13. Imaging of the Upper Limb

Question 1

What are the advantages and disadvantages of X-ray?

Answer 1

A: Cheap, quick, good for bone (high spatial resolution), low radiation dose

D: Poor contrast resolution (bad for soft tissue), 2D image

Question 2

What are the advantages and disadvantages of CT?

Answer 2

A: Quick, widely available
Cross-sectional images
Good for soft tissue (high contrast resolution)

D: Radiation higher, IV contrast risk

Question 3

What are the advantages and disadvantages of MRI?

Answer 3

A: Good contrast resolution (soft tissue), can be used for specific applications (e.g. view the brachial plexus), no radiation

D: Limited availability, patient experience, £££, magnet/contrast risks, unsuitable for trauma

Question 4

What are the advantages and disadvantages of US?

Answer 4

A: cheap, easily available, no radiation, specific applications

D: limited field of view, requires expert handler

Question 5

Answer 5

Question 6

What do the following stand for when searching X-Rays?
A
A
B
C
S
S

Answer 6

A - Adequacy
A - Alignment
B - Bones
C - Cartilage / Joint spaces
S - Soft tissues
S - Satisfaction of search (check again)

Question 7

Which is the most common dislocation of the shoulder?

Which is the rarest?

Answer 7

Most common = anterior dislocation

Inferior = rarest

Question 8

How do Ps with a posterior dislocation of the shoulder present?

Answer 8

Unable to lower their arm

Question 9

What pathology is seen here?

Answer 9

Anterior dislocation of glenohumeral joint

Question 10

Normal or abnormal?

Answer 10

Normal - young P with epiphysis of humerus seen in the neck.

Question 11

Normal or abnormal?

Answer 11

Abnormal - clavicle lateral end displaced = dislocation of acromioclavicular joint.

Question 12

What signs on xray can indicate osteoarthritis in a joint?

Answer 12

Reduced joint space
Osteophytes
Subchondral sclerosis

Question 13

What is subchondral sclerosis and how does it appear on X-ray?

Answer 13

Subchondral sclerosis is a thickening of bone that happens in joints affected by osteoarthritis.

In Xray it can appear as a brighter white joint

Question 14

What does this x-ray show?

Answer 14

Osteoarthritic changes of the shoulder - reduced subacromial space

Question 15

What type of scan is this?

Answer 15

Question 16

Answer 16

Question 17

What is the go-to scan for rotator cuff assessment?

Answer 17

US

Question 18

When is MRI used for rotator cuff assessment?

Answer 18

When there is complex injury / instability of the joint

Question 19

Answer 19

Question 20

What is used to assess the glenoid labrum or for ligament lesions?

Answer 20

MR arthrography - where contrast agent is injected into the joint

Question 21

How do bursae appear on US?

Answer 21

Thin and anechoic (dark)

Question 22

How do tendons appear on US?

Answer 22

Homogenous in texture with a brightness and smooth contour

Question 23

Answer 23

Question 24

Answer 24

Question 25

In what order do ossification centres develop on children between 6 and 12?

Answer 25

CRITOL rule Capitellum Radial head Internal (medial) epicondyle Trochlear Olecranon Lateral Epicondyle

Question 26

What are raised fat pads on an elbow xray a sign of?

Answer 26

That there is a fracture present

Question 27

When is CT used for an elbow?

Answer 27

To assess bone or soft tissue tumours when MRI is contraindicated. Can be used in trauma cases to establish the extent of a fracture To make 3D reconstruction to allow assessment before surgery Not commonly performed.

Question 28

When is MRI of the elbow done?

Answer 28

To determine soft tissue pathology (inc tumours) Avascular necrosis of the bone

Question 29

Answer 29

Question 30

What muscles does the radial nerve run between?

Answer 30

The brachialis and brachioradialis

Question 31

Answer 31

Question 32

Where do the ulnar nerve branches pass in the hand?

Answer 32

Deep - dorsal and distal to hook of hamate. Superficial - distally into the palm

Question 33

Answer 33

Question 34

What is wrong in this X-ray?

Answer 34

Lunate dislocation

Question 35

What is wrong in this X-ray?

Answer 35

Colles fracture - fracture of radius with dorsal displacement

Question 36

What type of image is this?

Answer 36

CT Scan

Question 37

What type of image is this?

Answer 37

MRI

Question 38

What is the problem with a scaphoid fracture?

Answer 38

Part of the fractured bone can die because the blood vessel passes through the scaphoid itself = avascular necrosis of the scaphoid.

Question 39

What joints does RA usually affect?

Answer 39

MCP PIP Ulnar styloid joint

Question 40

How can RA appear on MRI?

Answer 40

Multiple bone erosions Multiple bone erosions and destruction of the TFCC by an aggressive, (predominantly) hypervascular pannus.

Question 41

What scan is best for early detection of RA? What does it show?

Answer 41

US & Doppler US - very sensitive - can show early stages of inflammation, synovial hypertrophy and erosion Doppler - shows inc blood supply in inflamed joint (synovitis)

Question 42

What late changes are seen to the joints in RA?

Answer 42

Carpal fusion (ankylosis) Joint subluxation

Question 43

When is X-Ray most commonly used for hands?

Answer 43

For trauma

Question 44

What is MRI used for in hands?

Answer 44

Assessing soft tissue masses, bone infection and RA Can also show acute synovitis and erosions

Question 45

What is US used for in hand?

Answer 45

Assessing inflammatory changes & bony erosions (RA)

Question 46

What pathology is this?

Answer 46

Extensor tenon avulsion

Question 47

What is mallet finger? How does it present?

Answer 47

Is avulsion of the extensor tendon from the DIP joint attachment. Ps present with inability to extend the finger at the DIP or PIP joint. Bony fragment may be seen at the insertion of the tendon.

Question 48

What pathology is this?

Answer 48

RA

Question 49

How does RA present?

Answer 49

Symmetrical Affects MCP, PIP and the carpal joints Can get subluxation of the joints Can get bone erosions

Question 50

How does OA present?

Answer 50

Usually asymmetric Affects the DIP joints Get osteophytes Bright joints on X-ray fro, Reduced joint space Can get degenerative changes between scaphoid, trapezium and triquetral