Sudan University of Science and Technology College of $Edical Radiologicjfciences Department of Piagiiosticpechnology Project Ti

INIS-SD-136 SD0000061

SD0000061 Sudan University of Science and technology College of $edical Radiologicjfciences Department of Piagiiosticpechnology

This Research is presented to the department ofpiagnostic Radiologic ^technology for the Award. of(B.SC inftadiolctgicjechnology)

Project title:

u (h?

Prepared by: Ahmed Mohamed Saeed Mahsin Hago Hamad Elneil Mohamed A.Alla Elawad 4th Diagnostic

supervised By Ustaz Elsadig Abdalla A. Tarn Ass- Professor, Head of diagnostie RadiologicTechnology

Khartoum , (Jun 2000} We sincerely appreciate the kind assistance and guidance of Mr El Sadig A. A El Tarn our research supervisor 5 we should also extend our thanks and appreciation to the teaching staff members of the college of Medical Radiologic ^cience^ our clinical supervisors in the various clinical department for their an failing evidence and support, the college library staff in giving us the references without hesitation and finally to Miss Azhar without whose professional typing we would not have done thin piece of research project

The Researchers ^esearchobj^tiyes] *>

In doing this research we thought thatjwill:- 1. Assist student* technologists, in shedding light to the important aspects of upper limb radiography, 2. To show the most appropriate projections with several alternative methods. 3. To draw the attention of radiographers to the most references which would broaden their knowledge in radiographic technique A» Contents

- Acknowledgement - Introduction - Research Objectives - Section One :- Anatomy Section Two :- Physiology - Section Three :- Pathology - Section Four :- Basic Technique Optional Views - Conclusion • References Introduction

Radiologic technology is an Important medical specially without which no hospital or clinic would be complete. In our research we have considered anatomy, physiology and pathology of upper limbs. The research is divided into four main sections. The first section deals with anatomy of upper limbs and shoulder griddle in details. The second section include the physiology of the bone of the upper limbs. The third section deals with pathology and the diseases which affected the upper limbs JL The fourth section consist of />Basic techniques and additional techniques of the upper limbs. (Qdfo$

The researchers ANATOMY Coracoid process Acromlon Superior (Medial) angle Lesser tubercle Sternal end Greater tubercle Intertubercular sutcus (Bicipital groove) Medial (Vertebra!) border Surgical neck

Deltoid tuberosUy Inferior nnjjle Lateral (.Axillary) border HUMERUS

Lateral supracondylar ridge—^-1-f* "Media! siijirnroudylnr

Lateral epicondyle Medial rpicondyle Capitulum Tronhlen Head of radius Coronoid process Tuberosity of radius Tuberosity of ulna

Anterior oblique line

Pronator Teres impression

RADIUS ULNA

•.-"Pronntor" crest

-Hend of ulna Styloid process Stylold process — Carpnl boneR

Metncarpnl bones Proximal phalanx—y Distal phalanx- (1st) Proximal — (2nd) Middle

— (3rd) Dlstnt }

6-1 BONES OF THE UPPER LIMB, FROM THE FRONT For bones of the hand, see Figures 6-97 nnd 6-114. For muscle attachments, see Figures 6-10, 6-3.5, nnd 6-55. Rough for flnger-pftd for Fl. Digit. Profundus , /Fibrous shcnth Distal end for \F1. Digit. Sitpernc. Head (Trochlea) Head for Fibrous slienth (Trochlea)

Head Tubercle

Trapezoid Hook of hamate Tubercle (Crest) of trapezium Pisiform (gtr. multangular) Triquetrum Tubercle of senphoid (nnvictitnr)

A. PALMAR ASPECT

Smooth for I Distal fiiiRci-nnil

Phalanges Middle

Proximal

Hetacarpals Shaft or Mclncnrpnls

Trapezoid arpals Trapezium

Scaphoid L,lnnte Triquetnim

B. DORSAL ASPECT

BONES OF THE HAND The bones of the upper limb The upper limb is attached to trunk by the shoulder girdle , which is made up of two bones. The clavicle anteriorly and the scapula posteriorly. The shoulder girdle is attacked to the trank by one joints the sterno clavicular joint, and by muscles the shoulder girdle is able to move in several directions, and its movements are important in the range of movements that are possible with the upper limb . The upper consists of three segments :- 1- the upper arm, which has one bone the humerus 2-the forearm, which has two bones the radius and the ulna 3-the wrist and hand, which is made up of: The (8) carpal bones. - The (5) metacarpal bones and the (14) phalanges. The clavicle : the clavicle or coller bone is a long bone it differs from other long bones in tow ways :- 1 - it has no medullar cavity 2- it is ossified in membrane The shaft of the clavicle is S. shaped : the medal two thirds of the shaft is concave anteriorly, and the lateral third is concave posteriorly the lateral third of the shaft is flatterned having superior and inferior surface and anterior and posterior borders, hi the middle third of the shaft the anterior borders become progressively less promnent and the medial third of the shaft is cylindrical. The superior surface of bone is subcutaneous through out its length. The medial two - third of this surface is smooth but the lateral third is roughened where the dettoid and trapezes muscles are attached to it. The inferior surface has a roughened area at its medial end where aligament. The Costo claviculor ligament is attached this ligament binds the medial end of the clavicle to the 1st ribe. At the outer end of the inferior surface, and close to the posterior border there is a projection, the coroniod tubercle, and running laterally and from this turbid is ridge the trapezoid line the cronoid tubercle and the trapezoid line give attachment to the clavicle ligament which binds the lateal prat of the clavicle to the coracoid proess of the scapula. The scapula The scapula, or shoulder blad, is posterior bone of shoulder girdle. It is aflattened triagular bone consisting of tringular body at latral angle of which is an expanded portion the head of the scapula. This bears the glenoid cavity which articulates with the head of humerus at the shoulder joint. A process called the coracoid process. Projects forwards from the anterior part at the head of scapula. The posterior surface of the body is divided in to two parts by the spine of the scapula, which widens out at it's latral end to form the acromion proccess . The body of the scapula :- The body of the scapula is aflat triangle having anterior and postierior surface, and latral, medial and superior borders . The anterior or costal surface is concave and is called the subscapular fossa. Attached to the medial two - thirds of the floor of this fossa is a muscle, the scapular muscle and the floor is therefore, slightly ridged . The posterior surface:- The posterior surface of the body is slightly convex. The spine of the scapula divides the posterior surface into and upper third called the supraspinous fossa and lower two - theerd called infraspinous fossa. The superior border of the body runs slihtly up words from the root of the coracoid process to the superior angle, close to the root of the coracoid process there is anotch in the superior border colled the suprascapular notch. The medial border of the scapula longist to order and it extend from the superior to inferior angles. It is slightly convex, reaching apromince at the root of the spine of the scapula. The latralporder:- Runs from the inferior angle to the head of the scapula. The head of the scapulaisthe thickest part of the bone and forms the latral angle. The medial border of the scapula is longist border and it extend from the superior to inerior angles. It is slihgtly convex. Reaching and promince at the root of the spine of the scapula. The latral sutface to the head bears the glenoid couity which is oval , slightly concave articular surface. Between the head of the scapula and the body, there is slight constriction called the neck of scapula. The coracoidprocess :- The coracoid process arises from the upper part of the anterior side of the head of the scapula and bends sharply to runs for word and laterally, so that it has the appearance of abent finger. The outer part of the coracoid process is slightly flattened and overhangs the glenoid cavity . The spine ofscapula:- The spine of scapula project from the posterior surface of the body dividing in the supera spinous and infraspinous and infraspinous fossae . The spine project in creasingly from the body as it runs laterally. The crest of the spine has aflat subcutaneous surface. The upper and lower borders of which give attachment to muscles . • The humerus ;- The humerus is along bone. It is largest bone of the upper limbs and possesses a shaft and lower and upper ends . The Radius: The radius is the latral bone of the forearm and it is along bone. It has a shaft , as mall circular upper end and wider lower end. The upper end of the radius :- The upper end of the radius is composed of the head, the neck and the radial tuberosity. The head of the radius is disc-shopped and its upper surface is concave particular surface which articulates with the capitutum of the humor as at the elbow joint - the circumference of the head is narrow , smooth articular surface. Which articulates with the radial notch of the ulna at superior radioulner joint. Below the head is constricted portion. The neck of the radius on the medial side of bone, just below the neck, is ablunt projection called the rachial tuberosity . Which gives attachment to the biceps brachii muscle . The lower end of radius :- The lower end of radius a widest portion of the bone, and is quadrilateral in cross - section . The lateral surface projects down ward below the rest of bone as the styloid process of the ulna. The medial surface has anarrow concave articular surface, the ulner notch. Which is articulates with the lower end of the ulna at the distal radio-umer joint. The anterior surface is a wide and is rough end by the attachment of the anterior ligament of the wrist joint. The posterior surface : is also wide and is grooved by the extensor tendons which pass from the forearm to the hand. The inferior surface. Of the lower end of the radius is concave articular surface which is divided. By aridge. In to latral and medial portion . the latral surface articulate with scaphoid. The medial surface articulate with the lunate. The ulna :- The ulna is medial bone of the forearm and it is along bone . it has a shaft has a wide upper end, and small rounded lower end. The upper end of the ulna: The upper end of ulna is composed of two large processes , the olecranon and the coronoid processes. And two articular notches. The trochlear and the radial notches, which articulate with the humerus and radius respectively. The olecranon process forms the upper most of bone . it carves for ward at its summit to over hang thetrochlear notch. This forward projection is accommodated by the olecranon fossa of the lower end of humerus when the elbow joint is fully extended . The carpal Bones The carpal Bones are eight small bones which are arranged in a proximal and a distal row. Those of the proximal row are named, from the lateral to the medial side, the scaphoid , the lunate, the triqetral to the pisiform. The distal row are named. From the lateral to the medial side. The trapezium , the trapezoid, the capitate and the hamate. The pisiform lies on the palmar suface of the triquetral and articulates with that bone alone , but all the other bones of the carpus articulate with their neighbors. The proximal row of the carpus forms an arch which is convex to words the arm. And which articulates with the distal surface of the radius and the articular disc of the wrist joint. The capitate and the hamate project in to the concavity formed by the proximal row of bones and the trapezium and the trapezoid articulate with the distal surface of scaphoid the distal surface of the distal row of carpal bones articulate with the bases of the metacarpal bones . The carpus is deeply concave from side to side on its palmor surface . but its dorsal surface is only gently convex from side to side . The metacarpal hones: The metacarpal bones, five in number, are miniature long bones. They are composed of rounded head which distally, a shaft and expanded proximal end called the base . The heads the metacarpal bones: The heads the metacarpal bones form the prominence of the knuckles. On the distal surface of each is rounded articular facet which extended onto surface of the anterior surface of the head. This articalar surface articulates with the base of the proximal phalanx . The phalanges: There are 14 phalanges, three for each of the four fingers and two for the thumb . The proximal phalanges articulate

10 with the metacarple bones by the proximal ends 5 and with the medial phalanges by distal ends. The middle phalanges : are similar is shape to the proximal phalanges but are smallest. Articulates with the proximal phalanges by the bases and the distal phalanges by the distal end. The distal phalanges : are the smallest of phalanges and have a flat posterior surface. And concave anterior surface. Muscles of the upper limbs :- Muscles are the active part of the motor apparatus : Their contraction produce various movements. Function all muscles are divided in to two groups . Voluntary muscle and involuntary muscles the voluntary muscles consist of striated muscles tissue and contract by the will of man. (A) shoulder: there are muscles in the shoulder girdle :- l.deltoideus 2. Supraspinatous 3. infraspinatous 4. subscapularis 5. Teresmajor 6. Teres minor (B) The muscle of the arm : The muscle of the arm the muscle of upper arm are divided in to anterior and postrior groups the postrior is composed of three muscles 1. biceps brachii 2. Brachialis 3. Coracobrchialis The posterior a group of muscles is composed of the triceps brachii which originates with one of its head (long) on the scapula and two of its heal on the humerus, and has its insertion on the olecranon process of the ulna it extends the

n elbow joint two groups muscles 9 anterior and posterior are distinguished on the forearm most of anterior muscles have there origin on the medial epicondyle of the humerus and the posterior muscles have their on lateral epicondyle the anterior group consists of the following muscle : 1- two flexors of the fingers . 2- two flexors of wrist joint 3- flexors pollicis longus 4- two pronating muscles The posterior group consists of the following muscles :- 1- three extensors of the wrist 2- extensor digitorum communis of the hand 3- two extensors of the thumb 4- abductor pollicis longus 5- supinator The muscles of the hand :- 1-thenar muscles 2-middle group 3-hypothenar muscles

Nerve supply of limbs: - Limb plexuses each limb consists of a flexor and an extensor comparment, which meet at the pre-axial and post axial borders of the limb these bordes are marked out conveniently by veins. In the upper limb the cephalic vein lies at the preaxial and basilic vien at the posaxial border

12 Arteries and nerves related to the bones of the upper limb: Certain arteries and nerves are related to the bones of the upper limb and are liable to damage if the bones is fractured. 1- The subclavian artery passes behind the middle of the shaft of the clavicle as it curries over the first rib to enter the axilla . on rare occasions a fracture of the clavicle can damge the subclavian artery . 2- The axillary artery is closely related the medial side of the surgical neck and upper end of the shaft of the humerus as It runs down the lateral wall of the axilla. fracture of the surgical neck of the humerus may on occasions, damage the axillary artery . 3-the brachial artery lies in front the lower end of the humerus separated from the bone only by the barchial muscle . the brachial artery is particular liable to damage in fractures of the lowever end of the humerus (supracondlylar fracture). 4-The radial artery lies in front of the radius through out its whole length , separated from it only by muscles the ulner artery which lies in front of the ulna in the lower two thirds of the forearm is separated from it only by muscles . Both these artries may be damaged in fractures of the radius and ulna. 5- The circumfex nerve winds round the lateral and posterior aspect of the surgical neck of the humerus it is

13 liable to damage both in fractures of the surgical neck of humerus and in dislocation of the shoulder joint. 6- The radial nerve passes obliguety across the postion aspect of the middle third of the shaft of the humurus in the spiral groove . It is occasionally damaged in fractures of the shaft of the humerus . 7-The ulna never lies in the groove on the back of the middle epicondyle of the humerus . It is liable to damage in fractures of the medical epicondyle and may be damaged by stretching in supra condylar fractures of the humerus. 8-The medical nervs lies on the medial side of the brachial artery in front of the lower end of the humerus . It may be damaged in supracondylar fractues of the humerus .

14 PHYSIOLOGY Bone physiology Bone is special form of connective this sue made up of a collogues on matrix that has been impregnated with mineral salts especially phosphates and calcium . Because at its high calcium and phosphate content. It plays a vital role in calcium homeostasis. It protects vital orgins, and rigidity that it provides permits to comotion and the support of loads against gravity. It is a living tissue bone is constantly being resorbed and new bone formed. Permitting it to respond to the stresses and strains that are put up on it .It is welt vascularized and has a total blood flow of 200 - 400 ml/min in adult humans. The protein in bone matrix is mostly type. Collagen, which is also the major structural protein in tendons and skin this collagen which weight for weight is as strong as steel. Is made up of atriple helixe of 3 polypeptides bound tightly together. Two of these are identical and polypeptides encoded by one gene, and one is an it is worth that the collagen represent a family of structurally related proteins which maintain the integrity of many different organs to date 13 different type have been indetiried, and these are encoded by more than 20 different genes . Adequate amount of both protein and minerals must be available for the maintenance of normal bone structure mineral in bone is mostly in the form of hydroxyapipties which have the general formula 2+ + Ca l0-X(H3O ]2(POI)6(OH2)2 . These salts form crystals

15 that measure 20 by 3-7 nm - sodium and small amounts of magnesium and carbonate are also present in bone. Most bones are mate up of an enter layer of compact bone surrounding trabecular bone and, in many instances a bone marrow cavity. Trabecular or spongy bone is made up of bone spicules separated by spaces - compact bore is much denser and is less active metabolically about 75% of bone in body is compact and 25% is trabecular . In spongy bore nutrients diffuse from bore ECF into the trabecular, but in compact bore nutrients are provided via haversian canals , collagen is arranged in concentric layers, forming cylinders called osteons or aversion systems . The cells in bone that are concerned primarily with bone formation and resorbrtion are as to blasts ostescytes , and osteoclastasts . astes blasts are the bone formfltting cells that secreate collagen. Forming matrix around themselves which then calcifies when surrounded by calcified matrix . They are called osteocytes . They send processes into the canceliculi that ramify through out the bone and via tight junction connect to the processes of other osteocyte . Osteoclasts are multinuclear cells that erode and resorb previously formed bone . They are derived from hematopoietic stem cells via monocytes they phagocytes bone , digesting it in their side plasm; this is why bone around an active osteoclast has characteristic ruffled or "ohewed - out " edge. The esteoclasts, which are rich in carbonic anhydrase. Form

16 protons from H2Co3 and secrea them in the ruffled area, aiding bona dissolution. Osteoblasts, on the other hand, arise from osteo progenitor cell hat are of origin. Osteoblasts remain in contact with one another via tight junctions between long protoplasmic processes that run through canaliculi in the bone. Calcium and phosphorus : (1) calcium the adult human body contains about llOOg (25.5 mol) of calcium (1.5% of body weight ) ninety-nine percent of the calcium is in the-* skeleton. The plasma calcium , normally about 10 mg/1(5 meg/1 2.5 m mol/1), the result is hypocalcemic Lenten which is due to increased activity of the motor nerve fibers . The calcium in bone is of 2 types : areadily exchangeable reservoir and a much larger pool of stable calcium that only slowly exchangeable. Table 21-1 Distribution (m mol/1) of calcium in normal human plasma. - diffusible 1.34 - lionized cca2 1.18

- complexes Hco3 0.16 - nondiffusible (protion - bound) 1.16 - bound to albumin 0.92 - bound to globulin 0.24 Total plasma calcim 2.50

17 Phosphorus : phosphorus metabolism is not as finely regulated as calcium metabolism, but phosphorus is found in ATP, cyclic AMP, 2.3 - diphosphoglycerate, and other vital compounds in the body. Total body phosphorus is 500 - 800g ( 16.1 - 25,8 mol ) 85 - 90% of which is in the skeleton . Total plasma phosphorus is about 12mg /dl, with two - thirds of this total in organic compounds and the remaining inorganic phosphorus (pi) mostly in 3 2 po^ HP^ O and H2PO4 amount interning normally about 3 mg ( 97nm/kg) with and equal amount leaving via reabsorption. Development of bones tissue costegensis orossificationt- This begins before birth and is not complete unit about the 25th year of life . Long, short and irregular bones develop from cortiglage models flat bones from membrance and sesamoid bones from tendon . Bone development consists of two processes:- • The secretion by osteo blasts of osteodie collagen fibres in amucopoly sacharide matrix which gradually replaces the original cartilage and membrane models . • Calafication of the osteoid immediately after its deposition. There are two types of arrangement of collagen in osteoid.

18 Non - lamellor bone (woven bone) :- The collagen fibres are deposited in bundes , then ossified . This occure in • Ossification of bones that originate as menbrane models, e.g skull and scapula bone . •Healing of fractures , when collagen fibers are diposited in the granulation tissue that grows between the brocken ends . lamellar bone :- • The collagen fibers are deposited as in non - ~ lamellar bone, organized into the characteristic Haversian systems then ossified this occurs when cartilage models , are replaced by bone and in fracture healing. Functions of bones Bones have a variety of functions they :- • Provide the frame work of the body. • Give attachment to the muscle and tendons . • Permit movement of the body as a whole and or parts of the body, by forming joints that are moved by muscle. • Contain red bone marrow in which blood cells develop : haematopoiesis. • Provide a reservoir of calcium phosphorus and fat.

19 PATHOLOGY Pathology Diseases of upper limbs divides in to those of bones , joints and muscle Bones Disease :- Osteoprosis (osteopenia) :- Refers to an absolute decrease in the amount of bone below the levels required for adequate mechanical support. Some loss of skeletal mass and indeed , the muscular mass is a universal attribute of aging . Only when the loss of bone becomes sufficiently advanced to include symptoms does it merit the designation of Osteoporosis . The bone structure although reduced in amount . Appears normal by hstologic criteria , and the ratio of mineral to organic elements within the bone remains unchanged . Since the basic abnormality appears to be too little bone , this condition is also called osteoperia. Osteoprosis can be classified into two cateories: Primary, the more common form , and secondary, which reffers to bone loss associated with avariety of weel . Defined pathologic syndromes. These include : (1) malnutrition , the result of dietary protein deficiencies or of mal absorption syndromes. (2) Various endocrinopathies, including cushing's syndrme and thyrotoxicosis. And (3) prolonged immobilization . Of greater interest to us is the form of stesprosis called primary - apalide term frequently used in medicine to express ignorance

20 of etiology this is the most common form of metabolic bones disease and its incidance increase with age. (3) Although males develop symptomatic osteoporosis between 50 and 70 years of age, it is predominately the disease of postmenopausal woman, for this reason, primary osteoporosis is also called senile or post menopausal osteoporosis . An estimated four million older American are affected by osteoporosis, leading annually to about one million fractures. Pathogenesis :- New bone formation and reabsorption occurs through out life for bone mass to increase.. Osteogensis fias tow exceed reabrorption ; this occurs during the early growing years of life. Following the growth phase. An equilibrium is maintained well in to the third decade of life, in about the fourthdecade of life, the bony skeleton start undergoing a progressive erossion of it's mass marking the beginning of osteoporosis. Whether this occur be cause of excessive reabsorption inadequate bone formation, or a combination of the two processes is still controversial. Ostergensis and osteolysis are complex phenomena that are finely tuned by several metabolic, nutritional and endocrine factors. Although a detailed review of the homeostasis of bone mass is beyond our scope, some salient

21 features with relevance to the pathogenesis of osteoporosis are worthy of recall. The absorption of calcium is forored by active form of vitamin D. The effects of bone loss are understand by more severe in individuals end owed with delicate skelaton or low orignal density of bones . This may well under lie the differential occurrence of symptomatic osteoporosis in various racial and sex subgroups. The primary osteoprosis is amultifactorial and possibly hetrogeneous disorder. It has no single cause but rather is* common morphologic expression. Rickets and osteomalada :- These disordars are mainly caused by lack of active vitamin D

\\..25-(OH)2D3] . In children this deficiency produces rikets, osteomalasia in adualt counter part. Both were discribed along with vilamin D metabolism . The most common causes of vitamin deficiency are :- (1) lack of exeposure to sunshine (2) intestinal malabsorption from any cause (3) Chronic renal insufficiency in which osteomalacia appear as a component of renal asdeotystrophy. It may also be recalled that osteomalacia, in contrast with oestoporosis, is charactrized pimaritly by impaired min rlization of bone of matrix however, if calcification continues to be inadequate, the production of organic bone matrix also decreases .

22 Giant cell tumors are set apart from other neoplasms of bone by having numerous multinucleated giant cell in the spindle cell stroma that maks up these lesion. The tumors affected femal over age of 20 years than males. Ewing's sarcoma :- These type arises in bone marrow cavity of bone . most frequently between the age of 10 and 15 years . Osteomyelitis :- The tow most imprtant infection of bone are : (1) hematogenous pyogenic osteomyelitis (2) tuberculosis. pyogenic osteomyelitis:- This usually derolops in children.. In most cases the primary focus of bacteria infection can not be demonstrated and a transient bacteremia from trivial causes is presumed, hematogenous pyogenic osteomyelitis is caused principally by streptococcus aurous, followed in importance by streptococci pneumcocci, gonococci. Hemophilia influenza, and coliform bacilli. Tuberculous osteomyelitis: Tuberculous osteomyelitis is not longer a significant clinical problem except in developing countries where the incidence of tuberculosis is high. Seeding of the bones usually occurs by the hematogenous route but in many cases a primary focus in the longs or else where may not be identifiable.

23 administration of agents such as calcitonin and diphosphonates. Fibrous dysplasia of bone :- This uncommon disorder is chractrized by focal areas of fibrous replacement of bone . although the etiology is unknown, it is believed to represent a disturbance of normal bone development, perhaps a mal formation that result in progressive replacement of bone by fibrous tissue . Usually the lesion is monostatic, effects males slightly more often than females , and may be appear at any time between in fancy and middle age, with median age in one serous of 14 years occasionally , fibrus dyplasia is polyostotic and is very small percentage of cases the polyostotic form is associated with scattered areas of melanotic pigamatation of the skin and with sexual precocity concrance of this disparate feature, is known as albright's syndrome . in contrast to monostotic form of fibrus dysplasia albright's syndrom occures primarily in females . although the multisystem involvement suggest some congenital defect , no herditory or familial pattren has been established. The monostotic form shows a predilection for the long bone of the extremities . Hypertrophic osteoarthropathy :- This mysterious entity has three separate components :- (a) clubbing of fingers

24 (b) periostitis with new bone formation at the distal end of long bone as will as metacarpals and proximal phalanges (c) swelling and tenderness of the joints these changes are seen in multitude of clinical settings :- the most common causes of this trial are intrathrocic diseases lung cancer chronic lung sepsis (bronchiectasis) and chronic interstitial pnermonia. Clubbing alone may be seen in conganital cyanotic heart diseases, pactical endocarditis. Biliarycorrhosis , Ulcerative colitis crohon's disease, and thyroid cancer. The changes involved in clubbing of fingers are edema, fibrous overgrowth at the tip of the fingers and increased vascularization in nail bed with rounding or watshglass deformity of the nail.

25 Bone fractures :- Fractures classification: Complete non comminuted fracture Are those where the bone has separated into two fragments the fracture may be recognized according to direction of the fracture line a spiral or oblique fracture is an example of this type such fracture usually results from arotary type injury which twists the bone apart and is particularly common in the shaft of long bones . Tranverse fracture is another type of complete . Apatbology fracture is commonly a transverse fracture occurring in abnormal bone which is weakened by various disease they may result from the disease process itself or from are relatively minor trauma. Often pathologic fracture may be the first indication of the presence of pathology. Multiple fracture , are another type of complete non comminuted fracture . where two or more complete fractures occur involving the shaft of single bone Avulsion fracture occur when afragment of bone is pulled away from the shaft . These usually occur around joint due to ligament . Tendon and muscle tearing as associated with aspiring or dislocation - a chip of fracture is an avulsion fracture of as mall fragment or chip of bone from the corner of the long bone. These are very common in the fingers and are often very ting incomplete fracture a common example of this is the greenstick fracture little or displacement, where the cortex breaks on one side without separation or breaking

26 of the opposing corrtix . The effect is similar to that of trying to break agreetwig. Attars fracture is green stick fractious in which the cortex folds back upon itself, preducing only a slight irregularity- penetrating . Fracture resulting from pentration by a sharp object such as a bullet or a knife . Growth plate fracture are those that involve the end of a long bone of a child these fracture may be limited to growth plate cartilage, and displacement occurs or it may extend in to the metaphysis , epiphysis or both . Crush injuries stress fracture or fatigue occur at sites of maximal strain on a bone usually in connection with an unaccustomed activity. Fracture Classified according to location: Some fracture occur in selected areas and are usually easily recognized .One of these is the colles fracture, which is fracture through the distal one inch of the radius, and the distal fragment move back ward. Boxer's fracture: Occurs in fifth metacarpal bone as the result a blow to or with the hand. Monteggia fracture : Is one of the proximal third of ulna.

Joints diseases Movable joints have a capsule around cartilage - covered ends of bones and are lined by a synovial membrane

27 which enclosed a cavity containing a small amount of lubricating fluid. The joint is formed of commective tissue derivatives . It functions as an organ of support and passive motion and is affected by mechanical, circulatory, neurologic and inflammatory changes Disease of jonits may be classified as (1) specific infectious arthritis (2) arthritis of rheumatic fever (3) rheumatoid arthritis (4) rheumatoid like arthritides (5) osteoarthritis (6) traumatic injury (7) arthritis of gout (8) arthritis associated with other disease (9) tumors The numerically most important disease of joints are rheumatoid arthritis and osteoarthritis .Being at very common occurance , they account for atremendous total of pain , crippling , and disability . Rheumatoid arthritis is essentially an inflammation of synovial membrane, the cauese of which is unknown. Osteoarthritis is a degenerative change affecting primarily articular cartilage, with secondary hypertrophic changes in the under lying bone . It is often assent changes and is possibly related to wear and tear and to changes in vascular supply .

28 Arthritis: Infectious arthritis . Infection of a joint by known organism is usually the result of hematogenous spread in pyemic or septicemia . less commonly s the pactria may reach the joint from an adjacent infection of bone such as osteomyelitis or tuberclosis of bone . Also there may be introduction from without by pentrating wounds. any of the pyrgonic organism may thus infect the joints particulary the staphylococei, streptococei , gonocoeci, pneumococci and meningcocci . metastatic infection of joints may occur in gonorhea, bacterial endocarditis meningitis 5 otitis media pneumonia , typhoid fever and other infections Although effective antibiotic therapy has decreased the incidence of this complication. The joint becomes swelling and acutely inflamed . Fluid at first serious but later purulent accumulates in the joint cavity . The synovial membrane is greatly congested swollen and infiltrated with inflammotary cells . They may be considerable distraction of tissue, so that in healing there is formation of fibrous adhesion (fibrous ankylosis). In some cases this may be transformed into bone on disability disabling bony ankylosis result Gonorrheal arthritis is a complication that usually develops fairly early in acute gonorrheal infection .Several joint frequently are affected, but only a single joint may be involved tuberculous arthritis is commonly an extension joint a tuberculous involvement of bone . It recurs mainly in

29 children and most frequently affects the hip.The synovial membrane is greatly thickened by tuberculous granulation tissue. The inflammation may spread to erode the articular surface separation of flakes of cartilage or synovial fringes with adherent fibrin may form small, rounded, firm loose bodies in the joint (melon seed bodies ). Arrest may occur at any stage, or there may be rupture and sinus formation or an end result of fibrous or bony and ankylsis. Alrthritis of rheumalic fever. Acute nonsuppurative arthritis is aften a prominent feature of rheumatic fever, particularly in the acute cases arising in a dolesince or early adult life . Several joints tend to be affected in succession acute tenderness and swelling occur, with an excess of turbid fluid in the cavity. The inflammation is predminantly in the synovial membrane but nodules may develop in subsynovial and periarticular tissue . The histologic character of these may resemble that of the asch of bodies of the myocardium or rheumatic riodules else where . The inflammation usually subsides completely without residual disability . Rheumatoid arthritis: Rheumatoid arthritis is also referred to as atrophic proliferative, or chronic nonspecific infectious arthritis a prevalence in the general population of about 4% . It has its greatest incidence among women of reproductive age and

30 occurs about three times more frequently in women than in men. Although of unknown cause, evidence suggest that it is a chronic inflammation resulting most likely from hypersensitivity auto-immunity. It usually starts gradually but it may begin acutely and aften is accompanied by general symptoms, fever, leukocytosis, anemia, etc . The small joints of the hand and feet are most frequently affected and larger joints are involved later . The affected joints show a spindle shaped swelling are very painful, and progress to deformity and limitation of movement. Subcutaneous nodules are present in some cases and show ahistologic picture some what similar to that of rheumatic fever nodules. Rheumatoid disease is a systemic condition and may include visceral lesions such as granulon as of heart valves, pericardium, myocardium and pleura. Traumatic injury. Trauma to a joint may be followed by effusion of fluid into the joint cavity and by acute inflammation of surrounding soft tissues (traumatic arthritis) charcot's joint is acondition that occurs in certain cases of tabes dorsaliss, neuropathy (e.g. diabetic) and syringomyelia. Destruction of nerve fibers results in loss of sensation in the joint, which is then subjected to unusual trauma. The painless joint is excessively mobile , and destructive changes occur in the joint cartilage and adjacent bone.

31 Bennett's fracture - a fracture of the base of the first metacarpal involving its lower articulator surface and showing out and displacement of the distal fragment. Colles fracture - a fracture of the lower end of the radius about half to one inch above the wrist joint with out word and fack ward displacement of the lower fragment there is after an accompanying fracture of the ulnar styloid process . Smith's fracture - is after called are versed colles . It is a fracture of the lower end of the radius with forward displacement of the lower fragment. Dislocating - a dislocation is a condition of placement of the end of bone which form a joint. Arthritis of gout. Primary gout is a disease of genetic nature that is commented in some fashion with a disturbance of Purina (protein) metabolism. The uric aid content of the blood is increased, but this alone does not precipitate and acute arthritic attack .The disease occurs chiefly in middle - eged men. Secondary gout , such as that associated with hematopoietic disorders , also may be accompanied by arthritis . Acute attacks commence suddenly with pain, swelling and tenderness in a joint toes - fingers, of knees there is an effusion into the joint cavity of fluid containing crystals of sedum biuate.

32 The joints tumors:- Only rarely do tumors arise from joint structures but chondromas lipomas synoviomas spindly cell sarcomas and chondrosarcomas have been descried. Synovial sarcma is amaligment tumor arising from the lining cells of the synovial menbrane of a joint or bursa histologeally it shows dsistorted peicture syggestive of synovia but the appearance in various examples is far from uniform. Amixed peiture of sarcomatous and pseudoepithelial structures is frequently present. There is aground work of rounded or spindle cells with tissue spaces or pavement like area of tissue syggesting low epithelium. Tendons:- Inflammation tenosynovitis is an 'inflammation of tendon sheaths usually at the wrist of ankle it may be traumatic supportive or tuberculous in the last with fibrin in the extoller culovs. In the last with fibrin in the extuberculous. In the last with fibrin in the exudate ovoid melon seed bodies may be formed ganglion is a cyst like swelling arising from a tendon sheath or joint capsule . It is most common the back of the hand or wrist. There is proliferation of fibrous tissue of the sheath with mucoid degeneration producing the cyst like swelling there is no true lining and the ganglion does not communicate with the cavity of the tender sheath.

33 Tendon sheath tumors . Giant cell tumor ( xanthema) of a tendon sheath is a yellow or yellowish brown tumor that arises near the tendinous insertion most often in the hand .It has a ground work of fibrous tissue in which there are scattered giant cells and aggregates of large lipid - containing foam cells ( xanthoma cells ) . The xanthoma cells are found when there are deposits of iron and cholesterol. Except for this xanthomatous tendency the tumor is histocogically similar to the giant cell equlis and the benign cell tumour of bone . Palmar fibromatosis (Dupuytren's controeture ): fibrosis of the palmar fascia, with thickening and shortening, cause flexion of the fingers, with deformity and inability to make normal use of the hand . Although the cause has been < considered to be inflammatory, the condition is characterized mainly by a proliferation of fibrocytes, which may produce nodular masses and may be mistaken for fifrosarcoma. Bone tumors :- Bone is a complex structure that contains cartilage hematopoietic elements, and fibrous tissue in addition to bony ( osseous ) tissue itself. Hence primary tumors in the. bone may arise from any one of these elements. Tumors of hematopoietic cells and connective tissue have been described else where in this chapter. Use will consider osteo blastic (bone forming) and chonderomatous (cartilaginous) tumors along with two neoplasms of uncertain origin .

34 Bone -forming (ostes blastic) tumors :- Tumors in this category are marked by the formation of osteoid matrix ( that may become mineralized) and hence may be considered to have arisen from primative mesenchymal cells that have differenfcated a long the ostcoblastic pathway . These tumors have also been called osteogenic. The three prencipile tumors in this category are the osteoma, the osteoid osteoma and the osteosarcome. By far the most imprtant of these is osteosarcoma. Uosteoma: benign tumour found in the skull. Qsteoid osteoma: benign growth affect the long bone . Occur in person under 20 years and affect males twice as often as females . The tumor typically arises within cortical bone, where it inrodes the under line normal bone, producing a discrete, red-brown nodule . Osteosarcoma ( osteogenic sarcoma) :~ This lemurs arising from mesenchymal cells is characterize by osteoblastic differentiation of the neoplastic cells . As such the amount of osteoid and bone formation with a given tumors is available . Excluding maltiple myeloma, osteosarcoma is the most common primary malignant tumors of the bone. These type of neoplasm affected the young people Between 10 and 25 years , and moles are affected device as frequently as females.

35 Chondroma series of tumors :- There are three important cartilaginous tumors : The osteochondroma, the enchondroma, and the chondrosarcema. Osteochondroma (exostois cartilaginea) :- This knobby, benign, bony neoplasm protrudes from the metophyseal surface of long bones, mostly the lower femur or upper tibia, and is capped by growing cartilage . Enchondroma: This is also abenign catilaginwus tumor, but unlike the exostoses , it occurs deep with in the bone, in the spongiosa. Most frequently involved are the small bones of the hands and small bones of the hands and feet. Young adults are principally affected. Enchondrosar coma: This is also abenign cartilaginous tumor, but unlide the exostoses, it occars deep within the bone, in spongiosa, most frequently involved are the small bones of the hands and feet. Young adults are principally affected . chondrosar coma: Chondrosarcma is a malignant tumor of chondroblosts. Among bone cancers it is next to ostessarcoma in frequency chondrosarcomas differ from osteosarcamas in several respects . they occur in an older age group. Other bone tamors: Giant cell tumor " osteoclastoma " :

36 On the other hand decrease on bone mass, which is characteristic of osteoporosis, must necessarily be associated with slowed mineralzation thus the tow disorders merge. Not suprisinglllly, therefore the radiologic appearance of osteoporosis and osteomalacia may be very similar, and it may be default to distiguih the on basis of x ray findings alone . Osterities fibrosa cystica generisata (Von recklingh uster's disease):- This is the pattern of bone disease associated with severe hyperparathyrodism, whether primary or secondary. Demineralization of bones is the hallmark of excessive secretion of parathormone, in it's advance form primary parathyroidism give rise to the lesion known as ostitisafirosacystica generalisata or Von Reckling housen disease of bone. The basic antomic change with ostitis Abrosacystica is osteoclastic resorption of bone with fibrous replacement. Both microscopic and grosses cysts form with fibrous tissue. Frequanetly the first manifestation of the well devolped lession is acystic lesion. In many instances, the radiographic cystic are in reality soft tissue mosses refferred to as (bown tumors). Although these lesion are resemble giant cell tumors of bone ( presence of multinucleate osteoclasts in fibrustoma), they are non neoplastic and better referred to as reparative giant cell granulomas.

37 Secondary hyper parathyroidism resulting from chronic renal failure can also give rise to bone cysts. Osteitis deformans pagefs disease: - Ostieitis deformans is yet anthor skeletal disordr of unknown etiology characterized by continuos excessive destruction of bone and its simulateous replacement by an abonrmally soft, poorlly mineralized matrix . This lesion is present in form of 1 to 3% of elderlly individual and is almost never detected in patient below 40 year of age in most cases paget's disease is mil and symptomatic, althouhg more advanced cases are associated with intense pain in the involved bones. The etiology of paget's disease remains unknown genetically determined defects in connective tissue metablism have been suspected on basis .of some reports familiar clusternig of paget's disease basis on the presence of tubular strictures resembling paramyxoviruses in the nuclei of osteoclasts , aviral etiology has been suggested. Antigenically , these tubular structure seem to cross-react with the antigens of measles virus and respiratory syncytial virus. However virus have never been isolated from the lesion and serum antibodies directed against the viral agents are not consistently seen . Hence, this currently favored hypothesis need further substantiation since the etiology is unknown. Therapy is directed toward reducing osteoclastic activity by

38 PASIC & OPTIONAL TECHNIQUE Section (4) Basic techniques :- 1. the clavicle : posteroanterior - film size 10xl2inch '24x30cm' with grid. - Pt position: the patient erect face the backy, or prone. - Part position: the clavicle is centred to the film in closed contact - Central rays: angled 10- 15 caudal centre to the centre of the clavicle. 2. A.C. joints: Anteroposterior: with and without wieghts . -film size: 7x17 in or two film 8x10 in. - Pt position: the patient erect with equal weight on both hand, no rotation of the trank. - Part position: posterior aspect of both shoulder against film holder - central rays: use72 in FFD with C.R perpendicular to film

39 3. Steronclavicular joints : PA - film size 8x10 in - patient position : pt erect faced the film holidler or prone . - patient position : centre the seternal notch to the centre of the film. - central rays : perpendecular to the centre of the film The scapula :- Antero posterior - film size 10x12 inch lengh wise . ^ < ,. - Pt position :patient erect or '/^I l supine with posterior surface of t, s i * ~* - the scapula against film holder . , , - Part position : Abduct arm of m jl ** interest 90° supiate hand. ?| 0 \ centre the escapula of the film . | h - Central rays : CR centre to mid "j ?J of the scapuls 2 inch below the cracoid process. perpendicular to film holder

40 latral of the scapula :- film size size 10x12 patient position : pt erect in anterior oblique part position : palpate the scapula and rotate the patient antile the scapula become in true latral C.R : Direct the central ray perpendicular, centre to the centre to the medial border of the scapula. The shaulder joint: Anteroposterior projection: - film size 8x10 inch - patient position: erect or supine with posterior aspect of shoulder against film holder rotate the patient till the side of interst become inclose contact with film. - part position: it is necessary to put the shoulder in closecontact with film holder . top of the film 2 inch above the shoulder - rotate hand internally untill the epicondyle perpendicular

41 To film holder C.R - perpendiciar to the shoulder joint 4crn below the cracoid process. Inforsuperior: - film 10x12 - patient: erect or supine partpositioon: abduct the affected arm to right angle - C.R: horizentully through the axilla the humeras: anteroposterior:- film size: 7x17 inch or 14x17 in patient position ; erect or supine part position : supinate hand untill the epicondyle is parallet to the film rotate the pt utill the humerus is inclose contact to the film. C.R : CR perpendicular to film holder centred to the centre of the numerous as .

42 Latral humerus : - film size : 7x17 in or 14x17 in for two vieus - patient position : pt erect or supine - part position : rotate the patient to affected side untill the humerus is close contacted to the film - Rotate hand internally untill the epicondyle is perpendicular to the film. - CR: direct the central rays perpendicular to the film holder centre to the centre of the cantre of the humerus . Elbow joint: Anteroposterior Film size : 10x12 in , divided in to two half Patient position: seated at end of table with elbow fully extended if possible Part position: extend elbow and supinaate hand centred the the elbow to the uncoverd half.

43 CR: centre to the centre of elbow join perpendicular to the film. Latral: Film size 10x12 in divided in to two holt. patient position : seated at the end of the table part position : rotate hand internally and flexed the elbow joint untiil the two epicondyle of the distal humerus is perperdecular to the film holder . central rays: centre to the elbow joint perpendialar to the film holder forearm : Antro Posterial: film size 12x14 or 7x17 in patient position : seated at the end of the table part position : forearm extended rested on the table top fully

extended elbow and supinate hand :J iVvi,! include joint near the injury or both joint if possible.

44 CR : perpendicular to the film holder centre to the centre of radius and ulna. Latral forearm : film size: 12x14 in or 7x17 in patient position: seated at the end of the table part position : flex the elbow joint 90° drop the shoulder to rest the humerus on table top the thumb must be up . wrist and elbow in true latral. central ray: perpenchicular to the film holder centred to centre of ulna shaft wrist joint :- postero anterior projection and oblique position film size: 10x12 in divided in to thirds. or 10x12 in divided in to two or 10x12 for one view inlarge pt hand patient position: seated at the end of the table part position : PA: pronatehand and forearm 90 to film holder into true lateral position extend finger and wirst C.R : perpendicular to film holder centred to the centered of the wrist joint latral wrist; Film size 10x12 divided in to thirds , "'" r- 1 k i 10x12 divided in to tow ,. w J j 10x12 one view for largwnst }\^ j patient position ; patient sented at m rX> - the end of the table part positior: rotale hand and forearm 90° to film holder into true latral position extend finger and wrist. Central rays: perpendicular to film halder, centred to the centre of.

45 The hand : posteroanterior projection. Obligue position Film size : 8x10 in for small hand £ *aH divided 8x10 to two half i.1 > 10x12 in divided in to two half "3 patient position : the patient I • »* seated at the x ray table part position : PA : - pronate hand with palmer surface in contact with the film holder insure that the digits are in eluded on the film holder oblique : hand in prone position then rotate it 45° latrally separate the fingers to rest fingers tips and thumb on film holder CR: per pendicular to film holder cenrted to the third metacarpohalageal joint

46 Latral hand : Film size: 10x12 divided in to thirds in to thirds 10x12 divided in to thirds into two patient position; the Pt seated at the end of the table part position: finger super inposition the wrist and finger in true latral CR: perpendicular to film holder centred to the metacarpophangeal joint

47 And Optional Technique

A ' '

Elderllly patients, particularly with degenerative changes in the wists, may find it difficult to place their hands flat on the radiographic table . this simple variant of the orthodox technique facilitates the examination .

Norgaard's position. With the hands in a position of semi-supination, minor erosions of rheumatoid arthritis may be visible much more clearly than in the orthodox postero-anterior and oblique projections. The erosions demonstrated on the metacarpal heads in this patient were barely in the standard views. Supination of each hand to an angle of 350- as opposed to 450 recommended originally by Norgaard - usually avoids overlapping of the metacarpal heads .

rtSa '

•k. In this patient an initial diagnosis of a fracture of the radial styloed process was made. The angled projection, however, shows that the proximal pole of the scaphoid had impinged on the articular surface of the radius and had also been separated from the lunate .

48 More convincing evidence of this compression defect was obtained by the use of the stryker position, which is illustrated in these two photographs .

V t

Demonstration of the head of the humerus may be enhanced by angling the tube 30° towards the feet, as illustrated. This lytic defect of the articular surface of the humeral head proved to be pyogenic in origin. The angled-down projection demonstrates the erosin on much more clearly than the orthodwox view. The tube is centred just below the acromio-clavicular joint.

This 46-year-old man complained of pain over the right scapula. Prthodox projections showed onlly a suspicious fluency in the inferior portion ofthe scapula . Examination with a ten - second exposure and a low milliamperage, accompanied by gentle breathing, demonstrated clearly a lucent area at this site. A supplementary axial projection, obtained with the shoulder remote from the film, as illustrated, confirmed the presence of this large osteolytic lesion, which was proved histologically to be an adenocarcinomatous metastasis .

50 » i

The orthodox antero-posterior projection in this patient suggested that a fracture had united in malposition. In fact, the lateral view, obtained by the technique described a bove, demonstrated non-union.

51 Pathologic Features :-

Fracture ofupper third of humural heading

Fracture of mid of shaft of radius and unla

52 Suplaxation of elbow joint

Dislocation of shoulder joint

53 Supra condylar fracture

Outhoplast of elbow joint

54 Fracture of mid shaft of humrus

56 Conclusion

From what we have seen from the previous sections of the project we would like to suggest the following 2— Radiologic imaging of orthopedic and specially upper limbs necessitate special attention from technologist staff to be very aware whenever faced with special situation where the standard technique is impossible with special reference to upper limb disease investigation we did find stripp w.j (6) as an important reference to be consulted for special situations. However investigation of upper limbs radiography is very difficult in children as it has been always of a problem to get either the basic or alternatives technique. Finally we suggest for our college technologist to spend some time in consulting the college library so as to refresh and update themselves with the available references indeed we discover that the college library has a very rich references in all imaging techniques. We wish this research would answer some of the un seen projection which we have selected with great interest.

57 References :-

l.Ross and Wilson - ANATOMY AND PHYSIOLOGY IN HEALTH AND ILLNESS -Khatheleen J.W Wilson OB.E Anne Waugh - Eight Edition . 2.Robbins and Kumar -BASIC PATHOLOGY - Fourth Edition. 3.W.A.D Anderson - SYNOPSIS OF PATHOLOGY - Tenth Edition - Thomas M. Scotti. 4.M.R.E Dean -MB Bchir DMRD - BASIC ANATOMY AND PHYSIOLOGY FOR RADIOGRAPHER-COnsultant Radiographic - The Royal Shrewsbury . Third Edition. 5.Willam . F Ganogy - MEDICAL PHYSIOLOGY - 5th Edition 6. William J. Stripp - SPECIAL TECHNIQUE IN ORTHOAETIC RADIOGRAPHIC - In corporation with Roland Murray and Harold G. Jacpbspn - New York 1979.