IMAGING OF THE UPPER EXTREMITIES ➔ May ibang attributed problems as well aside s
spain during mvmt/rest, it might also cause
OBJECTIVES – UPPER EXTREMITY IMAGING
● Familiarize with the upper back and upper extremity
anatomic structures in different imaging modalities
● Interpret a plain radiograph of the thoracic spine,
shoulder, elbow, wrist and hand
● Correlate disease entities to clinical presentation and
features in imaging reports
● Pick the modality of choice and approach to
diagnosis of the clinical entity
● Understand how medical imaging can make the
physical therapy evaluation more comprehensive
and design the most practical treatment scheme for
patients
● Know the risks and benefits of each imaging
technique for patients
REVIEW OF ANATOMY SHOULDER
• BONES
− Proximal Humerus
− Scapula
− Clavicle
• JOINTS
− Glenohumeral joint
− Acromioclavicular joint
• JOINT MOBILITY
SHOULDER RADIOGRAPHY GOALS
The goal of the radiographic examination at the shoulder
joint complex is to identify or exclude anatomic
abnormalities or disease processes.
➔ It’s true that in every aspect that you have in the
shoulder might comprise difficulties in doing the
actions.
➔ Isang component lang na mali or problematic would
cause considerable problems to the shoulder
complex
INDICATIONS OF SHOULDER IMAGING
Indications for radiologic examination include, but are
not limited to:
− trauma including suspected physical abuse
− osseous changes secondary to metabolic disease,
systemic disease, or nutritional deficiencies
− Neoplasms
➔ If there are some unexplainable pain or
problems aside from the organic problem of the
shoulder, it might be a neoplasm - either
benign/malignant
− Infections
systemic problems
− Arthropathies
− Pre-operative, post-operative, and follow-up studies
➔ They would want to see if there are some
changes or if they were able to target the defects
− Pain
− Correlation of abnormal skeletal findings on other
imaging studies
BASIC PROJECTIONS AND RADIOLOGIC
OBSERVATIONS
● SHOULDER
- AP view, ideally IR and ER view
● ACROMIOCLAVICULAR JOINT
- Upright AP view which may be viewed with or
without weights
- They would want to put tension on the shoulder
region to delineate the N areas concerning the
problem
● SCAPULA
- AP and lateral view
- There are few imaging tech that we use for
scapular d/o
➔ When you say observations, these are the
positionings of anat. structures in relation to a
radiograph or an imaging machine
➔ For us to know what are the N positioning,
movements, or anat structures defined on a certain
mcmt
SHOULDER AP – EXTERNAL ROTATION
− The greater tuberosity is visualized in profile at the
most lateral aspect of the humeral head.
− The lesser tuberosity is superimposed at the mid-
area on the humeral head.
− The medial portion of the humeral head is partially
superimposed in the glenoid fossa.
− Thus, the glenohumeral joint space is not visualized
as completely “open.”
− The average width of the glenohumeral joint is 5mm
- If <5mm = rheumatoid arthritis
- IF >5mm = joint effusion, acromegaly or
posterior humeral dislocation
− The crest of the spine of the scapula can be seen
extending across the scapula and broadening into
the acromion.
− The vertebral and lateral borders of the scapula are
superimposed behind the rib cage.
− The acromioclavicular joint is seen superior to the
glenohumeral joint.

ER OR IR?

➔ Since ER positioning to, greater tub will lean more on

posterior aspect and lesser tuberosity on med aspect
➔ 5 mm = half a cm
➔ RA = Diba sa mga autoimmune disease like RA, there
is a multisystemic or multiple joint involvement. So
➔ ER on L, IR on R
meron talagang joint space narrowing
➔ Vertebral border of the scapula is almost obscured
by the ribs but still visible naman
SHOULDER AP BILATERAL WITH OR WITHOUT
➔ Superior border is obscured; almost not visible
because of the thickness of the structures WEIGHTS
surrounding the upper region of the shoulder ➔ At some point, there are some radiographs that
➔ For example may direct blow sa shoulder tapos require weights to see the perfect view of a
biglang nawalan sa alignment yung AC Joint. Anong certain anat. structure or the anatomic
deformity yun? Step deformity. configuration of a certain condition like in the
case of a stress view:
− Stress view is done to view instability of the AC joint
SHOULDER AP – INTERNAL ROTATION
− A 10-15 lbs weight is use on both wrist
− The greater tuberosity is superimposed over the mid-
area of the humeral head. ➔ At times there are some x rays naman that
− The lesser tuberosity is seen in profile on the medial require a higher poundage held by the px while
aspect of the humeral head xray is being done
− The medial portion of the humeral head is partially
superimposed on the glenoid fossa.
- glenohumeral joint space is not visualized as an
“open” joint space.
➔ Saan mas taut yung GH jt? ER
− The crest of the spinous process of the scapula can − The AC joint is evaluated by examining the
be seen extending across the scapula and relationship of the acromion to the clavicle
broadening into the acromion. − The normal joint space distance at this articulation
➔ The crest is the region wherein it almost ranges from 0.3 to 0.8 cm
connects with the acromion process − The relationship of the coracoid process to the
− The vertebral and lateral borders of the scapula are clavicle is also examined
superimposed behind the rib cage. - normal distance between the inferior aspect of
− The coracoid process is visualized end-on the clavicle and the coracoid process, the
− The acromioclavicular joint is seen superior to the coracoclavicular distance, ranges from 1.0 to 1.3
glenohumeral joint. cm
− Any calcium deposits present in muscles, tendons, or
bursae of the shoulder may also be demonstrated
➔ Calcium deposits are leaning on the radiopaque
side
➔ Fats, fluids, effusions: radiolucent
SETTING UP THE RADIOGRAPH

➔ Difference between the WB and NWB xray:

➔ Victor: Fig A looks more compressed - the bones
are pressed downwards compared to the opp
side. Fig B bones look more equal
➔ Victor: Angulation of clavicle on NWB is at an
angle pero sa WB it looks more flat ➔ Look at the angulation of the clavicle and jt
➔ Victor: Coracoclavicular distance on NWB less spaces and compare
distance between the structures compared to
WB
➔ Sir: For WB status, for stress view, for example in AP X-RAY OF THE SCAPULA
the case of a px held a certain eight,
coracoclavicular distance is much larger
compared to those who have no weight at all
➔ Sir: Angulation as well. Angulation for WB almost
approaches 0 vs a slightly elevated angle, maybe
around 15-20 deg above the baseline of the
clavicle [in NWB].
➔ Sir: Joint spaces - Clearance bet acromion and
superior border of GH jt
− Grading of AC separation can be quantified using
− The patient’s arm is in ABER.
these distances:
− Allows the lateral half of the scapula to be assessed
➔ Graded by radiologists/orthopedic surgeons since the rib cage is cleared from the
o Grade I (mild sprain) superimposition
- Minimal widening of the acromio-clavicular joint − All three borders and angles of the scapula are
space with the coracoclavicular distance still usually visible.
within normal range: AC ligaments are sprained.
➔ If we abduct, there is such thing as
o Grade II (moderate sprain)
scapulohumerala, rhythm: Scapula will ride on top
- Widening of the AC joint space to 1.0 to 1.5 cm
of the ribcage and it will be visible on an AP x ray (if
with a 25% to 50% increase in the
sh is in ABER)
coracoclavicular distance: AC ligaments are torn,
cora-coclavicular ligaments are sprained. ➔ At rest, vertebral bored is obscured but once ABER
o Grade III (severe sprain) is done, visible na all borders
- Widening of the acromioclavicular joint space
1.5 cm or greater with a 50% or more increase in
the coracoclavicular distance: Both the AC and
coracoclavicular ligaments are torn. The AC joint
is dislocated and the clavicle appears to be
displaced superiorly
SETTING UP THE RADIOGRAPH
− Diagnostic ultrasound is appropriate for examinaFon
− As always, the results of any advanced imaging study
ADVANCE IMAGING OF THE SHOULDER
− most frequently requested exams for the shoulder
for in depth assessment is MRI
- due to the frequency of soft tissue injuries at
these joints which are best defined by MRI (since
it provides superior view)
➔ MRI should be performed only for a valid
reason—that being the results are anticipated
to effect treatment decisions.
➔ There are times na as low as the CT scan or X
Ray, the decision making process can be almost
CT SCAN OF THE SHOULDER
at a perfect design kase kung minsan, yung isang
Indications for CT:
condition masasabi mo na na OA kunware
● Primary indications for CT include, but are not
without needing further imaging techniques
− radiographs are still the first imaging test performed
for most suspected bone and soft tissue
abnormalities of the shoulder, and will often suffice
either
➔ They suffice in a sense that the dx and problem
can be defined and readily initiate tx for
➔ And at times, with the radiographic imaging, we
can exclude an abnormality and we can define if
there is a direct further imaging that needs to be
requested
➔ syempre depende pa rin. halimbawa, di mo
nakita dito. you do step up -> Go CT then Ultra. If
not, MRI. If not ule, PET with contrast ganyan
- diagnose the problem and initiate treatment
- exclude an abnormality and direct further
imaging
− MRI will be used to define soft tissue injuries
− CT scans will be used most often to define complex
fractures assist in surgical decisions
➔ At times, intra-operatively, they will subject a
patient to a certain technique like the CT scan or
a series of radiograph to see if the fx is stable or
will serve as a basis during the intra-operative
procedure if they are doing the right thing
of the superficial soft tissue structures, including the
rotator cuff muscles and tendons, the long head of
the biceps, and the bursas.
➔ The US basically is an acoustic imaging - it
reduces sound waves to recreate a form of image
into the screen and it is basically used in
superficial structures (MSK), although it can be
used in indepth lien structures but have a lot of
limitations
test may be misleading if not closely correlated with
radiographs, clinical history, and physical
examination of the patient.
➔ At times, you will see na mukhang mas increased
yung coracoclavicular distance nito and AC jt
separation nito pero is the px symptomatic? Are
tehre any sx compatible with what the xray is
showing in reference to the pxs complaint?
Based sa ax, normal ba to sa px? The key here is
you have to correlate whatever the imagingr
result to the situation of the px - you have to
appraise.
limited to:
- Severe trauma
- Assessment of alignment and displacement of
fracture fragments
➔ Why do we consider fracture fragments esp in
the shoulder? What makes it delicate for the
sh region to be assessed that thorough if px
had a recent trauma nd presents with multiple
sx?
➔ Chlowe: Since the sh area is composed of
bones and a part of ribcage so there are also
organs, muscles, and tendons so important
siya.
➔ There are times na may displacement of
fragments would cause significant weakness
d/t nerve impingement, hypovascular
situations on the distant space d/t
compression of blood-rich vascular tissues like
 in the arteries/veins and some compressions ➔ So if you try to assess, the abnormalities are not
to to other regions. We do not want this to present, the jt space are ideal, ribs are there but
happen kasi magiging symptomatic si px not perfectly defined due to the angle, and other
- Identification of loose bodies in the bony structures are in place. Magtaka ka nalang
glenohumeral joint if may displacement or more narrowing bet
- Evaluation of labral or rotator cuff pathology, if structures = suggests ractrue or further imaging
MRI if unavailable or contraindicated
➔ Cases like if the px has metallic
implants/pacemakers/urgency of the case
➔ Paano daw masasabi na urgent? Kunware
may dalawang case: nerve compression and
avascular compression. Which one will you
choose to decompress first?
➔ Raph: Avascular compression
➔ Sir: Yes because it can cause hypoxia - supply
will kill the normal living cells. Insufficiency
of oxygen will kill the other normal living ➔ Coracoid process is there, hum head is in place,
cells. there is an axillary pouch
➔ Sir: Neural compression can be relieved
shortly after the avascular compression.
➔ Sir: Remember na case to case basis pa rin
daw kasi depende din kung gaano kalala
yung effects nung nerve impingement. For
the shoulder, mauuna yung avascular comp.
Kunware in the case of TBI, then there's
neural compression and this could be fatal,
esp that it is crucial to breathing and
regulation of the heart.

➔ 3D CT ng shoulder region
➔ Try niyo hanaping AC joint, coracoid process

MRI OF THE SHOUDER

➔ You can see the AP view and Post view
➔ At times, di mo makiita if mukhang humeral head
or glenoid fossa kasi nasa horizontal view.
− MRI of the shoulder may be indicated to further
clarify and stage conditions diagnosed clinically
and/or suggested by other imaging modalities,
including, but not limited to:
- Arthritides: inflammatory, infectious,
neuropathic, degenerative, crystal-induced,
posttraumatic
- Congenital and abnormal development
- Frozen shoulder and adhesive capsulitis
- Primary and secondary bone and soft tissue
tumors
- Fractures and dislocations
- Infections
- Muscle disorders (depends on the extent of d/o)
- Neurologic conditions
− MRI of the shoulder may be useful to evaluate
specific clinical scenarios, including, but not limited
to:
 - Prolonged, refractory, or unexplained shoulder
pain
- Acute shoulder trauma
➔ In the case na they were able to stabilize but
need to assess further if there are some
structures that they need to stabilize too
− Possible contraindications include, but are not
limited to, the presence of:
- cardiac pacemakers
- ferromagnetic intracranial aneurysm clips
➔ Since ferromagnetic, they might be
displaced and provoke the presence of
aneurysm.
- Neurostimulators and certain cochlear implants
- extensive tattoos
- nonremovable body piercings
➔ Additional: MAYBE claustrophobia - they are
sometimes sedated first before they do MRI
➔ More defined structures
TRAUMA OF THE SHOULDER
− The trauma series includes an AP with the arm in
neutral and special projections indicated by clinical
presentation, such as:
- Axillary view of the glenohumeral joint—
demonstrates the exact relationship of the
humeral head to the glenoid fossa
- Anterior oblique (scapular Y lateral view)—
demonstrates a lateral view of the humeral head
and scapula without having to move the arm
from a neutral position
− MRI is recommended for acute and subacute
shoulder pain if initial radiographs are normal and if
rotator cuff pathology, instability, or labral tears are
suspected.
➔ at times if there is a fibrocartilaginous problems
in the case of the glenoid labrum they subject the
patient to a higher type of study
➔ difference of CT vs MRI, higher and radiation
dose ng CT and none sa MRI
− CT arthrography is recommended if MRI is
unavailable or contraindicated.
− Diagnostic ultrasound, “with appropriate expertise,”
is also recommended in the evaluation of soft tissue
pathology.
➔ kaya with appropriate expertise kasi its too
difficult for the ultrasound to see the soft tissue
problems
FRACTURE OF THE PROXIMAL HUMERUS
● MOI: FOOSH injury
- Elderly: osteoporosis
➔ osteoporosis in elderly is believed to be one of
the culprit that makes the elderly susceptible for
fracture of the proximal humerus
➔ kasi nadedecrease ang bone mineral density
kaya mas susceptible na magkaroon ng fracture
ng proximal humerus
- Young adults: MVA
- These injuries are often complicated by
associated fractures, dislocations, and soft tissue
disruption
● NEER four-part classification system
- The humeral head, from the articular surface to
the anatomic neck
- Greater tuberosity
- Lesser tuberosity
- The shaft, at the level of the surgical neck
▪ Fractures are then identified as nondisplaced or
displaced
* A fracture is displaced if 1 cm or more
separates the fragments or if 45 degrees or
more of angulation is present
● FRACTURES OF THE GREATER TUBEROSITY
- Fractures of the greater tuberosity in middle-
aged and older adults usually result from a fall
directly on the point of the shoulder
 ➔ plus may comorbidity pa like osteoporosis
kaya mas nagiging susceptible to have
fracture ng greater tuberosity
➔ kaso sa mga younger patients they dont
usually develop or have osteoporosis so
they are less likely to have fracture of the
greater tuberosity kasi their bone density is
competitive enough
- These fractures are often displaced and treat
conservatively with several weeks of sling
immobilization.
➔ what are the complications that the patient
could have if its has been immobilized for a
long time; contractures
➔ paano daw marereverse ang long term
effects/complications of contractures
considering pa na may fracture ka pa ng
greater tuberosity? sabi ni alexandria the
great is isometric exercises daw like stress
ball
● FRACTURES OF THE LESSER TUBEROSITY
- Fractures of the lesser tuberosity are rare and
are usually cause by avulsion forces resulting
from forceful contraction of the subscapularis
muscle.
➔ ano raw yung avulsion forces and bakit raw
concerned yung subscapularis? kasi raw
doon raw yung insertion ng subscapularis
muscle
➔ sabi ni mama april avulsion daw is yung
machichip off yung bone and since kasama
doon rin inserted yung subscapularis sa
lesser tubercle kapag nagkaroon ng trauma
na sobrang lakas pati yung bone affected
➔ sir: when the subscapularis has a full
decontraction meaning it was too strong
what will happen is that the point of
insertion might be avulsed from the bone
➔ shear force: an external force will come into
contact with the body and what will happen
is that it will produce friction force and kapag
hindi even yung production nya ng friction
yung isang certain segment will be parang
dislocated or detached
● FRACTURES OF THE HUMERAL HEAD
- Fractures of the humeral head are rare and,
when present, are often associated with
dislocation.
* a portion of humeral head may be sheared
off against the glenoid labrum.
- This type of fracture may be considered an
osteochondral fracture because the fracture
fragment would be partly composed of articular
cartilage.
➔ vascular supply sa cartilage vs bone which has
lesser? cartilage daw yung lesser, so the cartilage
will heal slower
➔ any tissue that is devoid of vascular flow will
entail a longer healing time and will ensue a lot of
complications compared doon sa may rich
vascular supply (need ng antibiotics, fluid,
antiseptic techniques) and healing time daw of
avascular areas may vary depende sa location,
presence of microorganisms
➔ kaya raw doon sa mga nagpapapierce highly
avascular area daw yon kaya matagal magheal
and nagkakaroon pa ng infection compared to the
lower pole ng ears
➔ byproducts daw ng inflammation, yung parang
palpable mass kapag nagsara yung piercing, wbc,
necrotic tissue etc is deposited there
➔ hypovascular: may part daw sa meniscus na
highly vascular and hypovascular
● FRACTURES OF THE SURGICAL NECK
- Fractures of the surgical neck of the humerus are
common.
- Fractures occurring here resulting from direct
blows tend to be transverse and somewhat
comminuted.
- Impacted fractures at the surgical neck are
common in the elderly, especially in
osteoporotic women, often resulting from a
relatively minor fall.
➔ bakit raw kahit minor fall lang pwede nang
magkaroon ng fracture sa surgical neck
especially daw in women: kasi kapag daw nga
may osteoporosis mababa ang bone mineral
density kaya mas susceptible sa fracture
➔ and in the case daw of postmenopausal kaya sila
at risk for fracture is di sinabi ni sir…...
- Management:
* Impacted fractures are treated
conservatively with sling immobilization
* ORIF
TREATMENT OF HUMERAL FRACTURES
● NON-SURGICAL
- Generally, minimally displaced fractures are
treated non-surgically with sling immobilization.
 ➔ papasok raw ang PT during immobile stage
para hindi maging atrophied yung mga muscle
and stiff yung mga joints
- Rehabilitation for early shoulder mobilization
may be instituted at 7 to 10 days after injury, if
the fracture is stable or impacted.
➔ syempre daw dapat stable muna yung fracture
bagio mag initiate ng PT treatment
- Sling immobilization continues for 4 to 6 weeks
until sufficient callus formation is achieved.
➔ ilang weeks daw ba before mag down yung
tone ng muscles? 2-3 weeks daw ang humihina CLAVICULAR FRACTURE
and di na same ang strength. meron − MOI: FOOSH
downgrade sa strength, principle or − About three-fourths of these fractures occur in
reversibility or overload daw ata children younger than age 13 and are known to heal
well.
● SURGICAL FIXATIONS − Fractures of the clavicle are designated by their
- Displaced fractures can be difficult to maintain location at the proximal, middle, or distal third of the
via closed reduction because of opposing muscle bone
forces. - Most fractures (80%) occur in the middle third
➔ kapag raw may displaced fracture or
comminuted fracture nagcocontract daw
yung bone??? in different direction kaya raw
indicated ang ORIF
- Displaced and irreducible fractures generally
require surgical fixation.
- Older patients may benefit from primary
prosthetic replacement (hemiarthroplasty).
➔ kasi one component is weak and they have
to stabilized and they have to put a bridge
and they will install a prosthetic device and
other one will be healing on primary
approach
● Rehabilitation is extensive because of the necessary
length of immobilization.
➔ and patients na nagunderwent surgery they
will in the clinics for long period of time
➔ and px who were recently discharged from
surgical procedure they are readily referred
to clinics to reverse possible complications
● Adhesions that restrict joint motion are a usual
sequela and require aggressive joint mobilization to
TREATMENT OF CLAVICULAR FRACTURES
restore normal joint arthrokinematics and normal
− Most clavicular fractures in children or adults are
scapulohumeral rhythm necessary for normal active
successfully treated with figure-eight bandage
movements of the upper extremity.
splinting of the shoulder girdles.
- restricts shoulder motion to less than 30 degrees
of abduction, flexion, or extension
- Slings also may be used, alone or in combination
with the figure-eight bandage.
- Immobilization continues for 4 to 8 weeks until
no crepitus or tenderness is present at the
fracture site.
 ➔ PT try to reverse the complication during − CT is useful in defining humeral head or glenoid
that healing period impaction fractures, loose bodies, and anterior labral
➔ if may crepitus and tenderness we bony avulsions.
continue pa to immobilize the area − MRI is recommended to assess injury to the rotator
cuff, capsule or labrum.
− Treatment after an initial dislocation is generally
FRACTURES OF THE SCAPULA
nonsurgical and consists of reduction followed by
− Fractures of the body of the scapula are relatively
immobilization and support.
rare and, when present, are usually the result of a
➔ Bankart lesion - lesion on the end of the scapula
direct blow or violent trauma
- common etiology: Motor vehicle accidents ➔ hill-sachs- lesion- deformity on the end of the
account for over half of scapular fractures, and humerus
the high incidence of other associated serious
injuries reflects the great force required to
fracture the scapula.
− Fractures of the glenoid are associated with shoulder
dislocations.
➔ if may shoulder dislocation it might be complex
with glenoid fracture as well or a disruption of
glenoid labrum
− Acromion fractures result from direct downward
blows.
➔ rare or hindi naman panay naffracture and
scapular

DISLOCATION OF THE GLENOHUMERAL JOINT

− The glenohumeral joint is susceptible to subluxation
and dislocation because of the relative lack of bony
stability and the large, redundant articular capsule.
➔ may 3 degrees of freedom (flexion-extension, er-
ir, abd-add) kaya very mobile
− It occurs most often in young adults, less often in the
elderly, and rare in children.
➔ dahil sa extent and level of activity ng younger
adults kay sila mas susceptible
− Classification of glenohumeral dislocations is by the
direction that the humeral head displaced in
relationship to the glenoid fossa: anterior, posterior,
superior, or inferior
- vast majority of dislocations are anterior (over
90%)
● MOI
- Forceful external rotation and extension while
the arm is abducted
- Posterior dislocations are usually caused by a
direct blow to the front of the shoulder or
seizures.
➔ seizures: because of the electric
imbalance activity of the brain will cause
seizures and seizures will cause
uncontrolled firing of the muscles and
will pull the bony structures into
different locations

ROTATOR CUFF TEARS
− Rotator cuff tears may result from an acute
traumatic episode as during a glenohumeral
dislocation, a fall on an out- stretched hand, or a
forceful abduction movement of the arm.
➔ rotator cuffs: SITS (supraspinatus, infraspinatus,
teres minor, subscapularis)
− The most common tear involves the hypo-vascular
critical zone in the supraspinatus tendon 1 cm
proximal to its insertion on the greater tuberosity.
− Tears are either incomplete (partial) or complete (full
thickness).
- may irregularity sa greater tuberosity and may
narrowing sa distance ng acromion and humeral
head
GLENOID LABRUM TEAR
− Avulsion of the labrum off the glenoid rim (Bankart
lesion or fracture) is most often seen in acute trauma
such as during glenohumeral dislocation.
➔ kapag may GH dislocation more or less merong
glenoid labrum tears
− The labrum can also be injured from repetitive
overhead movements.
➔ because that is the time (during overhead
motions) these structures needs to support the
shoulder
− MR arthrography is the most appropriate imaging
study to assess suspected instability and labral tears.
ADHESIVE CAPSULITIS
− Adhesive capsulitis, or “frozen shoulder,” is a chronic
inflammation and fibrosis of the glenohumeral joint
capsule.
− Imaging is important to assess the presence of
predisposing pathology
− Radiographs are the first choice
− MRI would follow if intra-articular pathology is
suspected.
➔ based raw sa observations ni doc hindi lang daw
sa mga may repetitive injury common and
adhesive capsulitis pati rin daw sa mga may
diabetes they are of a higher chance in having
shoulder pain + hindi pa sila active
*check notes on the image
 ELBOW IMAGING
− The routine radiologic evaluation of the elbow
includes three projections demonstrating the distal
humerus, proximal ulna, proximal radius, and their
associated articulations:
- Anteroposterior—The elbow is demonstrated in
anatomic position
- Lateral—The elbow is flexed 90 degrees and the
forearm is in neutral.
- Oblique—The elbow is extended and the
forearm is either fully pronated (internal
oblique) or supinated (external oblique).
− The routine radiologic evaluation of the forearm
includes AP and lateral projections of the entire
length of the forearm as well as the articular ends.
- Abnormal increases or decreases in this angle
may be a sign of fracture or posttraumatic
deformity and can lead to difficulties carrying
heavy objects by one’s side.
− The olecranon process is articulated in the olecranon
fossa in this position of elbow extension.
− The olecranon process can be visualized
superimposed behind the trochlea of the humerus.
− The humeroradial and humeroulnar joint spaces are
well demonstrated.
➔ kaninong bone si olecranon process and
coronoid process - ulna
➔ capitulum and trochlea - humerus
➔ coracoid process - scapula

ELBOW TRAUMA RADIOGRAPHY

− Trauma at the elbow is often associated with fracture
or dislocation
− Two abnormal soft tissue signs indicative of joint
trauma are visible on radiographs
- Fat pad sign—Fat pads become displaced out of
their fossae in response to increased capsular
volume from effusion.
So if there is a joint effusion because of the
trauma, suggestive of whatever etiology it is -
infection, autoimmune problems, it might
demonstrate an increased fat pad sign ELBOW LATERAL
- Abnormal supinator line — An elevation or − The olecranon process is seen in profile articulating
blurring of the outline of the supinator muscle is the olecranon fossa.
seen in association with radial head fractures. − The coronoid process of the olecranon is
− Advanced imaging is warranted if radiographs are superimpose on the posterior portion of the radial
non- diagnostic. head.
− Subtle or osteochondral fractures may be diagnosed − Only the anterior portion of the radial head is viewed
with either MRI, or with CT if MRI is not available or free of superimposition.
contraindicated. − The fat pads of the coronoid and radial fossae are
− Soft tissue injuries or abnormalities of the tendons, normally visualized superimposed together as a thin
ligaments, capsule, cartilage, or synovium may be triangular lucency just anterior to the distal humerus.
evaluated by the use of MRI, MR arthrography, or - In the presence of joint effusion, the fat pads will
ultrasound. displace further anteriorly into a triangular or
sail-like appearance.
ELBOW AP VIEW
− Normally the long axis of the forearm forms a valgus
angle with the long axis of the humerus.
− Values for this angle are usually stated as being larger
in women,
➔ gunstock deformity - cubitus varus
➔ female gender is leaning on the child rearing side
so there is an increase angulation of the elbow
(sabi daw ni God)
− Average normal values range from approximately 5
to 15 degrees.
− The coronoid process is visualized free of FOREARM X-RAY – AP VIEW
superimposition on the internal oblique angle
− The olecranon process is articulated in the olecranon
fossa.
− The joint space between the trochlear notch and
trochlea is visible.

− The radial head, neck, and tuberosity are visualized

free of superimposition. ADVANCE IMAGING OF THE ELBOW
− The capitulum and lateral epicondyle are viewed in − The basic CT exam of the elbow extends from the
profile distal humeral metaphysis to below the radial
− The humeroulnar and humeroradial joint spaces are tuberosity, and across the joint from epicondyle to
visible. epicondyle.
− The basic MRI exam of the elbow includes these
typical pulse sequences:
- T1-weighted sequences to define anatomy
(proton density is common)
- T2-weighted sequences to detect abnormal fluid
and thus highlight pathology (fat saturation and
IR are commonly used)

COMPUTED TOMOGRAPHY OF THE ELBOW

ELBOW LATERAL X-RAY

MRI OF THE ELBOW more defined and distinct the fat pads from their normal position—
rendering them visible as radiolucent structures
within the gray soft tissues.

ELBOW FRACTURE
− Fractures of the distal humerus are classified by
Sign of joint effusion
location as supracondylar, transcondylar,
− ABNORMAL SUPINATOR LINE
intercondylar, articular, or epicondylar.
- lucent line parallel to the anterior aspect of the
- The supracondylar type is the most common
proximal third of the radius approximately 1 cm
elbow fracture in children.
from the anterior margin of the radius
➔ ano kayang vascular structure ang pwedeng
tamaan - brachial artery
- The intercondylar type is most common in
adults.
− Fractures of the radial head comprise about one-
third of all elbow fractures in adults.
− Fractures of the proximal ulna that disrupt the
trochlear notch have the potential to impair the
stability and function of the elbow joint.
− In children, fractures of the distal radial shaft are the
most common of all fractures in the body.
➔ Colles, smith, galeazzi fractures
➔ Tinanong niya if naaalala yung mga yan

➔ left: extension-type supracondylar fracture

➔ right: volkmann’s ischemia; the one on the right
is yung ischemic sa dalawa

➔ Nabanggit naman dito yung mga Medial Epicon,

Lat Epicon - Naalala niya pa daw yung mga ST nila

RADIOGRAPHIC SIGNS OF TISSUE TRAUMA

JOINT EFFUSION
− POSITIVE FAT PAD SIGN
- A positive fat pad sign is produced when an
effusion distend the capsule enough to displace
 Monteggia fracture

➔ transcondylar fracture, foosh injury, cortical

ends are disrupted

HAND AND WRIST IMAGING

− The routine radiographic evaluation of the hand
ELBOW DISLOCATION
− Elbow dislocations are described by the direction in
which the radius and ulna have displaced in relation
to the distal humerus.
− The majority of elbow dislocations involve both the
radius and ulna displaced in a posterior or
posterolateral direction.
includes three projections:
- PA— demonstrates the phalanges, metacarpals
carpals, and joint spaces of the hand.
- Lateral—the long axes of the radius, lunate,
capitate, and third metacarpal normally align
within 10 degrees of each other.
- Oblique—demonstrates the lateral aspects of
the shafts of the long bones of the hand without
the superimposition seen in a true lateral view

WRIST IMAGING
− The routine radiographic evaluation of the wrist
includes three projections:
- PA—demonstrates the arcuate lines of the carpal
rows, ulnar variance, and the radial articular
angle
Colles fracture: fracture on the distal part of the - Lateral—demonstrates the volar tilt of the
radius, scapo-lunate angle, and
radius; distal segment will be dislocated on the dorsal
aspect capito-lunate angle
Smith's fracture: reverse of colles; dislocate the distal - Oblique—the radial-side carpals and the hamate
are well visualized
on the volar aspect
 FRACTURES OF THE WRIST
− The scaphoid bone is the most frequently fractured
carpal bone.
− The entrance of the blood supply through the distal
pole puts fractures occurring at the waist or proximal
pole at risk for avascular necrosis.
➔ kienbock's disease - osteonecrosis of the lunate
− The distal radius is the most frequently fractured
bone of the wrist.
- Colles’ fracture
* extra-articular fracture located about 1 1/2
inches proximal to the distal end of the radius,
with dorsal angulation of the distal fragment.
* Associated fractures of the ulnar styloid are
often present.
➔ first ossified bone sa carpal bones - capitate
➔ most dislocated - lunate
➔ most fractured - scaphoid

FRACTURES OF THE HAND

− Fractures of the hand are probably the most ➔ LEFT: 5th metacarpal fracture - boxer’s fracture
common fractures in adults.
− Distal phalanges most often sustain crush-type
fractures. Fractures of the remaining phalanges and
metacarpals are described by their location at the
head, neck, shaft, base, or intra-articular region,
including avulsive-type fractures at the attachment
sites of tendons and ligaments.
− Fractures of the metacarpals of the hand occur most
frequently at the neck of the shaft.
➔ it is believed that it is the weakest point, and
that's the point of the meeting up whenever the
person develops osteochondral ossification,
kaya more common in this are
− Fractures of the metacarpals of the thumbs occur
➔ pls zoom yung picture sa taas at baba nito
most frequently at or near the base of the shaft and
are divided into intra- and extra-articular types.
 synovial cysts, and joint deformities such as
swan-neck deformity and boutonnière deformity

SOFT TISSUE DISORDERS

− triangular fibrocartilage complex (TFCC)
- important stabilizer of the distal radioulnar joint
- can be torn in isolation or in association with
other injuries
- MRI and MR arthrography identify these lesions.
− Carpal tunnel syndrome
- compressive neuropathy of the median nerve as
it passes through the wrist.
- Electrodiagnostic studies are currently the
definitive diagnostic modality but some special
tests are helpful naman
- advanced imaging is may be of help to diagnose
this syndrome

DULO Q n A
- fracture daw na may callus formation - makikita
daw sa images na parang may nodes
- may name daw ba sa adults yung avascular
necrosis - AVN of the femoral head lang daw
talaga
- most likely images daw lalabas sa quiz
- small amount of steroids walang significant
systemic effect sa body, pero too much will
ARTHRITIDES OF THE WRIST cause reversal chena tas may HPO axis
− Degenerative joint disease (DJD) is common in the something
small joints of the hand after the fifth decade of life.
Radiologic hallmarks are decreased joint spaces,
sclerosis, and osteophytosis.
− Heberden’s nodes are DJD deformities in the distal
interphalangeal joints; Bouchard’s nodes are DJD
deformities in the proximal interphalangeal joints.
− Rheumatoid arthritis characteristically manifests in
the small joints of the wrist and
metacarpophalangeal joints.
- The radiologic hallmarks of rheumatoid arthritis
include uniform joint space narrowing,
periarticular rarefaction, articular erosions,