X ray of elbow joint

imaging of elbow joint

1. X-Ray of elbow joint DR. ATHUL D

2. Anatomy of elbow joint - hinge joint - 3 bones involved

3. Distal humerus humeral condyle is its expanded distal end.  Trochlear articulates with the ulna.  Capitulum articulate with head of radius.  Lateral epicondyle  Medial epicondyle

4. Ossification around elbow- CRITOE Capitulum – 1 years Radial head – 3 years Internal epicondyle – 5 years Trochlea – 7 years Olecranon- 9 years External epicondyle – 11 years

5. X-ray elbow ap view Part Position: Arm fully extended, and the hand supinated. CR: To the elbow, between and 1 inch below the level of the epicondyles. Collimation: To the arm. kVp : 55 (50 to 60). Demonstrates: Distal humerus , proximal ulna, proximal radius, and elbow joint.

6. Clinicoradiologic Correlations: Alignment - Carrying angle The axial relationships of the humerus to the ulna should be assessed

7. X-ray anatomy in ap view 1. Shaft of the humerus . 2. Olecranon fossa, ulna. 3. Medial epicondyle, humerus . 4. Lateral epicondyle, humerus . 5. Capitellum , humerus . 6. Trochlea, humerus . 7. Supracondylar ridge, humerus . 8. Radial head. 9. Neck of the radius. 10. Radial tuberosity. 11. Shaft of the radius. 12. Coronoid process, ulna. 13. Ulna. 14. Olecranon process, ulna.

8. Radio capitular line This line is drawn through the middle of the radius and should bisect the capitulum on both the lateral and the AP elbow radiograph.

9. Specialized Projections: 1. Forearm views: With the palm supinated and the wrist and elbow extended, an AP view is obtained to include the elbow and wrist. 2. Humerus views: for the full length of the humerus . -AP view the arm is slightly abducted & forearm supinated. - lateral view the elbow is flexed, the arm slightly abducted, and the hand placed over the iliac fossa

10. X ray elbow lateral view Part Position: Elbow flexed to 90 ° , with the ulnar surface of the forearm flat. The hand in true lateral position. CR: Mid-elbow joint, just anterior to the lateral epicondyle. Collimation: To the arm, 10 inches along the forearm axis and 6 inches top to bottom kVp : 55 (50 to 60).

11. Lateral view anatomy 1. Shaft of the humerus . 2. Capitellum and trochlea. (superimposed) 3. Olecranon process, ulna 4. Coronoid process, ulna 5. Radial head. 6. Neck of the radius. 7. Radial tuberosity. 8. Coronoid fossa, humerus . 9. Olecranon fossa, humerus . 10. Supinator fat line ( arrow)

12. True lateral view must show hourglass or figure of eight Distal humerus hockey stick appearance

13. Lateral view The yellow line represents the anterior humeral line and the red line represents the proximal radial line. The important observation regarding these lines is that they should intersect the middle third of the capitellum on the lateral view

14. Clinicoradiologic Correlations: Lateral view is very useful for elbow for fracture & to demonstrate joint effusion Alignment: The plane of the radius passes through the middle of the capitellum ( radiocapitellar line ). Soft tissue: Anterior and posterior to the distal humeral surfaces are pericapsular fat layers interposed between the joint synovium and fibrous joint capsule ( fatpads ).

15. Specialized Projections Radial head capitellum view : magnified view of the radial head, which is projected clear of the ulna and humerus for joint effusion and fractures of the radial head, coronoid process, and capitulum elbow flexed to 90° in the true lateral position the tube is angled 45° toward the radial head

16. Radial head views: Multiple views in various degrees of rotation can be used to profile the entire circumference of the radial head. In the lateral position t he forearm is slightly supinated in true lateral with palm down Extreme internal rotation with the thumb down.

17. ELBOW: Medial Oblique Projection Part Position: Arm fully extended and the forearm pronated. CR: 1 inch below the epicondyles. Collimation: To the arm kVp : 55 (50 to 60).

18. Uses Close scrutiny of the ulnar-placed structures including the medial supracondylar ridge, medial epicondyle olecranon Trochlea coronoid process

19. Medial oblique anatomy 1. Shaft of the humerus . 2. Olecranon fossa, humerus . 3. Medial epicondyle, humerus . 4. Lateral epicondyle, humerus . 5. Supracondylar ridge. 6. Olecranon process, ulna. 7. Coronoid process, ulna. 8. Radial head.

20. Specialized Projections: 1. Lateral oblique view : extended elbow is rotated externally by 45°, . The view optimizes visualization of the radially sited structures, lateral supracondylar ridge lateral epicondyle, radiohumeral joint lateral margin of the radial head.

21. Tangential (Jones) Projection Demonstrates: Olecranon, ulnar groove, trochlea, and radial head. Patient Position: Elbow is fully flexed and the humerus is placed parallel to the film. CR: 2 inches above the olecranon kVp : 55 (50 to 60).

22. Clinicoradiologic Correlations: Visualization of the olecranon–trochlear joint compartment is useful for detecting intra-articular loose bodies and degenerative osteophytes. The ulnar groove , in which lies the ulnar nerve, is also well seen.

23. Normal Anatomy 1. Olecranon process. 2. Trochlea. 3. Head of the radius. 4. Neck of the radius. 5. Tuberosity, radius. 6. Medial epicondyle, 7. Olecranon fossa. 8. Ulnar groove.

24. Specialized Projections: 1. Superior-to-inferior view : elbow flexed to about 110° the forearm is placed on the cassette in a supine position with the beam passing through the distal humerus to the proximal forearm. used in supracondylar fractures , both before and after reduction, to assess axial position. Fractures of the epicondyles and subtle tendon calcifications

25. Cubital tunnel view: From the tangential position, with the elbow fully flexed, the forearm is externally rotated 15° to show the cubital tunnel Medial trochlear lip osteophytes and osteoarthritis of the medial trochlea– olecranon joint, clearly shown

26. Supra condylar Fractures anterior fat pad sign (sail sign) posterior fat pad sign anterior humeral line should intersect the middle third of the capitellum in most children Classification of supracondylar fractures   type I:   undisplaced type II:  displaced with intact posterior cortex type III:  complete displacement

27. AP and lateral view – supracondylar fracture 95% are extension type 5 % belong to flexion type In adults invariably needs surgery

28. Medial epicondyle fracture avulsion fracture of the medial epicondyle has occurred ( arrow ). : A similar injury in child or adolescent has been called Little Leaguer’s elbow and is usually associated with sports requiring strong throwing motions.

29. INTERCONDYLAR FRACTURE T or Y shaped 50% of distal humerus fracture in adults

30. Olecranon fracture Note the two fracture lines through the olecranon process. The proximal fragment has retracted owing to the pull of the triceps muscle

31. CORONOID PROCESS FRACTURE. Lateral Elbow X-ray Observe the clearly visible fracture line through the tip of the coronoid process ( arrow ).

32. FAT pad sign Lateral, Elbow, Positive Fat-Pad Sign. The anterior and posterior fat-pads are elevated away from the humeral surface as a result of joint effusion or hemarthrosis ( arrows ) associated with a subtle impaction fracture of the radial neck, evidenced only by a sharp, angular change in the contour of the ventral cortex ( arrowhead ).

33. Fracture radial head A linear fracture line is visible extending from the articular surface distally ( arrow )

34. CHISEL FRACTURE: RADIAL HEAD. AP Elbow x-ray Note the vertical fracture line extending through the articular surface of the radial head, with minimal offset of the articular contour ( arrow ).

35. OCCULT RADIAL HEAD FRACTURE. AP Elbow x-ray A- there is no evidence of fracture in the radial head. B. 2-Month Follow-Up, AP Elbow. Note that a vertical fracture line is now apparent ( chisel fracture ) ( arrow ).

36. RADIAL HEAD FRACTURE: DOUBLE CORTICAL SIGN. increased density of the articular cortex of the radial head, with projection of the opacity below the articular surface ( arrow ). Posteriorly, a fracture line is identified as a linear radiolucency It is the result of an impaction fracture from the capitellum into the radial head, which displaces the cortex distally. this is the only sign of a radial head fracture

37. Fracture RADIAL HEAD- MASON CLASSIFICATION 1. Undisplaced

38. Type ii – displaced fracture

39. Type iii - communited

40. Radial neck fracture the thin fracture line disrupting the lateral aspect of the radial cortex ( arrow ).

41. #CAPITELLUM-HALFMOON APPEARANCE

42. OLECRANON fracture TYPE I-1A Extra articular oblique 1B-Intra articular transverse TYPEII MIDDLE –INTRA ARTICULAR 2A Single# line 2B-2 #line [ transverse,oblique ] TYPEIII- OLECRANON FOSSA

43. Panners Osteochondritis Dissecans of the Capitellum Valgus strain of the elbow in throwing sports such as baseball and football has been implicated as one causative factor. Apparently during the throwing motion, the capitulum is subjected to compression and to shear forces.

44. Essex- lopresti fracture

45. Elbow dislocation Posterior & posterolateral comprise 85% of dislocations. 50% associated with fractures if medial epicondyle, radial head or neck

46. Monteggia’s fracture MONTEGGIA’S FRACTURE OF THE FOREARM. A fracture through the proximal one-third of the ulna is present, with associated anterior angulation of the proximal fracture fragment. The radial head has also been displaced anteriorly, with dislocation at the elbow ( arrow ).

47. Giant cell tumor in radial head Within the radial head and extending into the radial neck is a loss of bone density, bone expansion, and thinning of the cortex caused by a slowly growing tumor

48. OSTEOCHONDROMA. Lateral Elbow the large, cauliflower exostosis arising from the radial tuberosity. Observe the flocculent calcification scattered throughout this cauliflower exostosis

49. PAGET’S DISEASE: EXPANSILE MANIFESTATIONS. AP Elbow. Observe the expansion of the proximal radius, affecting its subarticular surface.

50. Non-traumatic myositis ossificans circumscripta at elbow joint 

51. Thank you