X-Ray Interpretation

Objectives

 Describe a systematic method for interpretation of chest and abdomen x-rays  List findings to accurately identify common X-ray Interpretation pathology in chest & abdomen x-rays  Describe a systematic method to approach the Denise Ramponi, DNP, FNP-C, ENP-BC, FAANP, FAEN important components in interpretation of upper & lower extremity x-rays

Chest X-ray: Standard Views Lateral Film

 Postero-anterior (PA):  (LAT) view can determine th  On inspiration – diaphragm descends to 10 rib the anterior-posterior posteriorly structures along the axis of the body

Normal LAT film

Counting Ribs AP View - Portable http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/cxr_f.htm

 When the patient is unable to tolerate routine views with pts sitting or supine

 No participation from the patient  Film is against the patient's back (supine)

1 Consolidation, Atelectasis, Chest radiograph Interstitial involvement

 Consolidation - any pathologic process that fills the alveoli with  Left and right heart fluid, pus, blood, cells or other borders well defined substances  Interstitial - involvement of the  Both hemidiaphragms supporting tissue of the lung visible to midline parenchyma resulting in fine or coarse reticular opacities  Right - higher  Atelectasis - collapse of a part of  Heart less than 50% of the lung due to a decrease in the amount of air resulting in volume diameter of the chest loss and increased density.

Infiltrate, Consolidation vs. Congestive Heart Failure Atelectasis

Fluid leaking into interstitium Kerley B

2 Kerley B lines Prominent interstitial markings Kerley lines Magnified CXR  Cardiomyopathy & interstitial pulmonary edema  Short 1-2 cm white lines at lung periphery horizontal to pleural surface  Distended interlobular septa - secondary to interstitial edema.

emedicine.medscape.com/article/348284- media

CHF Bat Wing edema Alveolar edema progressing  Bat wing edema = central, alveolar edema  < 10% of cases of pulmonary edema occurs with rapidly developing severe cardiac failure ◦ acute mitral insufficiency ◦ renal failure

Clinical and Radiologic Features of Pulmonary Edema http://radiographics.rsnajnls.org/cg...full/19/6/1507 http://radiographics.rsna.org/search?author1=Patrizio +Capasso&sortspec=date&submit=Submit

CHF

3 Dextrocardia Surface Anatomy

 Dextrocardia situs inversus: heart is a mirror image of normal placement  Dextrocardia situs totalis - all visceral organs are mirrored  Incidence - 1 in 12,000 people

w.meddean.luc.edu/lumen/MedE d/medicine/pu

http://www.meddean.luc.edu/lumen/MedEd/med icine/pulmonar/cxr/cxrl5.htm

Right Lung – RUL/RML Right Lung – RLL/Diaphragm

http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/cxr_f.htm http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/cxr_f.htm

Lateral – RUL & RML Left lung – LUL/L Lingula

http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/cxr_f.htm

4 Left Lung - LLL

http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/cxr_f.htm

Silhouette Sign Spine Sign  Loss of a cardiac border may indicate a lung abnormality adjacent to that anatomical structure  Obscuration of right border of heart (arrows) due to density of another tissue

Silhouette Sign 53 yr old female – Fever & Cough

5 Cardio-thoracic ratio Extracardiac causes for CTR>50%

 Portable AP films  Obesity  Pregnancy  Ascites  Straight back syndrome  Pectus excavatum

Cardiomegaly & AP film Pericardial Effusion

 If the heart touches the lateral chest wall, it’s enlarged

6 Steeple sign of croup Pleural Effusion (subglottic narrowing)

 Need at least 250-500 ml to be able to view

Right Lateral Decubitus film

Widened Mediastinum Aortic Dissection

7 Rib fractures Rib Fractures

 Chest radiograph obtained solely to exclude complication such as pneumothorax  Oblique views of the ribs are not necessary; clinical management is rarely altered by seeing rib fx.

Shortness of Breath 3 yr old with fever & barky cough

Pneumothorax Expiration Views Consider expiratory film if small

 Air trapping conditions:  Pneumothorax  Partial bronchial obstruction  Foreign body aspiration – if you hear a unilateral wheeze that does not clear with coughing!

8 Coin vs. Button Batteries

Asthma Asthma

 Hyperinflation  Hyperinflation – with flat  Mucus plugging can diaphragm down to the 11th lead to atelectasis rib  Prominent interstitial  Interstitial markings (scarring) – from inflammation inflammation

9 COPD COPD

 Hyperinflation (loss of interstitial tissue/darker-more air) ◦ low set diaphragm/ 12th rib ◦ increased AP diameter ◦ vertical heart ◦ increased retrosternal air. ◦ blunted costophrentic angles

http://www.meddean.luc.edu/lumen/MEdEd/Radio/curriculum/Mechanisms/396a1.jpg

COPD

15 month old suddenly red in face and SOB

10 Fever, cough, SOB History CA Lung with SOB

28 yr old female with cough

48 yr old patient wheezing

11 Fever, productive cough, SOB

Fever, cough, noisy respirations 4 yr old with choking episode

Fever, wheezing Abdominal Radiographs

 Useful for:  Perforation  Obstruction  Renal colic

12 Large vs. Small Bowel Small Bowel

 Large Bowel  Peripheral  Haustral markings don’t extend from wall to wall  Small Bowel  Central  Valvulae extend across lumen  Maximum diameter of 2 inches

Large Bowel Normal Abdominal Film

Constipation Abnormal Gas Patterns

 Functional Ileus  Localized Ileus (Sentinel loops)  Generalized adynamic ileus

 Mechanical Obstruction  Small bowel obstruction  Large bowel obstruction

13 Localized Ileus – Sentinel Loops Sentinel Loops

 Many times the location of the sentinel loops  Key Features indicate the nature of the underlying irritative process  One or two persistently dilated loops of large or small bowel  Gas is in rectum or sigmoid Cholecystitis Pancreatitis or Ulcer

Diverticulitis Appendicitis

Ureteral Calculus

Generalized Ileus Ileus Key Features  Hypomotility of GI Tract  Paralytic Ileus  Primarily post-op patients - generalized ileus  May resemble mechanical early SBO  Spinal cord injuries, opiates, hx. DKA  How to differentiate  Gas in dilated small bowel and large bowel to  Clinical Course rectum  Follow-up  Long air-fluid levels

Generalized Ileus Is it an Ileus

 Is the patient immediately post op?  Are bowel sounds absent or hypoactive?  Patients with Ileus have no bowel sounds  Symptoms of nausea & vomiting, no bowel movements

14 Mechanical SBO SBO

 Can occur anywhere distal to duodenum  Dilated small bowel  Little gas in the colon, especially rectum  Key – disproportionate dilatation of the small bowel

Mechanical SBO Causes Small Bowel Obstucion

 Adhesions  Hernia*  Volvulus  Gallstone ileus  Intussusceptions

 * Cause may be visible on plain films

Mechanical LBO Large Bowel Obstruction

 Dilated colon to point of obstruction  Little or no air in rectum or sigmoid  Little or no air in small bowel, if….  Ileocecal valve remains competent

15 Mechanical LBO Causes Major points

 Best film for overall gas pattern is supine  Tumor  Four major abnormal gas patterns:  Volvulus  Localized ileus  Hernia  Generalized ileus  Diverticulitis  Mechanical SBO  Intussusception  Mechanical LBO

Step ladder – air fluid levels Dilated small bowel – stacked coins Small bowel obstruction

String of Beads Pathognomonic: mechanical obstruction of What is it? small bowel

16 Free Air 3 Signs of Free Air

 Air will rise to the highest part of the abdomen  Air beneath the diaphragm  Both sides of the bowel wall  Falciform ligament sign

17 Pneumoperitoneum – Abdominal Free Air

Rigler’s sign Lateral decubitus – free intraperitoneal air air on both sides of bowel

Falciform ligament sign – Silver's Causes of Free Air Sign  Rupture of a hollow viscus  Perforated ulcer  Perforated diverticulitis  Perforated carcinoma  Trauma or instrumentation  Post op 5-7 days  Not perforated appendix

18 Is there free air? Is there free air?

Is there free air?

Approach to Extremity X-ray Mallet Finger Interpretation  Mechanism of injury – direct blow to the tip of  Two views – often fracture only seen in 1 view the finger.  Abnormal black lines = fracture  Hyperextension of the  Cortex interruption – should always be smooth tip of the extended finger  Joint space – narrow vs. wide  Soft tissue swelling and displaced fat pad

19 Mallet Finger Thumb metacarpal fractures

 Drop finger, baseball finger  Extra-articular fractures – more frequent  DIP Flexion Deformity of Extensor tendon  Transverse, oblique, comminuted & epiphyseal  Intra-articular  Bennett fracture  Rolando fracture

Bennett’s Fracture Bennett fracture Fracture or dislocation base of the first metacarpal  Fracture through articular surface with dislocation of metacarpal base

Bennett’s Fracture Rolando fracture

 Any comminuted intra-articular 1st metacarpal fracture (usually base)  T or Y configuration  Frequent complications  Residual pain  Loss of mobility  Full function recovery difficult

20 Rolando fracture Bennett Fx or Rolando Fx?

Boxer fracture Boxer Fractures 4th or 5th metacarpal fracture

Physical Exam of Carpal bones the Navicular/Scaphoid Bone  Some - Scaphoid  Lovers - Lunate  Palpation of the radial aspect of the wrist  Try - Triquetrum  Localized tenderness in the snuffbox  Positions - Pisiform  Palpation with ulnar deviation  That - Trapezium  Axial loading of the thumb  They - Trapezoid  Can’t - Capitate  Handle - Hamate

21 Carpal bone fractures Scaphoid blood supply Scaphoid fracture

 Accounts for 60 -70% of carpal bone fractures  Irregular, oblong bone that articulates with five other bones

Mechanism of Injury Lunate Bone Lunate Dislocation  Protected by the position in the Lunate fossa and  Fall on outstretched the triangular dorsiflexed hand - fibrocartilage complex FOOSH  Blood is supplied  May also be associated through the distal with other carpal bone portion of the bone fractures

Lateral View Lunate Dislocations

 Radius, lunate and capitate articulate with each other and lie in a straight line  Capitate sits in the lunate which sits on the radius  Apple, cup and saucer

22 Wrist Fractures Scapholunate dissociation Mechanism of Injury  Scaphoid & lunate torn apart, tear of  Slips on wet floor or scapholunate ligament icy walk with an  Space widened outstretched hand  Terry Thomas sign  Seen in the elderly more than young adult

Colles Fracture Colles fracture Dinner fork deformity

 A fracture of the distal radial metaphysis  Dorsal angulation

Smith fracture Smith Fracture Reverse colles – volar angulation

 The radius has a metaphyseal fracture and is shortened (reverse Colles fracture)

23 Buckle Fracture Greenstick Fracture

 Buckled Cortex is due to a fall on an outstretched hand  Torus fracture

Greenstick fracture Normal Fat Pad

Abnormal Fat Pads of Elbow Abnormal Fat Pads

Anterior Posterior

24 Anterior Humeral Line Radiocapitellar Line

Case Studies



25 Knee Fractures Normal Knee X-rays

 Most fractures easy to detect  Only sign of intra-articular fracture may be fat fluid level in supra-patellar bursa

Fat-fluid level Patella Fractures

 Need minimum 3 view x-rays  Sunrise or skyline  Consider comparison views

Tibial Plateau Fracture Mechanism of Injury

 “Bumper/Fender” fracture  Axial most common  Twist  Lateral directed force  Simple, comminuted, or depressed

26 Tibial Plateau Fracture Tibial Plateau Fracture

 Draw line perpendicular at most lateral margin of  Lateral tibial plateau most often fractured femur  (75-80%)  No more than 5 mm of adjacent Tibia outside of  Medial plateau stronger it  If > 5 mm = plateau fracture

Fracture Proximal Fibula

 Assoc with other injuries  > 5mm = fracture  Damage to ligaments or another fracture of knee

Ankle Anatomy Ankle mortise view

 “Square peg in square hole”  Uniform joint space  Integrity of talar dome

27 Lateral view of Ankle Inversion injury

 Lateral malleolus extends more inferiorly than medial malleolus  Posterior malleolus

Eversion injury Malleolar Fractures

 Bimalleolar fracture  Trimalleolar fracture  Maisonneuve fracture

28 Maissoneuve fracture

 High fracture of the shaft of fibula (above joint line)  Isolated fracture of the medial malleolus (or the posterior malleolus)  Widening of the ankle joint space  KEY – Always examine the upper leg in all patients with an ankle injury (1 in 20 ankle fractures)

Foot Fractures

 Hindfoot  Talus and calcaneous  Midfoot  Navicular, cuneiforms, and cuboid  Forefoot  Metatarsals and phalanges

Calcaneal Fracture Calcaneal Fractures

 Most obvious on lateral view  “Lovers fx”  Some only apparent when Bohler’s angle is  Boehler’s angle assessed  Mechanism of injury  Normal Bohler’s angle does not exclude fracture  Fall from height   10-20% T-L burst fx Sclerotic line may represent an impacted fracture  Simple twisting  CT optimal imaging technique  10% bilateral

29 Mid Foot Anatomy and Fractures Foot fractures

 Mid Foot  Navicular  Tarsometatarsal fractures/dislocations – Lisfranc injury

30 Lisfranc injury Lisfranc injury Mechanism of injury

 If bony fragment is  High energy mechanism detached from the base  Falls of any of the four medial  Vehicle crashes metatarsals then a tarsometatarsal dislocation  Direct crush should be suspected  Base of the 2nd metatarsal held in place by ligaments (may have normal AP view)

Lisfranc fracture-dislocation Mechanism of injury

Metatarsal Fractures Forefoot Anatomy and Fractures Mechanism of injury

 Metatarsal fractures  Direct blow to the foot  Shaft fractures  Inversion injury with 5th metatarsal  Jones – proximal 1.5 cm of shaft  Stress fractures  March fracture  Phalangeal fractures  Great toe fracture  Lesser toe fracture  Turf toe

31 5th Metatarsal Fracture

 Stress fracture of 5th metatarsal diaphysis  Jones – fx at metaphysis/diaphysis junction  Watershed blood supply

Fracture Base of 5th Metatarsal Proximal 5th metatarsal

 Common injury, often inversion of ankle  Avulsion at the insertion of the peroneus brevis tendon

Fracture 5th metatarsal Proximal 5th metatarsal fracture Stress & Jones fracture Avulsive fracture of tuberosity

32 Unfused apophysis at base of 5th metatarsal Unfused apophysis at base of 5th metatarsal

March Fracture Mechanism of injury

 Stress fracture of 2nd or 3rd metatarsal  Repetitive minor trauma

Fracture Great Toe Fracture toes Mechanism of Injury

 Direct blow  Axial load  Axial load  Direct trauma  Buddy tape 3-4 weeks  Wooden shoe

33 34 35