What process is best seen Olecranon using a perpendicular CR with the elbow in acute flexion and with the

posterior aspect of the humerus adjacent to the image receptor? When the elbow is placed the olecranon process of the ulna in acute flexion with the is seen in profile posterior aspect of the humerus adjacent to the image receptor and a perpendicular CR is used The coronoid process is best visualized Which of the following articulations participate in the formation of the elbow joint? elbow joint. in the medial oblique position. 1. Between the humeral trochlea and the semilunar/trochlear notch 2. Between the capitulum and the radial head 3. The proximal radioulnar joint The distal humerus articulates with the radius and ulna to form a part of the elbow joint. The lateral aspect of the distal humerus presents a raised, smooth, rounded surface, the capitulum, that articulates with the superior surface of the radial head. The trochlea is on the medial aspect of the distal humerus and articulates with the semilunar notch of the ulna. All three articulations are enclosed in a common capsule to form the elbow joint proper. 1. olecranon process within the olecranon fossa. 2. coronoid process free of superimposition. the radial head and ulna are normally somewhat superimposed demonstrates the radial head free

The medial oblique projection of the elbow demonstrates the AP projection of the elbow lateral oblique of the

elbow lateral projection of the elbow demonstrates

of superimposition with the ulna the olecranon process in profile.

medial oblique position of considerable overlap of the the elbow demonstrates proximal ulna, but should clearly demonstrate the coronoid process free of superimposition and the olecranon process within the olecranon fossa. Which of the following projections of the elbow should demonstrate the coronoid process free of superimposition and the olecranon process within the olecranon fossa? All of the following statements regarding the inferosuperior axial (nontrauma, Lawrence method) projection of the shoulder are true Medial oblique

1. the coracoid process and lesser tubercle are seen in profile 2. the arm is abducted about 90 from the body 3. the CR is directed medially 25 to 30 through the axilla.

The inferosuperior axial the glenohumeral joint and (nontrauma, Lawrence adjacent structures. The patient is method) projection of the supine with arm abducted 90, and shoulder demonstrates in external rotation. The (horizontal) CR is directed medially 25 to 30 through the axilla. The coracoid process and lesser tubercle are seen in profile "scapular Y" this refers to the characteristic Y formed by the clearly visible humerus, acromion, and coracoid. The patient is positioned in a PA oblique position, The MCP is adjusted to approximately 60 to the IR, and the affected arm is left relaxed at the patient's side. The scapular Y position is employed to demonstrate anterior or posterior humeral dislocation. The humerus is superimposed on the scapula in

this position; any deviation from this may indicate dislocation and the acromion process is free of superimposition. To demonstrate a profile toward the affected side. view of the glenoid fossa, the patient is AP recumbent and obliqued 45 AP projection of the shoulder there is superimposition of the humeral head and glenoid fossa. With the patient obliqued 45 toward the affected side, the glenohumeral joint is open, and the glenoid fossa is seen in profile. The patient's arm is abducted somewhat and placed in internal rotation. a compression fracture of the posterolateral humeral head, usually associated with anterior dislocation of the shoulder joint. It can involve the cartilage of the humeral head, causing instability and predisposing the shoulder to subsequent dislocations. a fracture of the anteroinferior portion of the rim of the glenoid fossa. involves injury to one or more of the muscles participating in formation of that muscular structure. The supraspinatus, infraspinatus, subscapularis, and teres minor are the major muscles of the rotator cuff. "frozen shoulder," causes very diminished shoulder movement as a result of chronic joint inflammation. a greater portion of the glenoid

Hill-Sachs defect

Bankart lesion

rotator cuff tear

Adhesive capsulitis

When the shoulder is

placed in internal rotation fossa is superimposed by the humeral head and the lesser tubercle is visualized The external rotation position removes the humeral head from a large portion of the glenoid fossa and better demonstrates the greater tubercle. 1. Scapular Y projection 2. Inferosuperior axial 3. Transthoracic lateral an oblique projection of the shoulder and is used to demonstrate anterior or posterior shoulder dislocation may be used to evaluate the glenohumeral joint when the patient is able to abduct the arm used to evaluate the glenohumeral joint and upper humerus when the patient is unable to abduct the arm. PA oblique scapular Y

Which of the following may be used to evaluate the glenohumeral joint? scapular Y projection

inferosuperior axial projection transthoracic lateral projection

Which of the following projections or positions will best demonstrate subacromial or subcoracoid dislocation? "scapular Y" refers to

the characteristic Y formed by the humerus, acromion, and coracoid processes. patient is positioned in a PA oblique positionan RAO or LAO, depending on which is the affected side. The midcoronal plane is adjusted approximately 60 to the IR, and the affected arm remains relaxed at the patient's side. anterior (subcoracoid) or posterior (subacromial) humeral dislocation. The humerus is normally

scapular Y

scapular Y position is employed to demonstrate

superimposed on the scapula in this position; any deviation from this may indicate dislocation. The scapular Y projection 1. an oblique projection of the of the shoulder shoulder. demonstrates 2. anterior or posterior dislocation. The vertebral and axillary anterior or posterior dislocation borders of the scapula are superimposed on the humeral shaft, and the resulting relationship between the glenoid fossa and humeral head will demonstrate Lateral or medial the AP projection dislocation of the shoulder is evaluated on Which of the following is (are) valid criteria for a lateral projection of the forearm? To accurately position a lateral forearm 1. The coronoid process and radial head should be superimposed. 2. The radial tuberosity should face anteriorly. the elbow must form a 90 angle with the humeral epicondyles superimposed. The radius and ulna are superimposed only distally. Proximally, the coronoid process and radial head are superimposed, and the radial head faces anteriorly. Failure of the elbow to form a 90 angle or the hand to be lateral results in a less than satisfactory lateral projection of the forearm. adjacent to the ribs

The scapula's anterior, or costal, surface is that which is The scapula has no

sternal articulation

When examining a patient 1. With humerus parallel to IR, whose elbow is in partial central ray perpendicular flexion, how should an AP 2. With forearm parallel to IR,

projection be obtained? When a patient's elbow needs to be examined in partial flexion When a patient's elbow needs to be examined in partial flexion

central ray perpendicular the lateral projection offers little difficulty the AP projection requires special attention. If the AP is made with a perpendicular central ray and the olecranon process resting on the tabletop, the articulating surfaces are obscured. two exposures are necessary. One is made with the forearm parallel to the IR (humerus elevated), which demonstrates the proximal forearm. The other is made with the humerus parallel to the IR (forearm elevated), which demonstrates the distal humerus. In both cases, the central ray is perpendicular if the degree of flexion is not too great, or angled slightly into the joint space with greater degrees of flexion. The axillary and vertebral borders are superimposed. The acromion and coracoid process are visualized; the coracoid process is partially superimposed on the axillary portion of the third rib.

With the elbow in partial flexion

lateral projection of the scapula.

A scapular Y projection is shoulder dislocation, but the often performed to affected arm is left to rest at the demonstrate patient's side Which of the following projections is most likely to demonstrate the carpal pisiform free of superimposition? AP (medial) oblique

In the direct PA projection the carpal pisiform is of the wrist superimposed on the carpal triquetrum. The AP oblique projection (medial surface

adjacent to the IR) separates the pisiform and triquetrum and projects the pisiform as a separate structure. The pisiform is the smallest and most palpable carpal. Which of the following projections will best demonstrate the carpal scaphoid? The carpal scaphoid Ulnar flexion/deviation

is somewhat curved and consequently foreshortened radiographically in the PA position. To better separate it from the adjacent carpals, the ulnar flexion (ulnar deviation) maneuver is frequently employed. In addition to correcting foreshortening of the scaphoid, ulnar flexion/deviation opens the interspaces between adjacent lateral carpals.

Radial flexion/deviation is medial carpals. used to better demonstrate The scapula presents two borders: the lateral or axillary border and the medial or vertebral border. It also presents three angles: the inferior angle, the superior angle, and the lateral angle. The processes of the scapula are the coracoid, the acromion, and the scapular spine. The scapula has a (supra) scapular notch, a supraspinatus fossa, and an infraspinatus fossa

With the patient seated at coronoid process the end of the x-ray table, elbow flexed 80, CR directed 45 laterally from the shoulder to the elbow joint, which of the following structures will be demonstrated best?

The axial trauma lateral (Coyle)

With the patient seated at the end of the x-ray table, elbow flexed 80, CR directed 45 laterally from the shoulder to the elbow joint these positions can be used to demonstrate the coronoid process and/or radial head. With the elbow flexed 90 and the CR directed to the elbow joint at an angle of 45 medially (i.e., toward the shoulder), the joint space between the radial head and capitulum should be revealed. With the elbow flexed 80 and the CR directed to the elbow joint at an angle of 45 laterally (i.e., from the shoulder toward the elbow), the elongated coronoid process will be visualized.

If routine elbow projections in extension are not possible because of limited part movement

Which of the following Lateral oblique will separate the radial head, neck, and tuberosity from superimposition on the ulna? In the AP projection of the the proximal radius and ulna are elbow, partially superimposed. In the lateral position of the elbow In the medial oblique position of the elbow The lateral oblique projection of the elbow the radial head is partially superimposed on the coronoid process, facing anteriorly. there is even greater superimposition. completely separates the proximal radius and ulna, projecting the radial head, neck, and tuberosity free of superimposition with the proximal ulna. must be supported parallel to the IR

To evaluate the interphalangeal joints in the oblique and lateral positions, the fingers

The fingers must be supported parallel to the IR (eg, on a "finger sponge") in order that

the joint spaces parallel the x-ray beam. When the fingers are flexed or resting on the cassette, the relationship between the joint spaces and the IR changes, and the joints appear "closed."

Which of the following is 1. Chip fracture of the ulnar (are) associated with a styloid Colles' fracture? 2. Posterior or backward displacement A Colles' fracture is usually caused by a fall onto an outstretched (extended) hand, to "brake" a fall. The wrist then suffers an impacted transverse fracture of the distal inch of the radius, with an accompanying chip fracture of the ulnar styloid process. Because of the hand position at the time of the fall, the fracture is usually displaced backward approximately 30.

A plane passing through the IR (and perpendicular to the the epicondyles is parallel CR). To project the coracoid to process with less selfsuperimposition, the CR must be angled cephalad between 15 and 45. The amount of cephalad angulation depends on the degree of thoracic kyphosis; the greater the drgree of kyphosis, the greater the degree of cephalad angulation required. A 30 angle is used for the average patient. Which of the following would be the best choice for a right-shoulder examination to rule out fracture? The AP projection of the shoulder AP and scapular Y

will give a general survey and show medial/lateral and inferior/superior joint relationships.

The scapular Y position

(LAO or RAO) is employed to demonstrate anterior (subcoracoid) or posterior (subacromial) humeral dislocation. The humerus is normally superimposed on the scapula in this position; any deviation from this may indicate dislocation. Rotational views must be avoided in cases of suspected fracture.

The AP and scapular Y two views at right angles to each combination is the closest other. to To obtain an exact axial in a lordotic position and direct projection of the clavicle, the central ray at right angles to place the patient the coronal plane of the clavicle The exact axial projection is performed by placing the patient in a lordotic position, leaning against the vertical grid device. This places the clavicle at right angles, or nearly so, to the plane of the IR. The central ray is directed to enter the inferior border of the clavicle, at right angles to its coronal plane. Other axial projections may include a prone position with a 25 to 30 caudal angle. However, none of these produce an exact axial projection of the clavicle. With the patient seated at Radial head the end of the x-ray table, elbow flexed 90, CR directed 45 toward the shoulder to the elbow joint, which of the following structures will be demonstrated best? The axial trauma lateral (Coyle) With the patient seated at the end of the x-ray table, elbow flexed 90, CR directed 45 toward the shoulder to the elbow joint

If routine elbow projections in extension are not possible

because of limited part movement, this position can be used to demonstrate the coronoid process and/or radial head. With the elbow flexed 90 and the CR directed to the elbow joint at an angle of 45 medially (ie, toward the shoulder), the joint space between the radial head and capitulum should be revealed. With the elbow flexed 80 and the CR directed to the elbow joint at an angle of 45 laterally (ie, from the shoulder toward the elbow), the elongated coronoid process will be visualized. First metacarpal

With which of the following does the trapezium articulate? The first metacarpal,

on the lateral side of the hand, articulates with the most lateral carpal of the distal carpal row, the greater multangular/trapezium. This articulation forms a rather unique and very versatile saddle joint, named for the shape of its articulating surfaces.

Which of the following is Radial styloid process proximal to the carpal bones? Which of the following is AP and lateral most likely to be the correct routine for a radiographic examination of the forearm? To demonstrate the radius the forearm must be radiographed and ulna free of in the AP position, with the hand superimposition, supinated. Pronation of the hand causes overlapping of the proximal radius and ulna. Two views, at right angles to each other, are generally required for

each examination. Therefore, AP and lateral is the usual routine for an examination of the forearm. Shoulder arthrography may be performed to evaluate Shoulder arthrograms complete or incomplete rotator cuff tears are used to evaluate rotator cuff tear, glenoid labrum (a ring of fibrocartilaginous tissue around the glenoid fossa), and frozen shoulder.

Acromioclavicular joint on erect AP images with and separation is demonstrated without the use of weights. shoulder arthritis demonstrated with transthoracic humerus or scapular Y would demonstrate Routine radiographs dislocation.

The first carpometacarpal trapezium joint is formed by the articulation of the base of the first metacarpal and the The bases of the proximal the heads of the metacarpals to row of phalanges form the (condyloid) articulate with metacarpophalangeal joints, which permit flexion and extension, abduction and adduction, and circumduction. The bases of the each other and the distal row of metacarpals articulate with carpals at the carpometacarpal joints. The first carpometacarpal saddle joint, permitting flexion joint (thumb) is a and extension, abduction and adduction, and circumduction; it is formed by the articulation of the base of the first metacarpal and the trapezium. For the AP projection of 1. patient's arm is abducted at

the scapula, the

right angles to the body. 2. patient's elbow is flexed with the hand supinated. 3. exposure is made during quiet breathing.

With the patient in the AP the scapula and upper thorax are position for the scapula normally superimposed. With the arm abducted, the elbow flexed, and the hand supinated, much of the scapula is drawn away from the ribs. The patient should not be rotated toward the affected side, as this causes superimposition of ribs on the scapula. the exposure for the scapula is made during quiet breathing to obliterate pulmonary vascular markings.

Which of the following 1. Epicondyles parallel to the IR criteria is (are) required 2. Arm in external rotation for visualization of the 3. Humerus in AP position greater tubercle in profile? The greater and lesser tubercles The AP projection of the humerus/shoulder are prominences on the proximal humerus separated by the intertubercular (bicipital) groove. places the epicondyles parallel to the IR and the shoulder in external rotation, and demonstrates the greater tubercle in profile. places the shoulder in extreme internal rotation with the epicondyles perpendicular to the IR and demonstrates the lesser tubercle in profile.

The lateral projection of the humerus

In the lateral projection of 1. vertebral and axillary borders the scapula, the are superimposed. 2. patient may be examined in the erect position. A lateral projection of the superimposes its medial and scapula lateral borders (vertebral and axillary, respectively). The coracoid and acromion processes

should be readily identified separately (not superimposed) in the lateral projection. The erect position is probably the most comfortable position for a patient with scapula pain. bony structures into order (A) Trapezium (A-D) from lateral to (B) Trapezoid medial. (C) Capitate (D) Hamate wrist is composed of the proximal row of carpals eight carpal bones arranged in two rows (proximal and distal). consists of, from lateral to medial, the scaphoid, the lunate/semilunar, the triangular/triquetrum, and the pisiform. from lateral to medial, consists of the trapezium/greater multiangular, the trapezoid/lesser multiangular, the capitate/os magnum (the largest carpal), and the hamate/unciform (which has a hooklike process, the hamulus). the articulations between the carpals (intercarpal joints), which provide a gliding motion, and the radiocarpal joint (between the distal radius and scaphoid), which provides flexion and extension, abduction and adduction.

The distal row of carpals

The joints of the wrist include

Which of the following fat 1. Anterior fat pad pads/stripes should be 2. Supinator fat stripe demonstrated radiographically in a lateral projection of the normal adult elbow? There are three important The anterior fat pad is located just fat pads associated with anterior to the distal humerus. The the elbow. posterior fat pad is located within the olecranon fossa at the distal posterior humerus. The supinator

fat pad/stripe is located at the proximal radius just anterior to the head, neck, and tuberosity. The posterior fat pad is not visible radiographically in the normal elbow. The fat pads of the elbow in the lateral projection of the can be demonstrated only elbow (the posterior pad only in the presence of trauma/injury). A lateral projection of the 1. a foreign body. hand in extension is often 2. soft tissue. recommended to evaluate The lateral hand in extension, with appropriate technique adjustment, is recommended to evaluate foreign body location in soft tissue. A small lead marker is frequently taped to the spot thought to be the point of entry. The physician then uses this external marker and the radiograph to determine the exact foreign body location. Extension of the hand in the presence of a fracture would cause additional and unnecessary pain, and possibly additional injury. (A) Vertebral border (B) Scapular notch (C) Coracoid process (D) Acromion process is a flat bone, shaped like an inverted triangle, with a costal surface that lies against the upper posterior rib cage. The scapula has a superior border, a medial (or vertebral) border, a lateral (or axillary) border, and an inferior angle, or apex. Its superior border presents a scapular notch projecting anteriorly just medial to the palpable coracoid process. The scapular spine divides the

following structures into order (A-D) from medial to lateral. The scapula

posterior surface into a supraspinatus fossa and infraspinatus fossa; the acromion process is the lateral extension of the scapular spine. The glenoid fossa is on the lateral aspect of the scapula and, with its articulation with the humeral head, forms the (ball and socket) shoulder joint. lateral oblique (external removes the proximal radius from rotation) projection of the superimposition with the ulna and elbow demonstrates its articulation with the ulna at the radial notch, the proximal radioulnar articulation. An AP projection of the partial overlap of the proximal elbow would demonstrate radius and ulna A medial oblique of the complete overlap of the proximal elbow would demonstrate radius and ulna; this position is used to demonstrate the coronoid process in profile and the olecranon process within the olecranon fossa Which of the following Lateral humerus projection(s) require(s) that the shoulder be placed in internal rotation? When the arm is placed in the epicondyles are parallel to the the AP position plane of the cassette and the shoulder is placed in external rotation. In this position, an AP projection of the humerus, elbow, and forearm can be obtained; it places the greater tubercle of the humerus in profile. For the lateral projection of the humerus the arm is internally rotated, elbow somewhat flexed, with the back of the hand against the thigh and the epicondyles superimposed and perpendicular to the IR. The lateral projections of the humerus, elbow, and forearm all require that the epicondyles be perpendicular

to the plane of the cassette. The fifth metacarpal is Medial located on which aspect of the hand? With the arm in the anatomic position, What portion of the humerus articulates with the ulna to help form the elbow joint? The distal humerus articulates with the fifth metacarpal and the ulna lie medially Trochlea

the proximal radius and ulna to form the elbow joint. Specifically, the semilunar/trochlear notch of the proximal ulna articulates with the trochlea of the distal medial humerus.

The capitulum is lateral to the radial head the trochlea and articulates with All the following can be associated with the distal radius a. styloid process. B. ulnar notch. C. radioulnar joint.

The distal radius presents a styloid process laterally; the ulnar notch is located medially, helping to form the distal radioulnar articulation. The distal surface of the radius (carpal articular surface) is smooth for accommodating the scaphoid and lunate to form the radiocarpal (wrist) joint. The proximal radius has a cylindrical head with a medial surface that participates in the proximal radioulnar joint; its superior surface articulates with the capitulum of the humerus. skeletal fractures.

Fracture of the distal radius is one of the most common

Fractures of the radial head and neck frequently result from

a fall onto an outstretched hand with the elbow partially flexed

Severe fractures often are the elbow joint. accompanied by posterior dislocation of Colles' fractures of the a fall onto an outstretched hand distal radius usually result with the arm extended. from The following procedure 1. elevate hand and wrist 20. can be employed to better 2. place wrist in ulnar deviation. demonstrate the carpal scaphoid: The carpal scaphoid is a curved, boat-shaped, bone, and is therefore superimposed on itself ("self-superimposition") in a routine PA projection. Since the scaphoid is the most frequently fractured carpal, special projections have been developed to help overcome selfsuperimposition. Stecher (in 1937) recommended elevating the hand and wrist 20 and using a perpendicular CR directed to the scaphoid. Effective variations of this position include employing ulnar deviation and angling the CR 20 proximally (toward the elbow). The 20 tube angulation would be used in place of the elevated

Which of the following is Oblique the hand no more than an important consideration 45 to avoid excessive metacarpophalangeal joint overlap in the oblique projection of the hand? The oblique projection of should demonstrate minimal the hand overlap of the third, fourth, and fifth metacarpals. Excessive overlap of these metacarpals is

caused by obliquing the hand more than 45. The use of a 45 foam wedge ensures that the fingers will be extended and parallel to the IR, thus permitting visualization of the interphalangeal joints and avoiding foreshortening of the phalanges. Clenching of the fist and ulnar flexion are maneuvers used to better demonstrate the carpal scaphoid.

All the following can be A. the capitulum. associated with the elbow B. the trochlea. joint C. the epicondyles. The distal humerus articulates with the radius and ulna to form the elbow joint. The lateral aspect of the distal humerus presents a raised, smooth, rounded surface, the capitulum, that articulates with the superior surface of the radial head. The trochlea is on the medial aspect of the distal humerus and articulates with the semilunar/trochlear notch of the ulna. Just proximal to the capitulum and trochlea are the lateral and medial epicondyles; the medial is more prominent and palpable. ("tennis elbow") is a painful condition caused by prolonged rotary motion of the forearm. the proximal humerus and are anatomically remote from the elbow joint. A. head. B. radioulnar joint. C. styloid process. presents a head and styloid

Lateral epicondylitis

The tubercles are prominences located at All the following can be associated with the distal ulna The distal ulna

process and articulates with the distal radius to form the distal radioulnar joint. The ulna is slender distally but enlarges proximally and becomes the larger of the two bones of the forearm. At its proximal end, the ulna presents the olecranon process (posteriorly) and coronoid process (anteriorly) that are joined by a large articular cavity, the semilunar, or trochlear notch. The coronoid process fits into the humeral coronoid fossa during flexion, and the olecranon process fits into the humeral olecranon fossa during extension. Just distal and lateral to the semilunar/trochlear notch is the radial notch, which provides articulation for the radial head to form the proximal radioulnar articulation. elbow joint wrist joint AP erect, both shoulders

The ulna is the principal bone of the the radius is the principal bone of the Which of the following will best demonstrate acromioclavicular separation? Acromioclavicular joints

usually examined when separation or dislocation is suspected. They must be examined in the erect position, because in the recumbent position, a separation appears to reduce itself. Both AC joints are examined simultaneously for comparison, because separations may be minimal.

Which of the following 15 to 30 caudad tube angle and direction combinations is correct for

an axial projection of the clavicle, with the patient in the PA position? When the clavicle is examined in the PA recumbent position the central ray must be directed 15 to 30 caudad to project most of the clavicle's length above the ribs. The direction of the central ray is reversed when examining the patient in the AP position.

Muscles that contribute to 1. subscapularis. the formation of the 2. infraspinatus. rotator cuff include the 3. teres minor. The rotator cuff is a musculotendinous structure that includes the supraspinatus, infraspinatus subscapularis, and teres minor muscles. The muscles function to stabilize the humeral head in all arm motions and, together with the deltoid, function to abduct and rotate the arm. Weakness of the rotator cuff can lead to impingement syndrome and/or tendonitis. subluxation; calcification can lead to shoulder immobilization. 1. epicondyles perpendicular to the cassette. 2. hand supinated as much as possible. 3. hand lateral and in internal rotation. conditions may exist (such as an elevated fat pad) that seem to indicate the presence of a small fracture of the radial head. To demonstrate the entire circumference of the radial head, four exposures are made with the elbow flexed 90 and with the humeral epicondyles superimposed and perpendicular to the cassette: one with the hand

A tear of the cuff can result in To demonstrate the entire circumference of the radial head, exposure(s) must be made with the

Although routine elbow projections may be essentially negative,

supinated as much as possible, one with the hand lateral, one with the hand pronated, and one with the hand in internal rotation, thumb down. Each maneuver changes the position of the radial head, and a different surface is presented for inspection. The coronoid process should be visualized in profile in which of the following positions? The coronoid process The medial oblique projection of the elbow demonstrates Medial oblique elbow

is located on the proximal anterior ulna. the coronoid process in profile, as well as the ulnar olecranon process within the humeral olecranon fossa.

The lateral oblique elbow projects the proximal radius and ulna free of superimposition. The coracoid process is located on the scapula.

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