1) The document discusses radiology of the upper limb, including the shoulder, elbow, hand, and wrist regions. It covers common fractures like supracondylar fractures in children and Colles' fractures in the wrist. 2) Details are provided on age estimation based on appearance and fusion of epiphyseal centers in long bones, with timelines given for the shoulder, elbow, hand, and wrist regions. 3) Assessment of bone age is described for different developmental stages from infancy to post-puberty based on features of the epiphyses.

1. Radiology of Upper Limb
Dr Mathew Joseph MBBS, MD(AIIMS), BCC(Palliative Medicine)
Assistant Professor
Department of Anatomy
Al Azhar Medical College & Super Speciality Hospital
Thodupuzha

2. Content
• Shoulder Region
• Elbow Region
• Hand & Wrist
• Age Determination
• Common Fractures & Dislocations

3. Facts
• In X-ray , translucent portion appears black.
• Dense area absorbs X-ray and shows different
shades of white.

4. Shoulder Region

5. Shoulder Region

7. ELBOW
AP & Lateral

10. Wrist & Hand

13. Clinical Anatomy

17. Supracodylar fracture – common and most serious fractures in
childhood
Mechanism- Fracture is caused by a fall on an out-stretched hand.
As the hand strikes the ground, the elbow is forced into
hyperextension resulting in fracture of the humerus above the
condyles.
Extension- Distal fragment is
extended(tilted
backwards) in relation to
the proximal fragment
Flexion- the distal fragment
is flexed (tilted forwards) in
relation to the proximal
fragment.

18. Monteggia fracture
• Monteggia- Fracture of
the upper-third of ulna
with dislocation of the
head of the radius.it is
caused by a fall on out-
streched hand.

19. Galeazzi- (Counter part of Monteggia)
• Galeazzi- (Counter part
of Monteggia) fracture
of the lower third of the
radius with dislocation
or subluxation of the
distal radio-ulnar joint.

21. Colles Fracture

23. Colles Fracture

25. Colle’s fracture-
• Radius gets fractured about 2 cm above its lower end
due to fall on outstretched hand
Smith’s fracture- Reverse of Colle’s fracture
• If distal fragments gets displaced anteriorly

26. Smith Fracture

28. Age Estimation
• Areas where bone formation or ossification
starts in cartilaginous model are known as
centres of ossification.
• Primary centre appear before birth, secondary
centre(epiphyseal centre) after birth.but
primary centre of carpals and tarsals appear
after birth.

29. Age Estimation
• In long bone with two epiphysis- centre of
ossification appearing first is usually last to
fuse with shaft.
• Long bones with single epiphysis- epiphysis at
more movable end e.g. head of 2-5
metacarpals, base of first metacarpal and all
phalanges.
• Appearance and fusion of epiphyseal centre
occur about 1-2 years earlier in females

30. Shoulder Region
• 1st Year- Head of
humerus
• 2nd –Greater tuberosity
• 5th year- Lesser tub.
• 6th Year- Fusion of upper
end of humerus into one
mass
• FUSION
• 20th Year - Fusion of
upper end of humerus
with shaft

33. Elbow
• Appearance(Years)
• 1st- Capitulum and lateral
part of trochlea
• 5th – Head of Radius
• 6th- Medial epi. Of
humerus
• 9th- Medial part of
trochlea
• 10th- Top of Olecranon
process
• 12th- Lateral epi. Of
humerus
• Fusion
• 15th- Olecranon epiphysis
with upper end of ulna
• 16th – lateral epicondyle,
capitulum and trochlea
into one mass, and with
shaft.
• 17th- Head of radius to
shaft
• 20th – Medial epicondyle
of humerus to shaft

37. i. 6 years: fusion of head
with tubercles
ii. CRITOE (mnemonic): Count
1-3-5-7-9-11 for age
iii. Capitulum: 1 year
iv. Radial head: 3 years
v. Internal
(medial)epicondyle: 5
years
vi. Trochlea: 7 years
vii.Olecranon: 9 years
viii.External (lateral )
epicondyle: 11 years

38. Hand and Wrist
Appearance(Years)
• 1st – lower end radius, capitate,
hamate
• 2nd – Head of 2,3,4,5th
metacarpal, bases of proximal
phalanges
• 3rd – Triquetral, base of first
metacarpal, middle and
terminal phalanges
• 4th – lunate
• 5th – trapezium,trapezoid,
scaphoid
• 6th – lower end of ulna
• 12th- Pisiform
Fusion(Years)
• 17th – base of first
metacarpal
• 18th – epiphysis of
metacarpals, phalanges
and lower end of ulna
• 19th – lower end of
radius

39. Ossification
• Depiction of the order of appearance of the
individual carpal bones. The usual sequence is:
capitate (1), hamate (2), triquetral (3), lunate (4),
• trapezium (5), trapezoid (6),
• navicular or scaphoid (7) and
• pisiform (8).
• The distal epiphysis of the radius ossifies before the
triquetum and that of the ulna before the pisiform

41. Infancy
• Bone age is primarily based on
the presence or absence of
ossification of the capitate, the
hamate and the distal epiphysis
of the radius.
The capitate usually appears slightly
earlier than the hamate, and has a
larger ossification center and
rounder shape. The distal radial
epiphysis appears
later

42. Toddler- Upto Two Years
• Epiphyses of the
proximal phalanges;
• Epiphyses of the
metacarpals;
• Epiphyses of the middle
phalanges; and,
• Epiphyses of the distal
phalanges.

43. Pre-puberty
2 years to 7 years of age
• Depiction of the
progressive growth of
the width of the
epiphyses, which,
during this stage of
development,
• become as wide as the
• metaphyses

44. Pre- puberty
• During this stage, bone
age is primarily based
on the number of
recognizable epiphyseal
ossification centers in
the phalanges and
metacarpals

45. Early and Mid-puberty
7 years to 13 years of age
Depiction of the progressive
growth of the epiphyses,
which, during this stage
of development, become
larger than the metaphyses.
Special attention is also
placed on epiphyseal shape,
which, prior to epiphyseal
fusion, overlaps the metaphyses,
depicting tiny hornlike
structures at both ends
of the epiphysis (picture at
far-right)

46. Early and Mid-puberty
7 years to 13 years of age

47. Late Puberty
Females: 13 years to 15 years of age
• Fusion of the distal
phalanges;
• 2) Fusion of the
metacarpals;
• 3) Fusion of the
proximal phalanges;
and,
• 4) Fusion of the
middle phalanges

48. Late Puberty
Females: 13 years to 15 years of age

49. Post-puberty
15 years to 17 years of age
Depiction, fromleft to
right, of the progressive
degrees of fusion of the
ulna and the radial
epiphyses, which usually
begins at the center of the
physis

50. Post-puberty
15 years to 17 years of age
At this stage of
development, skeletal
maturity is based on
epiphyseal fusion
of the ulna, which occurs
first, and the radius

52. Test

58. Full term Child Has These Centres
• F – femur(Distal ep.)
• T- Tibia(Proximal ep.)
• C- calcaneum
• H- Humerus(proximal ep)
• T- Talus
• C- cuboid

59. Thank You