1. hand and wrist (27 bones- phalanges 14-metacarpals 5- Carpals 8)

2. Forearm ( 2 bones raduis and ulna)

3. Arm (humerus)

4. Shoulder Griddle

phalanges (fingers and thumb) (digits)

Each finger called a digit

Each digit has 2 or 3 separate bones called a phalngs (singular phalanx)

Digits are numbered starting with the thumb as 1 little finger and 5

Each digit (2-5) compssed of 3 phalanges- proximal, middle and distal

Thumb or first digit has 2 phalanges- proximal and distal

Each Phalanx has 3 parts- rounded head, body(shaft) and extended base

Metacarpals

Make up the bones ofthe palm of hand

Consist of 5 metacarpals

numbered 1(thumb) through 5(little finger)

Rounded head which is distal, Body (shaft) and base extended proximal end

1 digit (thumb) two joints 

Interphalangeal or IP, joint between the first metacarpal and proximal phalanx

First Metacapophalangeal or MCP Joint - named for two bones that make up the joint starting with the proximal bone first.

Digits 2-4 consist of 3 joints

Distal interphalangeal or DIP joint-joint between distal and middle phalange 

Proximal interphalangeal or PIP joint-joint between middle and proximal phalange

Metacapophalangeal or MCP joint-joint between metacarpal and proximal phalange.

Carpometacarpal or CMC joint-joint between carpals and metacarpals

1 1st MC with Tripezium

2nd MC with Trapezoid

3rd MC with Capitate

4th and 5th MC with Hamate

Carpals

Proximal row

Scaphoid (navicular) lateral or thumb side, 1st carpal, boat shaped, largest of the proximal row, articulates with the proximal radius and Scaphoid proximally most frequently fracture carpal bone.

Lunate, 2nd carpal, moon shaped, does not directly articulate with the radius, disquished by the deep concavity on its distal surface towards the capitate, articulate with the scaphoid laterally, triquetrum medially and capitate/Trapezoid distally.

Triquetrum, 3 articulating surfaces, pyrmidal shape and articulates anteriorly with the pisiform, articulates with the lunate laterally and hamate distally.

Pisiform, smallest of the carpal bones located anteriorly to Triquetrum and most evident in the Carpal Sulcus view.  

Carpals

Distal Row

Articulates with Metacarpals

Trapezium - lateral or thumb side, four sided somewhat irregular shaped, located medial and distal to scaphoid and proximal to the first MC

Trapezoid - Wedge shaped, four sided, smallest bone in distal row, articulates with the 2nd MC distally, Trapezium laterally and Hamate Medially, articulates to the Scaphoid proximally.

Capitate - Largest of the carpal bones, articulates to the 3rd MC,  laterally to the Trapezoid, medially to the Hamate and proximal to the Triquetrum.

Hamate - distiguished by hook like process called the humulus (palmar Surface), articulates with the 4th and 5th MC and with the Capitate laterally.

View best demenstrates the Pisiform and humulus process.

Concave area or groove in which the median nerve nerve and tendons pass through

Forarm

Radius and Ulna

Radius on lateral or thumb side

Ulna on medial side

Considered to be long bones 

Styloid process on distal end towards the carpal bones

Articulate with the ulna at the proximal and distal radioulnar joints

Disc like Head and neck are located on the proximal end of the radius near elbow joint

Ulnar notch is located on radius

Radial tuberosity is located on anterior side

Has body (shaft)

Radius is the shortest of the 2 forarm bones

Longest of the 2 forearm bones

2 beaklike process of the proximal ulna are called the Olecranon and the coronoid process.

Olecranon process can be palpated easily on posterior side of elbow

Has radial notch on proximal end of ulna.

Ulnar is located medially in the anotomic position

Has large concave depression or notch called the Trochlear notch that articulates with the distal humerous

Head articulates with the distal end of the radius

body consisting of long center section

Humeral Condyle - Expanded distal end of the humerus which is divided into 2 parts: Trochlea and capitulum

Tochlea - shaped like a pully or spool, it has 2 rimlike outer margins and a smooth depressed center portion called a trochlear sulcus or groove. Articulates with the ulna and is less dense (radiolucent)

Capitulum - Little head, located lateral aspect and articulates with the head of the radius

The articular surface that makes up the rounded articular margin of the capitulum is just slighlty smaller than that of the trochlear.

Distal humerus

(continued)

Epicondyle

Fossa (depressions)

Lateral Epicondyle - small projection on the lateral aspect of the distal humerus above the capitulum.

Medial Epecondyle - is larger and more prominent than the lateral and is located on the medial edge of the distal humerus.

Coronoid Fossa/ Radial Fossa - shallow aterior depression, as the elbow is fully flexed, the coronoid process and the radial head are recieved by the reapective fossa.

Olecranon Fossa - located posteriorly on the dstal end of the humerus. The olecranon process of the ulna fits into this depression when the arm is fully extended.

A good criterion by which to evaluate a true lateral position:

90 degree flexion

3 concentric arcs:

Tochlear Sulcus first and smallest

Intermediate Arc appears double lined as the outer ridges or rounded edges of the capitulum and trochlear.

Trochlear nothch of the ulna appears as a third arc of a true elbow

* if the elbow is rotated even slightly froma a true lateral the arcs do not appear symmetrically aligned in this way and the elbow joint space is not open.

IP Joints - Ginglymus or hinge joints, joints with movement in 2 direction Flexion and extension.

MCP joints - Ellipsoidal (condyloid) joints that have movement in 4 directions, flexion, extension, abduction and adduction. Circumduction occurs in these joints which is a conelike sequentioal movement.

CMC joints -  Seller (saddle) joints, allows a great range of movement including flexion, abduction, adduction, circumduction, opposition and some degree of rotation.

Intercarpal Joints - Plane (gliding) joint

Wrist joint - ellipsoidal type joint and is the most freely movable or diarthrodial or the synovial classification.

Ulnar collateral ligament - Attached to the styloid process of the ulna and fans out to attach to the Triquetrum and the pisiform.

Radial collateral ligament - extends from the stlloid process of the radius primarily to the lateral side f the scaphoid, but it also has attchment to the Trapezim.

Ulnar deviation (apecial scaphoid projection) - movement toward the side of the ulnar. Opens up or best demenstrates the carpals on the opposite side (radial or lateral side) of the wrist namely the scaphoid, Trapezium and Trapizoid.

Radial deviation - a less PA wrist projection, movement towards the side of the radial, opens up or best demenstrates the the ulnar side of wrist namely the Hamate, pisiform, Triquetrum and Lunate.

Forearm generally should not be radiographed in a pronated position.

Forearm should be radiographed in an AP position with the hand supinated or palm up this prevents superimposition of the radius and the ulna.

Elbow rotational movement

Appearance of the proximal radius and ulna changes as the elbow and distal humerus are rotated or obliqued either medially or laterally

Lateral rotation sepaerates the radius and ulna

Medial rotation superimposes the radius and ulna.

Scaphoid fat pad - elogated and slighlty convex in shape and is located between the radial collateral ligament and adjoining muscle tendons immediately lateral to the scaphoid, visualized on a PA and oblique view, Absense or displacement of the fat pad may be the only indicator of a fracture on the radial aspect of the wrist.

Pronate Fat Pad - visualized on lateral view of the wrist, approximately 1cm from the anterior surface of the radius, subtle fracture of the distal radius can be indicated by displacement or obliteration of the plane of this fat pad.

Elbow Fat Pads

3 significant fat pads

Visualized only on the true lateral prosition, not seen on the AP because of being superimposed over bony structure.

Anterior Fat Pad - formed by the superimposed coronoid and radial pads, is seen as a slighly radiolucent teardrop shape located just anterior to the distal humerus. Trauma or ifection causes fat pad to be be more elevated and more visiable and distorted in shape.

Posterior Fat Pad - located deep within the olecranon fossa and normally is not visiable on a negative elbow exam. Visualization on a 90 degree flexed elbow, visualiztion is considered more reliable that the anterior fat pad

Supinator Fat Pad - long thin stripe just anterior to the proximal radius of the forearm, diagnosis of nonobvious radial head or neck fracture.

Patient seated sidways at the end of the table

reduces amount of radiation recieved by patient.

All patients should have gonadal shielding

Lead apron can be used to be drapped over the patients lap or gonadal area.

Can be radiographed on the table or directly on the strecher.

Radiographs are taken 90 degrees from each other.

Motion plays and important role pediatric radiography

Immobilition is needed tin many case to assist children in maintaining proper position.

Sponges, tape are useful but saddle bags should be used with caution because of there weight.

Paerent can be asked to help hold child. Lead apron must be provided.

Technologist should speak to the child in a soothing manner in language the child can readily understand to ensure maximum cooperation.

use clear complete instruction

Have greater dificulty in holding strenuous positions, ensure adequate immobilization is used to prevent movement.

Uncontrollable movement such as Parken's Disease may cause movement.

Exposure technique may have t be reduced because of certain destructive pathologies such as osteoporosis.

Lower to medium kV (50 to 70)

Short exposer time

Small Focal spot

Adeqiate mAs for suffient density.

Increase Factors with Cast:

small to medium plater cast - increase mAs 50%-60% or +5-7kV

Large plaster cast - increase mAs 100% or +8-10 kV

Fiberglass cast - increase mAs 25%-30% or +3-4 kV

Collimation borders should be visiable on all 4 sides

Always place the long axis of the part being imaged parallel to the long axis of that portion of the IR being exposed.

Use appropriate side markers within collimation borders.

Pathologic Indications

Bone Metastases - Transfer of disease or cancerous lesions from one organ or part that may not be directly connected.

Bursitis - inflamation of the bursea or fluid-filled sacs that enclose the joints.

Carpal tunnel syndrome - Common painful disorder of the wrist and hand that results from compression of the median nerve.

Fracture - Break in structure of bone caused by a force (direct or indirect)

Barton's Frcture - Fracture and dislocation of the posterior lip of the distal radius involving the wrist joint.

Bennett's Fracture - Transverse fracture of the base of the first Metacarpal bone, extenting into the CMC joint.

Boxer's Fracture - Tranverse fracture that extends through the metacarpal neck; most commonly seen in the fifth metacarpal.

Colles' Fracture - transverse fracture of the distal radius in which distal fragment is displaced posteriorly.

Smith's Fracture - Transverse fracture of the distal radius in which the distal fragment is dispaced anteriorly.

Osteomyelitis - Lacal or general infection of boane  or bone marrow that may be cause by bacteria

Osteoporosis - Reduction in the quantity of bone or atrophy of skeletal tissue

Paget's Disease - destructive bone disease

Pathology continued

Rheumatoid athritis - Closed joint space with subluxation of the MCP. early bone erosion occurs first at the 1st and 2n and 3rd MCP

Skier's Thumb - caused fram falling and forcing thumb backward toward arm

Multiple Myeloma - Primary cancerous bone tumors.

Osteogenic Sarcoma (asteosarcoma) - 2nd most comon type of bone cancer effect patients in there 10 to 20 years.

Ewing's Sarcoma - Milinat bone tumor in children.

Basic and special projections

Fingers

Basic PA

Demonstrated - Fractures or dislocation, osteoporosis, and asteoarthritis may be demonstrated.

Technical factors - 8x10 IR, 50 to 60 kV range, 2 mAs,

CR - CR perpindicular to IR, Directed at PIP, Minimum 40" SID

Collimation - all four sides to area of affected finger

Structure Shown - Distal,  Middle and proximal phalanges, distal metacarpal and associated joints.

position - Loang axis of finger should be aligned with and parallel to side border of IR, No roatation of fingers is evident by symmetric appearance of both sides or concavities of the shft of the phalanges and distal metacarpals. Amount of tissue on each side should appear equal. Fingers should be seperate with nooverlapping of soft tissue. Interphalangeal joints should appear open.

Basic and special projections

Fingers

PA Oblique

Demonstrated - Fractures or dislocation, osteoporosis, and asteoarthritis may be demonstrated.

Technical factors - 8x10 IR, 50 to 60 kV range, 2 mAs,

CR - CR perpindicular to IR, Directed at PIP, Minimum 40" SID

Patient position, place hand with finger extended against 45 oblique foam wedge, place hand on cassette so the position of the fingers are parellel to IR or long axis of IR.

Collimation - all four sides to area of affected finger

Structure shown - IPa nd MCP joint spaces should be ipen, indicating correct CR location and phalanges are parellel to IR, Long axis of finger should be aligned with border of IR, View of finger should be at a 45 degree oblique, No superimposition of adjacent fingers.

Basic and special projections

Fingers

Lateral, lateromedial or mediolateral

Demonstrated - Fractures or dislocation, osteoporosis, and asteoarthritis may be demonstrated.

Technical factors - 8x10 IR, 50 to 60 kV range, 2 mAs,

CR - CR perpindicular to IR, Directed at PIP, Minimum 40" SID

Part Position - Place hand in lateral position (thumb up) with finger to be fully extended and centered to portion of IR being exposed, Align and center finger to long axis of portion of IR and to CR, Use sponge block or other radiolucent device to support finger and prevent motion. Flex unaffected fingers, Ensure long axis of finger is parellel to IR.

Structures Shown - Later views of the distal, middle , and proximal phalanges, distal MC, and associated joints

Position - IP and MCP joint spaces should be open, true lateral position as indicated by the concave appearance ofthe anterior surface of the shaft of the phalanges.

AP Projection of thumb

Demenstrated - Fractures and or dislocations, osteoporosis and asteoarthritis may be demenstrated. * see special AP modified Robert's projection for bennet's fracture

Tecnical factors - 8x10 IR, 50 to 70 kV, mAs 3, 40" SID

Part postion - Interally rotate hand with fingers extended until posterior surface of thumb is in contact with IR ( may have to hold fingers back with other hand), Center first MCP joint to CR and to center of portion of IR being exposed.

Exception PA only if patient cannot position for AP - place near lateral pasition and rest thumb on support block, ensure thumb is not rotated

CR - perpendicular to IR, to first MCP joint

Structure Shown - Distal and proximal phalanges, first MC, Trapezium, IP and MCP joints should be open.

PA oblique projection - medial rotation

Thumb

Demonstrate - Fractures and dislocations, osteoporosis and osteoarthritis

Technical Factors - 8x10 IR, 50 to 60 kV, 3 mAs, minimum 40" SID

Part postion: Abduct thumb slighlty with palmar surface on hand in contact with cassette, align long axis of thumb with long axis of third of IR, Center first MCP Joint to CR and to center portion of IR being Exposed.

CR - CR perpindicular to IR, directed to 1st MCP joint

Collimation - all 4 sides to thumb ensuring that all of 1st MC is included

Structures Shown - Distal and proximal phalanges, 1st MC, Trapezium and associated joints, IP and MCP joints should appear open if the phalanges are parallel to the IR