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