Matthew Tommack, D.O. October 13, 2018 Chest radiography Anatomy, - - PowerPoint PPT Presentation

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Matthew Tommack, D.O. October 13, 2018 Chest radiography Anatomy, - - PowerPoint PPT Presentation

Jan 04, 2024 41 likes •1.19k views

Matthew Tommack, D.O. October 13, 2018 Chest radiography Anatomy, pathology Shoulder Radiography Anatomy, pathology Knee Radiography Anatomy, pathology Anatomy Consolidation Atelectasis Pulmonary Edema Pleural Effusion

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Matthew Tommack, D.O. October 13, 2018

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 Chest radiography

  • Anatomy, pathology

 Shoulder Radiography

  • Anatomy, pathology

 Knee Radiography

  • Anatomy, pathology
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Anatomy Consolidation Atelectasis Pulmonary Edema Pleural Effusion Pneumothorax

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 Technique, type and

quality

 Ribs and spine  Upper abdomen  Soft tissues  Borders of the

mediastinum/heart

 Lungs

  • Pneumothorax
  • Consolidation
  • Pleural effusion
  • Interstitium/vessels
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 When fluid/cells accumulate in lung

  • Alveolar (airspace) compartment
  • Interstitial compartment

 In addition to increasing the lung density,

the consolidation cancels the contrast between vessels and lung boundaries, and these structures disappear, ie silhouette sign

 Air filled bronchi, normally invisible, will be

contrasted by consolidation creating air bronchograms

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 RUL: right superior mediastinum (SVC)  RML: right heart border  RLL: right hemidiaphragm or right heart

border if medial RLL

 LUL: left superior mediastinum (aortic arch)  Lingula: left heart border  LLL: left hemidiaphragm or descending aorta

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 Obstructive / Resorptive

  • Endobronchial Lesion

 Passive / Relaxation

  • Pleural Effusion, Pneumothorax

 Compressive

  • Bulla

 Cicatricial/Scarring

  • Radiation Fibrosis

 Adhesive

  • Neonatal Respiratory Distress Syndrome/Hyaline

Membrane Dz

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 Lobar  Segmental  Subsegmental

(Plate/Streak)

 Round

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 Heart size on ideal PA film

  • Heart width should be less than 50% of chest cavity

width.

  • Cardiac enlargement is common in CHF

 Normal upright upper lung pulmonary vessels 1/3

the size of basilar vessels.

 Early CHF

  • Basilar edema causes shunt to upper lobe = cephalization
  • f flow.

 Interstitial edema

  • Thin Kerley B lines (septal lines) and thick bronchi

 Parahilar alveolar edema

  • Usually symmetric and non-segmental
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 Measurement of the Cardiothoracic ratio:

[(MRD+MLD)/ID]

 A value of <0.5 is normal (<0.6 in infants).  Enlargement may come from heart or

pericardium.

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 Pleural effusion is seen in many conditions

  • Heart failure
  • Tumor
  • Pneumonia
  • Trauma

 Obscures and compresses underlying lung  Effusions are readily detected

  • Can point to underlying problem that may not be seen on

x-ray, ie infection, tumor

 On routine upright chest x ray, need 200-300 mL of

pleural fluid to blunt costophrenic angle

 On lateral view, need only 75cc to blunt posterior

costophrenic sulcus

 Lateral decubitus is most sensitive and can be helpful

to determine of fluid is loculated

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 Injury to the lung, either trauma or iatrogenic  Air leakage into the pleural space  Spontaneous cases (idiopathic) also occur  Severity and duration of pneumothorax is made

worse by increased airway pressure

  • Obstructive airway disease or positive pressure ventilation

 If a "flap valve" mechanism is present, progressive

enlargement of space may compromise cardiac filling and ventilation (tension pneumothorax)

 Expiratory films aid in detection

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 Skin folds often simulate pleural lines

  • True pleural line has air on both sides of a fine line
  • Most pneumothorax look-alikes have air on only one side

and are not real lines

 Mastectomy  Bulla/blebs

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 Discussed normal chest x ray with

development of approach

 Common clinical pathologies  Questions

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 Anatomy  Pathology

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Acromion Clavicle Greater tuberosity Lesser Tuberosity Coracoid process Glenoid

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Glenohumeral Joint

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Acromion Clavicle coracoid Glenoid

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Acromion Clavicle Glenoid Face

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Footprint Labrum Cartilage Supraspinatus Tendon

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footprint Supraspinatus Bursa

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Subscapularis Supraspinatus Infraspinatus Biceps Tendon

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 Fractures  Dislocations  Arthritis  Calcific tendonosis  Avascular necrosis  Indirect signs of soft tissue injury  Tumors

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Humeral Head Fracture

  • can be very subtle and CT or MRI may be needed
  • surgical management depends on amount of humeral head involved

and degree of displacement

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Anterior Dislocation

  • most common type of dislocation
  • complications include Hill sachs impaction fracture and

Bankart lesions as well as rotator cuff injury

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AC Joint Injury-High Grade

  • Grading depends on degree of diplacement which

relates to degree of soft tissue involvement

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Osteoarthritis and chronic rotator cuff tear

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Calcific Tendonosis, HADD

  • may be incidental, but

can acute cause pain

  • supraspinatus is one of

the most common sites

  • Treatment is usually

conservative, but ultrasound guided lavage can be performed, surgery rarely needed

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Avascular Necrosis

  • humeral head is second most common site behind hip
  • can lead to subchondral collapse
  • MRI is most sensitive for early detection in high risk patients
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Cartilage forming bone tumor

  • enchondroma,

chondrosarcoma

  • predilection for

metaphasis of long bones, tubular bones of hands and feet

  • treatment depends on

aggressive features and many times symptoms may be the only deciding factor

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 Anatomy  Common Pathology  Questions

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 Anatomy  Pathology

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Tibial Spines Fibular Head MCL PCL ACL Menisci

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Quadriceps Tendon Patellar Tendon ACL PCL Suprapatellar Recess

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Patellofemoral joint space Menisci Cartilage

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 Fractures  Arthritis  Osteochondral Lesions  Signs of internal derangement  Soft tissue injuries  Tumors

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Tibial Plateau Fractures

  • Treatment depends on severity of comminution,

displacement, depression of subchondral bone, and associated soft tissue injuries

  • will generally go on to CT or MRI
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Osteoarthritis

  • osteophyte formation, joint space loss,

subchondral cyst, subchondral sclerosis

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Transient dislocation of patella with joint effusion and

  • steochondral lesion
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Arcuate Complex fracture and Segond Fracture

  • associated with ligament tears, MRI next
  • insertion of lateral stabilizing ligaments

and tendons

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Complete patellar tendon tear

  • patella alta and edema
  • can have associated bony fragment
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Quadriceps Tendon Tear

  • can have patella baja, edema,

bony fragment

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Cartilage forming bone tumor

  • presumed enchondroma, ie no

symptoms or aggressive features

  • can be small, cartilage rests
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Osteochondroma

  • common about the knee
  • can cause symptoms most commonly due

to mass effect or fracture

  • rarely degenerate into chondrosarcoma
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Osteoid Osteoma

  • classic finding of night pain relieved by

nsaids

  • can create exuberant periosteal rxn and

can be distant from nidus

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 Can the pt receive contrast

  • Allergies
  • Renal function
  • Medical history
  • Medications

 Does the pt need contrast

  • Can we answer the question without contrast
  • If we are going to give contrast, how can we optimize it’s

use

 Different ways to use contrast

  • Venous phase
  • Arterial phase
  • Delayed
  • Intrarticular
  • Outline lumen
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 Prior reaction to iodinated contrast  Prior severe allergy to anything  Kidney function, eGFR

  • Preexisting renal insufficiency
  • Over 60
  • Diabetes
  • metformin
  • Kidney disease
  • HTN
  • CVD
  • Solitary kidney
  • Transplant
  • Other factors contributing to nephrotoxicity

 Chemotherapeutic drugs  myeloma

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 Biggest worry is nephrogenic systemic sclerosis,

NSF, fibrosing disease of skin and subcutaneous tissues

  • Identified in 2006 with association to GBCA’s
  • eGFR used to screen

 Brain deposition-appears to be dose dependent

  • Safety alert announced in 2015, however no adverse

health effects have been discovered

  • Rigorous investigation on going

 Well tolerated as IV contrast

  • Much lower rate of adverse rxn, 0.7-2.4%
  • And allergic rxn, 0.004-0.7%
  • No cross reactivity with GBCA and Iodinated contrast

media

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 Contrast

  • Vessels/vessel injury
  • Visceral enhancement
  • Bowel Wall enhancment
  • Identifying structures

adjacent to vessels or bowel

  • Enhancement pattern

 Masses  Liver, kidneys  Excretory system

 Ureters, bladder

  • Abscesses
  • Arthrograms

 Labrum, shoulder, hip  Cartilage  Post op

  • Myelogram

 In pt who can’t have MRI

 No contrast

  • Air

 Pneumothorax  Pneumoperitoneum

  • Calcification

 renal stones  Sometimes gallstones

  • CT lung cancer screening or

lung nodule follow up

  • Bones

 Fractures, alignment

  • Head trauma/stroke

 BOTH

  • Dissection, Aneurysm
  • Visceral masses, ie liver,

kidney, adrenal

  • urogram
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Brant W & Helms C. Fundamentals of Diagnostic Radiology, 2nd ed. Philadelphia, PA: Williams & Wilkins. 1999.

Goodman L. Felson’s Principles of Chest Roentgenology, 2nd ed. Philadelphia, PA: WB Saunders Co. 1999.

Webb, Higgins. Thoracic Imaging Pulmonary and Cardiovascular Radiology. Lippincott. 2005

myweb.lsbu.ac.uk

  • Resnick. Bone and Joint Imaging. 3rd edition. Elsevier. 2005

radiology.creighton.edu/introtocxray.html

www.acr.org

www.statdx.com

www.radiologyassistant.com

www.orthobullets.com

Gottsegen, CJ, et al. Avulsion Fractures of the knee:Imaging findings and Clinical

  • Significance. Radiographics. Oct. 2008. 28:1715-1770.

Markhardt, BK, et al. Schatzker Classification of Tibial Plaeau Fractures: Use of CT and MRI Improves Assessment. Radiographics 2009. 29:585-597.

www.radiopeadia.com

www.sportsillustrated.com

  • Netter. Atlas of Human Anatomy. 3rd edition. Elsevier.