RAD POS 1: Hand, Finger, Thumb, Wrist

Bones of Hand pic

1. Fingers = phalanges (14); distal, middle, proximal (thumb only distal and proximal)

2. Bones between fingers + wrists = metacarpals (5)

3. Wrist = carpals (8)

Joint of hand + wrist

1. Distal interphalangeal joint (DIP) = between the distal and middle bones of the fingers (not thumb)

2. Proximal interphalangeal joint (PIP) = between the middle and proximal bones of the fingers (not thumb)

3. Interphalangeal joint joint (IP) = between the distal and proximal bones of the thumb (ONLY THUMB)

4. Metacarpophalangeal joint (MCP) = between the proximal and metacarpal bones (1-5 = all 5 fingers)

5. Carpometacarpal joint (CMC) = between metacarpals and carpal bones (1-5 = all 5 fingers)

Hand protocol views; Baystate + Textbook techniques (3+1 trauma views)

All tabletop TT SID of 40'“; use arrow to identify site of pain or injury on most relevant view

Technique for PA/OBL = Baystate 0.5-0.8 mAs @ 55-60 kVp; Handout 58-60 kVp

Technique for Lateral = 0.8-1 mAs @ 58-62 kVp

1. PA hand = CR 3rd MCP, marker on the lateral border along pinky, use arrow to indicate pain if relevant, wrist/forearm on the same plane

• Eval. Criteria = entire hand + carpals shown, CR at 3rd MCP, no rotation of phalanges/metacarpals, proper exposure factors

2. PA oblique 45 degrees = CR 3rd MCP, separate fingers and no curling of them

• Eval. Criteria = entire hand + carpals shown, CR at 3rd MCP, joints open, enough separation of phalanges/metacarpals, proper exposure factors

3. Fan lateral (straight lateral for trauma) =  CR at 2nd MCP, pt make “okay” sign then spread fingers (use sponge/tape if needed)

• Eval. Criteria = entire hand + metacrapals/carpals shown, CR at 2nd MCP, fingers separated + wrist no rotation, proper exposure factors 

4. Straight lateral (trauma only) = “karate chop” position fingers superimposed, CR at 2nd MCP

• Eval. Criteria = entire hand + carpals shown, CR at 2nd MCP, proper exposure factors

Baystate Finger Protocol (3 views)

All tabletop TT SID 40”; use arrow to identify site of pain or injury on most relevant view

Technique PA/OBL = 0.5-0.6 mAs @ 58 kVp

Technique Lateral = ADD

1. PA hand = to include all fingers

• CR = PIP

Eval. Criteria =  entire finger and minimum ⅓ of MCP demonstrated, CR at PIP joint, no rotation of phalanges, proper exposure factors

1. PA oblique (45 degrees) = of affected finger, digit parallel to IR

• CR = PIP of affected finger

Eval. Criteria = entire phalanx and MCP joint demonstrated, IP and MCP joints open, CR at PIP, proper exposure factors

1. Lateral (of affected finger) = digit parallel to IR, reduce OID when possible, use sponges if needed

• CR = PIP of affected finger

Eval. Criteria = Entire phalanx and MCP joint demonstrated, CR at PIP, true lateral position, digit parallel to IR, proper exposure factors

Baystate Thumb Protocol (3 + 1 trauma view) revise

All tabletop TT SID 40”; use arrow to identify site of pain or injury on most relevant view

Technique PA Hand (OBL thumb) = 0.5-0.8 mAs @ 58-60 kVp

Technique Lateral/AP = 0.5-0.6 mAs @ 58 kVp

1. Oblique

2. PA

3. AP

4. Lateral

Dislocation | Subluxation

1. Dislocation = displacement from joint

2. Subluxation = partial dislocation

Sprain | Contusion

1. Sprain = rupture or tearing of connective tissue 

2. Contusion = bruise, without fracture

Fracture types (4)

1. Simple = closed fracture

2. Compound = open fracture that breaks through skin

3. Comminuted = fracture where bone is splintered or crushed

4. Impacted = fracture where fragments driven into each other

Types of Hand Fractures (4)

1. Displaced = the bones break into two or more pieces and becomes misaligned; there is a separation between the two fracture faces or the faces are no longer lined up

2. Non-displaced = the bone cracks or breaks but doesn’t move and maintains its proper alignment and position; the two fracture surfaces have not moved relative to each other

3. Comminuted = the bone is broken in several pieces in different places

4. Open fracture = the bone breaks through the skin; closed is when the bone breaks but there is no puncture or wound

Barton’s fracture

Fracture and dislocation of the posterior lip of the distal radius involving the wrist joint

Bennett’s fracture

Fracture of the base of the first metacarpal bone, extending into the carpometacarpal joint, complicated by subluxation with some posterior displacement

Boxer fracture

fracture of the metacarpal neck, 5th metacarpal most common boxer fracture

Colles fracture

Transverse fracture of the distal radius in which the distal fragment is displaced posteriorly; an associated ulnar styloid fracture is seen in 50% to 60% of cases

Smiths fracture

Reverse of Colles fracture, or transverse fracture of the distal radius with the distal fragment displaced anteriorly

Greenstick fracture

Break on one side only; the cortex on one side of the bone is broken, and the other side is bent

Skier’s Thumb Injury

sprain or tear of the ulnar collateral ligament of the thumb; appears as  widening of inner MCP joint space of thumb and increase in degrees of angle of MCP line

1. Positioning considerations for upper limb (6)

1. 40 in SID (100cm) minimum

2. Gonadal shielding

3. Four sided collimation when possible

4. Long axis of part to long axis of IR

5. Side marker visible on lateral border

6. Use arrow to identify pain

2. Positioning considerations (6)

1. Make sure your patient’s upper limb is on the same place, elbow is at right angle if possible

2. Do not have hand and wrist at an angle

3. If splint if possible removed

4. Increase exposure factors for cast/splint

5. Separate fingers

6. Remove rings if possible

AP oblique bilateral hands “ball catchers” view

used when looking for rheumatoid arthritis (not routine at clinical)

Pediatric bone age (3)

1. Left hand and wrist 

2. For children with advanced or delayed growth

3. Radiologist will measure and estimate the maturity of a child's skeletal system

Wrist Protocol (4 views)

All tabletop TT 40” SID, 8×10 FOV; use arrow to indicate pain

Technique PA/OBL/ULDV = 0.8-1.2 mAs @ 60 kVp

Technique Lateral = 1-1.2 mAs @ 62 kVp

1. PA = CR midcarpal area, pt make loose fist to decrease OID, collimate appropriately (more rectangle then square), marker on lateral border along pinky side

• Eval. criteria = distal radius + ulna + carpals, CR at field of midcarpals, no rotation

2. Oblique 45 degrees = CR at midcarpal area, fingers straight but thumb down when needed (thumb kickstand to stabilize)

• Eval. criteria = distal radius + ulna + carpals + trapezium seen in entirety, CR at midcarpals

3. Lateral = CR to midcarpal area, hand/wrist in true lateral + SUPERIMPOSE radius/ulna (tilt further than u think)

• Eval. criteria = distal radius + ulna + carpals demonstrated; radius/ulna SUPERIMPOSED; CR at midcarpals; no rotation

4. Ulnar deviation (age 10+ only) = CR at scaphoid, deviate wrist toward ulna 20 degrees without moving forearm

• Eval. criteria = scaphoid elongated 

1. Special Projections for Scaphoid (2)

1. PA axial with ulnar deviation = textbook: 15-20 degrees towards elbow; Baystate: 20 degrees tube angle toward elbow CR to scaphoid

• Eval. criteria = scaphoid seen without superimposition and not foreshortened 

2. Modified stretcher method = sponge elevates hand 20 degrees with tube not angeled 

• Eval. criteria = scaphoid seen without imposition 

2. Special projection = Tangential (1) Carpal Canal

1. Carpal canal (tunnel) Inferosuperior Projection w/ Gaynor Hart Method = CR 1st inch distal to base of 3rd metacarpal 25-30 degrees to hand; hyperextend wrist while holding fingers back making the long axis of the metacarpals near vertical + rotate wrist 10 degrees toward radius

• Eval. criteria = carpal sulcus demonstrated, pisiform + hamate separated + scaphoid in profile  

2. Special projection = Tangential (2) Carpal Bridge

Carpal bridge = flex wrist CR 1 ½ inches proximal to wrist joint, angle CR 45 degrees

• Eval. criteria = demonstrates dorsal (posterior) aspect

Wrist bones (8) + their Synonyms

1. Some = Scaphoid (navicular)

2. Lovers = Lunate (semilunar)

3. Try = Triquetrum (triangular or cuneiform)

4. Positions = Pisiform (none/pea shaped)

5. That = Trapezium (greater multangular)

6. They = Trapezoid (lesser multangular)

7. Can’t = Capitate (Os magnum)

8. Handle = Hamate (unciform)

Interphalangeal (IP) joint

Ginglymus (hinge) joint; Flexion and extension motion

Metacarpophalangeal (MCP) joint

Ellipsoid (condylar) joint; Flexion and extension, abduction, adduction, and circumduction motion

Carpometacarpal (CMC) joint (2)

articulations between the bases of the metacarpals and the carpal bones

1. 1st finger (thumb) is a saddle (sellar) joint. Allows flexion, extension, adduction, abduction, opposition, and circumduction, and some rotation movement

2. 2nd to 5th finger (plane/gliding jt); allows sliding/gliding movement

Intercarpal joints

Plane (gliding) joint; Sliding/gliding motion

Wrist Carpal joint

Ellispoid (condylar); Flexion and extension, abduction and adduction, and circumduction movement

Proximal radioulnar joint

Pivot (trochoid); Rotational movement

Distal radioulnar joint

Formed at the head of ulnar notch on the lower extremity of radius

Pivot joint; rotation movement

Elbow joint (humeroulnar and humeroradial)

Ginglymus (hinge); Flexion and extension movement

Wrist movements (2)

• Ulnar deviation (scaphoid)

• Radial deviation (lunate, triquetrum, and hamate)

Wrist fat stripes (2)

1. Scaphoid fat stripe (seen on PA and oblique)

2. Pronator fat stripe (seen on lateral wrist)

Bone metastases

A transfer of disease or cancerous lesions from one organ or part to another; appears as dark holes or bright white patches

Bursitis

Inflammation of bursae or fluid-filled sacs that enclose the joint; process involves formation of calcification in associated tendons; appears as fluid-filled joint

Carpal tunnel syndrome

Common painful disorder of the wrist/hand from compression of the median nerve as it passes through the center of the wrist, most common in middle-aged women; appears as fluid-filled joint space with possible calcification

Joint effusion

refers to accumulated fluid (synovial or hemorrhagic) in the joint cavity, sign of an underlying condition like a fracture, dislocation, soft tissue damage, inflammation; appears as fluid-filled joint cavity

Osteoarthritis

aka degenerative joint disease (DJD), is a noninflammatory joint disease where this is a gradual deterioration of the articular cartilage with hypertrophic (enlarged/overgrow) bone formation; appears as a narrowing of the joint space with periosteal growth on joint margins

Osteomyelitis

is a local or generalized infection of bone/bone marrow that may be caused by bacteria from trauma or surgery; appears as soft tissue swelling and loss of fat pad detail visibility

Osteoporosis

the reduction in quantity of bone or atrophy or skeletal tissue, commonly from fracture of bone that may lead to obliteration of marrow space; appears most visibly in distal extremities and joints as a decrease in bone image receptor exposure, long bones demonstrating in thin cortex

Paget’s disease

common chronic skeletal disease characterized by bone destruction followed by reparative process of overproduction of dense but soft bones that tend to easily fracture; appears as missed areas of sclerotic and cortical thickening along with radiolucent lesions creating a “cotton wool” appearance

Rheumatoid arthritis

chronic systemic disease with inflammatory changes throughout the connective tissue, the earliest change is soft tissue swelling that is most prevalent around ulnar styloid of the wrist, 3x more common in women than in men; appears as closed joint spaces with subluxation of MCP

Bone neoplasia

tumors that are most often benign but can be malignant; appearance based on type

Malignant bone tumors (4)

cancerous tumors

1. Multiple myeloma = most common primary cancerous bone tumor, affects ages 40-70, tumors occur in various parts of the body arising from the bone marrow/marrow plasma cells (not exclusively bone tumors); highly malignant + fatal; appears as multiple “punched-out” osteolytic (loss of calcium in bone) lesions throughout affected bone

2. Osteogenic sarcoma = aka osteosarcoma, second most common type of primary cancerous bone tumor affecting ages 10-20 but can happen at any age, may lead to Paget disease; appears as a bone lesion and mass in the metaphysis

3. Edwing’s sarcoma = common primary malignant bone tumor in children/young adults that arises from bone marrow; appears as new bone formation that looks like an “onion peel” pattern

4. Chondrossarcoma = slow growing malignant tumor of the cartilage; appearance similar to other malignant tumors but dense calcifications often seen within cartilaginous 

Benign (2)

non cancerous bone tumors

1. Endochondroma = slow- growing benign cartilaginous tumor most often found in small bones of the hands and feet of adolescents and young adults; appears as  well defined radiolucent appearing tumors with a thin cortex

2. Osteochondroma = most common type of benign tumor. Most common at the knee but also appear on scapula and pelvis on young adults or children. Arises from outer cortex with the tumor growing parallel to the bone, point away from the adjacent joint.