Radiologic Eval Elbow, Wrist and Hand

Question 1

what imaging study is typically ordered first with suspected bone and soft tissue injuries to the elbow?

Answer 1

radiographs

Question 2

what radiographic views are available at the elbow?

Answer 2

1. AP views
2. lateral views

Question 3

what can be observed well in a radiographic AP view of the elbow?

Answer 3

1. carrying angle
2. humeroulnar joint spaces
3. humeroradial joint spaces
4. distal humerus
5. radial head, neck, tuberosity
6. proximal ulna

Question 4

what can be observed well in a lateral radiographic view of the elbow?

Answer 4

1. Spatial relationships
   
   1. olecranon and olecranon fossa
   2. superimposed epicondyles, circular trochlear sulcus directly below
2. Continuity/structures
   
   1. olecranon
   2. corinoid process
   3. radial head
   4. fat pads anterior and posterior to distal humerus

Question 5

what is the sail sign? what radiographic view is it best observed?

Answer 5

sail sign → when effusion pushes fat pads upward/outward

best seen in the lateral view

Question 6

T/F: the forearm should be included during routine radiographic exam of the elbow?

Answer 6

TRUE

Question 7

list radiographic views of the forearm

Answer 7

1. AP views
2. lateral views

Question 8

what is best observed in the radiographic AP view of the forearm?

Answer 8

1. entire length of radius and ulna
2. proximal and distal articulations

Question 9

what is best observed in the radiographic lateral view of the forearm?

Answer 9

1. normal bowing of radius and ulna
2. elbow structures (as with lateral view of elbow)
3. radial head superimposed over coronoid process
4. proximal and distal articulation

Question 10

what type of imaging study is typically performed first with suspected bone and soft tissue injuries to the wrist and hand?

Answer 10

Radiographs

Question 11

what are the common projections for radiographs of the wrist, hand, and digits?

Answer 11

1. PA
2. Lateral
3. Oblique
4. Other projections available → carpal tunnel view

x-ray beam coned down for close up and fingers point upward on images

Question 12

what is best observed in the hand PA view?

Answer 12

1. Spatial relationships
   
   1. long axis of 3rd metacarpal and long axis of radius
   2. oblique line along met heads 3-5
   3. overlapping met bases 2-5
   4. overlap trapezium and trapezoid, pisiform and triquetrum
2. Symmetry
   
   1. lateral metacarpal shafts
3. Continuity
4. Other → tuft distal fingers

Question 13

what is best observed in the hand oblique view?

Answer 13

1. spatial relationships of IP and MCP joint spaces
2. symmetry
3. continuity

Question 14

describe the projection for the hand oblique view

Answer 14

45 degree rotation from PA position

digits do not superimpose

Question 15

describe the projection for the hand lateral view

Answer 15

thumb magnified (farthest from receptor)

overlap: phalanges, metacarpals, distal radius and ulna

Question 16

what is best observed in the lateral view of the hand?

Answer 16

1. spatial relationships
   
   1. displacement of fracture fragments (dorsal/volar)
   2. long axes of radius, lunate, and capitate
2. continuity

Question 17

what is best observed in the wrist PA view?

Answer 17

1. spatial relationships
   
   1. arch distortions: carpal subluxation/dislocations
   2. overlap trapezium and trapezoid; pisiform and triquetrum
2. symmetry
3. continuity
   
   1. hook of the hammate

Question 18

describe the projection for the wrist oblique view

Answer 18

45 degree rotation from PA position

Question 19

what is best observed in the oblique wrist view?

Answer 19

1. spatial relationships
   
   1. trapezium’s articulations
   2. hamate
   3. triquetrum
2. symmetry

Question 20

what is magnified in a lateral wrist view?

Answer 20

the 1st metacarpal

Question 21

what is best observed in the lateral wrist view?

Answer 21

1. spatial relationships
   
   1. volar tilt of the articular surface of the radius
   2. scapholunate angle
   3. capitolunate angle
2. Continuity

Question 22

what does the carpal tunnel view offer?

Answer 22

visualization of hook of hamate

arched arrangement of carpals

Question 23

List general indications for CT of the elbow

Answer 23

1. severe trauma
2. assessing fracture alignment/displacement
3. ID loose bodies in elbow joints
4. If MRI contraindicated, ID osteochondral lesions and other health conditions for which MRI is typically indicated

Question 24

List general indications for MRI of the elbow

Answer 24

1. soft tissue type injuries
2. bony abnormalities
3. fluid
4. cancer
5. congenital/developmental conditions

Question 25

list clinical scenarios in which an MRI of the elbow may be required

Answer 25

1. chronic/unexplained elbow pain 2. acute trauma 3. instability 4. mechanical symptoms 5. limited/painful ROM 6. swelling/mass/atrophy 7. planned arthroscopy 8. residual symptoms following surgery

Question 26

what initial imaging is most appropriate for a pt presenting with chronic elbow pain?

Answer 26

X-ray elbow

Question 27

what follow-up test is most appropriate for a pt with mechanical symptoms such as locking, clicking, and limited motion at the elbow and there is a suspected intra-articular osseocartilaginous body or synovial abnormality? Radiographs were taken and nondiagnostic

Answer 27

MRI, MR arthrography best CT, CT-arthrography good as an alternative

Question 28

what follow-up test/image is most appropriate for a pt with chronic elbow pain and a suspected occult fracture or other bone abnormality? Radiographs were nondiagnostic

Answer 28

MRI elbow

Question 29

what follow-up test/image is most appropriate for chronic elbow pain along with a palpable soft-tissue mass and radiographs were nondiagnostic?

Answer 29

MRI elbow US elbow as alternative

Question 30

what follow-up test/image is most appropriate for a pt with suspect chronic epicondylitis, refractory to empirical treatment and radiographs were nondiagnostic

Answer 30

MRI elbow US elbow as alternative

Question 31

what follow-up test/image is most appropriate for a pt with chronic elbow pain and suspected collateral ligament tear but radiographs were nondiagnostic

Answer 31

MRI elbow, MR arthrography

Question 32

what follow-up test/image is most appropriate for a pt with suspected biceps tendon tear but radiographs were nondiagnostic?

Answer 32

MRI elbow US elbow as alternative

Question 33

what follow-up test/image is most appropriate for a pt with chronic elbow pain and a suspected nerve abnormality but radiographs were nondiagnostic?

Answer 33

MRI elbow US elbow as alternative

Question 34

what follow-up test/image is most appropriate for a pt with elbow stiffness; and suspected HO/osteophytosis by radiography?

Answer 34

CT elbow

Question 35

what follow-up test/image is most appropriate for a pt with chronic elbow pain and suspected inflammatory arthritis or bursitis and radiographs were obtained?

Answer 35

MRI elbow US elbow as an alternative

Question 36

once x-rays have been ordered, if there is need for further imaging at the elbow what image/test is most appropriate?

Answer 36

MRI elbow for essentially all other conditions except HO

Question 37

what initial imaging is most appropriate for a pt with chronic wrist pain, with or without prior injury?

Answer 37

X-ray of the wrist

Question 38

once x-rays have been ordered for a patient with wrist pain what is generally the most appropriate follow-up image/test?

Answer 38

MRI wrist

Question 39

what wrist conditions/ACR variants do not call for an MRI as the second/follow-up imaging study?

Answer 39

1. Variant 4 → chronic wrist pain, normal radiographs or show nonspecific arthritis, exclude infection = **aspiration wrist 2nd study** 2. Variant 8 → chronic wrist pain. Kienbock's disease on radiography = **CT wrist** 3. Variant 10 → chronic wrist pain. suspect occult fracture or stress fracture with nondiagnostic radiographs = **MRI wrist or CT wrist** 4. Variant 12 → chronic wrist pain, normal/nondiagnostic radiographs with suspected carpal tunnel syndrome = **US wrist or MRI may be appropriate**

Question 40

what initial imaging is most appropriate for a pt with acute blunt or penetrating trauma to the hand or wrist?

Answer 40

Radiography of interest

Question 41

what follow-up imaging study is most appropriate for a pt with suspected acute hand or wrist trauma. Initial radiographs negative or equivocal.

Answer 41

MRI area of interest, repeat radiography, CT

Question 42

what follow-up imaging study is most appropriate for a pt with acute wrist fracture on radiographs and suspected wrist tendon or ligament trauma?

Answer 42

MR arthrography, MRI wrist, CT arthrography, or US wrist

Question 43

what follow-up imaging study is most appropriate following initial radiographs showing distal radioulnar joint or carpal malalignment in the absence of fracture?

Answer 43

CT wrist, MRI wrist, MR arthrography

Question 44

what follow-up imaging study is most appropriate for acute hand fracture on radiographs with suspected hand tendon or ligament trauma?

Answer 44

MRI hand, US hand

Question 45

what follow-up imaging study is most appropriate after an initial radiographs show MCP, proximal IP, or distal IP joint malalignment in the absence of fracture?

Answer 45

MRI hand or US hand

Question 46

what follow-up imaging study is most appropriate for a pt with suspected penetrating trauma with a foreign body in the soft tissues in the hand or wrist. Initial radiographs are negative.

Answer 46

US area of interest, CT area of interest