radius and
ulna.
Dislocated humerus. Note the
humeral head is dislocated from
the glenoid cavity.
Under this condition, would an
internal and external rotation
series be advisable.
Answer: Not if I am the patient!
Another dislocated humerus. See the
glenoid cavity.
This is an attempt at a “Y” view.
Note that the proximal humerus along
with the coracoid process are located
within the thoracic cavity. This
observation indicates that the degree
of rotation is greater than it should be.
R
Transthoracic positions are seldom
employed today. However, there will be an
instance in which this approach is the only
one available to you in determining humeral
dislocations and mid-shaft fractures.
It has been suggested that a breathing
technique be employed in the transthoracic
position to blur out the lung markings. If this
approach is used, make sure the humerus
does not become part of the respiratory
excursion process or otherwise the
humerus will exhibit motion.
What a neat job of repairing a 3rd digit
proximal phalanx fracture.
Is this image an internal or external AP of the shoulder?
Is this image an internal or external AP of the shoulder?
I hate to complain, but could the lead blocker spacing be a bit more
equally divided? Also, note the degenerative changes in the finger.
Do you think someone
needs to work on equal
lead blocker
placement.
1 is________________, 2 is___________________, 3 is________________
A good example of a correctly positioned routine wrist.
Other than clipping the distal phalanx
of digits 3 and 4, it looks like a good
attempt at a fan lateral.
1 is rib number______________, 2 is____________________________
3 is________________________ Both scapula removed from the lung
field? Wow!
Is this a lateral projection of the humerus? The answer lies in identifying the
humeral epicondyles (white arrow). Are they perpendicular or parallel to the
IR? If , then the image is a lateral projection.
If this is a clavicle view, was the CR angled? If this image is an AP shoulder, is
the humerus externally rotated?
This image qualifies as a
terrific portable KUB.
A great example of a good “Y”
view
A is______________________
B is______________________
C is______________________
D is______________________
E is______________________
F is______________________
G is______________________
H is______________________
This “Y” view demonstrates what
happens when too much rotation is
applied. Note the presence of the
humeral head and the coracoid
process situated within the thoracic
cavity. To correct the problem
decrease the body rotation to less
than 450
Obtaining an axillary view while the patient is seated in a wheelchair
This “Y” view demonstrates
what happens when the
degree of rotation is less
than desired. Note that the
scapula appears to be
obliqued. To correct the
problem, increase the
patient’s body rotation, but
not to 450
An interesting comparison
Because of its size, I do not recommend attempting to study the labeling
A
B
Which image (A or B) demonstrates a pneumothorax and how do you know?
While the white arrows could provide a clue, they do not explain – how do you
know?
What does the encircled arrow tell you and do you believe it is correct?
The radiographer who performed the exam stated the arrow was/is correct.
The other arrows on the left side indicate the presence of pleural fluid.
The Influence of Patient Types
Hyposthenic
Hypersthenic
A
B
Do these images meet the criteria for satisfactory AP and Lateral projections of
the humerus? By the way, which one (A or B) is the AP? The answer lies in
locating the humeral epicondyles and determining which one is parallel and
which one is  .
A perfect lateral scapula
An AP clavicle with a 150 CR angulation. Appears to be fractured. Do you
think?
L
The AP reveals a comminuted fracture of the neck of humerus. There is also some
evidence of subluxation of the GH joint which may be pseudosublaxation
rather than a true dislocation of the glenohumeral joint.
The radiographer decided that it was appropriate to perform a transthoracic lateral
projection of the shoulder given the patient's age( 95 ) ,injury and level of pain. The
fracture is well demonstrated in the transthoracic lateral
A good example of a
great “Y” view
B
A
Image ______ represents an internal rotation. Image ______ represents an AP
The value of the “Y” view is
demonstrated in this image
showing fracture and
dislocation.
A good example of AC joints
Is that a necklace attached to the patient?
B
A
Which image ( A or B) demonstrates an internal rotation?
AP abdomen demonstrating “ground glass” appearance due to pus or
fluid in the peritoneal space.
Remember, extraluminal gas is
abnormal. So, what do you see
bilaterally beneath each
diaphragm?
Where could the free air located
beneath the R & L diaphragm
come from?
Meganblase is not the answer.
We don’t do these
anymore.
fini