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 Copyright: PEA, LLC 2016 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 Copyright: PEA, LLC 2016 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 Copyright: PEA, LLC 2016 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 Copyright: PEA, LLC 2016 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