1. Radiographic Interpretation
What’s Normal?
Bucky Boaz, ARNP

3. Cervical Spine (Lateral)
Anterior arch of the atlas

Dens of axis
Posterior arch of the atlas

Soft palate
Root of the tongue

Transverse process

Intervertebral disc

Inferior articular process

Superior articular process

Zygapophyseal (facet) joint

Spinous process of C7
2nd-7th: The bodies of 2nd to 7th cervical vertebrae

4. Lateral Cervical Spine

5. Anterior soft tissue swelling
soft tissue swelling is indirect indicator of significant trauma, esp. when the soft tissue swelling is above the epiglottis;
retropharyngeal soft tissue swelling should not exceed:
anterior to C3 should not exceed 3 mm.
if > than 5 mm at C3 consider minimally displaced C2 fracture;
w/ children, crying increases the C3 distance;
below C4 the thickness varies from 8 to 10 mm & is less reliable;

6. Anterior soft tissue swelling
distance between tracheal air column & anterior aspect of vertebral body should be No greater than:
Adults: no > than 7 mm at C2 or 22 mm at C6;
Child: no > than 14 mm at C6
during x-ray child should be in neutral or sl extension and w/ a full inspiration;
fullness and laxity of child's prevertbral soft tissues may simulate traumatic swelling if film is obtained during expiration or flexion;

7. Spinal Laminal Lines Three curves to follow
Anterior aspect of vertebral bodies
Posterior aspect of vertebral bodies
Spinolaminar line
Abnormalities in the curves
posterior malalignment is more significant than anterior because of proximity of the spinal cord
spinal canal diameter is significantly narrowed if < 14 mm
anterior subluxation is caused by facet dislocation
< 50% of vertebral body width = unilateral dislocation
> 50% of vertebral body width = bilateral dislocation

8. Lateral Findings Examine bones for symmetry
May provide evidence of fracture
Abnormal symmetry is often due to compression
compression of > 40% of normal vertebral body height usually indicates a burst fracture with possibility of bone fragments in the spinal canal
anterior compression may cause a teardrop shaped fracture

9. Cervical Spine (Lateral)
Bifid spinous process of C3

Superimposed articular processes

Uncinate processes

Air filled trachea

Transverse process of C7

Transverse process of T1

1st rib

Clavicle
4th-7th: The bodies of 4th to 7th cervical vertebrae

10. AP Cervical Spine

11. Odontoid View to evaluate: C1 (Jefferson), Dens, superior facets of C2
for evaluating dens fractures, body of C2, & rotary C1-C2 dislocations;
mach lines - teeth, C1 arch;
open mouth view, along w/ lateral view, will reveal fractures of the dens ;
atlantoaxial articulation & integrity of dens and body of C2 are best seen on the odontoid view;

12. Odontoid View
this is most technically most difficult film to obtain as it requires patient to open his mouth as wide as possible
lateral masses of C1 should align over the lateral masses of C2;
lateral displacement of masses of C1 w/ respect to C2 may indicate Jefferson or burst fracture of the Atlas;
combined lateral mass displacement > 7 mm suggests that transverse ligament is torn;

13. Anatomy of C2
C2 provides rotation at its superior articulation w/ C1, & limited flexion, tilt, & rotation at its inferior articulation w/ C3;
body of C2 is the largest of the cervical vertebrae;
superior articulations are on the lateral masses;
superior projection of the odontoid is stabilized to the C1 ring by transverse and alar ligaments;

14. Anatomy of C2
lateral masses of C2 have aperture for accepting transversing vertebral artery;
axis is transverse vertebra w/ its superior articular facets located anterior and its inferior facets located posterior;
prominent spinous process of C2 is palpable beneath of occiput;

15. Odontoid

16. Thoracic Vertebra
Each vertebra is composed of a body anteriorly and a neural arch posteriorly
The arch encloses an opening, the vertebral foramen, which helps to form a canal in which the spinal cord is housed.
Protruding from the posterior extreme of each neural arch is a spinous process and extending from the lateral edges of each arch are transverse processes.
The parts of the neural arch between the spinous and transverse processes are known as the laminae and the parts of the arch between the transverse processes and the body are the pedicles.
At the point where the laminae and pedicles meet, each vertebra contains two superior articular facets and two inferior articular facets.
The pedicle of each vertebra is notched at its superior and inferior edges. Together the notches from two contiguous vertebra form an opening, the intervertebral foramen, through which spinal nerves pass

17. Thoracic Spine Spinous process Pedicles Intervertebral disc space Ribs
Vertebral body
Neural foramen

18. Lumbar Vertebra
Lumbar vertebrae are characterized by massive bodies and robust spinous and transverse processes.
Their articular facets are oriented somewhat parasagittally, which is thought to contribute the large range of anteroposterior bending possible between lumbar vertebrae.
Lumbar vertebrae also contain small mammillary and accessory processes on their bodies.
These bony protuberances are sites of attachment of deep back muscles

19. Lateral Lumbar Spine

20. Lateral Lumber Spine

21. AP Lumbar Spine

22. Vertebral Fractures

23. Pelvis

24. AP Pelvis Lateral part of the sacrum Pubic tubercle Lesser trochanter
Gas in colon
Ilium
Sacroiliac joint
Ischial spine
Superior ramus of pubis
Inferior ramus of pubis
Ischial tuberosity
Obturator foramen
Intertrochanteric crest
Pubic symphysis
Pubic tubercle
Lesser trochanter
Neck of femur
Greater trochanter
Head of femur
Acetabular fossa
Anterior inferior iliac spine
Anterior superior iliac spine
Posterior inferior iliac spine
Posterior superior iliac spine
Iliac crest

25. AP Hip Anterior superior iliac spine Ilium
Anterior inferior iliac spine
Pelvic brim
Acetabular fossa
Head of femur
Fovea
Superior ramus of pubis
Obturator foramen
Inferior ramus of pubis
Pubic symphysis
Ischium
Lesser trochanter
Intertrochanteric crest
Greater trochanter
Neck of femur

26. Lateral Hip Greater trochanter Intertrochanteric crest
Lesser trochanter
Neck of femur
Head of femur
Acetabular fossa
Superior ramus of pubis
Obturator foramen
Inferior ramus of pubis
Ischium

27. AP Knee Femur Patella Medial epicondyle of femur
Lateral epicondyle of femur
Medial condyle of femur
Lateral condyle of femur
Intercondylar eminence
Intercondylar notch
Knee joint
Lateral condyle of tibia
Medial condyle of tibia
Tibia
Fibula

28. Lateral Knee Femur Lateral condyle of femur Medial condyle of femur
Fabella
Patella
Base of patella
Apex of patella
Intercondylar eminence
Apex of fibula
Fibula
Tibia
Tibial tuberosity

29. AP Ankle Fibula Tibia Distal tibiofibular joint Malleolar fossa
Lateral malleolus
Ankle joint
Medial malleolus
Talus

30. Lateral Ankle Fibula Tibia Ankle joint Promontory of tibia
Trochlear surface of talus
Talus
Posterior tubercle of talus
Calcaneus
Sustentaculum tali
Tarsal tunnel
Navicular
Cuneiforms
Cuboid

31. Talar Dome
The talar dome should be scrutinised for a subtle indentation of the joint surface, or a small detached fragment.
This is evidence of an osteochondral fracture.
May be subtle, is often missed, but this injury is clinically significant.

33. Boehler’s Angle
Compressive fractures occur after a fall from a height.
Subtle fractures may only be identified by assessing Boehler’s angle.
This angle is measured by drawing a line from the highest point of the posterior tuberosity to the highest midpoint, and a 2nd line from the highest midpoint to the highest point of the anterior process.
The angle, posteriorly, should be >30 degrees.
If there is flattening of the bone due to a fracture, this angle will be decreased, to <30 degrees.

34. Boehler’s Angle

35. AP Foot A-E: Toes 1-5. (A:Great toe) I-V. Metatarsals Cuneiform
1,3. Distal phalax

4. Middle phalax

2,5. Proximal phalax
Interphalangeal joints
Metatarsophalangeal joints
Sesamoids
Head of metatarsal
Shaft (body) of metatarsal
Base of metatarsal
Cuneiform
Navicular
Cuboid
Talus
Calcaneus
Tibia
Fibula
Tarsometatarsal joints
Transverse midtarsal joint

36. Oblique Foot Base of metatarsal Cuneiforms Navicular Cuboid Talus
Calcaneus
Tibia
Fibula
Tarsometatarsal joints
Transverse midtarsal joint
A-E: Toes 1-5. (A:Great toe)
1,3. Distal phalax

Middle phalax

2,5. Proximal phalax
Interphalangeal joints
Metatarsophalangeal joints
Sesamoids
Head of metatarsal
Shaft (body) of metatarsal

37. AP Foot

38. Oblique Foot

39. Lateral Foot

40. Lisfranc

41. Lisfranc

42. AP Shoulder Clavicle Acromioclavicular joint Acromion
Greater tubercle of humerus
Head of humerus
Lesser tubercle of humerus
Surgical neck of humerus
Coracoid process
Glenoid fossa
Shoulder joint
Lateral border of scapula

43. AP Elbow Lateral supracondylar ridge Medial supracondylar ridge
Olecranon fossa
Medial epicondyle
Lateral epicondyle
Capitulum
Olecranon
Trochlea
Coronoid process of ulna
Proximal radioulnar joint
Head of radius
Neck of radius
Tuberosity of radius
Ulna

44. Lateral Elbow Supracondylar ridge Trochlea Olecranon Trochlear notch
Coronoid process of ulna
Head of radius
Neck of radius
Tuberosity of radius
Ulna

45. PA Wrist I-V: Metacarpals Trapezium Trapezoid Capitate
Head of capitate
Hamate
Hook of hamate
Scaphoid
Lunate
Triquetrum
Pisiform
Styloid process of radius
Head of ulna
Styloid process of ulna
Radiocarpal joint
Distal radioulnar joint

46. Lateral Wrist 1st metacarpal Metacarpals II-V Trapezium
Tubercle of scaphoid
Lunate
Triquetrum
Radiocarpal joint
Distal end of radius
Distal end of ulna

47. Rule of 11’s Radial length or height
Radial length is measured on the PA radiograph as the distance between one line perpendicular to the long axis of the radius passing through the distal tip of the radial styloid. 

A second line intersects distal articular surface of ulnar head. 

This measurement averages mm.

48. Rule of 11’s Radial inclination or angle
Radial inclination represents the angle between one line connecting the radial styloid tip and the ulnar aspect of the distal radius and a second line perpendicular to the longitudinal axis of the radius. 

The radial inclination ranges between 21｡ and 25｡. 
Loss of radial inclination will increase the load across the lunate.

49. Rule of 11’s
Radial tilt

Radial tilt is measured on a lateral radiograph. 

The radial tilt represents the angle between a line along the distal radial articular surface and the line perpendicular to the longitudinal axis of the radius at the joint margin.
The normal volar tilt averages 11｡ and has a range of 2｡-20｡.

50. PA Hand Thumb Index Middle finger Ring finger Little finger
I-V. Metacarpal bones
1,4. Distal phalanx

Middle phalanx

3,5. Proximal phalanx

Sesamoid bones
Distal interphalangeal joint (DIP)
Metacarpophalange al joint (V.)
Carpometacarpal joints
Trapezium
Trapezoid
Capitate
Hamate
Scaphoid
Lunate
Triquetrum
Pisiform
Radius
Ulna

51. QUESTIONS?