Upper & Lower Extremities for Radiology Technologists Ce Course

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ANATOMY, DISEASES, & CONDITIONS:

UPPER & LOWER EXTREMITIES

FOR

RADIOLOGY TECHNOLOGISTS

CE COURSE

Mary Stela Gallegos, ABD, RT, (R), (M)

Zapp! Educational Services (559) 859-4725 Zappeducationalservices.com

COURSE GOALS

There are several goals in presenting the following material. The main objective of this course is to provide an “anatomy review of the upper and lower extremities” for all radiology technologists. The second goal is to provide review material regarding diseases and conditions pertaining to extremities, related terminology, body planes, and bone fractures.

COURSE OBJECTIVES

By the end of this course students should be able to:

1. Describe the difference between functional and structural joints in the human body

2. Present basic anatomy information concerning the upper extremities: shoulder, clavicle, humerus, elbow, forearm, wrist, hand

3. Present basic anatomy information concerning the lower extremities: pelvis, hip, femur, knee, tibia-fibula, ankle, foot

4. Identify specific anatomy for upper and lower extremities using illustrations provided

5. Describe and recognize the bone diseases and/or conditions associated with upper and lower extremities

6. Define keywords and phrases presented in the content, glossary, and definition sections

7. Describe and recognize the body planes, bone fractures, and body movements associated with all bones

2 An anatomist is a specialist in the field of anatomy. These specialists have divided the upper extremities into four categories: the hand, the forearm, the arm, and the shoulder girdle. Since the purpose of this course is to provide a brief radiological review of the upper and lower extremities with associated diseases and conditions, as well as body planes and bone fractures, the material will be presented in the following manner:

Table of Content

Page Appendicular Skeleton ………………………………………………… 4 Articulations (Types) …………………………………………………... 5

Section One: Upper Extremities - Anatomy Page Shoulder………………………………………………………… 14 Clavicle…………………………………………………………. 16 Humerus………………………………………………………… 17 Elbow…………………………………………………………… 18 Forearm…………………………………………………………. 20 Wrist……………………………………………………………. 21 Hand……………………………………………………………. 24 Section Two: Lower Extremities – Anatomy Page Hip ...…………………………………………………………… 27 Pelvis ...………………………………………………………… 28 Femur…………………………………………………………… 29 Knee……………………………………………………………. 30 Tibia-fibula……………………………………………………... 33 Ankle…………………………………………………………… 33 Foot……………………………………………………………... 34 Section Three: Extremity Diseases/Conditions Clinodactyly 5th digit …………………………………………... 38 Thumb- Hypoplasia/Aplasia …………………………………… 42 Polydactyly …………………………………………………….. 43 Syndactyly ……………………………………………………… 45 Section Four: Body Planes, Dislocation/Fractures Page Aphoristic body planes………………………………………… 48 Dislocations ……………………………………………...... 50 Fractures ……………………………………………………….. 50 Causes …………………………………………………………. 50 Types ………………………………………………………….. 52 Body Movements ……………………………………………... 57 Section Five: Diseases and conditions (lower extremities).…………………. 60 References…………………………………………………….. 83

3 APPENDICULAR SKELETON

In addition to anatomy, osteology, which is the study of bones is also an important subject for all radiologic technologists. These topics are indispensable, however, in this section only a short review of material pertaining to bones will be presented. There are approximately 206 separate bones in the average adult. The skeletal system is divided into two subdivisions, the axial and the appendicular. The axial skeleton, which includes all the bones in the skull, hyoid, auditory ossicles, vertebral column, and the thorax, will not be discussed in this course. Because this course focuses on upper and lower extremities, only the appendicular skeleton system will be presented. The skeletal system (appendicular) – which includes the upper and lower extremities, consists of 126 bones. It should be noted that the pelvic and shoulder girdle are also included. Depicted below are the number of bones to the corresponding anatomical part:

APPENDICULAR SKELETON Number of bones A. Shoulder Girdle clavicle – 2 scapula – 2

B. Upper Extremities humerus – 2 radius – 2 ulna – 2 carpals – 16 metacarpals – 10 phalanges – 28

C. Pelvic Hips – 2

D. Lower Extremities Femur – 2 Fibula – 2 Tibia – 2 Patella – 2 Tarsals – 14 Metatarsals – 10 Phalanges – 28

______

TOTAL = 126

4 ARTICULATIONS (JOINTS)

Articulations, more commonly referred to as joints, are where the bones intersect and provide the strong connections the body needs to move. The radiology technologists must be aware of the various joints within the body in order to obtain appropriate and accurate radiographs. Each specific joint has various structural components which allows the possibility for range of motion. Consequently, joints may be classified by either function or by structure.

STRUCTURAL JOINTS

Structural Joints is one type of classification for joints which is established because of their function. The basis stems from the consideration of whether there is a joint cavity or whether the connecting bones are sturdily affixed to one another by or fibrous-connective tissue or cartilage. Consequently, these variables serve to establish three structural classifications: fibrous, cartilage, and synovial.

Fibrous: Tough collagen fibers make up the first type of structural joint. These fibrous joints consist of connective tissue which do not allow movement. Examples of structural fibrous joints include (a). syndesmosis joint that holds the ulna & radius of the forearm together, (b). sutures of the skull, and (c). gomphoses, tooth in its socket - immovable joint. Figure 1.0 illustrates three examples of fibrous articulations.

Figure 1.0 Fibrous Joints. Copyright: Creative Commons Attribution-ShareAlike

Cartilaginous: Composed of a band of cartilage which binds bones together, cartilaginous joints are a second type of structural joint. This type of joint (cartilaginous) does not allow very much movement between the articulating bones. Cartilaginous joints play a vital role in forming the growth regions of immature long bones. Presently, joints may be categorized into two groups: synchondroses and symphyses. The first type of joints are synchondroses and consist of

5 hyaline cartilage. Joints that are symphyses are made up of fibrocartilage. Figure 2.0 illustrates that intervertebral disks of the spine and joints between the ribs and costal cartilage (see section Amphiarthrosis) are types of cartilaginous joints (Barclay, 2018). Another example of a cartilaginous joint is between the manubrium and the sternum.

Figure 2.0 Cartilaginous Joints. Copyright: Studyblue.com. Labeled to reuse.

Synovial joints: Synovial joints are identified as the upmost common group of joints and are described as joint spaces that are fluid-filled at their articulating site (Barclay, 2018). The articulating bone ends of synovial joints are situated within an all-inclusive joint cavity filled with lubricating fluid. It should be noted that the articulating end of bones do not connected with one another. The joint capsule is surrounded by dense and tough tissue (connective) that is lined with synovial membrane. This membrane creates oily fluid that lubricates the articulation to reduce wear and tear, as well as reducing the amount of friction. Ligaments which are strong

6 bands reinforce the articulating joint and keep it moving in any undesirable fashion, or from dislocating. Figure 3.0 illustrated the human body’s synovial joints which can be classified in several methods:

• Pivot • Hinge • Saddle • Plane • Condyloid, • Ball and socket joints

Figure 3.0 Synovial Joints. Copyright: Labeled for reuse

7 a. Pivot joints: Pivot articulations allow rotational movement (on its axis) by fitting into a notch formed by the receiving articulating bone. Both C1 and C2 of the cervical spine are examples of pivot joints as the head pivots back and forth (see Figure 4.0). A second example of a pivot joint is the wrist as the hand has the capability to flip up and down (Barclay, 2018).

Figure 4.0. Cervical Spine – Synovial Joint (Pivot). Copyright: courses.lumenlearning.com. Free to share and use commercially. b. Hinge joints: Joints that have the capability to increase and decrease the angle of the two articulating bones is referred to as a hinge joint. The knee is an example of a hinge joint because it can only move in one direction thus having limited movement. The elbow is another example of a hinge bone. The structure design of hinge joints provides the muscles and bones more strength and support. c. Saddle joints: Joints such as the one between the first metacarpal and trapezium bone, are called saddle joints. They permit a 360-degree range of motion by allowing the bones to pivot along two axes. d. Planar (Gliding) joints: The joints such as the ones between the wrist (carpals) with articulating surfaces have slightly curved or flat faces which allow for the bones to glide past one another in any direction. Thus, the reason they are called gliding joints. When describing planar (gliding) joints, it is essential to note that there is no rotation among the articulating bones because the range of motion is limited. In addition to the carpal bones, planar joints are also found in tarsal bones of the foot and between vertebrae (lumenlearning, n.d.). e. Condyloid (Ellipsoid) joints: Bones having oval-shaped ends will articulate effortlessly with the receiving end which also has a similar hollow end (lumenlearning, n.d.). The articulations in the fingers are considered condyloid joints. Condyloid joints have the capability to move in two axes meaning they can move side to side as well as up and down. f. Ball-and-Socket: Of all the joints, the ball and socket have the most “range of motion” with the capability of completing a full circle and rotation on the axis. Unfortunately, a great disadvantage to having so much range of motion in a ball and socket articulation is its predisposition for dislocation of that joint. The human body has two joints (hip and

8 shoulder) that are classified as being a ball and socket joint. Figure 5.0 presents a hip radiograph which is classified as ball and socket joint.

Figure 5.0. Hip Radiograph illustrating ball and socket joint. Copyright: Westphal Orthopedics. Labeled for reuse

FUNCTIONAL JOINTS

Functional Joints are so classified based on the amount of movement they allow. The degree of motion within a joint range from immobile, to slightly mobile, to freely moveable joints and is significant as it has a direct correlation to its main function. For example, freely moveable joints allow a higher range of motion but provide little protection of internal organs. On the other hand, joints that are immobile or slightly moveable have a higher degree of responsibility to protect internal organs. There are three types of functional joints: synarthrosis, amphiarthrosis, and diarthrosis.

Synarthrosis: Synarthrosis is those joints the permit no movement (immobile) between connecting bones. The immobile nature of these joints is vital for the protection of the body and internal organs. For example, the sutures of the skull provide for a strong union to protect the brain (see Figure 6.0). Another example of synarthrosis can be seen in the sutures of the skull that connect the teeth to the skull.

Amphiarthrosis: Amphiarthrosis is a type of articulation that allows a slight amount of movement or has limited mobility. This type of joint forms a juncture between the bony surfaces of bones prohibits a higher amount of motion and allows a small amount of movement. Cartilage (elastic) and ligaments connect amphiarthrotic joints. Examples of amphiarthroses include the intervertebral discs of the spine (see Figure 7.0) and the pubic symphysis of the pelvic bones (see Figure 8.0). The intervertebral discs (fibrocartilage) of the spine join the bony vertebrae, but the spinal column maintains a minimal amount of movement between discs. Fortunately, the vertebral column has a large range of motion when combining all intervertebral disc actions. The pubic symphysis (pelvic cartilaginous joint) is another example of amphiarthrosis. The pubic symphysis’ strength plays a vital role in providing the pelvic area with weight-bearing stability. This amphiarthrotic joint typically has very minimal mobility but can move up to two millimeters, however, the amount of movement changes during childbirth (Healthline, 2015).

Figure 6.0 Skull Sutures – Synarthrosis Joint. Copyright: Creative Commons Attribution 4.0 International

Figure 7.0 Vertebrae– Amphiarthrosis Joint. Copyright: Creative Commons Attribution 4.0 International

Figure 8.0 Pelvis – Amphiarthrosis Joint. Copyright: Creative Commons Attribution 4.0 International

10 Diarthrosis: Uninhibited (freely) movable joints are called diarthrosis and are the third functional category of joints. In addition, they have the highest range of motion of any articulation. Most body movements are performed by all the synovial joints. The appendicular skeleton, illustrated at the beginning of this course, consists of most of the diarthrosis articulations which allow the extremities a wide range of motion. Anatomically, an axis is described as the movements in coordination to the three anatomical planes: frontal, sagittal, and transverse (BCCampus, n.d.). As a result, diarthrosis is divided into the types:

➢ Uniaxial - for movement in one plane ➢ Biaxial - for movement in two planes ➢ multiaxial joints - for movement in all three anatomical planes

• Uniaxial joint is the diarthrosis with the least amount of movement. It simply permits a joint motion in a single plane such as around a primary axis. One anatomical part of the human body is the elbow joint and simply allows the arm to bend or straight. It is classified as a uniaxial joint.

• Biaxial joint prohibits the human body to have a range of motion more than two planes. The knuckle joint (hand) is called the metacarpophalangeal joint. It is a biaxial joint and allows the phalanges to abduct and adduct from each other along one axis. Plus, it has the capability to bend and straighten the phalanges along another axis.

• Multiaxial joint is the diarthrosis with the most amount of movement and allows for several directions of movement. It is also referred to as polyaxial or triaxial joint as it allows for a range of motion along all three axes. The upper extremity (shoulder) and the lower extremity (hip) can be rotated around its long axis resulting in allowing rotation of the limbs so that its anterior surface is moved either toward or away from the midline of the body (BCCampus, n.d.). Second, multiaxial and hip have the capability to move in an anterior-posterior direction and a medial-lateral joint such as the shoulder direction. Figure 9.0 illustrates a hip, which is a multiaxial joint. It allows for three types of movement: anterior-posterior, medial-lateral, and rotational.

Figure 9.0 Hip – Multiaxial Joint Copyright: Creative Commons CC0

11 Figure 10.0 provides anatomical type of synovial joints with examples for each category.

Figure 10.0. Synovial joints with examples. Copyright: Pinterest. Labeled for reuse

SECTION ONE

Upper Extremities:

Shoulder Clavicle Humerus Elbow Forearm Wrist Hand

13 SHOULDER GIRDLE

The basic function of the shoulder girdle is to connect the upper extremities to the trunk. The shoulder consists of the clavicle and scapula. These two structures articulate with each other to form the acromioclavicular joint. The clavicle and scapula articulate with one another to provide a suspension type of support for the arm by means of the glenohumeral joint. The shoulder is considered a synovial ball and socket joint. Anteriorly, the girdle is finalized with the sternum, which articulates with the medial end of the clavicle. This articulation forms the sternoclavicular joint. Posteriorly, the scapulae are widely separated.

Scapula

The scapula is defined as a flat triangular bone. It is situated over the second and seventh ribs (Martini, Timmons, and Tallitsch, 2009). The scapula consists of an anterior surface, as well as a posterior surface. It also contains three borders: medial (vertebral), superior, and lateral (axillary). Furthermore, the scapula also consists of three angles: superior, lateral, and inferior. The lateral border extends from the glenoid cavity to the inferior angle. The superior border begins with the superior angle and extends to the coracoid process. The third scapular border, which is the medial border, extends from the superior angle to the inferior angle.

Figure 11.0 and Figure 12.0 illustrate the anatomical features of the scapula (anteriorly, posteriorly, and laterally). The junction of the superior border and medial border creates the superior angle, while the junction of the superior border and lateral border creates the lateral angle. This angle ends in a thick, shallow, oval depression termed the glenoid fossa (cavity). The glenoid fossa is separated from the main portion of the scapula by a constricted region called the neck, while the glenoid cavity accommodates the head of the humerus. The coracoid process arises from the thick base of the scapular notch to the neck of the scapula. The coracoid process can be palpated slightly medial to the acromioclavicular joint. The inferior angle of the scapula is formed by the union of the lateral border and the medial border. The inferior angle, which is sometimes used as a landmark by radiology technologists, is easily located on most patients.

Due to its protected position, the scapula is rarely injured. However, injuries to the scapula occur due to any severe trauma or motor vehicle accident. Most fractures of the scapula involve either the body or neck. Scapular fractures also occur in association with dislocations of either the scapulohumeral joint of the acromioclavicular joint. Anteriorly, the exterior appears smooth and is slightly concave. Posteriorly, the surface is convex. The back (dorsal) part of the scapula can be split into two unequal areas by a projecting ridge called the spine of the scapula. This spine divides the dorsal surface of the scapula into the supraspinatus (supraspinous) and the infraspinatus (infraspinous) fossae. The scapular spine begins at the vertebral border and inclines upward across the bone, ending in a flattened process called the acromion.

14 Figure 11.0. Scapula. Copyright: Wikimedia Commons, Creative Commons Attribution 3.0.

Figure 12.0 Scapula Lateral. Copyright: Wikimedia Commons, Creative Commons CC0

15 Clavicle

Figure 13.0 illustrates the clavicle is a sigmoid, or S-shaped bone and is the first bone to begin ossification and the last to complete ossification. It is classified as a long bone, which contains a body (shaft), and two articular processes. The clavicle lies anteriorly, thus completing the anterior part of the shoulder girdle. The sternal end of the clavicle connects medially to the manubrium of the sternum. This articulation is called the sternoclavicular joint. This sternal end is quadrangular, occasionally triangular (Martini, et al., 2009). Laterally, the clavicle’s acromial end joins with the acromion process of the scapula. The acromial end is flat and contains a small oval articular facet. This facet connects with the acromion process to form the acromioclavicular joint. A diarthrodial joint is formed at both the proximal and distal ends of the clavicle. The A.C. joints form a synovial gliding joint, which performs with a gliding and rotary movement. The sternoclavicular joint is a synovial double-gliding joint. It allows for circumduction, elevation, depression, as well as forward and backward movements of the clavicle. The degree of curvature of the clavicle varies between individuals and gender. However, it is believed that the curvature is more acute in males than in females (Martini, et al., 2009). The clavicle is a very commonplace site of fractures. It is distinctively the most frequently fractured bone among children accounting for 8-15% of all skeletal injuries in the pediatric population (Beck, n.d.).

Figure 13.0. Clavicle. Copyright: Wikidoc. Free to share and use commercially

16 Humerus As one of the longest and largest upper extremities, the humerus is considered part of the shoulder girdle. It includes a shaft and two expanded ends. Posteromedial, a round semispherical “head” connects with the glenoid cavity of the scapula. The head is set at approximately 45 degrees with the long axis of the humeral shaft. Other anatomical features include: the shaft, anatomic neck, surgical neck, greater and lesser tuberosities (see Figure 14.0). The humeral head is separated from the humeral shaft by a shallow compressed groove called the anatomical neck. Lateral to the anatomical neck are two protruding areas of bone for muscle attachment, the greater and lesser tuberosities. The lesser tuberosity is anterior and just below the anatomical neck. It has a smooth muscular impression that is palpable by radiology technologists (Martini, et al., 2009). The greater tuberosity is the most lateral aspect of the proximal humerus. It is located immediately below the anatomic neck. It is separated from the lesser tuberosity by a deep concavity called the bicipital (intertubercle) groove. Just below the tuberosities, the proximal humeral bone narrows to form the surgical neck. The surgical neck is so-called because it is frequently the site for various fractures. Other fracture sites within the proximal end may include the anatomic neck, the greater and or lesser tuberosity.

Figure 14.0 Humerus Anterior and Posterior. Copyright: courses.lumenlearning.com Free to share and use commercially

17 Elbow

Distal Humerus The distal end of the humerus is partially flattened and wide, having articular and non- articular parts. The articulating parts join with the radius and ulna at the elbow. On the inferior surface are two enhancements. The first of which is the trochlea and is located on the medial aspect of the distal humerus. The second elevation is the capitulum and is located on the lateral side of the distal humerus. The trochlea articulates with the proximal end of the ulna, while the capitulum articulates with the head of the radius. The non-articulating condyles (medial and lateral) encompass the medial and lateral epicondyles. The distal humerus, furthermore, incorporates the olecranon, coronoid, and radial fossae. Proximal to the trochlea are two fossae. Anteriorly, above the trochlea, is the coronoid fossae. It secures the coronoid process of the ulna when the forearm is flexed. On the posterior surface of the distal humerus is the olecranon fossa. It receives the olecranon process when the forearm is extended. Directly proximal to the capitulum is the radial fossa which receives the anterior edge of the radial head when the forearm is completely flexed.

Proximal forearm The radius is on the lateral side of the forearm and is easily identified by most radiologic technologists as the “thumb-side.” The proximal end of the radial shaft is smaller than the distal end. The radial shaft is shorter than the shaft of the ulna. The head of the radius is a circular disk that contains a flat upper surface. This surface articulates with the capitulum of the humerus and whose medial edge articulates with the radial notch of the ulna. Just below the head, exists a narrow area called the neck. Immediately adjacent to the neck medially, is a roughened process called the radial tuberosity. The tuberosity is rough posteriorly, but smooth anteriorly. When analyzing the anatomy of the forearm, one will notice that the ulna is positioned on the medial aspect. The ulnar shaft is long and narrow, which tapers down. The proximal end of the ulna contains two curved processes, the olecranon and the coronoid process. The proximal end also encompasses two concave articular cavities, the semilunar and radial notches. The semilunar notch is formed by the upper portion of the olecranon, and by the coronoid processes. This smooth concave surface articulates with the trochlea of the humerus. The coronoid process (lateral side) has a shallow, smooth, oval depression called the radial notch. The radial notch articulates with the radial head. Figure 15.0 illustrates the anatomy of the distal humerus and the proximal forearm (radius and ulna). Figure 16.0 illustrates the anatomy of the proximal Ulna.

Figure 15.0 Elbow Anterior and Posterior. Copyright: courses.lumenlearning.com Free to share and use commercially

Figure 16.0 Proximal Ulna. Copyright: studyblue.com. Public Domain

Figure 17.0. Forearm anatomy. Copyright: courses.lumenlearning.com Free to share and use commercially

. Let’s check our positioning!

For a true lateral of

the elbow which

bones (distal

humerus) should be

superimposed? a.

(a). Elbow Positioning. Copy right: Air Force Medical Service. Labeled for Reuse. (b) Lateral X-ray. Copyright: b. Radiopaedia. Labeled for reuse

20 Wrist

The distal end of the radius is broad and flattened and consists of a pointed tip called the styloid process (see Figure 17.0). This articular surface articulates with the lunate and the navicular carpal bones. At its medial side, it articulates with the head of the ulna. The lower segment of the ulna is small and has around process laterally labeled the head of the ulna. The ulna (head) articulates with the ulnar notch of the radius. However, it does not articulate with the carpals. The distal radioulnar articulation is separated from the wrist by an articular disk (Martini, et al., 2009). On the medial aspect is a projection called the styloid process, which is palpable in supination. The carpus, or wrist, is classified as a synovial ellipsoid joint as it allows movement in two axes: a). abduction and adduction, and b). flexion and extension. It is composed of eight bones, which are arranged in two rows.

The proximal row consists of the following bones: Navicular - scaphoid Lunate - semilunar Triquetrum - cuneiform (triangular) Pisiform

The distal row consists of the following carpal bones: Greater multangular – trapezium Lesser multangular – trapezoid Capitatum – os magnum (capitate) Hamate – unciform

All the carpals have two names (except for the pisiform) that are commonly used. Each of the carpals (except pisiform) has six surfaces, with two to four articular surfaces (Martini, et al., 2009). The various margins are visualized radiographically. These bones are classified as short bones and articulate with one another. The navicular and lunate bones articulate with the distal radius. The distal row of carpal bones articulates with the metacarpals (see Figure 18.0). The radiocarpal articulation is classified as a diarthrodial condyloid joint.

Figure 18.0 Wrist anatomy. Copyright: Wikimedia Commons. Creative Commons CCO

Just for Fun!

Can you name the carpals?

Wrist X-ray. Copyright: Wikimedia Commons. Creative Commons CCO.

SCAPHOID (NAVICULAR) The scaphoid (navicular) carpal bone is situated on the lateral (radial) or “thumb” side of the wrist. Of all the carpals in the proximal row, it is the largest. Symptoms of a scaphoid fracture include pain with original injury followed by prompt swelling on the posterior side of the wrist. If a scaphoid (navicular) fracture is suspected, the radiology technologist should perform a scaphoid view, in addition to the routine views of the wrist. However, if the physician’s order does not specifically request a scaphoid/navicular view, the radiology technologist may query the provider for further clarification or follow the institution’s policy. A scaphoid view will demonstrate the elongated scaphoid bone, which is foreshortened in the standard PA view (see Figure 19.0).

Figure 19.0. Scaphoid positioning and x-ray. Copyright: Wikipedia, Creative Commons Attribution-ShareAlike.

22 CARPAL TUNNEL The carpal tunnel is a passageway which is rigid and narrow that contains ligaments and bones at the base of the hand. It holds the median nerve and the tendons that allow flexing of the phalanges. The role of the median nerve is to provide feelings to the thumb and the other fingers. Its second role is to provide control to small muscles at the base of the thumb. With carpal tunnel syndrome (CTS), the median nerve runs from the forearm into the hand (palm) and becomes compressed at the wrist. It is believed that the compression of the median nerve is associated with chronic motion and repetitive motion. Another important radiographic position of the wrist is the carpal tunnel view. The rate of carpal tunnel syndrome has risen in recent years. Virtually all workers, including radiology technologists, who use their hands and wrists repeatedly, are at risk for developing CTS. The carpal tunnel view is significant in diagnosing the pinched median nerve. Figure 20.0 and Figure 21.0 illustrates the anatomy of carpal tunnel views and its radiological positioning.

Figure 20.0 Carpal Tunnel anatomy. Copyright: Wikimedia Commons. Creative Commons CCO

a . b c . .. . .

Figure 21.0 Carpal Tunnel positioning and x-ray. Copyright: a-b. Creative Commons' Attribution-Non Commercial-Share Alike 3.0.; c. Pinterest - Labeled for reuse

23 Hand

The last part of the upper extremities is the hand. The hands are closely associated with the “sense of touch” which makes the hands a vital anatomical part of the human body. In addition, the hands have a role sign language as well with body language. The hand is composed of 27 bones. The hand’s skeletal segments are divided into three groups (Marini, et al., 2009): carpus (wrist – previously presented), metacarpus (palm bones), and phalanges (fingers).

Metacarpals

In the palm of the hand there are five metacarpals. Therewith, these bones are numbered one through five, lateromedially, beginning with the thumb as number one (see Figure 22.0). Each of these bones is “long in miniature,” and every metacarpal has a proximal portion, a body, and a distal portion (Martini, et al., 2009). The distal rounded heads articulate with the proximal phalanges. The well-known “knuckles” are created by metacarpal heads. The proximal bases articulate with the distal carpal row. The metacarpophalangeal articulations are diarthrodial (condyloid) joints. The exception is the thumb joint. These joints can flex, extend, abduct, adduct, and circumduct. The thumb also has axial rotation capabilities, which is classified as a saddle joint.

Phalanges The phalanges (fingers) have many dense nerve endings, which are responsible for feedback from tactile sources. The phalanges are numbered beginning at the lateral (thumb) side as with the metacarpals:

1. first finger – thumb 2. second finger – index 3. third finger – middle 4. fourth finger – ring 5. fifth finger – small

F igure 22. 0 . Hand (simple) Copy right: P ublic Domain

The thumb contains a proximal and distal phalanx (first and second respectfully), the middle phalanx is missing (see Figure 22.0 and 23.0). The phalanges in the other four fingers are described as first, second, and third, or as proximal, middle, and distal. The phalanges are semi- cylindrical, with a slightly concave surface anteriorly. The distal phalanges differ slightly by having a club-shaped end. The interphalangeal articulations are diarthrodial joints (see Figure 24.0). They have only forward, and backward movements as classified by the hinge type of joint.

Figure 23.0. Hand anatomy. Copyright: Wikimedia Commons. Creative Commons CCO

Figure 24.0 Hand Radiograph – Joints. Copyright: Wikimedia Commons. Creative Commons CCO.

SECTION TWO:

LOWER EXTREMITIES

HIP PELVIS FEMUR KNEE TIBIA-FIBULA ANKLE FOOT

26 Hip

The hip is a common site for fractures among the elderly as they have a higher risk of falling, which is a cause of hip fractures. The hip bone is shaped by three separate iliac bones which purposefully unite at the acetabulum. The acetabulum is a cup-shaped pocket that articulates with the head of the femur. The three iliac bones units are as follows and illustrated in Figure 25.0:

1. Ilium 2. Ischium 3. Pubis

The ilium is one of the largest bones in the human body, but it is the largest bone of the iliac bones, and its body enters to form 2/5th of the acetabulum pocket. The upper border is called crest of the ilium (iliac crest). The ilium serves to widen the upper portion of the acetabulum posteriorly. The ischium is the inferoposterior part of the hip and is the thickest and strongest of the three hip bones. It also forms 2/5th of the acetabulum pocket. The ischium connects to the ilium to form the lower portion of the acetabulum. Thus, its function is to provide support to the acetabulum. The ischial tuberosity is a large rough area on the ischium’s lower dorsal surface. The ischial spine projects down and slightly medially. The anterior portion extends forward to join the pubis. The pubis is heeded as the ventral part of the hip bone. It forms 1/5th of the acetabulum and forms the pubic symphysis with its counter fellow. The pubis includes a body and two rami. The body of the rami has an anterior, posterior, and a symphysial surface. The superior pubic ramus passes upward, backwards, and laterally from the body. The inferior pubic ramus descends inferolateral to join the ischial ramus medially. The ischial, pubic rami and the bodies of the ischium and pubis unite to form an opening called the obturator foramen, a large opening for blood vessels and nerves. The pubis bone protects internal organs found in the pubic area, which is why the pubis is in the frontal part of pelvis.

Iliac Crest

Figure 25.0. Hip anatomy. Copyright: Wikimedia Common. Free to share and use commercially.

27 Pelvis

The pelvis consists of a basin-shaped structure situated at the lower end of the trunk. It is formed by the iliac bones (ilium, ischium, and pubis), the sacrum, and the coccyx (Martini, et al., 2009). The posterior wall of the pelvis is formed by the sacrum and coccyx, while the hip bones form the anterior and lateral walls (see Figure 26.0). The pelvis’s main function is to provide a support system for the vertebral column. While performing a radiograph of a hip, many facilities will include a pelvis view as part of their protocol, especially if there is evidence of trauma.

Acetabulum

Figure 26.0. Pelvis anatomy. Copyright: Wikimedia Common - Creative Commons CCO.

Just for Fun!

Can you name these pelvic bones?

Femur

Proximal Femur As one of the heaviest, strongest, and longest bones, the femur is part of the lower extremities. The femur (thigh bone) supports the whole weight of the skeleton from the pelvis to the tibia. It curves medially, and posteriorly, and consists of three parts: superior extremity, a shaft, and an inferior extremity. The upper portion consists of the femoral head, neck, and trochanters (see Figure 27.0). The femoral head is smooth and shaped like a half-sphere. It faces up and anteromedially to articulate with the acetabulum. This articulation forms a ball and socket joint in the hip. The femoral neck connects the head to the shaft at a slight angle. This allows vast movement at the hip joint. The surface of the neck tends to be concave and only 2/3rds is enclosed in the joint cavity (Martini, et al., 2009). From the junction of the neck and shaft, posterosuperior projects a large quadrangular process called the greater trochanter. The lesser trochanter is a smaller posteromedial projection. A prominent ridge connects both greater and lesser trochanters and is called the intertrochanteric line. The proximal shaft is cylindrical in shape, while the distal end is prismatic in shape.

Figure 27.0. Femur – Proximal. Copyright: Courseslumenlearning – Free to share and use commercially

Figure 28.0. Femur. Copyright: Courseslumenlearning – Free to share and use commercially

Knee

Distal Femur The distal end of the femur is expanded for the purpose of transmitting the weight onto the tibia. The distal femur contains two massive prominences: the lateral and medial condyles (see Figure 29.0). The lateral condyle is less prominent than the medial condyle, however, it is more massive and transmits more weight directly to the tibia, with its most prominent point being the lateral epicondyle. The medial condyle is somewhat larger than the lateral condyle, and has a slight prominence called the epicondyle. The intercondylar fossa is a deep depression that separates the condyles posteriorly.

Anteriorly, the condyles are isolated by a slight, triangular depression called the patellar surface. The patella surface articulates with the patella.

Proximal Tibia-fibula There are two bones in the lower leg, the tibia (shin bone) and the fibula (calf bone) which carry the weight of the body via the foot. The larger bone being the tibia, is located on the medial side of the leg. The proximal end of the tibia has an expanded surface, with two concave eminences, the medial and lateral condyles. These condyles articulate with the corresponding condyles of the femur. Between the tibial condyle surface is a sharp projection called the tibial spine or intercondyloid eminence. On the anterior surface of the tibia, directly below the condyles, is a prominent projection called the tuberosity. Posteriorly, a shallow depression referred to as the intercondyloid fossa separates the two condyles. The shaft of the tibia presents with several borders. On the upper 2/3rds of the anterior surface is a prominent peak known as the anterior crest. The knee joint articulation is considered a diarthrosis of the hinge type. It is the largest joint in the body. Figure 29.0 illustrates the anatomy for the knee joint.

Proximal Fibula The tibia is one of the longest and thinnest bones of the body while the fibula is smaller and is located on the lateral side of the tibia (Marini, et al., 2009). The fibula is not directly involved in supporting body weight. The proximal end, or head, is small and somewhat bulbous. On the lateral side, rising from the head is a pointed apex known as the styloid process. The head of the fibula articulates medially with the posteroinferior surface of the lateral condyle of the tibia. The shaft varies in form due to numerous grooves which furnish muscular attachments.

Figure 29.0. Knee Joint – Proximal. Copyright: Courseslumenlearning – Free to share and use commercially

31 Patella The patella (kneecap), which is considered the largest sesamoid bone lies in the tendon of quadriceps and femoris. It is flat, triangular, and serves to protect the front of the knee joint. The kneecap consists of a posterior and anterior surface, three borders, and an apex, which is directed downward (see Figure 30.0). C (Martini, et al., 2009). It is attached to the tuberosity of the tibia by the patellar ligaments. The patella is freely movable when the knee is extended in a relaxed state. Yet, if the knee is flexed, the patella is firmly locked in place in front of the intercondyloid fossa.

Figure 30.0. (a). Patella anatomy. (b). patella fracture (x-ray). Copyright: Wikipedia - Creative Commons Attribution-ShareAlike

Patella Views Do you know all these views?

❖ Skyline Laurin view ❖ Merchant view ❖ Sunrise view ❖ Rosenberg view ❖ Schuss view ❖ Tunnel view

Figure 31.0 Tibia-Fibula. Copyright: Courseslumenlearning, Free to share and use commercially

Ankle

Distal tibia The tibia’s distal end in broad, with the anterior surface being smooth, while the posterior surface is rough. The medial surface is extended into a large process called the medial malleolus. On the lateral surface is a slight triangular depression for the articulation with the fibula. The distal articulation surface is smooth and slightly concave for the articulation with the talus tarsal bone.

Distal fibula The distal end of the fibula is somewhat flattened and pyramidal in shape. It projects distally and posteriorly to form the lateral malleolus and on the inside of the ankle forms the medial malleolus. The lateral malleolus is of interest in radiology due to its frequent involvement in injuries to the ankle. The medial surface presents a smooth triangular plane, which articulates with the lateral side of the talus. The talus will be discussed in the ensuing section. The joint classification for the ankle is a diarthrosis of the hinge type. Its articulation

33 with the tibia, fibula, and talus allows movements of flexion and extension. Figure 31.0 illustrates the anatomy of the tibia-fibula.

Just for fun! How many of these bones and joints did you know?

Foot

Tarsus When reviewing the skeleton system, one can see that the foot contains 26 bones, which may be divided into three sections: tarsus, metatarsus, and phalanges (see Figure 32.0). There are seven tarsal bones that occupy the proximal ½ of the foot.

1. calcaneus - os calcis 5. first cuneiform – medial 2. talus – astragalus 6. second cuneiform – intermediate 3. cuboid – os cuboideum 7. third cuneiform – lateral 4. navicular – scaphoid

Like the bones of the carpus, tarsal bones also have two commonly used names. These bones are arranged in proximal and distal rows. They each have six surfaces, some of which are articular, while others are attachments for ligaments. The first (proximal) row contains the calcaneus and talus. The talus supports the tibia, while it sits on the calcaneus.

34 The navicular is positioned directly anterior to the talus, and on either side are the lateral and medial malleolus. As one of the largest bones of the ankle, the calcaneus forms the heel of the foot, thereby transmitting the weight of the body to the ground. Superiorly, and anteromedially it articulates with the talus. Anteriorly, the calcaneus articulates with the cuboid. The navicular bone articulates with the talus proximally and the cuneiforms distally. The three cuneiforms articulate with the navicular proximally, and with the bases of the first, second, and third metatarsals distally. The cuneiforms are numbered starting with the medial side. The first cuneiform articulates with the navicular and the first metatarsal base. The second cuneiform articulates with the navicular and with the second metatarsal base. The third cuneiform lies between the second cuneiform and cuboid while articulating with the navicular and third metatarsal base. The first cuneiform is the largest, while the second cuneiform is the smallest of the three cuneiforms. The cuboid bone is the most lateral in the distal tarsal row. It lies between the calcaneus proximally and the fourth and fifth metatarsals bases distally. It also articulates with the third cuneiform.

Metatarsals There are five metatarsals, simply numbered beginning with the medial side of the foot, one through five respectfully. Their proximal bases are wedge-shaped and articulate with the tarsal, and with each other. The distal ends called the heads, articulate with the proximal phalanges. The thickest and shortest metatarsal is the first one, while the 5th metatarsal has a projecting tuberosity at its lateral aspect of the base. It also articulates with the cuboid by means of a long triangular facet.

Phalanges There are fourteen phalanges in the toes. Except for the hallux, or great toe, there are three phalanges in each digit. The hallux contains a proximal (first) and distal (second) phalanx. The other four toes contain proximal, middle, and distal phalanges, also called first, second, and third respectfully. The interphalangeal articulations are of the hinge type.

The top of the foot is referred to as dorsal surface, while the bottom of the foot is referred to as the plantar surface.

Figure 32.0 Foot surface. Copyright: biology.stackexchange.com, Free to share and use commercially

Figure 33.0. Foot anatomy. Copyright: OpenStax College, Free to share and use commercially

Figure 33.0 illustrates the anatomy of the foot in three different perspectives: superior (AP view), lateral view, and medial view.

SECTION THREE:

DISEASES & CONDITIONS FOR

UPPER & LOWER EXTREMITIES

37 Anomalies of Hand, Foot, and Arm

Radiology technologists have a diverse population of patients requiring their services. Consequently, they must be aware of the many conditions that may affect their population. The following section will attempt to present a few of the conditions RTs may encounter. However, as the scope of this course is not specifically aimed at identifying bone conditions, only a few bone conditions that may require radiography will be presented.

Clinodactyly of the 5th finger

A medical term, “Clinodactyly” refers to an abnormality of the 5th finger, being bent or curved (CHoP, 2019). The abnormal finger uncharacteristically curves to the side and/or may overlap with one of the other fingers (see Figure 34.0). While this condition is rare, it does affects 3% of the general population, and affecting about one in four (25%) children with Down syndrome. (CHoP, 2019). Clinodactyly is a congenital condition and may be a symptom of an associated syndrome: Carpenter syndrome, Prader-Willi Syndrome, and Rubenstein-Taybi Syndrome.

Figure 34.0. Clinodactyly. Copy right: Wikipedia, Creative Commons.

Carpenter Syndrome Carpenter syndrome is a genetic condition in which a protein gene (RAB23 or MEGF8) becomes mutated causing premature fusion of certain skull bones (craniosynostosis). This protein gene is important for transporting materials which trigger and regulates a developmental route which is vital for cell growth and specialization for typical human development (NIH, 2019a). Individuals with this syndrome may experience intellectual disability ranging from severe to mild, but some people with this condition may have normal intelligence. Besides the craniosynostosis, there are other characteristics such as upper and lower extremality

38 abnormalities, and additional developmental problems. The condition of Craniosynostosis causes the head to have the appearance of being pointy because the skull is prohibited from developing as it should. Plus, craniosynostosis may also cause (acrocephaly) or causing a severe deformity called a cloverleaf skull. Next, craniofacial asymmetry (face and head) is a physical condition seen in individuals with Carpenter syndrome. Distinctive facial characteristics for Carpenter syndrome may include: • abnormal eye shape • ears (shaped abnormal) • upper and lower mandibles are underdeveloped • Flat nose (low set) • Irregularities in teeth (baby) • Visual conditions

Deformities of the upper and lower extremities are very common among individuals with Carpenter syndrome. A few of the more common abnormalities are:

✓ Syndactyly – cutaneous: fusion between upper or lower extremities (skin)

✓ Brachydactyly: short phalanges

✓ Polydactyly: extra digits on the hands and feet

With this condition (see Figure 35.0), syndactyly (skin fusion) is often seen in the 3rd and 4th digits, while polydactyly is often seen between the 1st or 2nd toe or the 5th digit (NIH, 2019a).

Figure 35.0: (a). Syndactyly, cutaneous (b), Brachydactyly, and (c). Polydactyly. Copyright: see references

39 Prader-Willi Syndrome

Prader-Willi syndrome (PWS) is a problematic genetic disorder caused by the loss of chromosome 15. Approximately, 70% of patients with Prader-Willi syndrome are missing the paternal copy of chromosome 15 (NIH, 2019b). Also, they may experience minor mental impairment; or even a high level of intellectual impairment. In addition, patients with PWS may also experience learning disabilities. Many will have additional behavioral problems such as: • Sleep disturbance • temper outbursts • stubbornness • compulsive behavior (i.e. picking at the skin) • Delayed or incomplete puberty • Infertile (underdeveloped genitals) • Unusual far skin and light-colored hair

Other characteristics in people with Prader-Willi include hypotonia poor growth, alimentary issues, and delayed development. They may also have facial features such as almond-shaped eyes, wedge-shaped mouth, and a tapered forehead. Many individuals with this condition reach childhood and are continuously hungry which leads to obesity as a child (see Figure 36.0), then into adulthood; thus, ultimately leading to diabetes. Last, other physical features may consist of having short stature and small hands and feet. These characteristics are some that the radiology technologist may encounter during their scheduled workdays.

Figure 36.0. Patient with PWS. Copyright: Wikipedia, Creative Commons Attribution-ShareAlike

40 Rubenstein-Taybi Syndrome Rubinstein-Taybi syndrome is a disorder in which genes CREBBP and EP300 are mutated. The CREBBP gene is responsible for providing information to make a protein that supports the actions of its counter-part genes; plays an important role in regulating cell growth for vital normal fetal growth. The EP300 gene plays a role in forming a protein which is responsible for helping other genes by limiting their movements (NIH, 20019c). There are many features found in patients with Rubenstein-Taybi syndrome. For example, here are a few characteristics: * short physique * irregularities of the eyes * teeth (oral conditions) * intellectual or mental disability * distinguishing facial features * heart and kidney conditions * broad 1st digits (thumbs and toes) There are many different signs and symptoms seen in patients with this condition. For example, some may develop noncancerous and cancerous tumors such as brain tumors or leukemia. The life span of infants born with this severe form of the disorder usually survives only into early childhood (NIH, 2019c).

Figure 37.0 Rubinstein-Taybi Syndrome features. Copyright: Creative Commons

Thumb - Hypoplasia or Aplasia

Fanconi Syndrome Fanconi syndrome (FS) is a rare disorder most often inherited or acquired from diseases, certain drugs, or chemicals (Stephens, 2018). It impacts the urinary system by affecting the filtering tubes of the kidney. The most common cause of FS is cystinosis, which is inherited, and results in the amino acid cystine to accumulate throughout the whole body. Fanconi syndrome causes the kidneys to malfunction and absorption of essential metabolites are lacking – resulting in failure to thrive, dehydration, and bone deformities. Other symptoms of Fanconi syndrome include:

• corneal abnormalities • vomiting • slow growth • excessive thirst • excessive urination • low muscle tone • frailty

A study (2016) found that 1 out of every 100,000 to 200,000 newborn babies have cystinosis (Stephens, 2018). However, other genetic metabolic conditions that involve FS are Rickets, Lowe syndrome and Wilson’s Disease. Dr. Guido Fanconi, first described rare anemia in the 1930s called Fanconi anemia, however, this is an entirely different condition unrelated to FS and should not be confused with one another.

Holt-Oram Syndrome Holt-Oram syndrome is a mutation of the TBX5 gene, which plays a vital role in providing a protein that is responsible for the development of the upper extremities before birth (NIH, 2019d). The mutated gene disrupts the embryonic growth of the bones in the upper limbs such as the hands (see Figure 38.0). The leading characteristics of Holt-Oram syndrome is a condition in which the upper extremities are severely abnormal, and the heart has irregularities. In addition to the heart abnormalities, and shortened upper limbs, other skeletal characteristic features of Holt-Oram syndrome include:

• abnormal wrist (carpal bones) • absent 1st digit of hand • elongated 1st digit of hand • Clavicle or scapula irregularities • Complete or fractional presence of bones in the forearm • immature development of bone in upper extremities

42 A condition called Duane-radial ray syndrome is similar to Holt-Oram syndrome as the features are similar, but they are caused by two different mutating genes. In addition, with Holt-Oram syndrome, skeletal abnormalities may affect both upper extremities and simply affect one side.

b a

Figure 38.0. Features of Holt-Oram Syndrome. Copyright: (a-b). NIH, Public Domain.

Polydactyly Ellis-van Creveld syndrome Ellis-van Creveld syndrome is a polydactyly condition that affects bone growth but is an uncommon genetic disorder. This condition is inherited (autosomal recessive) and involves genes EVC and EVC2 (Baujat, 2012). The gravity of Ellis-van Creveld syndrome varies from patient to patient. Some of the symptoms in people with this condition are dwarfism, dental problems, disfigured fingernails, and toenails. Radiology technologists must be aware of other symptoms of this condition as the patient may require radiographs for bone disorders such as short upper and lower extremities and narrow rib cage. These patients may also require radiographs for the diagnosis of polydactyly digits (extra fingers and toes). An important note about Ellis-van Creveld syndrome is that it is similar to another condition called Weyers acrofacial dysostosis, the latter being a mild version of the first syndrome. The two conditions are allelic and caused by the same gene mutation (CTGT, 2019).

Noack Syndrome Another polydactyly condition is Noack Syndrome, which is now referred to as Pfeiffer syndrome or acrocephalosyndactyly Type V (Accesspediatrics, 2019). It is an inherited (genes) disorder where some skull bones fuse prematurely preventing normal cranial growth that results in misshapen head and face. Characteristics of patients with Pfeiffer (Noack) syndrome include eyes set widely apart and bulging, forehead abnormalities, and small mandible. Pfeiffer syndrome similarly affects bones in the upper and lower extremities and include condition such as: ➢ Polydactyly - a duplicate of the great toes ➢ Brachydactyly – short fingers and toes ➢ Syndactyly – digit with webbing or fusion

43 Taking a closer look at Pfeiffer (Noack) syndrome, one can see that it is divided into several categories: Type 1 (known as traditional Pfeiffer syndrome), Types 2 (presence of cloverleaf- shaped cranial, and Type 3 also involves the nervous system (NIH, 2019e). Brain growth is slowed or impacted due to the premature fusion of the cranial bones causing neurological abnormalities and delayed development. Radiology technologists may encounter Type 2 or Type 3 patients with this disorder if they require diagnostic imaging procedures for their abnormalities: ankylosis (fusion) of elbows or other joints or face deformities. Next, Pfeiffer patients may also experience breathing issues, which can cause life-threatening respiratory problems (NIH, 2019e).

Due to the serious and graphic nature of this condition, no images were provided. However, feel free to perform your own research on this disorder.

Goltz syndrome The third form of polydactyly condition is Goltz syndrome. This rare genetic disorder is a form of ectodermal dysplasia involving the skin, facial, and skeletal system. Abnormal skin issues include missing skin, pigment changes, and wart-like papilloma’s. Facial concerns include small or no eyes, iris and retina abnormalities, and tear duct problems. Next, abnormal facial features include facial asymmetry, jagged nasal skin, cleft palate, and pointed chin. While performing their duties, radiology technologists may encounter patients with Golz syndrome as some of their conditions will include:

• 75% with ectrodactyly – malformation (split) of upper and lower extremities • 50%-80% with long bone reduction defect – long bones are short • 20%-40% with Oligodactyly – having less than 5 digits (bilateral or unilateral) • 70%-90% with Syndactyly – webbing or fusing of ≥2 fingers or toes • 15% with Acheiria – an absence of unilateral or bilateral hands, wrists, forearms, or elbows (Nfed, 2019).

In addition to the previously mentioned conditions, patients with Goltz syndrome may also experience hemimelia, a condition in which there is gross shortening or complete absence of the distal part of the upper or lower extremities. It should be noted that characteristics or

44 abnormalities are commonly asymmetrical, meaning that the right side may be affected differently than the left side (Nfed, 2019).

Syndactyly (cutaneous – osseous)

Bloom Syndrome Bloom syndrome, a rare hereditary disorder, is considered as a syndactyly condition and causes problems with DNA reparation. Due to abnormal DNA repair, patients with Bloom syndrome are more susceptible to all types of cancers. For example, about 50% of patients with Bloom syndrome will ultimately develop a carcinoma such as gastrointestinal or leukemia (Cunniff and Djavid, 2016). This syndrome is characterized by abnormalities such as:

• Short stature • Sensitivity to photosensitivity • Telangiectasia (nose and cheeks like a butterfly) • Abnormality to eyes and ears • Polydactyly and syndactyly - upper and lower extremities

As with many of the other syndromes presented in this course, Blooms syndrome has features that impact the role of radiology technologists. Patients with Bloom syndrome will manifest polydactyly (multiple digits) and syndactyly (fused or webbed digits). In addition to the conditions stated above, many patients with this disorder have a remarkably high-pitched voice and distinct features of the head and face, which may require diagnostic imaging procedures.

Silver Syndrome Silver syndrome is also known as Russell-Silver dwarfism and is a growth disorder resulting from genes on chromosome 7 and 11 (NIH, 2019f). With this disorder, there are also learning disabilities, speech impairment, and delayed growth. One of the biggest features of Silver syndrome is the delayed growth before and after birth, which results in low birth weight, poor appetites, and short statures (dwarfism). These patients will manifest unique facial abnormalities such as small mandibles, downturned corners of the mouth, and abnormal forehead. Researchers have found that many incidents of Russell-Silver syndrome are random with no family history of the disorder. In addition, 40 percent of patients with Russell-Silver syndrome have unknown etiology (NIH, 2019f). A common feature among Silver syndrome patients is the high rate of clinodactyly (curving of the 5th digit). This characteristic will be visible on a radiograph. Furthermore, when performing radiograph procedures on these patients the radiology technologist must consider the characteristics such as uneven growths of specific anatomy, gastric abnormalities, and asymmetrical body parts.

Hallermann-Streiff Syndrome Hallermann Streiff Syndrome also known as Francois dyscephaly syndrome and oculomandibulodyscephaly with hypotrichosis is a rare condition manifesting many abnormal characteristics:

45 ✓ craniofacial – brachycephaly, dyscephaly, hypoplastic mandible, a narrow, highly arched roof of the mouth (palate); and a thin, pinched, tapering nose. ✓ hypotrichosis – thin and sparse hair ✓ short stature – proportionate ✓ dental problems –neonatal teeth, delayed tooth eruption, enamel hypoplasia, hypodontia or adontia, short roots and early loss of teeth, irregular teeth alignment ✓ ocular – congenital cataracts, microphthalmia, glaucoma, retinal detachments ✓ skeletal – see below Patients with this condition have an extraordinary amount of physical limitations that are outside the scope of this paper. However, radiology technologists must be aware of the physical limitations these patients may have in addition to those mentioned above. Pediatric radiology reports illustrate ill-defined ossified skull, several Wormian (extra bone pieces in skull sutures), and mid-facial hypoplasia. Plus, radiographs illustrate slender and long bones, bowing of the radius and ulna, and metaphyseal widening of ends. Other skeletal features found in HSS patients include winged-flared scapula, scoliosis or lordosis, and syndactyly. Next, radiology technologists must know when performing a sternum radiograph on patients with HSS, that they may have pectus excavatum (depressed breastbone) and adjust their positioning accordingly.

Just for Fun! We have not discussed Apert Syndrome. Have you heard of it? Would you like to research it?

See Section V for more information on diseases and conditions of lower extremities.

SECTION FOUR:

BODY PLANES

and

BONE Dislocations & Fractures

and

BODY MOVEMENT

APHORISTIC PLANES

As most radiologic technologists are aware, the anatomical position of the body is with the arms at the sides and the palms turned forward. When performing radiographic procedures, it is essential to know not only the anatomical position, but also the three aphoristic planes of the body. The three-body planes include: sagittal (median), coronal (frontal), and the transverse (horizontal).

BODY PLANES Sagittal (median) Plane A vertical plane which divides the body into equal right and left sections is called a median plane. This plane passes through the sagittal suture of the skull, consequently, the median plane is also called the sagittal plane. Sagittal and parasagittal planes are any planes that pass parallel through it. (see Figures 39.0 and 40.0).

Coronal (Frontal) Plane A plane which segments the body into anterior and posterior portions is called a coronal plane. It is thusly called because one of the frontal planes crosses through the coronal suture of the skull. Coronal planes are parallel to the long axis of the body and are perpendicular to the median plane. Other common terms used in radiology to describe coronal planes are midcoronal and midaxillary.

Transverse (Horizontal) Plane A transverse plane will pass through the body at right angles to both the sagittal and coronal planes. This results in the body being divided in superior and inferior sections. Cross- sectional images are seen by utilizing transverse planes.

Figure 39.0. Human anatomy planes. Copyright: Wikimedia Commons, Creative Commons CCO

Figure 40.0. Special Sagittal Planes. Copyright: Creative Commons from J-T-M,

Let’s practice: Can you name these anatomical planes?

49 BONE DISLOCATIONS & FRACTURES

Trauma is defined as an injury or wound (physical) to living tissue caused by an external agent, force, or violence (Clayton, 1981). The characteristics of bone disorders exhibit symptoms such as swelling, bruising, deformity, and loss of mobility. Approximately, 6.8 million patients seek medical treatment for fractures annually and are the biggest problem seen by orthopedic providers (Shah, 2019). These characteristics are more noticeable if the bone disorder involves any trauma. There are two prevalent types of lesions most visible by radiographs, dislocations and fractures. A dislocation is any part of a bone that is temporarily displaced from its normal position in a joint. Dislocations may result from traumatic injuries or by extreme stress placed on a bone. The ensuing pressure on adjacent soft tissues may cause the bones to move out of their normal alignment. In dislocations there is a complete loss of congruity between the articulating surfaces of a joint. The bones in the joint articulation are displaced relative to one another. For example, a dislocated shoulder presents with the humeral head displaced from the glenoid cavity. Most commonly, it is an anterior displacement. Complete dislocations are frequently seen in synovial joints, and are also called luxation. Complete dislocations due to traumatic situations are fully disarticulated from the adjacent bones. Partial dislocations are more subtle and are called a subluxation. A fracture is the sudden breaking of a bone, or when there is a loss of continuity in the substance of a bone. The term “fracture” covers all bony disruptions ranging from hairline fractures to comminuted fractures. Radiology technologists must be prepared to carefully and accurately position any patient with a possible dislocation or fracture in order to optimize quality imaging.

Causes of fractures Fractured bones are the result of many types of causes or stressors. Some fractures are caused by direct violence (injury). Fractures occur because the application of stress placed on the bone exceeds the limit of strength that the bone may have. A bone may be fractured by being struck by a falling or motile object. For example, a falling grid cassette may fracture any part of the technologist’s foot. Bones may also be fractured if it forcibly strikes a stationary and/or resistant object. For example, if a patient strikes a wall, they may fracture one or more of their metacarpal bones. The second cause of many fractures results from indirect violence (injury). If a twisting or bending strain is applied to a specific bone, then a fracture may result as some point away from where the force was applied. For example, sport injuries in which a rotational force is applied to the foot may cause a spiral fracture of the tibia or fibula. The third cause for fractures is due to pathological abnormalities. In some cases, bones may break spontaneously without having any trauma involved. Pathological fractures are fractures that transpire through an area of diseased or weakened bone. In cases such as these, the bone is weakened due to an underlying process that has altered the structure of the bone. If force is applied to this weakened area, fractures are inevitable. Qualifying factors believe that the abnormality reduces the strength of the bone; thus, the force required to produce a fracture is significantly diminished. Fractures are also caused by repeated stresses, with an exorbitant amount of wear and tear on the bone. These types of fractures a called fatigue fracture. One of the most common fatigue

50 fractures is seen in military bases. Army recruits frequently fracture their second metatarsal due to excessive marching.

CLASSIFICATION OF FRACTURES Fractures are classified as:

1. complete or incomplete 2. closed (simple) or open (compound) 3. type of fracture line 4. body part that is affected 5. relationship of fractured fragment – alignment

COMPLETE OR INCOMPLETE

A fracture is described as complete or incomplete according to the extent of the fracture line athwart the bone. If the line of fracture does not include the whole bone, it is considered an incomplete fracture. On the other hand, if the fracture line crosses the whole bone, it is classified as a complete fracture.

CLOSED (SIMPLE) OR OPEN (COMPOUND)

All fractures are either closed (simple) or open (compound). The deciding factor is whether there is communication from within the bone to the external environment. If the skin is not broken, it is classified as a simple fracture. If the skin remains intact, there is no risk of infection from the outside surface. The term “simple” does not bear any relationship to the problem associated with the injury or fracture. An open fracture does communicate with the external environment through the broken skin. The existence of a wound creates a potential for organisms to enter the fracture site from the outside. For this reason, all compound fractures carry a risk of becoming infected. In addition, the patient may lose a significant amount of blood due to hemorrhaging. Open fractures are classified as grades I-III (Barclay 2018). The grading system is dependent on the nature off soft tissue injuries. Punctures from within outward by a bony fragment are considered as grade I. This is a puncture from inside out. Usually, the skin is broached by the sharp edge on one of the bone ends. Compounding may occur at the time of the injury, or later from unguarded handling of a simple fracture. A patient may be brought into the department with the bone obviously still penetrating the skin. However, it is more commonly seen that fractures having once broken through the skin, promptly and spontaneously abate. What is seen on the outside is a wound at the level of the fracture. Penetration of the skin by an external injury that proceeds to fracture the underlying bone is classified as grade II. This is an injury from the outside in. Grade II fractures are caused by direct violence (injury). Causes include injuries from falling or moving objects, violent attacks, or motor vehicle accidents. This type of fracture is at greater risk for infection because dirt, clothing, and foreign bodies may be driven into the wound. The skin is such cases, is often badly damaged. If the wound is large, some skin may be lost. The radiologic technologist needs to be cautious when radiographing patients with severe compound fractures.

51 A crush or avulsion injury with extensive soft tissue damage or tremendous amount of destruction is classified as a grade III. The classification of fractures as open or closed includes the grading of open fractures by the nature and extent of soft tissue damage.

TYPE OF FRACTURE LINE

Furthermore, fractures are classified by the type of fracture line, by how complex the fracture is, and by the direction of the line about the long axis of the bone. The categories for classifying fractures by the type of fracture line are as follow: 1. hairline 2. greenstick 3. avulsion 4. longitudinal 5. transverse 6. oblique 7. spiral 8. impacted (compression) 9. segmental 10. comminuted

Hairline fractures result from minimal trauma, in which there was just enough force to produce a slight fracture, but not enough force to cause displacement of the fragments. This type of fracture may be classified as complete or incomplete. Hairline fractures may be difficult to detect on radiographs. An additional oblique view of the affected area may be essential in determining a fracture. If an initial reading was negative, a patient may return for follow-up views. Fractures may be clearly visible at the second reading due to decalcification at the site of the fracture. Greenstick fractures occur in children. However, not all fractures in children are of this type. A bone with this type of fracture will partially bend and slightly break. The less brittle bones of a child tend to buckle on the opposite side of the causal force (see Figure 41.0). An avulsion fracture or chip fracture is the breaking off a small portion of bone where the attachment of a tendon or ligament is located. Avulsion fractures may result from a sudden muscle contraction or as a result from traction on ligaments. Longitudinal or linear fractures run parallel to the long axis of the bone, while a transverse fracture is at right angles with the long bone shaft (Barclay, 2018). These are usually caused by direct violence to the anatomical part. For example, a patient who is warding off a blow may receive a transverse fracture of the ulna. Another type of fracture line is an oblique fracture. Oblique fractures have a toric or twisted direction which runs at an angle less than 90 degrees to the long axis of the bone (Barclay, 2018). With spiral fractures the line of the fracture curves in a spiral fashion around the bone. Both oblique and spiral fractures may result from indirect violence. Impacted fractures occur when one fractured fragment is collapsed or driven into another. Cancellous bone is usually involved, making a more natural union. However, the stability of these fractures varies. For example, a fractured humeral head will often come adrift if fixation is not performed. Compression fractures are a special case of impacted fractures. Compression,

52 also called crush fractures, occur in cancellous bones which are compressed beyond the limits of tolerance. One common site is the body of the vertebra. A compression fracture of the vertebral body results from a flexion injury. Another common site for compression fractures occurs in the heels following a fall from a significant height. A double or segmental fracture consists of fracture lines at two or more levels in the same bone. Double fractures must be distinguished from comminuted fractures. Comminuted is the presence of multiple fracture lines with two or more fractured fragments occurring. In both cases, there exists the potential problem of instability and difficulty in reduction and fixation. Internal fixation may impair precarious blood supply to the fractured segment. Comminuted fractures sometimes have a radiographic silhouette that gives a “T” or “Y” appearance on the film. The presence of severely comminuted fractures indicates ominous violence. With this type of bone damage, there is greater risk of damaging the neighboring muscles, nerves, skin, and vessels. A radiographic technologist needs to be wary of accompanying injuries.

Figure 41.0. Types of fractures. Copyright: emedprimarycare.com, Free to share and use commercially.

PART THAT IS AFFECTED

A fourth important method in describing fractures is by their location (see Figure 42.0). There are four location descriptions for fractures:

1. intra-articular 2. distal or proximal shaft 3. mid-shaft 4. epiphyseal plate

Figure 42.0 Fracture by location. Copyright: Zapp! Educational Services

In long bones, the shaft is divided into thirds for descriptive purposes. In figure 42.0, a fracture at level “x” would be described as a midshaft fracture of the femur; a fracture at level “z” would be described as a fracture in the distal third portion of the femur. If the fracture site occurs at level “y,” then the fracture would be described as having a fracture of the proximal and middle thirds of the femur, more specifically at the juncture.

Intra-articular fractures extend into a joint cavity. Fractures at the ends of the bones are either anatomically named or are referred to by a personality whose name is associated with the fracture - for example, a Pott’s fracture, or a Colles’ fracture.

A fracture that involves the epiphysis plate or that goes through the growth cartilage is called an epiphyseal fracture. These types of fractures occur in children. To distinguish the different types of epiphyseal fractures in children, an organizational system was devised, namely the Salter and Harris system. Salter-Harris classification (see Figure 43.0) of epiphyseal plate injuries are listed below:

Type I - The whole epiphyseal plate is separated from the shaft Type II - The epiphysis is displaced, together with a small metaphyseal fragment Type III - Separation of part of the epiphysis Type IV - Separation of part of the epiphysis, including part of a metaphyseal fragment Type V - Crush injury of part or all the epiphyseal (McRae, 1989).

Figure 43.0 Salter-Harris Classification. Copyright: emdocs.net, Free to share and use commercially

RELATIONSHIP OF FRACTURED FRAGMENTS – ALIGNMENT

Displacement The final thought with regards to describing fractures is the alignment of the fractured fragments. If the injury had the insufficient force applied to the bone ends, and both bone ends are not moved (or displaced), then the fracture is said to be anatomically correct. However, if the bone ends have been shifted or are out of their normal position, then they are considered displaced. The direction of displacement is specified by the movement of the distal fragment. For example, Figure 44.0 illustrations depict several types of displacements:

(a). lateral displacement (b). posterior displacement (c). posterior and lateral displacement

c a b

Figure 44.0. Knee displacement Copyright: Zapp! Educational Services

Besides the direction of the displacement, the degree must also be determined. The radiologist makes an estimate as to the percentage of bony apposition. If the fractured surfaces are not in contact, the fracture is considered to have no bony apposition, or also called off-ended. There are several potential risks involved with these types of fractures:

1. unstable 2. likelihood for progressive shortening 3. delaying or difficulty in a union 4. often hard to reduce

Displacement of spiral, oblique, or transverse fractures will result in the shortening of the limb. Displacement is much less crucial than angulation.

a. b .

Figure 45.0 Femur. (a). medial angulation; (b). posterior angulation

ANGULATION Angulation is the abnormal formation of angles by fractured bones. The recognized methodology in describing the angulation of fractures is in terms of the direction in which the point of the angle is aimed. For example, Figure 45.0 (a). reveals a fracture of the femur with medial angulation, while (b). illustrates a posterior angulation of the fracture in the femur.

Deformity of the affected limb are salient if the consequential angulation is not corrected. Patients may perceive this as a sign of poor treatment. In the upper extremities, movement may

56 be gravely impaired with less range of motion. Alterations of the plane of movement in the ankle, knee, and hip may lead to abnormal joint stress.

AXIAL ROTATION A third form of describing a fracture is by the amount of axial rotation. Axial rotation occurs when one fragment rotates on its long axis. There may or may not be angulation or displacement. Radiographs that forsake one or both ends of the bone frequently impede a radiologist from pronouncing axial rotation. For this reason, it is especially vital for radiologist technologist to obtain both distal and proximal ends on a radiograph. This same practice is also crucial when obtaining radiographs of patients with prostatic appliances in place. The distal end of an artificial appliance should appear on the radiograph.

TYPES OF BODY MOVEMENT

The bottommost part of the foot is referred to as the plantar, while the top of the foot is called dorsal. The ankle has limited movement due to the type of joint it is. The radiology technologist needs to be aware of the two movements the ankle is capable of dorsiflexion and plantar flexion. These two types of body movements involve the ankle joint – classified as a hinge joint. Dorsiflexion is described as lifting the foot upward toward the anterior tibia-fibula. On the other hand, plantar flexion is described as pointing the toes downward when the foot is off the ground (see Figure 46.0). Regarding the hands, pronation is when the patient turns the palm down where the radius rotates over the ulna. Supination occurs when the patient turns their hands up (palms upward) making the radius and ulna parallel.

Figure 46.0. Dorsiflex/Plantar flexion; Pronation and supination. Copyright: OpenStax College, Free to share and use commercially

57 Protraction and Retraction

Both the mandible and scapula have limited movements due to the type of joints they are. These two bones can only move anterior-posteriorly, commonly referred to by protraction and retraction. Moving the shoulder forward also moves the scapula forward, which is called protraction. Retraction of the scapula occurs when the shoulder is pulled posteriorly and medially towards the spinal cord. When the mandible is pushed forward such as thrusting the jaw out, this is called protraction. In reverse, pulling the mandible posteriorly is referred to as protraction (see Figure 47.0). Inversion occurs when the foot is turned inward towards the other foot, while eversion is when the foot is turned outward – away from the other foot.

Figure 47.0. Protraction/retraction; Inversion/eversion. Copyright: OpenStax College, Free to share and use commercially

Flexion and Extension

Flexion occurs when the angle of two articulating bones is decreased; bending causes the bones of the joints to come closer. Flexing joints happens as the muscles contract creating a physical position. For example, Figure 48.0 illustrates flexing (bending) of the knee, cervical spine, and lumbar spine. When flexing a joint beyond its reasonable limitation, a condition referred to as hyperflexion occurs. This type of severe injury may result in trauma to the muscles, ligaments, and tendons. Bending in the opposite direction is called extension and occurs when the joint becomes straight. Typically, a joint extends to increase an angle with its limitation being 180 degrees or less (Quinn, 2019). Figure 48.0 illustrates the knee, cervical spine, and lumbar spine

58 being straighten (flex). Hyperextension results when the joint is stretched markedly beyond its normal capacity of 180 degrees. Like hyperflexion, straightening a joint beyond its limits may result in severe injuries to the tendons, ligaments, or cartilage.

Figure 48.0 Flexion/extension. Copyright: OpenStax College, Free to share and use commercially

Section Five

Diseases and Conditions

Lower Extremities

60 Reiter’s Syndrome A rare form of arthritis is known as Reiter’s syndrome and results in inflammation of the eyes, integumentary system, mucous membranes, and the articulation of the bones. This disease is more commonly known as reactive arthritis because it results in a reaction from specific infections of the digestive system and the reproductive system (rightdiagnosis, 2019). Gastrointestinal infections that contribute to Reiter’s syndrome are Shigella, Yersinia, and Salmonella food poisoning. However, the most common cause of Reiter's syndrome is a type of reproductive infection called chlamydia – a common sexually transmitted disease. One consequence of Reiter's syndrome is related to the joints. Unfortunately, there is no specific procedure that will determine and diagnose Reiter's syndrome. Providers may order specific exams and tests to rule out conditions and other diseases. One common complaint among patients with this condition is chronic arthritis and pain. Thus, radiology technologists may receive patients with symptoms of Reiter’s syndrome (see Figure 49.0). Radiographs may illustrate changes in the bones that are characteristic of Reiter's syndrome. In addition, radiographs may rule-out further conditions related to the symptoms.

a b

Figure 49.0. Reiter’s syndrome. (a). Wikimedia Commons, Creative Commons CCO, (b) constantinereport.com. Labeled for reuse.

Chilblains

Chilblains is also called “pernio,” which causes swelling, red patches, itching, and forms blisters on the hands and feet (Mayo Clinic, 2018a). Other symptoms include skin ulcers, burning sensation on the skin, and change of skin color with associated pain (see Figure 50.0). While the exact cause of Chilblains is not known, but it is believed to be a result of the body’s reaction to cold exposure followed by immediate rewarming. The symptoms are a consequence of inflammation of the small blood vessels in the skin as a result of chronic exposure to cold but not freezing air. The small blood vessels expand more rapidly than the larger blood vessel’s capabilities, causing a bottleneck effect resulting in blood leaking into adjacent tissues. Chilblains generally clears up within several weeks and does not usually result in permanent damage. There are several risk factors that relate to developing Chilblains:

61 a. Having poor circulation b. Environment and seasonal temperatures (higher in November to April) c. History of Raynaud's disease d. Autoimmune Disorders (i.e., Lupus) e. Gender (women at higher risk)

Figure 50.0 Chilblains. Copyright: Wikipedia, Creative Commons Attribution-ShareAlike.

Treatment involves protecting oneself from the cold temperatures. In addition, if blisters or ulcers develop, medical treatment from a provider may be necessary. Prevention strategies include avoiding exposure to cold weather, wearing warm clothing with mittens and water- resistant footwear, and keeping personal settings (i.e., home and office) warm. Radiology departments located in cold geographical locations or settings may wish to consult with their maintenance department regarding regulating departmental temperatures. Last, smoking may exacerbate Chilblains and is not recommended (Mayo Clinic, 2018a). As the patient may have blisters or open ulcers on the plantar surface of the feet, the radiology technologist may have to use protective barriers such as plastic cassette covers when performing a radiograph.

Bunions Another condition found in the foot is a bunion, which is a bony projection or deformity at the base of the first metatarsal (Mayo Clinic, 2017). The bony projection is formed because the big toe pushes up against the adjacent toes (see Figure 51.0). The superficial skin covering the bunion may be reddish in color and sore. While the precise cause of bunions is unknown, there are several theories and beliefs about how they are developed, such as prior foot injuries, inherited or genetics, arthritis, and congenital. There is no consensus among the medical researchers about whether wearing high-heeled, tight, or narrow shows causes bunions.

62 However, the experts do agree that wearing tight, narrow shoes, or high heels contribute to bunions. The treatment for bunions is to have them surgically corrected. Other complications associated with bunions are:

*Metatarsalgia – ball of foot has pain and inflammation *Hammertoe – abnormal bend in toe joint *Bursitis – bursae become inflamed

Figure 51.0. Bunion and hammertoe. Copyright: Wikipedia, Creative Commons Attribution-ShareAlike

Bunions can be treated by podiatrists or orthopedic doctors. Radiology technologists may encounter patients who have bunions as radiographs may be ordered by providers. Orthopedic surgeons commonly order foot radiographs prior to surgery. Diagnoses such as persistent pain, visible bump, or decreased movement of the big toe are some of the complications experienced by patients with bunions. Many patients with bunions also have other specific conditions, including inflammatory rheumatoid arthritis. A special notation is presented in which patients may also develop smaller bunions called bunionettes. Unlike bunions that develop on the big toe, bunionettes develop on the little toe. Again, these smaller bunionettes may require radiographs just like their counterparts.

Flatfeet When the podiatrist diagnoses the condition of “Flatfeet,” this means the arches of the inside of the feet become flat which causes the whole foot to touch the floor when standing upright (Mayo Clinic, 2018b). There may be several reasons why the condition of flatfeet occurs. First, it can develop because the arches do not grow normally during childhood. Second, flatfeet may develop after a traumatic injury that causes damage to the arches. Last, flatfeet may occur due to the normal aging process and the standard wear-and-tear of life from a weakened tendon. This condition, which is typically painless, is very common. Upon further research, there appears to be some risk elements that may contribute to flatfeet: diabetes, rheumatoid arthritis, and obesity (Mayo Clinic, 2018b).

Figure 52.0 Flatfeet. Copyright: (a). Wikipedia, Creative Commons Attribution-ShareAlike., and (b). Wikimedia Commons, Creative Commons Attribution-ShareAlike

Symptoms of this condition range from having no pain at all, to foot pain in the arch, or swelling on the medial aspect of the ankle. Some patients may experience chronic pain in the foot or increase pain with any activity, which brings them into the radiology department for radiographs. Radiology technologists must be prepared to perform standing weight-bearing unilateral or bilateral feet radiographs (see Figure 52.0).

Pes Cavus (High arch) The exact opposite of flatfeet is “Pes Cavus,” which is a foot with an exceptionally high plantar longitudinal arch, as seen in Figure 51.0 (ACFAS, 2019). As a result of having a Pes Cavus (high arch), an extraordinary amount of weight is put on the heel and ball of the foot while walking or standing. The etiology for this condition may occur from a neurologic disorder. For example, about two-thirds of individuals with Pes cavus experience:

✓ spinal cord tumors ✓ poliomyelitis ✓ cerebral palsy ✓ muscular dystrophy ✓ stroke ✓ Friedreich ataxia ✓ Charcot-Marie-Tooth (CMT) disease (Pes cavus, 2019).

If patients with Pes cavus that does not stem from a neurological condition, typically result in the foot not changing in appearance. Symptoms for Pes cavus include pain while walking or standing, calluses on the lateral side of the heel, claw toes, or hammertoes (ACFAS, 2019). The patient may also experience instability, and the condition may occur bilaterally, or simply in one foot.

a b

Figure 53.0 Pes Cavus. Copyright: (a). and (b). Wikipedia, Creative Commons AttributionsShareAline.

The radiology technologist must be familiar with other deformities associated with Pes cavus: great toe distortion, contraction of the plantar fascia, and hindfoot malformation (Pes cavus, 2019). For an accurate diagnosis, the surgeon may order radiographs of the foot (including weight-bearing) to assess the patient’s condition.

Plantar Fascia

The foot has a dense, fibrous band of tissue which is called fascia, and when it gets inflamed, it causes Plantar fasciitis (Wheeler, 2019). This condition is excruciating, resulting in pain that radiates from the heel to the toes. In addition, patients will complain that the pain is more noticeable in the morning when they first wake up but gets better as the day wears on. The tissues, which sustain the arch of the foot including the muscles get overstretched, causing minute tears resulting in pain and inflammation. At one point, researchers believed the pain was caused by bone spurs in the heel. However, new evidence now shows that the heel spurs are not the cause of the pain, but instead are the result of plantar fascia.

Several characteristics may be contributing factors to plantar fasciitis. For example, women are more prone to developing this foot condition than men. Another contributing factor is obesity; being overweight puts more pressure on the feet. Employees such as radiology technologists who are always on their feet for numerous hours are at a higher risk of developing plantar fascia. Last, people who are elderly or advanced age may be at risk as muscle tissue weakens with age (Wheeler, 2019). While most doctors can diagnose plantar fascia in their office, they may occasionally request imaging exams. Consequently, radiology technologists may encounter patients with this condition (see Figure 54.0). Second, it is also somewhat common for doctors to order an MRI or an ultrasound to rule out other conditions for unknown etiology or unknown neuropathology.

a b

Figure 54.0. Plantar Fascia. (a). Heel bone with heel spur (red arrow) (b). Thickened plantar fascia in ultrasound. Copyright: Creative Commons Attribution-ShareAlike

Achilles tendonitis

Located at the back of the ankle, is the Achilles tendon, which attaches the muscles in the lower leg to the calcaneus

Figure 55.0. Achilles tendon. Copyright: Focus Medica, Free to share and use commercially

A condition of the ankle is called Achilles tend onitis, which is described as an injury due to the overuse of the Achilles tendon (Healthline, n.d.). Achilles tendonitis is also referred to as Achilles tendinopathy. It may occur from physical movements, such as jumping, running, or other sports activities. Patients with this condition frequently complain of pain which typically begins as a mild ache in the posterior part of the lower leg or above the ankle. They may also experience morning stiffness which improves with increased activity. Researchers have found that there are two categories of Achilles tendonitis: non-insertional Achilles tendonitis and insertional Achilles tendonitis (Healthline, n.d.).

66 • Non-insertional Achilles tendonitis

• Insertional Achilles tendonitis

Non-insertional Achilles tendonitis typically affects active young people, especially those participating in sports events. This type of tendonitis affects the middle fibers of the tendon. Insertional Achilles tendonitis involves the tendons that attach to the calcaneus (see Figure 56.0).

Figure 56.0. Achilles tendinitis. Copyright: Wikipedia, Creative Commons Attribution-ShareAlike.

Achilles tendonitis can become serious if left untreated causing the tendon to tear. Consequently, medical treatment is necessary for which the provider or surgeon may request imaging exams to diagnose Achilles tendonitis. For example, the provider may request an ultrasound or MRI to identify tendon damage, inflammation, or tissue degeneration. In addition, the radiology technologist may perform radiographs of the foot or lower leg (Healthline, n.d.). Risk characteristics and elements that may increase the probability of developing risk of Achilles tendonitis including:

• Medical conditions (higher risk with high blood pressure and psoriasis)

• Gender (more common in men).

• Physical issues (flatfeet, obesity, and muscle cramps)

• Physical activity (physical events, sports and training)

• Age (higher risk with aging process)

• Medications (antibiotics namely fluoroquinolones)

67 Charcot’s Foot Another condition that affects the foot and ankle is called Charcot’s foot. This condition is not well known and is also called Charcot arthropathy. It affects many people who may have nerve damage in their lower extremities, such as their feet and ankles. This disease is important for radiology technologists to be aware of because of the severe deformity of the feet and ankle. This deformity may be the reason the provider sends the patient for radiographs. Charcot’s foot affects the bones and joints, attacking the bones and soft tissue. Patients who have diabetes are susceptible to this condition. Other risk factors include: o Infections

o Spinal cord injury or disease

o Parkinson’s disease

o HIV

o Drug or alcohol abuse

o Syphilis

While there is no known cause for Charcot’s foot, researchers have found some characteristics that may trigger the condition. For example, they believe one such trigger is an injury (sprain or fracture). Second, sores or surgical wounds that do not heal quickly can also trigger Charcot’s foot.

Figure 57.0. Charcot’s Foot. Copyright: Wikipedia, Creative Commons Attribution-ShareAlike

Osgood-Schlatter Disease Approximately 60% of adults who have a bony lump on their proximal tibia have some pain with kneeling (HarvardHealth, 2018). This bony bump is a result of what is known as

68 Osgood-Schlatter (OSD), a condition that is found in adolescents. The patellar tendon affixes the distal part of the kneecap to the upper section of the tibia (see Figure 58.0). When applying excessive pressure to the patellar tendon, the tendon may become inflamed, causing pain and swelling at the tibial tuberosity. Anatomically, the tibial tuberosity is situated on the tibia – the part of the bone that attaches to the patellar tendon. This condition is caused by excessive stress to the patellar tendon when participating in activities or sports such as gymnastics, running, ballet, soccer, or volleyball, etc.

a b

Figure 58.0. Osgood-Schlatter Disease. Copyright: (a). Wikipedia, Creative Commons Attribution-ShareAlike, and (b). Boston Sports Medicine, Free to share and use commercially.

Symptoms of Osgood Schlatter typically last for weeks or months and may affect one or both knees. To determine and confirm Osgood-Schlatter Disease, the provider may order knee radiographs. Once the x-rays are done, the radiology technologist will see tiny bone fragments (at the tibial tuberosity site) that have separated from the top of the shinbone (see Figure 58.0b). With persistent pain or discomfort, the provider or orthopedic doctor may order additional exams such are MRI or ultrasound. Once a diagnosis has been determined, the medical provider may treat OSD in a conservative manner without surgery by prescribing medication and ice packs every 20 minutes for every 2-4 hours (HarvardHealth, 2018).

Plica Syndrome The anatomy and physiology of the knee are complex; therefore there may be many causes for knee pain. However, one such reason can be attributed to Plica Syndrome. A description of a plica is a fold or ridge found in the thin tissue layers that line the knee joint. People

69 have four plicae in each knee, and these allow for bending and moving the leg effortlessly. Plica syndrome happens if the plicae, which are synovial tissue bands are injured or overuse (WebMD, n.d.). Typically, it is the medial plica that gets irritated. Symptoms of Plica syndrome of the knee include a clicking sound, pain, and swelling. In addition, some patients may experience their knee(s) giving out or locking in place. Patients develop Plica syndrome because of trauma, using stair machines, running, or riding a bicycle.

Figure 59.0. Copyright: Radiopaedia.org, Creative Commons

Patients with Plica syndrome are not steady or stable on the affected knee and complain of:

• pain while climbing stairs

• worse at night

• worse when active

• pain with squats and bending

• getting up after a long sedentary period

The signs and symptoms of Plica syndrome are like many other knee problems, which makes it difficult for providers to diagnose knee Plica syndrome. During the office visit and physical exam, the doctor will evaluate and assess the knee. Unfortunately, a radiograph of the knee does not reveal knee plica syndrome, but the provider may still order one regardless to rule out other knee conditions. However, other modalities, such as CT or MRI, may be chosen as other alternatives for confirming a diagnosis (see Figure 59.0). As with Osgood-Schlatter, treatment for Plica syndrome includes ice packs and anti-inflammatory medication for pain.

Genu varum (Bowlegged), Blount Disease, and Genu valgum (knock-knees) Genu varum is a condition that is common among children and toddlers who are younger than 2 years of age. It refers to the bowing of the legs, which is a simple and normal variation in leg appearance within this young population (see Figure 60.0). Genu varum (physiologic) typically resolves itself spontaneously by the age of 18 months (Boyadjiev-Boyd, 2018). The condition of physiologic genu varum (bowleg) will begin to resolve itself and continue to improve, and by the ages of 3 or 4, it should be completely gone. However, if the condition does not improve, there may be other underlying conditions. The provider may wish to rule out metabolic conditions such as Blount disease (tibia vara) or Rickets. Blount disease is a condition in toddlers and adolescents in which there is a growth abnormality of the medial aspect of the proximal growth plate of the shinbone (tibia). It is common for patients with Blount disease to be overweight. The primary diagnosis of Blount disease is somewhat complex and problematic, mainly since radiographs of the lower leg may be normal. The radiology report will present the classic impressions and findings of angulation of the medial metaphysis of the lower leg. Orthopedic providers may prescribe leg braces or splints, but commonly, these pediatric patients will eventually need surgery. Genu valgum is less common the genu varum and is known as knock-knees. About 75% of young children from 3 to 5 years of age have this condition (Hecht, 2017). It is a condition in which the knee is misaligned and turns inward. In the upright position, patients with knock-knees have a 3-inch gap or more between their ankles since their knees are bowed so far inward (see Figure 61.0). In 99% of cases with Genu valgum, they typically resolve themselves by the age of 7 or 8 years old (Hecht, 2017). While this condition is common among children, it can develop in older populations from:

❖ Obesity ❖ Arthritis of the knee ❖ An injury or infection ❖ Extreme lack of vitamin D and calcium (Hecht, 2017).

While Genu valgum is a benign condition, research shows that it may be inherited. It may be caused by arthritis in joints, infection of knee, Rickets, obesity, or lack of vitamin D. In addition, other bone diseases may cause Genu valgum.

Figure 60.0. Genu Varum. Copyright: frontiersin.org. Free to share and use commercially

a b

Figure 61.0. Genu Valgum (knock-knees). Copyright: jocr.co.in, Free to share and use commercially

Deep vein thrombosis A medical condition that is painful and affects one or both legs is deep vein thrombosis (DVT). It develops as a result of blood clots (thrombus) in one or more of the deep veins in the legs. Some diseases affect how the body process clots (Mayo Clinic, 2018d). DVT can cause leg swelling or pain, but some patients are asymptomatic. Blood clots of DVT may be caused by events that prohibit the blood from circulating or clotting normally. For example, specific medications, limited physical activity, and trauma from an injury. Unfortunately, DVT can be life-threatening as a blood clot can dislodge in a vein, then travel to block veins in the lungs.

Figure 62.0. DVT Ultrasound. Copyright: Wikipedia, Creative Commons Attribution-ShareAlike

Factors which can contribute to developing DVT Obesity (increases the pressure in the veins)

Age (older than 60 increases your risk)

Smoking (affects blood clotting and circulation)

Inheriting a blood-clotting disorder

Prolonged bed rest (hospitalization or paralysis) Surgery or Injury or surgery (to veins)

Cancer

Heart failure (limited lung and heart function)

A personal history (or family) of deep vein

thrombosis or pulmonary embolism

Table 16 Mayo Clinic, 2018d

While radiographs will not assist in the diagnosis of DVT, the provider may order an ultrasound to determine if the patient has DVT (see Figure 62.0). Consequently, radiology technologists (especially those in ultrasound) must be aware of the symptoms of DVT. Symptoms of DVT consist of swelling, aching and pain in the affected leg beginning at the calf,

73 redness of the skin or discoloration, and a warm or hot feeling in the leg. Since DVT is a life- threatening condition, symptoms of a pulmonary embolism must be watched, and warning signs include:

• Sudden respiratory distress (shortness of breath)

• Coughing up blood

• Feeling lightheaded or dizzy, or fainting

• Rapid pulse

• Chest pain or discomfort (worsens with deep breath or cough)

Dejerine Sottas Syndrome Hypertrophic Interstitial Neuritis, Hypertrophic Interstitial Neuropathy, Hereditary Motor Sensory Neuropathy Type III, and HSMN Type III are other names for the more commonly known condition of Dejerine Sottas Syndrome (DSS) or disease (NORD, n.d.). This disease begins during infancy and causes demyelinating peripheral neuropathy. It is a genetic neurological disorder that gradually affects agility and mobility due to the recurrent loss of the protective sheath surrounding the nerves (myelin). Unfortunately, researchers have not determined why the myelin disappears. Dejerine-Sottas syndrome frequently starts around the age of ten and thirty years, and equally affects both females and males.

Figure 63.0. Dejerine Sottas Syndrome. Copyright: YouTube, Free to share and use commercially

74 This syndrome causes the peripheral nerves to become thick and enlarged, which leads to muscle weakness. Patients with this disease will have delayed motor skills because of their severe distal motor and sensory disabilities. Consequently, they have a difficult time walking and managing their gait (see Figure 63.0). Other characteristics they may have include scoliosis, sensory ataxia, and pes cavus. Many patients will also experience a burning sensation in the legs, pain or numbness, weakness, numbness, and a tingling (NORD, n.d.). As the disease progresses, the upper extremities may also be affected as the hands and forearm become weaker. Also, the patient may develop some vision difficulties with the progression of the disease. With all these medical conditions, it is very likely that the radiology technologist will encounter patients with DSS. Consequently, they must take into consideration the patient’s condition, and make the necessary assessment and precautions when obtaining the radiograph. For example, the patient may require a wheelchair if their gait is unsteady, or they may need assistance climbing onto the radiology table.

Panniculitis Panniculitis is the inflammation of the connective tissue and fat that rests under the skin. However, inflammation can also occur in the fatty tissue surrounding the body organs. While the cause of Panniculitis is unknown by experts, they have determined that many factors and diseases contribute to its condition. For example, experts believe that infections, trauma, and systemic diseases play a vital role in causing Panniculitis. Plus, they believe that other factors such as drugs, pregnancy, and autoimmune diseases also play a role in causing Panniculitis (Raj, 2018).

Common Types of Panniculitis

• Erythema nodosum – most common, septal panniculitis • Erythema induratum – lobular panniculitis/damage to blood vessels • Mesentric panniculitis – panniculitis of the mesentry / bowels • Lupus panniculitis – Panniculitis caused by systemic lupus • Pancreatic panniculitis – pancreatic panniculitis • Cold panniculitis • Lipodermatosclerosis – inflammation of the subcutaneous fat under skin • Necrotising panniculitis – destruction of the fatty tissue • Traumatic panniculitis

TABLE 17. SOURCE: DR. RAJ

75 There are many types of panniculitis, but only a few of the most important and common ones are illustrated in Table 17. Panniculitis may be classified as a disease by itself or an indication of another underlying disease. The classification is determined by the part of the fatty tissue in the body that is involved, and if the inflammation is involves blood vessels (vasculitis).

Figure 64.0. Panniculitis Copyright: emedicalhub.com, Free to share and use commercially There are many symptoms of Panniculitis and depend on the cause. For example, each core disease manifests with a specific group of symptoms, in addition of the general skin symptoms of Panniculitis. Medical providers must be caution in identifying the correct symptoms of Panniculitis, as it may be the indicator for a more serious underlying disease (Raj, 2018). Below are listed the symptoms of Panniculitis, which range from minor to serious and life-threatening:

1. Fever, nausea, and vomiting 2. Weight loss, joint pain 3. Depression in the skin – lipoatrophy 4. Dark pigmentation of the skin - Red or dark brown (see Figure 64.0) 5. Commonly seen in lower legs (thigh, buttocks and chest with more fatty tissue) 6. Skin is thick and has a woody feel upon touch 7. Skin has discoloration 8. Raised lumps

76 Lipodermatosclerosis

Following the preceding section, one form of panniculitis is called Lipodermatosclerosis. Lipodermatosclerosis occurs with inflammation of the subcutaneous fat under the skin and refers to lower extremity’s skin changes. Patients with this condition are affected because they have insufficient venous blood flow, which may cause them to develop this disease in either one or both lower extremities. Researchers have not determined the exact cause of lipodermatosclerosis. One study found that two-thirds of patients with this condition are obese (NIH, 2014). Other reports state that perhaps the cause of Lipodermatosclerosis is due to vein abnormalities.

Figure 65.0. Lipodermatosclerosis. Copyright: (a). www.dermnetnz.org, (b). medicalfoster.com, Free to share and use commercially

Lipodermatosclerosis is typically determined and diagnosed according to the patient’s signs and symptoms. The signs and symptoms of Lipodermatosclerosis include redness of skin, swelling, pain, tapering of lower legs, and hardening of the skin (see Figure 65.0). Other symptoms of this condition include varicose veins, small white scarred areas, and leg ulcers (NIH, 2014). Some people may also have difficulty walking. The medical provider may not choose to order radiographs but instead may prefer to order other procedures such as ultrasound and MRI. One important treatment includes compression therapy.

Legg-Calve-Perthes Disease One disease that affects the hip is called Legg-Calve-Perthes disease (LCPD) and occurs when the blood supply to the femoral head of the hip is disrupted. This disruption causes a deformity in the femoral head (see Figure 66.0). The bone cells of the femoral head will die if it does not receive enough blood supply. The population, most at risk for this disease, are children between the ages of 4 and 10 (NIH, 2016). Like many of the previous diseases and conditions

77 mentioned previously, researchers do not know the cause of LCPD. However, experts believe that LCPD may be caused by trauma, steroid use, a slipped capital femoral epiphysis, or perhaps toxic synovitis. In addition, they have seen LCPD cases in which other diseases or conditions such as sickle-cell crisis or congenital hip dysplasia play a role in causing LCPD. Some studies have concluded that: 1). genetic factors are not a major cause but may contribute if an autosomal inheritance is present, and 2). COL2A1 gene has mutation (NIH, 2016).

Figure 66.0 Legg-Calvé-Perthes Disease of Hip. Copyright: Everipedia, Creative Commons Attribution-ShareAlike

This condition may last for numerous years before new bone cells begin to form (re- ossification). Patients with LCPD will have various symptoms, which may include hip pain, limping, radiating pain to knee or thigh, and reduced range of hip motion. However, as the disease continues to grow, the person may notice that one leg is longer than the other. If there is a leg length discrepancy, the provider may order a bone survey for measurement to be completed in the radiology department. For patients with LCPD, the prognosis depends on the severity and extent of bone involvement, and residual deformity. As most of the patients with LCPD have bone abnormalities in the hip, radiology technologists must be familiar with this condition. The medical provider may prescribe a treatment that focuses on keeping the femoral head inside the acetabulum, so rest or medication for pain, and physical therapy may also be prescribed. Last, the patient may eventually require the use of a brace or perhaps hip surgery.

Fibular Hemimelia The term “hemimelia” refers to a congenital developmental anomaly in which there is an absence or gross shortening of the lower distal half of an extremity. A diagnosis is determined according to which anatomical part is missing or deformed (i.e., radial, ulna, tibia, etc.) as illustrated in Figure 67.0(a). A birth defect, such as fibular hemimelia (FH) occurs when part or

78 all the fibular bone is absent (see Figure 67.0b), or there is length discrepancy, knee abnormality, or foot deformity. With FH, the fibula is absent, but FH is currently known as a fibular deficiency which results in anteromedial bowing of tibia. Most children who have this disorder have no family history. Researchers have not determined the cause of FH, but they have found that genes activated in an abnormal order, may contribute to the development of FH. However, other studies show some genes going through a mutation process may also contribute to FH; this disorder is not heritable. Patients that have FH have three significant complaints:

• Knee anomaly • Extremity length discrepancy • Foot and ankle deformities

One of the biggest challenges with FH is the level of deformity in the foot. A characteristic of the deformed foot is related to deformed ankle and the absence of anatomical parts of the foot. There are several levels of deformities, which are outside the scope of this course. Besides the foot deformity, the second issue to FH is related to limb length discrepancy; the affected limb grows slower – resulting in a shorter limb. Plus, numerous patients with FH also have shorter femur as well creating an overall discrepancy of the entire lower extremity.

a b

Figure 67.0. (a). Tibial Hemimelia, by www.trishlafoundation.com, and (b). Fibular Hemimelia, by boneandspine.com, Copyright: Free to share and use commercially.

Proximal Femoral Focal Deficiency (PFFD

Children’s Hospital of Philadelphia (CHoP) treats many patients who have birth defects such as proximal femoral focal deficiency (PFFD). It is a complication in which the bone of the proximal femur is either deformed or absent, resulting in one leg being shorter than the other. Consequently, the child will have difficulties walking and causes other bones in the body to have extra stress from over-compensating from the short femoral bone. Children affected with PFFD

79 may have additional muscle or bone disorders, including limb-length discrepancies, fibular hemimelia, malrotation, and joint instability (CHoP, n.d.). As with previous disorders presented, researchers do not know what causes PFFD but suspect it is caused by a disruption (from infection or trauma) during early prenatal stages. The drug thalidomide is known to cause limb deficiencies in unborn babies. Patients with PFFD will manifest symptoms that vary from one child to another. However, typical symptoms include a femoral bone that is:

• Shortened and turned outward (external rotation) • Flexed • Whole leg pivots at abnormal angle (from the hip) • Absent hip joint or unstable (affected leg) • Unstable knee joint on the (affected leg)

PFFD patients may have other anomalies

Shortened or absent fibula in the lower leg (fibular deficiency) Club foot or valgus foot Spine differences Congenital heart defects

Table 3.0 Source: CHOP. (n.d).

Using ultrasound, children with PFFD are diagnosed before birth. Depending on the child’s severity of PFFD, the gravity of their physical condition, and their functional abilities, the medical provider will request diagnostic radiographs. Some of the more common exams include, regular radiographs, 3D imaging systems, MRI, Ultrasound, or CT scan. Often, the patient will also require a hip arthrogram.

4 Types of PFFD

• Type A —femur bone is slightly shorter on the proximal end. X-ray of hip – may reveal congenital short femur; externally rotated femur could lead to genu varum (bowlegged). • Type B —more severe than type A; femur bone is shorter on the proximal end and affects both the femoral head and the femoral shaft. It will not heal spontaneously. • Type C — whole half of the femoral bone is absent, including the femoral head and trochanters; proximal femur is not connected to the hip in any way; may also have acetabular dysplasia (features acetabulum that is shallow, shaped abnormally, and turned outward). • Type D —most severe form of PFFD; most of femur bone is not presented, distal femoral epiphysis has only a small irregular piece of bone; pelvis has no acetabulum (affected side had pelvic wall that is flat). Table 4.0 Source: CHoP, n.d.

HIP PAIN

As presented at the beginning of this course, the hip is a synovial (ball and socket) joint with many different anatomical components. Fortunately, the hip is very strong and can withstand repeated, chronic motion, and a good amount of wear and tear. The function of the hip is to provide stability and support weight-bearing. The hip joint space consists of anatomy, articulating surfaces, tendons, ligaments, and neurovascular elements. Thus, it is easy to understand and sympathize with those patients that have chronic hip pain. Unfortunately, there can be various reasons and conditions that cause hip pain. Listed below are only a few conditions that a radiology technologist should be familiar with as they may encounter these when performing their duties:

Bursitis. The sacs (bursae) of liquid which act a cushion between tissues such as tendons, bone, skin, and muscles. Their purpose is to relieve the friction from these tissues rubbing together. When bursae become inflamed, the result is pain. Bursitis, (inflammation) of the bursae is caused by repetitive actions that irritate the hip joint. Patients with bursitis have symptoms such as swelling, pain, and somewhat limited movement. The medical provider may diagnose bursitis by ordering radiographs and an MRI of the affected hip.

Hip Dysplasia: This is a condition which patients are born with, whereas the acetabulum does not completely cover the femoral head. Consequently, hip dysplasia can cause frequent hip complete or partial dislocations. When diagnosed at infancy, the provider may prescribe a soft brace to correct the condition. Cases that are not so severe, may not experience hip dysplasia symptoms until the patient is an adolescent or young adult. A consequence of hip dysplasia is a hip labral tear, a tear in the cartilage (labrum) that borders the hip socket. A second consequence is damage to the cartilage lining the joint from repeated dislocations.

Hip labral tear. A hip labral tear occurs in the band of cartilage (labrum) that tracks the outer rim of the hip socket joint. One role of the labrum is to hold the femoral head securely in the acetabulum by acting as a seal. This condition is seen more often in people who perform twisting and repetitive movements. While this condition may not appear on a normal radiograph, the provider may choose to order an MRI instead.

Sprain vs. Strain: Many people confuse the terms “sprain” and “strain.” A hip sprain occurs due to an injury to the ligaments surrounding the hip. A patient with a hip sprain will experience pain with any type of hip movements, such as internal rotation and flexion. Radiology technologists must take this fact into account when positioning for a hip radiograph. A hip strain happens when there is an injury to the tendons or muscles near the hip, thereby causing pain and limited movement. Both sprains and strains cause pain with movement, but with strains, the pain gets worse with increased muscle activity or higher levels of heavy muscle use. Patients with strains normally play sports and have symptoms such as swelling, pain, muscle spasms, and difficulty with muscle movement.

Sprain vs. Strain

❖ Strain = tendons/muscles ❖ Sprain = ligaments

Tip to remember: Strain has a “t”; Tendon starts with “t”. Table 5.0

Cancers. There are numerous types of cancers, which are outside the scope of this course. However, it is warranted to mention that tumors may begin in the bone and metastasizes to other parts of the body (or vice-a-versa). Cancer that metastasize to the hip bone may result in hip pain.

Hip fractures. As previously presented, there are several types of fractures. The radiology technologist must be aware of all these types of fractures, including those that may affect the hip. As patients age and become elderly, they are at a higher risk of falling a fracturing their hip because their bones become brittle.

Arthritis. There are two different types of arthritis: Osteoarthritis and rheumatoid arthritis (RA). Among the older population, osteoarthritis and RA are the two most common causes of hip pain. With arthritis, hip pain gradually worsens, as it leads to inflammation of the joint and the breakdown of the cartilage. Patients with arthritis typically have a lower range of motion and stiffness.

Osteonecrosis/Avascular necrosis. This condition commonly affects the hip but does occur in other bones. The term “necrosis” refers to the death of cells in the tissue and organs from injury, disease, or blood supply failure. Osteonecrosis (avascular necrosis) is a result of reduced blood flow to the hip bone causing the death of bone tissue. The cause of Osteonecrosis stems from a hip dislocation or fracture, or chronic use of steroids.

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Wrist X-ray. December 09, 2013. Provided by Lengerke, Jochen - Wikimedia Commons. Located at: https://commons.wikimedia.org/wiki/File:Xray_hand_with_color.jpg. License: Creative Commons CCO.

95 ANATOMY, DISEASES, & CONDITIONS:

UPPER & LOWER EXTREMITIES

TEST

1. The skeletal system (appendicular) – which includes the upper and lower extremities, consists of ______bones. a. 79 b. 102 c. 126 d. 147

2. Synovial joints are identified as the upmost common group of joints and are described as joint spaces that are ______at their articulating site. a. fluid-filled b. ligaments c. amphiarthrosis d. uniaxial

3. Which of the following is NOT a type of FUNCTIONAL joint? a. synarthrosis b. amphiarthrosis c. diarthrosis d. hinge

4. Joints that are uniaxial, biaxial, and multiaxial are all classifications of: a. synarthrosis b. amphiarthrosis c. diarthrosis d. pivot

5. The scapula contains three borders: a. medial (vertebral), superior, and lateral b. inferior angle, superior, and lateral c. medial (vertebral), inferior, and dorsal d. superior, lateral, and infraspinous

6. In the humerus, the head is set at approximately _____ degrees with the long axis of the humeral shaft. a. 10 degrees b. 21 degrees c. 35 degrees d. 45 degrees

96 7. Which of the following bones is NOT found in the distal humerus? a. Olecranon fossa b. Coronoid fossa c. Trochlear notch d. Lateral epicondyle

8. The scaphoid (navicular) carpal bone is situated on the ______or “thumb” side of the wrist a. medial side b. mid-sagittal c. lateral (radial) d. none of the above

9. Except for the ______, all the phalanges have first, second, and third, or as proximal, middle, and distal phalanx. a. ring finger b. thumb. c. 5th finger d. 3rd finger.

10. Which are the three iliac bones in the hip? a. Ilium, ischium, pubis b. Ilium, ischium, acetabulum c. Obturator foramen, ischium, pubis d. Ischial tuberosity, ischium, pubis

11. In the proximal femur, from the junction of the neck and shaft, posterosuperior projects a large quadrangular process called the greater trochanter. a. True b. False

12. Which of the following statements is FALSE concerning the patella? a. It is also called the knee cap. b. It is largest sesamoid bone, flat and triangular c. It is attached to the trochanter of the tibia by the patellar tendons d. The patella is freely movable when the knee is extended in a relaxed state

13. There are ______metatarsals numbered beginning with the medial side and there are ______phalanges in the toes. a. 4, 10 b. 5, 12 c. 5, 14 d. 6, 15

97 14. ______refers to an abnormality of the 5th finger, being bent or curved, or curves to the side. a. polydactyly b. clinodactyly c. brachydactyly d. syndactyly

15. The characteristics that a radiology technologist may encounter with patients that have PWS include: a. small hands and feet b. short stature and obese c. stubbornness and compulsive behaviors d. all the above

16. Patients with Ellis-van Creveld syndrome may also require radiographs for the diagnosis of ______digits (extra fingers and toes). a. polydactyly b. clinodactyly c. brachydactyly d. syndactyly

17. Which of the following is a CORRECT statement for syndactyly syndromes? a. Blooms syndrome has features that impact the role of radiology technologists because they will manifest brachydactyly (multiple digits) and clinodactyly (fused or webbed digits). b. A common feature among Silver syndrome patients is the high rate of polydactyly (curving of the 5th digit). c. Hallermann Streiff Syndrome also known as Goltz syndrome d. Radiology technologists must know when performing a sternum radiograph on patients with HSS, that they may have pectus excavatum (depressed breastbone).

18. The three aphoristic planes of the body are: a. Sagittal, coronal, and transverse b. Sagittal, median, and tangential c. Coronal, frontal and transverse d. Parasagittal, coronal, and tangential

19. There are two prevalent types of lesions most visible by radiographs: a. Dislocations and cancerous lymphomas b. Bloodborne Pathogens and fractures c. Dislocations and fractures d. Pathological fractures and genetic disorders

20. Read the description regarding fracture types below and determine which one is CORRECT. a. Hairline fractures - minimal trauma to produce a slight fracture. b. Greenstick fractures – mostly in children, partially bend and slightly break.

98 c. An avulsion fracture - are a special case of impacted fractures. d. “a” and “b” are CORRECT

21. With the Salter-Harris classification of epiphyseal plate injuries, Type III is ____. a. The whole epiphyseal plate is separated from the shaft b. The epiphysis is displaced, together with a small metaphyseal fragment c. Separation of part of the epiphysis d. Crush injury of part or all the epiphyseal 22. The direction of displacement is specified by the movement of the ______fragment. a. distal b. proximal c. lateral d. posterior 23. Why is it especially vital for radiologist technologists to obtain both distal and proximal ends on a radiograph. • To please the radiologist, otherwise they will be upset • It impedes the radiologist from pronouncing axial rotation • So, the radiologist can determine the type of fracture • To comply with federal and state regulations 24. Which of the following statements is FALSE? a. Moving the shoulder forward moves the scapula forward and is called protraction. b. Inversion occurs when the foot is turned inward towards the other foot c. When flexing a joint beyond its limitation, is called hyperflexion d. Hyperextension results when the joint is stretched markedly beyond its normal capacity of 96 degrees. 25. When comparing the conditions of Chilblains and Bunions, which statement below is CORRECT? a. Chilblains is more common in women; Bunions may result in bursitis b. Chilblains results in flatfeet; Bunions can never be removed c. Bunions are caused by cancerous cells; Chilblain is inherited d. Bunions are inherited; Chilblains is caused by hot temperatures

26. Which condition does the radiology technologist need to be aware of performing a weight bearing standing radiograph? a. Chilblains b. Reiter’s syndrome c. Flatfeet d. Achilles tendonitis

27. Symptoms of Plica syndrome of the knee include ______, ______, and swelling. a. vomiting, nausea

99 b. hardening of skin, discoloration c. pain, clicking sound d. tendonitis, pain 28. Genu varum is more commonly known as ______, while Genu valgum is commonly known as ______. a. Blount disease, bowlegged b. Reiter’s syndrome, knock-knees c. Bowlegged, Plica d. Bowlegged, knock-knees

29. Patients with Dejerine Sottas Syndrome may require a wheelchair because…… a. their gait is unsteady due to the deformity of their feet b. they have an amputated leg c. they are paralyzed d. many of them have degeneration of the hip

30. ______is a condition which patients are born with, whereas the acetabulum does not completely cover the femoral head. a. hip sprain b. hip strain c. hip labral tear d. hip dysplasia

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