Procedures - Upper Limb (Unit 1-2)

Number of bones (per side) in hand:

• Phalanges

• Metacarpals

• Carpals

• 14

• 5

• 8

DIP

Distal Interphalangeal Joint

PIP

Proximal Interphalangeal joint

MCP

Metacarpophalangeal joint

IP

Interphalangeal joint

Carpal bone that articulates with:

• 1st metacarpal

• 2nd metacarpal

• 3rd metacarpal

• 4th and 5th metacarpal

• Trapezium

• Trapezoid

• Capitate

• Hamate

The lunate and scaphoid bones articulate with the _____ proximally.

Radius

The most frequently fx carpal bone:

Scaphoid

The lunate articulates with the _____ (bone).

Radius

The radial tuberosity is located on the _____ & _____ side of the radius.

Medial and Anterior

The two processes of the proximal ulna:

Olecranon and Coronoid processes

Notch on the proximal ulna where articulation with the humerus occurs:

Trochlear notch

What portion of the humerus articulates with the ulna to form the elbow joint:

Trochlea (distal humerus)

Processes at the distal ends of the radius and ulna:

Styloid processes

IP joints are ginglymus, which is defined as:

Hinge-type. Movement in 2 directions: flexion and extension

MCP joints are ellipsoidal (condyloid), which is defined as:

Condyloid type. Movement in 4 directions: flexion, extension, abduction, and adduction. (Circumduction)

List the joint classifcations:

• IP

• MCP

• Ginglymus (hinge)

• Ellipsoidal (condyloid)

List the joint classifcations:

• CMC (thumb)

• CMC (2nd - 5th)

• Saddle

• Plane (gliding)

List the joint classifcations:

• Intercarpal

• Wrist

• Elbow

• Plane (gliding)

• Ellipsoidal (condyloid)

• Ginglymus (hinge)

_____ deviation provides the best demonstration of the lateral carpal including the trapezium, trapezoid, and _____.

• Ulnar

• Scaphoid

_____ deviation provides the best demonstration of the medial side of the wrist.

Radial

On the AP elbow, the proximal radius is slightly superimposed by the:

Ulna

To prevent superimposition of the radius & ulna, the forearm is placed with the hand _____ and in an _____ projection.

• Supinated

• AP

The scaphoid fat stripe (wrist) can be viewed on which projections?

PA and Oblique

The pronator fat stripe (wrist) can be visualized on which projection(s)?

Lateral

Elbow fat pads cannot be seen in the projection:

AP

Which projection of the elbow is the best for visualizing fat pad pathology?

Lateral

The nogaard method (aka _________ position) is used for early detection of ___________. Describe this view:

• Ball Catcher’s

• Rheumoatoid arthritis

• Bilateral hands (to compare with each other). Hands are oblique 45 degress with palms up.

To avoid excessive MCP joint overlap in an oblique hand, the hand should be angled no more than _____ degrees.

45

What is an alternative to a fan-lateral hand to evaluate a fracture or foreign body.

Lateral in Extension and Flexion

Why is it important to support the fingers so that they remain parallel to the IR?

• Prevent foreshortening of phalanges

• Prevent obscuring of IP joints

What method is best used to evaluate a Bennett fracture?

AP axial of thumb

CR is angled 15 degrees proximally (towards wrist)

Describe the Brewerton method:

AP axial of the hand. Supinate hand with fingers touching IR. Flex hand 65 degrees. CR 15 degress promixally toward ulna (3rd MCP joint).

Why should the hand be slightly arched / fingers bent for a PA wrist?

Reduce OID of carpals

A PA axial projection to visualize the scaphoid bone requires _________ deviation of the wrist and a _________ degree tube angle directed proximally.

• Ulnar

• 10-15

The Gaynor-Hart method is primarily used to evaluate:

Carpal Tunnel Syndrome

CR 25-30 degrees proximally to long axis od hand

Which oblique will separate the radial head, neck, and tuberosity from the ulna?

Lateral oblique (external rotation)

The coyle method will visualize the _________ & _________ when the patient has their elbow flexed 90 degrees and the CR is angled ________ - degrees medially (towards the shoulder). This can be done with the patient plying down or sitting beside the table.

• Radial head

• Capitulum

• 45

The coyle method for the coranoid process is a __________ projection with the elbow 80-degrees. The CR is 45-degrees directed ______ from the shoulder.

• Mediolateral (axial)

• Away

A partial flexion elbow requires 2 projections to obtain a 'full' AP. Describe each:

• AP - forearm parallel to IR

• AP - humerus parallel to IR

To visualize the entire circumference of the radial head, 4 projections must be obtained:

All projections are in lateromedial with arm flexed 90 degrees. Epicondyles perpendicular to IR

• Supinate hand

• Hand in true lateral

• Pronate hand

• Internally rotate hand

Label

1. DIP joint

2. PIP joint

3. MCP joint

4. Distal phalanx

5. Middle phalanx

6. Proxmial phalax

7. Metacarpal

Label

1. Thumb

2. Capitate

3. Trapezium

4. Scaphoid

5. Radius

6. Ulna

Label

A. Scaphoid

B. Lunate

C. Triquetrum

D. Pisiform

E. Trapezium

F. Trapezoid

G. Capitate

H. Hamate

Label

1. Lateral Epicondyle

2. Capitulum

3. Radial Head

4. Radial Tubercle

5. Radius

6. Humerus

7. Medial Epicondyle

8. Olecranon Process

9. Trochlea

10. Coronoid Process

11. Ulna

Label

1. Lateral Epicondyle

2. Capitulum

3. Radial Head

4. Radial Neck

5. Radial Tubercle

6. Radial Shaft

Label

G. Superimposed epicondyles of humerus

H. Olecranon Process

I. Trochlear sulcus

J. Trochlear notch

K. Double outer ridges of capitulum and tochlea

L. Coronoid process of ulna

M. Radial Head

N. Radial Neck

What projection may be done in replacement of a PA Digit?

PA Hand

What projection may be done in replacement of an oblique thumb?

PA Hand

Oblique Hand: Image Criteria

Midshafts of metacarpals should not overlap

Oblique Wrist: Image Criteria

• Distal radius, ulna, carpals, and at least to mid metacarpals.

• Trapezium and Scaphoid should be well visualized

Lateral Wrist: Image Criteria

• Distal radius, ulna, carpals, and at least to mid metacarpals.

• Ulnar head superimposed over distal radius

AP Elbow: Image Criteria

• Distal humerus, elbow joint space, and proximal radius and ulna are visible

• Bilateral epicondyles seen in profile and radial head, neck, and tuberosity separated or only slightly superimposed by ulna

Lateral Elbow: Image Criteria

• One-half of radial head should be superimposed by the coronoid process, and olecranon process should be visualized in profile

• Superimposition of the humeral epicondyles occurs

Medial Oblique Elbow: Image Criteria

• Visualize coronoid process of the ulna in profile

• Radial head and neck should be superimposed

• Medial epicondyle and trochlea should appear elongated

• Olecranon process should appear in olecranon fossa and trochlear notch partially open and visualized

Lateral Oblique Elbow: Image Criteria

• Visualize radial head, neck, and tuberosity, free of superimposition by the ulna

• Lateral epicondyle and capitulum should appear elongated and in profile

PA thumb results in:

a lot of OID. Not a common projection

PA Stress Thumb (Folio Method)

Hands side by side, rotated laterally 45 degrees, thumbs in PA, wrap rubber bands around distal thumb

Skier’s Thumb (hyperextension and ulnar collateral ligament)

Acute Flexion Elbow Projections

• Same patient position but different CR angles

• AP - CR perpendicular to distal humerus

• PA - CR perpendicular to proximal forearm

On the proximal humerus, the anterior process directly below the anatomic neck is the __________. The larger process on the lateral aspect is the __________

• Lesser tubercle

• Greater tubercle

Which muscles attach to the greater tubercle of the humerus?

Pectoralis major and Supraspinatus muscles

The deep groove between the lesser and greater tubercle is called

Intertubercular or bicipital groove

What rotation of the shoulder allows for a true AP projection of the proximal humerus?

External

The __________ tubercle is located anteriorly and the greater tubercle is __________ in a true AP projection.

• Lesser

• Laterally

The upper margin of the scapula is located at the level of the __________ posterior rib

2nd

The lower margin of the scapula is located at the level of __________

7th posterior rib (T7)

The bilateral SC joints form the:

Jugular notch

What differences are there in clavicles between a male and a female?

• Female - shorter and less curved than male clavicles

• Male - thicker and more curve

Axilla refers to:

Armpit

Anatomy that articulates to form the Acromioclavicular (AC) joint:

Lateral/acromial end of the clavicle with the acromion of the scapula

Anatomy that articulates to form the Sternoclavicular (SC) joint:

Medial/sternal end of the clavicle with the manubrium

Anatomy that articulates to form the Scapulohumeral (glenohumeral/shoulder) joint:

Humeral head with the glenoid cavity of the scapula

The wing of the scapular can also be referred to as the:

ala

The anterior surface of the scapula is called __________ surface.

Costal

A thick, beaklike process on the scapula that project anteriorly beneath the clavicle is called the __________. It is located __________ inches interior to the lateral portion of the AC joint.

• Coracoid process

• 2 inches

A long, curved process that extends laterally over the head of the humerus:

Acromion

The 3 joints of the shoulder are classified as:

Synovial

The 3 joints of the shoulder have this type of mobility:

Diarthrodial

List the movement type of each joint:
a. scapulohumeral/glenohumeral:
b. sternoclavicular:
c. acromioclavicular:

• Ball and socket

• Plane/gliding

• Plane/gliding

Position and Projection

• Pos - External rotation

• Proj - AP

• A - Greater tubercle

• B - Lesser tubercle

Position and Projection

• Pos - Internal rotation

• Proj - Lateral

• A - Greater tubercle

• B - Lesser tubercle

Position and Projection

• Pos - Neutral rotation

• Proj - Oblique

• A - Greater tubercle

• B - Lesser tubercle

95% of shoulder dislocations are:

Anterior

To demonstrate a profile view of the glenoid fossa, the patient is AP recumbent and oblique 45 degrees towards the:

Affected side (IR)

If a patient has surgically implanted hardware, it is best practice to set a __________ technique.

Manual

AC joints require that both joints are visualized together, this is called the __________ method. A(n) __________ projection is taken with and without __________. If a fracture is suspected, these views can/cannot be obtained.

• Pearson

• AP

• Weights

• Can

A true AP of the clavicle will visualize:

• Clavicular body

• AC joint

• SC joint

• Acromion

The lesser tubercle will be in profile and the epicondyles will be superimposed on this projection of the humerus:

Internal rotation (Mediolateral)

Why might an orthostatic breathing technique be used on a transthoracic lateral humerus?

Allows best visualization of humerus by blurring out ribs and lung structures.

An AP scapula requires the arm to be abducted 90 degrees to the body, with the elbow flexed and hand __________. It is best practice to do a __________ breathing technique.

• Supinated

• Orthostatic 

If only 2 views were obtained to rule out a fracture of the shoulder, what are the best views?

• AP

• Scap Y

The Clark’s method of the shoulder utilizes this projection __________. It can be used to replace the axial shoulder, Lawrence method.

Superoinferior Axial

The Fisk method of the shoulder is best used to evaluate the:

Intertubercular sulcus/groove

The Lawrence method (exaggerated external rotation) is best used to demonstrate a:

Hill-Sachs Defect

Which projection will reduce OID of the humerus? mediolateral/latermedial

Mediolateral

Label

1. Greater Tubercle

2. Intertubercular Groove

3. Surgical Neck

4. Head

5. Anatomical Neck

6. Lesser Tubercle

7. Deltoid Tuberosity

8. Body

Label

A. Head of Humerus

B. Greater Tubercle

C. Intertubercular Sulcus

D. Lesser Tubercle

E. Anatomical Neck

F. Surgical Neck

G. Body

Label

A. Sternoclavicular Joint

B. Sternal Extremity

C. Body

D. Acromial Extremity

E. Acromioclavicular Joint

Label

1. Body

2. Superior Angle

3. Subscapular Notch

4. Coracoid Process

5. Acromion

6. Glenoid Cavity

7. Lateral Angle

8. Neck

9. Costal Surface

10. Inferior Angle

Label

A. Acromion

B. Neck of Scapula

C. Suprascapular Notch

D. Superior Angle

E. Medial Border

F. Inferior Angle

G. Lateral Border

H. Glenoid Cavity