Commonly encountered radiographs during clerkship:

Commonly Commonly encountered encountered

radiographs during radiographs during clerkship:clerkship:

The Basics

Seng Thipphavong, PGY4

Department of Diagnostic Imaging

Objectives and OutlineObjectives and Outline

To review the commonly To review the commonly encountered radiographs during encountered radiographs during clerkship, with a review of clerkship, with a review of radiographic anatomy and disease radiographic anatomy and disease entitiesentities

Radiographs:Radiographs:– The Chest RadiographThe Chest Radiograph– The Abdominal RadiographThe Abdominal Radiograph– Miscellaneous Radiographs…Miscellaneous Radiographs…

The Chest The Chest RadiographRadiograph

1.1. AnatomyAnatomy

2.2. Cases (3)Cases (3)

trachea

clavicle

SVC

right atrium

left ventricle

left atrial appendage

main pulmonary artery

aortopulmonary window

aortic arch

right hemidiaphragm left

hemidiaphragm

AnatomyAnatomy

AnatomyAnatomy

IVC

right heart chambers

right pulmonary artery

retrosternal airspace

trachea

left heart chambers

left pulmonary artery

Case 1Case 1

69 y.o. female presents with 69 y.o. female presents with shortness of breathshortness of breath

Case 1Case 1

Case 1Case 1

peribronchial cuffing

Kerley B lines

Pulmonary edemaPulmonary edema

Radiographic signs of pulmonary Radiographic signs of pulmonary edema? (5)edema? (5)– Enlarged cardiac silhouetteEnlarged cardiac silhouette– Kerley B lines (fluid in the interlobular Kerley B lines (fluid in the interlobular

septae)septae)– Peribronchial cuffingPeribronchial cuffing– Indistinctness of the pulmonary vesselsIndistinctness of the pulmonary vessels– Pleural effusionPleural effusion

Case 2Case 2

69 y.o. with fever and cough69 y.o. with fever and cough

Case 2Case 2

Case 2Case 2

Air bronchograms

Case 2Case 2

Findings of pneumonia on radiograph?Findings of pneumonia on radiograph?– Consolidation (white) and air Consolidation (white) and air

bronchogramsbronchograms How are pneumonia and atelectasis How are pneumonia and atelectasis

similar on radiograph?similar on radiograph?– Both are whiteBoth are white

How are pneumonia and atelectasis How are pneumonia and atelectasis different on radiograph?different on radiograph?– Look for air bronchogramsLook for air bronchograms– Atelectasis will have signs of volume lossAtelectasis will have signs of volume loss

Case 3Case 3

69 y.o. with chest pain69 y.o. with chest pain

Case 3Case 3

Case 3Case 3

Visceral pleura

Case 3Case 3

Causes of pneumothorax?Causes of pneumothorax?– Numerous! Numerous!

Treatment?Treatment?– UrgentUrgent– Chest tubeChest tube– 25 G needle 225 G needle 2ndnd intercostal space intercostal space

Companion CaseCompanion Case

Case 3Case 3

Deep sulcus sign?Deep sulcus sign?– pneumothorax on supine filmspneumothorax on supine films– especially seen in ICU patientsespecially seen in ICU patients

The Abdominal The Abdominal RadiographRadiograph

1.1. AnatomyAnatomy

2.2. Cases (3)Cases (3)

AnatomyAnatomyRight kidney

Air in descending colon

Left psoas

Left kidney

Properitoneal fat

Hepatic angle

Case 1Case 1

69 y.o. with abdominal pain69 y.o. with abdominal pain

Case 1Case 1

Case 1Case 1

What films are obtained in a conventional What films are obtained in a conventional abdominal series?abdominal series?– Supine and upright abdomen, chest radiographSupine and upright abdomen, chest radiograph

What are the 4 cardinal symptoms of small What are the 4 cardinal symptoms of small bowel obstruction?bowel obstruction?– Nausea, vomiting, abdominal distension, Nausea, vomiting, abdominal distension,

obstipationobstipation What are the causes of SBO?What are the causes of SBO?

– Adhesions, hernia, stricture, neoplasm, Adhesions, hernia, stricture, neoplasm, gallstone ileusgallstone ileus

Companion CaseCompanion Case

Case 1Case 1

What are the signs of SBO on What are the signs of SBO on radiograph?radiograph?– Dilated and fluid filled loops, “step-Dilated and fluid filled loops, “step-

ladder” appearanceladder” appearance What is the difference between ileus What is the difference between ileus

and SBO?and SBO?– SBO indicates mechanical obstructionSBO indicates mechanical obstruction– Ileus is an adynamic state (“bowel shuts Ileus is an adynamic state (“bowel shuts

down”)down”)

Case 2Case 2

69 y.o. with abdominal pain69 y.o. with abdominal pain

Case 2Case 2

Case 2Case 2

Cupola sign

Football sign

Case 2Case 2

Signs of free intraperitoneal air on upright Signs of free intraperitoneal air on upright radiograph?radiograph?– Air under the diaphragmAir under the diaphragm

Signs of free intraperitoneal air on supine Signs of free intraperitoneal air on supine radiograph?radiograph?– ““football sign”, football shaped lucency central football sign”, football shaped lucency central

abdomenabdomen– ““cupola sign”, free air in the mid-subphrenic cupola sign”, free air in the mid-subphrenic

spacespace What is Rigler’s sign?What is Rigler’s sign?

– Free air outlining both sides of bowelFree air outlining both sides of bowel

Companion caseCompanion case

Companion caseCompanion case

Rigler’s sign

Case 2Case 2

What are the 2 most common reasons What are the 2 most common reasons to see free intraperitoneal air?to see free intraperitoneal air?– Post-operative or perforated duodenal ulcerPost-operative or perforated duodenal ulcer

Is free air commonly seen on radiograph Is free air commonly seen on radiograph from perforated diverticulitis?from perforated diverticulitis?– No. No. – Why?Why?

the omenteum usually contains the air, and is the omenteum usually contains the air, and is not seen on radiographnot seen on radiograph

Case 3Case 3

69 y.o. with abdominal pain69 y.o. with abdominal pain

Case 3Case 3

Case 3Case 3

What are the signs of large bowel What are the signs of large bowel obstruction?obstruction?– Dilated large bowel proximal to the site Dilated large bowel proximal to the site

of obstructionof obstruction– Paucity of air distal to obstructionPaucity of air distal to obstruction

What are the most common causes What are the most common causes of large bowel obstruction?of large bowel obstruction?– Colon Ca, stricture (post-inflammatory Colon Ca, stricture (post-inflammatory

diverticulitis or IBD), volvulus diverticulitis or IBD), volvulus

The Miscellaneous The Miscellaneous RadiographRadiograph

Cases (4)Cases (4)

Case 1Case 1

69 y.o. in a fight69 y.o. in a fight

Case 1Case 1

Case 1Case 1

What is a Boxer’s fracture?What is a Boxer’s fracture?– Fracture of the 5Fracture of the 5thth metacarpal metacarpal

Potential complications of a Boxer’s Potential complications of a Boxer’s fracture?fracture?– Metacarpal shorteningMetacarpal shortening– Usually the distal fragment is rotated in Usually the distal fragment is rotated in

a radial direction, and may heal with a radial direction, and may heal with deformitydeformity

Wrist and hand anatomyWrist and hand anatomyDistal phalynx

DIP joint

Middle phalynx

Proximal phalynx

Metacarpal

Distal ulna

PIP joint

MCP joint

Sesamoid

CMC joint

Distal radius

Wrist anatomyWrist anatomy

pisiform

lunate

capitatetrapezium

triquetrumscaphoid

trapezoidhamate

Companion caseCompanion case

Case 2Case 2

69 y.o. who fell69 y.o. who fell

Case 2Case 2

Case 2Case 2

Case 2Case 2

What is the classic clinical What is the classic clinical presentation for a hip fracture?presentation for a hip fracture?– Shortened lower extremity and external Shortened lower extremity and external

rotationrotation

Pelvic anatomyPelvic anatomyIliac crest

SI jointSacral ala

Femoral neck

Ischial tuberosity

Obturator foramenInferior pubic ramus

Pubic symphysis

Superior pubic ramus

Iliopectineal line Greater

trochanter

Lesser trochanter

Femoral head

Case 3Case 3

69 y.o. who fell69 y.o. who fell

Case 3Case 3

Case 3Case 3

What are the 3 radiographs that are What are the 3 radiographs that are obtained with an ankle series?obtained with an ankle series?– AP, lateral, ankle mortice viewAP, lateral, ankle mortice view

How is the ankle mortice view How is the ankle mortice view obtained?obtained?– Internal rotation 15 degreesInternal rotation 15 degrees

What does the ankle mortice view tell What does the ankle mortice view tell you clinically?you clinically?– Ankle joint stability!Ankle joint stability!

Ankle and foot anatomyAnkle and foot anatomy

2nd cuneiform

Talus Navicular

3rd cuneiform1st cuneiform

Sesamoid

Proximal phalynx

Calcaneus

Cuboid

metatarsal

Case 4Case 4

69 y.o. who fell69 y.o. who fell

Case 4Case 4

Case 4Case 4

Where is the position of the humerus Where is the position of the humerus in an anterior dislocation?in an anterior dislocation?– Anterior!, and inferiorAnterior!, and inferior

What is a Bankart lesion?What is a Bankart lesion?– Impaction fracture at inferior glenoid rimImpaction fracture at inferior glenoid rim

What is a Hill-Sachs lesion?What is a Hill-Sachs lesion?– Impaction fracture at the superolateral Impaction fracture at the superolateral

aspect of the humeral headaspect of the humeral head

Case 4Case 4

Which is more common, anterior or Which is more common, anterior or posterior dislocations?posterior dislocations?– Anterior (90%)Anterior (90%)

What are the causes of posterior What are the causes of posterior shoulder dislocations?shoulder dislocations?– Ethanol, epilepsy, electrocutionEthanol, epilepsy, electrocution

Shoulder anatomyShoulder anatomy

Acromium

Anatomical neck

Greater tuberositySurgical neck of humerus

Glenoid

Scapula

Coracoid

Clavicle

AC joint

End!End!

Questions?Questions?

Email:Email:– sthip028@uottawa.casthip028@uottawa.ca