Chapter 4 - Upper Limb

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T/F: Lead gonadal shielding is not required for upper limb radiographs if the patient can sit upright for these exams.

False

T/F: The hands are placed in a true PA position when using the Norgaard method

False

T/F: for a forearm study, the technologist needs to include only the joint closest to the site of the injury.

False

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

False

T/F: shielding is only required for upper limb studies performed on patients who are child-bearing age or younger.

False

T/F: Placing multiple images on the same digital IP is recommended as long as close collimation is applied.

False **Recommended only 1 projection be placed on a digital IP. The anatomy should be centered to the IP. **

T/F: Anterior and posterior fat pads of the elbow are best seen on correctly positioned and correctly exposed AP elbow projections

False; Lateral.

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

Fan Lateral

Where is the central ray centered for an AP projection of the thumb?

First MCP joint

Radiographic appearance: Disruption in bony cortex with soft tissue swelling.

Fractures

All interphalangeal joints are _____, or hinge-type. They can move in two directions only; flexion and _____.

Ginglymus Extension

Humeroulnar and humeroradial joint of the elbow are...

Ginglymus/Hinge

The interphalangeal joints are...

Ginglymus/Hinge

Which carpal contains a hooklike process?

Hamate

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

Hamulus

List the three parts of each metacarpal, starting DISTALLY.

Head, body, base

The three parts of the phalanx, starting DISTALLY are the _____, _____, and the _____.

Head, body, base

7. 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.

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 w/ lateral deviation

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

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

PA oblique

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 no 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

Radiographic appearance: Mixed areas of sclerotic and cortical thickening along with radiolucent lesions; "cotton wool" appearance.

Paget's disease

The long axis of the anatomic part being imaged should be placed ...

Parallel to the long axis of the IR

The _____ constitutes the fingers and thumb, the _____ make up the palm of each hand, and the _____ consists of the bones of the wrist.

Phalanges Metacarpals Carpals

The intercarpal joints between the various carpals (wrist bones) have only a _____ movement.

Plane (gliding)

Intercarpal joints are...

Plane/Gliding

In what position should the hand be for an AP medial rotation oblique elbow position?

Pronated

The radius and ulna articulate with each other at the _____ and _____ radioulnar joint.

Proximal Distal

Where is the CR centered for a PA oblique projection of the 2nd digit?

Proximal interphalangeal joint (PIP)

Which joint permits the forearm to rotate during pronation?

Proximal radioulnar joint

How does the forearm appear radiographically if pronated (palm down) for a PA projection?

The proximal radius crosses over the ulna.

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

The rotation position of the hand and wrist

Which carpal articulates with the base of the thumb?

Trapezium

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 projections could be performed to demonstrate the coronoid process?

Trauma axial lateral projection - Coyle method for coronoid process

The articular (joint) portion of the medial aspect of the distal humerus is called the _____.

Trochlea

The large concave depression that articulates with the distal humerus is the _____.

Trochlear notch

Proximal radioulnar joints are...

Trochoidal/Pivot

How many bones make up the phalanges of the hand?

14

How much are the hand and wrist elevated from the IR for the modified Stecher Method?

20 degrees

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

In an erect anatomical position, which one of the following structures is considered to be most inferior or distal? A.) Head of ulna B.) Olecranon process C.) Radial tuberosity D.) Head of radius

A

What is the major disadvantage of performing a PA projection of the thumb rather than an AP? a.) Increased OID b.) Increase in patient dose c.) More painful for patient d.) Awkward position for patient

A

Where is the CR centered for a PA projection of the of the 2nd digit? a.) Affected PIP joint b.) Affected middle phalanx c.) Affected MCP joint d.) Affected CMC joint

A

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

AP Oblique with 45 degree medial rotation

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

AP and lateral forearm projections to include the wrist

An abnormality of the cartilage affecting long bones

Achondroplasia

All metacarpophalangeal joints are classified as _____, meaning they can move in two planes, allowing flexion, extension, adduction, abduction, and circumduction.

Ellipsoidal (condyloid)

The metacarpalphalangeal joints are...

Ellipsoidal/Condyloid

Wrist joints are ...

Ellipsoidal/Condyloid

How would you reduce distortion for a lateral position?

Perform a thumb down lateral to decrease OID.

Sprain or tear of the ulnar collateral ligament

Skier's thumb

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

metacarpophalangeal joint

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 be extended at all?

Two projections: - CR perpendicular to humerus - CR perpendicular to to forearm

Radiographic appearance: Widening of inner MCP joint space of thumb and increase in degrees of angle of MCP line

"Skier's thumb" (ulnar collateral ligament injury)

What is the mnemonics given in the textbook that uses the first letter of each of the preferred terms of the eight carpal bones?

"Steve left the party to take Carol home."

Why is accurate identification of all joints so important in radiography?

Because small chip fractures may occur near the joint spaces.

Fracture of the base of the first metacarpal

Bennett's fracture

Fluid-filled joint space with possible calcifications

Bursitis

Inflammation of the fluid filled sacs enclosing the joints

Bursitis

Radiographic appearance: Fluid filled joint space with possible calcification.

Bursitis

What type of fracture is best demonstrated with a modified robert's method? a.) Barton fracture b.) Colles' fracture c.) Bennett's fracture d.) Smith fracture

C

Hereditary condition marked by abnormally dense bone.

Osteopetrosis

Mixed areas of sclerotic and cortical thickening along with radiolucent lesions

Osteopetrosis

.

.

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

45

What is another name for joints?

Articulations

Accumulated fluid within the joint cavity

Joint effusion

A three projection study of the hand was taken using the following analog exposure factors: 64 kV 1000 mA 1/100 second Large focal spot 36 inch. SID detail High speed screens Which of these factors should be changed on future hand studies to produce more optimal images?

- Use a SMALL focal spot - Minimum 40 inch SID - Use detail speed screens (analog) This will produce a higher quality study.

Where is the central ray centered for a PA projection of the hand?

3rd Metacarpophalangeal joint

A minimum of ___ inch(es) of the forearm should be included radiographically for a PA projection of the hand.

1

Increase/Decrease/Remain the same A. Advanced Paget's disease B. Joint effusion C. Advanced rheumatoid arthritis D. Osteoporosis E. Osteopetrosis F. Bursitis

A. Increase B. Same C. Decrease D. Decrease E. Increase F. Same

What are the 3 routine positioning routines for the second through fifth digits of the hand?

PA PA Oblique Lateral

Why are the joints/articulations between the individual bone of the upper limb so important?

Because small chip fractures may occour near the joint spaces.

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

1. Symmetric appearance of both sides of the shafts of phalanges and distal metacarpals 2. Equal amounts of tissue on each side of the phalanges

What are the 4 main groups of the upper extremity?

1.) Hand and wrist 2.) Forearm 3.) Arm 4.) Shoulder girdle

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

1.) Ulnar deviation 2.) Radial deviation Ulnar deviation is most commonly performed for a scaphoid fracture.

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

1.) one w/ the humerus parallel to the IR 1.) one w/ the forearm parallel to the IR.

During the PA axial scaphoid projection with CR angle and ulnar flexion, the CR must be angled ____ degrees (proximally/distally)

10-15 degrees proximally

In our hands and wrists, we have _____ phalanges (fingers and thumb) _____ metacarpals (palm) _____ carpals (wrist) totaling _____ bones on each hand/wrist.

14 phalanges 5 metacarpals 8 carpals = 27 bones in each hand/wrist

Which IR size should be used for a thumb projection?

18 x 24 cm (8x10 in)

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

25-30 degrees

What is the total number of bones that make up the hand and wrist?

27

A reduction in the quantity of bone or atrophy of skeletal tissue

Osteoporosis

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

45 degrees

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

How many bones make up the carpal region?

8

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 elbow should be generally flexed at ___ degrees for routine positions of the wrist.

90

The hand and wrist form a ____ angle to the forearm with the carpal bridge projection.

90 degree

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

A PA forearm projection was performed rather than AP

Match the following articulations with the correct joint movement types, given the choices of: - Ginglymus - Ellipsoidal - Trochoidal - Plane - Sellar A. Interphalangeal B. Carpometacarpal of 1st digit C. Elbow joint (humeroulnar and humeroradial) D. Metacarpophalangeal of 2nd to 5th digits E. Radiocarpal F. Intercarpal G. Elbow joint H. Proximal radioulnar joint

A. Ginglymus B. Sellar C. Ginglymus D. Ellipsoidal E. Ellipsoidal F. Plane G. Ginglymus H. Trochoidal

Match the following joint with the correct term. A. Between the two phalanges of the first digit (thumb). B. Between the first metacarpal and the proximal phalanx of the thumb. C. Between the middle and distal phalanges of the fourth digit. D. Between the carpals and the first metacarpal. E. Between the forearm and the carpals. F. Between the distal radius and ulna.

A. Interphalangeal Joint (IP) B. 1st Metacarpophalangeal Joint (MCP) C. Fourth Distal Interphalangeal Joint (DIP) D. 1st Carpometacarpal Joint (CMC) E. Radiocarpal F. Distal radioulnar

Match the following articulations to the correct joint movement type; each may be used more than once. A. Intercarpal joints B. Radiocarpal joint C. Elbow joint D. 1st CMC joint E. 3rd CMC joint

A. Plane B. Ellipsoidal C. Ginglymus D. Sellar E. Plane

Indicate whether the following structures are part of the radius, ulna, or distal humerus. A. Trochlear notch B. Radial notch C. Olecranon fossa D. Trochlea E. Coronoid tubercle F. Coronoid process G. Olecranon process H. Coronoid fossa

A. Ulna B. Ulna C. Humerus D. Humerus E. Ulna F. Ulna G. Ulna H. Ulna

Match the projection of the elbow that best demonstrates each of the following structures: A. Coronoid process in profile B. Radial head and tuberosity without superimposition C. Olecranon process in profile D. Coronoid tubercle E. Trochlear notch in profile F. Capitulum and lateral epicondyle in profile G. Olecranon process seated in olecranon fossa

A.) AP, medial rotation oblique B.) AP, lateral rotation oblique C.) Lateral elbow D.) AP elbow E.) Lateral elbow F.) AP, lateral rotation oblique G.) AP elbow

How would you reduce distortion for a PA oblique projection?

A.) Perform medial oblique to decrease OID.

The forearm should generally not be radiographed in a pronated (palm down) PA position, but rather in an _____ projection with the hand _____, or palm up. Why is this?

AP Supinated To prevent superimposition of the radius and ulna.

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

AP & lateral

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

AP projection w/ hand slightly arched

Where are the coronoid and radial fossa located?

Anterior aspect of distal humerus

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

Ap Oblique w/ 45 degree lateral rotation

_____ 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

Where is the CR placed for a PA projection of the hand? a.) Second MCP joint b.) Third MCP joint c.) Middle phalanx of the third digit d.) Third PIP joint

B

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

B

A fracture and dislocation of the posterior lip of the distal radius.

Barton's fracture

A Bennett's fracture involves the _____ of the 1st metacarpal.

Base

Radiographic appearance: Long bones demonstrate thin cortex.

Osteoporosis

Which is the largest of the carpal (wrist) bones?

Capitate

The structure found on the lateral aspect of the distal humerus is called the _____.

Capitulum

Situation: A patient with a history of carpal tunnel syndrome comes to the radiography 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

Painful disorder of hand and wrist from compression of the median resulting nerve

Carpal tunnel syndrome

Possible calcifications in the carpal sulcus

Carpal tunnel syndrome

Radiographic appearance: Possible calcification in carpal sulcus.

Carpal tunnel syndrome

Why should a forearm never be taken as a PA projection?

Causes the proximal radius to cross over the ulna

Transverse fracture of the distal radius with posterior displacement of the distal fragment.

Colles' fracture

The general rule for collimating for upper limb radiography states...

Collimating borders must be visible on all 4 sides.

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 position 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)

Choose the best set of exposure factors for the upper limb radiography using an analog (film-based) system. A.) 75 kv, 200 mA, 1/20 second, small focal spot, 40 inch SID, high speed screens. B.) 75 kv, 600 mA, 1/60 second, large focal spot, 40 inch SID, detail speed screens. C.) 64 kv, 100 mA, 1/10 second, small focal spot, 40 inch SID, high speed screens. D.) 64 kv, 200 mA, 1/20 second, small focal spot, 40 inch SID, detail speed screens.

D

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, nondisplaced fractures near the joint D.) all of the above

D

Why is it important to keep the long axis of the digit parallel to the IR? a.) To reduce distortion of the phalanges b.) To properly visualize joints c.) To demonstrate small fractures d.) All of the above

D

All joints of the upper limb are defined as synovial, meaning freely moveable, or _____. Only the movement types differ.

Diarthrodial

The hand, wrist, forearm, and elbow are ____.

Diarthrodial

Ellipsoidal joints are classified as freely moveable, or _____, and allow movement in _____ directions.

Diarthrodial 4

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

Distal aspect of metacarpals

The fingers contain 3 portions (this excludes the thumb). What are they

Distal phalanx Middle phalanx Proximal phalanx

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

Excessive lateral rotation

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

Reduction in the quantity of bone or atrophy of skeletal tissue

Osteoporosis

What is the name of the joint between the proximal and distal phalanges of the first digit?

Interphalangeal joint

Radiographic appearance: Fluid-filled joint cavity.

Joint effusion

Which two bony landmarks are palpated to assist with positioning of the upper limb?

Lateral and medial epicondyles

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

Lateral in extension

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

Lateral, flexed 90 degrees

Where is the coronoid tubercle located?

Medial aspect of coronoid process

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

Metacarpophalangeal

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

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

Modified Roberts Method 15 degrees proximal

Most common type of primary malignant tumor occurring in bone.

Multiple myeloma

What is the proper name for the position referred to as the "ball-catcher's position?"

Norgaard method

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?

Norgaard method - ball catcher's position

The two beaklike processes of the proximal ulna are called the _____ and the _____ processes.

Olecranon Coronoid

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

Olecranon fossa

Narrowing of joint space with periosteal growths on the joint margins

Osteoarthritis

Radiographic appearance: Narrowing of joint space with periosteal growths on joint margins.

Osteoarthritis

Local or generalized infection of bone or bone marrow

Osteomyelitis

Radiographic appearance: Soft tissue swelling and loss of fat pad detail visibility.

Osteomyelitis

Soft tissue swelling and loss of fat pad detail visibility

Osteomyelitis

Radiographic appearance: Chalky white or opaque appearance with lack of distinction between the bony cortex and trabeculae.

Osteopetrosis

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

What is the less frequent PA wrist projection that opens up and best demonstrates the carpals on the ulnar side of the wrist?

Radial deviation

The small shallow depression located on the lateral aspect of the proximal ulna is the _____.

Radial notch

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

Radius Ulna

Radiographic appearance: Closed joint spaces with subluxation of MCP joints.

Rhematoid arthritis

The ball-catcher's position is commonly used to evaluate for early signs of...

Rheumatoid arthritis

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

Rotation

Which carpal is most commonly fractured?

Scaphoid

Which is the most commonly fractured carpal bone?

Scaphoid

What two carpals articulate with the radius?

Scaphoid (navicular) Lunate (semilunar)

Which two carpal bones are located most anteriorly as seen on a lateral wrist radiograph? (Hint: they are on the radial side of the wrist)

Scaphoid and trapezium

The 1st carpometacarpal joint of the thumb is _____, or a saddle-type joint. The 2nd - 5th carpometacarpal joints are _____, or a gliding-type joints, which allows the least amount of movement of the synovial class joints.

Sellar Plane

The first digit of the carpometacarpal joint is _____ while the second through fifth digits are _____.

Sellar/Saddle Plane/Gliding

In elbow rotational movements, lateral rotation _____ the radius and ulna, while medial rotation _____.

Separates (good, correct) Superimposes (bad, incorrect)

Sprain or tear of the ulnar collateral ligament

Skiers thumb

Reverse of a Colles' fracture

Smith fracture

Arthography is a radiographic study of _____.

Soft tissue structures within certain synovial joints.

Ulnar deviation movement of the wrist "opens up" and best demonstrates the carpals on the opposite side of the wrist. Because the scaphoid is the most frequently fractured carpal bone, the ulnar deviation projection is commonly known as a _____ projection.

Special scaphoid

In what position should the hand be for an AP elbow projection?

Supinated

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. Inital wrist radiographs are inconclusive in demonstrating the location of the foreign body. What additional projections 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 & increased resolution.

5. A PA axial scaphoid projection of the wrist using a 15 degree distal CR angle and ulnar flexion was performed. The resultant radiograph reveals 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, towards the elbow.

Unlike the fingers, the thumb only has two portions. What are they?

The distal and proximal phalanx

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

The elbow is rotated medially.

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

The forearm and humerus are not on the same horizontal plane.

T/F: Both hands are examined with one single exposure when using the Norgaard method.

True

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

True

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

True

T/F: The radial styloid process extends more distally than the ulnar styloid process.

True

T/F: To visualize fat pads surrounding the elbow, exposure factors must be adjusted to see both bony and soft tissue structures.

True

T/F: slight superimposition of the distal third, fourth, and fifth metacarpals may occur with a well positioned PA oblique projection of the hand.

True

T/F: The correct term for the tarsal bone of the foot is the navicular and the correct term for the carpal bone of the wrist is the scaphoid.

True.

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.

Which bone of the upper limb contains the coronoid process?

Ulna


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