Dr. Suraj Achar MD - 5-Minute Sports Medicine Consult

Ultrasound (US) is an ideal inexpensive way of assessing superficial soft tissues for both trauma and masses. It has the distinct advantage of being dynamic, imaging the patient in real time as they move, and also being interactive with the patient, assessing their points of pain. Magnetic resonance imaging (MRI) is a useful method for assessing the soft tissues for injury or mass, the bones for occult injuries, and bone marrow changes. UPPER EXTREMITIES FINGERS For 2nd to 5th digits. Specifically to look at one finger for trauma, foreign body, or localized mass. A marker should be applied, particularly on the lateral projection.

Consider US for radiolucent foreign body. Consider MRI or US for mass or tendon lesion/injury. FIGURE 1. A: PA hand. B: Oblique of fingers. C, D: Lateral of fingers.

THUMB Specifically to look at the thumb for trauma, foreign body, or localized mass. Good for ulnar collateral ligament (UCL) avulsion. A marker should be applied. Consider US for radiolucent foreign body. Consider MRI or US for mass, UCL injury (without or with Stener lesion) or tendon lesion/injury. Stress views are no longer encouraged for acute UCL injury for fear of converting to a Stener lesion but may be useful later on to assess stability.

Musculoskeletal Radiography FIGURE 2. A: PA hand. B: PA thumb. C: Lateral thumb. HAND Routine This includes an off-axis view of the wrist but should not be used to assess wrist alignment. Good overview for hand pain.

May need additional wrist views if pain is proximal or difficult to localize. Important to have fingers spread on lateral view so that all volar plates are well visualized. MRI or US may be useful adjuncts to look at adjacent soft tissues. FIGURE 3. A: PA of hand. B: Oblique of hand.

C: Lateral of hand. HAND Arthritis Survey Some centers prefer pronated obliques over supinated ball catcher (Norgaard) obliques. Both of these are good for overall assessment of arthritis, individual erosions, soft tissue swelling, and distribution. MRI and US are useful adjuncts to assess the soft tissues, for synovitis joint fluid, and are said to be more sensitive for erosions. FIGURE 4. A, B: PA of each hand.

C: AP Norgaard projection (ball-catchers position). WRIST Nontrauma, Infection For typical wrist pain evaluations, including arthritis or mass. Good for carpal alignment. US: good for soft tissue masses, tendon pathology. CT scan may be a useful adjunct to assess for occult scaphoid fractures and for healing as well as other occult injuries, such as hook of hamate fracture. CT is often used in the preoperative workup of intra-articular distal radial fractures.

MRI is good for occult fractures, Kienbck disease, avascular necrosis (AVN) of lunate or scaphoid, triangular fibrocartilage tears, or intercarpal ligament injuries. FIGURE 5. A: PA wrist. B: Ulnar oblique wrist. C: Lateral wrist. Trauma Additional scaphoid views include oblique and ulnar deviation with cranial angulation.

These are good to assess for most aspects of trauma, including fracture, subluxation, or dislocation. Of note, the lateral view can only be used to assess alignment when the volar aspect of the pisiform projects between the scaphoid and capitate. MRI is a useful adjunct to assess for occult injury, intercarpal ligament injury, triangular fibrocartilage complex injury, mass, or synovitis. FIGURE 6. A: PA wrist. B: Ulnar oblique wrist.

C: Radial oblique wrist. D: Lateral wrist. E: Navicular view. Additional Views Clenched fist views taken anteroposterior (AP) are useful for occult cases of scapholunate ligament disruption. Clenching the fist pushes the carpal bones apart. Carpal tunnel view is good for looking for hook of hamate, trapezial ridge fractures, or carpal tunnel syndrome posttrauma/wrist fracture.

CT is another good way to assess for occult carpal fractures. MRI without or with intra-articular dilute gadolinium is good to assess for internal derangement. FIGURE 7. A: Clenched fist. B: Carpal tunnel views. FOREARM Good for trauma, mass, foreign body, cellulitis/osteomyelitis, or abscess.

It is important that the elbow rotates through 90 degrees between the AP and lateral so that two identical views of the ulna are not obtained. Consider US or MRI to assess for mass or soft tissue injury. FIGURE 8. A: AP forearm. B: Lateral forearm. ELBOW Nontrauma Chronic injuries, arthritis, foreign bodies, and infection.

Lateral is good for effusion and olecranon bursitis. AP is good for epicondylar enthesopathy and osteophytes. Consider US or MRI for soft tissue mass. FIGURE 9. A: AP elbow. B: Lateral elbow.

Trauma Good to assess for otherwise occult radial head fractures. Often, AP, lateral, and radial head are enough for trauma. US or MRI can assess for ligamentous or tendon injuries. FIGURE 10. A: AP. B: Lateral.

C: Lateral (external or radial) oblique. D: Medial (internal or ulnar) oblique. E: Radial head view. Additional Views Good to assess for radio opaque causes of cubital tunnel syndrome, such as osteophytes. Consider US or MRI for further assessment of cubital tunnel.