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Radiographic
Interpretation
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What’s
Normal?
Bucky Boaz, ARNP
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Cervical Spine (Lateral)
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1. Anterior arch of the atlas
2. Dens of axis
3. Posterior arch of the atlas
4. Soft palate
5. Root of the tongue
6. Transverse process
7. Intervertebral disc
8. Inferior articular process
9. Superior articular process
10. Zygapophyseal (facet) joint
11. Spinous process of C7
2nd-7th: The bodies of 2nd to 7th
cervical vertebrae
Lateral Cervical Spine
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Anterior soft tissue swelling
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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;
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
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• 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;
Spinal Laminal Lines
•
Three curves to follow
– Anterior aspect of vertebral bodies
– Posterior aspect of vertebral bodies
– Spinolaminar line
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Abnormalities in the curves
– posterior malalignment is more
significant than anterior because of
proximity of the spinal cord
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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
Lateral Findings
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• 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
Cervical Spine (Lateral)
1.
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Bifid spinous process of
C3
2. Superimposed articular
processes
3. Uncinate processes
4. Air filled trachea
5. Transverse process of C7
6. Transverse process of T1
7. 1st rib
8. Clavicle
4th-7th: The bodies of 4th to 7th
cervical vertebrae
AP Cervical Spine
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Odontoid View
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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;
Odontoid View
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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;
Anatomy of C2
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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;
Anatomy of C2
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• 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;
Odontoid
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Thoracic Vertebra
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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
Thoracic Spine
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• Spinous process
• Pedicles
• Intervertebral disc
space
• Ribs
• Vertebral body
• Neural foramen
Lumbar Vertebra
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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
Lateral Lumbar Spine
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Lateral Lumber Spine
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AP Lumbar Spine
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Vertebral Fractures
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Pelvis
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AP Pelvis
1.
Lateral part of
the sacrum
2. Gas in colon
3. Ilium
4. Sacroiliac joint
5. Ischial spine
6. Superior ramus
of pubis
7. Inferior ramus of
pubis
8. Ischial tuberosity
9. Obturator
foramen
10. Intertrochanteric
crest
11. Pubic symphysis
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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
AP Hip
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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
Lateral Hip
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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
AP Knee
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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
Lateral Knee
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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
AP Ankle
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Fibula
Tibia
Distal tibiofibular joint
Malleolar fossa
Lateral malleolus
Ankle joint
Medial malleolus
Talus
Lateral Ankle
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Fibula
Tibia
Ankle joint
Promontory of tibia
Trochlear surface of talus
Talus
Posterior tubercle of talus
Calcaneus
Sustentaculum tali
Tarsal tunnel
Navicular
Cuneiforms
Cuboid
Talar Dome
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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.
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Boehler’s Angle
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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.
Boehler’s Angle
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AP Foot
A-E: Toes 1-5. (A:Great toe)
I-V. Metatarsals
1,3. Distal phalax
4. Middle phalax
2,5. Proximal phalax
6. Interphalangeal joints
7. Metatarsophalangeal
joints
8. Sesamoids
9. Head of metatarsal
10. Shaft (body) of metatarsal
11. Base of metatarsal
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Cuneiform
Navicular
Cuboid
Talus
Calcaneus
Tibia
Fibula
Tarsometatarsal joints
Transverse midtarsal joint
Oblique Foot
A-E: Toes 1-5. (A:Great toe)
1,3. Distal phalax
4. Middle phalax
2,5. Proximal phalax
6. Interphalangeal joints
7. Metatarsophalangeal
joints
8. Sesamoids
9. Head of metatarsal
10. Shaft (body) of
metatarsal
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11.
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Base of metatarsal
Cuneiforms
Navicular
Cuboid
Talus
Calcaneus
Tibia
Fibula
Tarsometatarsal
joints
20. Transverse midtarsal
joint
AP Foot
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Oblique Foot
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Lateral Foot
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Lisfranc
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Lisfranc
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AP Shoulder
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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
AP Elbow
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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
Lateral Elbow
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Supracondylar ridge
Trochlea
Olecranon
Trochlear notch
Coronoid process of
ulna
Head of radius
Neck of radius
Tuberosity of radius
Ulna
PA Wrist
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I-V:
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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
Lateral Wrist
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1st metacarpal
Metacarpals II-V
Trapezium
Tubercle of scaphoid
Lunate
Triquetrum
Radiocarpal joint
Distal end of radius
Distal end of ulna
Rule of 11’s
• Radial length or height
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– 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 10-13 mm.
Rule of 11’s
• Radial inclination or angle
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– 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.
Rule of 11’s
• Radial tilt
– Radial tilt is measured on a
lateral radiograph.
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– 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｡.
PA Hand
A.
B.
C.
D.
E.
I-V.
1,4.
2.
3,5.
6.
7.
8.
Thumb
Index
Middle finger
Ring finger
Little finger
Metacarpal bones
Distal phalanx
Middle phalanx
Proximal phalanx
Sesamoid bones
Distal
interphalangeal joint
(DIP)
Proximal
9.
10.
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11.
12.
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15.
16.
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18.
19.
20.
Metacarpophalange
al joint (V.)
Carpometacarpal
joints
Trapezium
Trapezoid
Capitate
Hamate
Scaphoid
Lunate
Triquetrum
Pisiform
Radius
Ulna
QUESTIONS?