Presentation on theme: "Orthopedic Radiology Dr. W. Pacheco 2 XI 2010"— 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 belowContralateral view for childrenSplint! Because of pain. Secondary na ang prevention of further injuryWeight-bearing vs. Dynamic jointsPrimum non nocere.
3 Reporting View, laterality, date Quality of X-ray (exposure, etc) Quality of bone and alignment (You’ll see bone trabeculae dapat)Assess joint surfacesAssess soft tissues
4 Common Views for Upper Extremities Shoulder: AP, Scapular Y viewHumerus :AP, LateralElbow: AP, LateralForearm: AP, LateralWrist: PA ,LateralHand: oblique, AP, Lateral
5 Shoulder routine: AP, axillary, transcapular, scapular Y viewAvoid manoeuvring patient esp if masakit (hx of trauma). Kaya you move the film and beam instead.
6 SHOULDERAPIndications for imaging Trauma - dislocations, fractures, tendon calcifications Arthritis survey Bone pain.Usong-uso ang dislocations.
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.
10 SHOULDER scapular Y view Anatomy Demonstrated Demonstrates relationship of humeral head to glenoid, spine of scapula and head of humerus in lateral profile.Indications for imaging Trauma - dislocations, fractures,
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 SHOULDERscapular Y viewA shows anterior dislocation
13 SHOULDERscapular Y viewB shows posterior dislocation
14 SHOULDERrecapBetween anterior and posterior dislocations, ano ang mas madalas mangyari?
15 Abnormalities1) Inferior Dislocation can’t say if it’s an anterior or posterior dislocation (xray has no depth)2) Greater Tuberosity fracture: with humeral dislocationWhich 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…)
17 HUMERUS AP Indications for imaging Trauma - dislocations, fractures, soft tissue calcifications Arthritis survey Bone pain.
18 HUMERUS WALA AKONG MAKITANG HUMERUS LATERAL SA NET 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 In any view (AP, Lat, Oblique), radial head must always be centered sa capitulum (“capitellem”).
20 ELBOWAPIndications for imaging Trauma, loose bodies, bone pain
24 ELBOW lateral Middle is normal This is an invaluable soft tissue finding in cases of intra-articular injury of the elbow. Fat is normally present within the joint capsule of the elbow, but outside the synovium. Typically "hidden" in the concavity of the olecranon and coronoid fossae, the fat is usually not visible on the lateral radiograph. However, injuries that produce intra-articular hemorrhage cause distension of the synovium and forces the fat out of the fossa, producing triangular radiolucent shadows anterior and posterior to the distal end of the humerus. When present in a patient with a history of acute trauma to the elbow, the fat pad sign indicates the presence of an intra-articular hemorrhage, which in turn is often associated with an intra-articular skeletal injury (usually the radial head in an adult).
25 Forearm routine: AP and lateral Always get 2 joints in view
26 FOREARMAPIndications for imaging Trauma*, metastases, bone pain. (*Monteggia's fracture, fracture of the ulna with dislocation of the head of the radius.
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;Monteggia Fracture - fracture of the proximal ulna with a dislocation of the radial head.
31 FOREARM AP GALEAZZI’S FRACTURE The combination of a fracture near the junction of the mid to distal third of the radius with disruption of the distal radioulnar joint (DRUJ) is a Galeazzi fracture. Ricardo Galeazzi described his experience of 18 such cases in 1934. The fracture has taken his name since then, although it was initially described by Cooper in 1842. The main ED priorities are accurate diagnosis and identification of early complications.
32 Fat Pad SignMore 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 viewUsually missed fracture: SCAPHOID (boat-shaped). Manifests as wrist pain. Where to palpate it? Look for your radial snuffbox.Nice to know: Terry Thomas Scapholunate dissociation (Madonna sign)- Clenched fist view: scaphoid and lunate could be seen dissociating
34 WRISTPAIndications for imaging Injury, pain, carpal tunnel syndrome,
35 WRISTlateralIndications for imaging Injury, pain, carpal tunnel syndrome,
46 PELVISAPAnatomy Demonstrated Iliac bones, femoral heads and necks, ishium, pubis and scrum.Indications for imaging Congenital abnormalities, Trauma, degenerative disease, carcinoma primary and secondary, pathologies e.g. Perthes disease, slipped femoral epiphyses.
47 PELVISAP1 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 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
49 PELVIS inlet vs outlet view 1) Pelvic Inlet: Normally inclined about 45 deg. (”Kitang kita yung butas”); patient supine, xray beneath, beam points to the foot at 45 deg, sacroiliac widening and displacement of hemipelviscan be seen; donut shaped2) Pelvic Outlet: View from the bottom - useful for those with pelvic fractures; beam directed cephalad; whole sacrum and superior and inferior pubic rami can be seen; butterfly-like
51 PELVISAPFemale 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)NORMAL
52 PELVISAPThis 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.Developmental Dysplasia of the Hip (DDH)
54 Sample CaseAsymmetrical (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? Nohemi pelvis moved upwards and posteriorly
55 PELVISfrog’s viewAnatomy Demonstrated Femoral heads and necks, acetabulumIndications for imaging Congenital abnormalities, Perthes disease, slipped femoral epiphyses.
57 PELVIS- acetabulum visualization obturator vs iliac viewObturator view obturator would be clearly defined, anterior column of acetabulum (anterior pelvic, posterior rim) is seenIliac internal Oblique View posterior column of the acetabulum is seen; can see the iliac wing
59 PELVISobturator vs illacHoho. Illac Diaz, hello!
60 Additional InfoCross table lateral viewpatient’s opposite/unaffected limb is raised, plate is beside the involved hip, beam is at 30 degreesFrog 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 Open-mouth: to see C1 and C2Get Obliques to check for nerve impingement
62 CERVICAL SPINE lateral Indications for imaging Trauma, pain, rheumatoid arthritis, upper limb paraethesia,vertebral artery syndrome.Check for normal curvature, visualize 7 vertebrae
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 compressionHangman’s fracture
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).Atlantoaxial subluxation
70 CERVICAL SPINE AP Cervical vertebrae 3 to 7, vertebral bodies, spinous processesintervertebral spaces
71 CERVICAL SPINE AP T1 Cervical vertebrae 3 to 7, vertebral bodies, spinous processesintervertebral spacesT1
72 CERVICAL SPINE open mouth - to view odontoid process should be centered- check space between odontoid and C1--> space should be equal on both sides (& symmetrical)*also check if disk space and alignment on both sides are equalJEFFERSON’S fracture - burst fracture of C1 (multiple fracture); (+) overhang of C1 over C2
73 CERVICAL SPINE open mouth Anatomy Demonstrated Cervical vertebrae 1 & 2,odontoid processintervertebral space,posterior arch of atlas andlateral masses.Indications for imaging Trauma,pain,rheumatoid arthritis,
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.... Water’s view? Joke lang.
75 CERVICAL SPINE open mouth 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).Jefferson, i.e. Burst fracture.
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 pillarsapophysial jointsspinous processes. - to view intervertebral foramina (a.k.a. Mga butas) where cervical nerve roots pass- done when suspecting encroachment of nerve roots; radiculopathies- notes: there are 8 cervical roots and 7 cervical vertebra
82 THORACIC SPINE AP AP VIEW Anatomy Demonstrated Thoracic vertebra, medial ends of ribs.Indications for imaging Congenital abnormalities,scoliosis,trauma,pain,metastasis's.
83 THORACIC SPINEAPThis is an inadequate radiograph of the thoracic spine although all thoracic vertebrae (T1-T12) are seen on this AP view. For trauma imaging, C7 and L1 must be entirely demonstrated to evaluate potential dislocation at the cervical and lumbar junctions. As for the radiograph technique, it is adequate for the upper vertebrae but the lower thoracic vertebrae are poorly penetrated. This is because the exposure favors high contrast rather than low contrast and good penetration. To correct for this you should use the anode-heel-effect or a wedge filter to even out the density difference between the upper and lower thoracic spine. When using anode-heel-effect place the thicker part under the cathode end of the anode. This will provide a greater number of photons with greater energy to that area. Using the 50/15 rule to create a radiograph with a slightly lower contrast is recommended to make this an optimal film.
85 THORACIC SPINE AP pedicles 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! Mets! If nakain na ang pedicles.
103 LUMBOSACRAL SPINE oblique Scotty Dog/Pars Defect- oblique! The parts of the dog are as follows:the transverse process-the nose;the pedicle-the eye;the pars interarticularis-the neck;the superior articular facet-the ear;the inferior articular facet-the front leg.If pars interarticularis is broken- SpondylolysisIf pars is borken AND has moved/slipped- Spondylolisthesis (beheaded Scotty Dog)
104 LUMBOSACRAL SPINE lateral Spondylolysis L Spondylolisthesis R Fracture in pars interarticularis
105 Knee routine: AP and lateral Special: patella’s skyline views