Radiography of the Hand Lecture Notes PDF

RMI 221 Radiographic Anatomy & Positioning 1 Lecture 2 Radiography of the Hand Learning Outcomes After today’s lecture you will be able to: Identify the bones of the hand. Identify the common reasons for performing hand radiography. List all of the routi...

RMI 221 Radiographic Anatomy & Positioning 1 Lecture 2 Radiography of the Hand Learning Outcomes After today’s lecture you will be able to: Identify the bones of the hand. Identify the common reasons for performing hand radiography. List all of the routine projections for hand radiography. Explain the key points required in patient assessment for hand radiography. Name supplementary projections necessary for specific clinical conditions. Describe the positioning methods for routine and supplementary projections of the hand. Reading The prescribed texts relating to this lecture are: Bontrager, K.L. & Lampignano, J.P. (2010), Textbook of Radiographic Positioning and Related Anatomy, 7th edition, Mosby, St. Louis, Missouri. McQuillen Martensen, K. (2011), Radiographic Image Analysis, 3rd edition, W.B. Saunders, St. Louis, Missouri. The prescribed reading is: Bontrager, K. & Lampignano, J. (2010), Textbook of Radiographic Positioning and Related Anatomy, 7th edition, Mosby, St. Louis, Chapter 5, pp.124-125, 138, 147-151. Overview 1. Hand anatomy basics and terminology 2. Clinical rationale 3. Protocols: the relationship between rationale and protocol – standard, modified, supplementary 4. Request forms 5. Patient assessment 6. Radiographic technique 7. Patient positioning and projections 8. Examples ST PACEMAN S Shielding T Technique P Positioning A Area covered C Collimation E Exposure M Marker A Aesthetics N Name blank fchs.ac.ae Radiography of the Hand Fig 5-68, Bontrager & Lampignano (2010), p.147. 1. Hand Anatomy Basics and Terminology Fig 5-1, Bontrager & Lampignano (2005), p.130. Fig 5-2, Bontrager & Lampignano (2005), p.130. 2. Clinical Rationale Can you identify the abnormality? Polydactyly of hand, is a congenital malformation of the hand that presents with an extra digit in the hand. Fig C5-159, Bontrager & Lampignano (2010), p.170. Clinical Rational Fractures, dislocation, of the phalanges, metacarpals and all joints of the hand. Injuries Trauma often the head of the 5th metacarpal- Distal part foreign body (FB) localization Bone pathologies Joint pathologies Clinical Rationale (continued) Bone disease: for example, a benign tumour. Joint disease: such as osteoarthritis (OA), rheumatoid arthritis (RA) Fig 4-13, Eisenberg & Johnson (2012), p.95. Mutilating rheumatoid arthritis, sever bilaterally symmetric destructive changes of the hands and wrists with striking subluxations. Hand Pathologies Osteoarthritis Osteopenia Rheumatoid arthritis Also known as degenerative Lower bone density, where Is a chronic systemic disease joint disease, Part of the the bones lose mass and get of unknown cause. Result in wear and tear of the aging weaker. inflammatory arthritis of the process. Result of small joints of the hands and inflammatory arthritis that feet's. destroy cartilage. Clinical Rationale (continued) Crush injury at work radiograph to ascertain state of bones of the hand prior to microsurgery (perhaps reattaching fingers). Fig 4-7, McQuillen Martensen (2011), p.162. Clinical Rationale Examples: Different Pathologies A B  3. Protocols Fan lateral projection Standard or routine protocol: PA (posteroanterior) PA oblique (anterior oblique) Applied protocol: Lateral projection - used for FB localization -(Lateral in flexion)- fracture of the 5th metacarpal Fig 1-53, McQuillen Martensen (2006), p.29. Applied Hand Protocol Example PA PA Oblique Lateral 4. Request Forms What are the key features? Fig 1-118, McQuillen Martensen (2011), p.57. 5. Patient Assessment Correct patient - check ID/DOB Pregnancy check!! Respect patient privacy. Patient comprehension - do they understand you? Talk to the patient (communication) = obtain a clinical history. Patient Assessment (continued) Artifacts (watch, bracelet, rings) Wound dressings Universal precautions (common pathogens: MRSA, VRE, TB) Ability of patient to maintain the position? (sponges for support) Will I need to demonstrate the positions to the patient? Always explain what you would like the patient to do. 6. Radiographic Technique Select the appropriate IR cassette size. SID/FFD ( minimum SID 40 inches/ 100-102cm). Exposure factors - adjusted according to the above Focal spot size Accessory equipment - lead rubber to mask each side of cassette/sandbags/sponges/chair to sit Fig 2-17, Bontrager & Lampignano (2010), p.44. patient  Standard Projection PA projection 7. Patient Positioning and Projections PA projection: Where does the patient sit? Seat patient at the end of table, with elbow flexed 90 degrees and with hand and forearm resting on the table. Fig 2-47, Bontrager & Lampignano (2010), p.53.  How do we position the hand to produce a true PA view ? -Pronate hand with palmar surface in contact with IR, spread fingers slightly. -Align long axis of hand and forearm with long axis of IR. - Center hand and wrist to IR. Where is the CR directed? - CR perpendicular to IR, directed to third MCP (Metacarpophalangeal joint).  Patient Positioning and Projections (continued) PA projection (continued): Do we include the wrist joint? -PA projection should include entire hand and wrist and about 2.5cm of distal forearm. Fig 4-22, McQuillen Martensen (2011), p.178.  Standard projection PA Oblique projection Patient Positioning and Projections (continued) PA oblique projection: Where does the patient sit? Seat patient at the end of table, with elbow flexed 90 degrees and with hand and forearm resting on the table. Fig 4-26, McQuillen Martensen (2011), p.182. How do we achieve a radiograph that shows slight overlap of the metacarpal bases and heads and minimal overlap of the 3rd/4th and 4th/5th metacarpal shafts? -PA Oblique projection, Pronate hand on IR, center and align long axis of hand with long axis of IR. -Rotate entire hand and wrist laterally 45° and support with radiolucent wedge, so all the digits are separated and parallel to IR. Patient Positioning and Projections (continued) PA oblique projection (continued): Where is the CR directed? CR Perpendicular to IR, directed to third MCP joint. Do we include the wrist joint? Collimate on four sides to hand and wrist. Fig 4-24, McQuillen Martensen (2011), p.180.  Applied protocol Lateral projection  Lateral Hand Technical Factors Kv mAs FFD (cm) Grid Focus Cassette 55 7 100 No Fine 24 x 30 cm Patient position Seated at end of radiographic table Apply lead shielding for Radiation safety Part position Hand in true lateral position Extend fingers with thumb perpendicular to palm of hand Central Ray: Perpendicular Center Point : To second metacarpophalangeal joint  Lateral Hand Structures shown Carpals , Metacarpals & Phalanges superimposed Note: Lateral hand is essential in suspected Fracture to demonstrate the bone Displacement and for a suspected foreign body to detect its depth. Protocol: Relating the Radiographic Projections to the Clinical Indications Relating the selection of radiographic projections for the hand with the clinical indications … If a patient has sustained an injury to the hand it may be very difficult for the patient to extend the hand enough to place its palmar surface in contact with the cassette /IR. What should be done in this case? Modify! Modified projection AP (Anteroposterior) - beam divergence achieves better demonstration of the metacarpo-phalangeal (MCP) and interphalangeal (IP) joints. Foreign Body Example with AP Hand Supplementary projections Supplementary Projections For ? RA (Rheumatoid arthritis): Best to use posterior or more commonly known as: AP (Anteroposterior) obliques: The Norgaard Method (also known as ball catchers' position), demonstrates better than PA obliques, to make an early diagnosis of rheumatoid arthritis. Fig 5-84, Bontrager & Lampignano (2005), p.157. Supplementary Projections Brewerton’s view: place fingers and heads of the metacarpals in the anatomical AP position tube angled 20 degrees across the hand from the ulnar side. Examples of Hand x-ray Examples: Applied Protocol - Three Projections Fig 5-81, Bontrager & Lampignano (2010), p.150. Fig 1-4, McQuillen Martensen (2005), p.6. Examples: Child and pediatric hand x-ray Examples: Child hand x-ray Examples: Hand Pathologies Osteoarthritis of Fingers Note: narrowing of the interphalangeal joints with spurring and erosions. Fig 4-23, Eisenberg & Johnson (2012), p.98. Examples: Hand Pathologies Boxer’s fracture Note: a fracture at the neck of the fifth metacarpal (arrow) with volar angulation of the distal fragment. Fig 4-104, Eisenberg & Johnson (2012), p.140. Examples: Hand Pathologies - Osteoarthritis and Osteopenia Mild soft tissue swelling around the wrist. Periarticular osteopenia. Considerations include disuse osteopenia, erosive arthritis and complex regional pain syndrome. Examples: Hand Injury – Boxer’s Fracture Examples: Hand Injury - Metacarpal Dislocation Summary Hand basic anatomy Clinical rationale (reasons) Protocols: deciding on the protocol from the rationale – standard or routine: PA, PA obl – applied :Lat including fan – modified: AP – supplementary: Norgaard (Ball catcher’s); Brewerton Request form features Patient assessment basics Radiographic technique Patient positioning and projections: PA and PA obl Examples References Bontrager, K.L. & Lampignano, J.P. (2005), Textbook of Radiographic Positioning and Related Anatomy, 6th edition, Mosby, St. Louis, Missouri. Eisenberg R.L., & Johnson, N. M. (2012), Comprehensive Radiographic Pathology, 5th edition, Mosby Elsevier, St. Louis, Missouri. McQuillen Martensen, K. (2006), Radiographic Image Analysis, 2nd edition, W.B. Saunders, St. Louis, Missouri.