Forearm and Elbow X-ray PDF

THE FOREARM AND ELBOW  ANATOMY: ► The Bones ► Radius ► Ulna ► Radial and Ulna styloid processes ► Head ► Body or shaft ► Ulnar notch ► Radial Notch ► Radial tuberosity ► Radial neck  Surface Anatomy INDICATIONS: ► Pain ► T...

THE FOREARM AND ELBOW  ANATOMY: ► The Bones ► Radius ► Ulna ► Radial and Ulna styloid processes ► Head ► Body or shaft ► Ulnar notch ► Radial Notch ► Radial tuberosity ► Radial neck  Surface Anatomy INDICATIONS: ► Pain ► Trauma/Fall - FOOSH – ► Lumps fall on outstretched hand ► Foreign Body ► Loss of function ► Swelling ► Deformity ► Infections ► Reduced Range of ► Cuts Movement (ROM) ► Bruising PATIENT PREPARATION: ► Correct Patient Identification ► Pregnancy check (if applicable) ► Explanation of procedure ► Remove jewellery (bracelet, watches, sleeves etc) ► Patient seated on chair with affected side next to the table, make sure knees are not under the table ► Table height to the level where their forearm/ elbow is resting comfortably flat for position PATIENT PREPARATION: Forearm Standard series: AP Forearm Lateral Forearm AP FOREARM: Xray: AP Forearm kVp: 55kVp mAs: 4mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Long axis of cassette parallel with long axis of forearm Cassette: If forearm is too long to fit, you can place the long axis diagonally across cassette Centre: To the mid forearm, include both joints Collimation: To include 2-3cm beyond both joints and include skin edge along forearm Pt sitting at end of table so legs aren't in primary beam Supinate the hand and extend the arm so the posterior aspect of the forearm is touching the cassette Check that the Radial and Ulnar styloid processes are equidistant from the cassette Patient Position: Check that the humeral epicondyles are equidistant from the cassette Bontrager’s Handbook of Radiographic Positioning and Techniques EVALUATION CRITERIA AP FOREARM: ► Regional anatomy included – proximal carpal row to distal humerus, including soft tissue ► Both joints included ► No rotation ► Refer to PA/AP criteria for wrist and elbow respectively ► Wrist: Slight superimposition of distal radius and ulna ► Elbow: Humeral epicondyles visualised in profile ► Elbow: Radial head neck and tuberosity slightly superimposed by ulna ► Density and contrast optimal to visualise bone & soft tissue, no motion Movement of the Forearm LATERAL FOREARM: Xray: Lateral Forearm kVp: 57kVp mAs: 4mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Long axis of cassette parallel with long axis of forearm Cassette: If forearm is too long you can place the long axis diagonally across cassette Centre: To the mid forearm, include both joints Collimation: To include 2-3cm beyond both joints and include skin edge along forearm Pt sitting at end of table so legs aren't in primary beam Raise the table to be nearly in line with the shoulder- the wrist, elbow and shoulder should be in the same line Flex the elbow so it's 90deg Patient Position: Place the medial aspect onto the cassette The thumb should be up Check that the wrist is in lateral position (radial and ulna styloid) Check that the elbow is in lateral position, humeral epicondyles are also superimposed (table height) Bontrager’s Handbook of Radiographic Positioning and Techniques  EVALUATION CRITERIA LATERAL FOREARM: ► Regional anatomy included – proximal carpal row to distal humerus, including soft tissue ► Wrist- Distal radius and head of ulna superimposed ► Elbow- Humeral epicondyles superimposed ► Elbow- Radial head should superimpose ulnar ► Both joints included on film ► Density and contrast optimal to visualise bone & soft tissue Alternative series: Modified Forearm series Horizontal beam lateral MODIFIED FOREARM SERIES: ► If patient has pathology previous two views might be difficult ► First view: PA Wrist with Lateral Elbow ► Second view: Lateral Wrist with AP Elbow MODIFIED FOREARM SERIES: https://radiopaedia.org/articles/bowing-fracture MODIFIED FOREARM SERIES Forearm immobilised in cast HORIZONTAL BEAM LATERAL: Lateromedial OR Mediolateral Elbow Standard series: AP Elbow AP External Oblique Elbow Lateral Elbow AP ELBOW: Xray: AP Elbow kVp: 55kVp mAs: 4mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of cassette parallel with long axis of forearm and humerus Centre: Center midway between the medial and lateral epicondyle Collimation: All four sides to include about 5-6cm of forearm and humerus Pt sitting at end of table so legs aren't in primary beam Extend the elbow into AP position Shoulder, elbow and wrist in same horizontal plane Patient Position: Supinate the hand and place the posterior aspect of the elbow on the cassette Bontrager’s Handbook of Radiographic Positioning and Techniques  EVALUATION CRITERIA AP ELBOW: ► Regional anatomy included – distal third of humerus to proximal third of radius and ulna, including soft tissue ► No rotation - humeral epicondyles visualised in profile, coronoid and olecranon fossae approximately equidistant to epicondyles ► Radial head, neck and tuberosity should slightly superimpose the proximal ulna https://radiopaedia.org/articles/elbow-ap-view-2?lang=us ► Density and contrast optimal to visualise bone & soft tissue, no motion AP EXTERNAL OBLIQUE ELBOW: Xray: AP Exernal Oblique Elbow kVp: 55kVp mAs: 4mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of cassette parallel with long axis of forearm and humerus Centre: Center midway between the medial and lateral epicondyle Collimation: All four sides to include about 5-6cm of forearm and humerus Pt sitting at end of table so legs aren't in primary beam Patient moves to the front edge of chair Patient Position: Patient then instructed to lean back in chair and rotate elbow externally approx. 45 degrees Check humeral epicondyles for 45 deg rotation Bontrager’s Handbook of Radiographic Positioning and Techniques EVALUATION CRITERIA AP EXTERNAL OBLIQUE ELBOW: ► Regional anatomy included – distal third of humerus to proximal third of radius and ulna, including soft tissue ► Radial head, neck and tuberosity projected free of superimposition of ulna ► Density and contrast optimal to visualise bone & soft tissue, no https://radiopaedia.org/articles/elbow-external-oblique-view?lang=us motion LATERAL ELBOW Xray: Lateral Elbow kVp: 57kVp mAs: 4mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of cassette parallel with long axis of forearm Centre: To lateral epicondyle Collimation: All four sides to include about 5cm of forearm and humerus Pt sitting at end of table so legs aren't in primary beam 90 degree elbow flexion Medial border of forearm and palm in contact with detector The shoulder, elbow and wrist are kept in the same horizontal plane Hand in lateral position Patient Position: If unable to turn hand laterally elevate PA hand slightly with a sponge Bontrager’s Handbook of Radiographic Positioning and Techniques  EVALUATION CRITERIA LATERAL ELBOW: ► Regional anatomy included – distal third of humerus to proximal third of radius and ulna, including soft tissue ► Humeral epicondyles superimposed ► Radial head should superimpose coronoid process ► Radial tuberosity seen in profile (if hand pronated) ► Elbow joint open ► Olecranon process in profile ► Density and contrast optimal to visualise bone & soft tissue Hand position affects radial tuberosity position Additional/ Alternative views: Radial head view AP Partial Flexion views  RADIAL HEAD VIEW: ► Patient positioned as for Lateral elbow however angle the central ray 45deg towards the shoulder (proximal) ► Projects radial head free of superimposition ► Also known as the “Coyle’s View” Bontrager’s Handbook of Radiographic Positioning and Techniques AP Partial Flexion views If patient cannot fully extend elbow can do two views in partial flexion Reasons patient may not be able to extend elbow:  Pain  Follow up imaging- Elbow in fixed cast  AP ELBOW PARTIAL FLEXION DISTAL HUMERUS: ► Position as for AP elbow however only the humerus is in contact with the imaging plate ► Support elevated forearm if needed ► Supinate the hand (if possible) ► Humeral epicondyles are equidistant from the cassette ► Center over elbow joint Bontrager’s Handbook of Radiographic Positioning and Techniques https://radiopaedia.org/articles/elbow-acute-flexion-ap  AP ELBOW PARTIAL FLEXION PROXIMAL FOREARM: ► Position as for AP elbow however only the radius and ulna are in contact with the imaging plate ► Patient standing or seated high ► Supinate the hand (if possible) ► Humeral epicondyles are equidistance from the cassette ► Center over elbow joint Bontrager’s Handbook of Radiographic Positioning and Techniques https://radiopaedia.org/articles/elbow-acute-flexion-ap Pathology FAT PADS: ► Fat pads can be visualised on the lateral elbow x-ray if joint effusion present ► Joint effusion almost always indicates fracture ► Anterior fat pads = Sail sign ► Posterior fat pads = Crescent shape ► Most common cause in adults- radial head fracture ► Children- supracondylar fracture Fat pads of the elbow DINNER FORK FRACTURE: What is this # also known as? https://radiopaedia.org/articles/dinner-fork-deformity-wrist?lang=us  SUPRACONDYLAR FRACTURE: ► Frequently seen in children (usually under 10yo) ► Due to falling from moderate height onto elbow and hyper-extension ► Olecranon acts as a fulcrum ► Undisplaced/displaced ► AP and Lateral radiographs sufficient- in trauma https://radiopaedia.org/articles/supracondylar-humeral-fracture-2?lang=us RADIAL HEAD FRACTURES: https://radiopaedia.org/articles/radial-head-fractures?lang=us DISLOCATION: Posterior dislocation of elbow https://radiopaedia.org/articles/elbow-dislocation  MID SHAFT FRACTURE: - Radius and ulna are bound together at proximal and distal joints and act as a ring - It is difficult to only fracture one bone in ring-like structures - It is likely another fracture or disruption to joint has occurred if one fracture if seen THEATRE: K- wires Supracondylar # Olecranon # ORIF Ulna # External Fixation Temporary method for stabilising open or complex fractures REFERENCES: ► Bontrager, K. L. (2005) Textbook of Radiographic Positioning and Related Anatomy. (6th edn.) St Louis: Mosby. ► Eisenberg, R. L. (2003) Comprehensive Radiographic Pathology (3rd edn.) St Louis: Mosby. ► McQuillen-Martensen, K. (1996) Radiographic Critique. Philadelphia : W.B. Saunders. ► Weir, J. & Abrahams, S. P. (2003) Imaging Atlas of Human Anatomy (3rd ed). London: Mosby. ► http://www.wikiradiography.net ► https://radiopaedia.org ► https://www.radiologymasterclass.co.uk/