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An Introduction to Extremity Radiography for student

radiographers
Part 1. Shoulder to fingers inclusive.
Part 2. Knee to toes inclusive.

With special reference to the following examinations.


Upper limb, shoulder, humerus, elbow, wrist, hand, thumb and fingers.
Lower limb, knee, tibia and fibula, ankle, tarsal bones, metatarsals and toes.

Details of the projections mentioned can be found in a selection of text including the latest edition of
Clark's Positioning in Radiography which should the standard for techniques.

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General Part 1 and Part 2.
Function:
Most of the extremities have both motor and support functions.

Indications:
These will be grouped into four major components.

Trauma, (See individual sections)


Degenerative diseases,
Metabolic diseases and Infections
Neo-plasms

The foot is a special case for deformities, with the several common examples following sometimes
requiring radiological investigation.
Club Foot, Calcaneo Valgus, Accessory Bones, Pes Cavus and Pes planus.

Degenerative diseases,

Rheumatoid arthritis.
This is a collagen disease and affects the collagen of multiple body systems particularly the joints
and tendons but may more rarely affect the eyes, lungs and arteries. Rheumatoid arthritis chiefly
affects the synovial tissues of joints and tendons with the most common sites being the hands, feet
and knees. In children the disease is known as 'Still's disease'.
Three % of the population in England are affected with women more commonly afflicted.

Radiographic features; early in the disease there may be increased radiolucency of the juxta-articular
bone due to re absorption secondary to hyperaemia. Later the joint space becomes narrow and
subchondral cysts may be visible. As secondary degenerative joint changes develop, frank erosion of
the bony surfaces is seen (secondary osteoarthrosis), and the joint may sub-lux.

Osteo arthritis.
In this condition the joint space narrows (1), usually at the site of maximum weight bearing, sclerosis
(increase in white-ness (bone density))(2) develops round the affected areas, and marginal bony
protuberances and cysts form(3) eventually completely destroying the joint space with increasing
sclerosis.(4)

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Metabolic diseases and Infections
Osteochondritis Dissecans
This disorder is of uncertain aetiology, a small segment of subchondral bone becomes avascular and
dies. It tends to separate from the condyle together with the overlying articular cartilage forming a
loose body in the joint. Most common in young males in the knee joint but may occur in the humerus
and sometimes the head of femur.

Osteochondrosis
This is a self healing disorder affecting the growing epiphysis where the bony centre of growth
becomes avascular and dies, the bone is subsequently revascularised and reforms, sometimes there
is a permanent residual deformity, the whole cycle can take up to two years.
Avascular necrosis probably forms after a period of ishcaemia, the cause may be from trauma but
the full aetiology is unknown.

Named osteochondrosis of the upper and lower limbs include.


Perthe's - Head of femur,
Osgood-Schlaters's - Superior tibial tubercle,
Freibergs - Head of second metatarsal,
Severs - Calcaneum,
Keinbocks - Lunate,
Kohler's - Navicular.

Rickets (osteomalacia)
(osteomalacia)
Rickets is a juvenile form of adult osteomalacia a demineralisation of the osteoid tissue caused by
vitamin D deficiency. The growing metaphysis becomes trumpet shaped, a woolly appearances
replaces the dense line of provisional calcification, a widened translucent epiphyseal plate and a less
distinct centre of ossification.

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Osteomyelitis
Bone infections caused by infection or minor trauma particularly in children (acute haematogenous
osteomyelitis) starts with a septic abscess within the bone which enlarges and pushes up and
spreads under the periosteum eventually breaking through. When adjacent to the epiphyseal plate
damage may later develop to the plate.

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Non Malignant Neoplasm's

Osteoid osteoma.
Patients: 10-25 Years males
Pathology: A spherical mass of osteoid tissue surrounded by a large region of sclerotic bone
Radiology: The nidus is often invisible in the mass of sclerotic bone, which may require tomography
to demonstrate it.

Enchondromata.
Patients: Any
Pathology: A cartilaginous cyst which expands from within the bone thinning the overlying cortex
Radiology: A radio lucent cyst expanding the bone and thinning the cortex.

Non osteogenic Fibroma.


Patients: Adolescents
Pathology:
Radiology: A growth of cells forming a radio lucent cyst in a metaphysis with a hard bony rim with
irregular septa within.

Malignant Neoplasm's
Osteosarcoma.
Patients: Usually under 30
Pathology: The lesion commences within the bone and destroys the medulla and cortex. It spreads
under the periosteum along the bone and around the circumference to produce a swelling, the
elevated periosteum lays down new bone in spicules under it at right angles to the shaft.
Radiology: A fusiform enlargement of bone with areas of destruction and irregular sclerosis from
new bone formation is visible. The periosteum is elevated along the shaft. The spicules of new bone
under it form a 'sunray' appearances. At the edge of the area of periosteal elevation the new bone
forms a dense triangle called Codmans triangle.(C)

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Chondrosarcoma
Patients: Males over 30
Pathology: It may develop from an existing eechondroma with the most common sites being pelvis,
scapula or upper ends of humerus and femur.
Radiology: Radiolucent areas with flecks of irregular calcification within.

Multiple myeloma
Patients: Over 40.
Pathology: Multifocal proliferation of plasma cells of bone marrow.
Radiology: The bones are generally less dense with multiple small punched out lesions.
Ewing's Tumour
Patients: Under 30
Pathology: The lesion commences in the medulla and spreads through the nutrient.
Radiology: Usually shows destruction in the medulla and cortex and elevation of the cortex with an
onion cell appearance.

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Contra Indications:
There are few if any contra indications other than that alternative forms of imaging may be
preferable or the fact that X-Ray imaging may be considered inappropriate in some cases where
treatment will not be affected by the result of X-Ray examination.
A contra indication to the use of ionising radiation is the use of imaging in order to reduce the
possibility of medico legal litigation and for psychological reassurance of the patient.

Patients Preparation:
In general and if possible, free access to the area to be examined is required, bandages, dressings
and splints should be removed, any doubts should be discussed with a medical or nurse practitioner
and advice taken in cases where the patient's safety may be compromised.
Basic psychological preparation with reassurance and explanation of technique.
Normal patient examination interview.

Equipment:
Medium powered X-Ray generator 40 -80 kW.
Ceiling suspended tube with good range of movements, especially vertical.
Fine focus X-Ray tube, preferably 0.3 mm focus.

Accessories:
Fine and standard/regular resolution, film speed screen combinations in an assortment of sizes.
Curved cassettes may be useful for some examinations.
Pads and immobilisation aids.

Contrast agents and drugs:


N/A

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Part 1:

Basic Anatomy:
The basic anatomy of these regions will only be considered in terms line diagrams of the bones and
joints. Reference may be made to soft tissue structures of importance in certain circumstances.

The upper limb:


Fig 1. Right Scapula Fig 2. Right Clavicle

Fig 3. Right Humerus Fig 4. Right Radius and


Ulna

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Fig 5 Right Hand and Carpus

Projections:

Upper limb,
AP shoulder survey,
AP shoulder joint examination,
AP Clavicle,
Infero superior shoulder,
Lateral scapula
AP & Lateral humerus.
AP & Lateral elbow
AP & Lateral wrist
DP & DP oblique hand
AP & Lateral thumb
AP & Lateral finger/s

Note: projections of limbs must include both medial and distal joints and be imaged with two
projections at 90°.

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Typical Exposure Values: (*Dose = Typical Dose from NRPB)

Projection Kv mAS F.F.D. Focus Grid Dose Film/Screen


AP shoulder 70 100cm Fine N/Y Detail
AP Clavicle, 65 100cm Fine no Detail
Infero superior 75 100cm Fine no Detail
shoulder,
Lateral scapula 75 100cm Fine N/Y Detail
AP & Lateral 70 100cm Fine no Detail
humerus.
AP & Lateral elbow 60 100cm Fine no Detail
AP wrist 55 100cm Fine no Detail
Lateral wrist 60 100cm Fine no Detail
DP & Oblique hand 55 100cm Fine no Detail
AP & Lat thumb 55 100cm Fine no Detail
AP & Lat finger 50 100cm Fine no Detail

Film Sequence:
An appropriate sequence of projections should be determined to minimise patient discomfort and
maximise examination speed.

Additional Projections:
Modifications for 'plaster' immobilisation.
Shoulder:
Modified axial,
Trans thoracic head of humerus,
Elbow:
Radial head
Wrist:
Oblique,
Scaphoid projection series,
Carpal tunnel,
Macro carpal bones.
Hand:
"Ball catching" Norgard's projection.

Radiation Protection:
In addition to all normal good techniques for radiation protection.
Direct lead rubber gonad protection when the primary beam is directed towards the gonads.

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Patient Aftercare:
General psychological reassurance.
Check patient understands how to receive the results.
Replace any splints and dressings removed.
Ensure patient understands any preparation instructions are finished
Escort to changing rooms/waiting area and bid good-bye.
If any fractures or dislocations are discovered the patient's affected limb should be immobilised and
the patient referred for medical opinion, a trolley/wheelchair should be used to transport the patient
in safety due to the risks of delayed shock.

Additional Imaging Techniques:


Arthrography
Ultrasound of 'foreign bodies.
Radio-nuclide Investigations, studies for bone pathologies and fractures i.e. scaphoid.
Computer Tomography may be appropriate in special cases.

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Examples of trauma to the upper limb.

1. Typical fractures of terminal 'tuft' of phalanx.

2. Typical fractures / dislocations of phalanges.

3. Typical metacarpal fractures 1st and fifth.

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Examples of trauma to the upper limb, cont.
4. Scaphoid fracture.

5. Ulna fracture with dislocation of radial head.

6."Colles' and 'Smith's" fractures.

7. Supracondylar fractures.

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8. Shoulder anterior dislocation. and posterior dislocation.

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Part 2

The lower Limb:


Basic Anatomy:
The basic anatomy of the lower limb regions will be considered in terms of line diagrams of the bones
and joints.

THE LOWER LIMB:

Lt Femur.

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Left Tibia and Fibula.

Left Foot,

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Basic Projections of the Lower Limb:

AP and Lateral Knee,


AP and Lateral Tibia and Fibula
AP and Lateral Ankle
Dorsi-plantar Foot
Dorsi Plantar Oblique Foot
Lateral Individual Toes,

Note projections of limbs must include both proximal and distal joints and be imaged with two
projections at 90°.

Typical Exposure Values: (*Dose = Typical Dose from NRPB)

Projection Kv mAS F.F.D. Focus Grid Dose Film/Screen


AP and Lateral Knee 65 100cm Fine No Detail
AP and Lateral Tibia 65 100cm Fine No Detail
and Fibula
AP and Lateral Ankle 60 100cm Fine No Detail
Dorsi-plantar Foot 55 100cm Fine No Detail
Dorsi Plantar Oblique 55 100cm Fine No Detail
Foot
Lateral Individual 50 100cm Fine No Detail
Toes,

Film Sequence:
An appropriate sequence of projections should be determined to minimise patient discomfort and
maximise examination speed.

Additional Projections:
Knee:
Stress views for joint luxation
Intra condylar projections for loose bodies 90° and 110°.
Oblique projections of patella.
Axial 'Skyline' patella,
Soft tissue tibial tubercle projection.
Weight bearing joint projections.
Ankle:
Stress views for joint luxation
Lateral malleolus projection.
Axial Calcaneum.
Talo-caneal joint projections (10°-40° cranial angulations)
Oblique projections of the tarsal bones.
Foot:
Lateral
Weight bearing projections,
Sesamoid bone projections.

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Radiation Protection:
In addition to all normal good techniques for radiation protection.
Direct lead rubber gonad protection when the primary beam is directed towards the gonads.

Patient Aftercare:
General psychological reassurance.
Check patient understands how to receive the results.
Replace any splints and dressings removed.
Ensure patient understands any preparation instructions are finished
Escort to changing rooms/waiting area and bid good-bye.
If any fractures or dislocations are discovered the patient's affected limb should be immobilised and
the patient referred for medical opinion, a trolley/wheelchair should be used to transport the patient
in safety due to the risks of delayed shock.

Additional Imaging Techniques:


Arthrography
Ultrasound of 'foreign bodies.
Radio-nuclide Investigations, studies for bone pathologies and fractures.
Computer Tomography may be appropriate in special cases.

August 8, 1996 NJO / EXTREMITY TECHNIQUE.doc 18


Examples of trauma to the lower limb.
Fracture of patella, lateral horizontal ray showing fat/fluid level.

Fractures of Tibia Displaced / Undisplaced

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Examples of trauma to the lower limb cont.
Fractures of the Talus.

Fractures of the Calcaneum,

'March' Fracture of a metatarsal,

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