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Orthopedic Radiology
Dr. W. Pacheco
2 XI 2010
Joyce and Cedes
Principles
• Orthogonal (90 degrees from last viewDEPTH)
• Joint above and below
• Contralateral view for children
• Splint! Because of pain. Secondary na ang
prevention of further injury
• Weight-bearing vs. Dynamic joints
• Primum non nocere.
Reporting
1) View, laterality, date
2) Quality of X-ray (exposure, etc)
3) Quality of bone and alignment (You’ll see
bone trabeculae dapat)
4) Assess joint surfaces
5) Assess soft tissues
Common Views for Upper Extremities
•
•
•
•
•
•
Shoulder: AP, Scapular Y view
Humerus :AP, Lateral
Elbow: AP, Lateral
Forearm: AP, Lateral
Wrist: PA ,Lateral
Hand: oblique, AP, Lateral
Shoulder
routine: AP, axillary, transcapular,
scapular Y view
SHOULDER
AP
Indications for imaging
Trauma - dislocations, fractures,
tendon calcifications
Arthritis survey
Bone pain.
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.
SHOULDER
AP
SHOULDER
axillary
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,
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.
SHOULDER
scapular Y view
SHOULDER
scapular Y view
SHOULDER
recap
Abnormalities
1) Inferior Dislocation can’t say if it’s an anterior or
posterior dislocation (xray has no depth)
2) Greater Tuberosity fracture: with humeral dislocation
– Which 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…)
Humerus
routine: AP and lateral
Translateral!
HUMERUS
AP
Indications for imaging
Trauma - dislocations, fractures,
soft tissue calcifications
Arthritis survey
Bone pain.
HUMERUS
lateral
Indications for imaging
Trauma - dislocations, fractures, soft tissue
calcifications
Arthritis survey
Bone pain.
WALA AKONG MAKITANG
HUMERUS LATERAL SA NET
Elbow
routine: AP and lateral
ELBOW
AP
Indications for imaging
Trauma, loose bodies, bone pain
ELBOW
AP
Elbow Radiograph - AP projection
1, Humerus.
2, Medial epicondyle.
3, Lateral epicondyle.
4, Olecranon fossa.
5, capitellum.
6, Radius.
7, Radial Head.
8, Ulna.
9, Olecranon process.
10, Coronoid process.
ELBOW
lateral
Indications for imaging
Trauma, loose bodies, bone pain
ELBOW
lateral
Elbow Radiograph - AP projection
1, Humerus.
2, Medial epicondyle.
3, Lateral epicondyle.
4, Olecranon fossa.
5, capitellum.
6, Radius.
7, Radial Head.
8, Ulna.
9, Olecranon process.
10, Coronoid process.
11, anterior fat pad
ELBOW
lateral
Forearm
routine: AP and lateral
FOREARM
AP
Indications for imaging
Trauma*, metastases, bone pain.
(*Monteggia's fracture, fracture of the ulna
with dislocation of the head of the radius.
FOREARM
AP
FOREARM
lateral
Indications for imaging
Trauma*, metastases, bone pain.
(*Monteggia's fracture, fracture of the ulna with
dislocation of the head of the radius.)
FOREARM
lateral
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;
FOREARM
AP
GALEAZZI’S FRACTURE
Fat Pad Sign
• More radiolucent area (less dense); seen in
fractures wherein hematoma and bleeding
pushes fat.
• Fracture  hematomoa  push out the
normal fat  visible radiolucent area
Wrist
routine: PA and lateral
Special: carpal tunnel view
WRIST
Indications for imaging
Injury, pain, carpal tunnel syndrome,
PA
WRIST
lateral
Indications for imaging
Injury, pain, carpal tunnel syndrome,
WRIST
carpal tunnel view
WRIST
others
COLLES’ FRACTURE
Hand
routine: AP and oblique
HAND
AP
Indications for imaging
Injury, ? rheumatoid arthritis,
?acromegaly, bone pain
HAND
AP
Hand X-ray - AP
1, Distal phalanx.
2, Distal interphalangeal joint.
3, Middle phalanx.
4, Proximal interphalangeal joint.
5, Proximal phalanx.
6, Metacarpophalangeal joint.
7, Head of 5th metacarpal.
8, Sesamoid bone.
HAND
oblique
HAND
others
Common Views for Lower Extremities
• Both hips AP, frog leg lateral (for children,
congenital problems)
• Cross table lateral (for hip fractures)
• Femur AP, lateral
• Knee AP, Lateral
• Leg AP, Lateral
• Ankle mortise, AP, Lateral
• Foot AP, oblique, lateral
• Pelvis AP
Pelvis
routine: AP only
Special: Pelvic Inlet, Pelvic Outlet
Acetabulum: Judets view (obturator & iliac)
PELVIS
AP
PELVIS
AP
Anatomy 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.
PELVIS
AP
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
PELVIS
AP
PELVIS
inlet vs outlet view
PELVIS
male vs female
PELVIS
AP
Female 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)
PELVIS
AP
This 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.
PELVIS
acetabulum
1,Acetabular fossa.
2, Head femoral.
3, Greater trochanter.
4, Lesser trochanter.
5, Femur.
6, Obturator foramen.
7, Inferior pubic ramus.
8, Superior pubic ramus.
9, Sacrum.
10, Iliac wing.
Sample Case
• Asymmetrical (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? No
• hemi pelvis moved upwards and posteriorly
PELVIS
frog’s view
Anatomy Demonstrated
Femoral heads and necks,
acetabulum
Indications for imaging
Congenital abnormalities,
Perthes disease, slipped
femoral epiphyses.
PELVIS
frog’s view
1, Symphysis pubis.
2, Obturator foramen.
3, Ischium.
4, Lesser trochanter.
5, Femur.
6, Femoral head.
7, Anterior inferior iliac spine.
8, Acetabular fossa.
9, Anterior superior iliac spine.
PELVIS- acetabulum visualization
obturator vs iliac view
PELVIS
obturator vs iliac
PELVIS
obturator vs illac
Additional Info
• Cross table lateral viewpatient’s
opposite/unaffected limb is raised, plate is
beside the involved hip, beam is at 30 degrees
• Frog 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.
Cervical Spine
Routine: AP and lateral
Special: Swimmer’s, Open Mouth
CERVICAL SPINE
lateral
Indications for imaging
Trauma,
pain,
rheumatoid arthritis,
upper limb paraethesia,
vertebral artery syndrome.
CERVICAL SPINE
lateral
CERVICAL SPINE
lateral
Cervical Spine X-ray: Lateral
view.
1, Vertebral body (TH1).
2, Spinous process of C7.
3, Lamina.
4, Inferior articular process.
5, Superior articular process.
6,Spinous process of C2.
7, Odontoid process.
8, Anterior arch of C1 (Atlas).
9,Trachea.
CERVICAL SPINE
lateral
CERVICAL SPINE
lateral
Normal cervical spine?
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 compression
CERVICAL SPINE
lateral
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).
CERVICAL SPINE
AP
Cervical vertebrae 3 to 7,
vertebral bodies,
spinous processes
intervertebral spaces
CERVICAL SPINE
AP
Cervical vertebrae 3 to 7,
vertebral bodies,
spinous processes
intervertebral spaces
CERVICAL SPINE
open mouth
CERVICAL SPINE
open mouth
Anatomy Demonstrated
Cervical vertebrae 1 & 2,
odontoid process
intervertebral space,
posterior arch of atlas and
lateral masses.
Indications for imaging
Trauma,
pain,
rheumatoid arthritis,
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.
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 openmouth 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).
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.
CERVICAL SPINE
oblique
Anatomy Demonstrated
Cervical vertebra bodies,
intervertebral foramina,
articular pillars
apophysial joints
spinous processes.
CERVICAL SPINE
oblique
Cervical Spine X-ray,
(Left Neural Foramina).
1, Rib.
2, Clavicle.
3, Neural Foramina.
4, Pedicle.
5, Trachea.
CERVICAL SPINE
swimmer’s view
CERVICAL SPINE
swimmer’s view
Thoracic Spine
routine: AP and lateral
THORACIC SPINE
AP VIEW
AP
Anatomy Demonstrated
Thoracic vertebra, medial ends of ribs.
Indications for imaging
Congenital abnormalities,
scoliosis,
trauma,
pain,
metastasis's.
THORACIC SPINE
AP
THORACIC SPINE
AP
THORACIC SPINE
AP
Thoracic Spine X-ray: AP projection.
1, Left ventricle.
2, Gas in stomach.
3, Right hemidiaphragm.
4, Posterior rib.
5,Clavicle.
pedicles
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.
THORACIC SPINE
AP
Di pala thoracic to sorry! HEHE!
Just to show scoliosis!
THORACIC SPINE
AP
Spot the Winking Owl!
THORACIC SPINE
AP
THORACIC SPINE
lateral
Anatomy Demonstrated
Thoracic vertebra,
Indications for imaging
Congenital abnormalities,
scoliosis,
trauma,
pain,
metastasis's.
THORACIC SPINE
lateral
Thoracic Spine X-ray: Lateral view.
1, Right hemidiaphragm.
2, Left hemidiaphragm.
3, Vertebral body.
4, Rib
THORACIC SPINE
lateral
Thoracic Spine X-ray: Lateral view.
1,Posterior rib.
2, Vertebral body.
3, Intervertebral discal space.
THORACIC SPINE
lateral
THORACIC SPINE
lateral
A 73-year-old female with L1 vertebral compression fracture treated with kyphoplasty
6 weeks after fracture. The focal kyphosis was corrected from 16° to 5°.
Lumbosacral Spine
routine: AP and lateral
LUMBOSACRAL SPINE
AP
Indications for imaging
Congenital abnormalities,
trauma,
pain,
metastasis's.
Anatomy Demonstrated
Lumbar vertebra,
sacro iliac joints,
Sacrum
coccyx
LUMBOSACRAL SPINE
AP
Lumbar spine X-ray,
AP projection
1, rib.
2, Transverse
process.
3, Pedicle.
4, Spinous Process.
5, Sacrum.
6, Sacroiliac joint
LUMBOSACRAL SPINE
AP
LUMBOSACRAL SPINE
AP
LUMBOSACRAL SPINE
AP
LUMBOSACRAL SPINE
lateral
Anatomy Demonstrated
Lumbar vertebra.
Indications for imaging
Congenital abnormalities, trauma, pain, metastasis's.
LUMBOSACRAL SPINE
lateral
Lumbar spine X-ray, lateral view
1, Sacrum.
2, Spinous Process.
3, Vertebral body.
4, Intervertebral disc space.
5, Intervertebral foramina.
, Pedicle.
7, Inferior articulating facet.
8,Superior articulating facet.
9, Rib .
LUMBOSACRAL SPINE
oblique
LUMBOSACRAL SPINE
lateral
Knee
routine: AP and lateral
Special: patella’s skyline view
s
KNEE
AP
AP
KNEE
Standing AP
AP
1
2
3
4
KNEE
LAT lateral
KNEE
skyline view
KNEE
merchant’s view
Ankle
routine: AP, mortise and lateral
s
ANKLE
AP
ANKLE
mortise view
ANKLE
lateral view
LAT
Calcaneus
Axial , lateral, axial view
s
CALCANEUS
lateral view
CALCANEUS
lateral view
Foot
AP and oblique
s
FOOT
AP
FOOT
lateral
FOOT
oblique
Lisfranc’s Fracture
The end.