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Advanced Skeletal Flashcards

1
Q

Inferosuperior Tangential Wrist: Clinical Indications

A

abnormal calcifications and bony changes in the carpal sulcus that may impinge on the median nerve; carpal tunnel syndrome. Possible fractures of the hamulus process, pisiform and trapezium

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2
Q

Inferosuperior tangential wrist: Technical factors

A

SID: 40inches
IR: 8X10; non grid
Exposure factors: 60kV and 4-5mAs

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3
Q

Inferosuperior tangential wrist: positioning and central ray

A

Position: patient seated at the end of the table. Hand aligned with the long axis of IR. Hyperextend hand (dorsiflex wrist) so that the metacarpals are perpendicular (90 degrees) to the IR without lifting the forearm or wrist. Internally rotate (radially) the hand 10 degrees.
CR: angled 25-30 degrees to the long axis of the hand. Directed 1 inch distal to the base of the third metacarpal (center of hand).

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4
Q

Inferosuperior tangential wrist: evaluation criteria

A

Anatomy:
- the carpals are demonstrated in a tunnel-like, arched arrangement.

Position:

  • the pisiform and the hamulus should be separated and visible in profile without superimposition.
  • The rounded palmar aspects of the capitate and the scaphoid should be visualized in profile as well as the aspect of the trapezium that articulates with the first metacarpal
  • CR and center of collimation to the midpoint of the carpal canal

Exposure:

  • optimal density (brightness) and contrast as indicated by visualization of soft tissues and possible calcifications in carpal canal regian and outlines of the superimposed carpals are visable without overexposure of the carpals in profile.
  • no motion as indicated by trabecular markings appearing sharp and clear
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5
Q

inferosuperior tangential wrist: adaption

A

If the patient is unable to dorsiflex wrist to place metacarpals perpendicular (90 degrees to the IR.

  • align CR parallel to the long axis of the patient’s palm
  • increase the angle 15 degrees from there
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6
Q

Clinical indication: Carpal Tunnel Syndrome

A 
Symptoms
-Numbness in 2 or more fingers
-Pain that can extend to the elbow
-Tingling or burning
-Unable to tell the difference between hot and cold
-Difficulty gripping small objects
Treatment
-Medication and or bracing
-Ergonomics
- surgery
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7
Q

Acute flexion elbow: clinical indications

A

Fractures and moderate dislocations of the elbow in acute flexion when the elbow cannot be extended to any degree

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8
Q

Acute flexion elbow: technical factors

A

SID:
40inches

IR:
10X12; landscape (2 exposures) ; nongrid

Exposure factors:
kV: 60 for distal humerus, 65 for proximal forearm
4-6mAs

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9
Q

Acute flexion elbow: positioning and Central ray

A

positioning
- patient seated with acutely flexed eblow resting on IR and the patients fingertips resting on their shoulder. Align and center humerus to the long axis of the IR. Center the elbow joint region. palpate humeral epicondyles and ensure they are parallel to the IR (no rotation).
Central Ray
- distal humerus: perpendicular to IR and humerus, directed midway between the epicondyles
-proximal forearm: perpendicular to the forearm (angle as needed). directed 2 inches proximal (superior) to the olecranon process

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10
Q

Acute flexion elbow: evaluation criteria

A

four sided collimation borders should be visable with CR and center of collimation field between epicondyles

Distal humerus

  • forearm and humerus directly sumerimposed
  • medial and lateral epicondyles and parts of trochlea, capitulum and olecrannon process are seen in profile
  • optimal exposure should visualize distal humerus and olecrannon process through superimposed structures
  • soft tissue detail is not readily visable

Proximal forearm

  • proximal ulna and radius, including radial head and neck should be viable through the superimposed distal humerus
  • optimal exposure visualizes outlines of proximal ulna and radisu superimposed over humerus
  • soft tissue detail not readily availble

Acute flexion study MUST include both projections unless otherwise specified

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11
Q

Oblique elbow: Clinical Indications

A
  • Fractures and dislocations of the elbow,
    primarily the radial head and neck
    -Certain pathologic processes, such as
    osteomyelitis and arthritis

-Lateral (External Rotation) Oblique Best
visualizes radial head and neck of the radius and capitulum of humerus
-Medial (Internal Rotation) Oblique Best
visualizes coronoid process of ulna and
trochlea in profile

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12
Q

Oblque elbow: technical factors

A

SID:
40inches

IR:
10X12in ; landscape (two exposures) ; nongrid

Exposure factors
60 kV
3.2-5 mAs

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13
Q

Internal Oblique elbow: position and central ray

A

Patient seated with arm fully extended with elbow and shoulder on the same horizontal plane
Align arm and forearm with long axis of IR

Medial (internal) rotation

  • pronate hand
  • rotate arm until distal humerus and elbow are rotated 45 degrees. the interepicondylar line is approximately 45 degrees to the IR (this should be achieved by simply pronating the hand)

CR
perpendicular to IR directed 3/4th of an inch distal to interepicondylar line

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14
Q

External Oblique elbow: positioning and CR

A

Patient seated with arm fully extended with elbow and shoulder on the same horizontal plane
Align arm and forearm with long axis of IR

Lateral (external rotation
- supinate hand and roate entire arm laterally so that the distal humerus and the anterior surface of the elbow joint are approximately 45 degrees to the IR (this can be achieved by leaning laterally so that the patient shoulder is is resting on the table)

Central ray (both medial and lateral obliques)

  • perpendicular to IR
  • directed approximately 2cm distal to the midpoint between the humeral epicondyles
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15
Q

Medial Oblique elbows: Evaluation Criteria

A

Anatomy
-Oblique view of distal humerus
and proximal radius and ulna is visible.

Position
- Long axis of arm should be aligned with side
border o IR.
-Correct 45° medial oblique should visualize
coronoid process of the ulna in profile.
-Radial head and neck should be superimposed and centered over the proximal
ulna.
- Medial epicondyle and trochlea should appear
elongated and in partial profile.
-Olecranon process should
appear seated in olecranon fossa and trochlear notch partially
open and visualized with arm fully extended.
-CR and center
of collimation field should be at mid-elbow joint.

Exposure:
-Optimal density (brightness) and contrast with
no motion should visualize soft tissue detail; bony cortical
margins; and clear, bony trabecular markings

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16
Q

External (lateral) oblique elbow: evaluation criteria

A

Anatomy
- Oblique projection of distal
humerus and proximal radius and ulna is visible

Position
-Long axis of arm should be aligned with side
border of IR.
- correct 45-degree oblique evident by visualization of radial head, neck and tuberosity, free of superimposition by ulna
-lateral epicondyle and capitulum should appear elongated and in profile
- CR and center of collimation should be to mid-elbow joint

Exposure
- Optimal density (brightness) and contrast with
no motion should visualize soft tissue detail; sharp, bony
cortical margins; and clear, bony trabecular markings

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17
Q

Radial Head lateral (4 views) : Clinical indications

A

fractures of radial head and neck

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18
Q

Radial Head laterals: technical factors

A

SID:
40inches

IR:
10X12in ; landscape (all four projections); nongrid

exposure factors:
60kV
3.2-6 mAs

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19
Q

Radial head laterals: position and CR

A

Center radial head to IR so that humerus and proximal forearm are parallel with IR borders.
4 projections:
-1. supinate hand (palm up) and externally rotate as far as the patient can tolerate
-2. place hand in true lateral position (thumb up)
-3. pronate hand (palm down)
-4. internally rotate hand (thumb down ) as far as patient can tolerate

CR
perpendicular to IR, directed to the radial head (approximately 1 inch distal to lateral epicondyle)

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20
Q

Radial head laterals: evaluation criteria

A
  • Elbow should be flexed 90° in true lateral position, as
    evidenced by direct superimposition o epicondyles
    -radial head and neck should be partially superimposed by ulna but completely visualized in profile in various projections
    -radial tuberosity should be visualized in various positions as follows from external to internal rotation of the hand:
    1. slightly anterior
    2. superimposed over radial shaft
    3. slightly posterior
    4. most posterior, seen adjacent to the ulna

Optimal exposure with no motion should clearly
visualize sharp, bony margins and clear trabecular markings of
radial head and neck area

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21
Q

Fat Pad signs

A

Indication of synovial effusion, bursal hemorrhage or fracture
Elbow
Anterior pad is normally slightly visible in lateral view
Posterior pad is not normally illustrated
With trauma the anterior pad is more rounded and pronounced and the posterior pad is visible
‘Sail’ sign
Other joints: hip, wrist & ankle

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22
Q

Weight-bearing foot: clinical indications

A
  • Demonstrates the position of the bones of the feet under full body weight
  • Shows the longitudinal arches
  • Joint fusions
  • Pathology i.e. arthritis
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23
Q

weight-bearing foot: technical factors

A

SID:
40in

IR:
10X12 in for unilateral, 14X17 in for bilateral study; landscape; non-grid

Exposure factors:
60kV; 3.2-4mAs

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24
Q

weight-bearing foot AP: positioning and CR

A

Place patient erect, with full weight evenly distributed on both
feet.
Feet should be directed straight ahead, parallel to each other

Central ray
Angle CR 15° posteriorly to the midpoint between feet at the level of
base of metatarsals

25
Weight-bearing foot Lateral: positioning and central ray
The patient is standing on a solid platform with a cassette lower than the soles of the feet May have a special box with a slot for the cassette Weight should be equally distributed between feet one on either side of the cassette Both feet are imaged for comparison typically done lateromedial (as described above) CR: perpendicular to the level of the base of the 3rd metatarsals
26
Weight-bearing foot AP: Evaluation Criteria
Anatomy Demonstrated: -shows bilateral feet from soft tissue surrounding phalanges to distal portion of talus. Position: -For AP, proper angulation is demonstrated by open tarsometatarsal joint spaces and visualization of joint between first and second cuneiforms. - Metatarsal bases should be at center of the collimated field (CR) with four-sided collimation, including the soft tissue surrounding the feet Exposure: -Optimal density (brightness) and contrast should visualize soft tissue and bony borders of superimposed tarsals and metatarsals. - Adequate penetration of midfoot region. -Bony trabecular markings should be sharp
27
Weight-bearing foot Lateral: Evaluation Criteria
Anatomy Demonstrated: - For lateral, entire foot should be demonstrated, along with a minimum of 1 inch (2.5 cm) of distal tibia- fibula. - Distal fibula should be seen superimposed over posterior half of the tibia, and plantar surfaces of heads of metatarsals should be superimposed if no rotation is present. -The longitudinal arch of the foot must be demonstrated in its entirety. Position: - For lateral, center of collimated field (CR) should be to level of base of third metatarsal. -Four-sided collimation should include all surrounding soft tissue from the phalanges to the calcaneus and from the dorsum to the plantar surface of the foot with approximately 1 inch (2.5 cm) of the distal tibia- fibula demonstrated. Exposure: - Optimal density (brightness) and contrast should visualize borders of superimposed tarsals and metatarsals. - No motion; cortical margins and trabecular markings of calcaneus and nonsuperimposed portions of other tarsals should appear sharply defined
28
Ankle stress views Inversion/eversion : Clinical Indications
Pathology involving ankle joint separation | secondary to ligament tear or rupture
29
Ankle Stress views Inversion/eversion: technical factors
SID: 40inches IR: 10X12in; portrait; nongrid Exposure factors: 60kV; 2.5-3.2 mAs
30
Ankle stress views: Inversion/Eversion: | positioning and Central ray
Position - Center and align ankle joint to CR and to long axis of portion of IR being exposed. -Dorsiflex the foot as near the right angle to the lower leg as possible. -Stress is applied with leg and ankle in position for a true AP with no rotation, wherein the entire plantar surface is turned -medially for inversion -laterally for eversion * This is done by a physician or an orthopedic technologist CR - perpendicular to the IR and directed to the midpoint of the malleoli
31
Ankle stress views: Evaluation criteria
Anatomy Demonstrated and Position: -Ankle joint for evaluation of joint separation and ligament tear or rupture is shown. -Appearance of joint space may vary greatly depending on the severity of ligament damage (if there is a ligamental injury present there will be an opening of the joint space) - Collimation to the area of interest Exposure: - no motion as evident by the sharp bony margins and trabecular patterns - Optimal exposure should visualize soft tissue, lateral and medial malleoli, talus, and distal tibia and fibula
32
Oblique Knees: Clinical Indications
Fractures Bony lesions Degenerative changes
33
Oblique Knees: Technical Factors
SID: 40inches IR: 10X12inches; portrait; nongrid Technical Factors: 70kV; 5 mAs
34
Oblique Knees Medial (Internal) rotation: Position and Central Ray
Position - patient is supine with the leg completely outstretched. - the leg is internally rotated 45 degrees CR: -centred 1/2 inch below the apex of the patella -for patients with an ASIS to table measurement of: less than 19cm a 3-5 degree caudal angle is applied for 19cm-24cm there is no angle greater than 24cm a 3-5 degree cephalic angle
35
Oblique Lateral (external) rotation: Position and Central ray
positon: - patient is supine with leg outstretched - entire leg is externally rotated 45 degrees CR: -centred 1/2 inch below the apex of the patella -for patients with an ASIS to table measurement of: less than 19cm a 3-5 degree caudal angle is applied for 19cm-24cm there is no angle greater than 24cm a 3-5 degree cephalic angle
36
Oblique Knees Medial (internal) rotation: evaluation criteria
Anatomy Demonstrated: -Distal femur and proximal tibia and fibula with the patella superimposing the medial femoral condyle are shown. -Lateral condyles of the femur and tibia are well demonstrated, and the medial and lateral knee joint spaces appear unequal Position: - The proper amount of part obliquity demonstrates the proximal tibiofibular articulation open with the lateral condyles of the femur and tibia seen in profile. - The head and neck of the fibula are visualized without superimposition, and approximately half of the patella should be seen free of superimposition by the femur. The center of the collimated field is to the femorotibial (knee) joint space. Exposure: -Optimal exposure with no motion should visualize soft tissue in the knee joint area, and trabecular markings of all bones should appear clear and sharp. - Head and neck area of fibula should not appear overexposed
37
Oblique Knees Lateral (external rotation): Evaluation criteria
Anatomy Demonstrated: -Distal femur and proximal tibia and fibula, with the patella superimposing the lateral femoral condyle, are shown. -Medial condyles of the femur and tibia are demonstrated in profile Position: - The proper amount of part obliquity demonstrates the proximal fibula superimposed by the proximal tibia, the medial condyles of the femur, and the tibia seen in profile. - Approximately half of patella should be seen free of superimposition by the femur. - Femorotibial (knee) joint space is the center of the collimated field. Exposure: - Optimal exposure should visualize soft tissue in the knee joint area and trabecular markings of all bones should appear clear and sharp, indicating no motion. -Technique should be sufficient to demonstrate the head and neck area of the fibula through the superimposed tibia
38
Advanced Knee intercondylar fossa: Clinical Indications
- Loose/foreign bodies - joint ‘mice’ ( fragments of bone that "float around in the knee cavity) - Congenital slipped patella - Osteochondritis dissecans
39
intercondylar fossa: Technical factors
SID: 40inch IR: 8X10inch (unilateral) or 14X17 (bilateral); portrait; nongrid Exposure factors 70kV; 4-6 mAs
40
intercondylar fossa: Holmblad method (PA)
- patient kneeling -IR placed against anterior knee and shin -Knee flexed 20 – 30 degrees so the femur forms an angle of 60 – 70 degrees with IR -CR perpendicular to IR Centre to midpopliteal crease
41
intercondylar fossa: Camp coventry method (PA)
-Pt. in prone position -Femur in contact with the IR -Knee flexed 40 or 50 degrees with foot supported -CR perpendicular to long axis of tib/fib -40 or 50 caudad angle Centre at the knee joint (popiteal crease)
42
intercondylar fossa; rosenburg method (PA)
- weight-bearing - evaulates joint space narrowing and articular cartelidge diease - Bilateral standing with flexion - Pt. stands facing upright bucky - Flex knees so femurs are at an angle of 45 degrees with IR - Have pt. hold on to the bucky for support - center to 1/2 in below the patella, CR angled 10 degrees caudal
43
Intercondylar fossa: Béclere Method (AP)
- Pt. supine, place support under knee - Cassette placed in between support and knee - Knee flexed 40 – 45 degrees - CR perpendicular to lower leg (40– 45 degrees) - Centre 1.25 cm distal to apex of patella
44
Intercondylar Fossa: Evaluation Criteria
- Proximal surface of fossa in profile - ICF not superimposed by patella - Tibial plateau visable - Open knee joint - No rotation
45
Sternoclavicular (SC) joints: Clincal Indications
pathologies involving the SC joints, dislocations or fractures
46
PA SC joints: Technical factors
SID: 40inches IR: 8X10inches; landscape; nongrid Exposure Factors: 70kV; 12-16 mAs
47
PA SC joints positioning and central ray
Positioning Have patient face IR. Erect or recumbent with arms at sides CR Directed to level of jugular notch (T2/T3)
48
PA SC joints: evaluation criteria
- SC joints and medial ends of clavicles seen without rotation as demonstrated by equal distance of sternoclavicular joints from vertebral column on both sides -Lateral aspect of manubrium and medial portion o the clavicles visualized lateral to the vertebral column through superimposing ribs and lungs. - no motion
49
Oblique SC joints: positioning and central ray
Position Patient can be prone or erect (facing IR) -Rotate pt. 10 – 15 degrees *Note: both joints must be imaged for comparison -Exposure on held expiration CR Directed to level of T2/T3 and 3-5cm laterally on raised side *downside is imaged
50
Oblique SC joints: Evaluation criteria
Anatomy The manubrium, medial portion of clavicles and sternoclavicular joint are best demonstrated on the downside. The SC joint on the upside will be foreshortened. Position: - Correct patient rotation demonstrates the downside sternoclavicular joint visualized with no superimposition of the vertebral column or manubrium.
51
Oblique SC joints: tube shift method
Patient is prone -Angle tube 15 degrees towards spine -Centre at T2/T3 and 3 – 5 cm lateral to spine to exit opposite SC joint
52
Lumbar spine Flexion/extension: clinical indications
Recheck spinal fusion
53
Lumbar spine flexion/extension: technical factors
SID 40 inches IR: 14X17; portrait (landscape if significant flexion); grid Exposure factors: 90kV; 50 mAs
54
L spine flexion/extension positioning and CR
Positioning Flexion - Keep pelvis in same position and have pt. bend forward or move into fetal position Extension -Keep the pelvis in the same position and have pt. bend backward extending their head, shoulders and torso as much as possible CR perpendicular to IR (unless the pt. has a wide pelvis than a 5-8 degree caudal angle may be needed); directed to the iliac crest or fusion site if known
55
L spine flexion/extension: evaluation criteria
-no rotation is indicated by superimposed greater sciatic notches and posterior vertebral bodies. -Correctly marked as flexion or extension -Intervertebral foramina L1-L4, vertebral bodies, intervertebral joints, spinous processes, and L5-S1 junction
56
Lumbar spine Obliques: clinical indications
Defects of the pars interarticularis (e.g., spondylolysis) both sides imaged
57
L-spine obliques: technical factors
SID: 40inches IR: 14X17in ; portrait; grid Exposure factors 80kV; 20 mAs
58
L-spine Obliques: positioning and CR
positioning - pt. is recumbent or erect - breathing is suspended on expiration Posterior - Rotate the pt. 45 degrees - Both sides will be imaged - side down is visualized CR Centre at L3 (4 cm above crest) and 5 cm medial to raised ASIS ``` Anterior Obliques -Rotate the pt. 45 degrees -Both sides will be imaged -Upside is visualized CR Centre at L3 (4 cm above crest) and 5 cm Lateral to raised spinous process ```
59
L- spine Obliques: Evaluation criteria
Anatomy: -Visualization of zygapophyseal joints (RPO and LPO show downside; RAO and LAO show upside). Position: - Accurate 45° patient rotation as indicated by open zygapophyseal joints and the pedicle (eye of the Scottie dog) between the midline and lateral aspect of the vertebral border. - If the pedicle is demonstrated closer to the midline of the vertebral border and less of the pedicle is seen, this indicates over-rotation. If the pedicle is demonstrated laterally on the vertebral body border with more of the lamina (body of Scottie dog) demonstrated, this indicates under-rotation. Exposure: -no motion, clear bony margins and trabecular marking

RADT2000 (7 decks)

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