Hand (bilateral PA view)

Last revised by Daniel J Bell on 8 May 2024

The bilateral PA view is merely a single film that includes both hands, side by side. Although convenient, research in 2023 showed that the distortion due to divergent rays when imaging bilaterally can impact diagnosis and x-raying the hands individually is preferred at a minimal dose increase 1.

This view often complements the ball-catcher view and is performed almost exclusively to examine for evidence of rheumatological disorders (e.g. rheumatoid arthritisosteoarthritis, psoriatic arthritis etc.). It allows symmetry and distribution to be assessed easily without having to switch between images or account for slight differences in positioning. 

  • patient may be seated alongside or facing the table

  • both hands are pronated with their palmer surfaces placed on the detector 

  • posterior-anterior bilateral projection

  • centering point

    • between the two hands at the level of the metacarpophalangeal joints 

  • collimation

    • laterally to the skin margins

    • distal to the skin margins of the fingertips

    • proximal to the include one-third of the distal radius and ulna

  • orientation  

    • landscape

  • detector size

    • 24 cm x 30 cm

  • exposure

    • 50-60 kVp

    • 3-5 mAs

  • SID

    • 100 cm

  • grid

    • no

There is neither overlap of the midshafts of the metacarpals nor is there overlap of the phalange bases.  

Hands are equal distance apart. 

The projection should appear to mimic that of a PA hand 

The hand is not a technically challenging radiograph, always ensure the fingers are equal distance apart and the detector is high enough to avoid overlap at the wrist. 

Always include the wrist joint on your PA radiograph, patients may have referred pain from pathology other than the hand.  

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