RADS – 216 Image Evaluation:

Radiograph Oral Presentation

Image Evaluation of the Hand, AP External

Oblique 45°By: Melissa Krezel

Is the Image HIPAA Compliant?

The image is HIPAA compliant.

All patients health information is

properly protected while allowing

the flow of health information

needed to provide and promote

high quality health care and to

protect the patients health and

well being.

The image does NOT violate

patient confidentially.

Marker & Patient ID

A right anatomical side marker is

visible in the image.

The marker is positioned so it is on

the viewers left side.

The technologists ID is included but

covered for confidential reasons.

The marker does NOT superimpose

any pertinent anatomy.

“A best practice on digital

radiography is the consistent use of

lead anatomic side markers

captured on the original image

during the x-ray exposure.”

Marker and Patient ID

An AP marker could be added

to demonstrate the correct

position of the part / patient.

The image is oriented correctly

with the patient’s hand rotated

medially to place the posterior

aspect of the hand on the IR.

However, it is difficult to see

the carpals (hamate,

triquetrum, & lunate) due to

soft tissue superimposition.

Radiation Hygiene Masking, shuttering, or cropping should NOT be

used as replacements for beam restriction

achieved through physical collimation of the x-

ray field size.

Beam restriction rule: Three sides of beam

restriction MUST be visible.

This image DOES have adequate three sided

beam restriction /collimation. The superior,

medial, and inferior aspect of the image displays

appropriate collimation.

“A best practice in digital radiography is the use

of secondary lead shielding for anatomic parts

that are adjacent to the x-ray field.”

Gonadal shielding rule: Shielding must be

provided if the gonads are within 5 cm of the

primary beam.

The image does in fact display evidence of

appropriate use of shielding because beam

restriction is visible on the medial, superior, &

lateral side of the IR, but should also have

included lateral aspect too.

Completeness of Position / Projection

PA

PA Oblique 45°

Lateral

Bilateral / Unilateral AP

Oblique 45°

My image is an attempt at a unilateral

AP oblique 45°

Artifact Identification

The ONLY artifact shown is the ID

bracelet.

There is presence of hospital

paraphernalia, but it does not obstruct

pertinent anatomy. (ID bracelet)

There is no evidence of foreign body or

indwelling artifacts.

There is no evidence of excess fog,

scatter, or noise present within the

radiographic image. Although the

image has an overall long scale of

contrast.

There is no evidence of patient clothing

/ belongings within the radiographic

image

Image Sharpness

There is NO gross voluntary motion visible

on the image.

There is NO excessive quantum mottle

present within the image, although the

image lacks overall spatial resolution.

There is NO evidence of double or

previous/ ghosted exposure.

No evidence of CR/DR artifacts.

Grid lines, grid artifact, or grid cut-off are

NOT visible in the image. A grid is NOT

used when imaging an oblique hand.

Size distortion does NOT appear to be

greater then expected.

There is NO evidence of shape distortion.

Accurate Part Positioning The part is not adequately centered to the

IR’s longitudinal axis. (white line)

The part is off centered to the IR (red lines)

The CR is centered to the IR (red lines)

The CR is NOT correctly centered over the

base of the 3rd metacarpal. (red lines)

AP Positioning of the External Oblique 45°

Positioning Criteria proceeds this info:

The CR should enter perpendicular to the

base of the 3rd metacarpal.

Seat the patient at the end of the

radiographic table.

Have the patient place their hand in a lateral

position.

Place two 45-degree radiolucent sponges

against the posterior aspect of the hand.

Extend the patient’s fingers, and abduct the

thumb slightly to avoid superimposition over

the fingers.

Similar hand position,

however my criteria is for a

Unilateral External Oblique

hand.

Accurate Part Positioning

Is the part accurately positioned based on this criteria?

The part is NOT correctly positioned

based on criteria listed on the previous

slides.

The CR needs to be centered over the

base of the 3rd metacarpal.

Does the CR’s Alignment Conform to an Accepted IR Exposure Field

Recognition Template / Field?

Yes, the image displays (3) sides of

beam restriction, However, the

medial side is not parallel to the

adjacent IR edge. The side closest

to the gonads has proper beam

restriction.

First Digit (Thumb) AP /PA Image Criteria

Positioning Criteria proceeds this info:

Area from the carpal bones to the tips of

digits in 45° oblique position are visible.

Midshafts of the 2nd though 5th metacarpals

and base of phalanges should not overlap.

(overlapping is evident.)

MCP joints should be open no

superimposition of the thumb and second

digit should occur. (superimposition is

evident.)

Carpals on medial side of wrist.

Triquetrum, hamate, and pisiform free of

superimposition & in profile.

Optimal brightness and contrast with no

motion.

Pisiform

Hamate

Triquetrum

Judicious Exposure Technique

Most Radiolucent structure: soft

tissue and the joint spaces.

Most Radiopaque structure: bony

cortex– but the image lacks overall

contrast and the cortex is not visible.

Window Level (brightness) & Window Width (contrast)

Many shades of gray are creating an overall

long scale of contrast. As a general rule,

images of bony structures should

demonstrate short scale contrast (black &

white)

It appears the kVp selected for this image is

too high, demonstrating over penetration of

the bony structures and long scale contrast.

The lack of adequate contrast prevents the

visualization of bony trabeculae.

The image appears to have appropriate

brightness. Soft tissue, bony structures are

visible. However soft tissue towards the

thumb is obstructing slight visualization of

the carpal bones.

The EI value would likely be on the low end

of

acceptable limit. The image needs to be

repeated moving the soft tissue, adding a

compensating filter and increasing MAS

Window level (brightness)

The image displays adequate window

level brightness, However the soft

tissue towards the thumb area

displays evidence of slight under

exposure.

Window width (contrast)

The many shades of grey (long scale

contrast) do differentiate soft tissue from

bone, but the bony structures lack

appropriate short scale contrast to

adequately demonstrate trabeculae and

cortex. The image lacks appropriate

contrast resolution, likely due to over

penetration.

Accept / Reject Image

I believe this image should be

REJECTED because all pertinent

anatomy is NOT visible.

The 1st phalanx is superimposing the 2nd

phalanx.

The 1st phalanx is not properly positioned

to demonstrate the joint space.

The 2nd phalanx is partially

superimposing over the 3rd phalanx.

The MCP joint does NOT appear open

on the 1st, 2nd, & 3rd phalanx.

How to Correct for Errors if Repeated

The image needs to be repeated moving

the soft tissue, adding a compensating

filter and increasing MAS ≥50%

Doing this will demonstrate a more

uniform short scale contrast with CMC

joints & carpals clearly shown.

The CR needs to be centered to the base

of the 3rd metatarsal.

Increase collimation to (4) sides.

Correctly position the thumb to display the

CMC joint & also correct for

superimposition of the thumb over the 2nd

digit.

Original Radiograph

(62 kVp)

15% Rule

(50 kVp)

Works Cited

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.

McQuillen-Martensen, K. (2011). Radiographic image analysis (4th ed.). St.

Louis, MO: Saunders/Elsevier.

Image: Jeans Hospital