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More upper extremity

IMAGE REVIEW & CRITQUELecture # 3 – Part 1 Upper ExtremityRT 123 – WEEK 9

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Shield ?

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Anatomy &Positioning Review

Upper Limb

7 RE: LATERALS PG 80

PROJECTION VS POSITION• CHEST / ABDOMEN / SKULL

• The lateral is referred to the POSTION – which is the SIDE TOUCHING THE IR

• SO LEFT LATERAL (position ) in referred to as a LATERAL PROJECTION

• LIMBS : Pos/Pro – side entered by IR

• MEDIOLATERAL OR LATERALMEDIAL

8 LEFT LATERAL OF CHEST

LEFT LATERAL POSITION – LATERAL PROJECTION

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Lateromedial mediolateral

10 Lateromedial humerus Mediolateral humerus Taken “AP” “Taken PA”

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Lateromedial mediolateral

12EPI’s ? Hand Position?Hand - lateralmedial Hand - mediolateral

Internal Rotation - (lesser tubercle in profile)

13 Greater tubercle Lesser tuberclein profile in

external rotation internal rotation

Proximal HUMERUS

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Anatomy Review

15 Position – Best Seen?

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?Position – Best Seen?

17 Position – Best Seen?

18 Position – Best Seen?

19 Scaphoid most commonly fx of carpel bones

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15 º 5 º

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? Taken for?

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24

Flexed joint

25supracondylar fracture of the elbow

Name 3 postions to best demonstrate this fx?

26supracondylar fracture of the elbow

If a child complains of elbow pain after a fall

and refuses to straighten his or her arm

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28

Will This Work?

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using shields when collimator head cannot be rotated.

30Patient positioning for AP humerus image when fracture is located close to shoulder.

31 Lateromedial humerus Mediolateral humerus Taken “AP” “Taken PA”

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Projection ? – For?

33Distal Humerus (poss fx)

Poor position distally - better position not good Rad Prot

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Epi’s are ┴ do not move arm if fracture is suspected!

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classifications

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Ossification of carpals

• It is useful to have some idea of the age at which each of the carpal ossific centres appears although one would not expect you to know them all by heart!

• Ossification is usually visible by the end of the first year in the capitate and hamate . The remainder of the carpals, except for the pisiform, have appeared by the eighth year.

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Bone age?• The capitate (1) and hamate (2) both are seen

as large circular bony structures. • A very faint smaller bony ossific centre is also

present just proximal to the hamate.• This is the first appearence of the triquetral

• The epiphyseal growth plates have also started to ossify on each of the metacarpals. These are at the proximal ends of these bones.

38 JOINT CLASSIFICATION• GLIDING

• BALL & SOCKET

• HINGE

•

• SADDLE

39 COMMON FRACTURES pg 74

40 fracture description• The first consideration is the age of the

patient.• Fractures in children require special

attention because a child's bones are still growing and changing.

• An adult fracture is classified based on its location, direction, alignment, articular involvement (involving most of the joint rather than the shaft), and whether it is open or closed.

41 The direction of the fracture is described as

• transverse (fracture line is straight across the bone)

• spiral (fracture line spirals down the bone) • oblique (slanted fracture line)• comminuted (more than two fragments) • segmental (several large fractures in the

same bone)• open fracture means that bone fragments

have broken through the skin causing an open wound

• closed fracture means that there is no opening in the skin.

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Fracture Terminology Review

• Greenstick fractures – occurs when bone is angulated beyond limit of bending

• Complete fractures  -  Transverse fractures

•      -   Spiral / Oblique  Comminuted / Segmental

• Avulsions: • Forcible tearing/separation of ligaments or

muscles from the bone

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COMMON FRACTURES PG 99

• Avulsion – tearing away from bone• Boxer – base 4th or 5th metacarpal• Colle’s – distal radius/ulnar – posteriorly• Smith’s distal radius/ulnar – anteriorly• Greenstick – bending of bone (children)• Pathologic – fx of a diseased or weakened

bone• + Galeazzi and Monteggia fractures

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Upper Extremity Avulsions

• Avulsion of muscles

•      Greater tubercle

•      Lesser tubercle/

•      Medial epicondyle of humerus

•      Lateral epicondyle of humerus

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Children

• Epiphyseal plate fractures: 

• 30% of children fractures involve the growth plate (epiphyseal plate

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• Buckle (torus) fractures – caused by compression failure of bones. It occurs usually near the metapysis where porosity is greatest

49 • The most difficult aspect of reconstruction of fractures of the distal humerus is the restoration of normal anatomic relationships

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MORE IMAGE ANALYSISPractice TEST

“FILM CRITIQUE”

WHAT DO YOU KNOW?

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Name the labeled anatomy #1

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54 Name the labeled anatomy #2

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56 www.rad.washington.edu

57 POSITIONS? #3

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59 Problem Pathology position?

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60 Problem Pathology ?

OSTEO ARTHRITIS

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61

Problem Pathology CRITIQUE

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62 CRITIQUEWhat projection

position?7 ?

63 Problem Pathology ?

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64

• A 14-year old boy was roughhousing with a friend when he heard a crack and felt a sharp pain in his mid-humerus.

• What is the correct terminology to use in describing this fracture?

• Why did this otherwise healthy young man break his arm from minor trauma?

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65

• comminuted fracture

• From?• a pathologic fracture

through a pre-existing bone lesion that had weakened the integrity of the bone

9 9

66 Position? Pathology?

• This 22-year old man has had a swollen wrist for several months. Take a look at his radiograph and answer the following questions. Is this lesion benign or malignant? What is the specific name for this bone tumor?

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Position? Pathology? 11

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11 • This clinical picture is classic for a fracture of the radial head.

• When an adult falls on an outstretched hand, the force of the fall is transmitted up the radius and frequently will impact or crack the radial head.

• In this lateral view there is a subtle disruption in the relationship between the head and the shaft of the radius.

69 Problem Pathology ?

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Name of fx #13

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greenstick

72Type of fracture? 14

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# 15

• What do fat pads

suggest?

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• Anterior fat pad displacement in the lateral view suggests effusion, but if the posterior fat pad is visible at all, an elbow fracture is likely.

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#16

Position / problems ?

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#17Name of FX?

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#18

78#19

Highresolution

digital

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#20

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100

• POSITION?

• CRITIQUES?

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101

• POSITION?

• CRITIQUES?

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102

• POSITION?

• CRITIQUES?

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103

• POSITION?

• CRITIQUES?

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104

• POSITION?

• CRITIQUES?

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105• POSITION?• CRITIQUES?

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106

• POSITION?

• CRITIQUES?

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107

• POSITION?

• CRITIQUES?

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107

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108

• POSITION?

• CRITIQUES?

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109

• POSITION?

• CRITIQUES?

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How did you do?

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More Pathology Review

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• A 6 year old boy - falling on his outstretched left arm

• displaced supracondylar fracture of the left humerus

94 Ulnar nerve injury“funny bone”

95 Giant cell turmor

96 Monteggia Fractures

• fracture of proximal radius

• dislocation of the radial head

• Involvement forearm& elbow joint

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98 Galeazzi Fracture

• Mechanism: Fall on outstretched hand with elbow flexed

• Fracture of the radius with shortening and dislocation of the distal ulna

•   Dorsal angulation

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Galeazzi Fracture

• Galeazzi and Monteggia fractures are both fractures in which there is a fracture with shortening of one of the two bones of the forearm with dislocation of the other bone

100 Fat pad sign

Radial

Head

fracture

101

Radial head fractures

• are common injuries, occurring in about 20 percent of all acute elbow injuries.

• They are more frequent in women than in men and occur most often between 30 and 40 years of age.

• Approximately 10 percent of all elbow dislocations involve a fracture of the radial head.

• As the humerus and ulna return to their normal alignment, a piece of the radial head bone could be chipped off (fractured).

102 Subluxation of radial head

• This is the most common traumatic injury of the elbow in children. 

• It is also known as "pulled elbow" or "nursemaid's elbow."  The average age of incidence is 2-4 years. 

• As children get older, the annular ligament gets thicker and resists tearing, making this injury less likely.

• Treatment entails reduction by forcefully supinating the forearm with the elbow flexed 60 to 90 degrees. 

1031. Radial Growth Plate

2. Colles Fracture