SURGICAL TECHNIQUE
Radiographic Evaluation of the Elbow Nicholas E. Crosby, MD, Jeffrey A. Greenberg, MD, MS Despite a number of advanced imaging modalities, plain film x-ray is essential for diagnostic evaluation of the elbow. Although computed tomography and magnetic resonance imaging continue to provide many uses in subtle processes or advanced evaluation, x-rays should typically provide initial, and often all, necessary imaging. Plain film imaging is used to evaluate trauma including fractures and dislocations, occult or suspected bony injury, instability patterns, tumor, arthritis and degenerative disease, and causes of associated pathology such as compression neuropathy. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Elbow, radiographic, evaluation, x-ray. ROUTINE RADIOGRAPHIC VIEWS A series of standard views should be obtained in many cases for elbow evaluation. These may be tailored to the patient presentation based on age, suspected diagnosis, and plans for further imaging. Anteroposterior view The standard anteroposterior (AP) view is obtained by placing the upper extremity adjacent to the radiographic table with the posterior surface of the extremity contacting the cassette. The beam passes perpendicular to the elbow from anterior to posterior. The elbow should be extended with the hand supinated so that the entire extremity is in contact with the cassette (Fig. 1). This view (Fig. 2) demonstrates the medial and lateral condyles, the radiocapitellar joint, the trochlear articular surface, the olecranon, the radial tuberosity, and the anteromedial facet of the coronoid (Fig. 3). The elbow carrying angle (5 e20 valgus) can also be evaluated. A true AP of the elbow is difficult to obtain in the presence of a stiff joint (often from contracture or injury) or an elbow that FIGURE 1: Demonstration of AP view positioning. From the Indiana Hand to Shoulder Center, Indianapolis, IN. Received for publication February 14, 2014; accepted in revised form April 22, 2014. The authors would like to acknowledge Deanna Mote, NP-C, and Zach Bolinger for their assistance with this manuscript. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jeffrey A. Greenberg, MD, Indiana Hand to Shoulder Center, 8501 Harcourt Rd., Indianapolis, IN 46260; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.035
cannot fully extend. In this case, two separate images should be obtained including an AP of the distal humerus and one of the proximal forearm.1 Lateral view In the lateral view, the elbow is flexed 90 and placed on the cassette. The entire upper extremity should be parallel to the floor, which may require adjusting
Ó 2014 ASSH
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Published by Elsevier, Inc. All rights reserved.
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RADIOGRAPHIC EVALUATION OF THE ELBOW
FIGURE 4: Demonstration of lateral view positioning.
FIGURE 2: Standard AP radiograph shows landmark details.
FIGURE 5: Standard lateral radiograph shows concentric rings of distal humeral landmarks.
FIGURE 6: Lateral radiograph shows displaced olecranon fracture.
the patient’s chair height, adjusting the table height, or placing the extremity on a radiolucent block to allow for the humerus to be flat. The beam is directed perpendicular to the elbow, and the forearm is in
FIGURE 3: AP view shows displaced coronoid anteromedial facet fracture.
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FIGURE 7: Demonstration of medial oblique view positioning. FIGURE 9: Demonstration of lateral oblique view positioning.
neutral position with the thumb facing the ceiling (Fig. 4). A true lateral will show 3 concentric rings representing, from outside to inside, the medial trochlear ridge, the capitellum, and the trochlear groove (Fig. 5). This image visualizes the elbow joint, the radial head and coronoid (superimposed), and the distal humerus and olecranon (Fig. 6). Again, in cases of stiffness or acute trauma, the elbow may not flex sufficiently. A true lateral of the distal humeral articular surface with the correct forearm neutral rotation should provide sufficient visualization.1 SPECIALTY RADIOGRAPHIC VIEWS Medial and lateral oblique views Although not always necessary for introductory x-rays, oblique views are useful in cases of subtle injury, particularly in the pediatric population. The oblique views are obtained utilizing a similar position to the AP view with the entire arm flat against the table. The beam passes from anterior to posterior perpendicular to the elbow. A medial oblique view is obtained by rotating the palm of the hand into pronation, which rotates the forearm and arm about 45 . This provides visualization of the olecranon,
FIGURE 8: Medial oblique view demonstrates displaced lateral condyle fracture.
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FIGURE 12: Radial head view.
FIGURE 10: Lateral oblique view.
FIGURE 13: Demonstration of coronoid view positioning.
FIGURE 14: Coronoid view.
FIGURE 11: Demonstration of radial head view positioning. J Hand Surg Am.
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FIGURE 16: Cubital tunnel view demonstrates impinging osteophytes in a clinically and electrodiagnostically supported cubital tunnel syndrome.
FIGURE 15: Demonstration of Jones view positioning.
trochlea, and coronoid (Figs. 7 and 8). The lateral oblique view places the upper extremity in maximal eternal rotation allowed by the shoulder with the entire arm on the cassette (Figs. 9 and 10). This provides additional visualization of the radiocapitellar joint, the proximal radioulnar joint, the medial epicondyle, and the sublime tubercle.1
pronation) to completely visualize the entire profile of the radial head.2,3 It is also important to note that rotation of this view into pronation allows a profile view of the biceps tuberosity. Coronoid view The coronoid view is obtained using the identical arm position as for the radial head view. The beam, however, is directed 45 away from the patient/ shoulder through the elbow in a standard lateral position (Fig. 13). This view exposes the profile of the coronoid (Fig. 14) and is especially useful for visualization of fractures.2,4
Radial head view Also known as the Coyle or Greenspan views, the radial head image is often one of the initial images used for evaluation of fractures or degenerative change. This view is obtained with the arm in the same position as for a lateral x-ray. The tube is then angled 45 toward the patient, which projects the radial head away from the ulna (Fig. 11). This allows for excellent visualization of the radial head (Fig. 12) and may also provide improved visualization of the fat pads. Of note, this same position and view can be taken with rotation of the forearm in 4 different positions (supination, neutral, 45 pronation, and full J Hand Surg Am.
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Axial views A number of axial views can demonstrate further detail about the olecranon, the epicondyles, and the retrocondylar groove. In the olecranon process axial,5 the dorsum of the forearm is positioned on the cassette with the elbow maximally flexed. The beam is either perpendicular to the table or directed 20 r
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FIGURE 19: Valgus gravity stress view shows medial collateral ligament avulsion fracture not seen on AP view.
will demonstrate bony changes or radiopaque spaceoccupying lesions about the retrocondylar groove. This view is obtained with the posterior arm contacting the cassette and the elbow in full flexion (as in the Jones position). The arm is then externally rotated 15 with the beam projecting perpendicularly from above. This provides an AP projection of the entire retrocondylar groove (Fig. 16). Finally, a valgus extension overload view can demonstrate osteophytes on the posteromedial or posterolateral aspects of the olecranon. It is obtained similar to a Jones AP flexion view; however, the beam is directed 20 toward the elbow from the perpendicular plane of the cassette. This captures an axial image of the far posteromedial and posterolateral compartments of the elbow (Fig. 17). It can demonstrate findings consistent with valgus extension overload8 as well as nonspecific degenerative changes.
FIGURE 17: Valgus extension overload axial view demonstrates degenerative findings in both the posteromedial and the posterolateral compartments.
Gravity stress view X-rays of the elbow while providing valgus stress can help to demonstrate instability, medial joint widening, and avulsion fractures of the medial coronoid often not seen on AP views. In this view, the patient is supine on the table with the arm abducted 90 from the body and the forearm supinated. The upper arm rests on the cassette while the remainder of the upper extremity is suspended over the edge (elbow straight) with the thumb pointing toward the floor. The cassette rests on the table posterior to the elbow. The beam is directed perpendicularly to the cassette (Fig. 18). In this view, the joint line can be assessed for widening or bony irregularity (Fig. 19).9
FIGURE 18: Demonstration of valgus gravity stress positioning.
toward the elbow for visualization of the olecranon and the articulation with the trochlea, the capitellum, and ulnar sulcus. The AP flexion or reverse axial olecranon (Jones position) view is obtained with the posterior aspect of the arm contacting the cassette and the elbow maximally flexed. The beam is directed perpendicularly from above. This view is often used during closed reduction in pediatric supracondylar humerus fractures (Fig. 15). A cubital tunnel view6,7 J Hand Surg Am.
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DISCUSSION Standard and specialized views of the elbow can be very beneficial and, when used appropriately, will provide valuable clinical information during the evaluation of patients.
4. Guilbeau JC, Mouilhi MM, Nahum H. Modified profiles of the elbow in traumatology. The value of the radial headecapitellum view or a new coronoid-trochlea view [in French]. J Radiol. 1986;67: 439e444. 5. Jaquerriere P. The need to use a special radiographic technique to get some skeletal details [in French]. J Radiol Electr. 1918;3: 145e148. 6. St. John JN, Palmaz JC. The cubital tunnel in ulnar entrapment neuropathy. Radiology. 1986;158(1):119e123. 7. Wadsworth TG, Williams JR. Cubital tunnel external compression syndrome. Br Med J. 1973;1(5854):662e666. 8. Wilson FD, Andrews JR, Blackurn TA, McCluskey G. Valgus extension overload in the pitching elbow. Am J Sports Med. 1983; 11(2):83e88. 9. Schwab GH, Bennett JB, Woods GW, Tullos HS. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orthop Relat Res. 1980;146:42e52.
REFERENCES 1. Morrey BF. The Elbow and Its Disorders. Philadelphia: Saunders; 2009:92e100. 2. Coyle GF. Special angled views of joints—elbow, knee, ankle. Radiographing Immobile Trauma Patients. Denver: Multi-Media Publishing; 1980. 3. Greenspan A, Norman A. The radial headecapitellum view: useful technique in elbow trauma. AJR Am J Roentgenol. 1982;138(6):1186e1188.
J Hand Surg Am.
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Radiographic Evaluation of the Elbow Nicholas E. Crosby, MD, Jeffrey A. Greenberg, MD, MS Despite a number of advanced imaging modalities, plain film x-ray is essential for diagnostic evaluation of the elbow. Although computed tomography and magnetic resonance imaging continue to provide many uses in subtle processes or advanced evaluation, x-rays should typically provide initial, and often all, necessary imaging. Plain film imaging is used to evaluate trauma including fractures and dislocations, occult or suspected bony injury, instability patterns, tumor, arthritis and degenerative disease, and causes of associated pathology such as compression neuropathy. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Elbow, radiographic, evaluation, x-ray. ROUTINE RADIOGRAPHIC VIEWS A series of standard views should be obtained in many cases for elbow evaluation. These may be tailored to the patient presentation based on age, suspected diagnosis, and plans for further imaging. Anteroposterior view The standard anteroposterior (AP) view is obtained by placing the upper extremity adjacent to the radiographic table with the posterior surface of the extremity contacting the cassette. The beam passes perpendicular to the elbow from anterior to posterior. The elbow should be extended with the hand supinated so that the entire extremity is in contact with the cassette (Fig. 1). This view (Fig. 2) demonstrates the medial and lateral condyles, the radiocapitellar joint, the trochlear articular surface, the olecranon, the radial tuberosity, and the anteromedial facet of the coronoid (Fig. 3). The elbow carrying angle (5 e20 valgus) can also be evaluated. A true AP of the elbow is difficult to obtain in the presence of a stiff joint (often from contracture or injury) or an elbow that FIGURE 1: Demonstration of AP view positioning. From the Indiana Hand to Shoulder Center, Indianapolis, IN. Received for publication February 14, 2014; accepted in revised form April 22, 2014. The authors would like to acknowledge Deanna Mote, NP-C, and Zach Bolinger for their assistance with this manuscript. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jeffrey A. Greenberg, MD, Indiana Hand to Shoulder Center, 8501 Harcourt Rd., Indianapolis, IN 46260; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.035
cannot fully extend. In this case, two separate images should be obtained including an AP of the distal humerus and one of the proximal forearm.1 Lateral view In the lateral view, the elbow is flexed 90 and placed on the cassette. The entire upper extremity should be parallel to the floor, which may require adjusting
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
RADIOGRAPHIC EVALUATION OF THE ELBOW
FIGURE 4: Demonstration of lateral view positioning.
FIGURE 2: Standard AP radiograph shows landmark details.
FIGURE 5: Standard lateral radiograph shows concentric rings of distal humeral landmarks.
FIGURE 6: Lateral radiograph shows displaced olecranon fracture.
the patient’s chair height, adjusting the table height, or placing the extremity on a radiolucent block to allow for the humerus to be flat. The beam is directed perpendicular to the elbow, and the forearm is in
FIGURE 3: AP view shows displaced coronoid anteromedial facet fracture.
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FIGURE 7: Demonstration of medial oblique view positioning. FIGURE 9: Demonstration of lateral oblique view positioning.
neutral position with the thumb facing the ceiling (Fig. 4). A true lateral will show 3 concentric rings representing, from outside to inside, the medial trochlear ridge, the capitellum, and the trochlear groove (Fig. 5). This image visualizes the elbow joint, the radial head and coronoid (superimposed), and the distal humerus and olecranon (Fig. 6). Again, in cases of stiffness or acute trauma, the elbow may not flex sufficiently. A true lateral of the distal humeral articular surface with the correct forearm neutral rotation should provide sufficient visualization.1 SPECIALTY RADIOGRAPHIC VIEWS Medial and lateral oblique views Although not always necessary for introductory x-rays, oblique views are useful in cases of subtle injury, particularly in the pediatric population. The oblique views are obtained utilizing a similar position to the AP view with the entire arm flat against the table. The beam passes from anterior to posterior perpendicular to the elbow. A medial oblique view is obtained by rotating the palm of the hand into pronation, which rotates the forearm and arm about 45 . This provides visualization of the olecranon,
FIGURE 8: Medial oblique view demonstrates displaced lateral condyle fracture.
J Hand Surg Am.
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RADIOGRAPHIC EVALUATION OF THE ELBOW
FIGURE 12: Radial head view.
FIGURE 10: Lateral oblique view.
FIGURE 13: Demonstration of coronoid view positioning.
FIGURE 14: Coronoid view.
FIGURE 11: Demonstration of radial head view positioning. J Hand Surg Am.
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RADIOGRAPHIC EVALUATION OF THE ELBOW
FIGURE 16: Cubital tunnel view demonstrates impinging osteophytes in a clinically and electrodiagnostically supported cubital tunnel syndrome.
FIGURE 15: Demonstration of Jones view positioning.
trochlea, and coronoid (Figs. 7 and 8). The lateral oblique view places the upper extremity in maximal eternal rotation allowed by the shoulder with the entire arm on the cassette (Figs. 9 and 10). This provides additional visualization of the radiocapitellar joint, the proximal radioulnar joint, the medial epicondyle, and the sublime tubercle.1
pronation) to completely visualize the entire profile of the radial head.2,3 It is also important to note that rotation of this view into pronation allows a profile view of the biceps tuberosity. Coronoid view The coronoid view is obtained using the identical arm position as for the radial head view. The beam, however, is directed 45 away from the patient/ shoulder through the elbow in a standard lateral position (Fig. 13). This view exposes the profile of the coronoid (Fig. 14) and is especially useful for visualization of fractures.2,4
Radial head view Also known as the Coyle or Greenspan views, the radial head image is often one of the initial images used for evaluation of fractures or degenerative change. This view is obtained with the arm in the same position as for a lateral x-ray. The tube is then angled 45 toward the patient, which projects the radial head away from the ulna (Fig. 11). This allows for excellent visualization of the radial head (Fig. 12) and may also provide improved visualization of the fat pads. Of note, this same position and view can be taken with rotation of the forearm in 4 different positions (supination, neutral, 45 pronation, and full J Hand Surg Am.
5
Axial views A number of axial views can demonstrate further detail about the olecranon, the epicondyles, and the retrocondylar groove. In the olecranon process axial,5 the dorsum of the forearm is positioned on the cassette with the elbow maximally flexed. The beam is either perpendicular to the table or directed 20 r
Vol. -, - 2014
6
RADIOGRAPHIC EVALUATION OF THE ELBOW
FIGURE 19: Valgus gravity stress view shows medial collateral ligament avulsion fracture not seen on AP view.
will demonstrate bony changes or radiopaque spaceoccupying lesions about the retrocondylar groove. This view is obtained with the posterior arm contacting the cassette and the elbow in full flexion (as in the Jones position). The arm is then externally rotated 15 with the beam projecting perpendicularly from above. This provides an AP projection of the entire retrocondylar groove (Fig. 16). Finally, a valgus extension overload view can demonstrate osteophytes on the posteromedial or posterolateral aspects of the olecranon. It is obtained similar to a Jones AP flexion view; however, the beam is directed 20 toward the elbow from the perpendicular plane of the cassette. This captures an axial image of the far posteromedial and posterolateral compartments of the elbow (Fig. 17). It can demonstrate findings consistent with valgus extension overload8 as well as nonspecific degenerative changes.
FIGURE 17: Valgus extension overload axial view demonstrates degenerative findings in both the posteromedial and the posterolateral compartments.
Gravity stress view X-rays of the elbow while providing valgus stress can help to demonstrate instability, medial joint widening, and avulsion fractures of the medial coronoid often not seen on AP views. In this view, the patient is supine on the table with the arm abducted 90 from the body and the forearm supinated. The upper arm rests on the cassette while the remainder of the upper extremity is suspended over the edge (elbow straight) with the thumb pointing toward the floor. The cassette rests on the table posterior to the elbow. The beam is directed perpendicularly to the cassette (Fig. 18). In this view, the joint line can be assessed for widening or bony irregularity (Fig. 19).9
FIGURE 18: Demonstration of valgus gravity stress positioning.
toward the elbow for visualization of the olecranon and the articulation with the trochlea, the capitellum, and ulnar sulcus. The AP flexion or reverse axial olecranon (Jones position) view is obtained with the posterior aspect of the arm contacting the cassette and the elbow maximally flexed. The beam is directed perpendicularly from above. This view is often used during closed reduction in pediatric supracondylar humerus fractures (Fig. 15). A cubital tunnel view6,7 J Hand Surg Am.
r
Vol. -, - 2014
RADIOGRAPHIC EVALUATION OF THE ELBOW
DISCUSSION Standard and specialized views of the elbow can be very beneficial and, when used appropriately, will provide valuable clinical information during the evaluation of patients.
4. Guilbeau JC, Mouilhi MM, Nahum H. Modified profiles of the elbow in traumatology. The value of the radial headecapitellum view or a new coronoid-trochlea view [in French]. J Radiol. 1986;67: 439e444. 5. Jaquerriere P. The need to use a special radiographic technique to get some skeletal details [in French]. J Radiol Electr. 1918;3: 145e148. 6. St. John JN, Palmaz JC. The cubital tunnel in ulnar entrapment neuropathy. Radiology. 1986;158(1):119e123. 7. Wadsworth TG, Williams JR. Cubital tunnel external compression syndrome. Br Med J. 1973;1(5854):662e666. 8. Wilson FD, Andrews JR, Blackurn TA, McCluskey G. Valgus extension overload in the pitching elbow. Am J Sports Med. 1983; 11(2):83e88. 9. Schwab GH, Bennett JB, Woods GW, Tullos HS. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orthop Relat Res. 1980;146:42e52.
REFERENCES 1. Morrey BF. The Elbow and Its Disorders. Philadelphia: Saunders; 2009:92e100. 2. Coyle GF. Special angled views of joints—elbow, knee, ankle. Radiographing Immobile Trauma Patients. Denver: Multi-Media Publishing; 1980. 3. Greenspan A, Norman A. The radial headecapitellum view: useful technique in elbow trauma. AJR Am J Roentgenol. 1982;138(6):1186e1188.
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