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Can I Offer More 4

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Can I Offer More 4

  1. 1. CAN I OFFER MORE SIM KIAN TZE JURU X-RAY SARAWAK GENERAL HOSPITAL UPDATE FOR RADIOGRAPHER
  2. 3. FAT PAD SIGN
  3. 4. Fat Pad Sign and Joint effusion <ul><li>Normal lateral view of the elbow flexed in 90° - a fat pad is seen on the anterior aspect of the joint. This is normal fat located in the joint capsule. - on the posterior side no fat pad is seen since the posterior fat is located within the deep intercondylar fossa. </li></ul>
  4. 5. Fat Pad Sign and Joint effusion Positive fat pad sign Distention of the joint will cause the anterior fat pad to become elevated and the posterior fat pad to become visible. An elevated anterior lucency and/or a visible posterior lucency on a true lateral radiograph of an elbow flexed at 90° is described as a positive fat pad sign
  5. 7. FAT PAD SIGN
  6. 8. FAT PAD SIGN
  7. 9. FAT PAD SIGN
  8. 10. TWO (2) LINES
  9. 11. ANTERIOR HUMERAL LINE PROXIMAL RADIAL/RADIOCAPITELLAR LINE
  10. 12. Normal Elbow Anatomy <ul><li>Radiocapitellar line A line drawn through the long axis of the radius should always point toward the centre of the capitellum whatever the positioning of the patient, since the radius articulates with the capitellum (figures A-D, even when not well positioned. Notice supracondylar fracture on B. </li></ul><ul><li>In dislocation of the radius this line will not pass through the centre of the capitellum. </li></ul>
  11. 13. Supracondylar fractures A : The anterior humeral line passes through the anterior third of the capitellum and in B even more anteriorly. Notice positive posterior fat pad sign in both cases
  12. 14. BACK TO BASIC
  13. 15. ELBOW AP <ul><li>Affected arm extended </li></ul><ul><li>Posterior aspect of entire limb in contact with cassette </li></ul><ul><li>Palm of hand facing upwards </li></ul><ul><li>Centering point </li></ul><ul><li>2.5 cm distal to midline between epicondyles of humerus </li></ul>
  14. 16. ELBOW AP CRITERIA OF GOOD IMAGE <ul><li>Include distal humerus,elbow joint space & proximal rad/ulna </li></ul><ul><li>Radial head, neck & tuberosity slightly superimposed over proximal ulna </li></ul><ul><li>Elbow joint open </li></ul><ul><li>& in center </li></ul><ul><li>Humeral epicondyles not rotated </li></ul>
  15. 17. ELBOW AP MODIFIED
  16. 18. ELBOW AP MODIFIED
  17. 19. ELBOW AP MODIFIED
  18. 20. Common errors in positioning Shoulder higher than elbow For a true lateral view the shoulder should be at the level of the elbow. If the shoulder is higher than the elbow the radius and capitellum will project on the ulna. The solution is either to lift the examination table which will lift the elbow or to lower the shoulder by placing the patient on a smaller chair.
  19. 21. ELBOW LATERAL <ul><li>Elbow flex 90º </li></ul><ul><li>Hand and wrist in lateral position </li></ul><ul><li>Entire arm same plane </li></ul><ul><li>Center at lateral epicondyle of humerus </li></ul>
  20. 22. ELBOW LATERAL CRITERIA OF QUALITY IMAGE <ul><li>Humeral epicondyle superimposed </li></ul><ul><li>Radial head partially superimposed on coronoid process </li></ul><ul><li>Olecranon process in profile </li></ul><ul><li>Humeroulna joint space sharply outline </li></ul>
  21. 23. Common errors in positioning : Wrist lower than elbow The wrist should be as high or even higher than the elbow depending on the normal valgus position of the elbow. The hand should be with the 'thumb up'. If the wrist is at a low position the humerus will rotate because the radius at the level of the wrist is lower than at the level of the elbow.
  22. 24. Incidence and Location of Elbow Injuries <ul><li>ADULTS </li></ul><ul><li>Radial neck 50% </li></ul><ul><li>Olecranon 20% </li></ul><ul><li>Supracondylar 10% </li></ul><ul><li>Fracture/dislocat 15% </li></ul><ul><li>CHILDREN </li></ul><ul><li>Supracondylar 60% </li></ul><ul><li>Lateral condyle 15% </li></ul><ul><li>Medial epicondyle 10% </li></ul><ul><li>Radial neck </li></ul><ul><li>olecranon </li></ul>
  23. 25. Fractures of The Elbow: Distal Humerus fractures <ul><li>Supracondylar fractures </li></ul><ul><li>Most common fracture to occur around the elbow in children </li></ul><ul><li>Transverse or oblique through the distal humerus above the condyles </li></ul><ul><li>Usually distal fracture fragment displaces posteriorly </li></ul>
  24. 26. Supracondylar fractures
  25. 27. Supracondylar fractures A : The anterior humeral line passes through the anterior third of the capitellum and in B even more anteriorly. Notice positive posterior fat pad sign in both cases
  26. 28. Fracture of the Radial head <ul><ul><li>Most commonly caused by a fall on an outstretched arm. </li></ul></ul><ul><ul><li>Most common elbow fracture in adults. </li></ul></ul><ul><ul><li>Radial head fractures can be very subtle and the fracture line may occasionally not be visible on the radiograph. Non-displaced radial head fractures are especially difficult to observe on plain films. </li></ul></ul><ul><ul><li>Look carefully for a visible posterior fat pad sign . This indicates an elbow effusion. Fractures of the radial head may only be detectable by this fat pad sign. The anterior fat pad may also be useful, particularly when it has the appearance of a sail, termed the sail sign. </li></ul></ul><ul><ul><li>When there is strong clinical suspicion for a radial head fracture but a fracture is not apparent on a standard projection, a radial head view or CT may aid in diagnosis.  In an adult patient with elbow effusion after trauma, radial head fracture should be highly suspected or even assumed. </li></ul></ul>Lateral view of elbow showing sail sign
  27. 29. FAT PAD SIGN <ul><li>sail sign </li></ul>
  28. 30. Fracture of the Radial head Left: both anterior and posterior fat pad signs are present. This should increase suspicion of a fracture. However, no fracture is apparent in this radiograph. Right: A different view taken from the same patient. In this view the radial head fracture is apparent.
  29. 31. Radial head-capitellum view <ul><li>A variant of lateral projection </li></ul><ul><li>Overcome the major limitation of the standard lateral view </li></ul><ul><li>Projecting the radial head ventrad, free of overlap by the coronoid process </li></ul><ul><li>Clearly demonstrate radial head, capitellum, both the humeroradial and humeroulnar articulations </li></ul><ul><li>Subtle fractures of these structures obscurred on other projections </li></ul>
  30. 32. Fracture of the Radial head AP and Lat views of elbow: markedly communited and displaced fracture of radial head.
  31. 33. Fracture of the Radial head
  32. 34. Dislocation of The Elbow <ul><li>Most common dislocation in children </li></ul><ul><li>3 rd most common dislocation in adult after shoulder and interphalangeal joints of fingers respectively </li></ul><ul><li>>50% have associated fractures – most common medial epicondyle and radial head/neck </li></ul><ul><li>Classified according to displacement of radius and ulna relative to the humerus: posterior, postero-lateral, anterior, medial and anteromedial </li></ul><ul><li>Practically in all elbow dislocations, both ulna and radius will be displaced </li></ul>
  33. 35. Dislocations of the Radial head LEFT: an obvious radial dislocation. No fracture of the ulna (Monteggia) was found RIGHT: a subtle radial head dislocation. Associated olecranon fracture is seen on carefull inspection
  34. 36. Dislocation of The Elbow <ul><li>Posterior and Posterolateral Dislocation </li></ul><ul><li>Most common dislocations of elbow (85-90%) </li></ul><ul><li>Small % of posterior dislocation will develop posttraumatic myositis ossificans at anterior aspect of joints </li></ul>
  35. 37. <ul><li>Dislocated elbow with avulsion of the medial epicondyle. In this case the epicondyle is not retracted into the joint. </li></ul>Dislocation of The Elbow
  36. 38. Fracture radial head DO YOU SEE ANY FRACTURE ?
  37. 39. NO FRACTURE ?
  38. 40. Repeat radiograph 2 weeks -Fracture epiphysis of radial head
  39. 41. Elbow dislocation
  40. 42. Fracture lateral condyle of Humerus
  41. 43. Fracture medial epicondyle of Humerus
  42. 44. Fracture radial head
  43. 45. Supracondylar fracture
  44. 46. conclusion conclusion
  45. 47. ELBOW LATERAL <ul><li>Elbow flex 90º </li></ul><ul><li>Hand and wrist in lateral position </li></ul><ul><li>Entire arm same plane </li></ul><ul><li>Center at lateral epicondyle of humerus </li></ul>
  46. 48. ELBOW LATERAL CRITERIA OF QUALITY IMAGE <ul><li>Humeral epicondyle superimposed </li></ul><ul><li>Radial head partially superimposed on coronoid process </li></ul><ul><li>Olecranon process in profile </li></ul><ul><li>Humeroulna joint space sharply outline </li></ul>
  47. 49. Normal Elbow Anatomy <ul><li>Radiocapitellar line A line drawn through the long axis of the radius should always point toward the centre of the capitellum whatever the positioning of the patient, since the radius articulates with the capitellum (figures A-D, even when not well positioned. Notice supracondylar fracture on B. </li></ul><ul><li>In dislocation of the radius this line will not pass through the cemtre of the capitellum. </li></ul>
  48. 50. Normal Elbow Anatomy <ul><li>Anterior humeral line: a line drawn parallel to the anterior humerus should pass through the middle third of the capitulum. </li></ul><ul><li>Proximal radial/Radiocapitellar line: a line along the longitudinal axis of the radius should pass through the center of the capitelum in all projections. </li></ul>Lateral view of elbow with anatomical lines
  49. 51. Normal Elbow Anatomy <ul><li>Anterior Humeral line. A line drawn on a lateral view along the anterior surface of the humerus should pass through the middle third of the capitellum. </li></ul><ul><li>In cases of a supracondylar fracture the Anterior Humeral line usually passes through the anterior third of the capitellum or in front of the capitellum due to posterior bending of the distal humeral fragment. </li></ul>
  50. 52. Fat Pad Sign and Joint effusion <ul><li>Normal lateral view of the elbow flexed in 90° - a fat pad is seen on the anterior aspect of the joint. This is normal fat located in the joint capsule. - on the posterior side no fat pad is seen since the posterior fat is located within the deep intercondylar fossa. </li></ul>
  51. 53. Fat Pad Sign and Joint effusion Positive fat pad sign Distention of the joint will cause the anterior fat pad to become elevated and the posterior fat pad to become visible. An elevated anterior lucency and/or a visible posterior lucency on a true lateral radiograph of an elbow flexed at 90° is described as a positive fat pad sign
  52. 54. FAT PAD SIGN
  53. 55. FAT PAD SIGN
  54. 56. FAT PAD SIGN
  55. 57. FAT PAD SIGN
  56. 58. MRI FAT PAD
  57. 59. THAT ALL FOR TODAY THANK YOU Diagrams and notes taken from kursus for trauma radiography Nov 2006-sept 2007 BY DR ZALEHA BT ABD MANAF

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