Imaging Modalities: Upper Extremities

bone/joint, dental, procedures, available, low, soft tissue, two, radiation, pregnancy

X-Rays: Indications, Benefits, Limitations, and Contraindications

-Indications:

• _____/_____ pain or injuries, lung/digestive/_____ issues, screenings, guiding medical ____________

-Benefits:

• Quick, readily __________, small radiation dose, and ___ cost

-Limitations:

• Does not reveal ____ ______ abnormalities (directly), ___ dimensional only, and _________ exposure

-Consider Risks vs Benefit:

• ______________ → avoid abdomen/pelvis

• Children

Radiolucent

a substance/area that allows x-rays or other radiation to pass through relatively easily, appearing dark or black on the resulting image

Radiopaque

a material’s ability to block or absorb radiation, particularly X-rays, making it appear white or bright on imaging

side, osteoarthritis, joint, 2-4, above, below, individual, alignment, swelling

Ordering and Reading X-Rays

-Ordering:

• Note which _____ you are interested in → left, right, or both. Imaging both sides for comparison is good in kids or for evaluation of ___________.

• Note if you want images of the ____ or long bone

• Number of views → _-_ views typically

• Consider joint _____ and/or ______ depending on findings

-Reading:

• Check each __________ bone → look for fractures, bony lesions, or tumors

• Assess _____________ of joints

• Look for soft tissue ___________

location, alignment, articulation, closed

Descriptive Terminology for Fractures

-__________ → what bone, which side

-Plane → transverse, oblique, spiral, vertical

-_______________ → displaced or non-displaced

-Angulation

-Comminution

-_____________ → intraarticular or extraarticular

-Open vs ______

Transverse

What is the plane of this fracture?

Oblique

What is the plane of this fracture?

Spiral

What plane is this fracture in?

Vertical

What plane is this fracture in?

-This type of fracture is really only seen in the patella

Non-displaced

Describe the alignment of this fracture

Displaced (dorsal)

Describe the alignment of this fracture

dorsal, volar

When describing a displaced fracture, you should state whether the distal piece is displaced towards the back of the hand (________) or the palm (_______)

No angulation

What angulation can be seen here?

Dorsal angulation

What angulation can be seen here?

Comminuted

Would you describe this fracture as comminuted or segmental?

Segmental

Would this fracture be described as comminuted or segmental?

joint, cartilage

Intra-Articular Fractures

-When the fracture enters the _____ space

-Can do damage to the articular _______ and cause downstream issues

Open

When there is an open wound over a fracture, the fracture is also described as _____.

quick, 3D, tumors, radiation, cost, kidney function, detail, surgical, complex, head, trauma, masses

CT Scans: Benefits, Limitations, and Indications

-Benefits:

• _____, gives complete circumference of bone, __ images help with surgical planning of complex fractures, and good for evaluation of ____

-Limitations:

• __________ exposure (more than x-ray), ____ ($1,000-2,000), contrast agents can lead to ________ _________ issues, and availability

-Indications:

• Evaluate for fracture → gives more ______ of the fracture and helps with _______ planning if needed

• Evaluate more _______ fractures → tibial plateau, calcaneal, spine, scaphoid, pelvis/acetabular, and comminuted

• Imaging modality of choice for ____/spine/abdominal/chest ______

• Evaluates _______/bony lesions

axial, coronal, sagittal, white, gray, black

Interpreting a CT

-Know your anatomy

-Identify the plane:

• ____ → looking through the body from the inferior aspect to the superior (horizontal slice)

• _______ → looking across the body from front to back

• _________ → looking across the body from right to left or left to right

-Shades of white, gray, and black

• Dense structures (bone) = _____

• Fat/fluid = varying levels of ____

• Air = _____

T1

What type of MRI is best for seeing occult fractures? It highlights fat (white) and fluid (dark)

T2

What type of MRI is better for identifying tears? It highlights water/fluid (white) and fat (intermediate)

soft, marrow, radiation, metal, claustrophobia, soft tissue, occult, failed, compression

MRI: Benefits, Limitations, and Indications

-Benefits:

• Best modality for ____ tissue, excellent for bone _______ changes/occult fracture, and no __________ exposure

-Limitations:

• Cost/insurance approval, not as widely available, time consuming (30-60+ minutes)

• Safety concerns → ____ objects in the body or room, pt ____________

-Indications:

• Positive exam findings after an acute injury concerning for ____ ______ injuries, evaluate for stress/_______ fractures, when conservative treatment has ________ and surgery is being considered, assessing for nerve ____________, and suspect osteomyelitis

Bone bruising

What does this show?

-Hint: a classic sign of ACL tear

injections, tendon, no, low, penetrate, destruction, metastasis, non-specific

Ultrasound and Bone Scans

-Ultrasound

• Common uses → needle guided ____________, evaluate vascular flow, ______ injuries, synovitis/bursitis

• Benefits → __ radiation, portable, dynamic (can have them move)

• Negatives → ___ image quality, operator dependent, doesn’t _________ bone

-Bone Scan

• Indications → bone healing/fracture follow up, bone _____________, and evaluate for bone _________

• Limitations → ___-________ cause, time consuming

AP, axillary, scapular Y, Grashey

What 4 views can you order for a shoulder?

-__, _________, __________ _, _________

AP

What view is this?

Axillary

What view is this?

humeral, middle

Scapular Y View

-__________ head should sit in the _______ of the Y

-Shows the profile of the acromion, as well as dislocations

GH, internal, external

Grashey View

-Not part of the standard shoulder films, more of an ortho thing

-Called the “true AP” view

-Provides a better view of the __ joint

-Can be taken with the humerus in ________ or _________ rotation

Glenohumeral Osteoarthritis

What can be seen on this image?

Rotator cuff (RTC)

Having an elevated humeral head can be indicative of an injury to what group of muscles?

Proximal humerus

This image shows a __________ _________ fracture

Greater tuberosity

What part of the humerus is fractured here? This type of fracture can result in issues with the rotator cuff muscles

Glenoid

Where is the fracture?

2, thirds

Clavicle Fractures

-Image with _ views

-Divided into ______ → distal, midshaft, and proximal

-MC in kids and young adults

-MOI → FOOSH or direct blow

Anterior

What type of shoulder dislocation can be seen here?

Hillsach’s

What kind of deformity can be seen here?

Bony Bankart

What type of lesion can be seen here?

Posterior

What type of shoulder dislocation can be seen here?

AC joint separation

What abnormality can be seen on this imaging?

AP, middle, capitellum, middle

Interpreting Elbow X-Rays

-Order __ and lateral films

-Anterior Humeral Line → should pass through the ______ of the _________

• If it doesn’t, then there is a supracondylar fracture present

-Radio-capitellar line → should pass through the ______ of the capitellum

Supracondylar

What type of humerus fracture am I describing?

-Fracture of distal humerus just above the epicondyles

-Check nerve function during examination → radial, ulnar, and median nerves can be damaged

Olecranon fracture

What can be seen here?

Radial head fracture (intraarticular)

Describe the fracture

head, humerus

Fat Pad Sign

-Anterior → “Sail sign”, usually indicates a radial ____ or distal __________ fracture

-Posterior

AP, lateral, wrist, elbow

Forearm X-Rays

-Two views → __ and _______

-Should include the _____ and _____ joints

Monteggia Fracture

What type of fracture is shown here?

-An ulnar shaft fracture with radial head dislocation, may need true elbow and wrist films

Galeazzi Fracture

What type of fracture is shown here?

-Distal radius fracture with radioulnar joint dislocation

AP, lateral, oblique

What views do you need for a wrist x-ray?

-__ → radial inclination of 20-25 degrees, should intersect with the ulna. Carpal arcs

-______ → distal radius, lunate, and capitate. Should be in a straight line

-_______

Scaphoid

What carpal bone is fractured?

base, shaft, neck

Metacarpal fractures can be described as ____ (proximal), _____ (middle), or ____ (distal)

Phalanx (first, proximal)

What bone is fractured here?

Mallet Fracture

What type of fracture is shown here?

Tuft

What type of fracture is shown here?

PIP, distal, volar

Finger Dislocations

-Types

• MCP, ___, DIP

-Classification → based on the location of the ______ bone in relationship to the proximal

• Dorsal, _____, lateral