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Commonly encountered radiographs during clerkship: The Basics Seng Thipphavong, PGY4 Department of Diagnostic Imaging Slide 2 Objectives and Outline To review the commonly encountered radiographs during clerkship, with a review of radiographic anatomy and disease entities To review the commonly encountered radiographs during clerkship, with a review of radiographic anatomy and disease entities Radiographs: Radiographs: The Chest Radiograph The Abdominal Radiograph Miscellaneous Radiographs Slide 3 The Chest Radiograph 1. Anatomy 2. Cases (3) Slide 4 trachea clavicle SVC right atrium left ventricle left atrial appendage main pulmonary artery aortopulmonary window aortic arch right hemidiaphragm left hemidiaphragmAnatomy Slide 5 Anatomy IVC right heart chambers right pulmonary artery retrosternal airspace trachea left heart chambers left pulmonary artery Slide 6 Case 1 69 y.o. female presents with shortness of breath 69 y.o. female presents with shortness of breath Slide 7 Case 1 Slide 8 peribronchial cuffing Kerley B lines Slide 9 Pulmonary edema Radiographic signs of pulmonary edema? (5) Radiographic signs of pulmonary edema? (5) Enlarged cardiac silhouette Kerley B lines (fluid in the interlobular septae) Peribronchial cuffing Indistinctness of the pulmonary vessels Pleural effusion Slide 10 Case 2 69 y.o. with fever and cough 69 y.o. with fever and cough Slide 11 Case 2 Slide 12 Air bronchograms Slide 13 Case 2 Findings of pneumonia on radiograph? Findings of pneumonia on radiograph? Consolidation (white) and air bronchograms How are pneumonia and atelectasis similar on radiograph? How are pneumonia and atelectasis similar on radiograph? Both are white How are pneumonia and atelectasis different on radiograph? How are pneumonia and atelectasis different on radiograph? Look for air bronchograms Atelectasis will have signs of volume loss Slide 14 Case 3 69 y.o. with chest pain 69 y.o. with chest pain Slide 15 Case 3 Slide 16 Visceral pleura Slide 17 Case 3 Causes of pneumothorax? Causes of pneumothorax? Numerous! Treatment? Treatment? Urgent Chest tube 25 G needle 2 nd intercostal space Slide 18 Companion Case Slide 19 Case 3 Deep sulcus sign? Deep sulcus sign? pneumothorax on supine films especially seen in ICU patients Slide 20 The Abdominal Radiograph 1. Anatomy 2. Cases (3) Slide 21 Anatomy Right kidney Air in descending colon Left psoas Left kidney Properitoneal fat Hepatic angle Slide 22 Case 1 69 y.o. with abdominal pain 69 y.o. with abdominal pain Slide 23 Case 1 Slide 24 What films are obtained in a conventional abdominal series? What films are obtained in a conventional abdominal series? Supine and upright abdomen, chest radiograph What are the 4 cardinal symptoms of small bowel obstruction? What are the 4 cardinal symptoms of small bowel obstruction? Nausea, vomiting, abdominal distension, obstipation What are the causes of SBO? What are the causes of SBO? Adhesions, hernia, stricture, neoplasm, gallstone ileus Slide 25 Companion Case Slide 26 Case 1 What are the signs of SBO on radiograph? What are the signs of SBO on radiograph? Dilated and fluid filled loops, step-ladder appearance What is the difference between ileus and SBO? What is the difference between ileus and SBO? SBO indicates mechanical obstruction Ileus is an adynamic state (bowel shuts down) Slide 27 Case 2 69 y.o. with abdominal pain 69 y.o. with abdominal pain Slide 28 Case 2 Slide 29 Cupola sign Football sign Slide 30 Case 2 Signs of free intraperitoneal air on upright radiograph? Signs of free intraperitoneal air on upright radiograph? Air under the diaphragm Signs of free intraperitoneal air on supine radiograph? Signs of free intraperitoneal air on supine radiograph? football sign, football shaped lucency central abdomen cupola sign, free air in the mid-subphrenic space What is Riglers sign? What is Riglers sign? Free air outlining both sides of bowel Slide 31 Companion case Slide 32 Riglers sign Slide 33 Case 2 What are the 2 most common reasons to see free intraperitoneal air? What are the 2 most common reasons to see free intraperitoneal air? Post-operative or perforated duodenal ulcer Is free air commonly seen on radiograph from perforated diverticulitis? Is free air commonly seen on radiograph from perforated diverticulitis? No. Why? the omenteum usually contains the air, and is not seen on radiograph Slide 34 Case 3 69 y.o. with abdominal pain 69 y.o. with abdominal pain Slide 35 Case 3 Slide 36 What are the signs of large bowel obstruction? What are the signs of large bowel obstruction? Dilated large bowel proximal to the site of obstruction Paucity of air distal to obstruction What are the most common causes of large bowel obstruction? What are the most common causes of large bowel obstruction? Colon Ca, stricture (post-inflammatory diverticulitis or IBD), volvulus Slide 37 The Miscellaneous Radiograph Cases (4) Slide 38 Case 1 69 y.o. in a fight 69 y.o. in a fight Slide 39 Case 1 Slide 40 What is a Boxers fracture? What is a Boxers fracture? Fracture of the 5 th metacarpal Potential complications of a Boxers fracture? Potential complications of a Boxers fracture? Metacarpal shortening Usually the distal fragment is rotated in a radial direction, and may heal with deformity Slide 41 Wrist and hand anatomy Distal phalynx DIP joint Middle phalynx Proximal phalynx Metacarpal Distal ulna PIP joint MCP joint Sesamoid CMC joint Distal radius Slide 42 Wrist anatomy pisiform lunate capitate trapezium triquetrum scaphoid trapezoidhamate Slide 43 Companion case Slide 44 Case 2 69 y.o. who fell 69 y.o. who fell Slide 45 Case 2 Slide 46 Slide 47 What is the classic clinical presentation for a hip fracture? What is the classic clinical presentation for a hip fracture? Shortened lower extremity and external rotation Slide 48 Pelvic anatomy Iliac crest SI joint Sacral ala Femoral neck Ischial tuberosity Obturator foramen Inferior pubic ramus Pubic symphysis Superior pubic ramus Iliopectineal line Greater trochanter Lesser trochanter Femoral head Slide 49 Case 3 69 y.o. who fell 69 y.o. who fell Slide 50 Case 3 Slide 51 What are the 3 radiographs that are obtained with an ankle series? What are the 3 radiographs that are obtained with an ankle series? AP, lateral, ankle mortice view How is the ankle mortice view obtained? How is the ankle mortice view obtained? Internal rotation 15 degrees What does the ankle mortice view tell you clinically? What does the ankle mortice view tell you clinically? Ankle joint stability! Slide 52 Ankle and foot anatomy 2 nd cuneiform Talus Navicular 3 rd cuneiform 1 st cuneiform Sesamoid Proximal phalynx Calcaneus Cuboid metatarsal Slide 53 Case 4 69 y.o. who fell 69 y.o. who fell Slide 54 Case 4 Slide 55 Where is the position of the humerus in an anterior dislocation? Where is the position of the humerus in an anterior dislocation? Anterior!, and inferior What is a Bankart lesion? What is a Bankart lesion? Impaction fracture at inferior glenoid rim What is a Hill-Sachs lesion? What is a Hill-Sachs lesion? Impaction fracture at the superolateral aspect of the humeral head Slide 56 Case 4 Which is more common, anterior or posterior dislocations? Which is more common, anterior or posterior dislocations? Anterior (90%) What are the causes of posterior shoulder dislocations? What are the causes of posterior shoulder dislocations? Ethanol, epilepsy, electrocution Slide 57 Shoulder anatomy Acromium Anatomical neck Greater tuberosity Surgical neck of humerus Glenoid Scapula Coracoid Clavicle AC joint Slide 58 End! Questions? Questions? Email: Email: sthip028@uottawa.ca