radio-ul, pelvic, ll

8/7/2019 radio-UL, pelvic, LL

1/132

NORMAL ANATOMY OFNORMAL ANATOMY OF

UPPER LIMBUPPER LIMB


2/132


3/132

Humerus and Shoulder

Joint


4/132


5/132


6/132

Shoulder joint

AP view

1. Clavicle

2. Acromion3. Greater

tubercle

4. Lessertubercle

5. Surgicalneck ofHumerus

6. Humerus

7. Coracoid

Process8. Lateral

border ofscapula

9. Rib


7/132

Shoulder joint:

Lateral View

1. CoracoidProcess

2. Clavicle

3. Acromion4. Head of

Humerus

5. Humerus

6. Lateral border

of scapula


8/132

Ulna, Radius and ElbowJoint


9/132


10/132


11/132

Elbow Joint

Anterior Posterior


12/132

Lateral


13/132

Lateral view: Extended

1. Humerus

2. Radius

3. Ulna

4. Olecranon Process of the Ulna

5. Lateral Epicondyle

6. Olecranon Fossa

Lateral view: Flexed

1. Humerus

2. Ra

dius3. Ulna

4. Olecranon process


14/132

Hand


15/132


16/132

Wrist Hand X-ray : AP view

1. Joint Between Radius and

Sca

phoid bone(Radiocarpal Joint)

2. Joint Between Trapezium

and First Metcarpal Bones

(carpometacarpal Joint).

3. First Meta

ca

rpopha

la

ngea

lJoint.

4. Interphalangeal Joint of

the Thumb.

5. Second metacarpo-

phalangeal joint.

6. Proximal inter-phallangeal

joint.

7. Distal inter-phallangeal

joint.


17/132

Wrist Joint


18/132


19/132

Radial length or height

-Measured on the PA radiograph

-A: distance between one line

perpendicular to the long axis of the

radius passing through the distal tip of

the ra

dia

l styloid.

-B: a line intersects distal articular

surface of ulnar head.

- Radius height: Distance between A and

B. This measurement averages 10-13 mm

Radial Length shortening results from

extensive comminution and impaction of

fracture fragments into the metaphysis.

A

B


20/132

Radial inclination or angle-Measured on the PA radiograph

- Angle between one line connecting the

radial styloid tip and the ulnar aspect of

the distal radius and a second line

perpendicular to the longitudinal axis of

the radius.

- The radial inclination ranges

between 21 -25.

-Loss of radial inclination will lead to

increased load across the lunate.-increase the risk of development of

chronic pain secondary to radio-lunate

joint osteoarthritis especially when there

is concomitant loss of dorsal inclination.


21/132

Radial tilt

- Measured on alateral radiograph

- Angle between a line along the distal

radial articular surface and the lineperpendicular to the longitudinal axis

of the radius at the joint margin

- The normal volar tilt averages 11

and has a range of2-20.


22/132

Normal Radiology of Pelvis


23/132

Anatomy

Bony pelvis consists of

1) Hip bones

Develop from fusion of 3 bones

ilium, ischium and pubis

2) Sacrum

Develop from fusion of5 sacral

vertebrae

3) Coccyx

Develop from fusion of4rudimentary coccygeal vertebrae

Ileum

Ischium

Pubis


24/132


25/132

Ra

dio-a

na

tomy of Pelvis


26/132

Antero-posterior (AP) view

Indications:

Primary survey of polytrauma patients

Suspected femur head fracture or dislocate

Congenital abnormalities

Degenerative disease

Carcinoma

Other pathologies e.g. Perthes disease,slipped femoral epiphyses


27/132

Evaluation Criteria of AP view pelvis:

1) L5, sacrum, coccyx, pelvic bone (ilium, ischium, pubis),

proximal femoral neck should be seen

2) No rotation: Symmetric appearance of the 2 obturator

foramen with symmetric iliac alae and ischial spines

3) Centering of radiograph: Both ilium, greater trochanter

equidistant to the edge of the radiograph and the lower

vertebral column centered to the middle

4) No motion: Clear pelvic structure


28/132


29/132

Important lines

On anteroposterior (AP) radiographs of pelvis,

7 major lines/structures should be considered:

Iliopectineal line

Ilioischial line

Teardrop

Dome

Anterior acetabular wall

Posterior acetabular wall

Shenton line


30/132

The teardrop sign is a landmark present in normal pelvic radiographs

* Absent of tear drop sign indicates:

a) acetabular fractures

b) patient is rotated


31/132


32/132


33/132

Paediatric Pelvis X ray

At birth, ilium, ischium & pubis joined with hyaline cartilage

In children, 3 bones are incompletely ossified & separated by Y-shaped triradiate cartilage

centered in acetabulum

Complete fusion occurred at 20-25 yo


34/132

Perkin's line is drawn vertically though the lateral most aspect of the acetabular roof,

perpendicular to Hilgenreiner's line (Horizontal line through the upper margin of

radiolucent triradiate or y cartilage.). The ossified femoral head should be located in

the inferomedial quadrant created.


35/132

Pelvic radiography veiw

Standard view :

AP Pelvis

Additional

Oblique view (Judet view)

Inlet/ outlet view

Frog lateral view

Groin lateral view


36/132

Judets view

-Patients is rotated with respect to cassette

-Cassette are approach through an AP approach

-Central ray is directed to the midpoint of pelvis-The opposite oblique would be obtained by

rotating the patient in opposite direction

Rt posterior oblique

Lt anterior oblique

***Judet views are basically 45 degree obliques of the affected hip.

***The 45 degree angle is best achieved by rolling the patient.


37/132

Rt posterior oblique (RPO)

Lt anterior oblique (LAO)

Right Post

Obliqueleft

anterior

Oblique

Indications:

Trauma especially for

fractures of the acetabulum


38/132

Normal anatomy: Columns and walls

The acetabulum

formed by anterior and posterior columnsof bone, which join

at the acetabular roof.

The anterior and posterior wallsextend from each respective

column and form the cup of the acetabulum.

The anterior and posterior columns connect to the axial

skeleton through a strut of bone called the sciatic buttress.

Anteroposterior and bilateral oblique (or Judet) views of the

pelvis are important to adequately assess each of the

radiographic lines for fracture


39/132

--Normal pelvic bone anatomy

Surface-rendering 3D CT of

pelvis in lateral view with

femur and right hemipelvisremoved shows anterior

column (green), posterior

column (blue), and sciatic

buttress (red).


40/132

Left Posterior Oblique View / Iliac


41/132

This demonstrates the posterior column and

anterior rim anatomy

PC

AR

ILIAC OBLIQUE VIEW


42/132


43/132

Left Anterior oblique view / obturator


44/132

This demonstrates the anterior column and posterior rim anatomy

AC

PR

OBTURATOR OBLIQUE VIEW


45/132

Lines of Judet on given radiographs:

AP radiograph (AP hip 1)

1. Iliopectineal (Iliopubic) line - this line represents the anterior column

2. Ilioischial line - this line represents the posterior column

3. Anterior lip of acetabulum - represents the anterior wall of the acetabulum

4. Posterior lip of acetabulum - represents the posterior wall of the acetabulum


46/132

Posterior Oblique (iliac) View radiograph

1. Ilioischial line - this line represents the posterior column2. Anterior lip of acetabulum - represents the anterior wall of the acetabulum



47/132

Anterior Oblique (obturator ) View radiograph1. Pelvic brim or Iliopectinial line - again, represents the anterior column

2. Anterior lip of acetabulum - represents the anterior wall of the acetabulum



48/132

Right Anterior oblique view


49/132

Pelvic Inlet View

allows the surgeon to view

anteroposterior displacement of the

hemipelvis.

Indication:

pelvic brim fracture,pubic rami fractures

caudal angulation

pubic rami image The inlet view is taken with the patient supine

and the x-ray tube angled 45 degrees caudal

and perpendicular to the pelvic brim


50/132

Inlet view:

demonstra

tes ring configura

tion of pelvis,narrowing or widening of diameter of ring

evaluates for posterior displacement of pelvic

ring or opening of pubic symphysis;

Rotation of hemipelvis


51/132

No rotation;

Evidence byPresence of

Ischial spine

Arrow shows

Fracture ofPelvic ring


52/132

Lateral compression injury as seen on an inlet radiograph of the pelvis.

The fractures of the left sacrum (long arrow) and left pubic rami (short

arrows) are shown.


53/132

Pelvic Outlet View

allows evaluation of superior and inferior

displacement of the hemipelvis.

Indication:

pelvic brim fracture,pubic rami fractures

cephalic

angulation pubic

rami view image patient in the true AP position and the

tube is angled 45 degrees cephalic.


54/132

outlet view

demonstrate the magnitude of vertical(cranial) displacement of the hemipelvis.

Additionally, some sacral and pubic rami

fractures are better visualized with the

outlet view than with other views


55/132

Vertical shear injury as seen on an outlet radiograph of the pelvis. The vertical

(cranial) displacement of the left hemipelvis and pubic symphysis is better visualized

by using the outlet view. In addition, a left iliac fracture is more readily apparent

(large arrows). Left sacroiliac joint diastasis is seen (small arrow).


56/132


57/132

Hip Joint


58/132

Look for:

1. Joint space

2. Femoral head:

shape, regularity

3. Shentons line

Smooth curve from

superior pubic

ramus to femoral

neck

Distorted in # &

subluxations

4. Neck-shaft angle


59/132


60/132

Groin Lateral view

Anatomy

Demonstrated

Femoral head and

neck, acetabulum

Indication:

-congenital abnormality-trauma

-degenerative disease

-carcinoma

-other pathologies e.g Perthes

disease, slipped femoral

epiphyses

L l Vi


61/132

Lateral View


62/132

Frog Lateral view

** do not order a frog leg lateral

in any patient suspected of

having hip fracture or

dislocation);


63/132

patient is supine w/ knees flexed, soles of

feet together, and the thighs maximally

abducted;

central beam is directed vertically or with

a 10 to 15 deg cephalic tilt to a point

slightly above pubic symphysis;

Indications for imaging

Congenital abnormalities, Perthes disease,

slipped femoral epiphyses


64/132

Anatomy Demonstrated

Femoral heads and necks, acetabulum

1. Lesser trochanter is

clearly visible

2. Angle of femoralneck cannot be

access

Adult Hip - Rolled Lateral


65/132

Slipped capital femoral epiphysis. Image of a 14-year-old male adolescent who

came to the emergency department with complaints of thigh and knee pain .A

more obvious posterior slip is noted on this frog-leg lateral view.


66/132

MRI and CT scan

MRI and CT of the pelvis is the technique of

choice for evaluating complex fracture

patterns, degree of displacement and soft

tissue injury


67/132

Indication for CT scan of pelvic Diagnose and monitor cancer

Diagnose the cause of pelvic pain

Evaluate after trauma to the pelvis

Evaluate a pelvic mass found during a physical exam

Guide a surgeon to the right area during a biopsy or other procedures

Help the health care provider plan for and evaluate the results of

surgery

Plan and deliver radiation treatment for cancer


68/132

Pelvis


69/132

Normal Anatomy

Radiology of Lower Limb


70/132

Views of X-ray ofLower Limb

Femur

AP Proximal

AP Distal

Lateral Proximal

La

tera

l Dista

l Knee

AP

Rolled Lateral

Skyline

Intercondylar

Tibia/Fibula

AP

Lateral

Ankle

AP

Mortise

Lateral

Foot

DP view (dorsiplantar) Oblique

Lateral

Weight bearing view

Calcaneum

Lateral

Axial

Toes

AP

Oblique


71/132

Adult femur

AP proximalview


72/132

Adult femur

AP distal view


73/132

Adult femur Lateralproximal view


74/132

Adult femur

La

tera

l dista

l view

Ad l k


75/132

Adult knee

AP view


76/132

Adult knee Rolled

lateral view


77/132

Adult knee Skyline view


78/132

- Taken with the knee flexed 30

- Look between the patellaand the femur

- There should be a consistent gap between the 2 bones

- Used to diagnose knee OA and patellar fracture

Adult knee Intercondylar view


79/132

Adult knee Intercondylar view


80/132

Hip and knee joint flexed 90 degrees . The beam projects 20 degrees to the

longitudinal axis of the femur posteroanteriorly


81/132

Adult Tib/Fib

AP view


82/132

Adult Tib/Fib

Lateral view

Adult ankle


83/132

Adult ankle

AP view


84/132

Adult ankle

Mortise view

-Taken with the

ankle internally

rotated 15 to 20 deg

- This bring the fibulaaround out to the

tibia

- The X ray beam is

nearly perpendicular

to the intermalleolar

line

- Allow us to assess

the lateral clear

space


85/132

Assess the congruence pf Mortise and look for evidence of talar shift due to

bony or ligamentous injury


86/132

- To assess syndesmotic integrity

-A syndesmosis joint connects 2 bones thru the connective tissue

- The tibia-fibula syndesmosis allows the 2 bones to work in unison

as part of the lower leg

Adult ankle


87/132

Adult ankle

Lateral view


88/132

Bohlers angle

A line is drawn from the superioraspect of the anterior process tothe superior aspect of theposterior facet. A second line isdrawn from the superior aspect ofthe posterior facet to the superior

most point of the calcanealtuberositymeasures height of theposterior facet;

normal range is 20-40 deg, hencecomparison views of oppositecalcaneus can be helpful;

in most cases, a decrease Bohler'sangle implies fracture anddisrupted of the posterior facet;


89/132

Adult foot


90/132

Adult foot

Oblique view


91/132

Adult foot Lateral view


92/132

Adult foot Lateral weight bearing view


93/132

Adult calcaneum Lateral view


94/132

Adult calcaneum Axial view

Adult toes


95/132

Adult toes

- AP


96/132

Adult toes- Oblique


97/132

Cross Sectional of Thigh


98/132

#1 femur#2 rectus femoris muscle

#3 sartorius muscle

#4 femoral artery

#5 adductor longus muscle

#6 gracilis muscle

#7 adductor brevis muscle

#8 adductor magnus muscle#9 vastus intermedius muscle

#10 vastus lateralis muscle

#11 lateral intermuscular septum

#12 gluteus maximus muscle

#13 sciatic nerve

#14 biceps femoris muscle

#15 semitendinosus muscle#16 semimembranosus muscle


99/132


100/132

#1 femur#2 vastus medialis

#3 tendon of quadriceps muscle

#4 vastus intermedius muscle

#5 vastus lateralis

#6 short head of biceps femoris

muscle

#7 long head of biceps femoris#8 semitendinosus

#9 semimembranosus

#10 gracilis

#11 sartorius

#12 popliteal artery

#13 popliteal vein

#14 great saphenous vein


101/132

#1 femur#2 vastus lateralis

#3 biceps femoris

#4 common peroneal nerve

#5 tibial nerve

#6 popliteal artery

#7 popliteal vein

#8 semimembranosus#9 semitendinosus

#10 gracilis

#11 sartorius

#12 vastus medialis

#13 articular muscle of the knee

#14 great saphenous ve


102/132


103/132

#1 femur#2 patella

#3 medial patellar retinaculum

#4 lateral patellar retinaculum

#5 iliotibular tract


#7 common peroneal nerve

#8 lateral head of gastrocnemius#9 popliteal artery

#10 popliteal vein

#11 tibial nerve

#12 semimembranosus

#13 medial head of

gastrocnemius

#14 sartorius#15 great saphenous vein


104/132

#1 femur#2 medial condyle of femur

#3 lateral condyle of femur

#4 anterior cruciate ligament

#5 posterior cruciate ligament

#6 popliteal artery

#7 popliteal vein

#8 medial head of gastrocnemius#9 lateral head of gastrocnemius

#10 plantaris muscle


#12 tendon of

semimembranosus muscle

#13 sartorius

#14 great saphenous vein


105/132

Septic ArthritisSeptic Arthritis

INTRODUCTIONINTRODUCTION


106/132

INTRODUCTIONINTRODUCTION

Septic arthritis is inflammation of a synovialSeptic arthritis is inflammation of a synovial

membrane with purulent effusion into jointmembrane with purulent effusion into joint

capsule.capsule.

Usually due to bacterial infection.Usually due to bacterial infection.

typically affects monoarticular joints.typically affects monoarticular joints.

Imaging studies :Imaging studies :


107/132

g gg g

1) Plain radiography1) Plain radiography

-- often normaloften normal

-- early stageearly stage--soft tissue swelling around the joint,soft tissue swelling around the joint,wideningwidening

of joint spaceof joint space and displacement of tissue planesand displacement of tissue planes

-- later stagelater stage bony erosions and joint spacebony erosions and joint space

narrowingnarrowing

2) Ultrasonography2) Ultrasonography

-- reveal joint effusionreveal joint effusion

-- can be used to define the extent of septiccan be used to define the extent of septic

arthritis and help guide treatmentarthritis and help guide treatment

Conventional Radiography forConventional Radiography for


108/132

g p yg p y

Infectious ArthritisInfectious Arthritis

Modality of choice for initial evaluation of suspected joint infectionsModality of choice for initial evaluation of suspected joint infections

Diagnosis can be made when characteristic findings areDiagnosis can be made when characteristic findings arepresentpresent

Early plain film findings:Early plain film findings:

Soft tissue swellingSoft tissue swelling

HazzinessHazziness Synovial thickeningSynovial thickening

Joint effusionJoint effusion--increase in joint spaceincrease in joint space

Joint space lossJoint space loss Later plain film findings:Later plain film findings:

Periosteal reactionPeriosteal reaction

Marginal and central erosions & destruction of subchondralMarginal and central erosions & destruction of subchondralbonebone

Subluxation or dislocationSubluxation or dislocation

IntraIntra--articular bony ankylosisarticular bony ankylosis


109/132


110/132

During the

progression of

infectious arthritis

of the hip, thisimage was

obtained early in

the disease and

shows only joint-

space loss.


111/132

During theprogression of

infectious

arthritis,

subchondralerosions and

sclerosis of the

femoral head are

present


112/132

Late stage

osteonecrosis

and complete

collapse of the

femoral head

are present.

SA of Left Shoulder


113/132

SA of Left Shoulder

Soft tissue swelling &

destructive metaphyseal

changes

One month later :

Dislocation of the left

shoulder

Soft tissue swelling


114/132

Bony destruction

Sclerosis


115/132

SA of the metacarpophalangeal joint following penetrating injury to the

fist on striking a tooth.

bony resorption


116/132

Soft tissue swelling with

soft-tissue air

Destructive focus in the medial humeral metaphysis

Destruction around the glenoid

fossa

Hip irregularity of the joint surface & narrowing

of the joint space


117/132

destructive focus in

the femoral head

marked osteoporosis of

prox femur.


118/132

Osteoporosis of prox femur

Destruction of femoral

head

Reactive sclerosis at the femoralneck n superior aspect of

acetabulum


119/132


120/132

89/ Malay/ Female

c/o axillary swelling and right knee swelling

for past few months.

Known case of peripheral nerve sheath tumor


121/132

Teenage, developed skin infection at anterior

of left leg, upper shin near to knee joint

Redness, discharge, pain

Single lesion

Chronic discharge for months, bone pain and

fever

No h/o trauma, fracture

Proximal (knee) and distal ( ankle) joint were not

involved No pain

No reduced ROM

No swollen


122/132

Then the discharge reduced in amount and

eventually ceased, but the hole persist

(sinus)

Examination of the sinus

- At left anterior shin, near to knee join

- Single sinus, no active discharge, no

bleeding, no surrounding redness, noincreased warmth

- Impression : an old well healed sinus

-radio-opaque

area at proximal1/3 of tibia


123/132

-cortical

thinkening-no sequestra,

no involucrum


124/132


125/132

31yo malay gentleman

Left tibial opened fracture 2years ago

External fixation done internal fixation

3/12 ago : leg swollen, painful, still able towalk

3/52 ago : ulcers with serous discharge,

painful, a/w fever,malaise

Metal seen at left tibial- exposed plate


126/132

Several scar on left leg, swollen

One ulcer with metal seen exposed plate

2 sinus with pus and discharge

Inflammed surrounding skin, tender, warmMovement : not affected

Sensory intact

Peripheral Pulse present.


127/132


128/132

-plating at left distaltibial with malelleousplate

-4 loosened nail(3 arebroken), evidenced by

translucency around the

nail-The lower nails are not

loosened

-Callus OR involucrum-Fracture line seen

(could be new fracture

d/t bone infection ornon-union of previous

fracture)


129/132

case


130/132

A 15yo indian boy presented with right thigh painfor 2 months

It was prickling in nature, not relieved byanalgesic and cause restricted range of

movement It was also associated with the swelling in his

right thigh which was gradually increased in size.

Patient also complaint of numbness of the right

leg +lethargic, +LOW, +LOA, +fever

Physical examination


131/132

Physical examination

Thin built boy, but no obvious muscle wasting Alert and conscious, not in pain

Vital signs were normal

There was a swelling noted at his right thigh

o Round

o

Around 15

X15

cmo No skin changes such as sinus

o tender

o Firm to hard

o Smooth surface

o Well-defined margin

o Not mobileo Transillumination test was negative

Restricted knee joints ROM

Neurovascular examination was unremarkable

Investigation


132/132

Investigation

Blood

o FBC

o BUSE

Imaging

o X-ray of the right thigh

o MRI of the right thigh

o CXR

radio-ul, pelvic, ll

Documents