ELBOW RADIOGRAPHY

Projection Method Part Position Central Ray Structures Shown

AP Projection No method Extend the elbow, Perpendicular to the elbow AP projection of the elbow
supinate the hand, and joint joint, distal arm, and
center the IR to the elbow proximal forearm
joint.
Lateral Projection No method From the supine position, Perpendicular to the elbow Elbow joint, distal arm, and
flex the elbow 90 degrees joint proximal forearm
AP Oblique Projection No method  Extend the limb in Perpendicular to elbow Oblique projection of the
(Medial Rotation) position for an AP joint elbow with the coronoid
projection and process projected free of
center the superimposition
midpoint of the IR
to the elbow joint.
 Medially
(internally) rotate
or pronate the
hand and adjust
the elbow to place
its anterior surface
at an angle of 45
degrees.
AP Oblique Projection No method  Extend the Perpendicular to the elbow Oblique projection of the
(Lateral Rotation) patient’s arm in joint elbow with the radial head
position for an AP and neck projected free of
projection, and superimposition of the
center the ulna.
midpoint of the IR
to the elbow joint.
 Rotate the hand
laterally
(externally) to
place the posterior
surface of the
elbow at a 45-
degree angle.
 Distal Humerus – AP No method If possible, supinate the Perpendicular to the Distal humerus when the
Projection (Partial Flexion) hand. Place the IR under humerus, traversing the elbow cannot be fully
the elbow, and center it to elbow joint. extended.
the condyloid area of the
humerus.
Proximal Forearm – AP No method  Seat the patient Perpendicular to the elbow Proximal forearm when
Projection (Partial Flexion) high enough to joint and long axis of the the elbow cannot be fully
permit the dorsal forearm extended
surface of the
forearm to rest on
the table.
 If this position is
impossible, elevate
the limb on a
support, adjust the
limb in the lateral
position, place the
IR in the vertical
position behind the
upper end of the
forearm, and direct
the central ray
horizontally.
Distal Humerus – AP Jones Method  Center the IR Perpendicular to the  This position
Projection (Acute Flexion) proximal to the humerus, approximately 2 superimposes the
epicondylar area of inches (5 cm) superior to bones of the
the humerus. the olecranon process forearm and arm.
 The long axis of the  The olecranon
arm and forearm process should be
should be parallel clearly shown.
with the long axis
of the IR.
Proximal Forearm – PA No method  Center the flexed Perpendicular to the flexed  Superimposed
Projection (Acute Flexion) elbow joint to the forearm, entering bones of the arm
center of the IR. approximately 2 inches (5 and forearm are
 The long axis of the cm) distal to the olecranon outlined.
 superimposed process  The elbow joint
forearm and arm should be more
should be parallel open than for
with the long axis projections of the
of the IR. distal humerus.
Radial Head – Lateral No method  Flex the elbow 90 Perpendicular to the elbow Radial head is projected in
Projection Lateromedial degrees, center the joint varying degrees of rotation
joint to the
unmasked IR, and
place the joint in
the lateral position
 1 st exposure: with
the hand supinated
as much as is
possible.
 2nd exposure: with
the hand in the
lateral position,
that is, with the
thumb surface up
 3rd exposure: with
the hand pronated.
 4 th exposure: with
the hand in
extreme internal
rotation, that is,
resting on the
thumb surface.
Radial Head and Coronoid Coyle Method Seated Position: Seated position  Show an open
Process Axiolateral  Pronate the hand  Radial head elbow joint
Projection and flex the elbow - Directed between the radial
90 degrees to show toward the head and capitulum
the radial head or shoulder at an or between the
80 degrees to show angle of 45 coronoid process
the coronoid degrees to the and trochlea with
process. radial head; the area of interest
  Center the IR to the central ray in profile.
elbow joint. enters the joint  These projections
 For patients with at mid-elbow are used to show
muscular forearms,  Coronoid process pathologic
elevate the wrist to - Directed away processes or
place the forearm from the trauma in the area
parallel with the IR shoulder at an of the radial head
Supine Position: angle of 45 and coronoid
 Elevate the distal degrees to the process.
humerus on a coronoid
radiolucent sponge. process; central
 Place the IR in ray enters the
vertical position joint at mid-
centered to the elbow.
elbow joint. Supine position for trauma
 Epicondyles should  Radial head
be approximately - The horizontal
perpendicular to central ray is
the IR. directed
 Slowly flex the cephalad at an
elbow 90 degrees angle of 45
to show the radial degrees to the
head or 80 degrees radial head,
for the coronoid entering the
process. joint at mid-
 Turn the hand so elbow
that the palmar  Coronoid process
aspect is facing - The horizontal
medially. central ray is
 An assistant may directed caudad
need to hold the at an angle of
hand depending on 45 degrees to
the severity of the coronoid
trauma. process,
entering the
joint at mid-
 elbow.
Distal Humerus – PA Axial  Ask the patient to Perpendicular to the ulnar Epicondyles, trochlea,
Projection rest the forearm on sulcus, entering at a point ulnar sulcus (groove
the table, and then just medial to the between the medial
adjust the forearm olecranon process epicondyle and the
so that its long axis trochlea), and olecranon
is parallel with the fossa.
table.  The projection is
 Flex the patient’s used in
elbow to place the radiohumeral
arm in a nearly bursitis (tennis
vertical position so elbow) to detect
that the humerus otherwise obscured
forms an angle of calcifications
approximately 75 located in the ulnar
degrees from the sulcus.
forearm.
 Supinate the hand
to prevent rotation
of the humerus and
ulna.
Olecranon Process – PA  Adjust the arm at Perpendicular to the Olecranon process and the
Axial Projection an angle of 45 to 50 olecranon process to show articular margin of the
degrees from the the dorsum of the olecranon and humerus
vertical position, olecranon process and at a
and ensure that the 20-degree angle toward
patient is not the wrist to show the
leaning anteriorly curved extremity and
or posteriorly. articular margin of the
 Supinate the hand olecranon process
and have the
patient immobilize
it with the opposite
hand.
 HUMERUS RADIOGRAPHY
Projection Method Part Position Central Ray Structures Shown
AP Projection – Upright No method  Adjust the height of Perpendicular to the Entire length of the
the IR to place its midportion of the humerus humerus.
upper margin and the center of the IR  The accuracy of the
about 11 2 inches position is shown
(3.8 cm) above the by the epicondyles.
level of the
humeral head.
 Abduct the arm
slightly and
supinate the hand.
 A coronal plane
passing through the
epicondyles should
be parallel with the
IR plane for the AP
(or PA) projection.
Lateral Projection,  Place the top Perpendicular to the Entire length of the
Lateromedial, No method margin of the IR midportion of the humerus humerus.
Mediolateral – Upright approximately 1 ½ and the center of the IR  A true lateral image
inches (3.8 cm) is confirmed by
above the level of superimposed
the humeral head. epicondyles
 Unless
contraindicated by
possible fracture,
internally rotate
the arm, flex the
elbow
approximately 90
degrees, and place
the patient’s
anterior hand on
the hip.
- This places the
 humerus in
lateral position.
 A coronal plane
passing through the
epicondyles should
be perpendicular
with the IR plane.
 A patient with a
broken humerus
may be easier to
position by
performing a
mediolateral
projection.
AP Projection –  Place the upper
Recumbent No method margin of the IR Perpendicular to the
approximately ½ midportion of the
inches (3.8 cm) humerusand the center of
cabove the the IR
humeral head.
 Elevate the
opposite shoulder
on a sandbag to
place the affected
arm in contact with
the IR or elevate
the arm and IR on
sandbags.
 Unless
contraindicated,
supinate the hand
and adjust the limb
to place the
epicondyles parallel
with the plane of
the IR.
  Shield gonads
 Respiration:
Suspend
Lateral Projection –  Adjust the top of Directed to the center of The lateral projection
Recumbent No method the IR to be the IR, which exposes only demonstrates the distal
approximately 1 ½ the distal humerus humerus
inches (3.8 cm)
above the level of
the head of the
humerus.
 Rotate the forearm
medially to place
the epicondyles
perpendicular to
the plane of the IR,
and rest the
posterior aspect of
the hand against
the patient’s side.
This movement
turns the
epicondyles in
lateral position
without flexing the
elbow.
 Adjust the position
of the IR to include
the entire length of
the humerus.

SHOULDER RADIOGRAPHY
Projection Method Part Position Central Ray Structure Shown
 AP Projection No method  Adjust the position of the IR Perpendicular to a point 1 Greater tubercle of the
(External Rotation) so that its center is 1 inch (2.5 inch (2.5 cm) inferior to the humerus and the site of
cm) inferior to the coracoid coracoid process, which insertion of the
process can be palpated inferior to supraspinatus tendon
 Supinate hand, unless the clavicle and medial to
contraindicated the humeral head
AP Projection No method  Adjust the position of the IR Perpendicular to a point 1 Posterior part of the
(Neutral Rotation) so that its center is 1 inch (2.5 inch (2.5 cm) inferior to the supraspinatus insertion,
cm) inferior to the coracoid coracoid process, which which sometimes profiles
process can be palpated inferior to small calcific deposits
 Palm of the hand against the the clavicle and medial to
thigh the humeral head
 Place the epicondyles at an
angle of about 45 degrees
with the plane of the IR
AP Projection No method  Adjust the position of the IR Perpendicular to a point 1 Proximal humerus is seen
(Internal Rotation) so that its center is 1 inch (2.5 inch (2.5 cm) inferior to the in a true lateral position
cm) inferior to the coracoid coracoid process, which
process can be palpated inferior to
 Ask the patient to flex the the clavicle and medial to
elbow, rotate the arm the humeral head
internally, and rest the back
of the hand on the hip
 Adjust the arm to place the
epicondyles perpendicular to
the plane of the IR
 Respiration: Suspend
Transthoracic Lateral No method  Have the patient raise the Perpendicular to the IR, Shoulder and proximal
Projection uninjured arm, rest the entering the MCP at the humerus projected
R or L Position forearm on the head and level of the surgical neck through the thorax
elevate the shoulder as much
as possible
 MCP perpendicular to the IR
 Center the IR to the surgical
neck area of the affected
humerus
 Shield gonads
 Respiration: full inspiration
 3 seconds of exposure time
with low mA – gives excellent
results

SHOULDER JOINT RADIOGRAPHY

Projection Method Part Position Central Ray Structure Shown
Inferosuperior Axial Lawrence Method  Abduct the arm with a minimum  Horizontally Proximal humerus, the
Projection of 20 degrees of the affected side through the axilla scapulohumeral joint, the
at right angles to the long axis of to the region of lateral portion of the
the body to prevent the AC coracoid process, and the
superimposition of the arm on articulation. AC articulation
the shoulder.  The degree of
 Keep the humerus in external medial angulation
rotation and adjust the forearm of the central ray
and hand in a comfortable depends on the
position. degree of
 Have the patient turn the head abduction of the
away from the side being arm.
examined.  The degree of
 IR on the edge against the medial angulation
shoulder and as close as possible is often between
to the neck. 15 degrees and
 30 degrees.
 The greater the
abduction, the
greater the angle.
Inferosuperior Axial Lawrence Method Externally rotate the extended arm until Horizontal and angled Proximal humerus, the
Projection (Rafert the hand forms a 45-degree oblique approximately 15 scapulohumeral joint, the
Modification) angle. The thumb is pointing downward. degrees medially, lateral portion of the
entering the axilla and coracoid process, and the
passing through the AC AC articulation
joint.

Inferosuperior Axial West Point  Abduct the arm of the affected Directed at a dual angle Bony abnormalities of
Projection Method side 90 degrees, and rotate so of 25 degrees anteriorly the anterior inferior rim
that the forearm rests over the from the horizontal and of the glenoid and Hill-
edge of the table or a Bucky tray, 25 degrees medially Sachs defects of the
which may be used for support posterolateral humeral
 Place a vertically supported IR head in patients with
against the superior aspect of the chronic instability of the
shoulder with the edge of the IR shoulder
in contact with the neck.
 Respiration: Suspend

Superoinferior Axial No method  Patient lean laterally over the IR Angled 5 to 15 degrees  Joint relationship
Projection until the shoulder joint is over through the shoulder of the proximal
the midpoint of the IR joint and toward the end of the
 Elbow to rest on the table elbow; a greater angle is humerus and the
 Flex the patient’s elbow 90 required when the glenoid cavity
degrees, and place the hand in patient cannot extend  AC articulation,
the prone position the shoulder over the IR the outer portion
 Have the patient tilt the head of the coracoid
toward the unaffected shoulder process, and the
 Shield gonads points of insertion
 Respiration: Suspend of the
 subscapularis
muscle (at body
of scapula) and
teres minor
muscle (at
inferior axillary
border)
Supraspinatus “Outlet” Neer Method  With the patient’s affected Angled 10 to 15 degrees Posterior surface of the
Tangential Projection shoulder centered and in contact caudad, entering the acromion and the AC
(RAO or LAO Position) with the IR, rotate the patient’s superior aspect of the joint identified as the
unaffected side away from the IR. humeral head superior border of the
 Average degree of patient coracoacromial outlet
rotation varies from 45 to 60
degrees from the plane of the IR
 Patient’s arm at the patient’s side
 Shield gonads
 Respiration: Suspend

AP Axial Projection No method  Center the scapulohumeral joint Directed through the Shows the relationship of
of the shoulder being examined scapulohumeral joint at a the head of the humerus
to the midline of the grid cephalic angle of 35 to the glenoid cavity
 Shield gonads degrees
 Respiration:

Proximal Humerus AP Stryker Notch  Patient to flex the arm slightly Angled 10 degrees Posterosuperior and
Axial Projection Method beyond 90 degrees and place the cephalad, entering the posterolateral areas of
palm of the hand on top of the coracoid process the humeral head
head with fingertips resting on
the head
 Shield gonads.
 Respiration: Suspend.
 Glenoid Cavity Radiography
Projection Method Part Position Central Ray Structure Shown
AP Oblique Grashey  IR to the scapulohumeral joint (joint is 2 Perpendicular to the IR; Joint space between the
Projection Method inches (5 cm) medial and 2 inches (5 cm) the central ray should humeral head and the
(RPO or LPO inferior to the superolateral border of be at a point 2 inches (5 glenoid cavity
Position) the shoulder) cm) medial and 2 inches (scapulohumeral or
 35 to 45-degree body obliquity toward (5 cm) inferior to the glenohumeral joint)
the affected side superolateral border of
 Scapula parallel with the plane of the IR the shoulder
 If the patient is in the recumbent
position, the body may need to be
rotated more than 45 degrees (up to 60
degrees) to place the scapula parallel to
the IR
 Abduct the arm slightly in internal
rotation, and place the palm of the hand
on the abdomen
 Shield gonads
 Respiration: Suspend
AP Oblique Apple Method  35 to 45-degree body rotation toward Perpendicular to the IR Scapulohumeral joint
Projection the affected side at the level of the
(RPO or LPO  Posterior surface of the affected side is coracoid process
Position) closest to the IR.
 Hold a 1-lb weight in the hand on the
same side as the affected shoulder in a
neutral position
 While holding the weight, the patient
should abduct the arm 90 degrees from
the midline of the body
 Shield gonads
 Respiration: Suspend
AP Axial Oblique Garth Method  Center the IR to the glenohumeral joint Perpendicular to the Scapulohumeral joint,
Projection (RPO or  45-degree body rotation toward the glenohumeral joint humeral head, coracoid
LPO Position) affected side process, and scapular head
  Posterior surface of the affected side is and neck
closest to the IR
 Flex the elbow of the affected arm and
place arm across the chest
 Shield gonad
 Respiration: Suspend
Intertubercular No method  With the patient supine, palpate the Angled 10 to 15 degrees
(Bicipital) Groove anterior surface of the shoulder to posterior (downward
Tangential locate the intertubercular (bicipital) from horizontal) to the
Projection groove long axis of the
 With the patient’s hand in the supinated humerus for the supine
position, place the IR against the position
superior surface of the shoulder and
immobilize the IR
Intertubercular Fisk  Flex the elbow and lean forward far Perpendicular to the IR Profiles the intertubercular
(Bicipital) Groove Modification enough to place the posterior surface of when the patient is (bicipital) groove free from
Tangential the forearm on the table leaning forward and the superimposition of the
Projection  Have the patient lean forward or vertical humerus is surrounding shoulder
backward as required to place the positioned 10 to 15 structures
vertical humerus at an angle of 10 to 15 degrees
degrees