Upper Limb Anatomy & Pathology Review PDF

The Campus of Tomorrow Medical Imaging Division HMI 2403 Health sciences program  MEDICAL IMAGING DIVISION 2 Learning objective CLO 2- Apply image critique skills in evaluating diagnostic images of the upper and lowe...

The Campus of Tomorrow Medical Imaging Division HMI 2403 Health sciences program  MEDICAL IMAGING DIVISION 2 Learning objective CLO 2- Apply image critique skills in evaluating diagnostic images of the upper and lower extremities. Radiographic anatomy/image critique fingers; thumb; hand;​ Common pathologies fingers; thumb; hand Radiographic anatomy/image critique wrist; forearm; elbow Common pathologies wrist; forearm; elbow Radiographic anatomy/image critique humerus; shoulder; clavicle Common pathologies humerus; shoulder; clavicle  MEDICAL IMAGING DIVISION 3 Image evaluation Patient data Technical quality Anatomical content Pathological outcome Reject if not available Patient ID Name Number date  MEDICAL IMAGING DIVISION 4 Image quality assess for rejection or acceptance Density mAs Contrast KVp 1.Scatter​ 2.kVp​ 3.X-ray tube/added filtration​ 4.Collimation​ Motion blur? Immobilization, breathing instructions, artifacts? From patient or from imaging chain​  MEDICAL IMAGING DIVISION 5 Image quality Anatomical content All anatomy demonstrated? Any pathology? Any altered appearances? Answered the clinical question? E.g ?# Is there a need for supplementary views?  MEDICAL IMAGING DIVISION 6 X-ray image terminology Radio-opaque White areas on X-ray High radiation absorption High density tissues Radiolucent Black/dark areas on X-ray Low radiation absorption Low density tissues Lucent = less  7 Xray image orientation MEDICAL IMAGING DIVISION AP Antero-posterior = X-ray beam from front to back PA Postero-anterior = X-ray beam from back to front (as seen in figure) Supine & Prone Supine = patient on back: Prone - patient on front Erect Patient in upright position Lateral and oblique Lateral = patient to side: Oblique +patient rotated  MEDICAL IMAGING DIVISION 8 X-ray anatomical orientation What is meant by the terms.. Proximal? A: Anatomy close to midline of body Distal? A: Anatomy away from midline of body Q: Which are the most proximal… The carpal bones or the phalanges? A: The carpal bones  MEDICAL IMAGING DIVISION 9 Parts of bones Thumb? A:Number 1 = 1st Index finger? A:Number 2 = 2nd Middle finger A:Number 3 = 3rd Ring finger A:Number 4 = 4th Little finger? A:Number 5 = 5th  MEDICAL IMAGING DIVISION 10 Parts of bones 1? Head metacarpal 2? Neck 3? Shaft 4? Base 5? DISTAL PHALYNX 6? Epiphyseal line Activity: Draw the hand and MEDICAL IMAGING DIVISION 11 label it  MEDICAL IMAGING DIVISION 12 Bones of the wrist  13 So Long To Pinky Here Comes The Thumb S = Scaphoid L= Lunate T= Triquetral P= Pisiform H= Hamate C= Capitate T= trapezoid T= Trapezium  MEDICAL IMAGING DIVISION 14 Carpal bones Proximal row Scaphoid (is most commonly #) Lunate (moon shaped) Triquetrum (hides the pisiform) Pisiform (anterior to triquetrum) Distal row Trapezium (under the thumb) Trapezoid Capitate (largest) Hamate (has a hook like process)  MEDICAL IMAGING DIVISION 15 Self test carpal bones Proximal row Distal row  S  Tr Trapezium  Scaphoid Tp  L Trapezoid  Lunate C  T Capitate  Triquetrum H  P Hamate  Pisiform  MEDICAL IMAGING DIVISION 16 Distal radius and ulna RS? Radial styloid US? Ulna styloid L? Lunate Which two bones are superimposed on the lateral? Radius and ulna  MEDICAL IMAGING DIVISION 17 Bony terminology Tuberosity An area of protruding roughened bone Eg. radial tuberosity An area where muscles attach Fossa An area of depressed shallow bone Eg Olecranon fossa Can be where other bones enter on movement but is not part of a joint  MEDICAL IMAGING DIVISION 18 Bony terminology Condyle A smooth rounded articular surface Eg. Femoral condyle Epicondyle A smooth rounded area of bone superior to a main condyle Eg. Epicondyles of elbow Epicondyles of femur Flash back 19 MEDICAL IMAGING DIVISION  MEDICAL IMAGING DIVISION 20 How to recognize bony pathology Bone density Increase = radio-opaque Decrease = radiolucent Bone shape Deformity = abnormal shape alignment = no displaced bones Bone lesions Sclerotic = increased density Lytic = low density  MEDICAL IMAGING DIVISION 21 Simple # Describe the # Oblique un-displaced oblique # of the distal third of the 4th metacarpal of the left hand Is there good alignment? Yes Is there mal-alignment? No  MEDICAL IMAGING DIVISION 22 Finger injuries Many types finger # Trapping & crush injuries Slicing injuries Impact Avulsion # Dislocation With/without # Complex if # involves joint After healing movement can be restricted and can develop localized arthritis  MEDICAL IMAGING DIVISION 23 Fractures of fingers Fingers can fracture And/or dislocate  MEDICAL IMAGING DIVISION 24 Dislocated proximal 5th PIP  MEDICAL IMAGING DIVISION 25 Post fracture Poor healing post # proximal PIP Disruption of joint space  MEDICAL IMAGING DIVISION 26 Bennets #of the thumb Fracture base 1st metacarpal  MEDICAL IMAGING DIVISION 27 Near amputation Amputate means to “cut off” Near amputation 3rd- 5th proximal phalanges  MEDICAL IMAGING DIVISION 28 Bone cysts  MEDICAL IMAGING DIVISION 29 Boxer’s #5th MC Fracture of the 5th metacarpal Most often neck of 5th MC Caused by direct impact e.g. boxers punch  MEDICAL IMAGING DIVISION 30 Scaphoid # Scaphoid is most commonly fractured carpal bone Unless it is a severe #, a scaphoid # is often occult (hidden – not seen) on immediate X-rays # only seen on X-ray when callus has formed (healing) 10 days after injury (arrows)  MEDICAL IMAGING DIVISION 31 Tomosynthesis in scaphoid # a. Immediate b. 10 days post cast c. Tomography  MEDICAL IMAGING DIVISION 32 Colles # of wrist Transverse # of distal radius with posterior displacement Distal radius slips backwards ‘Dinner fork’ shaped deformity Caused by ‘FOOSH’ Fall onto out-stretched hand  MEDICAL IMAGING DIVISION 33 Smiths # of the wrist  MEDICAL IMAGING DIVISION 34 Quiz Do bones appear radio-opaque or radiolucent on X-rays? Does soft tissue appear radio-opaque or radiolucent on X- rays? Are bones high or low density tissues? Are soft tissues high or low density tissues? Is a radio-opaque area high or low density? Is a radiolucent appearance high or low density? What is meant by the term lesion? What is meant by the term ‘lytic’? What is meant by the term ‘sclerotic’?  MEDICAL IMAGING DIVISION 35 Arthritis  MEDICAL IMAGING DIVISION 36 Arthritis Chronic inflammation of joints Arth = joint Itis = inflammation Two common types of arthritis Rheumatoid arthritis Affects small joints of hand and feet Destroys bone & cartilage of joint Osteoarthritis Affects large synovial joints such as hips and knees Builds up thick rough bones which narrow the joint space  MEDICAL IMAGING DIVISION 37 Rheumatoid arthritis Autoimmune disease causes inflammation, bone destruction with loss of bone density in joints of small bones. Hands and feet most commonly have affected joints. Gross (high) physical deformity and appearance Very painful Restricted movement MEDICAL IMAGING DIVISION 38 MEDICAL IMAGING DIVISION 39 Bursitis 40 MEDICAL IMAGING DIVISION Inflammation of the Bursa (fluid filled sac surrounding the joint). A bursa can become inflamed from injury, infection (rare in the shoulder), or due to an underlying rheumatic condition. Bursitis is typically identified by localized pain or swelling, tenderness, and pain with motion of the tissues in the affected area. MEDICAL IMAGING DIVISION 41  MEDICAL IMAGING DIVISION 42 Tendonitis Sometimes the tendons become inflamed for a variety of reasons, and the action of pulling the muscle becomes irritating. If the normal smooth gliding motion of your tendon is impaired, the tendon will become inflamed, and movement will become painful. This is called tendonitis, and literally means inflammation of the tendon. The most common cause of tendonitis is overuse.  MEDICAL IMAGING DIVISION 43 Carpal tunnel syndrome Any condition that causes swelling or a change in position of the tissue within the carpal tunnel can squeeze and irritate the median nerve. Irritation of the median nerve in this manner causes tingling and numbness of the thumb, index, and the middle fingers, a condition known as "carpal tunnel syndrome." MEDICAL IMAGING DIVISION 44  MEDICAL IMAGING DIVISION 45 Osteoporosis Osteoporosis is a term that means "porous bones." It is a skeletal disease affecting women and men. Osteoporosis is a condition in which bones have lost minerals especially calcium making them weaker, more brittle, and susceptible to fractures (broken bones). Any bone in the body can be affected by osteoporosis, but the most common places where fractures occur are the back (spine), hips, and wrists. MEDICAL IMAGING DIVISION 46 MEDICAL IMAGING DIVISION 47  MEDICAL IMAGING DIVISION 48 Rickets Rickets is the softening and weakening of bones in children, usually because of an extreme and prolonged vitamin D deficiency Some skeletal deformities caused by rickets may need corrective surgery. Gout 49 MEDICAL IMAGING DIVISION Gout is a disease that results from an overload of uric acid in the body. This overload of uric acid leads to the formation of tiny crystals of urate that deposit in tissues of the body, especially the joints. When crystals form in the joints it causes recurring attacks of joint inflammation (arthritis). Chronic gout can also lead to deposits of hard lumps of uric acid in and around the joints and may cause joint destruction, decreased kidney function, and kidney stones.  MEDICAL IMAGING DIVISION 50 Radius Ulna  MEDICAL IMAGING DIVISION 51 Radius and ulna anterior aspect Identify the labels A to J A: Head of radius B: Neck of radius C: Radial tuberosity D: Distal end radius E: Radial styloid F: Ulna styloid G: Ulna tuberosity H: Coronoid process I: Trochlea notch J: Olecranon process  MEDICAL IMAGING DIVISION 52 Radius and ulna posterior aspect Identify the anatomy 1-6 1.Olecranon process 2.Ulna styloid 3.Radial styloid 4.Radial tuberosity 5.Neck of radius 6.Head of radius  MEDICAL IMAGING DIVISION 53 Elbow anterior aspect E Lateral epicondyle F Radial fossa G Capitulum H Trochlea I Medial epicondyle J Coronoid/Olecranon fossae How do we know this is anterior? Because of the capitulum. Which elbow is it? The right because the capitulum is on the lateral aspect  MEDICAL IMAGING DIVISION 54 Label the anatomy 4-7 4: Olecranon fossa 5: Medial epicondyle 6: Trochlea 7: Lateral condyle Epicondyle How do we know this is the posterior aspect? No capitulum. Which elbow is it? The right because the lateral epicondyle is to the right  MEDICAL IMAGING DIVISION 55 AP forearm 1: Medial epicondyle 2: Olecranon process 3: Shaft of ulna 4: Inferior(distal) radio ulnar joint 5: Lateral epicondyle 6: Radial head 7: Radial tuberosity 8: Shaft radius 9: Radial styloid  MEDICAL IMAGING DIVISION 56 Lateral forearm 1: superimposed epicondyles 2: Olecranon process 3: superimposed condyles 4: Coronoid process 5: Shaft of ulna 6: Shaft of radius 7: Radial tuberosity 8: Head of radius 9. Humerus Elbow lateral view 57 MEDICAL IMAGING DIVISION  MEDICAL IMAGING DIVISION 58 AP Elbow What is the view? AP Identify the arrowed anatomy Radial head Medial epicondyle Olecranon fossa Capitulum Lateral epicondyle Radial neck Radial tuberosity Elbow X-ray series 59 MEDICAL IMAGING DIVISION  MEDICAL IMAGING DIVISION 60 Humerus The proximal aspect of the humerus articulates with the glenoid fossa of the scapula Forms glenohumeral joint Distally, at the elbow joint, the humerus articulates with the head of the radius and trochlear notch of the ulna.  MEDICAL IMAGING DIVISION 61 Humerus (proximal aspect)  MEDICAL IMAGING DIVISION 62 Humerus (distal aspect)  MEDICAL IMAGING DIVISION 63 Humerus: posterior aspect Identify labels 1-9 1: Head 2: Anatomical neck 3: Surgical neck 4: Olecranon fossa 5: Medial epicondyle 6: Trochlea 7: Lateral epicondyle 8: Spiral groove 9: Greater tuberosity How can we tell which aspect is anterior and which is posterior?  MEDICAL IMAGING DIVISION 64 Which humerus is this? Left or right? Right!! Clue: look for the trochlea and the direction of the humeral head Which image shows the anterior aspect? Clue: Look for the olecranon fossa The image on the right or the image on the left? Image on the left!!  MEDICAL IMAGING DIVISION 65 AP humerus 1: Lesser tuberosity 2: Bicipital groove 3: Shaft of humerus 6: Olecranon process 7: Olecranon fossa 8: Surgical neck humerus 9: Head humerus MEDICAL IMAGING DIVISION 66  MEDICAL IMAGING DIVISION 67 Lateral humerus Identify the arrows Head of humerus Surgical neck of humerus Shaft of humerus Radial head Superimposed condyles Olecranon process  MEDICAL IMAGING DIVISION 68 Revision Anterior aspect upper (proximal) humerus  MEDICAL IMAGING DIVISION 69 Upper humerus anterior aspect Identify labels A-M A: Lesser tuberosity B: Greater tuberosity C: Bicipital groove D: Deltoid tuberosity K: Surgical neck L: Anatomical neck M: Head of humerus How do we know this is an anterior diagram? Can see the bicipital groove & lesser tuberosity Which side is this? right  MEDICAL IMAGING DIVISION 70 Upper humerus posterior aspect Identify labels 1,2,3,8,9 1. Head 2. Anatomical neck 3. Surgical neck 8. Spiral groove 9. Greater tuberosity How do we know this is a posterior aspect diagram? Cannot see bicipital groove or lesser tuberosity  MEDICAL IMAGING DIVISION 71 X-ray humerus: external rotation Identify the marked anatomy Head of humerus Anatomical neck Surgical neck Greater tuberosity Lesser tuberosity Bicipital groove  MEDICAL IMAGING DIVISION 72 Xray humerus: internal rotation Identify the arrowed anatomy Head of humerus Anatomical neck Surgical neck Lesser tuberosity in profile  MEDICAL IMAGING DIVISION 73 Compare internal vs external rotation On external rotation can see… Anatomical neck, greater (in profile) and lesser tuberosity On internal rotation lesser tuberosity in profile External Internal  MEDICAL IMAGING DIVISION 74 Forearm injuries Common in children and adults Where is this #? Mid-shaft of left radius What type of #? Clue: Only one cortex is # Greenstick # of radius  MEDICAL IMAGING DIVISION 75 Elbow fat pads & intra-articular # Intra-articular # causes the fat pads of the elbow fossae to bulge into the tissues If the fat pads can be seen on X- ray it is always a sign of # ‘Flag’ or ‘Sail’ sign  MEDICAL IMAGING DIVISION 76 Radial head & neck # # radial head Often difficult to see (occult #) Clue is fat-pad sail-flag signs Indicates intra-articular # # radial neck Sometimes with radial head # Neck impacts into head Flag signs main clue to # Difficult to image Patient has restricted movement  MEDICAL IMAGING DIVISION 77 Fracture dislocation What has happened here? The radial head is dislocated from the capitulum The ulna is fractured Monteggia # Dislocation radial head with # ulna  MEDICAL IMAGING DIVISION 78 Supracondylar #humerus Serious # superior to epicondyles of distal humerus Risk of severing (cutting) radial nerve and brachial art. Common in children  MEDICAL IMAGING DIVISION 79 Humeral shaft Where is the #? Distal third right humeral shaft What kind of # is this? Spiral # MEDICAL IMAGING DIVISION 80  MEDICAL IMAGING DIVISION 81 Alignment is very important Good alignment Bowing # deformity Reduced #  MEDICAL IMAGING DIVISION 82 Fracture and dislocation Galeazzi fracture Fracture distal third radius With dislocated ulna  MEDICAL IMAGING DIVISION 83 Monteggia fracture Fractured proximal third of ulna With dislocated head of radius Opposite of Galeazzi fracture  MEDICAL IMAGING DIVISION 84 Fracture and dislocation Galeazzi fracture # distal third radius With dislocated ulna Monteggia fracture # proximal third of ulna With dislocated head of radius  MEDICAL IMAGING DIVISION 85 Elbow fractures are complex # Radial head # Olecranon  MEDICAL IMAGING DIVISION 86 … and often difficult to see  Soft tissue signs  Value of additional views (lat-oblique) in detecting  Joint effusion occult #  ‘Sail’ or ‘Flag’ sign  MEDICAL IMAGING DIVISION 87 Dislocation elbow- no # Dislocation of the radius and ulna from the humerus  MEDICAL IMAGING DIVISION 88 Fractures of the humerus Pre and post operative # images Pathological fracture  MEDICAL IMAGING DIVISION 89 Mal-alignment #humerus  MEDICAL IMAGING DIVISION 90 kVp- Image Critique Bony trabeculations are demonstrated which indicates optimum penetration so kVp is optimized and is demonstrated by the short scale of contrast Bony trabeculations are not demonstrated and ???BONES are radiolucent which indicates over penetration so kVp must be reduced to produce short scale of contrast. Bony trabeculations are not demonstrated and ???BONES are radiopaque which indicates under penetration so kVp must be increased to produce short scale of contrast and to penetrate the bone of interest.  MEDICAL IMAGING DIVISION 91 mAs Critique Overall density of the image is acceptable and soft tissue is well visualized implying the appropriate selection of mAs. Overall density of the image is high, soft tissue is not demonstrated implying the selection of high mAs. A decrease in mAs is required Overall density of the image is low implying the selection of low mAs. An increase in mAs is required  MEDICAL IMAGING DIVISION 92 Scapula: anterior aspect Identify the arrowed anatomy Acromion process Coracoid process Glenoid cavity Lateral border Subscapular fossa Inferior angle Medial border Suprascapular notch  MEDICAL IMAGING DIVISION 93 Scapula: posterior aspect Identify the arrowed anatomy Supraspinous fossa Spine Infraspinous fossa Medial border Inferior angle Lateral border Acromion process Coracoid process Glenoid  MEDICAL IMAGING DIVISION 94 Scapula: lateral aspect Identify the arrowed anatomy Acromion process Coracoid process Glenoid cavity Is the red arrow anterior or posterior? Anterior!! Rotator cuff muscles 95  MEDICAL IMAGING DIVISION 96 Clavicle: Anterior aspect What shape is the clavicle? Is an ‘S’ shaped bone Identify the arrowed anatomy Acromial (lateral) end for acromio-clavicular joint Superior mid shaft of clavicle Sternal (medial)end for sterno-clavicular joint Lateral aspect Medial aspect  MEDICAL IMAGING DIVISION 97 Shoulder anatomy Identify the arrowed anatomy Mid-shaft clavicle Coracoid process Acromium process Glenoid cavity Scapular Proximal shaft humerus  MEDICAL IMAGING DIVISION 98 X-ray shoulder anatomy Is this internal or external rotation? External Identify the anatomy Clavicle Lateral end of the clavicle Acromion process Coracoid process Glenoid Head of humerus  MEDICAL IMAGING DIVISION 99 X-ray shoulder anatomy Is this internal or external rotation Neutral ( no rotation) Identify the anatomy Clavicle mid-shaft Acromium of clavicle Acromio-clavicular joint Acromium process Coracoid process Glenoid Head of humerus Anatomical neck  MEDICAL IMAGING DIVISION 100 Axial X-ray shoulder anatomy Where is anterior? Anterior Coracoid process is anterior Identify the anatomy Clavicle Coracoid process Glenoid Head of humerus lesser tuberosity  MEDICAL IMAGING DIVISION 101 Axial X-ray shoulder anatomy Where is posterior? Clue? Scapula is posterior Identify the anatomy Acromial extremity of clavicle Acromion process Acromio-clavicular joint Posterior  MEDICAL IMAGING DIVISION 102 Profile scapular anatomy What is this view informally known as? ‘Y’ view Identify the anatomy 1. Coracoid process 2. Acromial extremity(lateral end) of clavicle 3. Acromion process 4. Head of humerus 5. Shaft of humerus 6. Inferior angle of scapula  MEDICAL IMAGING DIVISION 103 Surgical neck of humerus # Where is the #? Surgical neck of right humerus What kind of #? Oblique comminuted # Bone fragments What kind of #? Transverse # Linear extension into distal shaft  MEDICAL IMAGING DIVISION 104 Surgical neck of humerus #  MEDICAL IMAGING DIVISION 105 dislocation Bone out of joint Mostly in synovial joints Which joint is dislocated? Shoulder joint Which bone is dislocated? The head of the humerus is dislocated out of the glenoid cavity This is an… Anterior dislocation  MEDICAL IMAGING DIVISION 106 Scapular fracture Not easily fractured Usually by direct blow Squamous (flat) portion of scapula most common area Can you see the # on the AP view? # through subscapular fossa Also # 4th rib! Interesting case of cough # Normal Y view # inferior angle #  MEDICAL IMAGING DIVISION 107 Anterior dislocation The head of the humerus moves forward and down (anterior and inferior) Anterior dislocation MEDICAL IMAGING DIVISION 108  MEDICAL IMAGING DIVISION 109 Posterior dislocation The head of the humerus moves backward and down (posterior and inferior)  MEDICAL IMAGING DIVISION 110 Posterior dislocation  MEDICAL IMAGING DIVISION 111 Subluxation acromio-clavicular joint Partial dislocation – stretching/tearing of tendon Weight bearing and non-weight bearing images Treatment by immobilization or surgical wiring  MEDICAL IMAGING DIVISION 112 Clavicle # Can you see the #? Can you state where it is? Mid-shaft of clavicle Shaft most common # Falls and direct blows # common in children & construction workers Can you describe this #? Comminuted # with superior displacement (mal-alignment)  MEDICAL IMAGING DIVISION 113 Pathological # Diseased bone is easily # Weak – less dense than health bone Bone cyst in child Round lytic lesion proximal third humeral shaft Spiral # inferior to bone cyst Secondary tumour in adult Transverse # through surgical neck of humerus  MEDICAL IMAGING DIVISION 114 Resources Merrill’s Atlas of Radiographic Anatomy Vol:1 http://lifeinthefastlane.com/education/who-was/eponymous- fractures/ The Encyclopedia of Science Medical University of Virginia  Pocket Atlas of Radiographic Positioning  Clarke’s Positioning in Radiography (LRC)  http://www.ceessentials.net/article31.html  http://www.joint-pain-expert.net/shoulder-fracture.html  http://www.mysportphysio.com/Injuries-Conditions/Shoulder/Shoulder- Anatomy/a~361/article.html  http://radiopaedia.org/cases/normal-shoulder-x-rays?fullscreen=true  MEDICAL IMAGING DIVISION 115 References Merrill’s Atlas of Radiographic Anatomy Vol:1 http://www.info-radiologie.ch/en/forearm_x-ray.php Practice identifying the bones of the hand and wrist on this website http://www.info-radiologie.ch/en/hand_radiography.php  MEDICAL IMAGING DIVISION 116 Disclaimer Refer to Merrill’s Atlas Volume 1 ( pages 69-74) and Volume 2 ( section 16) Power points provide guidelines and a road map for you to direct your focus, they can never be the only source of studying for the exam.your reference book the one that you need to study from; Merrill’s volume 1 & 2 is the backbone of this course and will supersede any discrepancies  Thank you 800 MyHCT (800 69428) www.hct.ac.ae