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HLT-RADI64-07 · Lesson 5 · 30 clock hours · field

Upper Extremity Radiography: Hand, Wrist, Elbow, and Shoulder

Objective. The student will produce diagnostic-quality radiographs of upper extremity structures in all required projections, correctly positioning patients including those with trauma limitations, within the ARRT Limited Scope extremity pathway.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Upper Extremity Radiography: Hand, Wrist, Elbow, and Shoulder

Upper extremity radiography is one of the most common exam categories you will perform as a limited-scope radiographer. Producing diagnostic images requires precise positioning, appropriate technical factors, correct marker placement, and a patient-centered approach — especially when trauma is involved.

Anatomy Review

The upper extremity includes the phalanges, metacarpals, carpals (eight bones arranged in two rows), radius, ulna, humerus, and the bones of the shoulder girdle (scapula and clavicle). Key joints are the interphalangeal, metacarpophalangeal, radiocarpal (wrist), elbow (humeroulnar, humeroradial, and proximal radioulnar), and glenohumeral joints. You must know the names and locations of these structures so that you can place the anatomy of interest at the center of the image receptor and verify your images against known landmarks.

Standard Projections by Region

Hand and Fingers: Routine projections include PA, oblique, and lateral views of the hand. For individual fingers, PA, lateral, and oblique projections are standard. The hand is placed palm-down (PA) on the receptor with fingers extended and slightly separated.

Wrist: Routine views are PA, oblique, and lateral. Additional views such as the scaphoid (ulnar deviation) or carpal tunnel projection may be ordered. In the PA, the wrist is centered to the receptor with the elbow flexed approximately 90 degrees and the forearm in a true PA position.

Elbow: Standard projections are AP and lateral. A lateral elbow is obtained with the elbow flexed 90 degrees, the thumb pointing upward, and the epicondyles superimposed. For the AP, the elbow is fully extended with the epicondyles parallel to the receptor. When full extension is not possible (trauma), partial-flexion AP projections of the distal humerus and proximal forearm are performed separately.

Shoulder: Routine projections include AP internal rotation, AP external rotation, and a scapular Y (or transthoracic lateral) view. The AP projections demonstrate the glenohumeral joint space; rotation is assessed by the position of the humeral head and greater tubercle. The scapular Y view is taken with the patient's shoulder against the receptor, body obliqued approximately 45–60 degrees, and the central ray directed perpendicular to the scapular body.

Trauma Modifications

Trauma patients may not tolerate standard positioning. Your priority is patient safety and comfort — never force a limb into position. For a painful or splinted wrist, angle the central ray rather than rotating the wrist. For an elbow that cannot be fully extended, use the trauma AP technique: keep the limb as flat as possible and take two separate projections (one for the distal humerus, one for the proximal forearm) with the receptor flat on the table. For a shoulder injury where the patient cannot rotate the arm, a transthoracic lateral or a Velpeau view may substitute. Always notify the supervising technologist before modifying a projection, and document the modification in your clinical logbook.

Marker Placement and Patient Identification

Always place a lead R (right) or L (left) marker on the image before exposure, in an area that will not obscure anatomy. Correct laterality marking is a legal and safety requirement — an incorrectly marked image can lead to wrong-side treatment. Verify the patient's identity using at least two identifiers (name and date of birth) before beginning any exam. Confirm the order, the body part, and the side with the patient and the requisition.

Technical Factors and Image Quality

Upper extremity exams generally use low-to-moderate kVp (typically in the range appropriate for small parts and soft tissue) and relatively low mAs because the limbs are thinner than the trunk. For digital systems, collimate closely to the body part of interest — tight collimation reduces scatter, improves image contrast, and lowers patient dose. Evaluate each image for: correct positioning (anatomy of interest centered and fully included), adequate exposure (appropriate brightness and contrast on digital systems), absence of motion, correct marker, and proper patient identification information.

Radiation Safety

Lead aprons or gonadal shielding should be considered for all patients, especially when the primary beam is near the trunk or reproductive organs. Though upper extremity exams direct the beam away from the trunk in most cases, always follow your department's ALARA (As Low As Reasonably Achievable) policy. Keep your own body out of the primary beam; stand behind the control barrier or step back and use the Bucky when possible.

Scope of Practice Reminder

As a limited-scope radiographer, you are authorized to perform specific projections as defined by your state license and program scope. You must not perform fluoroscopy, computed tomography, or other modalities outside your credential. When in doubt about whether a requested view is within your scope, consult your supervising technologist immediately.

Documentation

Record every exam in your clinical logbook: date, exam type, patient age range, projections performed, positioning notes, and image quality comments. Accurate documentation is required for competency verification and for your ARRT application.

Key terms10

PA projectionA projection in which the X-ray beam travels from posterior (back) to anterior (front) of the body part; the body part is placed closest to the image receptor on its anterior (palm-down for the hand) surface.
Oblique projectionA projection obtained with the body part rotated partway between a true PA or AP and a lateral position, demonstrating structures that would otherwise be superimposed.
Central rayThe center of the X-ray beam; it is directed to a specific anatomical point on the patient and to the center of the image receptor to ensure proper positioning.
ALARAAs Low As Reasonably Achievable — the guiding principle of radiation protection requiring that patient and worker exposure be kept as low as possible while still producing a diagnostic image.
Trauma modificationAn adjusted positioning technique used when a patient cannot assume the standard position due to injury or pain; the central ray or receptor angle is changed instead of moving the injured limb.
Laterality markerA lead R or L marker placed on the image receptor before exposure to permanently identify the right or left side of the body part being imaged.
Glenohumeral jointThe ball-and-socket joint formed between the head of the humerus and the glenoid fossa of the scapula; the primary joint demonstrated in shoulder radiography.
Scapular Y viewA shoulder projection in which the patient is obliqued so that the scapular body, spine, and coracoid process form a Y shape, with the humeral head centered at the junction; used to evaluate glenohumeral dislocation.
CollimationThe restriction of the X-ray beam to only the area of clinical interest using adjustable lead shutters; reduces scatter radiation and patient dose.
Image receptor (IR)The device that captures the X-ray beam after it passes through the patient; in digital radiography this is a flat-panel detector or computed radiography (CR) cassette.
In class: Perform a minimum of 15 upper extremity exams covering at least three anatomical regions (hand/wrist, elbow, and shoulder), documenting each case with positioning notes and image quality comments. · Practice trauma modification techniques for wrist and elbow on a cooperative peer in the department hallway or practice area under technologist supervision before applying to patients. · Evaluate 10 upper extremity images with the supervising technologist, correctly identifying at least 8 anatomical landmarks per case and noting any positioning or exposure errors.
Materials: Radiographic table and digital receptor, positioning sponges and sandbags, lead markers (R and L), Bontrager's Handbook, image evaluation rubric, clinical logbook
Check: Formal competency checkoff for one region (hand/wrist OR elbow OR shoulder) as designated by the program coordinator; 8/10 or above on image evaluation rubric required; if failed, student repeats with additional supervised exams.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Patient Positioning and Procedures
1. When performing a routine PA projection of the hand, which surface of the hand is placed in contact with the image receptor?
Patient Safety and Trauma Positioning
2. A trauma patient presents with a painful, splinted elbow that cannot be fully extended. Which approach best protects patient safety while still obtaining an AP-equivalent view?
Patient Positioning and Procedures
3. For a lateral elbow projection, the elbow should be flexed to approximately how many degrees?
Radiation Protection and Safety
4. Which of the following best describes why close collimation is important during upper extremity radiography?
Patient Safety and Quality Assurance
5. Before beginning an upper extremity radiographic exam, the technologist should verify patient identity using:
Image Evaluation and Quality
6. During image evaluation after a PA wrist projection, the supervising technologist notes that the carpal bones are cut off on the ulnar side. This error is most likely due to:
Anatomy and Pathology Recognition
7. A scapular Y view of the shoulder is primarily used to evaluate for:
Scope of Practice and Professional Standards
8. A limited-scope radiographer is asked by a nurse to perform a fluoroscopy procedure in the absence of the supervising radiologist. The radiographer should:
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