ELBOW JOINT

OVER VIEWS

• indications
• Anatomy
• Patient preparation
• technique
• Pattern recognition
• Radiation protection

• Impact of different projection on image quality[exposure factors]

INDICATIONS

 Trauma
 Bony tenderness
 Suspected fracture of proximal radius and ulnar
 Suspected fracture of distal humerus
 Radial head dislocations
 Obvious deformity
 Arthritis
ANATOMY

• The elbow joint is also of synovial classification and is thus freely movable.
• It is generally considered a hinge type of joint with flexion and extension movements
between the humerus , ulna and radius.
• The complete elbow joint however includes three joints enclosed in one articular capsule
( Humeroradial, Humeroulnar and proximal radioulnar joint)
• The body (shaft) of the humerus is the long center section, and the expanded distal end of the humerus is the
humeral condyle.
• The articular portion of the humeral condyle is divided into two parts: the trochlea (medial condyle) and the
capitulum
• The trochlea is shaped like a pulley or spool; it has two rim like outer margins and a smooth depressed center
portion called the trochlear sulcus, or groove.
• This depression of the trochlea, which begins anteriorly and continues inferiorly and posteriorly, appears circular
on a lateral end
• on a lateral elbow radiograph, it appears as a less dense (more radiolucent) area,
• The trochlea is located more medially and articulates with the ulna.
• The capitulum, meaning “little head,” is located on the lateral aspect and articulates with the head
of the radius.
• The articular surface that makes up the rounded articular margin of the capitulum is just slightly
smaller than that of the trochlea.
• The lateral epicondyle is the small projection on the lateral aspect of the distal humerus above the
capitulum.
• The medial epicondyle is larger and more prominent than the lateral epicondyle and is located on
the medial edge of the distal humerus.
PATIENT PREPARATION

• Confirm the patient identification

• Create rapport with the patient
• Take brief history
• Explain the procedure to the patient and seek consent
• Give instruction to remove any radio-opaque objects
• Position the patient accordingly
 TECHNIQUE;AP VIEWS

Anteroposterior projection

centering point ;
- midpoint between epicondyles
Collimation: collimate on four sides to area of interest
Detector size-18x24cm
Kvp 55-80 for standard adult and 45-50 for children age from 7 years
mAs 5-30 adult and 2-6 for children
SID - 100cm
Grid -no
RADIATION PROTECTION

• Beam should be collimated within margins of the cassette

• Lead aprons
• Gonardal shields
AP PROJECTION: ELBOW
ELBOW FULLY EXTENDED

• The arm is extended fully, such that the posterior aspect

of the entire limb is in contact with the tabletop and the palm
of the hand is facing upwards.
• The unexposed half of the cassette is positioned under the
elbow joint, with its short axis parallel to the forearm.
• The arm is adjusted such that the medial and lateral epicondyles
are equidistant from the cassette.
• The limb is immobilized using sandbags
DIRECTION AND CENTRING OF THE X-RAY BEAM

• The vertical central ray is centred through the joint space at one inch below the mid point
between the epicondyles
EVALUATION CRITERIA

• Anatomy Demonstrated
• Distal humerus, elbow joint space, and proximal radius and ulna are visible.
Position:
• Long axis of arm should be aligned with long axis of IR.
No rotation is evidenced by the appearance of bilateral epicondyles seen in profile and radial head, neck, and
tubercles separated or only slightly superimposed by ulna.
• Olecranon process should be seated in the olecranon fossa with fully extended arm
• Elbow joint space appears open with fully extended arm and proper CR centering..
CONT`N

• CR and center of collimation field should be to the mid elbow joint

• Exposure: • Optimal density (brightness) and contrast with no motion should visualize
soft tissue detail; sharp, bony cortical margins; and clear, bony trabecular markings.
AP (EXTENDED).
AP PROJECTION: ELBOW
WHEN ELBOW CANNOT BE FULLY EXTENDED -UPPER ARM PARTIALLY FLEXION

• If the patient is unable to extend the elbow fully

• Elevate the forearm and put support the upper arm should be resting on the horizontal plane of
the image receptor on the table
• Centering point – is centred through the joint space at one inch below the mid point between
the epicondyles
Clinical Indications
• Fractures and dislocations of the elbow
• Osteomyelitis and arthritis
EVALUATION CRITERIA

• Distal humerus is best visualized

. Note:
• Structures in elbow joint region are partially obscured and slightly distorted, depending
on amount of elbow flexion possible.
AP ELBOW (UPPER ARM PARTIALLY FLEXED);
FOREARM PARTIAL FLEXION

• The posterior aspect of the forearm is placed on the table with the palm of the hand facing
upwards.
• The cassette is placed under the forearm, with its centre under the elbow joint.
• The forearm is rest on the table while elbow slightly bent and hand supinated
• Centering point - The vertical central ray is centred in the midline of the forearm one
inch distal to the mid point of the elbow
EVALUATION CRITERIA

• proximal radius and ulna are best visualized in these projection

AP ELBOW (FOREARM PARTIALLY FLEXED);
Note
• When the patient is unable to extend the elbow to 90 degrees,
a modified technique is used for the antero-posterior projection. If the limb cannot be
moved, two projections at right-angles to each other can be taken by keeping the limb in the
same position and rotating the X-ray tube through 90 degrees.
AP PROJECTIONS OF ELBOW IN ACUTE
FLEXION

• The patient is seat at the end of the table with acutely flexed arm resting on image receptor
• Align and center humerus to long axis of image receptor, with forearm acutely flexed and
fingertips resting on shoulder.
• Adjust image receptor to center of elbow joint region.
• Palpate humeral epicondyles and ensure that they are equal distances from cassette for no
rotation.
NOTE

• To visualize both the distal humerus and the proximal radius and ulna, two projections are
required—one with central ray perpendicular to the humerus and one with central ray
angled so that it is perpendicular to the forearm.
Centering point
• Distal humerus: central x ray perpendicular to image receptor and humerus, directed to a
point midway between epicondyles
• Proximal forearm: central x ray perpendicular to forearm (angling x ray tube as needed),
directed to a point approximately 2 inches proximal or superior to olecranon process
PROXIMAL FOREARM—CENTRAL RAY
PERPENDICULAR TO FOREARM.
FOR DISTAL HUMERUS—CENTRAL RAY
PERPENDICULAR TO HUMERUS.
EVALUATION CRITERIA FOR SPECIFIC PROJECTIONS

• Distal humerus. Forearm and humerus should be directly superimposed. Medial and
lateral epicondyles and olecranon process all should be seen in profile.
• Proximal forearm. Proximal ulna and radius, including outline of radial head and neck,
should be visible through superimposed distal humerus.
DISTAL HUMERUS. PROXIMAL FOREARM.
AP OBLIQUE PROJECTION—LATERAL (EXTERNAL)
ROTATION: ELBOW

• These projection is best in visualizes radial head and neck of the radius and capitulum
of humerus. patient Positioning
• Seat patient at end of table, with arm fully extended and shoulder and elbow on same
horizontal plane (lowering shoulder as needed)
• Supinate hand and rotate laterally the entire arm so that the distal humerus and the
anterior surface of the elbow joint are approximately 45° to IR. (Patient must lean
laterally for sufficient lateral rotation.) Palpate epicondyles to determine approximately
45° rotation of distal humerus
• Centering point
• a point approximately 2 cm distal to midpoint of line between the epicondyles
OBLIQUE—EXTERNAL ROTATION
EVALUATION CRITERIA

• Distal humerus and proximal radius and ulna is visible

• Correct 45° lateral oblique should visualize radial head, neck, and tuberosity, free of
superimposition by ulna.
OBLIQUE—EXTERNAL ROTATION
AP OBLIQUE PROJECTION—MEDIAL (INTERNAL)
ROTATION: ELBOW

• These projection is best in visualizes coronoid process of ulna and trochlea in profile
Patient position
• Seat patient at end of table, with arm fully extended and shoulder and elbow on same
horizontal plane
• Pronate hand into a natural palm-down position and rotate arm as needed until distal
humerus and anterior surface of elbow are rotated 45° (while palpating epicondyles to
determine a 45° rotation of distal humerus)
 Centering point
• a point approximately 2 cm distal to midpoint of line between the epicondyles
END VIEW, SHOWING
45° MEDIAL OBLIQUE.
EVALUATION CRITERIA

• medial oblique should visualize coronoid process of the ulna in profile. Radial head and
neck should be superimposed and centered over the proximal ulna.
MEDIAL
(INTERNAL ROTATION)
OBLIQUE.
TECHNIQUE FOR LATERAL VIEW

• Lateral projection
• collimation- colliminate on four sides of area of interest
• Centering point-lateral epicondyle of the humerus
• Orientation-landscape
• Detector size-18x24cm
• 50-60Kvp for standard adult
• 2-5mAs
• SID-100cm
• Grid-no
RADIAL HEAD LATERALS—LATEROMEDIAL
PROJECTIONS: ELBOW

•Clinical Indications - Occult fractures of the radial head or neck

Patient position
•Seat patient at end of table, with arm flexed 90°and resting on IR with humerus, forearm, and hand on same horizontal
plane. Place support under hand and wrist if needed.
•Take four projections, the only difference among the four being rotation of the hand and wrist from (1) maximum external
rotation to (4) maximum internal rotation; different parts of the radial head projected clear of the coronoid process are
demonstrated. Here complete rotation of radial head occurs in these four projections, as follows:
•1. Supinate hand (palm up) and externally rotate as far as patient can tolerate.
•2. Place hand in true lateral position (thumb up).
•3. Pronate hand (palm down).
•4. Internally rotate hand (thumb down) as far as patient can tolerate .
 Centering point
Approximately 2 to 3 cm [1 inch] distal to lateral epicondyle)
1 HAND SUPINATED
(MAXIMUM EXTERNAL ROTATION). FIGURE 1
2 HAND LATERAL. FIGURE 2
3 HAND PRONATED FIGURE 3
 4 HAND WITH
MAXIMUM INTERNAL ROTATION. FIGURE 4
EVALUATION CRITERIA FOR SPECIFIC ANATOMY

• Elbow should be flexed 90° in true lateral position, as evidenced by direct

superimposition of epicondyles. Radial head and neck should be partially superimposed
by ulna but completely visualized in profile in various projections. Radial tuberosity
should be visualized in various positions and degrees of profile as follows : (1) Fig,
slightly anterior; (2) Fig. not in profile,superimposed over radial shaft; (3) Fig. slightly
posterior; (4) Fig., seen posteriorly, adjacent to ulna when hand and wrist are at maximum
internal rotation.
TRAUMA AXIAL LATERALS—AXIAL LATEROMEDIAL
PROJECTIONS: ELBOW

• These are special projections taken for pathologic processes or trauma to the area of the
radial head or the coronoid process of ulna. These are effective projections when patient
cannot extend elbow fully for medial or lateral oblique projections of the elbow.
• Clinical Indications
Fractures and dislocations of the elbow, particularly the radial head and coronoid process
Patient Position -Seat patient at the end of the table for the erect position or supine on the
table for cross-table imaging.
Part Position 1—Radial Head
•Elbow flexed 90° if possible; hand pronated CR directed at 45° angle toward shoulder,
centered to radial head (mid elbow joint)
Part Position 2—Coronoid Process
• Elbow flexed only 80° from extended position (because >80° may obscure coronoid process)
and hand pronated CR angled 45° from shoulder, into mid elbow joint
Note ; Increase exposure factors by 4 to 6 kV from lateral elbow because of angled x ray
tube These projections are effective with or without a splint.
ERECT FOR RADIAL
HEAD—FLEXED 90°.
ERECT FOR CORONOID
PROCESS—FLEXED 80°.
SUPINE, ANGLED 45°
FOR RADIAL HEAD—FLEXED 90
SUPINE, ANGLED 45°
FOR CORONOID PROCESS—FLEXED
80°.
EVALUATION CRITERIA FOR SPECIFIC ANATOMY

• For Radial Head: Joint space between radial head and capitulum should be open and clear.
Radial head, neck, and tuberosity should be in profile and free of superimposition except for
a small part of the coronoid process. Distal humerus and epicondyles appear distorted
because of 45°angle.
• For Coronoid Process: Distal (anterior) portion of the coronoid appears elongated but in
profile. Joint space between coronoid process and trochlea should be open and clear. Radial
head and neck should be superimposed by ulna. Optimal exposure factors should visualize
clearly the coronoid process in profile. Bony margins of superimposed radial head and neck
should be visualized faintly through proximal ulna.
FOR RADIAL HEAD.
FOR CORONOID PROCESS
 RADIOLOGICAL CONSIDERATIONS

• An effusion is a useful marker of disease and may be demonstrated in trauma, infection and inflammatory
conditions. It is seen as an elevation of the fat pads anteriorly and posteriorly and requires a good lateral
projection with no rotation.
• It may be an important clue to otherwise occult fracture of the radial head or a supracondylar fracture of the
humerus.
• Radial head fracture may be nearly or completely occult showing as the slightest cortical infraction or
trabecular irregularity at the neck or just a joint effusion.
• Avulsion of one of the epicondyles of the humerus may be missed if the avulsed bone is hidden over other
bone or in the olecranon or coronoid fossae. Recognition of their absence requires knowledge of when and
where they should be seen.
REFERENCE

• CLARKS POSITIONING IN RADIOGRAPHY- 12 EDITION 2005 AUTHOR BY A. S.

Whitley, C. Sloane, G. Hoadley, A. D. Moore & C. W. Alsop
• CLARKS POSITIONING IN RADIOGRAPHY - 8 EDITION
• TEXBOOK OF RADIOGRAPHIC POSITION AND RELATED ANATOMY PP
8EDITION AUTHOR BY KENNETH L. BONTRAGER , JOHN P. LAMPIGNANO