Chapter 4 - Upper Limb
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
