Image EvaluationImage EvaluationChapter 3Chapter 3

Image EvaluationImage EvaluationChapter 3Chapter 3

Critique of Upper ExtremityCritique of Upper Extremity

Hand (PA)• ID requirements• Marker• No preventable artifacts• Contrast & density• ? True PA• ?long axes of 3rddigit and

metacarpal aligned

Hand (PA)• ? Soft tissue overlap• ? IP, MP, & CM joints open and

phalanges & metacarpals not foreshortened and thumb is in 45 degree oblique position

• ? 3rd MP joint in center

Hand (medial oblique)• Not enough rotation: midshafts of

metacarpals are evenly spaced and metacarpal heads are not superimposed

• Too much rotation: 3rd -5th metacarpal midshafts are superimposed

Hand ( medial oblique)• ? Long axes of 3rd digit and

metacarpal aligned• ? Soft tissue overlap• ? IP, MP joints open and phalanges

not foreshortened, thumb may be lateral or oblique

• ? 3rd MP join in center

Hand ( lateromedial)• 2nd – 5th superimposed ( palpate

knuckles)• If not the 2nd metacarpal is

demonstrated anterior to the 3rd – 5th metacarpal and the hand is rotated internally or pronated

Hand ( lateromedial)• ? Long axes of metacarpals aligned• ? IP joints open and phalanges not

foreshortened• MP joints in center• Optional Positioning: extension &

flexion

Wrist ( PA)• ? True PA : styloids of radial & ulnar

are lateral and medial edges of each bone; radioulnar articulation is open with minimal superimposition of metacarpal bases

• Rotation is affected by hand, humerus, & elbow movements

Wrist ( PA)• If externally rotated, carpal and

metacarpal are superimposed on medial side of wrist

• If internally rotated, carpal and metacarpal laterally superimposes and shows more pisiform and hamate

Wrist ( PA)• If hand & wrist are rotated, the

radioulnar articulation is closed• If humerus & elbow are rotated,

ulna placement changes• The ulna & radius cross each other

if humerus is not abducted

Wrist (PA)• ?carpal bones at center of field• Film should include carpal bones,

¼ of distal ulna and radius, and ½ of the proximal metacarpals.

Wrist ( medial oblique)• ?45 degree medial oblique• ?trapezoid & trapezium without

superimposition, with trapeziotrapezoidal joint space open

• ?2nd CM and scaphotrapezium joint spaces demonstrated

• ?long axes of 3rd metacarpal and radius aligned

Wrist (Lateral)• ? True lateral – distal end of

scaphoid & pisiform & radius with ulna superimposed

• ?90 degrees• If rotated the distal scaphoid &

pisiform relationship changes and the pronator fat stripe is obscured

Wrist (lateral)• If rotated externally (hand

supinated) distal scaphoid is seen posterior to the pisiform

• If rotated internally (hand pronated) distal scaphoid is seen anterior to the pisiform

Wrist (Ulnar-flexed)• ?ulnar flexed• ?scaphoid seen without

foreshortening and long axes of 1st metacarpal and radius aligned

• If patient can’t flex enough angle 20 degrees

Wrist(ulnar-flexed)• ?scaphoid in center of field• See carpal bones, radioulnar

articulation & proximal 1st – 4th metacarpals on film

• Scaphoid is most common fractured carpal bone

Forearm (AP)• ?long axis of forearm aligned• Forearm midshaft in center of field• wrist radius & ulna, elbow joints &

forearm soft tissue seen on film• ?distal forearm in true AP- radial styloid

is seen in profile laterally & very little superimposition of the metacarpal bases of ulna & radius

Forearm (AP)• ?proximal forearm in true AP• ?radial head & tuberosity

superimpose lateral part of proximal ulna. If on film, the medial and lateral humeral epicondyles are seen in profile

Forearm ( lateral)• Anode heel effect- density is less

at anode end of tube than cathode• So, we need to position which part

of forearm at the anode end?• Soft tissue sightings – anterior &

posterior fat pads and the supinator fat stripe at the elbow; pronator fat stripe at the wrist

Forearm ( lateral)• ?long axis of forearm aligned• ?midshaft of forearm at center of

field• ? Wrist, radius & ulna & elbow

joints and forearm soft tissue on film

Forearm ( lateral)• Proximal forearm & distal humerus

positioning: • Elbow flexed 90 degrees – poor elbow

positioning obscures fat pads that we need to see for diagnosis

• The radial tuberosity is superimposed by the radius and is not seen in profile

• Distal humerus in true lateral position

Elbow ( AP)• ? True AP projection• Medial & lateral humeral epicondyles

are seen in profile• Detecting elbow rotation(1)epicondyles

no seen in profile(2)radial head & tuberosity are seen with more than slight superimposition of the ulna(3)coronoid is seen in profile

Elbow (AP)• ?radial tuberosity medially in

profile & eliminates crossing of the radius & ulna

• Capitulum-radius joint is open• When patient can’t extend elbow;

ap proximal forearm& ap distal humerus

Elbow (medial & lateral oblique)

• ?capitulum-radial joint open• ?elbow joint at center of field• ?elbow joint, ¼ proximal forearm, distal

humerus on film• Medial oblique: 45 degrees medially• Coronoid process, trochlear notch & medial

aspect of trochlea in profile• Trochlear-coronoid joint is open with

superimposition of radial head & neck over ulna

Elbow(medial & lateral oblique)

• Lateral oblique: 45 degrees laterally

• ?captitulum & radial tuberosity are seen in profile

• ?radial head, neck, and tuberosity seen without superimposing ulna & radioulnar joint is seen

Elbow (lateral)• Posterior fat pad is not usually seen

unless there is injury• Displacement of supinator fat stripe

could mean fractures of radial head and neck

• Change in shape or placement of anterior fat pad may indicated joint effusion & elbow injury

Elbow (lateral)• ?elbow flexed 90 degrees• ? True lateral position• ?elbow joint space is open and radial

head superimposes coronoid process• ? Radial tuberosity superimposed by

radius and not seen in profile• ?elbow joint in center of field

Humerus(AP)• ?true AP • ?long axis aligned• ?midshaft of humerus in center of

film• ?shoulder and elbow joints &

lateral humeral soft tissue on film

Humerus (lateral)• ?mediolateral• ?lateromedial• ?long axis aligned• ?midshaft in center of field