UPPER_EXTREMITIES PART 2.pptx

HOLY INFANT COLLEGE OF TACLOBAN CITY, INC Benigno Aquino Ave., Youngfield, Tacloban City Tel. # (53) 832-2455; Email Address: [email protected] Owned and Administered by the Religious Sisters of Mercy (RSM) COLLEGE OF RADIOLOGIC TECHNOLOGY...

HOLY INFANT COLLEGE OF TACLOBAN CITY, INC Benigno Aquino Ave., Youngfield, Tacloban City Tel. # (53) 832-2455; Email Address: [email protected] Owned and Administered by the Religious Sisters of Mercy (RSM) COLLEGE OF RADIOLOGIC TECHNOLOGY RADIOGRAPHIC RT 112 : POSITIONING & RADIOLOGIC PROCEDURES 1 Prepared by: M R. A L LY S O N Q. F L O R E N D O , R R T Lecturer, College of Radiologic Technology HAND  PA PROJECTION PP: Hand palmar surface down; spread finger slightly RP: 3rd MCP joint CR: ┴ SS: PA oblique projection of the thumb  PA PROJECTION AP PROJECTION is used over PA if; Hand cannot be extended because of injury and pathologic conditions For metacarpal bones and MCP joints.  PA OBLIQUE PROJECTION (Lateral Rotation) PP: Hand pronated & rotated laterally; palmar surface down; MCP joints 45o to IR; 45o foam wedge RP: 3rd MCP joint CR: ┴ SS: PA oblique projection of the hand  PA OBLIQUE PROJECTION (Lateral Rotation) ER: To investigate fractures and pathologic conditions REVERSE PA OBLIQUE: for severe metacarpal deformities. Foam Wedge: For interphalangeal joints  PA OBLIQUE PROJECTION (Lateral Rotation) Fingertips Touching The Cassette: For metacarpal bones Index Finger Elevation: Cannot tolerate the mentioned above Use of radiolucent material Opens joint spaces Reduces the degree of foreshortening of phalanges  LATERAL PROJECTION (Lateromedial In Extension) PP: Hand in lateral position; digits extended; thumb 90o to palm. LATEROMEDIAL PROJECTION – Ulnar aspect down MEDIOLATERAL PROJECTION – Radial aspect down – More difficult to assume RP: 2nd MCP joint CR: ┴  LATERAL PROJECTION (Lateromedial In Extension) SS: Lateral projection of the hand in extension ER: The customary position for localizing foreign bodies and metacarpal fracture displacement  FAN LATERAL POSITION Eliminates superimposition of all phalanges (except proximal phalanges)  LATERAL PROJECTION (Lateromedial In Flexion) PP: Hand in natural arch position; digits relaxed RP: 2nd MCP joint CR: ┴  LATERAL PROJECTION (Lateromedial In Flexion) SS: Lateral projection of the hand in flexion ER: To demonstrate anterior or posterior displacement in fractures of metacarpals.  NORGAARD METHOD (AP OBLIQUE PROJECTION) BALL CATCHERS POSITION PP: Hand supinated & medially rotated; medial aspect against IR; 45o sponge support RP: Between level of 5th MCP joints of both hands CR: ┴  NORGAARD METHOD (AP OBLIQUE PROJECTION) SS: AP oblique projection of both hands ER: To diagnose Rheumatoid Arthritis WRIST  PA PROJECTION PP: Hand slightly arch (places wrist in close contact with IR) RP: Midcarpal area CR: ┴ Note: If swollen wrist, ask the patient to flex the wrist slightly. If the wrist is in cast or splint, compare the affected wrist on the opposite side.  PA PROJECTION SS: Open radioulnar joint space; slightly oblique rotation of ulna. AP Projection should be taken if ulna is under examination.  AP PROJECTION PP: Hand supinated; digits elevated (places wrist in close contact with IR) RP: Midcarpal area CR: ┴  AP PROJECTION SS: Carpal interspaces better demonstrated than PA Projection No rotation of ulna Rationale: Carpal interspaces are more closely parallel with the divergence of the beam.  LATERAL PROJECTION (LATEROMEDIAL PROJECTION) PP: Elbow flexed 90o Hand & forearm in lateral position – Ulnar surface against IR – Radial surface against IR (for comparison) RP: Midcarpal area CR: ┴  LATERAL PROJECTION (LATEROMEDIAL PROJECTION) SS: Proximal metacarpals & distal radius & ulna; trapezium & scaphoid (more anterior) ER: To demonstrate anterior or posterior displacement in fractures  LATERAL POSITION IN PALMAR FLEXION BURMAN et. al. SUGGESTION Wrist in palmar flexion SS: Lateral position of the Scaphoid FOILLE METHOD First to describe Carpe Bossu (Carpal Boss; 3rd CMC joint) Best demonstrated in a lateral position of wrist in palmar flexion  PA OBLIQUE PROJECTION (LATERAL ROTATION) PP: Palmar surface against IR; hand pronated & rotated 45o laterally; wrist ulnar deviation (for Scaphoid only) RP: Midcarpal area CR: ┴ SS: Carpals on the lateral side (Scaphoid & Trapezium) PA OBLIQUE PROJECTION (LATERAL ROTATION)  AP OBLIQUE PROJECTION (MEDIAL ROTATION) PP: Dorsal surface against IR; hand supinated & rotated 45o medially RP: Midcarpal area CR: ┴ SS: Carpals on the medial side – Pisiform, Triquetrum & Hamate AP OBLIQUE PROJECTION (MEDIAL ROTATION)  PA PROJECTION (In Ulnar Deviation) PP: Hand pronated Wrist in extreme ulnar deviation RP: Scaphoid CR: ┴ or 10-15o proximally/distally (for clear delineation)  PA PROJECTION (In Ulnar Deviation) SS: Scaphoid Opens carpal interspaces on lateral side. ER: The 10 to 15o proximally or distally corrects foreshortening of the scaphoid which occurs with a perpendicular CR. It opens the spaces between adjacent carpals.  PA PROJECTION (In Radial Deviation) PP: Seated position; hand pronated; wrist in extreme radial deviation. RP: Midcarpal area CR: ┴ SS: Opens carpal interspaces on medial side Best demonstrates Lunate, Triquetrum, Pisiform, Hamate  PA PROJECTION (In Radial Deviation)  STECHER METHOD (PA AXIAL PROJECTION) VARIATIONS: 1. IR elevated 20o 2. CR 20o toward elbow or CR 20o toward digits – Fracture line that angles superoinferiorly 3. Close the fist – Widens the fracture line RP: Scaphoid CR: ┴  STECHER METHOD (PA AXIAL PROJECTION) SS: Scaphoid ER (20o Angulation): – To place scaphoid at right angles to the CR – To project scaphoid without self- superimposition. Bridgman Method: Stecher Method with ulnar deviation  RAFERT-LONG METHOD SCAPHOID SERIES (PA & PA AXIAL PROJECTIONS) IN ULNAR DEVIATION PP: Hand pronated; wrist in extreme ulnar deviation RP: Scaphoid CR: ┴; 10o; 20o; 30o cephalad  RAFERT-LONG METHOD SCAPHOID SERIES (PA & PA AXIAL PROJECTIONS) SS: Scaphoid with minimal superimposition ER: To diagnose scaphoid fractures  CLEMENTS-NAKAYAMA METHOD (PA AXIAL OBLIQUE PROJECTION) PP: Seated position Palmar surface against 45o sponge Hand in ulnar deviation RP: Enters: Anatomical snuffbox Exit: Trapezium CR: 45o distally  CLEMENTS-NAKAYAMA METHOD (PA AXIAL OBLIQUE PROJECTION) If u n a b l e to achieve ulnar deviation. Align the straight wrist to the IR and rotate the elbow end of IR & arm 20o away from CR.  CLEMENTS-NAKAYAMA METHOD (PA AXIAL OBLIQUE PROJECTION) SS: – Trapezium and its articulation of the adjacent carpal bones. – The articulation of the trapezium and scaphoid is not demonstrated. ER: To demonstrate trapezium fractures  LENTINO METHOD (TANGENTIAL PROJECTION) PP: Hand palm upward Hand 90o to forearm RP: 1.5 in. (3.8 cm) proximal to wrist joint CR: 45ocaudad  LENTINO METHOD (TANGENTIAL PROJECTION) SS: Carpal bridge ER: Used to demonstrate; – Fractures of scaphoid – Lunate dislocation – Dorsum of wrist calcifications – Foreign bodies – Chip fractures (dorsal aspect of carpal bones)  MODIFIED METHOD If the wrist is too painful. For patient’s comfort.  GAYNOR-HART METHOD (TANGENTIAL INFEROSUPERIOR PROJECTION) PP: Seated position Wrist hyperextended Hand rotated slight toward the radial side (to prevent superimposition of Hamate & Pisiform shadows) Digits grasp with opposite hand. RP: 1 in. distal to 3rd MCP base CR: 25-30o to long axis of hand  GAYNOR-HART METHOD (TANGENTIAL INFEROSUPERIOR PROJECTION) SS: Carpal Canal / Tunnel (Carpal Sulcus + Flexor retinaculum) ER: Used to demonstrate – Carpal Tunnel Syndrome – Fractures of hook of hamate, pisiform & trapezium SUPEROINFERIOR PROJECTION PP: Dorsiflex the wrist (as much as tolerable) Lean forward (to place carpal canal tangent to IR) RP: Tangential or ┴ to the carpal canal to the level of midpoint of the wrist. CR: 20-35o from the long axis of the forearm TEMPLETON & ZIM Method- 40o toward the finger. SUPEROINFERIOR PROJECTION SS: Carpal Canal/Tunnel (concavity between trapezium laterally and hook of hamate and Pisiform medially. ER: Taken when patient cannot assume/maintain Gaynor-Hart Method FOREARM  FOREARM 2 bones: articulate with each other proximally and distally Interosseous membrane between them Ulna – Olecranon hinges with the humerus forming elbow – Styloid process distally Radius – Contributes to wrist joint – Styloid process anchors a Radius is thinner proximally, like a ligament to wrist (thumb side) spool of thread, and wide distally; ulna is slightly longer and looks like a monkey wrench (supposedly!) ULNA Olecranon process Coronoid process Radial notch Trochlear notch Styloid process RADIUS Head Shaft Styloid process Proximal and distal joints of the forearm proximal ulna  ARM HUMERAL HEAD – Shaft or body – Greater tubercle – Lesser Tubercle – Anatomical Neck – Surgical neck – Intertubercular groove – Deltoid tuberosity – Trochlea – Capitulum – Medial/Lateral epicondyle – Olecranon Fossa RIGHT HUMERUS  AP PROJECTION PP: Hand supinated Patient lean laterally Humeral epicondyles // to IR RP: Midshaft CR: ┴  AP PROJECTION SS: Elbow joints Radius & ulna Distorted carpal bones (proximal row) Slight superimposition of radial head, neck & tuberosity over the proximal ulna  H A N D P R O N AT I O N It crosses the radius over the ulna at its proximal third It rotates the humerus medially  LATERAL PROJECTION PP: Elbow flexed 90o; forearm & hand in true lateral; thumb must be up; humeral epicondyle ┴ to IR RP: Midshaft CR: ┴  LATERAL PROJECTION SS: Elbow joints; radius & ulna; carpal bones (proximal row) Superimposed radius & ulna at their distal end Superimposed radial head over the coronoid process Superimposed humeral epicondyles Radial tuberosity facing anteriorly ELBOW  AP PROJECTION PP: Elbow extended; hand supinated; patient lean laterally; humeral epicondyles & anterior surface of elbow // to IR RP: Elbow joint CR: ┴  AP PROJECTION SS: Elbow joints; distal arm & proximal forearm Radial head, neck & tuberosity slightly superimposed over the proximal ulna  L AT E R A L P R O J E C T I O N ( L AT E R O M E D I A L ) PP: Elbow flexed 90o; elbow flexed 30-35o (for suspected elbow injury); hand in lateral position; humeral epicondyles ┴ to IR RP: Elbow joint CR: ┴  L AT E R A L P R O J E C T I O N ( L AT E R O M E D I A L ) SS: Elbow joints Distal arm & proximal forearm Superimposed humeral epicondyles Radial tuberosity facing anteriorly Radial head partially superimposing coronoid process Olecranon process in profile  L AT E R A L P R O J E C T I O N ( L AT E R O M E D I A L ) GRISWOLD 2 Reasons for fl e x i n g e l b o w 9 0 degrees Olecranon process seen in profile Elbow fat pads are least compressed AP OBLIQUE PROJECTION (Medial Rotation) PP: Hand pronated or medially rotated 45o; anterior surface of elbow 45o to IR RP: Elbow joint CR: ┴ SS: Coronoid process in profile; trochlea  AP OBLIQUE PROJECTION (Medial Rotation) SS: Coronoid process in profile; Trochlea & Medial Epicondyle  AP OBLIQUE PROJECTION (Lateral Rotation) PP: Hand laterally rotated 45o; 1st & 2nd digits touching the table; posterior surface of elbow 45o to IR RP: Elbow joint CR: ┴ AP OBLIQUE PROJECTION (Lateral Rotation) SS: Radial head & neck in profile; capitulum & lateral epicondyle  TWO AP PROJECTIONS (In Partial Flexion) DISTAL HUMERUS PP: Hand supinated; elbow partially flexed RP: Elbow joint CR: ┴ to humerus SS: Distal humerus when elbow cannot be fully extended  TWO AP PROJECTIONS (In Partial Flexion) PROXIMAL FOREARM PP: Hand supinated; dorsal surface of forearm against IR; elbow partially flexed RP: Elbow joint CR: ┴ to forearm SS: Proximal forearm when the elbow cannot be fully extended TWO AP PROJECTIONS (In Partial Flexion) 2 AP Projections For patient cannot completely extend the elbow.  JONES METHOD (AP PROJECTIONS)  JONES METHOD (AP PROJECTIONS) ACUTE FLEXION DISTAL HUMERUS PP: Elbow fully (acutely) flexed RP: 2 in. superior to olecranon process CR: ┴ to humerus SS: Olecranon process  JONES METHOD (Acute Flexion) PROXIMAL FOREARM PP: Elbow fully (acutely) flexed RP: 2 in. distal to olecranon process CR: ┴ to flexed forearm SS: Elbow joint more open  JONES METHOD (Acute Flexion) DISTAL HUMERUS PROXIMAL FOREARM  JONES METHOD (Acute Flexion) DISTAL HUMERUS PROXIMAL FOREARM  RADIAL HEAD SERIES ( L AT E R A L P R O J E C T I O N ) FOUR-POSITION SERIES PP: Elbow flexed 90o; elbow joint in lateral position; four exposures: 1.) Hand supinated 2.) Hand in lateral 3.) Hand pronated 4.) Hand internally rotated RP: Elbow joint CR: ┴ RADIAL HEAD SERIES SS: Radial head in varying degrees of rotation Radial tuberosity facing anteriorly (1st & 2nd exposures) Radial tuberosity facing posterior (3rd & 4th exposures)  COYLE METHOD (AXIOLATERAL PROJECTION) PP: CR: Seated: Hand pronated Seated: Supine (t r a u m a ): 45o toward the shoulder Distal Humerus elevated (Radial Head) IR vertical 45o away from the Humeral epicondyles ┴ to shoulder (Coronoid IR Process) Palmar aspect of hand facing anteriorly Elbow flexed 90o (radial Supine: head) or 80o (coronoid Horizontal; 45o cephalad process) (radial head); 45o caudad RP: Mid-elbow joint (coronoid process)  COYLE METHOD (AXIOLATERAL PROJECTION) CR 45° t o w a r d the shoulder 90° flexion For radial head  COYLE METHOD (AXIOLATERAL PROJECTION) CR 45° away shoulder 80° flexion For coronoid process  COYLE METHOD (AXIOLATERAL PROJECTION) SS: Open elbow joint between radial head & capitulum or coronoid process & trochlea ER: Used to demonstrate; – Pathologic processes or trauma in the area of radial head & coronoid process – Cannot fully extend elbow for medial & lateral oblique  PA A X I A L P R O J E C T I O N D I S TA L H U M E R U S PP: Seated; arm rested vertically against IR; forearm // to IR; humerus 75o from forearm or 15o from CR; hand supinated RP: Ulnar sulcus CR: ┴  PA A X I A L P R O J E C T I O N D I S TA L H U M E R U S SS: Epicondyles; trochlea; ulnar sulcus (groove between medial epicondyle & trochlea); olecranon fossa ER: – Used in radiohumeral bursitis (tennis elbow) – To detect otherwise obscured calcification located in the ulnar sulcus  PA A X I A L P R O J E C T I O N O L E C R A N O N P R O C E SS PP: Seated; arm 45- 50o from vertical; hand supinated RP: Olecranon process CR: ┴ or 20o toward the wrist  PA A X I A L P R O J E C T I O N O L E C R A N O N P R O C E SS SS: Dorsum of olecranon process (┴); curved extremity & articular margin of olecranon process (20o) PA A X I A L P R O J E C T I O N O L E C R A N O N P R O C E SS HUMERUS  AP PROJECTION PP: Erect/seated- upright (more comfortable); arm abducted slightly; hand supinated; humeral epicondyles // to IR RP: Midshaft CR: ┴  AP PROJECTION SS: Humeral head & greater tubercle in profile  L AT E R A L P R O J E C T I O N ( L AT E R O M E D I A L U P R I G H T ) PP: Erect/seated-upright (more comfortable); arm rotated internally; elbow flexed approximately 90o; palmar aspect of hand against hip; humeral epicondyles ┴ to IR RP: Midshaft CR: ┴  L AT E R A L P R O J E C T I O N ( L AT E R O M E D I A L U P R I G H T ) SS: Lesser tubercle in profile; greater tubercle superimposed over humeral head MEDIOLATERAL UPRIGHT: for patients with broken humerus  AP PROJECTION (RECUMBENT) PP: Supine; unaffected shoulder elevated; hand supinated; humeral epicondyles // to IR RP: Midshaft CR: ┴ SS: Humeral head & greater tubercle in profile  L AT E R A L P R O J E C T I O N ( L AT E R O M E D I A L ) PP: Supine: Arm abducted slightly forearm rotated medially Dorsal aspect of hand against patient’s side Humeral epicondyles ┴ to IR Elbow flexed slightly (for comfort) Lateral Recumbent: Place IR closed to axilla Elbow flexed (unless contraindicated) Thumb surface of hand up  L AT E R A L P R O J E C T I O N ( L AT E R O M E D I A L ) RP: Midshaft or distal humerus (lateral recumbent) CR: ┴ SS: Distal humerus ER (Lateral Recumbent): For patient with known or suspected fracture