Lecture 2: Image Critique Upper Extremity Flashcards by Josie Curley

T/F

There is more soft tissue and concavity on anterior surface of the finger

True

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What should be seen on an image of a PA finger?

-Equal soft tissue
-Midpoint concavity the same on both sides of phalanges
-Open joint spaces

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What errors have been made in this image of the PA finger?

Lateral side of the digit is obliqued with the thumb away from the IR

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What digit is this?

Right index

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What errors have been made in this image of the PA finger?

No joint space visible, right index finger is flexed

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T/F

There is better joint space visibility when doing an AP projection for unextendable digits

True

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What should be seen on an image of a lateral finger?

-Open interphalangeal joints
-Superimposed heads of proximal and middle phalanges
-Fingernail in profile
-No overlap of adjacent digits

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What errors have been made in this image of the lateral finger?

-Finger is not parallel to the IR (tip down too low)
-Marker overtop of the finger

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What error(s) have been made in this image of the lateral finger? How can this be corrected?

-Fingers are not out of the way
-External rotation needed to align the 2nd metacarpal over the 4th

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Is this image repeatable?

No; because fracture is visualized

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T/F

The second metacarpal is the longest

True

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What corrections should be made to this image of the lateral finger?

More internal rotation needed

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What should be seen on an image of the PA thumb?

-Equal soft tissue
-Midpoint concavity the same on both sides of phalanges
-Open joint spaces
-Long axis of thumb in line with central ray
-Include trapezium

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What error(s) have been made? What could be done to correct this?

Slightly obliqued; externally rotate the wrist to fix

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What error(s) have been made? How could this be corrected?

-Distal joint space is not open
-Flatten thumb against IR to fix

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How can you visualize all four joints spaces of the trapezium?

By raising the elbow

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What projection is this?

AP thumb

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What should been seen in an image of the lateral thumb?

-Open interphalangeal joints
-Superimposed heads of proximal phalanx
-Fingernail in profile
-Include trapezium
-Abduct thumb

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What correction(s) if any, need to be made to this image of the lateal thumb?

-Internal rotation of the thumb needed

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What correction(s) if any, need to be made?

Thumb needs to be abducted slightly because the soft tissue is superimposed

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What should be seen on an image of the PA hand?

-No rotation
-Equal distance between MCP heads
-Thumb is in a PA oblique position
-5th phalanges lined up with metacarpal
-Open MCP and IP joint spaces

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What error(s) have been made to this image of the PA hand?

-Hand externally rotated

-Looks like oblique due to the metacarpal spaces getting closer together and concavity of the phalanges seen

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What error(s) have been made in this image of the PA hand?

-Hand is not flat (fingers flexed)
-Hand slightly obliqued

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What error(s) have been made in this image of the PA hand?

-5th phalange not in line with the 5th metacarpal (over abducted)
-Joint space closed on digits due to beam divergence from over abducted digits

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What should be seen in an image of the PA Oblique hand?

-Open MCP and IP joint spaces -Overlap of MC heads 3-5 -No overlap between 2nd and 3rd MC heads -Slight space between 4th and 5th metacarpal at the midshaft

What error(s) have been made in this image of the PA oblique hand?

-Poor centering; too much on wrist and cutting off middle tip of finger ## Footnote lol that's the amount in practice that they want on the wrist

What will be visualized if the hand is underobliqued in a PA oblique?

Space bigger between the metacarpal heads, and larger spaces between the metacarpal shaft

What could have been done to better visualize the joint spaces?

Fingers need to be more extended to visualize the joint spaces

What corrections need to be made to this PA oblique?

-Fingers need to be more extended to visualize joint space | (good oblique)

What error(s) have been made in this image of the PA oblique?

Over obliqued (too externally rotated)

What should be seen in an image of the fan lateral?

-2nd – 5th metacarpals superimposed -IP joints are open -2nd – 5th digits are separated

Wht error(s) have been made in this image of the fan lateral?

None

What error(s) have been made in this image of the fan lateral? What could be done to correct this?

-Not in a good lateral -Metacarpals are not superimposed; needs more external rotation

Where should the styloid processes be in a PA wrist image?

Styloid processes are at the extreme edges

What joint spaces need to be open in a PA wrist?

-Scapholunate joint -Radioulnar joint -CMC joints

Where should the pisiform be in relation to the triquetrum on in a PA wrist

Pisiform is positioned outside of ulnar border of the triquetrum

How can you visualize the radiocarpal joint space?

11 degree angle cephalad

What border is the red and yellow line on the radius?

Red: Anterior margin Yellow: Posterior margin

What oblique of the wrist best demonstrates the pisiform?

AP Oblique

What oblique is the best to to demonstrate the scaphoid?

PA oblique

What error(s) have been made in this image of the PA wrist?

-Wrist is obliqued (thumb is off the IR)

How could CMC joint space be better visualized?

Flatten the wrist

What carpal bone is visualized?

Trapezium

What radiographic sign is visable with radial deviation in the wrist?

Signet ring sign

# What is present? Radial deviation OR Ulnar deviation?

Radial deviation

# T/F In a PA wrist, having the proximal forearm higher than distal forearm will cause excessive foreshortening of the scaphoid

True

# T/F Ulnar deviation will cause excessive forshortening of the scaphoid.

False; radial deviation will cause excesive forshortening of the scaphoid

What happens with wrist extension to the scaphoid and CMC joints in a PA wrist?

-Less foreshortening of the scaphoid -CMC joint spaces closed

How should the pisiform and scaphoid be aligned in a lateral wrist?

Anterior part of distal scaphoid is nearly aligned with anterior part of pisiform

# T/F In a lateral wrist, the radius and ulnar should be superimposed.

True

Label the blue, purple and red lines

Red: Trapezium Purple: Scaphoid Blue: Pisiform

If you are doing lateral wrist, what do hit first; scaphoid or pisiform?

Scaphoid

How much of the radial tuberosity should be overlaped on the ulna in an AP elbow?

50% of the radial tuberosity should be overlapping on the ulna

How much should the radial head be overlapped over the ulna in an AP elbow?

0.25” (0.6 cm) overlap of radial head on ulna

What joint space should be open in an AP elbow?

Capitulum-radial joint space is open

# T/F In an AP elbow the radius and ulna should be parallel

True

What error(s) have been made in this image of the AP elbow?

Too much overlap (thumb has come off the IR)

What error(s) have been made in this image of the AP elbow?

Elbow too externally rotated

What projection is this?

Partial flexion elbow with forearm off IR

How should you image a child for a partial flexion elbow view?

Humorous parallel to the IR

How should you image an adult for a partial flexion elbow view?

Forearm parellel to the IR

What is the best way to demonstrate the radial head fracture?

AP External Oblique

What joint spaces need to be open for a AP External Oblique?

-Capitulum-radial joint space -Radio-ulnar joint space

# T/F The radial head, neck, and radial tuberosity should be superimposed on the ulna in an AP External Oblique.

False; No overlap of radial head, neck, or radial tuberosity on ulna

What error(s) have been made in this image of the AP External oblique elbow? How could this be corrected?

-Radial head joint space not open -Place forearm flat on the IR

What error(s) have been made in this image of the AP external oblique elbow?

Too externally rotated

What error(s) have been made in this image of the AP external oblique elbow?

-Not rotated enough -Radioulnar joint space is not open

How much of the radial head should be superimposed on the ulna in an AP internal oblique?

¾ of the radial head is superimposed on ulna (min 75% of superimposition)

What position best demonstrates the coronoid process?

AP internal oblique

# T/F The trochlear notch is visible in an AP internal oblique of the elbow.

True

What error(s) have been made in this image of the AP internal oblique elbow?

-Not enough internal rotation

What error(s) have been made in this image of the AP internal oblique elbow?

None :) ## Footnote yippie.

What structures should be aligned/superimposed in a lateral elbow?

-Capitulum and trochlea superimposed -Articulating surfaces of radial head and coronoid process are aligned

What occurs to the fat pads if there is excessive flexion in a lateral elbow projection?

The SAIL sign/anterior fat pad is pushed back

What structure is seen first in a lateral elbow?

The radius

What corrective measures should be made to correct the mistakes made in this image?

Raise the hand, slight more flexion

How can you tell the difference between the medial and the lateral condyles of the elbow?

Medial side: Smooth continuous bump Lateral side: Jutts in to form an abrupt angle

What corrective measure should be made in this image?

-Raise the elbow up/shoulder down

Label the red and the yellow lines:

Yellow: Medial Red: Lateral

What corrective measure should be made for the lateral elbow?

-Raise the hand and raise the elbow up

What corrective measures should be made for this image?

-Hand down -Elbow up -Flex elbow more -Center on the condyles

What is the corrective measure for this image?

Raise the hand, lower the elbow ## Footnote Note the posterior fat pad, sail sign

What position should be done first in a shoulder series?

External rotation | (includes all of scapula and clavicle)

Where is the greater tuberosity and the humeral epicondyles in an external rotation shoulder?

-GT in profile on the lateral side -Humeral epicondyles are parallel to IR

Where is the lesser tuberosity and the humeral epicondyles located in an internal rotation shoulder?

-Lesser tuberosity in profile medially -Humeral epicondyles are perpendicular to IR

Where is the Greater tuberosities located in a neutral shoulder projection? Where are the humeral epicondyles?

-Anterior on the humeral head -Humeral epicondyles at a 45 degree oblique

How can you image the subacromial space in the shoulder?

By using a caudad angle

What projection of the shoulder is this?

-External rotation ## Footnote -Grade 3 AC separation, broken ribs, scapula

What projection is this?

Internal rotation shoulder

What projection is this?

Neutral rotation

In a glenoid projection, what should be superimposing the humeral head and by how much?

Coracoid process superimposes humeral head by 0.25” or 0.6 cm

What corrections need to be made to this image of the glenoid?

-Need to be obliqued more (ribs need to be closer to the joint space)

What correction needs to be made to this image of the glenoid?

Patient needs to be obliqued more

What space needs to be open in a lateral Y scap?

Subacromial space

Where should the humeral head be in a lateral Y scap?

In the middle of the Y

What error(s) have been made to this image of the Y scap?

Patient was obliqued too far

If an angle was need for a Y scap, and the patient was PA, what angle would you use, caudad or cephalad?

Caudad

What correction needs to be made for this image?

Patient needs to be obliqued more

Where should the lesser tuberosity be seen in axillary projection of the shoulder?

Lesser tuberosity in profile anteriorly

What is the best projection to confirm shoulder dislocations?

Axillary projection of the shoulder

Where should the coracoid process and the glenoid cavity be in relation to one another in an axillary projection?

Glenoid cavity lines up with lateral border of coracoid process

What should the angle between central ray and the side of the body be for an infrosuperior axial shoulder?

Angle between central ray and the side of the body: 30-35 degrees

In an infrosuperior axial view, what structure do we hit first?

The glenoid

What error(s) have been made in this image?

Angle between the body and central ray is too small

What corrections need to be made to this image of the AP glenoid?

-Patient needs to be more obliqued -Axillary view needed