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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.
August 8, 1996
NJO / EXTREMITY TECHNIQUE.doc
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.
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)
August 8, 1996
NJO / EXTREMITY TECHNIQUE.doc
Avascular necrosis probably forms after a period of ishcaemia. Named osteochondrosis of the upper and lower limbs include. a small segment of subchondral bone becomes avascular and dies.Calcaneum. Osteochondrosis This is a self healing disorder affecting the growing epiphysis where the bony centre of growth becomes avascular and dies. Keinbocks .Head of femur. Kohler's . Most common in young males in the knee joint but may occur in the humerus and sometimes the head of femur. The growing metaphysis becomes trumpet shaped.Superior tibial tubercle. the cause may be from trauma but the full aetiology is unknown. It tends to separate from the condyle together with the overlying articular cartilage forming a loose body in the joint. Severs . August 8. sometimes there is a permanent residual deformity.Lunate.Head of second metatarsal. Rickets (osteomalacia) (osteomalacia) Rickets is a juvenile form of adult osteomalacia a demineralisation of the osteoid tissue caused by vitamin D deficiency.Navicular. 1996 NJO / EXTREMITY TECHNIQUE. a woolly appearances replaces the dense line of provisional calcification. a widened translucent epiphyseal plate and a less distinct centre of ossification. the bone is subsequently revascularised and reforms.Metabolic diseases and Infections Osteochondritis Dissecans This disorder is of uncertain aetiology. Osgood-Schlaters's . Perthe's . Freibergs . the whole cycle can take up to two years.doc 3 .
doc 4 . 1996 NJO / EXTREMITY TECHNIQUE. When adjacent to the epiphyseal plate damage may later develop to the plate.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. August 8.
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. It spreads under the periosteum along the bone and around the circumference to produce a swelling.(C) August 8. Radiology: A fusiform enlargement of bone with areas of destruction and irregular sclerosis from new bone formation is visible. 1996 NJO / EXTREMITY TECHNIQUE. 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.Non Malignant Neoplasm's Osteoid osteoma. Malignant Neoplasm's Osteosarcoma. Non osteogenic Fibroma. the elevated periosteum lays down new bone in spicules under it at right angles to the shaft. At the edge of the area of periosteal elevation the new bone forms a dense triangle called Codmans triangle. Patients: Usually under 30 Pathology: The lesion commences within the bone and destroys the medulla and cortex.doc 5 . Enchondromata. which may require tomography to demonstrate it. The spicules of new bone under it form a 'sunray' appearances. The periosteum is elevated along the shaft. 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.
Pathology: Multifocal proliferation of plasma cells of bone marrow. Radiology: Usually shows destruction in the medulla and cortex and elevation of the cortex with an onion cell appearance. Radiology: The bones are generally less dense with multiple small punched out lesions. Radiology: Radiolucent areas with flecks of irregular calcification within. 1996 NJO / EXTREMITY TECHNIQUE.doc 6 . Ewing's Tumour Patients: Under 30 Pathology: The lesion commences in the medulla and spreads through the nutrient. * August 8.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. Multiple myeloma Patients: Over 40.
Basic psychological preparation with reassurance and explanation of technique. preferably 0. dressings and splints should be removed. Ceiling suspended tube with good range of movements. Accessories: Fine and standard/regular resolution. bandages. Fine focus X-Ray tube. film speed screen combinations in an assortment of sizes.doc 7 .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.3 mm focus. especially vertical. 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. Pads and immobilisation aids. Equipment: Medium powered X-Ray generator 40 -80 kW. Contrast agents and drugs: N/A August 8. Curved cassettes may be useful for some examinations. free access to the area to be examined is required. Patients Preparation: In general and if possible. Normal patient examination interview. 1996 NJO / EXTREMITY TECHNIQUE. any doubts should be discussed with a medical or nurse practitioner and advice taken in cases where the patient's safety may be compromised.
Right Humerus Ulna Fig 4. 1996 NJO / EXTREMITY TECHNIQUE. Reference may be made to soft tissue structures of importance in certain circumstances. Right Clavicle Fig 3. The upper limb: Fig 1. Right Scapula Fig 2.doc 8 . Right Radius and August 8.Part 1: Basic Anatomy: The basic anatomy of these regions will only be considered in terms line diagrams of the bones and joints.
Fig 5 Right Hand and Carpus Projections: Upper limb. August 8. 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°.doc 9 . Infero superior shoulder. AP shoulder survey. 1996 NJO / EXTREMITY TECHNIQUE. AP Clavicle. AP shoulder joint examination. Lateral scapula AP & Lateral humerus.
F. Additional Projections: Modifications for 'plaster' immobilisation. Infero superior shoulder. Shoulder: Modified axial. Direct lead rubber gonad protection when the primary beam is directed towards the gonads.D. Carpal tunnel.doc 10 . Macro carpal bones.Typical Exposure Values: (*Dose = Typical Dose from NRPB) Projection AP shoulder AP Clavicle. Hand: "Ball catching" Norgard's projection. Focus Grid 100cm Fine N/Y 100cm Fine 100cm Fine 100cm Fine 100cm Fine 100cm 100cm 100cm 100cm 100cm 100cm Fine Fine Fine Fine Fine Fine no no N/Y no no no no no no no Dose Film/Screen Detail Detail Detail Detail Detail Detail Detail Detail Detail Detail Detail Film Sequence: An appropriate sequence of projections should be determined to minimise patient discomfort and maximise examination speed. AP & Lateral elbow AP wrist Lateral wrist DP & Oblique hand AP & Lat thumb AP & Lat finger Kv 70 65 75 75 70 60 55 60 55 55 50 mAS F. Radiation Protection: In addition to all normal good techniques for radiation protection. Lateral scapula AP & Lateral humerus. Scaphoid projection series. August 8. Elbow: Radial head Wrist: Oblique. Trans thoracic head of humerus. 1996 NJO / EXTREMITY TECHNIQUE.
If any fractures or dislocations are discovered the patient's affected limb should be immobilised and the patient referred for medical opinion. August 8. a trolley/wheelchair should be used to transport the patient in safety due to the risks of delayed shock. Replace any splints and dressings removed. Check patient understands how to receive the results. Ensure patient understands any preparation instructions are finished Escort to changing rooms/waiting area and bid good-bye. studies for bone pathologies and fractures i. Computer Tomography may be appropriate in special cases. 1996 NJO / EXTREMITY TECHNIQUE. Radio-nuclide Investigations.e.Patient Aftercare: General psychological reassurance. Additional Imaging Techniques: Arthrography Ultrasound of 'foreign bodies.doc 11 . scaphoid.
August 8. 2. Typical fractures of terminal 'tuft' of phalanx. 1996 NJO / EXTREMITY TECHNIQUE.Examples of trauma to the upper limb. 3. Typical fractures / dislocations of phalanges. 1.doc 12 . Typical metacarpal fractures 1st and fifth.
Examples of trauma to the upper limb. 1996 NJO / EXTREMITY TECHNIQUE. 4. Ulna fracture with dislocation of radial head. August 8. 6. 7.doc 13 . Scaphoid fracture."Colles' and 'Smith's" fractures. 5. cont. Supracondylar fractures.
and posterior dislocation. August 8.8. Shoulder anterior dislocation. 1996 NJO / EXTREMITY TECHNIQUE.doc 14 .
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. August 8. THE LOWER LIMB: Lt Femur. 1996 NJO / EXTREMITY TECHNIQUE.doc 15 .
August 8. .doc 16 . 1996 NJO / EXTREMITY TECHNIQUE. Left Foot.Left Tibia and Fibula.
Soft tissue tibial tubercle projection. Weight bearing joint projections. Oblique projections of patella. Talo-caneal joint projections (10°-40° cranial angulations) Oblique projections of the tarsal bones. Typical Exposure Values: (*Dose = Typical Dose from NRPB) Projection AP and Lateral Knee Kv 65 mAS F. Axial Calcaneum. Axial 'Skyline' patella.D. Focus Grid No No No No No No Dose Film/Screen Detail Detail Detail Detail Detail Detail 100cm Fine 100cm Fine 100cm Fine 100cm Fine 100cm Fine 100cm Fine AP and Lateral Tibia 65 and Fibula AP and Lateral Ankle 60 Dorsi-plantar Foot 55 Dorsi Plantar Oblique 55 Foot Lateral Individual Toes. Note projections of limbs must include both proximal and distal joints and be imaged with two projections at 90°. August 8. Sesamoid bone projections. Ankle: Stress views for joint luxation Lateral malleolus projection.Basic Projections of the Lower Limb: AP and Lateral Knee.doc 17 . 1996 NJO / EXTREMITY TECHNIQUE.F. 50 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°. Foot: Lateral Weight bearing projections. AP and Lateral Tibia and Fibula AP and Lateral Ankle Dorsi-plantar Foot Dorsi Plantar Oblique Foot Lateral Individual Toes.
August 8.doc 18 . Computer Tomography may be appropriate in special cases. Radio-nuclide Investigations.Radiation Protection: In addition to all normal good techniques for radiation protection. Patient Aftercare: General psychological reassurance. 1996 NJO / EXTREMITY TECHNIQUE. Additional Imaging Techniques: Arthrography Ultrasound of 'foreign bodies. studies for bone pathologies and fractures. Direct lead rubber gonad protection when the primary beam is directed towards the gonads. Check patient understands how to receive the results. Replace any splints and dressings removed. a trolley/wheelchair should be used to transport the patient in safety due to the risks of delayed shock. If any fractures or dislocations are discovered the patient's affected limb should be immobilised and the patient referred for medical opinion. Ensure patient understands any preparation instructions are finished Escort to changing rooms/waiting area and bid good-bye.
lateral horizontal ray showing fat/fluid level. 1996 NJO / EXTREMITY TECHNIQUE.doc 19 . Fracture of patella.Examples of trauma to the lower limb. Fractures of Tibia Displaced / Undisplaced August 8.
August 8. Fractures of the Talus.Examples of trauma to the lower limb cont.doc 20 . 'March' Fracture of a metatarsal. Fractures of the Calcaneum. 1996 NJO / EXTREMITY TECHNIQUE.
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