Matthew Tommack, D.O. October 13, 2018

Chest radiography◦ Anatomy, pathology

Shoulder Radiography◦ Anatomy, pathology

Knee Radiography◦ Anatomy, pathology

AnatomyConsolidation

AtelectasisPulmonary EdemaPleural EffusionPneumothorax

Technique, type and quality

Ribs and spine Upper abdomen Soft tissues Borders of the

mediastinum/heart Lungs◦ Pneumothorax◦ Consolidation◦ Pleural effusion◦ Interstitium/vessels

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

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

Obstructive / Resorptive◦ Endobronchial Lesion

Passive / Relaxation◦ Pleural Effusion, Pneumothorax

Compressive◦ Bulla

Cicatricial/Scarring◦ Radiation Fibrosis

Adhesive◦ Neonatal Respiratory Distress Syndrome/Hyaline

Membrane Dz

Lobar Segmental Subsegmental

(Plate/Streak) Round

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

of flow. Interstitial edema◦ Thin Kerley B lines (septal lines) and thick bronchi

Parahilar alveolar edema◦ Usually symmetric and non-segmental

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.

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

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

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

Discussed normal chest x ray with development of approach

Common clinical pathologies Questions

Anatomy Pathology

Acromion Clavicle

Greatertuberosity

Lesser Tuberosity

Coracoid process

Glenoid

Glenohumeral Joint

Acromion Clavicle

coracoid

Glenoid

AcromionClavicle

Glenoid Face

FootprintLabrum

Cartilage

SupraspinatusTendon

footprint

Supraspinatus Bursa

Subscapularis

Supraspinatus Infraspinatus

Biceps Tendon

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

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

Anterior Dislocation-most common type of dislocation-complications include Hill sachs impaction fracture and Bankart lesions as well as rotator cuff injury

AC Joint Injury-High Grade-Grading depends on degree of diplacement which relates to degree of soft tissue involvement

Osteoarthritis and chronic rotator cuff tear

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

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

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

Anatomy Common Pathology Questions

Anatomy Pathology

Tibial Spines

Fibular Head

MCL PCL ACL

Menisci

Quadriceps Tendon

Patellar Tendon

ACL PCL

Suprapatellar Recess

Patellofemoral joint space

Menisci

Cartilage

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

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

Osteoarthritis-osteophyte formation, joint space loss, subchondral cyst, subchondral sclerosis

Transient dislocation of patella with joint effusion and osteochondral lesion

Arcuate Complex fracture and Segond Fracture-associated with ligament tears, MRI next -insertion of lateral stabilizing ligaments and tendons

Complete patellar tendon tear-patella alta and edema-can have associated bony fragment

Quadriceps Tendon Tear-can have patella baja, edema, bony fragment

Cartilage forming bone tumor-presumed enchondroma, ie no symptoms or aggressive features-can be small, cartilage rests

Osteochondroma-common about the knee-can cause symptoms most commonly due to mass effect or fracture-rarely degenerate into chondrosarcoma

Osteoid Osteoma-classic finding of night pain relieved by nsaids-can create exuberant periosteal rxn and can be distant from nidus

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

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

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

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

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.