forearm elbowhumerus 1 Positioning principles as for upper limb applies to lower limb kV should be lower to medium 50 70 KVp For all parts discussed center and align the long axis of the part to central ray CR and to long axis of the film ID: 1048406
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1. RAD 222Upper extremity part 2(forearm, elbow,humerus)1
2. Positioning principles as for upper limb applies to lower limb. kV should be lower to medium (50 – 70) KVp.For all parts discussed, center and align the long axis of the part to central ray (CR) and to long axis of the film.No secondary radiation grid usedRadiation protection has to be well observed, using the special gonad shields over pelvic region, or the lead apron as necessaryFFD is generally 40 inches (100 cm).Optimal contrast and density will allow visualization of bony cortical margins soft tissue structures. Technical Points 2
3. PROJECTIONBASICSPECIALforearm1.AP Forearm2. Lateral Forearm-elbowAP ElbowAP elbow (partial flexion) – trauma caseLateral (Lateromedial )APO elbow (lateral/external rotation), ( medial/internal rotation) Radial head Survey Acute flexion elbow(Axial) – ulnar groove (Jones method)humerus1.AP Humerus2. Lateral Humerus :( Lateromedial ) ( Mediolateral)3. Lateral Humerus (Lateromedial – Trauma case). 3
4. 1. Scaphoid2. Lunate3. Styloid process of radius4. Styloid process of ulna5. Head of ulna6. Radius7. Ulna8. Tuberosity of radius9. Neck of radius10. Head of radius11. Proximal radioulnar jointLRADIOGRAPHIC ANATOMYAP Forearm4
5. 1.AP Forearm: Basic Film Size: 11x14 in. (30x35 cm, smaller patients ). 17x14 in. (35x43 cm, large patients ). lengthwise. SHIELDING: Place lead shield over patient’s lap to shield gonads.Patient Position: Patient sits at end of couch, shoulder at couch level. Part Position: forearm/palm supinated, elbow extended, both the elbow and the wrist joint to be included, ask pt to lean laterally as necessary to place entire wrist, forearm, and elbow in true frontal position as possible .M&L epicondyles should be the same distance from IR Distance: 100 cm or 40 in. C R: perpendicular to film.C P: directed to mid-forearm or Midshaft (between the wrist and elbow joints).Collimation: collimate on four sides to area of interest5
6. Structure shown: AP projection of entire radius and ulna is shown, with a minimum of Proximal row carpals and distal humerus, as well as pertinent soft tissue, such as fat pads and stripes of the wrist and elbow joint.6
7. The Forearm Lateral: BasicFilm Size: 11x14 in. (30x35 cm, smaller patients ).17x14 in. 35x43 cm, large patients )lengthwise. SHIELDING: Place lead shield over patient’s lap to shield gonads.Patient Position: Patient sits at end of couch, with elbow flexed 90 degree shoulder at level with couch. Part Position: Rotate hand and wrist into true lateral position and support hand to prevent motion if needed, ensure that distal radius and ulna are directly superimposed and included on the film.Distance: 100cm or 40 in. CR: perpendicular to film.CP: directed to mid-forearm. or Midshaft (between the wrist and elbow)Collimation: collimate on four sides to area of interest.7
8. Lateral left Forearm1. Scaphoid2. Lunate3. Distal end of radius4. Styloid process of ulna5. Head of ulna6. Ulna7. Radius8. Olecranon9. Tuberosity of radius10. Neck of radius11. Head of radius12. TrochleaStructure shown: lat projection of entire radius and ulna Proximal row of carpal bone, elbow, and distal end of the humerus are visible, as well as pertinent soft tissue, such as fat pads and stripes of the wrist and elbow joint. 8
9. Elbow Joint (Anatomy) 9
10. 10 Elbow Joint (Anatomy)
11. AP Elbow BasicFilm Size: 10x12 in. (24x30 cm) crosswise.SHIELDING: Place lead shield over pelvic area. Patient Position Patient sits at end of couch, shoulder at couch level. Part Position: forearm supinated, elbow extended on the film, patient then leans laterally to make a true AP position. epicondyles should be parallel to the IR, support hand as needed to prevent motionDistance: 100cm or 40 in. C R: perpendicular to film.C P: directed to mid-elbow joint, which is approximately (0.75 in ( 2 cm) distal to midpoint of a line between epicondyles). Collimation: collimate on four sides to area of interest11
12. RADIOGRAPHIC ANATOMYAP Elbow 1. Lateral supracondylar ridge2. Medial supracondylar ridge3. Olecranon fossa4. Medial epicondyle5. Lateral epicondyle6. Capitulum7. Olecranon8. Trochlea9. Coronoid process of ulna10. Proximal radioulnar joint11. Head of radius12. Neck of radius13. Tuberosity of radius14. UlnaStructure shown: distal humerus, elbow joint space , and proximal radius and ulna are visible.12
13. E. AP elbow (partial flexion) – trauma case (Basic) Film Size: Film: HD24x30 cm 10x12in (two films) crosswise.SHIELDING: Place lead shield over pelvic area.Patient Position : Patient sits at end of couch, with elbow partial flexed.Part Position: Two projections obtained with: (a) Forearm parallel to the film. (b) Humerus parallel to the film (with support under wrist as need to prevent motion).Distance: 100cm or 40 in. CR: perpendicular to film.C P: Midelbow which is approximately (3/4 in (2 cm ) distal to midpoint of a line between epicondyles ). Collimation: collimate on four sides to area of interestNB/ kV increased to (60 – 75) because of increased part thickness. (b)(a) 13
14. AP elbow partial flexion For distal HumerustraumaStructure shown: distal humerus, is best visualized on humerus parallel projection, Note structures in elbow joint region Are partially obscured, depending on the amount of elbow flexion possible.TrochleaCoronoid process of ulna14
15. Partial flexion forProximal forearmAP elbow Structure shown: proximal radius and ulna on forearm parallel projection, Note structures in elbow joint region Are partially obscured,depending on the amount of elbow flexion possible.15
16. Lateral (Lateromedial ): BasicFilm Size: HD18x24 cm (8x10in) crosswise.* SHIELDING: Place lead shield over patient’s lap to protect gonads.* Patient Position: Patient seated at end of table with elbow flexed about 90.Part Position : rotate hand and wrist into true lateral position, thumb side up. Place support under hand and wrist to elevate hand and distal forearm as needed for heavy muscular forearmDistance: 100 cm or 40 in. CR: perpendicular to film.C P: directed to mid elbow joint which is approximately 1.5 in ( 4cm) medial to posterior surface of the Olecranon process. Collimation: collimate on four sides to area of interest16
17. 1. Supracondylar ridge2. Trochlea3. Olecranon4. Trochlear notch5. Coronoid process of ulna6. Head of radius7. Neck of radius8. Tuberosity of radius9. UlnaRADIOGRAPHIC ANATOMYLateral Elbow Structure shown:lat projection of the distal humerus and proximal forearm, the olecranon process, and the soft tissue, and fat pads of the elbow joint. are visible . with the epicondyles superimposed (overlapping). Anterior fat pads Supinator fat strip17
18. APO elbow (lateral/external rotation) (Basic)Film Size: HD 10x12 in. (24x30 cm) crosswise.* SHIELDING: Place lead shield over patient’s lap to protect gonads.* Patient Position: Patient seated at end of table.Part Position: Arm fully extended on the film, shoulder at elbow level with shoulder lowered to couch level, hand facing outwards, arm rotated externally (laterally) so that entire elbow is 45 to the film (Patient must lean laterally for sufficient lateral rotation.).Distance:100 cm or 40 in. CR: perpendicular to film.C P: Mid elbow joint (2 cm distal to the midpoint between the epicondyles).Collimation: Collimate on four sides to area of interestNB/ External (lateral) oblique best shows radial head and neck, and Capitulum. AP and lateral oblique 18
19. APO elbow (lateral/external rotation)External (lateral) oblique best shows radial head and neck, and Capitulum. Capitulum19
20. APO elbow ( medial/internal rotation) (Basic)Film Size: HD10x12 in. (24x30 cm)crosswise.SHIELDING: Place lead shield over patient’s lap to protect gonads.Patient Position: Patient seated at end of table. Part Position: Arm fully extended on the film, shoulder at elbow level with shoulder lowered to couch level, arm rotated internally so that entire elbow is 45 to the film, palm in contact with the couch (facing the couch) Distance: 100 cm or 40 in. CR: perpendicular to film.C P : Mid elbow joint (2 cm (3/4in)distal to the midpoint between the epicondyles). Collimation: collimate on four sides to area of interest.20
21. NB/ * Internal (medial) rotation best shows the coronoid process of the ulna and Trochlea in profile.APO elbow ( medial/internal rotation) 21
22. The medial oblique will demonstrate the coronoid process of ulna.The Olecranon processThe radial head will be overlie the ulna. Olecranon fossaRADIOGRAPHIC ANATOMYMedial Oblique Elbow trochlea trochlea notchNB/ * Internal (medial) rotation best shows the coronoid process of the ulna and Trochlea in .profilemedial epicondyle 22
23. Radial head Survey (Special)Film Size: 8x10 in. (18x24cm) crosswise.* SHIELDING: Place lead shield over patient’s lap to protect gonads.* Patient Position: Patient sits at end of couch. Part Position: arm flexed 90. Four projections taken.1.Hand supine maximum external rotation (palm up). as far aspatient can tolerate.2.Hand in true lateral thumb up.3.Hand prone (palm down). 4. Hand internally rotated maximum internal rotation (thumb down)as far as patient can tolerate.Distance: 100 cm or 40 in. CR: perpendicular to the film.CP: direct to the radial head approximately 2 -3cm or (1in )distal to the lateral epicondyles.Collimation:collimate on four sides to area of interest.23
24. Acute flexion elbow(Axial) – ulnar groove (Special) Jones methodFilm Size: 8x10in. (18x24 cm) crosswise.* SHIELDING: Place lead shield over patient’s lap to protect gonads.* Patient Position: Patient sits at end of couch with acutely flexed arm resting on cassette.Part Position: Arm acutely flexed and placed on film, fingertips resting on the shoulder. Two projections are takenDistance: 100 cm or 40 in. CR: (a) CR 90 to the hummers* (b) CR 90 to the forearm. Collimation: collimate on four sides to area of interest. (a) Midway between epicondyles CP: (b) 5 cm superior to the Olecranon (a) CR 90 to the humerus(b) CR 90 to the forearm.24
25. Structure shown: provide a clear view of the Olecranon process and the surrounding soft tissue. The view is very useful in detecting loose bodies.RADIOGRAPHIC ANATOMY (a) CR 90 to the humerusOlecranon process 25
26. AP Humerus : BasicFilm Size: 11x14 in. (30x35 cm, smaller patients ) lengthwise. 17x14 in. (35x43 cm, large patients ). SHIELDING: Place lead shield over patient’s lap to shield gonads.Patient Position: May be taken erect or supine. Part Position : Affected side in contact with film, other side raised, arms abducted, hand supinated, humerus rests on the film with shoulder and elbow included, epicondyles of elbow are parallel to the film. Distance: 100 cm or 40 in. C R: perpendicular to film.CP: Midshaft (between elbow and shoulder joints). NB (suspend respiration during Exposure ) to reduce movement and tension. Collimation: collimate on four sides to area of interest26
27. Structure shown: AP projection of the entire humerus , including the shoulder and elbow joints, Is visible.AP HUMERUS27
28. Lateral Humerus :( Lateromedial ) BasicFilm Size: 11x14 in. (30x35 cm, smaller patients ). 17x14 in. (35x43 cm, large patients ) lengthwise.SHIELDING: Place lead shield over patient’s lap to shield gonads.Patient Position: May be taken erect or supine, body rotated toward the affected sidePart Position: elbow is partially flexed, internally rotate arm to give a lateral view so that epicondyles are 90 to the couch. Ask the patient to be relax to avoid motion. Distance: 100 cm or 40 in. C R: perpendicular to film. C P: Midshaft (between elbow and shoulder).NB/ (suspend respiration during Exposure )to reduce movement and tension. Collimation: collimate on four sides to area of interest28
29. Structure shown: A lat projection of the entire humerus , including the shoulder and elbow joints, Is visible.Lateral Humerus :( Lateromedial ) 29
30. Lateral Humerus (Mediolateral: Rotational): BasicFilm Size: 11x14 in. (30x35 cm, smaller patients ). 14x17in. (35x43 cm, large patients ) Lengthwise.SHIELDING: Place lead shield over patient’s lap to shield gonads.Patient Position: May be taken erect or supine. Part Position :face patient toward the film , and oblique as needed (20 to 30 from PA) to allow close contact of humerus to IR, the elbow flexed 90.Ask the patient to be relax to avoid motion.*Distance: 100 cm or 40 in. C R: perpendicular to film. C P: Midshaft (between elbow and shoulder).NB/ (suspend respiration during Exposure )to reduce movement and tension. Collimation: collimate on four sides to area of interest. 30
31. Lateral Humerus (Lateromedial – Trauma case). Basic* Film Size: HD 11x14 in. (30x35 cm) smaller patients . 10x12 in. (24x30 cm, ) large patients .SHIELDING: Place lead shield over patient’s lap to shield gonads.Patient Position: Patient recumbent. Part Position : support under the arm, elbow flexed (no rotation in case of injury), cassette placed between the arm and thorax (Top of IR to axilla).* Distance: 100 cm or 40 in.C R: perpendicular to film. CP: Midpoint of distal 2/3rd of humerusNB/ (suspend respiration during Exposure )to reduce movement and tension. Collimation: collimate on four sides to area of interest. 31
32. Lateral Humerus (Lateromedial – Trauma case). Structure shown: A lat projection of the mid and distal humerus , including the elbow joints, is visible the distal two thirds of the humerus should be well visualized.32