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Radiographic Interpretation QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. What’s Normal? Bucky Boaz, ARNP QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Cervical Spine (Lateral) QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 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 QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. Anterior soft tissue swelling • • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • 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 • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 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 Lateral Findings QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • 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. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 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 QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. Odontoid View • • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • • • 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 • • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • 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 • • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • • 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • 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 QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. Thoracic Vertebra • • • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • • • 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • Spinous process • Pedicles • Intervertebral disc space • Ribs • Vertebral body • Neural foramen Lumbar Vertebra • • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. • 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Lateral Lumber Spine QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. AP Lumbar Spine QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. Vertebral Fractures QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Pelvis QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. Fibula Tibia Distal tibiofibular joint Malleolar fossa Lateral malleolus Ankle joint Medial malleolus Talus Lateral Ankle QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 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 • • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 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. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Boehler’s Angle • • • QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 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 QuickTime™ and a TIFF (Uncomp resse d) de com press or are nee ded to s ee this picture. 12. 13. 14. 15. 16. 17. 18. 19. 20. 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 Quic kTime™ and a TIFF (Unc ompres sed) dec ompres sor are needed to see this pic ture. 11. 12. 13. 14. 15. 16. 17. 18. 19. Base of metatarsal Cuneiforms Navicular Cuboid Talus Calcaneus Tibia Fibula Tarsometatarsal joints 20. Transverse midtarsal joint AP Foot QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Oblique Foot QuickTi me™ and a TIFF ( Uncompressed) decompressor are needed to see thi s pi ctur e. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Lateral Foot QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Lisfranc QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Lisfranc QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. AP Shoulder QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. Supracondylar ridge Trochlea Olecranon Trochlear notch Coronoid process of ulna Head of radius Neck of radius Tuberosity of radius Ulna PA Wrist QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. I-V: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 1. 2. 3. 4. 5. 6. 7. 8. 9. 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. – 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 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. – 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. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. – 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. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Metacarpophalange al joint (V.) Carpometacarpal joints Trapezium Trapezoid Capitate Hamate Scaphoid Lunate Triquetrum Pisiform Radius Ulna QUESTIONS?