farfalla education llc radiology...

RADIOLOGY

OVERVIEW

Theresa M Campo DNP, APRN, NP-C, CEN

Farfalla Education LLC

Disclaimer

• Farfalla Education, LLC

• Owner and Primary Lecturer

• ALL patient information has been protected to the best of

my ability.


The Basics

• Anatomy and Physiology is key

• Remember the body is 3-dimensional BUT…

• Radiographs are 2-dimensional and shades of grey

• Depicting densities


Difference between

diagnosis and reading

• Pneumonia = Diagnosis

• Right Middle Lobe Infiltrate = FINDING

***Use the diagnostic triangle***


What do the shades of gray mean?

Radiopague

Doesn’t allow the passage

of rays through – high

absorbency/only a little bit

gets through – Resulting

in white color

Radiolucent

Permits the passage of

rays through – low

absorbency/most of the

rays get through –

resulting in dark image


Shades of Gray

Tissue absorbs x-ray beam to differing degrees ABSORPTION TISSUE

EFFECTS IN RADIOGRAPH

Least

Air Black

Fat Dark Gray

Soft tissue Grey

Bone/Calcium White

Most


10

10

In order to know that you are holding a pineapple

and a banana, your friend would have to see your

shadow in both positions and form a complete

mental image


THE RULES

• Treat the Patient not the radiograph

• History and physical examination before ordering

• Order radiographs only when necessary

• Look at the patient and the radiograph

• Look at the whole radiograph

• Re-examine the patient if incongruity exists

• Remember the rule of 2’s • Views, abnormalities, occasions, opinion, visits/procedures

• Failsafe measures in place



• Radiation exposure has been researched since the

atomic bomb exposure

• Increased use of plain radiographs, nuclear medicine

and CT scans has increased population exposure rates

Farfalla Education, LLC

The Basics

• X-rays are a type of high energy ionizing radiation

• Upon contact with a material causes loss of electrons and become

charged (ionized)

• Can cause damage to genetic material through

diminished cell division

• Risks:

fetus gonadal tissue

children rapid cell division



• Three measures to describe radiation dose

• Absorbed

• Amount of energy absorbed/unit mass

• Effective

• All irradiated tissue and organ risk of exposure

• Organ

• Organ risk of exposure



• Plain Radiographs

• 0.02 – 6.4 (Chest x-ray – Lower GI)

• CT scan

• 2.0 – 20-40 (Head – Pulmonary A-gram)

• Nuclear Medicine

• 9 – 10-25 (sestamibi scan – dual isotope scanning)

Richardson, L. (2010). Radiation exposure and diagnostic imaging. Journal of

the American Academy of Nurse Practitioners 22, 178 – 85.



• Use of CT and Nuclear Medicine has

significantly risen in past 25 years • CT increased >2000%

• Nuclear Medicine >285%

• Radiographs have recently been classified as

carcinogenic

• 1/4 - 1/3 of patients get multiple scans/tests

• Statistically significant increases in cancer with

doses over 50mSv • 10 – 25 mSv for single CT or nuclear medicine study



• Interrupt cell DNA causing mutations

• Organs and tissue have varying sensitivities

• Gender, pediatric and child bearing women

• Genetic component



• Studies suggest approximately 1% of cancer in the

United States is from radiation exposure

• Expanded evidence not available

• Can take 1 – 2 decades for radiation induced cancer to develop

after exposure


Chest Anatomy


http://medinfo.ufl.edu/year1/rad6190/images/pa_chest_xray.gif

http://medinfo.ufl.edu/year1/rad6190/images/LatChest3%5B1%5D.gif

Lobes of the lung


http://www.medcyclopaedia.com/library/r

adiology/chapter18/3.aspx

Chest Anatomy


http://www.medcyclopaedia.com/upload/book%20of%20radiology/chapter18/nic_k18_915.jpg

Anatomy


Left upper lobe

Lingula

Left lower lobe Right lower lobe

Right upper lobe

Anatomy


Middle Lobe

Right diaphragm

Left diaphragm

Lower lobe

Upper lobe

Positioning

• Posterior Anterior (PA)

• Facing the cartridge

• Supine Anterior Posterior (AP)

• Only in the critical patient

• Lateral Position

• Lateral Decubitus


Normal PA and Lateral


Heart and vasculature more prominent

Heart no bigger than ½ the width

of the space within the cage

PA vs AP


Lateral Decubitus Position

• Assess volume,

mobility or loculation of

pleural effusion

• Dependent lung should

have increased density

d/t atelectasis from

mediastinal pressure

• Airtrapping if not present


Normal Inspiration


Diaphragm at the level of the 8-10th posterior rib or 5-6th anterior rib

poor inspiration


Penetration

PA

• Thoracic disc spaces

should be barely

visible through the

heart with vertebral

bodies not visible

• Over-penetration =

Dark

• Under-penetration =

Light/White

Lateral

• Should see 2 sets of

ribs

• Sternal edge may be

visible

• Vertebrae appear

darker as you move

caudally


Under and Over Penetration


Rotation


Clavicle heads and spinal processes

should be symmetrical

Lungs


ABC’s of Interpretation

• Adequacy, Airway

• Breathing

• Circulation

• Diaphragm

• Edges

• Skeleton, Soft Tissue


Interpretation

• Trachea

• midline or deviated, caliber, mass

• Lungs

• abnormal shadowing or lucency

• Pulmonary vessels

• artery or vein enlargement

• Hila

• masses, lymphadenopathy

• Heart

• thorax: heart width > 2:1 ? Cardiac configuration?

• Mediastinal contour

• width? mass?

• Pleura

• effusion, thickening, calcification

• Bones

• lesions or fractures

• Soft tissues

• don’t miss a mastectomy

• ICU Films

• identify tubes first and look for pneumothorax


What do you see????


Okay now for the Lateral


Look for a Bronchogram

• Outline of airway that is made visible by surrounding alveoli with fluid or exudate

• 6 causes • normal expiration

• lung consolidation

• pulmonary edema

• nonobstructive pulmonary atelectasis

• severe interstitial disease

• Neoplasm


88 year old Female

• Presents with complaints of shortness of breath

• PMH – arthritis, hypercholesterolemia, HTN, CAD,

pulmonary HTN,

• PSH – CABG, Cataracts, Aortic Valve Repair

• Allergy – codeine, PCN

• PE – lungs decreased with bibasilar crackles

• Vital signs – BP 146/85, HR 85, RR 16, T 97F, pulse Ox

95% RA


What’s wrong with this picture????

Atelectasis

• increased density usually linear

• collapse or incomplete expansion of the lung or part of the lung

• Segmental and subsegmental collapse may show linear, curvilinear, wedge shaped opacities

• Causes • endobronchial lesion (i.e.

mucus plug or tumor)

• extrinsic compression centrally • mass such as lymph nodes or

peripheral compression by pleural effusion


78 year old Male

• Presents with shortness of breath for 1 day progressively

getting worse.

• PMH – CAD, HTN, Hypercholesterolemia

• PSH – CABG, pacemaker or AICD pt and family not sure

• Allergies – none

• PE – pale, diaphoretic, in mild respiratory distress. Mild

JVD. Lungs with course diffuse rhonchi. S1 S2 no M/G/C

• Vital signs – BP148/90, HR 102, RR 28, T 97.9F pulse Ox

94% RA


Pulmonary Edema

• Two basic types • Cardiogenic

• increased hydrostatic pulmonary capillary pressure

• Non-cardiogenic

• altered capillary membrane permeability or decreased plasma oncotic pressure

• NOT CARDIAC (Pneumonic)

• Near-drowning, Oxygen therapy, Transfusion or Trauma, CNS disorder, ARDS, Aspiration, or Altitude sickness, Renal disorder or Resuscitation, Drugs, Inhaled toxins, Allergic Alveolitis, Contrast or Contusion


Cardiogenic

• Cephalization of the pulmonary vessels

• Kerley A lines • thin linear opacities in mid and upper zones radiating to hila

• Kerley B lines • linear opacities 1-2cm long and 1-2mm thick perpendicular to

pleural surface caused by intertsitial fluid (septal lines)

• Peribronchial cuffing

• "bat wing" pattern

• Patchy shadowing with air bronchograms

• Heart enlargement

• Pleural effusions

• Perihilar consolidation


Pulmonary Edema Cephalization of Vessels Bat Wing


Pulmonary Edema


Diffuse Pulmonary Edema


Congestive Heart Failure


3 year old female

• 1-day onset fever 102F, sinus congestion and drainage,

cough

• PMH/PSH negative

• Medications – None

• Allergy – whole milk

• PE – only abnormal finding erythema

• Vital signs – HR 99; RR 24; T 102.8F, pulse Ox 98% RA


Pneumonia

• Airspace disease and consolidation

• Air spaces are filled with bacteria or other

microorganisms and pus


Types of Pneumonia

• Lobar • classically Pneumococcal pneumonia

• entire lobe consolidated and air bronchograms

• Lobular • often Staphlococcus

• multifocal, patchy, sometimes without air bronchograms

• Interstitial • Viral or Mycoplasma

• latter starts perihilar and can become confluent and/or patchy as disease progresses, no air bronchograms

• Aspiration pneumonia • follows gravitational flow of aspirated

contents

• anaerobic • Bacteroides

• Fusobacterium

• Diffuse pulmonary infections • community acquired

• Mycoplasma • resolves spontaneoulsy nosocomial

• Pseudomonas • high mortality rate

• patchy opacities, cavitation, ill-defined nodular

• immunocompromised host

• bacterial, fungal, PCP


Where is the Consolidation?

• Are both the heart borders and domes of the diaphragm

easily visible?

Right Heart Border = Middle Lobe

Left Heart Border = Upper Lobe

Right Diaphragm = Right Lower Lobe

Left Diaphragm = Left Lower Lobe


Right Upper Lobe


Right Middle Lobe


Right Lower Lobe and Middle lobe


Left Upper Lobe


Left Lower Lobe


52 Year Old Male

• Complaints of not feeling well, chest tightness, and racing

heart. Denied SOB or fever

• PMH – alcohol abuse, depression

• PSH – none

• Allergies – none

• Social – alcohol use daily 1 bottle of scotch; tobacco 1-2

PPD

• PE – unremarkable

• Vital signs – BP 154/103, HR 138, RR 27, T 100.8, pulse

Ox 97% RA


Pleural Effusion

• Causes

• CHF

• Infection (parapneumonic)

• Trauma

• PE

• Tumor

• Autoimmune disease

• Renal failure


Pleural Effusion


32 Year Old Male

• Aortic Valve Replacement Post-op 5 days thoracostomy

tube removed.

• Mild SOB


Day 5 Post-op


Pneumomediastinum

• Streaky lucencies over the mediastinum that extend into the neck, and elevation of the parietal pleura along the mediastinal borders

• Causes • asthma

• surgery

• traumatic tracheobronchial rupture

• abrupt changes in intrathoracic pressure (vomiting, coughing, exercise, parturition)

• ruptured esophagus

• Barotrauma

• smoking crack cocaine


Pneumomediastinum


Day 8 Post-op


Pneumothorax

Air inside the thoracic cavity but outside the lung

• Spontaneous

Pneumothorax -

Causes

• idiopathic

• asthma

• COPD

• pulmonary infection

• neoplasm

• Marfan syndrome

• smoking cocaine

• Pneumothorax

• most are iatrogenic

• caused by a provider

during surgery or central

line placement

• Trauma

• MVA, Blunt force trauma


Pneumothorax on X-Ray

• Air without lung markings in the least dependant part of

the chest – pleural edge visible

• Best demonstrated by an expiration film


Pneumothorax


Tension Pneumothorax


Should this patient had a

chest x-ray in the first place?

Emphysema

• Loss of elastic recoil of the lung with destruction of pulmonary capillary bed and alveolar septa

• Diffuse hyperinflation with flattening of diaphragms, increased retrosternal space, bullae (lucent, air-containing spaces that have no vessels that are not perfused) and enlargement of PA/RV (secondary to chronic hypoxia) an entity also known as cor pulmonale.

• Hyperinflation and bullae are the best radiographic predictors of emphysema


Emphysema


49 year old female

• Arrived to ED via ambulance – swallowed foreign body.

Attempted to vomit at home but unsuccessful.

• PMH – hypertension takes no medications

• No complaints offered

• PE – unremarkable

• Vital signs – BP 156/96; HR 85, RR 18, T 96.7F, pulse Ox

98% RA


Indications for Ordering

Abdominal Studies • Radiographs

• Perforation

• Obstruction

• Renal Colic

• Ultrasound • Biliary disease

• AAA

• CT of Abdomen and Pelvis • In some facilities replacing all other studies


Radiograph Studies

Perforation

• Well penetrated erect Chest X-ray

• Left Decubitus position if unable to sit-up or stand-up

• 1.0 ML of free air can be detected with erect film


Obstruction

• Erect Chest X-ray and Supine

• Intrathoracic Disease may be revealed on Chest X-ray

• Pneumonia may present as abdominal pain


Renal Colic

• Supine

• Part of limited IVP series

• Most facilities are replacing plain films with CT to rule out

stones


ABC’s of Interpretation

• Adequacy, Air

• Bowel

• Calcification

• Densities

• Edges

• Fat planes

• Skeleton, Solid organs


Normal


Air

• Free intraperitoneal are rises to the front of the abdomen

while supine

• Best viewed on erect films if perforation suspected


Free intra-peritoneal air


Bowel Gas Patterns

• Gas rises anteriorly while supine

• Stomach, transverse and sigmoid colon

• Small vs Large bowel

Small Large

Lies centre of abdomen Lies peripherally

Smaller calibre ~3cm No definite measurement

Contains air and fluid Contains feces


Calcifications

• Calcification can be seen and be normal or abnormal

• Phleboliths (small calcified vessels in pelvis) often

confused with stones

• More than 90% of renal stones visualized on plain films

• 10-15% of gall stones can be visualized


Densities

• Foreign bodies

• Ingested or inserted

• Tablets

• Tampons

• Tubular structures


Fat Planes

• Psoas

• Perirenal fat plane

• Perivesical fat plane

• Properitoneal fat plane

• Other solid organs


Skeleton

• Look for occult and obvious fractures

• There may be underlying organ and/or soft tissue damage


Dilated Small Bowel

• Most common cause is mechanical obstruction

and paralytic ileus

• Mechanical obstruction - causes

–Adhesions

–Strangulated hernia

–Masses

–Volulus (twisting of bowel loop) or intussuseption

–Gall stones

–Crohn’s disease

–Appendiceal abscess


Volvulus


Dilated Small Bowel

• Cardinal sign is dilated loops (usually > 3 cm) of small bowel containing variable air and fluid levels with collapse of large bowel

• String of beads appearance • Air becomes trapped between valulae connivates

• CT should be done whenever small bowel obstruction is suspected


Dilated Small Bowel


Dilated Large Bowel

• Obstruction or Pseudo-Obstruction

• Large bowel dilitation with or without obstruction

• Causes

• Carcinoma

• Volvulus

• Inflammation

• Diverticular disease

• Colitis


Dilated Large Bowel

• High risk of perforation especially when lumen

exceeds 9cm

• Volulus most often occurs in cecum and sigmoid

colon

• Dilation from colitis also associated with wall

thickening and mucosal edema (thumbprinting) –

known as toxic megacolon

• CT scan should be done on any patient

suspected


Dilated Large Bowel


Megacolon


Ulcerative Colitis


Injuries to Bones and Joints

• Indication

• When to order x-rays

• Minor or no trauma

• Fractures can occur simply in terms of the physiologic process

involved

• Stress fractures


Injuries to Bones and Joints

• Orthopedic emergencies

• Open fracture

• Dislocation

• Subluxation


Describing Radiographs

• Open or closed

• Location of the fracture

• Orientation of the fracture line

• Displacement, separation, shortening, and angulation

• Epiphyseal fracture

• Salter Harris Classification


Pediatric Considerations

• Bones more fibrous and less crystalline

• Enclosed in sheath of strong fibrous periosteum

• Buckle fractures and greenstick fractures more

common

• Bone ends do not separate as in adults with

complete fractures due to periosteal sleeve

• Epiphyseal growth plate is a zone of weakness

making fracture, separation, slipping more

common



• Growth disturbances can be expected from epiphyseal injuries

• Union of fractures occurs much faster than adults

• Re-modeling of fractures after union means that less than perfect reduction can sometimes be accepted since nature will correct mistakes

• Loss of length after fracture of a long bone tends to be made up in the 1-2 years after injury by overgrowth



• Dislocation occurs mainly at the elbow, hip and fingers

• Callus produced in larger quantities than in adults

• Pathological fracture occurs in children as result of local bone disease, simple bony cysts, osteitis, neoplasm, etc (example: osteogensis imperfecta – remember blue eyes)


Common types of bone injuries in children

• Elastic deformation: a momentary, non-permanent deformation

• Bowing deformation: a deformity of bone that may or may not be completely resolved with bone remodeling

• Torus (Buckle) Fracture: involves the buckling of one cortex

• Greenstick fracture: an incomplete transverse fracture with fracture and periosteal rupture on the convex side

• Salter-Harris fracture: involves epiphyseal plate

• Stress Injury: a fracture caused by repetitive trauma

• Avulsion Injury: a bony structural defect at a tendinous or aponeurotic insertion resulting from excess stress


Salter Harris Classifications

• Salter I – separation of the growth plate without involvement of metaphysis or epiphysis

• Salter II – fracture across the growth plate but with a small fragment of metaphysis remaining attached to the epiphysis

• Salter III – fracture across growth plate with extension of fracture across epiphysis

• Salter IV – combination of Salter II and Salter III fracture with the fracture line traversing the epiphysis and part of the diaphysis

• Salter V – crush injury of part of the epiphysis


Salter Harris I Fracture


Salter Harris II Fracture


Salter Harris III Fracture


Salter Harris IV Fracture


Salter Harris V Fracture


Shoulder


Shoulder - Approximate timings of

formation and fusion of secondary

ossification centres of the shoulder Seah, Elias & Chan. Chapter 5

BONE SECONDARY

OSSIFICATION

CENTRES

TIME OF

FORMATION

(YEARS)

Time of fusion

(years)

Humerus Head

Greater tuberosity

Lesser tuberosity

0-6 months

1

5

15-18 (with shaft)

4-6

7

Scapula Inferior angle

Coracoid

Acromium

15

1

15

20

15

20-25

Clavicle Medial Margin 18 25


Shoulder – Radiographs

• Anterioposterior (AP) view • Contour of each bone should be traced systematically

• Cortices should be smooth

• Don’t overlook the ribs

• Axial view • ID coracoid process 1st

• Useful in assessing glenohumeral alignment, avulsion of glenoid rim and Hill-Sachs defects of humeral head

• Y view • Confirms normal alignment of glenohumeral joint

• Valuable if posterior dislocation suspected


Extremities

• Adequacy

• Alignment

• Bone

• Cartilage and joints

• Soft tissues


Injuries

• Dislocations

• Anterior

• Posterior

• Suspect in seizure patient with pain

• Acromio-clavicular subluxation and dislocation

• Key Points

• Always order a post-reduction film

• Look for subtle fractures

• Inferior aspects of acromion and clavicle should be a

straight line


Direction of Dislocation


Dislocations - Anterior


Posterior Dislocation


Anatomy of Elbow


Pediatric Elbow


Pediatric Elbow

• Ossification Centres • There are 6 ossification centres around the elbow joint

• They appear and fuse to the adjacent bones at different ages

• It is important to know the sequence of appearance since the ossification centers always appear in a strict order

• Order of appearance

• Mnemonic C-R-I-T-O-E

• Capitellum - Radius - Internal or medial epicondyle - Trochlea - Olecranon - External or lateral epicondyle

• The ages at which these ossification centres appear are highly variable and differ between individuals

• It is not important to know these ages, but as a general guide you could remember 1-3-5-7-9-11 years


Pediatric Alignment

Radiocapitellar line

• A line drawn through the long axis of the radius should always point toward the centre of the capitellum whatever the positioning of the patient, since the radius articulates with the capitellum

• In dislocation of the radius this line will not pass through the centre of the capitellum.

Anterior Humeral line

• A line drawn on a lateral view along the anterior surface of the humerus should pass through the middle third of the capitellum

• In cases of a supracondylar fracture the Anterior Humeral line usually passes through the anterior third of the capitellum or in front of the capitellum due to posterior bending of the distal humeral fragment


Radiocapitellar line


Anterior Humeral line


Distal Humeral Fracture


Fat Pad


Elbow Fractures

• Essex-Lopresti’s Fracture – fracture radial head with

asociated dislocation of distalulnar joint

• Monteggia’s fracture – fractured proximal third ulna with

associated dislocation of radial head


Radial Head Fracture


Elbow Dislocation


Midshaft Fracture

Radius and Ulna


Distal Radius Fracture

• Barton’s Fracture – displaced articular lip fracture of

distal radius, may be associated with carpal subluxation

• Chauffeur’s Fracture (Hutchinson Fracture) – oblique

fracture of radial styloid. Originated from crank automobile

• Colles fracture – general fracture of distal radius with

dorsal displacement


Chauffeur’s Fracture

Hutchinson Fracture


Colles Fracture


Distal Radius Fracture


Distal Radius & Ulna Fracture


Hand Fractures

• Boxer’s fracture – fracture 5th metacarpal neck with volar

displacement head of the metacarpal

• Bennett’s fracture – oblique fracture 1st metacarpal base

separating triangular fragment of volar lip from proximally

displaced metacarpal shaft


Boxer’s Fracture


Metacarpal Fractures


Pelvis

• Comprised of three bone rings

• Main ring

• Sacroiliac joints and symphysis pubis

• Smaller rings

• Pubic and ischial bones


Shenton’s Line

• A radiographic, curved line formed by the top of the obturator foramen and the inner side of the neck of the femur, used to determine the relationship of the head of the femur to the acetabulum

• In fractures or congenital luxation this line is broken.


Shenton’s Line

Normal Fracture


Pelvis X-ray


Pelvis x-rays

• One view only – AP view

• If you seen one fracture always look for two

• Prostate and breast cancer love the pelvis

• Osteoblastic lesion – light colored

• Osteolitic lesion – dark colored


Pelvis x-rays

• Systematic approach • Main ring

• Inner and outer cortices

• 2 small rings • Form obturator foramina

• Sacroiliac joints • Equal widths

• Symphysis pubis • Alignment of superior surfaces of the pubic bone body

• Max width should be no more than 5mm

• Sacral foramina • Any distruption of smooth arcuate lines indicates sacral fracture

• Compare the arcs on the injured and uninjured side

• Acetabular region • Compare injured and uninjured sides (easy to miss fracture due to complexity)


Pelvic Fractures

• Main ring

• Widening at symphysis pubis or sacroiliac joint indicates a fracture

in the ring

• Fracture at 1 site associated with second fracture

• Double break indicated unstable fracture


Pelvic Fracture

• Acetabulum

• Frequently comminuted

• Bone fragments may be trapped within the joint

• Sacral

• Difficult to detect

• Arcuate lines need to be carefully assessed


Pelvic Fracture

• Coccygeal • Radiograph not always necessary to diagnose fracture

• Care unchanged whether fractured or not

• Normal coccyx may appear angulated and abnormal

• Avulsion of apophysis • Most commonly caused by repeated sudden or violent contraction

of muscles in young patients


Hip X-rays

• Adequacy and quality

of radiograph

• Check bone margins

and density

• Cartilage and joints

• Soft Tissue

• If X-ray for hip and

pelvis are negative,

make sure you walk

the patient. Subtle

fractures can be

missed on x-ray and

CT scan/MRI should

be ordered if unable to

ambulate.


Proximal Femur Fracture


Avascular Necrosis

(Osteonecrosis) • Painful condition involving weight-bearing portion

of femoral head

• Bone death results from lack of blood supply

• Trauma

• Prolonged corticocosteroid use

• Alcohol abuse

• Chemotherapy

• H/O diving and nitrogen toxicity

• Sickle cell disease



• Slipped Capital Femoral

Epiphysis

• Condition of femoral neck

• Moves proximally and

externally rotates on unfused

epiphysis

• 20% of cases are bilateral

• Occurs in overweight,

hypogonadal or tall but thin

adolescents

• Pain sometimes referred to

the knee

• Legg-Calve-Perthes

Disease

• Osteonecrosis of proximal

femoral epiphysis

• Children ages 4-8 years

• Four times more common in

boys than girls

• 10% occur bilaterally

• Genetic basis

• Imaging esential

• Most present with painful limp


• Shenton's curve: smooth, curved line connecting medial border of femoral metaphysis with the superior border of the obturator foramen

• Hilgenreiner's line: a horizontal line through the triradiate cartilage of the acetabulum

• Perkin's line: a vertical line (perpendicular to Hilgenreiner's line) from the lateral margin of the ossified acetabular roof that is normally tangential to the lateral margin of the ossification center of the femoral head

• Acetabular angle: angle that the acetabular line makes with Hilgenreiner's line


Slipped Capital Femoral Epiphysis

Anatomy


Slipped Capital Epiphysis

• A – Mild

• B – Moderate

• C - Severe


Slipped Capital Femoral Epiphysis


Legg-Calve-Perthes Disease


Knee Anatomy


Tibial Plateau

• AP view

• Perpendicular line drawn at the most lateral margin of the femoral

condyle

• Should not be more than 5mm of lateral margin of tibial condyle

• Similar line can be drawn medially


Tibial Plateau Fracture

• 80% involve the lateral plateau

• Causes

• Blow to the outside of the knee

• Pedestrian VS Automobile accident

• Fender Fracture


Pediatric Consideration

Osgood Schlatter

• Traction apophysitis of tibial tubercle

• Typically seen in children ages 10-15 years

• Self-limited course of several months – 2 years

• Tenderness ocer tibial tubercle onpalpation


Normal Patella X-ray


Skyline or Sunrise View


Ottawa Rules: Knee

• Order x-ray of the knee in the following:

• age 55 or over

• isolated tenderness of the patella

• no bone tenderness of the knee other than the patella

• tenderness at the head of the fibula

• inability to flex to 90 degrees

• inability to weight bear

• Immediately after injury or during evaluation

• 4 steps - unable to transfer weight twice onto each lower limb

regardless of limping


Knee Fractures

• Direct blow

• Usual cause of fracture

• Vertical, horizontal and comminuted

• Violent contraction of Quadricep muscle

• Transverse fracture in athletes

• Bipartite patella

• May mimic fracture


Patella Dislcoation

• Considered to be rare

• When occurs usually anterior translation of Tibia on the

femur

• Consider popliteal artery and nerve injury

• True dislocation associated with multiple ligamentous

tears


Proximal Fibula Fracture

• Fibula head fracture

• May be isolated or associated with Tibial plateau fractures

• Fibula neck or proximal shaft fracture

• May be associated with ankle injury

• Maisonneuve fracture

• Proximal Fibula fracture may be associated with peroneal

nerve injury


Ottawa Rules: Ankle

• Bony tenderness at tip or posterior edge of distal 6cm of

tibia or fibula

• Bony tenderness medial malleolus

• Tenderness base of 5th metatarsal

• Unable to bear weight immediately after injury or upon

evaluation


Ankle X-ray

Lateral AP


Ankle X-ray

Mortise Boehler’s Angle


Calcaneal fracture

• Most commonly fractured bone of the hindfoot

• Occurs most commonly – fall from height

• Suspect spinal fracture


Base of Fifth Metatarsal Fracture

• Avulsion fracture • Commonly caused by inversion injury

• Usually occurs at the metatarsal tuberosity at the insertion of the peronous brevis tendon

• Clinical evaluation will determine need for ankle and/or foot x-rays

• Don’t confuse with unfused apophysis

• Bone fragment from fracture usually lies transverse to long axis of metatarsal as opposed to apophysis lying oin the long axis of the metatarsal


Tarsals, Metatarsals and Phalanges – Oh

My!


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• Introduced in the 1970’s

• Three dimensional views

• Body organs

• bones

• Benefits usually outweigh the risks

• Radiation exposure



• Specialized X-rays generate images with computer

• Quickly identify traumatic injuries to the lungs, heart,

vessels, liver, spleen, kidneys, bowel and other organs

• Patient lies on a table that slides in and out of a tube



• The tube rotates around the patient

• Opposite side of the patient is x-ray detector

• Detector receives the beam going through the patient

• Measurements are made about 1000 times per second

• Scan rotations are usually 1-2 seconds long

• Each scan is compared to calibration data of air, water and polyethelyne (soft plastic) previously acquired in the same relative location • Comparisons allow for the image

• More samples, or views, the better the picture



• Iodine based

• Absorbed by abnormal tissue

• Tumors, vascular malformations

• Risks

• Renal failure

• Metformin



• Procedural guidance

• Biopsy

• Incision and drainage

• Assess post-surgical procedures

• Organ transplant

• Gastric bypass

• Radiation therapy

• Stage

• Plan and administer radiation

• Bone mineral density



• Readily detects inflammation of the mesentery (fat streaking) • May be non-specific and should be correlated with the History and

Physical Examination

• Abscesses or Tumors • Intra-abdominal

• Intra-hepatic

• Intra-splenic

• Blunt Trauma – must be performed quickly • Spleen

• Liver

• Pancreas



• Painless, noninvasive and accurate

• Bone, soft tissue and vessels visualized same time

• Fast and simple

• Cost-effective

• Less sensitive to movement

• Real time images



• Not recommended in pregnancy

• Allergic reaction to contrast

• Large amount of radiation



• Powerful magnet and radio waves generate images

• Detection coils in scanner read the energy produced by

water molecules as they mis-align themselves after each

radio frequency alignment pulse

• Reconstruction of the collected data into 2-dimensional

illustration through any axis of the body

• Best suited for soft tissue



• Organs and blood vessels of chest, abdomen and pelvis

• Tumors of chest, abdomen, and pelvis

• Vascular and heart abnormalities

• Liver disease

• Cyst and tumors of genitourinary tract

• Breast cancer and implants

• Pelvic pain, congenital malformations leading to infertility



• Non-invasive

• No radiation

• Early detection focal lesions and tumors

• View soft tissue obscured by bone

• Biliary system without contrast

• Can be used in pregnancy



• Almost no risk

• Clostrophobia

• Metallic, pacemaker

• Nephrogenic systemic fibrosis from contrast material



CT Scan MRI

Radiation Exposure Moderate to High None

Generated Image X-Ray Magnet and Radio

Waves

Duration of Test Very Quick < 5

minutes

Moderate approx. 30

minutes

Cost of Test >$1000 $1000 – 4000

Bony Structure Detailed Less Detail

Soft Tissue Less Detail Great Detail

Image Plane Can not be changed

without moving the

patient

Image produced in

any plane without

moving patient



MRI CT Scan

Magnetic Field – No radiation exposure Great bony detail

Great soft-tissue detail Can be performed on patient with metal

Pacemaker, metallic FB, Clips, etc

Ability to change contrast of image

different types of tissue can be

contrasted with different contrast

settings

Test performed in less time

Image plane can be changed without

moving patient

Food for claustrophobic patients

Lower rate of reaction with non-iodine

contrast

Paramagnetic preparation –

Gadolinium

Cheaper

Superior tumor detection and

identification



CT MRI

Bone Tendons

Lungs Ligaments

Organs in chest and

abdomen

Spinal cord

Cancer Ischemia (stroke)

Pneumonia Cartilage

Brain - Bleed Brain - Tumor

Acute organ injury

Vascular (AAA, PE)



THANK YOU!!!!



[email protected]

609-602-3034


mailto:[email protected]

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