Upper Extremity 2: Elbow, Humerus

AP of Elbow w/ Partial Flexion

1.Distal Humerus 2.Proximal Forearm •This is done to give a full field of view to the radiologist when the patient is unable to full extend their arm for a typical AP view of the elbow. •These images are obtained to diminish anatomic distortion

Anatomy: Distal Humerus

The distal end of the humerus is called the humeral condyle and is made of 2 parts: 1.Trochlea - medial side of distal humerus 2.Capitulum - Lateral side of the distal humerus Medial and Lateral epicondyles are superior to the humeral condyle •Epicondyles are easily palpated and critical in positioning Coronoid fossa: a shallow depression on the anterior surface just superior to the trochlea. This receives the coronoid process when the elbow is flexed Radial Fossa: located laterally to the coronoid fossa and proximal to the capitulum. This receives the radial head when the elbow is flexed. Olecranaon Fossa: deep depression found on the posterior surface, behind the coronoid fossa, and receiveds the olecranon process when the elbow is extended.

Humerus: AP Projection (6+2)

• IR: 14 x 17 lengthwise (portrait) •Patient in a seated upright or standing position facing the x-ray tube •Adjust the height of the IR so the upper margin is 1 ½ inches above the humeral head •Abduct the arm slightly and supinate the hand •Humeral epicondyles should be parallel with the IR plane •Suspend respiration Central Ray: •Perpendicular to the middle of the humerus and center of the IR Structures Shown: •AP projection of the entire length of the humerus.

Coyle Method (Ambulatory and Trauma Patients) Radial Head Evaluation Criteria (5)

• Open Joint Space between radial head and capitulum •Radial head, neck and tuberosity in profile and free of superimposition (exception of a small portion of coronoid process) •Humeral epicondyles distorted because of CR angle •Radial tuberosity facing posteriorly •Elbow flexed 90 degrees

Anatomy: Elbow

•3 main articulation points in the elbow: 1.Humeroulnar - where the trochlea of the humerus fits into the trochlear notch of the ulna 2.Humeroradial - where the capitulum of the humerus sits atop the flattened head of the radius (Remember: put the "cap" on the "head") 3.Proximal radioulnar articulation - the proximal head of the radius articulates with the radial notch on the medial side of the ulna. •The radioulnar articulation is performed when the hand is supinated or pronated. •When the hand is pronated the radius turns medially and crosses over the upper 1/3 of the ulna. •Take note of the position of the lateral and medial epicondyles of the humerus. They are pivitol in properly positioning the elbow joint.

Elbow: AP Projection (Partial Flexion) Distal Humerus Evaluation Criteria (4)

•Distal humerus without rotation or distortion •Proximal radius superimposed over the ulna •Closed elbow joint •Greatly foreshortened proximal forearm

Humerus: AP Projection Evaluation Criteria (4)

•Elbow and shoulder joints visble •Humeral epicondyles without rotation •Humeral head and greater tubercle in profile •Outline of lesser tubercle, located between the humeral head and the greater tubercle

Humerus: Lateral Projection Evaluation Criteria (4)

•Elbow and shoulder joints visible •Superimposed humeral epicondyles •Lesser tubercle in profile on medial aspect •Greater tubercle superimposed over the humeral head

Elbow: AP Oblique Projection (Lateral Rotation) Evaluation Criteria (5)

•Elbow joint centered in the exposure field •45 degree lateral rotation of the elbow **Radial head, neck and tuberosity free of superimposition of the ulna **Elongated lateral humeral epicondyle •Capitulum visualized

Elbow: AP Oblique Projection (Medial Rotation) Evaluation Criteria (7)

•Elbow joint centered in the exposure field •45 degree medial rotation of the elbow **Coronoid process is profile **Elongated medial humeral epicondyle **Ulna superimposed by the radial head and neck •Trochlea visualized •Olecranon process within the olecranon fossa

Elbow: Lateral Projection Evaluation Criteria (7)

•Elbow joint centered in the exposure field •Elbow in true lateral position: **Superimposed humeral epicondyles **Radial tuberosity facing anteriorly **Radial head partially superimposing the coronoid process **Olecranon process in profile •Elbow flexed 90 degrees

Anatomy: Proximal Humerus

•Head: large, smooth and round end of the humerus that lies in an oblique plane on the superomedial side. •Anatomic neck: narrow constriction below the head, on the same oblique plane. •Surgical neck: constriction of the bodyjust below the tubercles. --*Most common site of fracture in the humerus* •Lesser tubercle: located on the anterior suface directly below the anatomic neck •Greater tubercle: located on the lateral surface of the bone just below the anatomic neck. •Intertubercular groove: deep depression that separates the greater and lesser tubercles

Humerus: Lateral Projection (6+3)

•IR: 14 x 17 lengthwise (portrait) •Patient in a seated upright or standing position facing the x-ray tube •Adjust the height of the IR so the upper margin is 1 ½ inches above the humeral head •Unless contraindicated by possible fracture, internally rotate and flex the arm approx. 90 degrees and place the posterior of the hand against the hip. •This places the humerus in a lateral position •The epicondyles should be perpendicular to the IR Central Ray: •Perpendicular to the middle of the humerus and center of the IR Structures Shown: •Lateral projection of the entire length of the humerus. •True lateral shows perpendicular epicondyles

Coyle Method (Ambulatory and Trauma Patients) Coronoid Process Evaluation Criteria (4)

•Open joint space between coronoid process and trochlea •Coronoid process in profile and elongated •Radial head and neck superimposed by ulna •Elbow flexed 80 degrees

Coyle Method (Trauma Patient) - Coronoid Process (6+4)

•Patient should be laying on a stretcher. This is ideal for this position. •Elevate the distal humerus on a radiolucent sponge •Place the IR vertically centered to the elbow joint •Epicondyles should be approx. perpendicular to the IR •Slowly flex the elbow 80 degrees to show the coronoid process •Turn the hand so the palmar surface is facing medially Central Ray: •The horizontal CR is directed caudad at an angle of 45 degrees to the coronoid process. •CR enters the joint at mid elbow Structures shown: •An open elbow joint between the coronoid process and trochlea •Used to show pathologic processes or trauma in the region of the coronoid process

Coyle Method (Trauma Patient) - Radial Head (6+4)

•Patient should be laying on a stretcher. This is ideal for this position. •Elevate the distal humerus on a radiolucent sponge •Place the IR vertically centered to the elbow joint •Epicondyles should be approx. perpendicular to the IR •Slowly flex the elbow 90 degrees to show the radial head •Turn the hand so the palmar surface is facing medially Central Ray: •The horizontal CR is directed cephalad at an angle of 45 degrees to the radial head. •CR enters the joint at mid elbow Structures shown: •An open elbow joint between the radial head and capitulum •Used to show pathologic processes or trauma in the region of the radial head

Elbow: AP Projection (Partial Flexion) Distal Humerus (5+3)

•Place entire humerus on the same plane •Supinate the hand to the best of the patient's ability •Support the elevated forearm •Center the condyloid region of the humerus to the IR •Have patient lean laterally until the humeral epicondyles and anterior surface are parallel to the IR. Central Ray: •Perpendicular to the humerus, transversing the elbow joint •Distal angle may be needed based on the amount of flexion Structures Shown: •Distal humerus when the forearm cannot be fully extended

Elbow: AP Projection (4+2)

•Place shoulder, elbow and wrist joints all on the same plane. •Extend the elbow and supinate the hand •Center the elbow joint to the center of the IR •Have patient lean laterally until the humeral epicondyles and anterior surface are parallel to the IR. Central Ray: •Perpendicular to the elbow joint Structures Shown: AP projection of the elbow joint, distal humerus, and proximal forearm

Elbow: AP Oblique Projection (Medial Rotation) (5+2)

•Place shoulder, elbow and wrist joints all on the same plane. •Extend the elbow and supinate the hand •Center the elbow joint to the center of the IR •Medially (internally) rotate or pronate the hand to place anterior surface of the elbow at a 45 degree angle to the IR. •This angle will clear the coronoid process of the radial head Central Ray: •Perpendicular to the elbow joint Structures Shown: •Oblique projection of the elbow with the coronoid process projected free of superimposition

Elbow: AP Oblique Projection (Lateral Rotation) (6+2)

•Place shoulder, elbow and wrist joints all on the same plane. •Extend the elbow and supinate the hand •Center the elbow joint to the center of the IR •Rotate the hand laterally (externally) to place the posterior surface of the elbow at a 45 degree angle to the IR. •Proper angulation is usually achieved when the patient's 1st and 2nd digits touch the table. •The humeral epicondyles should be at a 45 degree angle to the IR Central Ray: •Perpendicular to the elbow joint Structures Shown: •Oblique projection of the elbow with the radial head and neck free of superimposition of the ulna

Elbow: Lateral Projection (5+2)

•Place shoulder, elbow and wrist joints all on the same plane. •Flex the elbow 90 degrees keeping the wrist and elbow on an equal plane •Center the elbow joint to the center of the IR •Rotate the hand and forearm into a true lateral position •The humeral epicondyles should be perpendicular to the IR Central Ray: •Perpendicular to the elbow joint Structures Shown: •Lateral projection of the elbow joint, distal humerus and proximal forearm

Coyle Method (Ambulatory Method): Coronoid Process (3+4)

•Place the humerus, elbow and wrist joints on the same plane •Pronate the hand •Flex the elbow 80 degrees Central Ray: •Directed away from the shoulder at angle of 45 degrees to the coronoid process. •CR enters the joint at mid elbow Structures Shown: •An open elbow joint between the coronoid process and trochlea •Used to show pathologic processes or trauma in the region of the coronoid process

Coyle Method (Ambulatory Method): Radial Head and Capitulum (3+4)

•Place the humerus, elbow and wrist joints on the same plane •Pronate the hand •Flex the elbow 90 degrees Central Ray: •Directed toward the shoulder at an angle of 45 degrees to the radial head. •CR enters the joint at mid elbow Structures Shown: •An open elbow joint between the radial head and capitulum •Used to show pathologic processes or trauma in the region of the radial head

Elbow: AP Projection (Partial Flexion) Proximal Forearm Evaluation Criteria (4)

•Proximal radius and ulna without rotation or distortion •Radial head, neck and tuberosity slight superimposed over the proximal ulna •Partially open elbow joint •Foreshortened distal humerus

Elbow: AP Projection Evaluation Criteria (4)

•Radial head, neck and tuberosity slightly superimposed over the proximal ulna •Elbow joint centered in the exposure field •Open humeroradial joint •No rotation of humeral epicondyles (coronoid and olecranon fossae equidistant to epicondyles)

Elbow: AP Projection (Partial Flexion) Proximal Forearm (3+3)

•Seat patient high enough to have dorsal surface of the forearm resting on the table •Supinate the hand to the best of the patient's ability **If patient is unable to perform this position then elevate the extremity on a support, adjust the extremity in a lateral position, place the IR in the vertical position behind the upper end of the forearm, and direct the CR horizontally. Central Ray: •Perpendicular to the elbow joint and long axis of the forearm •Adjust the IR so the CR passes to its midpoint Structures Shown: •Proximal forearm when the elbow cannot be fully extended

Radial Head and Coronoid Process Axiolateral Projection (Coyle Method)

•This projection was devised for obtaining images of the radial head and coronoid process on patients that cannot fully extend the elbow for medial and lateral projections. This is primarily used as a trauma view. •There are 2 different methods of imaging the patient for these images: 1.Seated - for ambulatory patients 2.Supine - for trauma patients •There are 2 different regions of interest when using the Coyle Method: 1.Radial head 2.Coronoid process •Each of these regions of interest offer their own specific positions and CR angles to visualize the desired anatomy