radiology clinical ii upper extremity image review
TRANSCRIPT
Radiology Clinical II~~~
Upper Extremity ~~~~~
Image Review
The following information is only a personal suggested guideline to follow when
positioning Upper Extremity exams.
For additional information on positioning of these
exams, please reference your Radiographic
Positioning and Related Anatomy Textbook.
Hand & Fingers
PA Finger(s)• SID 40” / TT• Elbow 90° • Hand pronated w/ fgrs extended• CR ┴ to IR• CP to effected digit @ PIP joint• Collimate• Shield
4
Oblique Finger(s)• SID 40” / TT• Elbow 90° • Hand rotated 45° w/ fgrs
extended• CR ┴ to IR• CP to effected digit @ PIP joint• Collimate• Shield
5
Lateral Finger(s)• SID 40” / TT• Elbow 90° • Hand true lat w/ fgrs extended• Use sponge and/or tongue blade• CR ┴ to IR• CP to effected digit @ PIP joint• Collimate• Shield
6
AP OBL LAT
AP/PA Thumb• SID 40” / TT• AP-Thumb nail on cassette• AP-Pull fingers back with opposite hand• PA-Hand in true lat position• PA-Rest thumb on a sponge • CR ┴ to IR• CP 1st MCP joint• Collimate• Shield
8
PA Oblique Thumb• SID 40” / TT• Hand pronated w/ thumb
extended• CR ┴ to IR• CP 1st MCP joint• Collimate• Shield
9
Lateral Thumb• SID 40” / TT• Hand pronated & digits 2-5
slightly arched & deviated toward the ulna
• CR ┴ to IR• CP 1st MCP joint• Collimate• Shield
10
AP OBL LAT
PA Hand• SID 40” / TT• Elbow 90° • Hand pronated w/ fgrs extended• CR ┴ to IR• CP to 3rd MCP joint• Collimate• Shield
12
Oblique Hand• SID 40” / TT• Elbow 90° • Hand rotated 45° w/ fgrs
extended• CR ┴ to IR• CP to 3rd MCP joint• Collimate• Shield
14
Lateral Hand X 3*• SID 40” / TT• Elbow 90° • Hand true lat w/ fgrs separated for Fan*,
extended for Extension*, and relaxed for Flexion*
• Use sponge and/or tongue blade• CR ┴ to IR• CP to 2nd MCP joint• Collimate• Shield
16
Fan Flexion Extension
ThumbRepeatable Error?
Poor Positioning
*Need to separate thumb from other
digits
ThumbRepeatable Error?
Poor Positioning
*Need to get palm out of the way
of the 1st MC
HandRepeatable Error?
Poor Collimation
*Or either wrong centering point or
patient moved
Oblique Hand
Repeatable Error?
Poor Positioning
*Over rotated
Good Image
Oblique Hand
Repeatable Error?
Poor Positioning
*Over rotatedAnd digits are not
separated
Good Image
Fan Lat Hand
Repeatable Error?
Poor Positioning
*Under rotated and digits are not
separated.
Good Image
FingerPathology
Dislocation
*Why 2 views at right angles to
each other are so important!
FingerPathology
Dislocation
FingerPathology
Congenital Abnormality
Thumb Pathology
Attacked by a nail gun
ThumbPathology
TraumaFx
HandPathology
Polydactyl
HandPathology
4th Metacarpal DeformityTurner’s
Syndrome
HandPathology
Rheumatoid Arthritis
HandPathology
Degenerative ArthritisFixation
HandPathology
TraumaSnowblower
HandPathology
TraumaUnknown
HandPathology
TraumaSaw
Who took this X-ray?
Who’s hand is it?
211
10
13121
45
6
7
8
9
3
Wrist
PA Wrist• SID 40” / TT• Elbow 90° • Hand pronated w/ fgrs flexed• CR ┴ to IR• CP to mid-carpals• Collimate• Shield
38
Oblique Wrist• SID 40” / TT• Elbow 90° • Hand rotated 45° outward• CR ┴ to IR• CP to mid-carpals• Collimate• Shield
40
Lateral Wrist• SID 40” / TT• Elbow 90° • Hand true lateral • Use sponge for stability• CR ┴ to IR• CP to mid-carpal joint• Collimate• Shield
42
PA Axial Scaphoid Wrist
“Ulnar Deviation”• SID 40” / TT• Elbow 90°• Hand pronated, then gently deviate
hand toward the ulna• CR < 10°-15° proximally up forearm• CP at the scaphoid• Collimate • Shield
44
PA Scaphoid Wrist“Ulnar Deviation – Modified Stecher Method”• SID 40” / TT• Elbow 90°• Hand pronated onto 20° < sponge,
then gently deviate hand toward the ulna• CR ┴ to IR• CP at the scaphoid• Collimate • Shield
45
Carpal Canal (Tunnel) Wrist
“Gaynor-Heart Method”• SID 40” / TT• Hand hyper-extended/dorsiflexed• Rotate hand 10° internally• CR < 25°to 30°to long axis of hand• CP 2-3cm (1”) distal to the base of
the 3rd metacarpal (center of palm of hand)
• Collimate • Shield
47
A = Trapezium B = ScaphoidC = Capitate D = Hamulus E = Pisiform
Oblique Wrist
Technical Error
Poor Positioning
*Under rotated.
Lateral Wrist
Technical Error
Poor Positioning
*Under rotated.
WristPathology
TraumaPrev Surg.
With new fx and gun
shot
WristPatholog
y
TraumaFx
Fall
WristPathology
TraumaFall
Wrist PathologyTrauma – Fall - Cast Info!!
Wrist Pathology
TraumaUnknown
Fx Scaphoid
AP Forearm• SID 40” / TT• Upper limb extended hand supinated• Shoulder in same plane as forearm• Epicondyles are ll to IR • CR is ┴ to IR• CP Mid-forearm• Collimate • Shield
57
AP Forearm
58
Lateral Forearm• SID 40” / TT• Upper limb flexed 90° in true lat pos• Shoulder in same plane as forearm• Epicondyles are ┴ to IR (may have
to slightly elevate wrist)• CR is ┴ to IR • CP Mid-forearm• Collimate • Shield
60
LateralForearm
Repeatable Error?
Poor Positioning
*Not a true lateral and not
a 90° flexion.
LateralForearm
Repeatable Error?
Poor Positioning
*Not a true lateral and not
a 90° flexion.
LateralForearm
Repeatable Error?
Poor Centering
*Poor image due to poor centering
of the CR.
ForearmPatholo
gy
TraumaUnknown
ForearmPatholo
gy
TraumaFallFx
WristPatholo
gy
Bone grafts
ForearmPatholog
y
TraumaHomemade
FireworkGone bad
Elbow
ABCD
E
I
H
G
F
Elbow
Radial neckRadial Head
Capitulum
Lateral epicondyle
Olecranon
Radial tuberosity
Coronoid process
Trochlea
Medial Epicondyle
Medial Epicondyle
74
1) Trochlear Sulcus
13 2
2) Outer Ridges of:Capitulum & Trochlea
3) Trochlear Notch of the Ulna
Elbow Fat Pad Sign
75Normal Abnormal
AP Elbow• SID 40” / TT• Upper limb extended hand supinated• Shoulder in same plane as forearm• Epicondyles are ll to IR • CR is ┴ to IR• CP Mid-elbow joint• Collimate • Shield
76
External ObliqueAlso called Lateral Oblique
• SID 40” / TT• Upper limb extended hand rotated lat• Shoulder in same plane as forearm• Epicondyles are at a 45°< to IR• CR is ┴ to IR• CP Mid-elbow joint• Collimate • Shield
78
Internal ObliqueAlso called Medial Oblique
• SID 40” / TT• Upper limb extended hand rotated
medially, pronate palm• Shoulder in same plane as forearm• Epicondyles are at a 45°< to IR• CR is ┴ to IR• CP Mid-elbow joint• Collimate • Shield
80
Lateral Elbow• SID 40” / TT• Upper limb flexed 90° in true lat pos• Shoulder in same plane as forearm• Epicondyles are ┴ to IR (may have
to slightly elevate wrist)• CR is ┴ to IR • CP Mid-elbow joint• Collimate • Shield
82
Acute Flexion Elbow X2”Jones Method”
• SID 40” / TT• Shoulder in same plane as humerus• Align humerus to long axis of IR, with
elbow flexed and fingers on shoulder• Ensure no rotation by checking
epicondyles to be equal distance from IR.• *CR is ┴ to Humerus *CR is ┴ to Forearm• CP 2” from Olecranon• Collimate • Shield
86
Trauma Lateral Elbow“Coyle Method”
“For Radial Head”• Upper limb flexed
90° in true lateral position-hand prone
• Shoulder in same plane as forearm
• Epicondyles are ┴ to IR
• CR 45°< toward shoulder
• CP Mid-elbow joint89
“For Coronoid”• Upper limb flexed
80° in lateral position-hand prone
• Shoulder in same plane as forearm
• Epicondyles are ┴ to IR
• CR 45°< from shoulder
• CP Mid-elbow joint
Coyle Method ~ “For Radial Head”
Upper limb flexed 90° and CR 45°< toward shoulder
Upper limb flexed 80° and CR 45°< from shoulder
Coyle Method ~ “For Coronoid”
ElbowTechnical
Error
Poor Positioning
*Not a true AP. Pt probably was
not able to extend arm.
ElbowRepeatable
Error?
Poor Positioning
*Not a true AP. Appears as though the patient placed their palm prone.
ElbowRepeatable Error?
Poor Positioning
*Over rotated Internal Oblique.
ElbowRepeatable
Error?
Poor Positioning
*Not flexed to 90° and arm is rotated. Epicondyles are not
┴ to IR.
ElbowRepeatable
Error?
Poor Positioning
*Not flexed to 90° and shoulder is not
in same plane as elbow. Epicondyles
are not ┴ to IR.
ElbowRepeatable
Error?
Poor Positioning
*Shoulder is not in same plane as
elbow. Epicondyles are not ┴ to IR.
ElbowPatholog
y
TraumaRadial Head
Fx
Elbow PathologyTrauma: Capitulum Fx
Elbow PathologyTrauma: Proximal Ulna Fx
ElbowPatholog
y
TraumaOlecranon
Fx
Elbow PathologyTrauma: Distal Humerus Fx
103
Elbow PathologyOsteomyelitis
AP Humerus• SID 40” / Bucky• Pt. is supine or uprt w/ arm extended• Shoulder in same plane as elbow*• Abduct arm slightly & supinate hand• CR ┴ to the IR• CP Mid-humerus• Collimate • Shield - Breast also, if you don’t turn the
tube
105*Epicondyles are ║ to IR
Lateral Humerus• SID 40” / Bucky• Pt. is supine or AP/PA uprt w/ arm extended• Shoulder in same plane as elbow• Internally rotate arm*• CR ┴ to IR• CP Mid-humerus• Collimate • Shield – Breast also, if you don’t turn the
tube
107*Epicondyles are ┴ to IR
AP Humerus
Repeatable Error?
Poor Positioning
*Arm is over rotated. Epicondyles
are not ║ to IR.
AP HumerusRepeatable Error?
Poor Centering
and collimation
AP HumerusRepeatable Error?
Poor centering and
collimation
AP HumerusRepeatable Error?
Poor centering and
collimation
AP HumerusRepeatable Error?
Poor centering
Lateral Humerus
Repeatable Error?
Poor Positioning
Lateral Humerus Repeatable Error?
Poor Positioning
Lateral Humerus Repeatable Error? Poor positioning
Humerus Pathology
TraumaDislocatedHumerus
HumerusPathology
TraumaFX
Also under penetrated.
HumerusPathology
TraumaFX
Remember to remove artifacts.
HumerusPathology
OUCH!Trauma
FX
121
P
Shoulder Girdle
123
AP Clavicle• SID 40” min Bucky/Grid• Pt. AP with arm neutral (puts
epicondyles in 45° to IR)• CR ┴ to IR• CP Mid-clavicle• Shield/Cone• Suspend respiration
125
AP Axial Clavicle• SID 40” min Bucky/Grid• Pt. AP with arm neutral (puts
epicondyles in 45° to IR)• CR < 15°-30° cephalad (15°=Hypersthenic - 30°=Asthenic)• CP Mid-clavicle• Shield/Cone• Suspend respiration
127
AP Bilat A/C Jts• SID 72” min • Pt. AP with arms neutral (puts
epicondyles in 45° to IR)• CR ┴ to the IR• CP Midpoint between A/C Jts (1” above jugular notch)• Shield/Cone• Suspend respiration
Bilat Clavicles– After Delivery
131
AP Scapula• SID 40” min Bucky/Grid• Pt. AP Uprt or Supine, abduct arm
90° and supinate hand• CR ┴ to IR• CP mid-scapula (2” inferior to
coracoid process/ level of axilla• Shield/Cone• Respiration=breathing technique
133
Lateral Scapula• SID 40” min Bucky/Grid• Pt. PA Uprt & rotated 45°-60° toward
affected side w/ arm across chest. Feel for true-lat scapula*
• CR ┴ to IR• CP mid-scapula @ medial border• Shield/Cone• Suspend respiration *A/C jt & Superior Angle ┴ to IR
136
AP Shoulder-Neutral Position• SID 40” min Bucky/Grid• Pt. AP with arm neutral (puts
epicondyles in 45° to IR)• CR ┴ to IR• CP Mid-scapulohumeral jt.• Shield/Cone• Suspend respiration
139
AP Oblique Shoulder(Grashey Method) (Ortho refers to as “True AP”
• SID 40” min Bucky/Grid• Pt. rotated 35°-45° toward affected
side, w/ arm abducted in neutral position*
• CR ┴ to IR• CP scapulohumeral jt.• Shield/Cone• Suspend respiration*Elbow flexed 90° @ some sites
Internal Oblique External Oblique
142
AP External Rotation Shoulder• SID 40” min Bucky/Grid• Arm extended and externally rotated
to put epicondyles ║ to IR• CR ┴ to IR• CP Mid-scapulohumeral jt.• Shield/Cone• Suspend respiration
144
AP Internal Rotation Shoulder• SID 40” min Bucky/Grid• Arm is extended and internally rotated
to put epicondyles ┴ to IR• CR ┴ to IR• CP Mid-scapulohumeral jt.• Shield/Cone• Suspend respiration
146
Scapular “Y” Lateral Shoulder• SID 40” min Bucky/Grid• Pt. PA & rotated 45°-60° toward
affected side, w/ arm in neutral position. Feel for true-lat scapula*
• CR ┴ to IR• CP mid-scapula @ medial border• Shield/Cone• Suspend respiration*A/C jt & Superior Angle ┴ to IR
Outlet Neer Method
CR 10°-15° caudal angle
149
Inferosuperior Axial Shoulder
(Lawrence Method)• SID 40” min TT (XTL)• Pt Supine with arm abducted to 90°• Keep hand in external rotation with
palm up, and support arm if needed• CR medially 25°-30° horizontally• CP to the axilla/humeral head• Shield/Cone/Suspend respiration
151
Superoinferior PA Transaxillary Shoulder
(Hobbs Modification)• SID 40” min TT or Bucky/Grid• With arm raised superiorly above
head, place axilla against IR, with slight 5°-10° anterior oblique.
• CR is ┴ to IR• CP is to the glenohumeral joint• Shield/Cone/Suspend respiration
153
Transthoracic Lateral Shoulder
• SID 40” min Bucky/Grid• Pt. Uprt or Supine with affected side
to IR, & arm in neutral position• Raise opposite arm above head• CR horizontal & ┴ to IR• CP surgical neck of humerus• Shield/Cone/Breathing technique
(Lawrence Method)
Clavicle Repeatable Error?Poor centering
ShoulderRepeatable Error?
Artifact
ShoulderRepeatable Error?
Artifact
ShoulderRepeatable Error?
Artifact
ShoulderRepeatable Error?
Poor marker placement
ShoulderRepeatable Error?
Poor Positioning
and *centering
“Grashey”ShoulderRepeatable Error?
Poor Positioning
Scap-YShoulderRepeatable Error?
Poor Positioning
*under rotated
Scap-YShoulder
Repeatable Error?
Poor Positioning
*Over rotated
Scap-YShoulderRepeatable Error?
Poor Positioning
*Over rotated
AxialShoulder
Repeatable Error?
Poor Positioning
Clipped anatomy
Clavicle PathologyTrauma FX
Axial Shoulder PathologyTraumaFX
ShoulderPathology
Scapular-YTrauma
FX
AP ShoulderPathology
TraumaFX/Dislocation
Scapular-YShoulderPathology
TraumaFX/Dislocation
Shoulder PathologyTraumaDislocationMedially
ShoulderPatholog
y
TraumaDislocation
ShoulderPathology
TraumaFX
Peds Pt
Shoulder PathologyTraumaGSW
~~~ The End ~~~