Commonly encountered radiographs during clerkship:

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Commonly encountered radiographs during clerkship
The Basics
Seng Thipphavong, PGY4 Department of Diagnostic
Imaging
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Objectives and Outline

• To review the commonly encountered radiographs
  during clerkship, with a review of radiographic
  anatomy and disease entities
• Radiographs
• The Chest Radiograph
• The Abdominal Radiograph
• Miscellaneous Radiographs

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The Chest Radiograph

• Anatomy
• Cases (3)

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Anatomy
trachea
clavicle
aortic arch
SVC
aortopulmonary window
main pulmonary artery
left atrial appendage
right atrium
left ventricle
right hemidiaphragm
left hemidiaphragm
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Anatomy
trachea
retrosternal airspace
left pulmonary artery
right pulmonary artery
right heart chambers
left heart chambers
IVC
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Case 1

• 69 y.o. female presents with shortness of breath

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Case 1
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Case 1
Kerley B lines
peribronchial cuffing
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Pulmonary edema

• 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

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Case 2

• 69 y.o. with fever and cough

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Case 2
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Case 2
Air bronchograms
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Case 2

• Findings of pneumonia on radiograph?
• Consolidation (white) and air bronchograms
• How are pneumonia and atelectasis similar on
  radiograph?
• Both are white
• How are pneumonia and atelectasis different on
  radiograph?
• Look for air bronchograms
• Atelectasis will have signs of volume loss

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Case 3

• 69 y.o. with chest pain

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Case 3
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Case 3
Visceral pleura
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Case 3

• Causes of pneumothorax?
• Numerous!
• Treatment?
• Urgent
• Chest tube
• 25 G needle 2nd intercostal space

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Companion Case
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Case 3

• Deep sulcus sign?
• pneumothorax on supine films
• especially seen in ICU patients

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The Abdominal Radiograph

• Anatomy
• Cases (3)

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Anatomy
Right kidney
Left kidney
Hepatic angle
Left psoas
Properitoneal fat
Air in descending colon
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Case 1

• 69 y.o. with abdominal pain

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Case 1
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Case 1

• 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?
• Nausea, vomiting, abdominal distension,
  obstipation
• What are the causes of SBO?
• Adhesions, hernia, stricture, neoplasm, gallstone
  ileus

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Companion Case
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Case 1

• What are the signs of SBO on radiograph?
• Dilated and fluid filled loops, step-ladder
  appearance
• What is the difference between ileus and SBO?
• SBO indicates mechanical obstruction
• Ileus is an adynamic state (bowel shuts down)

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Case 2

• 69 y.o. with abdominal pain

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Case 2
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Case 2
Cupola sign
Football sign
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Case 2

• Signs of free intraperitoneal air on upright
  radiograph?
• Air under the diaphragm
• 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?
• Free air outlining both sides of bowel

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Companion case
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Companion case
Riglers sign
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Case 2

• 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?
• No.
• Why?
• the omenteum usually contains the air, and is not
  seen on radiograph

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Case 3

• 69 y.o. with abdominal pain

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Case 3
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Case 3

• 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?
• Colon Ca, stricture (post-inflammatory
  diverticulitis or IBD), volvulus

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The Miscellaneous Radiograph

• Cases (4)

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Case 1

• 69 y.o. in a fight

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Case 1
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Case 1

• What is a Boxers fracture?
• Fracture of the 5th metacarpal
• Potential complications of a Boxers fracture?
• Metacarpal shortening
• Usually the distal fragment is rotated in a
  radial direction, and may heal with deformity

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Wrist and hand anatomy
Distal phalynx
DIP joint
Middle phalynx
PIP joint
Proximal phalynx
MCP joint
Sesamoid
Metacarpal
CMC joint
Distal ulna
Distal radius
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Wrist anatomy
capitate
trapezoid
hamate
trapezium
pisiform
triquetrum
scaphoid
lunate
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Companion case
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Case 2

• 69 y.o. who fell

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Case 2
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Case 2
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Case 2

• What is the classic clinical presentation for a
  hip fracture?
• Shortened lower extremity and external rotation

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Pelvic anatomy
Iliac crest
SI joint
Sacral ala
Femoral head
Iliopectineal line
Greater trochanter
Femoral neck
Superior pubic ramus
Ischial tuberosity
Lesser trochanter
Obturator foramen
Inferior pubic ramus
Pubic symphysis
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Case 3

• 69 y.o. who fell

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Case 3
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Case 3

• What are the 3 radiographs that are obtained with
  an ankle series?
• AP, lateral, ankle mortice view
• How is the ankle mortice view obtained?
• Internal rotation 15 degrees
• What does the ankle mortice view tell you
  clinically?
• Ankle joint stability!

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Ankle and foot anatomy
Proximal phalynx
Sesamoid
metatarsal
3rd cuneiform
1st cuneiform
2nd cuneiform
Cuboid
Navicular
Talus
Calcaneus
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Case 4

• 69 y.o. who fell

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Case 4
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Case 4

• Where is the position of the humerus in an
  anterior dislocation?
• Anterior!, and inferior
• What is a Bankart lesion?
• Impaction fracture at inferior glenoid rim
• What is a Hill-Sachs lesion?
• Impaction fracture at the superolateral aspect of
  the humeral head

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Case 4

• Which is more common, anterior or posterior
  dislocations?
• Anterior (90)
• What are the causes of posterior shoulder
  dislocations?
• Ethanol, epilepsy, electrocution

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Shoulder anatomy
AC joint
Acromium
Clavicle
Anatomical neck
Coracoid
Greater tuberosity
Glenoid
Surgical neck of humerus
Scapula
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End!

• Questions?
• Email
• sthip028_at_uottawa.ca