Upper Limb 2 PDF

UPPER LIMB 2  Forearm (radius & ulna) Styloid process: located at extreme distal end of both the radius & ulna. Radial tuberosity: is the oval process on the medial aspect of radius just distal to neck. Olecranon & coronoid processes: two beaklike processes of the prox. ulnar...

UPPER LIMB 2  Forearm (radius & ulna) Styloid process: located at extreme distal end of both the radius & ulna. Radial tuberosity: is the oval process on the medial aspect of radius just distal to neck. Olecranon & coronoid processes: two beaklike processes of the prox. ulnar Trochlear notch: The large concave notch articulate with distal humerus. 2 Humeral condyle: is the distal end of the humerus & it divided into trochlea & capitulum. Lateral epicondyle: it is located at lateral edge distal humerus above the capitulum. Medial epicondyle: it is located at medial edge of the distal humerus. Coronoid fossa & radial fossa: are two shallow anterior depression on distal humerus. Olecranon fossa: is the posterior depression on distal humerus. 3 4 Forearm rotational movements 5  FOREARM  Two projections (AP & Lat.) are required to demonstrate the full length of the radius & ulna to include both the elbow & the wrist joint.  AP projection with the forearm supinated demonstrates the radius & ulna lying side by side.  A 30x40cm IR used include both joints on one image. Both projections are normally acquired on one film. 6 7  AP projection  Pathology demonstrated: fractures & dislocation of the radius or ulna, osteomyelitis or arthritis, etc….  Film size: 30x 40 cm. L.W. 2 views.  Patient position: Seat patient at end of table (affected side nearest to the table), with hand & arm fully extended & palm up (supinated).  Part position: The shoulder is lowered to the same level as the elbow joint. Align and center forearm to long axis of IR, ensuring that both wrist & elbow joints are included. (Use as large an IR as necessary) 8  Place entire wrist, forearm, & elbow in a true AP position. (Medial & lat. epicondyles should be the same distance from IR) The lower end of the humerus & the hand are immobilized using sandbags. CR: The vertical central ray is centered in the midline of the forearm to a point midway between the wrist & elbow joints. 9  Essential image characteristics Long axis of forearm should be aligned to long axis of IR. Both the elbow & the wrist joint must be demonstrated on the IR Both joints should be seen in the true AP position, with the radial & ulnar styloid processes & the epicondyles of the humerus equidistant from the IR. Note: PA projection of the forearm with the wrist pronated is not satisfactory because, in this projection, the radius is superimposed over the ulna for part of its length. 10  Lateral projection Film size: 30x40cm. Division in half. L.W. Patient & part position: From the AP position, the elbow is flexed to 90°. The humerus is internally rotated to 90° to bring the medial aspect of the upper arm, elbow, forearm, wrist & hand into contact with the table. The IR is placed under the forearm to include the wrist joint & the elbow joint. The arm is adjusted such that the radial & ulnar styloid processes & the medial & lateral epicondyles are superimposed. 11 CR: The vertical central ray is centered in the midline of the forearm to a point midway between the wrist & elbow joints.. 12  Essential image characteristics Both the elbow & the wrist joints must be showen on the image Both joints should be seen in the true lateral position, with the radial & ulnar styloid processes and the epicondyles of the humerus superimposed. Notes: In trauma cases, it may be impossible to move the arm into the positions described, If the limb cannot be moved through 90°, then a horizontal beam should be used. Both joints should be included on each image. No attempt should be made to rotate the patient’s hand. 13  ELBOW: AP projection Pathology demonstrated: fractures & dislocation of the radius or ulna, osteomyelitis or arthritis, etc…. Film size: 24x 30 cm. C.W. 2 projections Patient position:  Patient seated with hand & arm fully extended. Part position:  Arm extended with shoulder, elbow on the same plane.  Hand in AP position.  Epicondyles parallel to the IR.  Support hand as needed to prevent motion. CR: perpendicular to elbow joint. (2 cm distal to the point midway between epicondyles of the humerus) 14 Structures shown: Olecranon fossa, 2 epicondyles, Capitulum, Olecranon, Trochlea, Coronoid process of ulna, Head of radius, Neck of radius, Tuberosity of radius, Ulna Image quality:  No rotation: epicondyles parallel to the IR.  Elbow joint appears open.  The image should demonstrate the distal 3rd of humerus & the proximal 3rd of the radius & ulna. 15  Lateral elbow Film size: 24x30cm C.W. Patient & part position: The patient is seated alongside the table, with the affected side nearest to the table. The elbow is flexed to 90° & the palm of the hand is rotated so that it is at 90° to the tabletop. Shoulder & elbow on the same plane. Medial aspect of the entire arm is in contact with the tabletop. Hand in lateral position. 16 CR: perpendicular over the lateral epicondyle of the humerus. (4 cm medial posterior surface of olecranon process) Image quality:  Epicondyles superimposed.  Proximal radius & ulna in true lateral.  The image should demonstrate the distal 3rd of humerus & the proximal 3rd of the radius & ulna. 17  AP projections: partial flexion 1. Distal humerus Pathology demonstrate: fractures &dislocation of elbow. Film size: 24x 30 cm. Division in half, C.W. Patient position: The posterior aspect of the humerus is placed on the table, with the palm of the hand facing upwards. The arm is adjusted such that the medial & lateral epicondyles of the humerus are equidistant from the film. The limb is supported and immobilized in this position. 18 CR: perpendicular to elbow joint. (2 cm distal to the point midway between the medial & lateral epicondyles of the humerus) Structures shown: distal humerus , proximal radius & ulna, elbow joint partially obscured. Image quality: - density is sufficient to visualized distal humerus & proximal, radius & ulna. - no rotation: epicondyles parallel with film. 19 2. Proximal forearm: The same as the distal humerus except:  In patient position the forearm is on IR with proximal part parallel to IR CR:2cm distal to the point midway between the medial & lateral epicondyles of the humerus) Essential image characteristics The image should demonstrate the distal third of humerus & the proximal third of the radius and ulna. 20  AP lateral oblique (external) projection: elbow (Proximal radio-ulnar joint – oblique) Patient demonstrated: fractures and dislocation of the elbow especially radial head & neck. Film size: 24x30cm. Division in half, C.W. Patient position: The patient is positioned for an anterior projection of the elbow joint. The long axis of the IR parallel to the forearm. The humerus is then rotated laterally until the line between the epicondyles is approximately 45o with parallel to IR. 21  C.R: on the mid elbow joint (2cm distal to the midpoint between the epicondyles). Structures shown:  An oblique view of elbow.  Radial head, neck free of superimposed. Image quality:  Lateral epiocondyle appear elongated.  Radial neck free of superimposed. 22  AP oblique ( internal ) projection: elbow Pathology demonstrated: fractures & dislocation of elbow especially the coronoide process. Film size: 24x30cm. Division in half, C.W. Patient position:  Patient seated with arm extended.  Shoulder and elbow on the same plane.  Pronate the hand  Elbow joint forms 45o with IR. CR: on the mid elbow joint (2cm distal to the midpoint between the epicondyles). 23 Structures shown:  Oblique projection of elbow.  Coronoid process free of superimposed.  Distal humerus.  Proximal radius & ulna is visible. Image quality:  Radius over ulna.  Medial epicondyle appear elongate 24 25  Acute flexion projection 1.Distal humerus: Pathology demonstrated: fractures & dislocation of the elbow. Film size: 18x24 cm. Division in half, crosswise. Patient position: The patient is seated alongside the table, with the affected side nearest to the table. The elbow is fully flexed, & the palm of the hand is facing the shoulder, & fingertips resting on shoulder The posterior aspect of the upper arm is placed on the IR, with the arm parallel to the long axis of the IR. 26  The patient’s trunk is adjusted in order to bring the medial & lateral epicondyles of the humerus equidistant to the IR. C.R: perpendicular to distal humerus at the midway between epicondyles Structures shown: medial & later epicondyles, trochlea, capitulum & olecranon process. 2. Proximal forearm: The same as in distal humerus except: CR: perependicular to forearm at 5 cm superior to the olecranon process. 27 28  Axial lateral projection: elbow Pathology demonstrate: fractures & dislocation of elbow particularly to radial head & coronoid process. Note: this position is elective position for patient can’t extend elbow fully for medial or lateral obliques of the elbow. Film size: 18x24 cm, crosswise. Patient position: - patient seated with elbow flexed 90o for radial head & 80o for coronoid process. -hand pronated C.R: angled 45o toward shoulder for radial head & 45o from shoulder in coronoid process. 29 Structures shown:  Radial head & capitulum in radial projection.  Coronoid process & trochlea, radial head superimposed with ulna in coronoid process. 30  Radial head lateral :Elbow Pathology demonstrate: not clear fractures of the radial head. Film size: 18x24 cm, 2 views. C.W. Patient position: - patient seated with elbow flexed 90o resting on IR. - Humerus, forearm, & hand on the same plane. - for four different projection the various position are varies as follow: 1. Supinate hand & extremely rotate as far as possible. 2. Hand in lateral position. 3. Pronate hand. 4. Hand is medially rotated until the palm of hand is facing a way from body. 31 C.R: perpendicular 2-3cm distal to the lateral epicondyle 32 Structures shown:  radial head & neck are partially superimposed by ulna.  Radial tuberosity visualized in various postion indifferent angle. 33 34  HUMERUS Humerus is consist from: 1. Head of humerus: is the most proximal part of humerus & nearly hemispherical in form. 2. Anatomic neck: is a notch distal to the head of the humerus on which adjacent greater & lesser tubercles. 3. Lesser tubercle:it is below the anatomic neck on the anterior surface. 35 3. Greater tubercle: The greater tubercle is situated lateral to the head & lesser tubercle, & just lateral to the anatomical neck. 4. The intertubercular groove : is the deep groove between tubercles. 5. Surgical neck: The surgical neck is a narrow area distal to the tubercles that is a common site of fracture. 6. Body: long shaft of humerus. 36  AP projection: humerus:  When movement of the patient’s arm is restricted, a modified technique may be required. Pathology demonstrate: fractures & dislocation of the humerus. Film size: 35x43cm or 30x40cm. L.W. Patient position: - Pt erect or supine. - Pt in AP position. - Upper IR margin above shoulder 3-4cm. - Mid IR with mid humerus. - Arm abducted slightly. - Arm extended in true AP. - Anterior surface of epicondyles parallel with IR. 37  CR: The vertical central ray is centered to a point midway between the shoulder and elbow joints. Collimation: collimate four sides of humerus border, ensuring that all shoulder & elbow joints are included. Structures shown:  AP projection of humerus.  Shoulder & elbow joint are included. Image quality:  Elbow joint are open.  Greater tubercle is seen in profile.  Lateral & medial epicondyles in profile. 38  Lateral projection: humerus 1) Lateromedial Pathology demonstrate: fractures & dislocation of the humerus: Film size: 35x43cm or 30x35cm L.W. Patient position: - pt. erect or supine - pt. in AP position. - Upper IR margin above shoulder 3-4cm. - Mid film with mid humerus. - arm abducted slightly. - Flex arm partially. - Rotate body toward affected side to bring humerus & shoulder in contact with IR. 39 - The arm is abducted & then medially rotated through 90° to bring the medial aspect of the arm, elbow & forearm in contact with the table. - Epicondyles perpendicular on IR. - The IR is placed under the arm & adjusted to include both the shoulder & the elbow joints. CR: The vertical central ray is centered to a point midway between the shoulder & elbow joints. 40 2) Mediolateral - Pt face the IR in oblique position”20o-30o from PA” - Humerus contact with IR. - Flex elbow 90o. - Shoulders & elbow joints are equidistance from ends of IR. CR: Perpendicular to midpoint of humerus. Structures shown:  Lateral projection of humerus.  Shoulders & elbow are included.  Epicondyles are superimposed.  Lesser tubercle in profile. 41 42  Horizontal beam lateral projection Pathology demonstrate: fractures & dislocation of mid & distal humerus. Film size: 30x40cm or 24 x30 cm L.W. Patient position:  Patient supine.  Flex elbow 90o.  Placing support under arm  Place film between arm & thorax.  Top film at axilla. CR: perpendicular to two-thirds of humerus. Structures shown:  Lateral projection of mid & distal humerus. 43 44