Upper Limb Imaging PDF

Diagnostic Imaging Technique of the Upper Limb Karis Vercoe, University of Leeds  Consideration of the following: Terminology Learning Common clinical indications Outcomes Radiographic technique Additional projections  Terminology...

Diagnostic Imaging Technique of the Upper Limb Karis Vercoe, University of Leeds  Consideration of the following: Terminology Learning Common clinical indications Outcomes Radiographic technique Additional projections  Terminology recap  Lateral – away from the midline of the body  Medial – towards the midline of the body  Distal - furthest from, distant from (the farthest point from the centre of the body or torso)  Proximal - nearest to, closest to or in proximity to (closest to the centre of the body or torso)  ☢ What must we do before we enter the room? ☢ What must we check for every patient? ☢ Confidentiality RE-CAP… ☢ Privacy, dignity & respect ☢ Radiation protection ☢ Palpable anatomy we can use to aid positioning and centring – communication with patients is key Why are all of these factors important? Areas to know… Anatomical snuff box Landmarks Lumps & know.... Thenar eminence Bones of the Hand Lumps & Bumps to know.... Heads of metacarp als Lumps & Bumps to know.... Radial and ulna styloid processes Lumps & Bumps to know.... -Olecranon -Medial and lateral epicondyle s Lumps & Bumps to know.... -Acromion process -Coracoid process Why do fractures happen?  A fracture is the scientific and medical term for a break or crack in a bone  They occur when there is a transfer of energy through a bone that exceeds what that bone can cope with  Where a fracture occurs depends on two things – where the bone is weakest and where the majority of the force is applied Mechanism of Injury Mechanism of injury  This refers to the method by which an injury occurs  Fall on outstretched hand, inversion, blunt trauma etc  Fractures tend to follow patterns so the MOI can give us a hint as to what kind of fracture is most likely to have occurred Boxer's Colles # What is the SID for Upper Limb x-rays? 100cm Do we need to use No grids? Not a big enough area to generate enough Why? scatter to justify the increased radiation dose The Importance of 2 Views THE HAND  ☢ OA/RA ☢ Trauma (Punch injury, FOOSH, stab wounds, blender!) HAND – ☢ Osteomyelitis CLINICAL ☢ ?Foreign Body (specific INDICATIONS views – what are these?) ☢ Follow-up imaging ☢ Congenital abnormalities  Standard projections DP Oblique HAND – Lateral PROJECTION Additional projections S Finger views Thumb Ball catcher’s (Norgaard method) HAND – DP Patient position Patient seated at the side of the x-ray couch Elbow flexed; arm relaxed Palmar aspect of the hand placed on the image receptor  Centring point: HAND – Central ray vertical DP  to the image receptor Head of the 3 rd metacarpal HAND – Collimation: DP Laterally – include skin margins Proximally – include distal radioulnar joint Distally – include the tips of the distal phalanges HAND - DP Palm not flat Fingers not flat  Centring point: FINGERS Central ray vertical  to the image receptor – DP Between the heads of the two metacarpals (buddy fingers) FINGERS Collimation: – DP Laterally – lateral margins of both fingers and metacarpals Proximally – include distal radioulnar joint Distally – include the tips of the distal phalanges HAND – Patient position DP Patient seated at the side of the x-ray couch Oblique Elbow flexed; arm relaxed Palmar aspect of the hand placed on the image receptor Rotate the hand laterally 45degrees, ensuring the medial aspect of the hand is still in contact with the image receptor HAND – DP Centring point: Oblique Central ray vertical  to the image receptor Head of the 2 /3 nd rd metacarpal HAND – DP Oblique Collimation: ☢ Laterally – include skin margins ☢ Proximally – include distal radioulnar joint ☢ Distally – include the tips of the distal phalanges HAND – DP Oblique  Patient position Patient seated at the side of the x-ray couch Hand – Lateral aspect of affected hand in contact with the image Lateral receptor Palmar aspect of the hand 90 degrees to the image receptor Slightly abduct the thumb Hand – Lateral Centring point: ☢ Central ray vertical  to the image receptor ☢ Head of the 2nd metacarpal  Collimation: Laterally – dorsal and Hand – palmar skin margins Lateral Proximally – include distal radioulnar joint Distally – include the tips of the distal phalanges Hand - Lateral  Centring point: FINGERS Central ray vertical  to the image receptor – DP Between the heads of the two metacarpals (buddy fingers) FINGERS Collimation: – DP Laterally – lateral margins of both fingers and metacarpals Proximally – include distal radioulnar joint Distally – include the tips of the distal phalanges  Centring point: Fingers – Central ray vertical  to the image receptor Lateral Over the proximal interphalangeal joint of the affected finger  Collimation: Laterally – lateral soft FINGERS tissue margins – Lateral Proximally – include metacarpophalangeal joint Distally – include the tip of the distal phalanx FINGERS - Lateral Hand – Top tips COMMON ERROR WHY? Interphalangeal joint spaces are Fingers may be flexed; extend to not clearly demonstrated… clear. (“I can’t straighten them”) Superimposition of soft tissue Fingers not separated adequately outlines of fingers… Patient’s struggling to hold Assist them with a small 30degree position, especially on the sponge oblique view… Extensive superimposition of the The hand is externally elevated metacarpals on the oblique too much view… (Carver & Carver, 2006) Discuss… Discuss… Discuss… Spot the abnormality Spot the abnormality Spot the abnormality Ballcatchers  Why do we perform this projection?  RA  Joint visualisation  Anterior bilateral projection  Centring: between the two hands at the level of the metacarpophalangeal joints The Thumb /DP Thumb - PA Patient position ☢ Patient seated at the side of the x-ray couch ☢ Elbow extended ☢ Posterior aspect of the thumb on the image receptor ☢ Standing against wallstand  Centring point: Thumb - Central ray vertical to PA the image receptor Over 1st metacarpophalangea l joint  Collimation: Laterally – include skin Thumb - margins PA Proximally – carpometacarpal joint Distally – distal phalanx and skin margins THUMB-PA Thumb - Lateral Patient position ☢ Patient seated at the side of the x-ray couch ☢ Elbow flexed; arm relaxed ☢ Palmar aspect of the hand raised off the image receptor (can use pads to assist) so that thumb is lateral  Centring point: Thumb - Central ray vertical to Lateral the image receptor Over 1st metacarpophalangea l joint  Collimation: Laterally – include skin Thumb - margins Lateral Proximally – carpometacarpal joint Distally – distal phalanx Thumb - Lateral The Wrist Wrist – Clinical ☢ OA/RA Indications ☢ Trauma (FOOSH) ☢ Osteomyelitis ☢ ? Foreign Body ☢ Follow-up imaging Wrist - Standard projections Projections ☢ DP ☢ Lateral Additional projections ☢ Scaphoid projections – oblique/zitters or banana ☢ Oblique Wrist Wrist – DP/PA Patient position ☢ Patient seated at the side of the x-ray couch ☢ Elbow flexed; arm relaxed ☢ Palmar aspect of the hand placed on the image receptor but place fingers slightly curled (or over the top edge of the image receptor if not using a wallstand) ☢ Wrist joint flat  Centring point: Wrist – Central ray vertical to DP/PA the image receptor Midway between the radial & ulna styloid processes  Collimation: Laterally – include skin WRIST – margins DP/PA Proximally – distal 1/3 radius and ulna Distally – heads of metacarpals WRIST -PA  CARPA L BONES Sometimes Lovers Try Pancakes That They Cannot Hack Wrist – Lateral Patient position ☢ From the PA position, externally rotate the arm until the ulnar aspect of the hand/wrist is in contact with image receptor ☢ Extend fingers ☢ Palmar aspect of the hand is perpendicular to the image receptor  Centring point: Wrist – Central ray vertical Lateral  to the image receptor Radial styloid process WRIST – Lateral Collimation: ☢ Laterally – dorsal and palmar skin margins ☢ Proximally – distal 1/3 radius and ulna ☢ Distally – heads of metacarpals Wrist – Lateral Wrist – Lateral TOP TIP Wrist – Additional Views PA wrist with ulnar deviation ☢ Position as for a PA wrist. ☢ Ulnar deviation of the wrist (laterally) as far as possible WRIST – ADDITIONAL VIEWS PA Axial (Zitters/banana projection)  Position as for PA wrist, angle tube 30degrees towards elbow  Centre to the anatomical snuff box  Ensure ulnar deviation  10 days after initial presentation – blood supply  Patient position From the DP position externally rotate arm until ulnar aspect of the hand/wrist is in Wrist – contact with the image receptor Palmar aspect of the hand/wrist 45degrees to PA the image receptor Oblique Support with 45degree radiolucent pad if necessary Extend fingers  Centring point: Wrist – Central ray vertical  to PA the image receptor Oblique Midway between the radial & ulnar styloid processes  Collimation: Laterally – include skin Wrist – margins PA Proximally – distal 1/3 Oblique radius and ulna Distally – heads of metacarpals WRIST – PA OBLIQUE WRIST – Top tips COMMON ERROR WHY? Radial & Ulnar styloid processes Styloid processes not equidistant appear displaced from lateral & from image receptor medial margins of these bones; superimposition of the radius & ulnar over the distal radioulnar joint Radius/Ulnar appears posteriorly Excessive rotation Unclear joint space Anterior aspect of wrist not in contact with image receptor (Carver & Carver, 2006) Radius and Ulna Radius & Ulna – ☢ Trauma (FOOSH, guarding) Clinical ☢ Osteomyelitis Indications ☢ ? Foreign Body ☢ Follow-up imaging ☢ Imaging for fracture alignment Radius & Standard projections Ulna - ☢ AP/PA Projections ☢ Lateral Additional projections ☢ Joint specific projections if unclear from initial imaging Radius & Ulna– AP Patient position ☢ Patient seated with affected side next to the x-ray couch without placing legs underneath ☢ Affected arm abducted and extended and placed on image receptor ☢ Arm supinated with wrist and elbow and shoulder in same horizonal plane ☢ Humeral epicondyles and styloid processes equidistant from imaging plate  Centring point: Radius & Central ray Ulna - AP vertical to the image receptor Midway between elbow and wrist  Collimation: Laterally – include skin Radius & margins Ulna - AP Proximally – elbow joint Distally – wrist joint RADIUS & ULNA - AP Radius & Ulna - Lateral Patient position ☢ From the AP position, flex the elbow 90 degrees and medially rotate the arm so that the ulnar aspect is in contact with the imaging receptor ☢ Ensure wrist, elbow and shoulder are in the same transverse plane ☢ Palmar aspect of the hand should be 90 degrees to the image receptor ☢ Humeral epicondyles and styloid processes superimposed  Centring point: Radius & Central ray Ulna - vertical to the Lateral image receptor Midway between elbow and wrist  Collimation: Laterally – include skin Radius & margins Ulna - Proximally – elbow joint Lateral Distally – wrist joint Radius & Ulna - Lateral Radius & Ulna – Alternative views Ulna – Spot the abnormality ELBOW Elbow – ☢ OA/RA Clinical ☢ Trauma Indications ☢ Pain & swelling ☢ Osteomyelitis ☢ ? Foreign Body ☢ Follow-up imaging ☢ Inability to straighten Elbow - Projections Standard projections ☢ DP ☢ Lateral Additional projections ☢ Radial head views Elbow - AP Patient position ☢ Patient seated with their affected side next to the x-ray table without placing legs underneath ☢ Affected arm abducted and extended and placed on image receptor ☢ Arm supinated with wrist, elbow and shoulder in the same horizontal place ☢ Humeral epicondyles equidistant from image receptor  Centring point: Elbow - Central ray vertical to the image receptor AP Midway between humeral epicondyles and 2.5cm distally  Collimation: Laterally – include skin Elbow - margins AP Proximally – distal 1/3 of humerus Distally – proximal 1/3 of radius and ulna Elbow - AP ELBOW - Lateral Patient position ☢ From the AP position, flex the elbow to 90 degrees and medially rotate the arm so that the ulnar aspect is in contact with the image receptor ☢ Ensure the wrist, elbow and shoulder are in the same transverse plane ☢ Palmar aspect of the hand should be 90 degrees to the image receptor ☢ Humeral epicondyles superimposed  Centring point: Elbow - Central ray Lateral vertical  to the image receptor Over the lateral humeral epicondyle  Collimation: Laterally – include skin Elbow - margins Lateral Proximally – distal 1/3 of the humerus Distally – proximal 1/3 of radius and ulna ELBOW - Lateral ELBOW – Alternative views Elbow – Spot the abnormality Elbow – Spot the abnormality Elbow – Spot the abnormality Humerus HUMERUS – CLINICAL INDICATIONS ☢ Trauma ☢ Osteomyelitis ☢ ? Foreign Body ☢ Follow-up imaging HUMERUS - PROJECTION Standard projections S ☢ DP ☢ Lateral Additional projections ☢ Joint specific projections if unclear from initial imaging HUMERUS - AP Patient position ☢ Patient is stood with their back to the image receptor. ☢ The arm is in the true anatomical position, palm facing forwards ☢ The posterior aspect of the upper arm should be in contact with the image receptor to reduce movement and magnification  Centring point: Central ray horizontal to the HUMERU image receptor S - AP Middle of the humerus on the anterior aspect of the upper arm, midway between the shoulder and elbow joints  Collimation: Laterally – include skin margins HUMERU S - AP Superiorly – The skin margin above the glenohumeral joint Inferiorly – Include the distal humerus including the elbow joint HUMERUS - AP HUMERUS – Lateral (PA) Patient position ☢ Patient is stood facing the image receptor ☢ The elbow is flexed so that the palm of the hand rests on the anterior abdominal wall ☢ The anterior aspect of the upper arm should be in contact with the image receptor to reduce movement and enlargement ☢ The patient should be rotated so that the lateral aspect of the shoulder of the affected side, the upper arm and elbow are all in contact with the image receptor  Centring point: Central ray horizontal to the image HUMERU receptor S- (PA) Middle of the humerus shaft, on the medial aspect of the upper arm, Lateral midway between the shoulder and elbow joints (AP) Middle of the humerus shaft, on the lateral aspect of the upper arm, midway between the shoulder and elbow joints  Collimation: Laterally – include skin HUMERU margins S- Superiorly – The skin margin Lateral above the glenohumeral joint Inferiorly – Include the distal humerus including the elbow joint HUMERUS - Lateral SHOULD ER SHOULDER – CLINICAL ☢ Trauma INDICATIONS ☢ Osteomyelitis ☢ ? Foreign Body ☢ Follow-up imaging ☢ OA ☢ Obvious deformity ☢ Limited ROM SHOULDER Standard projections - ☢ AP PROJECTION ☢ Axial Additional projections S ☢ Modified Axial ☢ Y-view Scapula ☢ Clavicle ☢ Acromioclavicular joint views SHOULDER - AP Patient position ☢ Patient is stood with their back to the image receptor ☢ The arm is in the true anatomical position with the palm facing forwards ☢ The patient is rotated 5-10 degrees towards the affected side (straight for trauma) ☢ The posterior aspect of the shoulder is in contact with the image receptor to reduce movement and magnification  Centring point: SHOULD Central ray horizontal to the ER - AP image receptor Corocoid process  Collimation: Laterally – include skin SHOULD margins ER - AP Superiorly – Skin margins Inferiorly – Include 1/3 of the proximal humerus SHOULDE R- AP SHOULDER – Axial Patient position ☢ Patient is seated with the affected arm nearest to the image receptor ☢ The affected arm is abducted and ”stretched” across the image receptor ☢ The image receptor is underneath the axilla (the gleno-humeral joint over the image receptor) ☢ Legs should not be underneath the image receptor ☢ The head should be tucked towards the unaffected shoulder  Centring point: SHOULD Central ray vertical ER - to the image Axial receptor Head of the humerus SHOULDE R- Axial CLAVICLE – AP AND AXIAL SCAPULA – Y VIEW OR LATERAL SHOULDER – Spot the abnormality Workbook for this week  Workbook focused on upper limb technique and clinical application  In dedicated time/over the weekend  No group-work  Reminder: I can see who has engaged with it ANY QUESTIONS?