1 FILM CRITIQUE UNIT 4 PELVIS HIPS SPINE Including ST Neck

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12 Hands Note Intertrochanteric fx

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15 End of Prosthesis Device Not seen

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22 Subcapital fx

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38 Intertrochanteric fx

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42Osteoporosis

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45 c/o Lt buttock pain

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49 Osteo arthritis Osteo arthritis

50 Pagets sarcoma

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59 Name of “view” for acetabulum?

60 This is not a Axiolateral HIP ! What is it? INF/SUP Shoulder

61 No gonad shield

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66 DISCLOCATED SI JT CA

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69 C-1 ring fx

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76 Jefferson’s fx a burst fx of C-1 –atlas = results from compression of the C.SP – may also be associated with fx of C-2 (axis) May or may not involve the transverse ligament

77 Rheumatoid arthritis

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83 Hangmans fx

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86 Ankylosing Spondylitis

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88 Hangman fx

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103 pointing to the superior and inferior vertebral notches on adjacent vertebrae. The pedicles form the intervertebral foramina; however, the atlas does not have pedicles nor does it form any intervertebral foramina

104torticolis

105 Spaces not well seen -calcification of ligaments

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123 CA mets transverse process

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129fx

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138 A body E transverse process D pedicle O superior articular facet, left P pars interarticularis, left R inferior articular facet, left I apophyseal (interfacetal) joint, left V disk space

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142 Calc disc comp fx osteop

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150 Facets distroyed

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153spondylolithesis

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155spondylolythesis

156sacralization

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158spurring

159 “CAGE” POST OP FOR HERNIATED DISK

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161 SPINE CRITIQUE additional information Review on your own

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163 If the technologist had pulled down on the patient’s shoulders to image this person’s spine, paralysis may have occurred.

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165 Next, observe that the 7th cervical vertebra has no rib attachment, and as its name (vertebra prominens) implies, it has a long spinous process that is not bifid (white arrow). Note the rib attachment to the first thoracic vertebra (long yellow arrow). Next, observe that the 7th cervical vertebra has no rib attachment, and as its name (vertebra prominens) implies, it has a long spinous process that is not bifid (white arrow). Note the rib attachment to the first thoracic vertebra (long yellow arrow). All apophyseal joints, especially C7/T1 so easily seen on this radiograph (short yellow arrow) must be seen on the Swimmer’s view when is it made. All apophyseal joints, especially C7/T1 so easily seen on this radiograph (short yellow arrow) must be seen on the Swimmer’s view when is it made.

166 This radiograph is difficult to critique because of the poor radiographic contrast. A good radiographer can make a good radiograph even under the most difficult patient conditions. This radiograph is difficult to critique because of the poor radiographic contrast. A good radiographer can make a good radiograph even under the most difficult patient conditions. Adequate penetration is demonstrated; but because of the graininess due to technical factors subject detail is lacking. Increasing the mAs, using high ratio grid, and using tighter collimation will optimize the subject detail. Adequate penetration is demonstrated; but because of the graininess due to technical factors subject detail is lacking. Increasing the mAs, using high ratio grid, and using tighter collimation will optimize the subject detail. To find T1 on this radiograph we must identify the 1st rib. It has an attachment to the manubrium at the clavicular notch anteriorly (white arrow). Just below it is the 1st costal cartilage where the 1st rib attaches. The yellow arrow indicates the first rib and T1. To find T1 on this radiograph we must identify the 1st rib. It has an attachment to the manubrium at the clavicular notch anteriorly (white arrow). Just below it is the 1st costal cartilage where the 1st rib attaches. The yellow arrow indicates the first rib and T1. The apophyseal joints of C7/T1 are seen but without good subject contrast. The alignment of the vertebrae can be determined because the positioning is good. The apophyseal joints of C7/T1 are seen but without good subject contrast. The alignment of the vertebrae can be determined because the positioning is good.

167 Here is an example of the head being extended too far. This view resembles a reverse Water’s view for profiling the odontoid tip (Fuchs). Here is an example of the head being extended too far. This view resembles a reverse Water’s view for profiling the odontoid tip (Fuchs). Also notice that the radiographic technique is inadequate. This low contrast image shows poor bone detail. In addition good patient positioning, subject detail must be adequate for soft tissues and bone detail. Also notice that the radiographic technique is inadequate. This low contrast image shows poor bone detail. In addition good patient positioning, subject detail must be adequate for soft tissues and bone detail. Repeat this image with the head tilted downward. Repeat this image with the head tilted downward. Use a higher ratio grid, or select a technique that allows for an increase in the mAs of at least a 15% reduction in kVp to improve subject contrast. Not using above 80 kVp initially will be less radiation to the patient than a repeated film Use a higher ratio grid, or select a technique that allows for an increase in the mAs of at least a 15% reduction in kVp to improve subject contrast. Not using above 80 kVp initially will be less radiation to the patient than a repeated film

168 Diagnostic Criteria for Imaging the Open- mouth odontoid view of the Cervical Spine Position the patient so that the upper incisors are superimposed over the base of the skull’s external occipital protuberance. This can be accomplished by placing the acanthiomeatal line perpendicular to the tabletop. Position the patient so that the upper incisors are superimposed over the base of the skull’s external occipital protuberance. This can be accomplished by placing the acanthiomeatal line perpendicular to the tabletop. Align the mid-sagittal plane (MSP) perpendicular to the horizontally directed central ray (CR). The part is positioned for non-trauma patients by having them raise or tuck their chin to achieve alignment. If the patient is in a cervical collar the CR is angled so that it is parallel with the infraorbitomeatal line (IOML). Align the mid-sagittal plane (MSP) perpendicular to the horizontally directed central ray (CR). The part is positioned for non-trauma patients by having them raise or tuck their chin to achieve alignment. If the patient is in a cervical collar the CR is angled so that it is parallel with the infraorbitomeatal line (IOML). The lateral margins of C1/C2 should be aligned unless there is pathological reason for its misalignment. The spinous process of the axis should be on the mid-sagittal line. The spacing of the atlantoaxial joints should be equal. Equal spacing on the lateral borders of the odontoid process; the tip should be completely seen. The lateral margins of C1/C2 should be aligned unless there is pathological reason for its misalignment. The spinous process of the axis should be on the mid-sagittal line. The spacing of the atlantoaxial joints should be equal. Equal spacing on the lateral borders of the odontoid process; the tip should be completely seen. Structures demonstrated are: atlantoaxial joints, occipitoatlantal joints, odontoid process and body of the axis, and lateral masses and transverse processes of the atlas. Structures demonstrated are: atlantoaxial joints, occipitoatlantal joints, odontoid process and body of the axis, and lateral masses and transverse processes of the atlas.

169 In addition to adequately visualizing C1 and C2, the following alignments should be meet when positioning the patient: In addition to adequately visualizing C1 and C2, the following alignments should be meet when positioning the patient: The lateral margins of C1/C2 should be aligned unless there is pathological reason for its misalignment. The lateral margins of C1/C2 should be aligned unless there is pathological reason for its misalignment. The spinous process of the axis should be on the mid- sagittal line. The spinous process of the axis should be on the mid- sagittal line. The spacing of the atlantoaxial joints should be equal. The spacing of the atlantoaxial joints should be equal. Equal spacing on the lateral borders of the odontoid process; the tip should be completely seen. Equal spacing on the lateral borders of the odontoid process; the tip should be completely seen.

170 Notice that this image is poorly collimated. There is nothing to be gained by including the maxillary sinuses! Notice that this image is poorly collimated. There is nothing to be gained by including the maxillary sinuses! Secondly, the upper incisors are projected above the base of the skull. The chin should be tucked down (flexed) to line up the teeth and base of skull. The acanthiomeatal line should be perpendicular to the tabletop. The atlantoaxial joints are not opened because of the poor positioning. Also notice the rotation of the spinous process and spacing on the lateral borders of the odontoid process. Secondly, the upper incisors are projected above the base of the skull. The chin should be tucked down (flexed) to line up the teeth and base of skull. The acanthiomeatal line should be perpendicular to the tabletop. The atlantoaxial joints are not opened because of the poor positioning. Also notice the rotation of the spinous process and spacing on the lateral borders of the odontoid process.

171 Don’t be fooled into thinking that this is a good radiograph just because the anatomy is present. Don’t be fooled into thinking that this is a good radiograph just because the anatomy is present. The anatomical relationships must be presented as well. The anatomical relationships must be presented as well. Here is another example of an open mouth odontoid view in which the head is extended too far back. Here is another example of an open mouth odontoid view in which the head is extended too far back. The chin should be brought down until the upper teeth are superimposed over the base of the skull (arrows). This will require bringing the acanthiomeatal line perpendicular to the tabletop. The spacing of the atlantoaxial joints is not properly demonstrated. The chin should be brought down until the upper teeth are superimposed over the base of the skull (arrows). This will require bringing the acanthiomeatal line perpendicular to the tabletop. The spacing of the atlantoaxial joints is not properly demonstrated. It is very possible to get a good view that demonstrates the joint spaces and odontoid process. Unfortunately, this view should be repeated. It is very possible to get a good view that demonstrates the joint spaces and odontoid process. Unfortunately, this view should be repeated.

172 Because of the metal tooth plate it will be difficult to image the odontoid tip. Because of the metal tooth plate it will be difficult to image the odontoid tip. Because the alignment of the teeth and base of the skull are adequate repeating this view may not yield the desired result. Because the alignment of the teeth and base of the skull are adequate repeating this view may not yield the desired result. Instead, bring the head down just a little, then lower the tube to about 20 cm. Instead, bring the head down just a little, then lower the tube to about 20 cm. Allow the divergence of the CR to clear the part. The other option is to add a Fuchs view. Allow the divergence of the CR to clear the part. The other option is to add a Fuchs view.

173 Consider that the lateral masses are covered by dental fillings; your positioning becomes even more critical. Consider that the lateral masses are covered by dental fillings; your positioning becomes even more critical. The chin is tucked down too much! Slightly tilt the head backwards. This will help to demonstrate more of each lateral mass and the odontoid tip. The chin is tucked down too much! Slightly tilt the head backwards. This will help to demonstrate more of each lateral mass and the odontoid tip. You still may need to add a Fuchs view to demonstrate the spacing on each side of the odontoid peg You still may need to add a Fuchs view to demonstrate the spacing on each side of the odontoid peg Collimation??? Collimation??? Should the image should be repeated!

degrees for zygos

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176 Breathing tech

177 C7 and L1 must be entirely demonstrated to evaluate for subluxation of the thoracic spine.

178 Poor centering poor contrast / spaces not open

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180 Because of the chest tube and intubation, the positioning seen here is acceptable.

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186 It appears there was some difficulty in locating the lumbosacral junction. It appears there was some difficulty in locating the lumbosacral junction. To find L5/S1 you should remember that the iliac crest is at the level of L4. To find L5/S1 you should remember that the iliac crest is at the level of L4. This places L5/S1 at approximately 1 inch below this point. T This places L5/S1 at approximately 1 inch below this point. T there is too much of the lumbar spine demonstrated and too little of the sacrum. there is too much of the lumbar spine demonstrated and too little of the sacrum. The collimation is poor The collimation is poor This radiograph must be repeated using the radiological landmarks for locating L5/S1. This radiograph must be repeated using the radiological landmarks for locating L5/S1. The radiographic exposure technique should also be changed so that the part is well penetrated. This is a high contrast film having poor penetration of the lumbosacral junction. The radiographic exposure technique should also be changed so that the part is well penetrated. This is a high contrast film having poor penetration of the lumbosacral junction.

187 For L5- S1 – is it acceptable?

188 part is not centered part is not centered it is clipped it is clipped metal snaps are present metal snaps are present The patient is not positioned in a true lateral. The patient is not positioned in a true lateral. A disruption of the column, or encroachment on the vertebral canal cannot be evaluated. A disruption of the column, or encroachment on the vertebral canal cannot be evaluated. Also, 5% of patients have spondylolisthesis secondary to chronic stress fractures Also, 5% of patients have spondylolisthesis secondary to chronic stress fractures

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194 Special thanks to the radiographers and physicians at Regions Hospital in St. Paul, Minnesota, a Level I trauma center, for their expert advice and radiographs.