1st week (wed,.ppt

8/12/2019 1st week (WED,.ppt

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Upper LimbsFingers, hand, wrist


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By the end of this Lecture the student will be able to:

Learning Objectives

List and identify the different bones and joints of hand and wrist

List the common indications for upper limbs radiography

Define the common pathologies associated with hand and wrist jointIdentify technical factors for hand and wrist radiography

List the basic and Optional projections of the fingers, thumb, hand, and wrist

Discus the correct body position, part position, central ray, and center point for

specific positions of the fingers, thumb, hand, and wrist joint

Critique and evaluate radiographs of fingers, thumb, hand, and wrist based on

(position, collimation and central ray, exposure, and structure best shown)

List and identify the different bones and joints of hand and wrist

List the common indications for upper limbs radiography

Define the common pathologies associated with hand and wrist jointIdentify technical factors for hand and wrist radiography

List the basic and Optional projections of the fingers, thumb, hand, and wrist

Discus the correct body position, part position, central ray, and center point for

specific positions of the fingers, thumb, hand, and wrist joint

Critique and evaluate radiographs of fingers, thumb, hand, and wrist based on

(position, collimation and central ray, exposure, and structure best shown)


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References

Positioning in Radiography: By k.C.Clarke.Text book of radiographic positioning and related anatomy;

By Kenneth L.Bontrager, 5thedition

Websites

http://www.e-radiography.net/
http://www.e-radiography.net/http://www.e-radiography.net/http://www.e-radiography.net/http://www.e-radiography.net/


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Anatomy of the hand

Review of anatomy

capitate

hamate

Pisiform

Triquetral

LunatePisiform

Pisiform

Pisiform1

2345

Phalanges

1-5 = metacarpals

8 = carpals

5 = metacarpals14 = Phalanges


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Joints of hand

Review of anatomy

metacarpophalanges .J

Intercarpal Joints

Carpometacarpal Joint

InterphalangealJoints


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Upper limb includes: Hand and wrist, forearm, humerus, and shoulder girdle.

Minimum FFD (SID) is 100 cm (40 inches) for Potter Bucky work. For over-

couch work, FFD should be increased by 810 cm.

Exposure: Lower to medium kV range ( 5070 ) KVp with short exposure time,

FFD is generally 100 - 102 cm at a small focus for improved image geometricsharpness (therefore, improved bony details).

All supports and sponge pads to be used are radiolucent. Sandbags are used for

immobilization and are usually opaque to x-rays and must, therefore, be employed

outside the X-ray field.

Upper Limbs Radiography (Technical aspects)


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Secondary radiation grids are not used except when the part to be x-rayed isgreater than 13 cm (as is the case of shoulder joint) in dimensions. In case

of plaster cast, the exposure should be increased (3 - 4 kVp for a fiberglass cast),

(5 - 7 kVp for small to medium cast), (8 - 10 kVp for the large cast).

High definition (HD), or high detail, films and screen combinations are to be used(as general) to show minute bony details. However, because of the higher

radiation exposure needed with these screens and films, regular screens

are used (of the fast Tungstate type), or high-speed screens are used (of the rare-

earth type).

Upper Limbs Radiography (Technical aspects)


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Fracture A discontinuity in the structure of bones. Types include: Simple,compound (open), incomplete (partial: includes the greenstick fracture),

complete, comminuted, impacted, compression, depressed (ping-pong),

pathologic, stress (fatigue), etc. Fracture names of the upper limb (hand and

forearm) are: Colles, Potts, Bartons, Smiths, Bennett's, and Boxers.

Bursitis The inflammation of the bursa (fluid-filled sacs) enclosing the joints.

Carpal tunnel syndrome A common painful disorder of the wrist joint and

hand due to a compression (by masses, calcifications,.etc).

Rheumatoid arthritis Are inflammatory changes of the human bodys

connective tissues (soft tissue swellings) around ulnar styloid process or MP

joints.

Bone tumors May be benign or malignant (cancerous):

Pathological Indications


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Gout A form of arthritis. Blood uric acid is excessive, deposited on joints and/or tissues. First attack is to the big toe (may also involve the thumb).

Joint effusion Accumulated synovial fluid or blood hemorrhage within a joint

cavity due to a fracture, dislocation, soft-tissue damage, or could only be due to

inflammation.

Osteoarthritis Degenerative joint disease of gradual deterioration of articular

cartilage with hypertrophic bone formation (generally part of the natural aging

process).

Osteomyelitis Local/generalized bacterial infection of bone/ bone marrow. May

also be introduced by trauma or surgery.Osteoporosis Bone atrophy (reduction in quantity of the bone) of the skeletal

bones in postmenopausal women and elderly men resulting in' thinning of bones

Bone cysts Benign neoplastic bone lesions filled with a clear fluid near the knee

joint in pediatric patients

Pathological Indications


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To show #s, dislocations, and pathology(osteoporosis (OP), osteoarthritis, (OA),etc..) and any opaque foreign bodies (FBs).

Body (Patient) & part position

Patient sits at the end of couch, elbow flexed

90, hand resting in profanation on the film,all fingers extended and separated from eachother. Sand bag over the lower forearm forimmobilization.

Film: 18x24 cm.

CR: 90vertically to the film center.

CP: Proximal I.P.J.

PA Fingers (Basic)

To show #s, dislocations, and pathology(osteoporosis (OP), osteoarthritis, (OA),etc..) and any opaque foreign bodies (FBs).


Patient sits at the end of couch, elbow flexed

90, hand resting in profanation on the film,all fingers extended and separated from eachother. Sand bag over the lower forearm forimmobilization.

Film: 18x24 cm.CR: 90vertically to the film center.

CP: Proximal I.P.J.


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To show #s, dislocations, and other pathology(osteoporosis, osteoarthritis, etc..) and opaqueforeign bodies (FBs).


Patient sits at the end of couch, hand mediallyrotated, the lateral aspect of index on the film,middle and other fingers flexed, sandbag overthe lower forearm.

Film: 18x24 cm.

CR: 90vertically on the film center.

CP: Proximal I.P.J.

Lateral index finger (Basic)


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Shows fractures, dislocation, and pathology indistal and proximal phalanges (OA, OP), andopaque F.Bs..


Patient sits at end of the couch, shoulder at couch

level, hand and wrist and forearm extended, arminternally rotated until posterior aspect of thumbrests supinated on the film, hand and wristimmobilized.

Film: 18x24 cm.

CR: 90to film center.

CP: First MPJ.

NB/ * PA thumb not recommended as image will

suffer magnification and, therefore, distortion due

to the greater OFD.

AP thumb (Basic)


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Same indication as before.


Patient sits at end of the couch, elbow thenflexed 90, hand pronated on the film, palmraised on pad (or fingers slightly arched) sothat thumb is in true lateral, hand and wristimmobilized.

Film: 18x24 cm.CR: 90to film center.

CP: First M.P.J.

Lateral thumb (Basic)


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For #s , dislocations, F.B.s, pathology(OA/OP) of phalanges, carpals, andmetacarpals.


Patient sits at end of couch, elbowflexed 90, hand pronated (palm down),hand and wrist immobilized.

Film: 24x30 cm


CP: 3rdM.P.J (or head of 3rdM.C.)

PA hand (Basic)


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A. Thumb

B. Index

C. Middle finger

D. Ring finger

E. Little finger

I-V. Metacarpal bones1,4. Distal phalanx

2. Middle phalanx

3,5. Proximal phalanx

6. Sesamoid bones

7. Distal interphalangeal joint (DIP)

8. Proximal interphalangeal joint (PIP)9. Metacarpophalngeal joint (V.)

10. Carpometacarpal joints

11. Trapezium

12. Trapezoid

13. Capitate

14. Hamate

15. Scaphoid16. Lunate

17. Triquetrum

18. Pisiform

19. Radius

20. Ulna


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To show forward/backward displacement and position of fractures and F.B.s

(whether in Palmar or dorsal aspect). All phalanges, metacarpals, and the carpals

are well superimposed in the lateral, except the thumb which will be in its true lateral

projection. It is an alternate projection to fan lateral.


Patient sits at the end of the couch, elbow flexed 90, hand and wrist in truelateral (thumb up).

Film: 18x24 cm.


CP: 2ndM.P.J. (or head of 2ndM.C.)

Lateromedial hand (Basic)


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For fractures/dislocations of phalanges, Pathology

processes for all joints of the hand such as OA, and

OP.


Patient sits at the end of the couch, elbow flexed

90, hand and forearm resting on table top

Pronate hand and then rotate entire hand and wrist

laterally 45.

Support hand with radiolucent wedge with digitsseparated from each others

Film: 18x24 cm.

CR: 90to Image receptor (IR)

CP : 3rdM.P.J. (or head of 3rdM.C.)

Oblique hand (Basic)


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A. Thumb

B. Index

C. Middle finger

D. Ring finger

E. Little finger

1,4. Distal phalanx

2. Middle phalanx

3,5. Proximal phalanx

6. Sesamoid bones

7. Distal interphalangeal joint (DIP)

8. Proximal interphalangeal joint (PIP)

9. Metacarpophalngeal joint (V.)

10. Carpometacarpal joints11. Trapezium

12. Trapezoid

13. Capitate14. Hamate

15. Scaphoid

16. Lunate

17. Triquetrum

19. Radius

20. Ulna


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For detection of early rheumatoid arthritis at2ndto 5thproximal phalanges and for fractureat base of 5thM.C.Both hands to be exposed in a single exposurefor purpose of comparison.


Patient sits at end of couch, hands rotatedinternally 45 degrees (cupped as if catchinga ball) and supported on 45sponge blocks.

Film: 24x30 cm


CP: Midway between the hands at levels of

heads of the 5thM.P.Js.

APO (Ball catchers) (Special)


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-V: Metacarpals

1. Trapezium2. Trapezoid

3. Capitate

4. Head of Capitate

5. Hamate

6. Hook of Hamate

7. Scaphoid8. Lunate

9. Triquetrum

10. Pisiform

11. Styloid process of radius

12. Head of ulna

13. Styloid process of ulna14. Radio carpal joint

15. Distal Radioulnar joint


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Basic view to show #s and dislocations of distal radius or ulna, namely: Colles

fracture, Smiths fracture, and Bartons fracture. Also shows any (OA, OP)

changes.


Patient seated at end of table , elbow flexed 90with and

forearm rested on table top.

Hand and wrist in true lateral (styloid processes must

superimpose), back of hand supported.

Film: 18x24 cm.


CP: To radial styloid process (Midcarpal area).

Lateral wrist (Basic)


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1. 1st metacarpal

2. Metacarpals II-V

3. Trapezium4. Tubercle of Scaphoid

5. Lunate

6. Triquetrum

7. Radio carpal joint

8. Distal end of radius

9. Distal end of ulna


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To show #s or pathology the Scaphoid bone.


Patient sits at the end of the couch, elbow flexed

90, hand and forearm resting on table top.

Pronate hand and then from the PA hand,the hand is deviated towards the ulna and immobilized

(ulnar deviation or radial flexion).

Film: HD 18x24 cm.

CR: 10- 15proximally to film center (along the long axis of forearm) .CP: To the Scaphoid (2 cm distal and medial to radial styloid process).

NB/ Several projections with different CR directions (90, 10, 15, 30

can be taken to show obscure fractures).

PA Scaphoid (ulnar deviation) Special


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To show #s or pathology the lunate, Hamate, Pisiform, and Triquetrum.


From the PA wrist, hand is moved gently towards the thumb side as far aspossible (radial deviationor ulnar flexion) .

Film: 18x24 cm.CR: 90to film center.

CP: Midcarpal area

(midway between ulnar and radial styloids).

PA wrist (radial deviation) (Special)


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To detect the carpal tunnel (carpal sulcus)syndrome.


Patient sits at the end of couch, wrist and hand

hyper extended (dorsiflexed) by grasping thefingers with the other hand until the metacarpals

are roughly 90to the forearm, entire hand and

wrist then internally rotated 10(toward the

radius).

Film: 18x24 cm.

CR: 25- 30to the long axis of the hand.CP: Midcarpal area (Center of palm), 3cmdistal to base of 3rdMC.

Tangential carpal tunnel (special)


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RADIOGRAPHICANATOMY

CARPAL TUNNEL

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