Upper Extremity Imaging

1
Upper Extremity Imaging

• Critical Thinking Activity

2
Case Study

• A patient with tennis elbow is scheduled for a
  routine elbow series.
• The patient is a 22 y/o male who has normal arm
  mobility
• Patient walks into the Medical Imaging Department
  at 200pm

3
Physicians Order

• Elbow routine series
• Routine projections are.
• History
• Patient complains of pain in the right elbow x10
  days
• R/O
• Fracture
• Tendonitis

4
Elbow Projections

• Select the projection you would complete now?
• AP Elbow
• Medial Oblique Elbow
• Lateral Oblique Elbow
• Lateral Elbow

5
AP Elbow

• What is your
• Image receptor choice?
• Arm position?
• CR entrance point?

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AP Elbow
7
You produced the following image.

• Anatomy included
• Centering
• IR (type, size, orientation)
• Collimation
• Rotation - 0º
• Arm Extension
• Correct labeling
• Exposure factors Next Position

8
AP Elbow Evaluation

• Anatomy distal humerus and proximal radius and
  ulna
• Centered well elbow joint
• 8x10 LW Extremity IR used
• Collimation to include the soft tissue
• Back to image

9
AP Elbow Evaluation

• Rotation - 0º
• Too much superimposition of the radius and ulna
• Olecranon process not symmetrical or rotated
  cobra
• This indicates
• Medial rotation
• Lateral rotation
• Back to image

10
Medial Rotation is correct
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Medial Rotation is correct

• How would you correct your positioning error?
• Rotate the arm laterally or toward the AP
  position until the epicondyles are parallel to
  the IR

Back to image
12
Do you think Lateral Rotation is the correct
answer? Yes or No
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AP Elbow Evaluation

• Lateral rotation is not the correct answer go
  back!
• Back to rotation

14
AP Elbow Evaluation

• Arm Extension
• Arm fully extended olecranon process in the
  olecranon fossa
• Labeling
• Marker missing add R marker
• Exposure factors
• Correct soft tissue and boney trabecular
  markings are visualized
• Back to image
• Next Position

15
Medial Oblique Elbow

• What is your
• Image receptor choice?
• Arm position?
• CR entrance point?

16
Medial Oblique Elbow
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You produce the following image

• Anatomy included
• Centering
• IR (type, size, orientation)
• Collimation
• Rotation - 45º
• Arm Extension
• Correct labeling
• Exposure factors
• Next Position

18
Medical Oblique Elbow Evaluation

• Anatomy distal humerus and proximal radius and
  ulna
• Centered well elbow joint
• 8x10 LW Extremity IR used
• Collimation to include the soft tissue
• Back to image

19
Medial Oblique Elbow Evaluation

• Rotation 45
• Too much superimposition of radius and ulna
• Radial head super imposes the coronoid process
• This indicates
• Excessive medial rotation
• Insufficient medial rotation

20
Excessive Medial Rotation is correct
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Excessive Medial Rotation is correct

• How would you correct your positioning error?
• Rotate the arm laterally or toward the AP
  position until the epicondyles are 45 to the IR
• Back to image

22
Do you think Insufficient Medial Rotation is
correct? Yes or No
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Medical Oblique Elbow Evaluation

• Insufficient medial rotation is not the correct
  answer go back to the original image.
• Back to rotation

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Medial Oblique Elbow Evaluation

• Arm Extension
• Arm fully extended olecranon process in the
  olecranon fossa
• Labeling
• Marker missing add R marker
• Exposure factors
• Correct soft tissue and boney trabecular
  markings are visualized
• Back to image
• Next Position

25
Lateral Oblique Elbow

• What is your
• Image receptor choice?
• Arm position?
• CR entrance point?

26
Lateral Oblique Elbow
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You produce the following image

• Anatomy included
• Centering
• IR (type, size, orientation)
• Collimation
• Rotation - 45º
• Arm Extension
• Correct labeling
• Exposure factors
• Next Position

28
Lateral Oblique Elbow Evaluation

• Anatomy distal humerus and proximal radius and
  ulna
• Centered well elbow joint
• 8x10 LW Extremity IR used
• Collimation to include the soft tissue could be
  opened superiorly and inferiorly
• Back to image

29
Lateral Oblique Elbow Evaluation

• Rotation 45
• The radius and ulna are not separated enough so
  the Radial head, neck, and tuberosity are not
  clearly seen
• This indicates
• Excessive lateral rotation
• Insufficient lateral rotation

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Do you think . . . Excessive Lateral Rotation is
the correct answer? Yes or No
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Lateral Oblique Elbow Evaluation

• Excessive lateral rotation is not the correct
  answer, go back!
• Back to rotation

32
Insufficient Lateral Rotation is correct
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Insufficient Lateral Rotation is correct

• How would you correct your positioning error?
• Rotate the arm laterally until the epicondyles
  are 45 to the IR
• Back to image

34
Lateral Oblique Elbow Evaluation

• Arm Extension
• Arm fully extended olecranon process in the
  olecranon fossa
• Labeling
• Marker missing add R marker
• Exposure factors
• Correct soft tissue and boney trabecular
  markings are visualized
• Back to image
• Next Position

35
Lateral Elbow

• What is your
• Image receptor choice?
• Arm position?
• CR entrance point?

36
Lateral Elbow
37
You produce the following image

• Anatomy included
• Centering
• IR (type, size, orientation)
• Collimation
• Total Extremity Position
• 90º flexion
• Correct labeling
• Exposure factors
• Next Position

38
Lateral Elbow Evaluation

• Anatomy distal humerus and proximal radius and
  ulna
• Centered well elbow joint
• 8x10 LW Extremity IR used
• Collimation to include the soft tissue
• Back to image

39
Lateral Elbow Evaluation

• Total Extremity Position
• The 3 concentric arcs are not superimposed
• The trochlear notch is closed inferiorly
• This indicates
• Humerus elevation
• Forearm elevation

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Humerus Elevation is correct
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Humerus Elevation is correct

• How would you correct your positioning error?
• Lower the shoulder or raise the arm until both
  humerus and forearm are in the same plane of
  reference
• (parallel to the IR)
• Back to image

42
Do you think Forearm Elevation is the correct
answer? Yes or No
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Lateral Elbow Evaluation

• Forearm elevation is not the correct answer go
  back!
• Total extremity positioning

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Lateral Elbow Evaluation

• 90º flexion
• Arm flexed 90º olecranon process seen in profile
  without superimposition
• Labeling
• Marker missing add R marker
• Exposure factors
• Correct soft tissue and boney trabecular
  markings are visualized
• Back to image
• Next Position

45
Congratulations

• You have just completed another procedure
• getting the patient
• Producing images
• to taking your completed images to the
  radiologist for interpretation!!