PA Hand

The PA hand x-ray is one of the most common exams you will perform, but don’t let its frequency make you complacent. Because the hand is composed of small bones and intricate joints, even a slight rotation can hide a hairline fracture or obscure joint space narrowing. Success here is about two things: flat fingers and proper markers.

The Goal

To capture a complete view of the hand from the distal tips of the fingers to the distal radius and ulna, ensuring all joint spaces are open and the anatomy is “true” to the PA plane.

Patient Positioning

The Setup: Seat the patient at the end of the x-ray table. Ensure their shoulder, elbow, and wrist are on the same horizontal plane.
The Hand: Place the palm flat against the IR.
The Fingers: Spread the fingers slightly. Instruct the patient to keep their hand very still to prevent motion blur.
Pro-Tip: If the patient has “clawed” fingers due to arthritis or injury, do not force them flat. Use a sponge if necessary to get the anatomy as parallel to the IR as possible while keeping the patient comfortable.

Technical Factors

Central Ray (CR): Perpendicular to the third MCP joint (the middle knuckle).
SID: 40″.
Collimation: Collimate to the skin margins of the hand, including the distal tips of the fingers and the soft tissue of the wrist.

Image Evaluation Criteria (The “Richie” Checklist)

Every PA Hand image must be evaluated against these standards before you submit:

Complete Anatomy: You must see the tips of all five fingers down through the carpal bones and the distal radius/ulna.
No Rotation: Equal concavity of the metacarpal bodies and symmetric soft tissue on both sides of the phalanges.
Open Joints: The interphalangeal and metacarpophalangeal joints should appear open if the hand is flat.
Sharp Detail: You should clearly see the sharp trabecular patterns of the bone; if it looks “fuzzy,” you likely have motion.

Richie’s Pro-Tips for Hand Imaging

Patient Comfort: Keep the room dim enough to see your light field, but never dark. We want our patients to feel safe and supported throughout the entire exam.

Marker Placement is Critical: Always place your physical R or L marker within the collimated field, but away from the anatomy. Remember, a digital marker is not a substitute for a physical one placed at the time of exposure.

Immobilization: If the patient is shaky, use a sandbag across the forearm to provide stability. Never be afraid to use sponges they are there to help you get the “True PA.”