Bontrager Chapter 4 Workbook

A routine radiograph of an AP oblique elbow with lateral rotation reveals that the radial tuberosity is superimposed on the ulna. In what way must this position be modified during the repeat exposure?

Increase lateral rotation of the elbow to separate the radius from the ulna

The name of the joint between the proximal and distal phalanges of the first digit is the ___________.

Interphalangeal joint

Which lateral projection of the hand best demonstrates a possible foreign body in the palm of the hand?

Lateral in extension

Which routine projection best demonstrates the pronator fat stripe?

Lateral wrist

The best position to evaluate the posterior fat pads of the elbow joint is ___________.

Lateral, flexed 90 degrees

A sesamoid bone is frequently found adjacent to the ____________________ joint of the thumb.

MCP - metacarpophalangeal

The joints between the metacarpals and the phalanges are the _____________________.

Metacarpophalangeal (MCP) joints

A radiograph of a PA projection of he second digit shows that the phalanges are not symmetric on both sides of the bony shafts. Which specific positioning error is involved?

Rotation

Situation: A patient with a possible fracture of the trapezium enters the ER. The routine projections do not clearly demonstrate a possible fracture. Which other special projection can be taken?

Modified Robert's method

Situation: A patient is referred to radiology with a possible injury to the ulnar collateral ligament. The patient complains of pain near the first MCP joint. Initial radiographs of the hand do not indicate any fracture or dislocation. Which special projection can be performed to rule out an injury to the ulnar collateral ligament?

PA stress (Folio method) projection

What is the positioning routine for the second through fifth digits of the hand?

PA, PA oblique, and lateral

Joint movement type: Carpometacarpal of first digit

Saddle

Which is the most commonly fractured carpal bone?

Scaphoid

Identify the technical factors most commonly used for upper limb radiography: Long or short exposure time

Short exposure time

Pathology term for this description: Sprain or tear of the ulnar collateral ligament

Skier's thumb

Identify the technical factors most commonly used for upper limb radiography: Large or small focal spot

Small focal spot

Ellipsoidal joints are classified as freely movable, or ____________, and allow movement in __________ directions.

diarthrodial; 4

Identify the technical factors most commonly used for upper limb radiography: Correctly exposed radiographs: Visualize ___________ margins and ___________ markings of all bones

soft tissue; trabecular

A radiograph of a lateral projection of the elbow shows that the humeral epicondyles are not superimposed and the trochlear notch is not clearly demonstrated. Which specific type of positioning error is involved?

The forearm and humerus are not on the same horizontal plane

Indicate whether the following structures are part of the radius, ulna, or distal humerus: Olecranon process

Ulnar

During the PA axial scaphoid projection with CR angle and ulnar flexion, the CR must be angled ________ degrees _______ (proximally or distally).

10 to 15, proximally

Which routine projection of the elbow best demonstrates the radial head, neck, and tuberosity with slight (if any) superimposition of the ulna?

AP oblique with 45-degree lateral rotation

Which projection of the elbow best demonstrates the coronoid process in profile?

AP oblique with 45-degree medial rotation

Identify the number of bones: Phalanges (fingers and thumb)

14

How much CR angulation to the long axis of the hand is required for the carpal canal (tunnel) projection?

25 to 30 degrees

Identify the number of bones: Total

27

Identify the technical factors most commonly used for upper limb radiography: Fiberglass casts, increase

3-4 kV

Identify the technical factors most commonly used for upper limb radiography: Most common minimum SID

40" (102 cm)

How much CR angulation from the long axis of the forearm is required for the carpal bridge (tangential) projection?

45 degrees

How much rotation is required for an oblique projection of the wrist?

45 degrees

Which alternative projection to the routine PA wrist best demonstrates the intercarpal joint spaces and wrist joint?

AP projection (with the hand slightly arched)

Identify the technical factors most commonly used for upper limb radiography: kV range

60-80 kV

Match each of the structures labeled onFigs. 4.4 and 4.5 with the correct term. 1. Capitate 2. Scaphoid 3. Base of first metacarpal 4. Pisiform 5. Trapezoid 6. Hamulus (hamular process)

A. 3 B. 9 C. 2 D. 5 E. 1 F. 8 G. 6 H. 7 I. 4

List the three parts of each metacarpal, starting proximally:

A. Base B. Body (shaft) C. Head

A Bennett's fracture involves: A. Base of first metacarpal B. Trapezium bone C. Scaphoid bone D. Fracture extending through first IP joint

A. Base of first metacarpal

A. Which special positioning method can be performed to demonstrate a Bennett's fracture? B. What degree of CR angulation is required for this projection?

A. Modified Robert's Method B. 15 degrees proximal

The two portions of the thumb (first digit) are the:

A. Proximal phalanx B. Distal phalanx

Which routine projections are required for a study of the forearm?

AP and lateral

Situation: A patient with a trauma injury enters the ER with an evident Colles' fracture. Which positioning routine should be used to determine the extent of the injury?

AP and lateral forearm projections to include the wrist

Pathology term for this description: An abnormality of the cartilage affecting long bones

Achondroplasia

_____________ is a radiographic procedure that uses contrast media injected into the joint capsule to visualize soft tissue pathology of the wrist, elbow, and shoulder joints.

Arthrography

Which of the following fractures is not demonstrated in a wrist routine? A. Barton's B. Pott's C. Smith's D. Colles'

B. Pott's

Pathology term for this description: Transverse fracture extending through the distal aspect of the metacarpal neck, most often the fifth metacarpal

Boxer's fracture

How much are the hand and wrist elevated from the IR for the modified Stecher method? A. None B. 10 degrees C. 20 degrees D. 15 degrees

C. 20 degrees

What is the largest of the carpal bones?

Capitate

Situation: A patient with a history of carpal tunnel syndrome comes to the radiology department. The orthopedic physician suspects that bony changes in the carpal sulcus may be causing compression of the median nerve. Which special projection best demonstrates this region of the wrist?

Carpal canal position (Gaynor-Hart method)

Pathology term for this description: Possible calcification in the carpal sulcus

Carpal tunnel syndrome

Pathology term for this description: Transverse fracture of the distal radius with posterior displacement of the distal fragment

Colles' fracture

The general rule for collimation for upper limb radiography states:

Collimation borders should be visible on all four sides if the IR is large enough to allow this without cutting off essential anatomy.

Which projection of the thumb is achieved naturally by placing the palmar surface of the hand in contact with the IR?

PA oblique

Why is it important to keep the affected digit parallel to the IR for the PA oblique and lateral projections? A. To prevent distortion of the phalanx B. To prevent distortion of the joints C. To demonstrate small, non-displaced fractures near the joint D. All of the above

D. All of the above

Which positioning error is involved if a majority of the carpal bones are superimposed in a PA oblique wrist projection?

Excessive lateral rotation from PA

List two of the mnemonics given in the textbook that uses the first letter of each of the preferred terms of the eight carpal bones.

Either of these two mnemonics is acceptable: 1.) Send Letter To Peter To Tell'im (to) Come Home 2.) Steve Left The Party To Take Carol Home

Joint movement type: Metacarpophalangeal of second to fifth digits

Ellipsoidal

Joint movement type: Radiocarpal

Ellipsoidal

A radiograph of a PA oblique projection of the hand shows that the fourth and fifth metacarpals are superimposed. Which specific positioning error is involved?

Excessive lateral rotation

True/False: For a forearm study, the technologist needs to include only the joint closest to the site of the injury.

False

True/False: If the posterior fat pad of the elbow is not visible radiographically, it suggests that a non-obvious radial head or neck fracture is present.

False

True/False: Trauma or infection makes the anterior fat pad more difficult to see on a lateral elbow radiograph.

False

Joint movement type: Elbow joint

Ginglymus

Joint movement type: Elbow joint (humeroulnar and humeroradial)

Ginglymus

Joint movement type: Interphalangeal

Ginglymus

What is the name of the hooklike process extending anteriorly from the hamate?

Hamulus/Hamular process

Pathology term for this description: Most common type of primary malignant tumor occurring in bone

Multiple Myeloma

The deep depression located on the posterior aspect of the distal humerus is the __________.

Olecranon fossa

Pathology term for this description: Narrowing of joint space with periosteal growths on the joint margins

Osteoarthritis

Pathology term for this description: Soft tissue swelling and loss of fat-pad detail visibility

Osteomyelitis

Pathology term for this description: Hereditary condition marked by abnormally dense bone

Osteopetrosis

Pathology term for this description: Reduction in the quantity of bone or atrophy of skeletal tissue

Osteoporosis

Joint movement type: Proximal radioulnar joint

Pivot

Joint movement type: Intercarpal

Plane

Where is the CR centered for a PA oblique projection of the second digit?

Proximal Interphalangeal (PIP) joint

Which joint permits the forearm to rotate during pronation?

Proximal radioulnar joint

Which ligament of the wrist extends from the styloid process of the radius to the lateral aspect of the scaphoid and trapezium bones?

Radial collateral ligament

Which special projection of the wrist helps rule out abnormal calcifications in the carpal sulcus?

Tangential inferosuperior or Gaynor-Hart projection

Situation: A patient enters the ER with a possible foreign body in the dorsal aspect of the wrist. Initial wrist radiographs are inconclusive in demonstrating the location of the foreign body. What additional projection can be performed to demonstrate this region of the wrist?

Tangential projection - Carpal bridge projection

Why is the AP projection of the thumb recommended instead of the PA?

The AP position produces a decrease in OID and increased resolution.

True/False: Excessive kV may obscure the visibility of a fat pad

True

True/False: In addition to the ulnar and radial collateral ligaments, the following five additional ligaments are also important in stabilizing the wrist joint. A. Dorsal radiocarpal B. Palmar radiocarpal C. Triangular fibrocartilage complex (TFCC) D. Scapulolunate E. Lunotriquetral

True

True/False: Slight superimposition of the distal third, fourth, and fifth metacarpals may occur with a well positioned PA oblique projection of the hand.

True

True/False: Guardians of young pediatric patients who are having upper limb studies can be asked to hold their child during the radiographic study.

True - ensure adults are given a lead apron to wear during exposures

A radiograph of an AP elbow projection shows considerable superimposition between the proximal radius and ulna. Which specific positioning error is involved?

The elbow is rotated medially

What is the only difference among the four radial head lateral projections of the elbow?

The rotational position of the hand and wrist

Situation: A patient has a routine elbow series performed. The AP projection indicates a possible deformity or fracture of the coronoid process. However, the patient is unable to pronate the upper limb for the AP oblique-medial rotation projection because of an arthritic condition. What other projection could be performed to demonstrate the coronoid process?

Trauma axial lateral projection - Coyle method for coronoid process

Indicate whether the following structures are part of the radius, ulna, or distal humerus: Trochlear notch

Ulnar

Change in manual exposure factors? Advanced rheumatoid arthritis

decrease (-)

Change in manual exposure factors? Osteoporosis

decrease (-)

Change in manual exposure factors? Advanced Paget's disease

increase (+)

Change in manual exposure factors? Osteopetrosis

increase (+)

Change in manual exposure factors? Bursitis

none (0)

Change in manual exposure factors? Joint effusion

none (0)

To position the patient properly for an AP projection of the elbow, the epicondyles must be __________ to the IR.

parallel

A three projection study of the hand was taken using the following exposure factors: 64 kVp, 1000 mA. 1/100 second, large focal spot and 36 inch SID. which of these factors should be changed on future hand studies to produce more optimal images?

use a small focal spot and minimum 40 inch SID to produce a higher-quality study.

True/False: Lead (protective) shielding is only required for upper limb studies performed on patients who are of childbearing age.

False (a good practice is to provide shielding for all patients)

True/False: Lead (gonadal) shielding is not required for upper limb radiographs if the patient can sit upright for these exams.

False (because of scatter, divergent rays, or both reaching gonads)

Which preferred lateral position of the hand best demonstrates the phalanges without excessive superimposition?

Fan lateral

How does the forearm appear radiographically if pronated for a PA projection?

The proximal radius crosses over the ulna

Which special projection(s) of the elbow should be performed instead of the routine AP if the patient's elbow is tightly flexed and cannot extend at all?

Two projections-CR perpendicular to humerus and CR perpendicular to forearm (acute flexion projections)

If the patient cannot fully extend the elbow for the AP projection, what alternative projection(s) should be performed?

Two AP projections (partially flexed), one with humerus parallel to IR and one with forearm parallel to IR

Situation: A patient with a dislocated elbow enters the ER. The patient has the elbow tightly flexed and is careful not to move it. Which specific positioning routine can be used to determine the extent of the injury?

Two AP projections with acute flexion and a lateral projection

Indicate whether the following structures are part of the Radius, Ulna, or Distal Humerus: Radial notch

Ulnar

Indicate whether the following structures are part of the radius, ulna, or distal humerus: Coronoid process

Ulnar

Indicate whether the following structures are part of the radius, ulna, or distal humerus: Coronoid tubercle

Ulnar

Of the two positions listed in the previous question, which is most commonly performed to detect a fracture of the scaphoid bone?

Ulnar Deviation

How much and in which direction should the CR be angled for the trauma axial lateral projection (Coyle method) involving the coronoid process?

45 degrees away from shoulder

How much is the upper limb rotated for a lateral (rotation) oblique projection of the elbow?

45 degrees laterally

How much and in which direction should the CR be angled for the trauma axial lateral projection (Coyle method) involving the radial head?

45 degrees toward shoulder

Identify the number of bones: Metacarpals (palm)

5

Identify the technical factors most commonly used for upper limb radiography: Small-to-medium dry plaster casts, increase

5-7 kV

The hand is flexed in relation to the IR for the AP axial projection (Brewerton method)

65 degrees

Pathology term for this description: Fluid-filled joint spaced with possible calcification

Bursitis

What type of CR angle is required for the AP axial projection (Brewerton method)?

15 degrees proximal toward the ulna

The three parts of each phalanx, starting distally, are the:

A. Head B. Body (shaft) C. Base

Indicate whether the following structures are part of the radius, ulna, or distal humerus: Coronoid fossa

Distal Humerus

Indicate whether the following structures are part of the radius, ulna, or distal humerus: Olecranon fossa

Distal Humerus

Indicate whether the following structures are part of the radius, ulna, or distal humerus: Trochlea

Distal Humerus

How much of the metacarpals should be included for PA projection of the digits?

Distal aspect of metacarpals

Situation: A patient with a possible fracture of the radial head enters the ER. When the technologist attempts to place the arm in the AP oblique-lateral rotation position, the patient is unable to extend or rotate the elbow laterally. Which other positions can be used to demonstrate the radial head and neck without superimposition on the proximal ulna?

Coyle method for radial head (lateral elbow, CR 45 degrees toward shoulder)

A minimum of _______ inches of the forearm should be included radiographically for a PA projection of the hand.

1"

Critique Radiograph: Lateral elbow (fig. 4.17) Description of possible error: 1. Anatomy Demonstrated: 2. Part positioning: 3. Collimation and CR: 4. Exposure: 5. Anatomic side Markers: Repeatable errors:

1. All pertinent anatomic structures demonstrated 2. Elbow over-flexed ( beyond 90 degrees) and not true lateral; too much distance between parts of concentric circles 1 & 2; trochlear notch space not open. 3. Satisfactory collimation; CR slightly of center to elbow joint. 4. Acceptable 5. Partially off radiograph and unacceptable Repeatable errors: 2 and 5

Critique Radiograph: Pediatric PA forearm (fig. 4.16) Description of possible error: 1. Anatomy Demonstrated: 2. Part positioning: 3. Collimation and CR: 4. Exposure: 5. Anatomic side Markers: Repeatable errors:

1. All pertinent anatomic structures not included because of PA projection being performed over AP. 2. Poor part positioning because proximal radius crossing over ulna as a result of PA. 3. No collimation evident; acceptable CR centering 4. Satisfactory 5. Side markers evident Repeatable errors: 1 and 2

Critique Radiograph: AP elbow (fig. 4.14) Description of possible error: 1. Anatomy Demonstrated: 2. Part positioning: 3. Collimation and CR: 4. Exposure: 5. Anatomic side Markers: Repeatable errors:

1. All pertinent anatomy included 2. Elbow rotated laterally, evident by slight separation of radius and ulna. 3. No collimation borders evident; CR centering excellent for elbow. 4. acceptable exposure 5. No markers repeatable errors: 2 and 5

Critique Radiograph: Lateral Wrist (Fig. 4.13) Description of possible error: 1. Anatomy Demonstrated: 2. Part positioning: 3. Collimation and CR: 4. Exposure: 5. Anatomic side Markers: Repeatable errors:

1. All pertinent anatomy included 2. upper limb rotated slightly; radius and ulna not directly superimposed; metacarpals not all superimposed. 3. No collimation evident, centering slightly off; CR centered to distal carpal; includes too much forearm. 4. acceptable exposure 5. side makers evident Repeatable errors: 2 and 3

Critique Radiograph: PA wrist with ulnar deviation (fig. 4.15) Description of possible error: 1. Anatomy Demonstrated: 2. Part positioning: 3. Collimation and CR: 4. Exposure: 5. Anatomic side Markers: Repeatable errors:

1. Aspect of prisiform cut off laterally 2. Poor positioning due to radial deviation rather than ulnar deviation. 3. CR centered over scaphoid and medial carpals; would have excellent collimation if CR wwere centered correctly. 4. Excellect exposure factors 5. side markers evident repeatable errors: 1 and 3

Critique Radiograph: PA hand (fig. 4.12) Description of possible error: 1. Anatomy Demonstrated: 2. Part positioning: 3. Collimation and CR: 4. Exposure: 5. Anatomic side Markers: Repeatable errors:

1. Because of rotation and flexion, the anatomy of hand is distorted and the joints are not open. 2. Fingers flexed preventing clear assesment of joint spaces. Medial rotation of hand distorts the proximal phalanges and metacarpals. 3. No collimation evident, centering satisfactory for hand. 4. Exposure factors acceptable 5. No Markers Repeatable errors: 1 and 2

Identify the technical factors most commonly used for upper limb radiography: Grids are used if the body part measures greater than ___________ cm

10 cm

Identify the number of bones: Carpals (wrist)

8

Which IR size should be used for a thumb projection?

8 x 10"

Identify the technical factors most commonly used for upper limb radiography: Large plaster casts, increase

8-10 kV

What is the amount of elbow flexion required for the trauma lateral projection (Coyle method) to demonstrate the coronoid process?

80 degrees of flexion

The hand and wrist form a _________ degrees angle to the forearm with the carpal bridge (tangential) projection.

90 degrees

Match each of the carpal bones labeled in Figs. 4.2 and 4.3 with its correct name. 1. Lunate 2. Hamate 3. Trapezium 4. Pisiform 5. Triquetrum 6. Tapezoid 7. Capitate 8. Scaphoid

A. 8 B . 1 C. 5 D. 4 E. 3 F. 6 G. 7 H. 2

The fat pads around the elbow joint are valuable diagnostic indicators if the following three technical/positioning requirements are met with the lateral position.

A. Elbow flexed 90 degrees B. Optimal exposure factors used C. In a true lateral position.

Fill in the names and parts of the following bones and joints of the right hand as labeled in Fig. 4.1. Include abbreviations for joints if applicable.

A. Fifth carpometacarpal (CMC) joint B. Body of third metacarpal C. Head of fifth metacarpal D. Fourth metacarpophalangeal (MCP) joint E . Head of proximal phalanx of fifth digit F. Base of middle phalanx of fourth digit G. Distal interphalangeal(DIP) joint of fourth digit H . Body of middle phalanx of second digit I. Proximal interphalangeal (PIP) joint of second digit J. Body of distal phalanx of first digit K. Interphalangeal(IP) join tof first digit L. Metacarpophalangeal (MCP) joint of first digit M . Head of first metacarpal N. Second carpometacarpal (CMC) joint O. First carpometacarpal (CMC) joint

Identify which positioning modification(s) should be used for a study of the second digit to reduce distortion for each of the following: A. PA Oblique projection B. Lateral position

A. Perform the medial oblique rather than lateral oblique to decrease OID B. Perform a thumb-down lateral (mediolateral projection) to decrease OID

The three portions of each finger (second through fifth) are the:

A. Proximal phalanx B. Middle phalanx C. Distal phalanx

Identify the parts labeled in figs 4.10 and 4.11 A-H

A. Radial tubercle (tuberosity) B. Radial neck C. Radial head D. Capitulum E. Lateral epicondyle F. Coronoid process G. Trochlea H. Olecranon process

Identify the parts labeled in figs 4.8 and 4.9 A-P

A. Radial tuberosity B. Radial neck C. Capitulum D. Lateral epicondyle E. Olecranon fossa F. Medial epicondyle G. Trochlea H. Coronoid tubercle I. Olecranon process J. Superimposed humeral epicondyles K. Radial head L. Radial neck M. Radial tuberosity N. Outer ridges of trochlea and capitulum O. Trochlear sulcus (groove) P. Trochlear notch

A. In the anatomic position, which of the bones of the forearm is located on the lateral (thumb) side? B. Which is on the medial side?

A. Radius B. Ulna

The two important fat stripes or bands around the wrist joint are the:

A. Scaphoid fat stripe B. Pronator fat stripe

List the two radiographic criteria used to determine whether rotation is present on the PA projection of the digits.

A. Symmetric appearance of both sides of the shafts of phalanges and distal metacarpals B. Equal amounts of tissue on each side of the phalanges

Where is the CR centered for a PA projection of the hand? A. Third MCP joint B. Mid-aspect of third metacarpal C. Second MCP joint D. Third PIP joint

A. Third MCP joint

A. The articular portion of the medial aspect of the distal humerus is called the __________. B. The similar structure found on the lateral aspect of the distal humerus is called the _________.

A. Trochlea B. Capitulum

The criteria for evaluating a true lateral position of the elbow are the appearance of three concentric arcs (fig 4.7) these arcs include: A. The first and smallest of the arcs: B. The intermediate double arc, consisting of the outer ridges of: (a) the smaller arc: (b) the larger arc: C. The third arc, which is part of the ulna:

A. Trochlear sulcus (groove) B. (a) Capitulum (b) Trochlea C. Trochlear notch

What is the name of the two special turning or bending positions of the hand and wrist that demonstrate medial and lateral aspects of the carpal region?

A. Ulnar Deviation B. Radial Deviation

Situation: A patient comes to the radiology department for a hand series to evaluate early evidence of rheumatoid arthritis. Which special position can be used in addition to the routine hand projections to evaluate this patient?

AP axial projection (Brewerton method)

What are the pertinent factors that help reduce image distortion during upper limb radiography? A. kVp B. 40 to 44 inches SID C. Milliamperage seconds D. Minimal OID E. Correct central ray placement and angulation F. use of small focal spot

B. 40 to 44" SID D. Minimal OID E. Correct CR centering and angulation F. Small focal spot

Pathology term for this description: Fracture and dislocation of the posterior lip of the distal radius

Barton's fracture

Where is the CR centered for an AP projection of the thumb? A. First interphalangeal (IP) joint B. Mid-aspect of proximal phalanx C. First metacarpophalangeal (MCP) joint D. First proximal interphalangeal (PIP) joint

C. First metacarpophalangeal (MCP) joint

The AP axial projection (Brewerton method) is commonly used to evaluate for early signs of: A. Osteoporosis B. Osteomyelitis C. Osteopetrosis D. Rheumatoid arthritis

D. Rheumatoid arthritis

Pathology term for this description: Mixed areas of sclerotic and cortical thickening along with radiolucent lesions

Osteopetrosis

Which routine projections best demonstrate the scaphoid fat pad?

PA and Oblique wrist

Situation: A patient with a metallic foreign body in the palm of the hand enters the ER. Which specific positions should be used to locate the foreign body?

PA and lateral-in-extension projection

In a radiograph study of the forearm, the proximal radius crossed over the ulna in the frontal projection. Which specific positioning error led to this radiographic outcome?

PA forearm projection was performed rather than AP

Which special projection of the wrist best demonstrates the interspaces on the ulnar side of the wrist between the lunate, triquetrum, pisiform, and hamate bones?

PA projection with radial deviation

A PA axial scaphoid projection of the wrist using a 15-degree distal CR angle and ulnar flexion was performed. The resultant radiograph shows that the scaphoid bone is foreshortened. How must this projection be modified to produce a more diagnostic image of the scaphoid?

The CR needs to be angled 15 degrees proximally, toward the elbow

True/False: The entire metacarpal and trapezium must be demonstrated on all projections of the thumb.

True