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Commonly encountered radiographs during clerkship:. The Basics. Seng Thipphavong, PGY4 Department of Diagnostic Imaging. Objectives and Outline. To review the commonly encountered radiographs during clerkship, with a review of radiographic anatomy and disease entities Radiographs: - PowerPoint PPT Presentation
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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
