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Orthopedic Radiology Dr. W. Pacheco 2 XI 2010 Joyce and Cedes.

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Presentation on theme: "Orthopedic Radiology Dr. W. Pacheco 2 XI 2010 Joyce and Cedes."— Presentation transcript:

1 Orthopedic Radiology Dr. W. Pacheco 2 XI 2010 Joyce and Cedes

2 Principles Orthogonal (90 degrees from last view- DEPTH) Joint above and below Contralateral view for children Splint! Because of pain. Secondary na ang prevention of further injury Weight-bearing vs. Dynamic joints Primum non nocere.

3 Reporting 1)View, laterality, date 2)Quality of X-ray (exposure, etc) 3)Quality of bone and alignment (You’ll see bone trabeculae dapat) 4)Assess joint surfaces 5)Assess soft tissues

4 Common Views for Upper Extremities Shoulder: AP, Scapular Y view Humerus :AP, Lateral Elbow: AP, Lateral Forearm: AP, Lateral Wrist: PA,Lateral Hand: oblique, AP, Lateral

5 Shoulder routine: AP, axillary, transcapular, scapular Y view

6 SHOULDER AP Indications for imaging Trauma - dislocations, fractures, tendon calcifications Arthritis survey Bone pain.

7 SHOULDER AP Shoulder X-ray, AP projection 1, Clavicle. 2, Acromion. 3, Greater tubercle. 4,Lesser tubercle. 5, Neck of Humerus. 6, Humerus. 7, Coracoid Process. 8, Axillary border of scapula. 9, Rib.

8 SHOULDER AP

9 SHOULDER axillary

10 SHOULDER scapular Y view Indications for imaging Trauma - dislocations, fractures, Anatomy Demonstrated Demonstrates relationship of humeral head to glenoid, spine of scapula and head of humerus in lateral profile.

11 SHOULDER scapular Y view Shoulder X-ray: lateral view 1, Coracoid Process. 2, Clavicle. 3, Acromion. 4,Head of Humerus. 5, Humerus. 6, Axillary border of scapula.

12 SHOULDER scapular Y view

13 SHOULDER scapular Y view

14 SHOULDER recap

15 Abnormalities 1) Inferior Dislocation can’t say if it’s an anterior or posterior dislocation (xray has no depth) 2) Greater Tuberosity fracture: with humeral dislocation – Which view will you request? Scapular Y View (so you don’t need to move the patient who’s in pain) 3) Problem in scapular body w/ multiple rib fractures  The Scapula is wrapped around muscle, so It’ll take a very large amount of energy to fracture it. Following such fracture, the rib cage is affected  rib cage fracture  pulmonary problems then arise (ex. pneumothorax…)

16 Humerus routine: AP and lateral Translateral!

17 HUMERUS AP Indications for imaging Trauma - dislocations, fractures, soft tissue calcifications Arthritis survey Bone pain.

18 HUMERUS lateral Indications for imaging Trauma - dislocations, fractures, soft tissue calcifications Arthritis survey Bone pain. WALA AKONG MAKITANG HUMERUS LATERAL SA NET

19 Elbow routine: AP and lateral

20 ELBOW AP Indications for imaging Trauma, loose bodies, bone pain

21 ELBOW AP Elbow Radiograph - AP projection 1, Humerus. 2, Medial epicondyle. 3, Lateral epicondyle. 4, Olecranon fossa. 5, capitellum. 6, Radius. 7, Radial Head. 8, Ulna. 9, Olecranon process. 10, Coronoid process.

22 ELBOW lateral Indications for imaging Trauma, loose bodies, bone pain

23 ELBOW lateral Elbow Radiograph - AP projection 1, Humerus. 2, Medial epicondyle. 3, Lateral epicondyle. 4, Olecranon fossa. 5, capitellum. 6, Radius. 7, Radial Head. 8, Ulna. 9, Olecranon process. 10, Coronoid process. 11, anterior fat pad

24 ELBOW lateral

25 Forearm routine: AP and lateral

26 FOREARM AP Indications for imaging Trauma*, metastases, bone pain. (*Monteggia's fracture, fracture of the ulna with dislocation of the head of the radius.

27 FOREARM AP

28 FOREARM lateral Indications for imaging Trauma*, metastases, bone pain. (*Monteggia's fracture, fracture of the ulna with dislocation of the head of the radius.)

29 FOREARM lateral

30 FOREARM AP MONTEGGIA’s FRACTURE - Giovanni Monteggia (1814) first described frx of proximal 1/3 of ulna in association w/ anterior dislocation of radial head; - hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity. - Mechanism: - proposed mechanisms include direct blow & hyperpronation injuries as well- as the hyperextension theory;

31 FOREARM AP GALEAZZI’S FRACTURE

32 Fat Pad Sign More radiolucent area (less dense); seen in fractures wherein hematoma and bleeding pushes fat. Fracture  hematomoa  push out the normal fat  visible radiolucent area

33 Wrist routine: PA and lateral Special: carpal tunnel view

34 WRIST PA Indications for imaging Injury, pain, carpal tunnel syndrome,

35 WRIST lateral Indications for imaging Injury, pain, carpal tunnel syndrome,

36 WRIST carpal tunnel view

37 WRIST others COLLES’ FRACTURE

38 Hand routine: AP and oblique

39 HAND AP Indications for imaging Injury, ? rheumatoid arthritis, ?acromegaly, bone pain

40 HAND AP Hand X-ray - AP 1, Distal phalanx. 2, Distal interphalangeal joint. 3, Middle phalanx. 4, Proximal interphalangeal joint. 5, Proximal phalanx. 6, Metacarpophalangeal joint. 7, Head of 5th metacarpal. 8, Sesamoid bone.

41 HAND oblique

42 HAND others

43 Common Views for Lower Extremities Both hips AP, frog leg lateral (for children, congenital problems) Cross table lateral (for hip fractures) Femur AP, lateral Knee AP, Lateral Leg AP, Lateral Ankle mortise, AP, Lateral Foot AP, oblique, lateral Pelvis AP

44 Pelvis routine: AP only Special: Pelvic Inlet, Pelvic Outlet Acetabulum: Judets view (obturator & iliac)

45 PELVIS AP

46 PELVIS AP Indications for imaging Congenital abnormalities, Trauma, degenerative disease, carcinoma primary and secondary, pathologies e.g. Perthes disease, slipped femoral epiphyses. Anatomy Demonstrated Iliac bones, femoral heads and necks, ishium, pubis and scrum.

47 PELVIS AP 1 Superior Ramus of Right Pubis 2 Symphysis Pubis 3 Inferior Ramus of Left Pubis 4 Left obturator foramen 5 Left lesser Trochanter 6 Left Greater Trochanter 7 Left iliac wing 8 Iliac crest 9 Vertebral Pedicle (Lumbar Spine) 10 Right Sacro-iliac joint 11 Head of right femur

48 PELVIS AP

49 PELVIS inlet vs outlet view

50 PELVIS male vs female

51 PELVIS AP Female pelvis. Note the sacro-iliac joints, the subpubic angle, and the continuous curvature of the margin of the obturator foramen and the neck of the femur (Shenton's line)

52 PELVIS AP This pelvis is of an 11 month old. To draw Shenton's line, the inferior border of the superior pubic ramus is traced laterally and should smoothly extend to the inferomedial border of the proximal femur.

53 PELVIS acetabulum 1,Acetabular fossa. 2, Head femoral. 3, Greater trochanter. 4, Lesser trochanter. 5, Femur. 6, Obturator foramen. 7, Inferior pubic ramus. 8, Superior pubic ramus. 9, Sacrum. 10, Iliac wing.

54 Sample Case Asymmetrical (imagine picture- may obvious rami fracture and a subtle SI fracture which John/.Joshua/Roel spotted) -Hole: symmetrical? -SI joint: normal? Widened? (if widened = Ala fracture) Request other views: outlet  is dislocation up or down? Inlet  did disloc hemipelvis move pa-front of back? *Sacral Wing problems involve Nerves S1-5 (which innervate the bladder, I.e. urinary and sexual function implications) True leg length (ASIS to medial malleolus), is it equal? Yes. Apparent leg length (umbilicus [fixed portion in midline] to medial malleolus) equal? No hemi pelvis moved upwards and posteriorly

55 PELVIS frog’s view Indications for imaging Congenital abnormalities, Perthes disease, slipped femoral epiphyses. Anatomy Demonstrated Femoral heads and necks, acetabulum

56 PELVIS frog’s view 1, Symphysis pubis. 2, Obturator foramen. 3, Ischium. 4, Lesser trochanter. 5, Femur. 6, Femoral head. 7, Anterior inferior iliac spine. 8, Acetabular fossa. 9, Anterior superior iliac spine.

57 PELVIS- acetabulum visualization obturator vs iliac view

58 PELVIS obturator vs iliac

59 PELVIS obturator vs illac

60 Additional Info Cross table lateral view  patient’s opposite/unaffected limb is raised, plate is beside the involved hip, beam is at 30 degrees Frog leg view  soles of the feet together then ask patient to make bukaka. Can see the relationship of the hip joint to the acetabulum. In kids, you can see if may dysplastic hip or a slipped capital femoral epiphysis.

61 Cervical Spine Routine: AP and lateral Special: Swimmer’s, Open Mouth

62 CERVICAL SPINE lateral Indications for imaging Trauma, pain, rheumatoid arthritis, upper limb paraethesia, vertebral artery syndrome.

63 CERVICAL SPINE lateral

64 CERVICAL SPINE lateral Cervical Spine X-ray: Lateral view. 1, Vertebral body (TH1). 2, Spinous process of C7. 3, Lamina. 4, Inferior articular process. 5, Superior articular process. 6,Spinous process of C2. 7, Odontoid process. 8, Anterior arch of C1 (Atlas). 9,Trachea.

65 CERVICAL SPINE lateral

66 CERVICAL SPINE lateral Normal cervical spine?

67 CERVICAL SPINE lateral A lateral radiograph of the cervical spine demonstrates a fracture through the posterior elements of C2 (yellow arrow) with forward subluxation of the anterior aspect of C2 on C3 (white arrow). This injury is caused by a combination of extension and compression

68 CERVICAL SPINE lateral

69 CERVICAL SPINE lateral A lateral radiograph of the cervical spine demonstrates subluxation of C1 on C2, in this instance anterior subluxation most likely caused by severe hyperflexion (white arrow).

70 CERVICAL SPINE AP Cervical vertebrae 3 to 7, vertebral bodies, spinous processes intervertebral spaces

71 CERVICAL SPINE AP Cervical vertebrae 3 to 7, vertebral bodies, spinous processes intervertebral spaces

72 CERVICAL SPINE open mouth

73 CERVICAL SPINE open mouth Indications for imaging Trauma, pain, rheumatoid arthritis, Anatomy Demonstrated Cervical vertebrae 1 & 2, odontoid process intervertebral space, posterior arch of atlas and lateral masses.

74 CERVICAL SPINE open mouth Atlas and odontoid process: AP view (Mouth wide open). 1, Transverse process of C1. 2, Lateral mass of C1. 3, Odontoid. 4, Inferior articular process of C1. 5, Superior articular process of C2.

75 Jefferson Fracture. There is bilateral offset of both the right and left lateral masses of C1 relative to the lateral masses of C2 on the open- mouth cervical spine view (above-white arrows). This indicates a burst-type injury to the ring of C1. A single axial CT scan through the level of C1 shows fractures involving the right and left anterior ring of C1 and the right posterior ring (yellow arrows). CERVICAL SPINE open mouth

76 CERVICAL SPINE oblique Anatomy Demonstrated Cervical vertebra bodies, intervertebral foramina, articular pillars apophysial joints and spinous processes. The intervertebral foramina demonstrated are those furthest from the film. Indications for imaging Trauma, pain, rheumatoid arthritis, upper limb paraethesia, vertebral artery syndrome.

77 CERVICAL SPINE oblique Anatomy Demonstrated Cervical vertebra bodies, intervertebral foramina, articular pillars apophysial joints spinous processes.

78 CERVICAL SPINE oblique Cervical Spine X-ray, (Left Neural Foramina). 1, Rib. 2, Clavicle. 3, Neural Foramina. 4, Pedicle. 5, Trachea.

79 CERVICAL SPINE swimmer’s view

80 CERVICAL SPINE swimmer’s view

81 Thoracic Spine routine: AP and lateral

82 AP VIEW THORACIC SPINE AP Indications for imaging Congenital abnormalities, scoliosis, trauma, pain, metastasis's. Anatomy Demonstrated Thoracic vertebra, medial ends of ribs.

83 THORACIC SPINE AP

84 THORACIC SPINE AP

85 THORACIC SPINE AP Thoracic Spine X-ray: AP projection. 1, Left ventricle. 2, Gas in stomach. 3, Right hemidiaphragm. 4, Posterior rib. 5,Clavicle. pedicles

86 THORACIC SPINE AP Thoracic Spine X-ray: AP projection. 1, Gas in Colon (Splenic flexure). 2, Gas in stomach. 3, Left hemidiaphragm. 4, Posterior rib. 5, Pedicle. 6, Spinous process. 7, Transverse process.

87 THORACIC SPINE AP Di pala thoracic to sorry! HEHE! Just to show scoliosis!

88 THORACIC SPINE AP Spot the Winking Owl!

89 THORACIC SPINE AP

90 THORACIC SPINE lateral Indications for imaging Congenital abnormalities, scoliosis, trauma, pain, metastasis's. Anatomy Demonstrated Thoracic vertebra,

91 THORACIC SPINE lateral Thoracic Spine X-ray: Lateral view. 1, Right hemidiaphragm. 2, Left hemidiaphragm. 3, Vertebral body. 4, Rib

92 THORACIC SPINE lateral Thoracic Spine X-ray: Lateral view. 1,Posterior rib. 2, Vertebral body. 3, Intervertebral discal space.

93 THORACIC SPINE lateral

94 THORACIC SPINE lateral A 73-year-old female with L1 vertebral compression fracture treated with kyphoplasty 6 weeks after fracture. The focal kyphosis was corrected from 16° to 5°.

95 Lumbosacral Spine routine: AP and lateral

96 LUMBOSACRAL SPINE AP Indications for imaging Congenital abnormalities, trauma, pain, metastasis's. Anatomy Demonstrated Lumbar vertebra, sacro iliac joints, Sacrum coccyx

97 LUMBOSACRAL SPINE AP Lumbar spine X-ray, AP projection 1, rib. 2, Transverse process. 3, Pedicle. 4, Spinous Process. 5, Sacrum. 6, Sacroiliac joint

98 LUMBOSACRAL SPINE AP

99 LUMBOSACRAL SPINE AP

100 LUMBOSACRAL SPINE AP

101 LUMBOSACRAL SPINE lateral Indications for imaging Congenital abnormalities, trauma, pain, metastasis's. Anatomy Demonstrated Lumbar vertebra.

102 LUMBOSACRAL SPINE lateral Lumbar spine X-ray, lateral view 1, Sacrum. 2, Spinous Process. 3, Vertebral body. 4, Intervertebral disc space. 5, Intervertebral foramina., Pedicle. 7, Inferior articulating facet. 8,Superior articulating facet. 9, Rib.

103 LUMBOSACRAL SPINE oblique

104 LUMBOSACRAL SPINE lateral

105 Knee routine: AP and lateral Special: patella’s skyline view s

106 AP KNEE AP

107 Standing AP KNEE AP

108 LAT KNEE lateral

109 KNEE skyline view

110 KNEE merchant’s view

111 Ankle routine: AP, mortise and lateral s

112 ANKLE AP

113 ANKLE mortise view

114 ANKLE lateral view

115 LAT

116 Calcaneus Axial, lateral, axial view s

117 CALCANEUS lateral view

118 CALCANEUS lateral view

119 Foot AP and oblique s

120 FOOT AP

121 FOOT lateral

122 FOOT oblique

123 Lisfranc’s Fracture

124 The end.


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