PA Oblique Hand Image Evaluation Final Dana Pilla

HIPAA Compliance This image is HIPAA compliant. There is no patient information seen on this image. There is nothing on this image that would compromise patient confidentiality.

Marker and Patient ID There is no anatomical side marker present on this image

I annotated a LEFT marker in that is placed correctly on the image

The marker is not superimposed over any pertinent anatomy

There are no additional markers needed for this xray

The image is now displayed correctly based on marker placement

L123

Radiation HygieneBeam Restriction Rule: at least 3 side of collimation must be seen on the image. This image only has two side of collimation which is not adequate Shielding Rule: Primary shielding (collimation) should be evident on side/edge closest to the gonads, which it is not

There is no evidence of secondary shielding in this image

L123

Completeness of Positioning/Projection

Routine projections of a hand are as follows:

PA Hand

PA Oblique Hand (lateral rotation)

Lateral Hand

This image complies with the routine because it is a PA oblique lateral rotation and all anatomical parts are correctly visualized

Artifact Identification There are preventable physical artifacts visible in this image (yellow) This patient has a severe trauma so maybe the swelling in their hand made is difficult for them to remove their ring On the oblique hand, the metacarpals should appear open, but in this image the fourth and fifth are superimposed because of over rotation of the part

Artifact Identification There is no hospital paraphernalia present on this image There is a ring present on this image that is patient belongings There is an indwelling artifact present on this image It seems as if the patient has a nail stuck in their hand, we would have to see a PA and a lateral to determine if it is in the soft tissue or the bone as well

Artifact Identification

There is no excess fog visible that is degrading the overall image

There are no CR/DR artifacts visible

Image SharpnessThere is no gross voluntary motion visible on this image

There is no excessive quantum mottle or noise visible

There is no evidence of a double exposure or ghosted image

There are no grid artifacts visible because a grid is not used for this examination

Image Sharpness Size distortion does not appear greater than expected

There is shape distortion being caused in this image because the CR should be centered to the third MCP joint

The CR is off centered >1 cm

Accurate Part Positioning

The part is adequately aligned to the image media but not accurately centered to the image media

The CR is off centered to the anatomical part by >1 cm

Accurate Part Positioning

This image shows acceptable alignment according to the IR exposure field recognition template/field

Accurate Part Positioning Seat the patient at the end of the radiographic tableAdjust the patient’s height to rest the forearm on the table

Rest the patient’s forearm on the table with the hand pronated and the palm resting on the IR Adjust the obliquity of the hand so that the MCP joints form an angle of 45 degrees with the IR plane

If possible or avaliable, use a 45 degree foam wedge to support the extended position to show the IP joints

When examining the metacarpals, obtain a PA oblique projection of the hand by rotating the patients hand laterally (externally) from the pronated position until the fingertips touch the IR

Center the IR to the third MCP joint and collimation 1 inch in on all four sides of the IR

Evaluation Criteria

The following should be clearly shown: Evidence of proper collimation Minimal overlap of the 3rd-4th and 4th-5th

metacarpal shafts Slight overlap of the metacarpal bases and heads Separation of the 2nd and 3rd metacarpals Open IP and MCP joints Digits separated slightly with no overlap of their

soft tissues All anatomy distal to the distal radius and ulna Soft tissue and bony trabeculation

This anatomical part is NOT positioned correctly based on this criteria

Judicious Exposure Technique The most radiolucent

structure seen on this image is the soft tissue surrounding the bony cortex

The most radiopaque structure seen on this image is the ring on the fourth metacarpal

Judicious Exposure Technique Assessment of the image’s

contrast (window width)The bony trabeculae and the outlines of the bony cortex are sharply defined. I believe that the window width is adequate

Assessment of the image’s brightness (window level) The image brightness appears to be acceptable. All bony structures are well visualized on the image. I believe that the EI value will be out of range because of the artifacts that are present in the image

Accept/Reject Image Because this was most likely a trauma examination and it is of diagnostic quality, I would not repeat it.

In the future I would definitely make an attempt to remove the patient’s ring and oblique their hand less to open up the 4th-5th metacarpal articulations I would also double check my centering to make sure that it is centered correctly as well as use my anatomical markers and collimate adequately.

References Frank, E. D., Long, B. W., Smith, B. J., Merrill, V., &

Ballinger, P. W. (2007). Merrill's atlas of radiographic positioning & procedures. St. Louis, MO: Mosby/Elsevier.

http://radiopaedia.org/articles/hand-x-ray-series

McQuillen-Martensen, K. (2015). Radiographic image analysis. Vol 4. St. Louis, MO: Elsevier