Chest

1. What are the 3 divisions of the chest?o Respiratory o Bony thorax o Mediastinum

2. What is the pharynx? What are the 3 subdivisons?Pharynx- passageway for food and air

o 3 subdivisions Naso Oro Laryngopharynx

Uvula- separates oro and laryngopharynx3. What is the larynx and where is it located?

Larynx- C3 to C6o Thyroid cartilage

4. What is the Trachea? Where is it located? C6 to T4/T5

o Windpipeo Rigid rings

5. What is different about the Rt./ Lt. bronchi? What is aspiration? o Carina- T5o Right bronchi- short, wider, more vertical o Aspiration- when food or water goes into lungs

More apt to go to right bc it is shorter and more vertical 6. How many portions do the left and right Lungs have?

o 2 portions on lefto 3 portions on right

7. What is the Apex? What are the apices? top of lungs

Apices- both top of lungs 8. What is the Parietal pleura? What is the pleural cavity?

outside lining of lungs o Pleural cavity- releases serous fluid to reduce friction

Pleurisy- inflammation in pleural cavity 9. What is Parenchyma?

general lung tissue 10. What are the steps of Respiration?

o Starts at larynx then trachea then right and left bronchi, secondary bronchi, then bronchial lobes, then alveoli

11. Landmarks for positioning? o Jugular notch T2- T3

Center 3 to 4 inches inferior to notch is central ray Want to put central ray at T6- T7 for AP

o Sternal angle/ Carina T4/T5

Hard to find o Xiphoid process- T9/T10 o Inferior scapula borders- T6/T7

On back of shoulder blade Brings you to exact level of central ray

12. What are the Clinical indications for a chest x-ray?o Pre op screeningo Chest paino Physical examo Numerous pathologies o Post trauma o F/U follow-up to phenomena

13. What are the Pathologies for a chest x-ray? 14. What is dyspnea?

Dyspnea- difficulty breathing 15. What does COPD stand for?

chronic obstruction pulmonary disease hard to breathe emphazema can come from this

16. What is atelectasis? collapse of lungs with scaring from the collapse

i. Looks blackii. Have to go up in technique

17. What is pnemothorax? accumulation of air in pleural space go down in technique

18. What is bronchiectasis? irreversible inflammation

19. What is the difference between benine and malignant? Benine- non-cancerous

1. More smooth Malignant- cancerous

2. No definite rounded shape, hazy around the edges or spiculated

20. What kind of technique do you use? What kind of contrast is it? What is the kVp range?

a. Long scale contrast b. 100 kVp or higher is required

21. What is hypersthenic vs hypostenic and asthenic?o hypersthenic male patients require 14*17 crosswise o hyposthenic- very small patient o sthenic- average patient

o asthenic- tall narrow patient o Women always safe doing 14*17 lengthwise

22. How do you reduce heart magnification? PA- reduce heart magnification

o 72’ SID for reduction of magnification o Left lateral- bring heart closest to image receptor

23. What is an Apical axial? o Requires a 25-30 degree cephalic angle to bring clavicles away from

lung apices o CR 2 inches inferior to jugular notcho Radiologist sees an artifact in chest only in superior aspect of chest o Same SID and technique as PA chest but increased collimation

24. What is an Apical lordotic? o Patient leaning backo Angle patient instead of tube

25. What is a Decubitus and why do you do it? How must the CR be?o See air fluid levelso Pneumo- side up/ effusion- side down o Patient should be in the side position for 10 minutes to allow for

delineation of air/fluid levelso Book/boards= 20 mins o Patient will need to be propped up to include all anatomy o CR must be horizontal o If right numothorax you want to do a left decubitis

Whatever side the air is in you want that side up If fluid in right lung you want right side down If you don’t know then side of interest is that side down

26. What is an Oblique and why would you do it?o If potential super imposition o 10-15 degrees for superimposition o 45 degrees RAO/LAO preferred for pathology in lung field, reduces

magnification o 60 degree LAO oblique for heart studies o CR level @ T7o 110=125 kVp, on 2nd inspiration

27. What does AEC do? automatic exposure control keeps technique consistent

o You have to set mA but it controls the time, sets total mAso Has 3 chambers

Right and left= PA, decubitis and oblique Lateral and apical would use center chamber

Abdomen

28. What are Clinical indications for the abdomen?o Rupture/perforation of abdominal viscerao Obstruction o Infectiono Pathologies

Pneumoperitoneum (free of intraperitoneal air) Air/fluid levels Cholelithiasis and urolithiasis

(biliary and renal calculi) Ascites (build up of fluid in abdomen)

Usually caused by fluid in liver Volvulus (twist of bowel upon itself) Intuessusception

29. What is pnemoperitoneum?30. What is cholelithiasis?31. What is urolithiasis?32. What is ascites?33. What does volvulus mean?34. What is intuessusception?35. What are the 9 regions of the abdomen?36. What are the Clinical landmarks?

o Xiphiod- T9-T10 for locating MSP, superior abdomen/diaphragmo Inferior costal margin- L2-L3, lower part of ribs o Iliac crest- L4-L5o Greater trochanter at level of symphysis pubis

37. What does Supine mean? Why is it performed?a. Most frequently performed for initial and f/u evaluation of most

pathologiesb. Also performed as the “scout” image for upper and lower G.I. series;

excretory urography; biliary procedures 38. What are the Positioning criteria for supine?

a. Patient placed in supine position with MSP centered to mid tableb. Central ray directed perpendicular to iliac crest (must include

symphasis pubis)c. kVp range 80 for digitald. Gonadal shield for a malee. Apply breast shield for a femalef. Correct respiratory phase on exhalation

i. Pushes the diagram up ii. Decrease peristaltic activity (gets rid of motion)

39. Why do you perform an Erect/upright position?a. Done for air/fluid levelsb. Rule out atopic organs

i. Situs Inversus is when intestines are reversed ii. Dextrocardia- just the heart on the reversed side

c. Must include diaphragms d. Patient should be positioned PA if kidneys not of primary interest to

reduce breast/godnal dosei. This needs to be done first when this is ordered

ii. Unless the renal system is involved then it is always PA because it reduces significant gonad and breast radiation

e. Allow 10 min for air/fluid levels to develop40. What is the Positioning criteria for an erect PA?

a. Patient positioned PA on vertical table or upright unit with MSP centered to film

b. Central ray directed perpendicular and 2 inches superior to iliac crestc. Respiratory phase on full exhalationd. Increase kVp 6-10e. Shield gonadal region

41. Why do you do a x-ray PA and not AP? When do you do an AP? a. You significantly decrease patient dose b. Do it AP only when looking at kidneys

42. What kind of Lateral decubitis is preferred and why?a. Left lateral preferred

i. Immediately turn on left side if in a stretcherii. Do left lateral so you get rid of gastric bubble only goes as far

as stomach and if there is free air then it goes into diaphram 43. Where do you put the central ray for a decubitis? What marker do you put?

a. Alternate for erect or if required by protocolb. Allow 10 mins for air/fluid separationc. Central ray directed to MSP and 2 inches superior to iliac crestd. Full exhalation e. Same exposure as erectf. Side marker on down sideg. Put marker near pelvic

44. Intestinal obstruction? What can common mechanical causes include? o Can be mechanical or malfunctiono Common mechanical causes include:

Surgical adhesions Diverticulitis - when diverticulum (balloon shaped coming out

from wall of lower intestine) bursts Foreign body Volvulus Tumors

Hand

45. What are the types of Fracture? a. Longitudinal b. Spiralc. Simpled. Compound

i. Very serious ii. Parts of fracture have gone through the skin

e. Oblique f. Comminuted

i. Multiple fragmentsg. Impacted

i. Common in elderly ii. Pushing the bone back against itself

iii. A lot in humerus and femur h. Compression

i. In thoracic or lumbar spine ii. Kyphosis- hunch back

46. What is the most common fractured site in the hand? a. Distal phalanx most commonly fractured site in hand of adults and

childreni. ½ of all hand related FX

ii. tuft- bony part at the very end of the finger b. Metacarpals are 2nd-1st digit (thumb) 3rd

47. How many phalanges are there? How many IP? How many metacarpals? How many MCP joints?

a. 14 phalanges b. 9 interphalangeal joints (IP joints)c. 5 metacarpalsd. 5 metacarphalangeal (MCP) joints

48. What side is the thumb always on?a. Thumb is always lateral side

49. What are the bones of the hand? What is the acronim for them?a. Phalanges labeled medial to lateral b. Proximal then lateral to medial then go to distal row by lateral to

medial c. S.C.T.P.T.C.H

50. What is a diarthrodial joint?a. Diarthrodial joint because they are freely moveable

51. How do you position a PA Hand? What kind of receptor plate do you use? What is the kVp? Where is the CR?

a. Affected side closet to table with arm flexed 90 degrees with elbow bent

i. Helps minimize angulation and rotation at the hand and wristb. 100 ss (extremity) receptor or CR platec. Usually 60-65 kVpd. Shield ½ shield appropriate for adults

i. Full apron for childrene. Hand fully pronanted with digits extended f. CR perpendicular to 3rd MCP joint g. Collimation from tufts to proximal carpal row

i. Include part of radius and ulna (1 inch)52. What anatomy is demonstrated on a PA hand?

i. Interphalangeal and MCP jointsii. Base of 3-5 metacarpals best seen free of superimposition

iii. All soft tissueiv. Include carpals and 1’ of distal radius/ulnav. 1st digit seen in PA oblique position

53. What is the position for a PA Oblique? Why do you increase kVp and by how much?

a. Hand rotated 45 degree laterallyb. Fingers in extension or slightly flexed per protocols c. CR perpendicular at 3rd MCP joint

i. Near knuckle d. +3 kVp because you need to penetrate because you start to

superimpose e. You want to see carpal and metacarpal of thumb and 1st phalange

54. What do you want to see in a PA oblique hand?a. Base of 1st and 2nd metacarpals seen free of superimposition, as well as

1st carpometacarpal jointb. Base of 3-5 metacarpals seen with slight superimpositionc. Sesamoid frequently seen medial to 1st metacarpal head

55. What is the positioning for a Fan lateral hand? Where is the CR? What do you increase the kVp by? Why would you do a fan lateral?

a. Most commonly performed lateral b. Medial aspect closest to receptor c. Digits separated as much as possibled. CR is perpendicular to 2nd MCP jointe. Get individual laterals of 4 digits f. Increase kVp by 10g. Provides whether the fraction is in the anterior or posterior part of

the anatomy 56. What is a Lateral with flexion “relaxed”? Why would you do this? Where is

the CR? What do you do to the kVp?a. Evaluate anterior vs posterior metacarpals FX’sb. Truest lateral of metacarpalsc. Less painful for painfuld. Always perform for post reduction radiographse. CR is perpendicular to 2nd MCP joint f. Fan and relaxed lateral= +6 kVp

57. Why do you perform a Full extension lateral? Where is the CR?a. Used to demonstrate suspected soft tissue foreign bodiesb. Provides optimal superimposition of phalanges

c. CR is perpendicular to MCP joint d. Usually recommend with “soft tissue exposure” (1/2 mAs) for analog

imaging only58. What is an AP oblique also called?

a. “ball-catcher’s/norgaard”59. Why do you do an AP oblique? Where is the CR?

a. Performed bilaterally so you can compare right and leftb. Use 100 ss analong receptor c. R/O early arthritic changes and base of proximal phalangesd. Rheumatoid arthritic- joints are deteriorated and very painful

i. Decrease kVp 6-10 depending on severity e. CR is right between two hands

60. What do you do for a Traumatic hand protocol?a. 2 AP approach b. Do AP of phalanges parallelc. Do AP of metacarpals parallel

61. In an AP thumb where is the thumb placed? What is the kVp?a. Affected hand is hyper pronanted to place the dorsal aspect of thumb

in contact with receptor b. CR is parallel to MCP joint

i. Make sure you get to bottom on hand to make sure you include scaphoid

c. 60 kVpd. Attempt to free the base of the carpometacarpal region of soft tissue

superimposition e. Must include carpometacarpal articulationf. Hyperpronante until thumb is in superimposition g. Have them take their other hand and pull the hand being x-rayed back h. Make sure they don’t over rotate the thumb

62. PA Oblique thumb placement? Where is the CR?a. Place hand in true PA position with 1st digit separated from other

digitsb. Thumb is naturally obliqued 45 degree when hand is pronanted c. CR is perpendicular to MCP Joint

63. What do you do for a Lateral thumb?a. Rotate digit into lateral position by arching fingersb. CR is perpendicular to MCP Joint

64. What is a Bennett’s FX? Where is it? a. Primary intrarticular type associated with the 1st digitb. A fracture dislocation- base of 1st MC- 1st CM joint c. Make sure it is healed so they don’t get severe arthritis d. Fracture of the proximal end of the 1st metacarpal with dorsal and

lateral dislocation of the distal segment65. When can an Avulsion fracture happen? What is it?

a. Bone fracture, which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma.

b. Occur at the ligament due to the application forces external to the body (such as a fall or pull) or at the tendon due to a muscular contraction that is stronger than the forces holding the bone together

66. What is a Rolando FX?a. A “comminuted” (has multiple fragments) Bennett’s b. Intra-articular type with many fragments c. Much more difficult to treat then regular Bennett’s because of

multiple fragments 67. Why would you do a Robert’s projection? How would you do it?

a. Useful in assessment of “Bennett’s” vs “Rolando” FXb. 1st digit is positioned same as routine AP thumbc. Incorporates a 15 degree angle proximally/to the elbow d. Uses distortion to help differentiate possible fragments

68. What position would you do if you wanted to see digits 2-5?a. PA- PA oblique and lateral positions are performedb. Positioning criteria is same as PA, PA oblique hand and lateral thumb c. For all digits (2-5) CR is perpendicular proximal interphalangeal joint

(PIP)i. Has to be here so there is no beam divergence/ no distortion

ii. As beam emerges from tube and spreads out laterally it starts to come out an angle so when you center at a certain joint then there is less distortion

69. Where is a Boxer’s FX? In what metacarpal is it the most common FX?a. Metacarpals are 2nd most frequently fractured area of the handb. Boxer’s is the most common FX of the 5th metacarpalc. It is a transverse FX through the neck of the metacarpal, with volar

(anterior) displacement 70. What do you do for a plaster cast? What if the cast is still wet?

a. Plaster = 2x > mAsi. If it still has moisture in it then you must 2x the mass plus 10%

more kVp71. What do you do for a waterproof cast?

a. Waterproof = +3 kVp

72. What is the difference between a closed reduction?a. Post reduction protocols b. Closed reduction-simple realignment w/o SX, apply pressure c. Internal fixation- put screws, etc or need SX

Wrist

1. What do you do for a PA wrist?a. Patient is positioned with affected side closest to table with arm

flexed 90 degreesb. Mid carpus centered to mid receptor

c. Fingers are then flexed or elevated to bring carpals in contact with receptor or make a fist

d. CR is perp to midcarpus 2. Why do you have the patient make a fist?

i. This minimizes OID (object image distance) and increases resolution and minimizes magnification distortion

3. What is the PA critique? What do you want to see?a. Collimation should include from mid metacarpals to 2” of the distal

radius/ulnab. Proximal scaphoid, capitate and hamate are the only carpals seen free

of superimpositionc. Radiolunar joint is well demonstrated

4. How do you do a PA Oblique wrist? What is the kVp?a. Wrist is rotated 45 degrees to receptor planeb. CR perp to midcarpusc. Best demonstrates the trapezium, trapezoid free of superimposition

and the distal scaphoid and lunate are well seen d. 3 kVp is good

5. How do you do an AP Oblique wrist? What does this projection show free of superimposition?

a. Wrist semisupinated and adjusted at 45 degrees obliquity to receptor place

b. CR directed perp to midcarpus c. Best demonstrates the pisiform and triquetral free of superimposition d. Only routine projection that shows pisiform free of superimposition e. Can either supinate or pronante

6. How do you do a Lateral wrist? What does this best demonstrate? Where do you put the marker?

a. Rotate hand and wrist to a true lateral position with ulnar aspect in contact with receptor

b. CR perp to midcarpusc. Best demonstrates anterior vs posterior displacement of structuresd. Put marker on anterior side

7. What is the difference between a Colle’s vs Smith’s FX? What are they both associated with?

a. Both associated with the distal radius and ulnab. Colle’s most common in females > 50 because of osteoporosis c. Colle’s- FX distal radius with posterior (dorsal) displacement

i. Happens when they fall forward on the outstretched armii. Posterior displacement with ulna styloid FX

d. Smith’s- FX distal radius with anterior (volar) displacement i. Fall backwards

ii. Anterior displacement 8. How would you see if there is a fracture?

a. To see if there is a fracture RA look for cortex of bone (outer lining of bone)

b. Suppose to be smooth c. And look for bone trabeculae pattern should be smooth endless

fractured i. Pathology more interrupts boney trabeculae

9. What is the most commonly fractured carpal? Why is it important to visualize early?

a. Scaphoid injuriesb. Most commonly fractured carpal (80% of all carpals FX)c. Important to properly visualize early due to vascular supply and

decrease ANV (avascular necrosis) bone begins to die 10. What Projections do you do for a scaphoid injury?

a. PA- ulnar deviationb. Stetcher’sc. Multi-angle series

11. What are the common sites of scaphoid FX?a. 70% happen at waistb. 20% proximalc. 10% distal

12. Why do you do Ulnar vs radial deviation? a. Do them for ligament stability b. Radial- medial carpal bonesc. Ulnar-scaphoid

13. What is the Stetcher’s projection?a. Performed to better demonstrate the scaphoidb. Scaphoid seen w/o anatomical foreshortening or bony

superimpositionc. 2 methods- both required hand in maximum ulnar deviation

i. Both open and elongate the scaphoid 14. What is a True Stetcher’s? Where is the CR? What does this do?

a. Wrist is pronanted in max. ulnar deviationb. Hand is then elevated 20 degreesc. CR is perpendicular “snuffbox”d. 20 degree angle brings scaphoid parallel to IRe. Deviation decreases palmar tilt of distal pole f. Open and elongate scaphoid

15. What is a Modified stetcher’s? what do you angle? What does this show?a. Hand and wrist are pronanted in maximum ulnar deviationb. CR @ 20 degrees proximal angle c. Fingers in flexed position d. Angle tube not anatomy e. Open and elongate scaphoid

16. What does ulnar deviation do?a. Ulnar deviated pulls the prox pole of the scaphoid out from

underneath the lunante17. What does the angle do to the scaphoid?

a. Angle reduced superimposition of scaphoid up on itself and opens and elongates scaphoid

18. What does the multi-angle series for scaphoid?a. 4 exposure seriesb. Demonstrates occult scaphoid FXc. Same as PA with ulnar deviationd. 0-10-20-30 degrees proximally

19. What is the Carpal canal/tangential/gaynor-hart? Why do you do it?a. Used to visualize the “carpal tunnel”b. R/o carpal tunnel syndrome

i. Usually damage or narrowing of a canal (stenosis)ii. Any type of narrowing puts pressure on the nerve

iii. Repetitive motion over a long period of time 20. What is an EMG?

a. electromylo cardiogram- test for carpal tunnel1. Nerve conduction study

21. What does the carpal canal show?a. Visualize pisiform and hamulus free of superimposition b. Perfect for hamulus and pisiform and AB oblique

22. How do you do a Carpal canal/tangential? a. Affected arm extended and parallel to tableb. Hyperextend hand and wrist (attempt to place fingers 90 degrees to

receptor)c. CR directed 25-30 degrees angled to base of 3rd metacarpald. Less hyperextension=more tube <e. Slight 5 degree rotated toward thumb to help elevate hamulus

23. Why do you perform a AP wrist? What does it demonstrate?a. Used to better demonstrate intercarpal spaces and r/o ligamentous

disruption or carpal instability DO NOT TO PA WRISTb. Fingers clenched to increase stress on ligaments c. Have patient clench wrist d. Do AP to demonstrate spaces in between carpals better because their

more parallel to beam and IR i. PA closes a lot of these carpal spaces

24. What is a Terry Thomas?a. Terry Thomas sign (scapholunar disruption) big space between

scaphoid and lunate 25. What does show Lunate dislocation?

a. lateral (if you see moon of lunate sitting over the radius then it’s a typical sign of lunar dislocation)

26. What is Kienbocks disease?a. avascular necrosis of the lunate b. It can re-vascularize quickly with immobilization

27. Lateral wrist in flexion a. Extension and flexion for carpal instability along with AP wrist

28. What is a carpal boss? Where does it occur?

a. Carpal boss- bony lump on the back of the hand. The carpal boss occurs at the junction of the long hand bones and the small wrist bones

Elbow and forearm

29. What side is the ulna on? What does the trochela notch allow for? Anatomy of the elbow?

a. Ulna side is medial b. Trochela notch allows for extension and flexion

i. Associated with distal head of the humerusc. Radial head, neck, and tuberosityd. Radial head associates with capitulum

30. What is the Arthrology of the elbow?a. Diarthrodial “hinge” articulationb. Humeroradial (capitulum and radial head)c. Humeroulnar (trochlea and trochlea notch)

31. Fractures associated with the forearm (Pediatric)a. Look for growth plates on child forearm b. Torus (“buckle” fracture)

i. Not an impaction fractureii. Prolapse and pops back out but leaves a fracture line

iii. From falling c. Greenstick

i. Occurs with complete fracture on cortex sideii. Bone doesn’t brake completely through

iii. Usually caused by bending of the arm iv. Also an early sign of child abuse

d. Salter- harris i. Lots of classifications

ii. Fracture that involves the apophysis32. Fractures associated with the forearm (adult)

a. Parry (nightstick)- an isolated fracture of the unlai. Mid shaft of the ulna

ii. Goes completely through bone b. Monteggia- FX of the proximal 1/3 of the ulna with dislocation of the

proximal radiusi. On outstretched arm

c. Galeazzi- mid to distal 1/3 radius with dislocation distal radiolunar joint

i. On outstretched arm33. How do you do an AP forearm? What do you do to the hand?

a. Long bone- must include joints proximal and distal to injuryb. Anode heel effectc. Arm extended and supinated- humeral epicondyles parallel to

receptor

i. Any pronation will cross over the radias and ulna d. CR is perpendicular to midshaft

34. How do you do a Lateral Forearm? Where is the CR?a. Arm flexed 90 degrees with humerus and forearm in same plane

i. If the table doesn’t move then you can use a sponge or ask patient to squat down

b. Hand and wrist rotated into lateral positionc. Humerus needs to be on the same plane d. CR is perpendicular to midshaft

35. What makes a perfect lateral?i. You want elecronon process free of superimposition

ii. Want to see trochelar notch free of superimpositioniii. See coronoid iv. Distal Radius and ulna is superimposed

Elbow

36. What is the percent of injuries to the adult elbow involve the radial head and neck (fall on outstretched arm with forearm pronated)

a. 50%37. What is the kVp for the elbow?

a. around 6538. What are the different types of fractures that can happen to the radial head?

a. Mason fractures 1-4:i. Type 1: non-displaced fracture simple fracture of the radial

headii. Type 2: fracture with radial displacement

iii. Type 3: comminuted iv. Type 4: fracture with dislocation of the proximal radius

39. What does type 3 and 4 have in common?a. Type 3 and 4 usually with open reduction with internal rotation

40. AP Elbow? Where is the CR? a. Elbow extended with hand supinationb. Epicondyles must be parallel with receptor planec. Wrist has to be fully supinated d. CR is perpendicular to joint

i. Right at the level of epicondyles 41. How can you tell it is an AP?

a. You can tell its AP:i. Medial epicondyle free of superimposition

ii. Rest of it is a survey iii. See elecronon fossa iv. 1/3 to ½ of the proximal radius will still be superimposed by the

ulna 42. Medial (internal) oblique

a. Elbow is positioned similar to AP, then entire arm is rotated medially to place epicondyles in a 45 degree plane

b. CR is perpendicular to jointc. Common area for an avulsion fracture

43. What does the internal oblique best demonstrate?a. Position best demonstrates the coronoid process and trochlea

44. What is the difference between AP vs Lateral oblique? a. Lateral- no superimposition of the proximal radius and ulnab. AP- 1/3 superimposition of the proximal radius

45. Lateral (external) obliquea. Elbow positioned same as APb. Entire is rotated laterally to place epicondyles in a 45 degree planec. Lean patient laterallyd. CR is perpendicular to joint

46. What does the lateral external oblique best demonstrate?a. Best demonstrates the radial head, neck and tubercle and capitulum

47. Lateral elbowa. Elbow is flexed 90 degrees with humerus and forearm in same planeb. Hand and wrist rotated into a lateral positionc. CR is perpendicular to joint

48. What does the lateral elbow best demonstrate?a. Best demonstrates olecranon process and trochlear notch

49. When should you see fat pads? What are the posterior, anterior, and supernator fat pads?

i. You should not see fat pads endless there is an injury ii. You do not see the fat pads on any other position but the

lateral iii. Posterior- elecronon fossa, distal humerus or elecronon iv. Supernator fat pad- lies in soft tissue anterior of the proximal

radius 1. 100% for radial head FX

v. Anterior- coronoid fossa, distal humerus FX 50. What does a supernator fat pad mean in terms of the radial head?

1. 100% for radial head FX

Shoulder and Trauma Elbow

51. Label the Anatomy of shoulder and clavicle.

52. What are the 4 primary muscles of the rotator cuff?o Responsible for stabilizing the shoulder during various movementso Consists of 4 primary muscles

Supraspinatus- assists the deltoid muscle in abduction Infraspinatus- lateral rotation Teres minor- lateral rotation Subscapularis- medial rotation

53. What do the various shoulder protocols depend on?o Various shoulder protocols

Protocol dependent on pt history Pain/pathology Hx of trauma Thoracic outlet syndrome

54. What is usually the pathology/pain protocol? Pathology/ pain protocol

Usually 2 AP positions AP with internal AP with external CR perp 1” inferior to coracoid

55. Why would you perform an AP internal shoulder? What does it show? AP Internal

o Used to r/o bursitis, tendonitis, Hill-Sach’s defect Hill-sachs- trauma to shoulder, caused by anterior dislocation

to humeral head o Moves the lesser tubercle inferomedial and into profile

Neutral position of the arm will not move the lesser tubercle56. What is a Hill sachs? What position shows this?

Hill-sachs- trauma to shoulder, caused by anterior dislocation to humeral head

Internal rotation 57. Why would you perform an AP external shoulder? What does it show?

o AP External Moves greater tubercle superiolateral and into profile

o Palm up58. What is a “Bankart lesions”? What position shows this?

External rotation Anterior dislocation of the rim of the glenoid

59. What does a 15-degree caudal angle show? Sometimes do a 15 degree caudal angle to look for osteophyte in

subacromial space 60. What is the usual trauma protocol?

Trauma Protocolso Usually include AP (anatomical or neutral)o Then any of the following:

Glenoid (AP Oblique)

Apical Oblqiue PA Scapular “Y” Inferosuperio axial Transthoracic

61. What is the AP Oblique? What is it also called? How is the pt positioned? Glenoid (AP Oblique)o Patient is either AP with arm either anatomical or neutral positiono MSP is rotated 45 degrees towards the affected sideo CR is perp glenoid o Do this is the patient cannot internally and externally rotate their

hand 62. What does the AP Oblique show?

o Shows glenoid in profile and glenohumeral space Greater tubercle in profile

o When clavicle looks like a snake that means their obliqued to that side When ribs elongated and more vertical than horizontal then

turned Not seeing face of glenoid

63. What is the AP Apical oblique also called? o Apical oblique

Referred to as 45-45 45 degrees towards affected side Position is same as AP Oblique but CR is directed @45 degrees

caudal64. What does the AP Apical oblique show?

o Opens subacromial space, elongates the humeral head and neck o See glenoid in profile, glenohumeral space, and greater tubercle o Clavicle looks like dinosaur/ very vertical

Humeral head looks bitten off= Hill Sach’s defect 65. What is a PA scapular “Y”? What does it show? How is the pt positioned? How

can you tell if there is over rotation on a PA Scapula Y? o PA Scapular “Y”

Provides a lateral of the shoulder to r/o anterior/posterior dislocations

Pt is PA with affected side towards the IR Oblique shoulder 30-45 degrees

towards IRo CR is perp to mid scapula

Palpate superior angle of the scapula

Palpate distal tip of acromin Line them up so they are

perpendicular to IRo Corcoid in lung field means there is over

rotation

66. Where is the coracoid always pointing in PA? Where is the acromin?o Coracoid should always be pointing mediallyo Acromin lateral

67. What is seen FSI in the PA Y?o Lesser tubercle should be seen free of superimposition and pointing

medially 68. Where are most shoulder dislocations?

Scapular anterior dislocationo 97% of all shoulder dislocations are anteriorly displacedo 2% are posteriorly displacedo 1% are interiorly displaced

humeral head down low/ underneath glenoid 69. How do you position for an AP Y? What does the AP Y increase?

AP Scapular “Y”o PA scapular Y can be performed in the supine positiono The affected shoulder would be rotated 60 degrees away from the IRo 60 LPO would demonstrate the right shouldero 60 RPO would demonstrate the left shouldero AP “Y” would visualize all the same anatomy as the PA scapular “Y”

but with increased magnification= less detail 70. Why do you do an Inferosuperio axial? What does it show? How do you do

it? Inferosuperio axial (Lawrence Method) o Orthopedics’ choice of lateralo Relationship between humeral head and

glenoid o Can be done supine or seatedo If supine, arm is abducted 90 degrees and

externally rotatedo CR directed 15-20 degrees medially

Tube is directed horizontally o Build shoulder upo Supinate hand o Should be using a grid o Lesser tubercle is on top

71. What happens when you supinate the hand?o When you supinate the hand you see lesser tubercle

Internal, Y, and inferosuperio axial 72. How do you do a seated axillary?

o Seated Axillary Pt seated at the end of the table CR is directed distally at a 5-10 angle Goes superiorly to inferiorly

Magnification with this projection Arm is pronanted

73. How do you do a transthoracic? What does it show? Transthoracic o Anterior/posterior displacement of the

shouldero Last resort because of heavy superimposition

of thoracic structureso Breathing technique (decrease mA and

increase exposure time) to blur lungs and vascular markings

o 3 seconds is a good amount of time in order to blur

74. What is the thoracic outlet syndrome? What is it also called? What angle does it require? What does it attempt to visualize?

Thoracic Outlet syndrome o Supraspinatus outlet syndrome or impingement syndromeo Requires positions/projections with caudal angles to better visualize

subacromial spaceo Attempting to visualize “osteophytes” extending from the inferior

acromial surfaceo Can also be performed to demonstrate subacromial bursitis

75. What are the usual projections for TOS? Usual projections for TOSo Apical APo Apical oblique (Garth)o Neer scap Yo Routine AP internal/external with 10 degree

caudal angle Apical APo PT is positioned similar to AP shoulder with arm in

neutral o 30 degree angle to open up subacromial space

Apical obliqueo 45/45o Position same as AP/Garth

Neer Scapular “Y” o Pt is positioned similar to routine PA Scapo 10-15 degree caudal angleo Open subacromial space

76. What are most elbow traumas associated with? Most elbow trauma is associated with the patient’s inability to extend or

rotate the extremity

o Never force into position77. When do you do a partial flexion elbow?

Partial flexion APo Use when pt cannot extend elbowo A series of 2 positions

78. What is the first position for a partial flexion AP? What does it show? 1st o Place humerus in same plane as receptor with epicondyles parallel o Bring humerus closer to IRo Demonstrate distal humerus o Extend eblow as much as possible then supporto CR perp distal humeruso +10 kVp from usual AP elbow make sure you penetrate through SI of

tissue and anatomy o Supracondila FX- make sure you don’t miss any o Lots of SI of tissue

79. What do you do for the 2nd image? 2nd o Place proximal radius and ulna in contact with receptor with hand

supinated Keep epicondyles // CR perp proximal radius/ulna

o With patient standing 80. How to you do a Coyles to show coronoid and radial head?

Axiolaterals (Coyle)o Trauma positions used as substitutes for visualization of coronoid and

radial head when pt cannot extend and rotate elbowo Can be easier than routine obliques- elbow remains in a “relaxed”

lateral position 81. How do you do a Coyles to show the radial head?

Axiolateral for Radial heado Elbow is placed in standard lateral positiono If possible rotate hand/wrist laterallyo CR @ 45 degrees toward shoulder/proximally o Parallel to long axis of humerus o CR enters approx 1 inch inferior to

elbow joint o +10 kVp from usual lateral

82. What is a Axiolateral for Radial head position good for showing?

o Excellent alternate for occult intra-articular FX

Bring elbow more towards upper part of cassette

o Supinator fat pads Communited vs simple fx

o Radius out from ulna shows proximal radius Radial head elongated

o Humeral anatomy superimposed 83. How do you do Axiolateral for coronoid?

o Elbow positioned same as standard lateralo Substitute for medial oblique o CR directed 45 from above shoulder, towards elbow o +10 kVp from usual lateralo Excellent for avulsion fx off coronoid process

84. What are the Full rotation laterals “round the clock”? When do you do this?o A series of 4 exposures with the hand and wrist in various stages of

rotationo Provides a profile of the entire radial heado Elbow is positioned in standard lateral, then wrist is rotated

Maximum supination Neutral lateral Pronation Maximum hyperpronation

o Turns radial head in a circle o By request only not routine

85. What does a Tangential (acute flexion) show? What is it also called? How do you do it?

o Used to assess olecranon process- 2nd most frequently fx region in adult elbow

o Aka “Jones Method” position o Humerus is placed in contact with receptor o Epicondyles //o Instruct pt to flex arm as much as possibleo CR perp and 2 inches distal to olecranon

86. What is a little league elbow? What is it also called? How does it happen? Little league elbow o Medial epicondylar apophysitis- more for adult o Panner’s disease o Chronic avulsions of medial epicondyles o Twisting motion and chronic stresses

87. When is the olecranon FSI? Olecranon free of superimposition=

acute flexion and lateral 88. What does this image show? What position?

PA Scap Y

89. What does this image show? What position?

Inferosuperior Axial

90. What is the difference between these 2 pictures? What is the position for each? How do you know?

Left- AP external lesser tubercle is superimposed over humeral head

Right- AP Oblique see humeral head in relationship to glenoid cavity

91. How do you position for an AP Scapula? What are the breathing instructions?

PT positioned similar to AP shoulder Affected arm is abducted 90 degrees with hand in supination CR directed perpendicular and 2 inches medial to axilla Use breathing technique (3 seconds) or full exhalation to improve

visibility 92. What does an AP Scapula look like on an image? What do the lungs look like?

Humerus is horizontal See much more of the scapula See blurring of the lungs

93. How do you do a Lateral Scapula? What is this position similar to? RAO/LAO affected side closest to receptor Position is similar to “Y” Instruct pt to place forearm and hand over posterior wrist Palpate vertebral and axiallary borders to ensure superimposition

94. What does a lateral scapula look like on an image? What fx can you see? See border of scapula Can see stellate FX

i. Occurs from blow to scapula ii. Radiating fx lines in a star pattern

95. How does a fx to the Clavicle usually happen? Who is this most common in? FX to the clavicle usually occur due to falls on the outstretched hand,

or direct blow Recognized as the most common injury associated with childbirth,

and children in general Images more easily obtained in the upright, PA position whenever

possible 96. How do you position for a PA Clavicle? What are the breathing instructions?

Position affected side closest to receptor Adjust shoulders to lie in the same transverse plane CR perp to exit mid-shaft of clavicle Must include S-C joints Suspended exhalation

97. What is the downfall of doing an AP clavicle? Increase OID will result in increase magnification and decrease in

detail 98. Why do you do a PA axial? What does this position do? What does the clavicle

look like? What are the breathing instructions? Projects clavicle superior to ribs/scapula

i. Push clavicle up as much as you can Clavicle imaged horizontal placement Position pt similar to PA

CR directed caudal, 25-30 degrees to exit the midshaft of the clavicle i. Thinner pt require greater of an angle

All axial methods should employ full inhalation to further push clavicle above ribs/scapula

You want full inhalation PA= caudally

99. How do you do an AP Axial? What are the 2 ways you can do it? Same image can be obtained in the AP erect or recumbent position 2 methods can be used

o CR directed 25-30 degrees cephalico Patient is positioned the same as a lordotic chesto Thinner pt usually require the use of a 15 degree cephalic

angle to try to straighten out the clavicle a little more 100. What should be done before Acromioclavicular articulations? What does this

position demonstrate? Performed frequently in orthopedic offices Done to demonstrate separation, dislocation of the AC joint Evidenced by widening of the joint of one side vs the other Radiographs of the shoulder should be performed/ reviewed prior to

these projections to r/o FX in the shoulder girdle 101. How are AC joints always performed? What is the minimum weight? What is

the SID? Always performed bilateral for comparison Images performed in AP Erect position

i. No weightii. With weights

Minimum 10 pound weights provided- attached to wrists (do not allow pt to hold in hands)

72” SID with CR perp to MSP and 1 inch superior to jugular notch Use routine AP shoulder technique @ 72” Hypersthenic pt may require individual exposures

Foot Anatomy

102. How many bones are in the foot? How many phalanges? How many phalanges does the 1st digit have?o 26 total bones comprise the footo 14 phalanges with tufts on distal phalanges

1st digit- hallux 2 phalanges only

o 5 metatarsals with styloid process off the base of the 5th

103. What is the site for the most common fx associated with the metatarsals? styloid process off the base of the 5th this site is the most

common FX associated with the metatarsals

104. How do you do a Dorsoplantar projection (AP)? Where is the CR? What does this demonstrate?o Affected foot is placed on the receptor with the plantar surface in

close contacto CR is directed posteriorly 7-10 degrees to midfoot- angle coincides

with arches Better demonstrates the tarsal interspaces Reduce elevation caused by the arch of the foot

o 10x12- 100 RSI system or CR/IP used lengthwise @60 kVpo CR and analog= anode heal effecto If for toes, or FB localization- use perpendicular CR @ 52 kVp

True AP of the foot does not use a perpendicular o Calcaneus SI o See 1st cuneiform

105. What does a true AP of the foot not use? True AP of the foot does not use a perpendicular

106. How do you position for a medial oblique? Where is the CR? What does this best demonstrate?o Leg and foot is internally rotated until the plantar surface forms a 30

degree angle to receptor planeo CR is perp to base of 3rd MTo Includes all toes and calcaneus o Best demonstrates

Cuboid, lateral cuneiform, base of 3rd, 4th, 5th MT FSI

107. How do you do a Lateral (mediolateral)? What does this include?o Externally rotate affected side until the patella is perp to receptor

Pinky toe side closest to IRo Position foot until the plantar surface is perp to receptor o Dorsiflex footo CR directed perp T-M jointso Include toes, calcaneus, and talotibial articulation o Increase kVp by 6

108. How do you do a Lateral (lateromedial)? Why is this a truer lateral? What does this position demonstrate?o Preferred lateral if the pt is capable of assuming this position

Places the foot in a truer lateral with increased SI of the metatarsals

o Affected leg is medially rotated with the plantar surface perpendicular to receptor

o Both lateral positions demonstrate the talus, calcaneus, the talocalcaneal, and talotibial joints FSI

Random Notes: PA away= that side is elongated AP towards= side gets elongated Anytime AP= LPO OR RPO Anytime PA= LAO OR RAO Center to PIP joint on 3rd digit AP wrist= increase separation of intercarpal spaces PA wrist= increase carpal radiolunar joint Tangential wrist- hamulus and pisiform Dorsorecumbant- foreshortened and diaphragm elevated Lateral chest shows SI of posterior ribs and open intervertebral foramina Surgical neck fx are more common than anatomical neck fx Aspirated FB would most likely be found in the right side of the chest

because the right bronchi are more vertical