RADIOLOGI BEDAH KELOMPOK B

1. Sebutkan tujuan utama analisis foto radiografi pada kasus tumor tulang Membedakan suatu tumor bersifat benigna atau maligna. Cirinya: Benign: batas tegas Maligna: periosteal maligna, kalsifikasi soft tissue, bisa osteoklastik/osteoblastik Membedakan origin tumor, apakah berasal dari soft tissue yang merusak tulang atau sebaliknya Penyebaran ke tulang yang lain (monoostosis) bila berasal dari tulang, jarang ke tulang lain, seringnya metas ke paru, kecuali dari jaringan lunak (joint) bisa merusak banyak tulang disekitarnya. Unduh: clues and cues bone tumor.ppt 2. Sebutkan tanda tanda radiografi benign tumor tulang Sumber: Lecture dr. Rahadyan http://www.imageinterpretation.co.uk/tumour.html 1. NON OSSIFYING FIBROMA (fibrous cortical defect) - X-ray finding radiolucent area with border around dense - One of the most common benign lytic lesions seen - Asymptomatic and usually an incidental finding - Metaphyisis of the long bone >>> - Most often seen around the knee and distal tibia - Non-Ossifying fibroma generally bigger than 2cm - Fibrous Cortical Defect generally smaller than 2cm - Arises in under 30 year age group - Develops from cortex of metaphysis; is eccentric within the bone - Bubbly - Usually has thin, sclerotic border that is often scalloped and slightly expansile - Become sclerotic as healing occurs and disappears as it ossifies - Therefore not seen in over 30 age group

2. FIBROUS DYSPLASIA - Trabecular bone replaced with fibrous tissue - Radiologic findings Cystic Area in the metaphysis / diaphisis of the bone ground glass - Long lesion in a long bone (often occurs in proximal femur) - Expansion and bone deformity

Lytic but becomes ground-glass in appearance as the matrix calcifies, and then becomes sclerotic Asymptomatic, but can fracture No periosteal reaction May be single or multiple lesion in different locations

3. OSTEOID OSTEOMA - Radiologic Findings Small radiolucent area NIDUS - DD: brodies abses

4. CHONDROMA / ENCHONDROMA Radiologic Findings Radiolucent area with calcifications at the center Most commonly seen in the phalanges Asymptomatic but commonly fractures Well-defined with narrow zone of transition Lobulated Can become slightly expansile Causes endosteal scalloping and cortical thinning Olliers Disease = Multiple enchondromas Maffuccis Syndrome = Multiple enchondromas with soft tissue haemangiomas Contain calcified chondroid matrix (irregular, speckled) when located away from phalanges

5. OSTEOCHONDROMA - Tumor at the distal of the physeal plate . >> Metaphysis area. - Radiologic findings Tumor at the metaphysis area

6. SYMPLE BONE CYST - Arises in under 30 year age group - Presents with pain - Expansile - Differential diagnosis: osteoblastoma, as very similar in appearance Radiologic findings: Strict border. Lucent area at meta and physeal pl. Thinning of the cortex.

7. ANEURYSMAL BONE CYST - Arises in under 30 year age group - Presents with pain - Expansile - Differential diagnosis: osteoblastoma, as very similar in appearance - Radiologic findings Lucent area with strict border.

8. GIANT CELL TUMOR. - Epiphyses must be closed - Must be epiphyseal and abut the articular surface - Well-defined with narrow zone of transition - Must have a non-sclerotic margin - Eccentric within the bone - Usually occurs within the distal femur or proximal tibia - 15per cent become malignant based on recurrence rate or subsequent metastases Radiologic findings soap buble appearence. ballooned -- thinning of the cortex . Pushing the surrounding of soft tissue.

3. Sebutkan 3 tanda ( sign ) temuan radiografi abdomen 3 posisi pada kasus kecurigaan perforasi 1. foot ball sign: gambaran pneumoperitoneum luas di kavum abdomen hanya bila udara massif, biasanya disertai 4 tanda lainya. 2. double wall sign/rigler sign: udara di kedua sisi abdomen (butuh >1000 ml gas dan cairan intraperitoneal) 3. tell tale triangle sign: kantung udara triangular diantara 3 segmen usus Right Upper quadrant gas: - Single large area of hyperlucency over the liver - Oblique linear area of hyperlucency outling the posteroinferior liver - Dodges cap sign: triangular collection of gas in morison pouch (posterior hepatorenal space) - Lig. Teres notch : inverted V shaped area of hyperlucency along undersurface of liver - Lig. Teres sign: air outling fissure of lig. Teres hepatis - Saddle bag/cupola sign: gas trapped below central tendon of diaphragm - Parahepatic air: gas bubble lateral to right edge of liver 4. Bagaimana gambaran ascites pada plain foto abdomen supine? Detection of intraperitoneal fluid on plain film requires at least 500 mL to be present. Plain film findings of ascites include: diffusely increased density of the abdomen (opasitas tipis menyeluruh seperti susu) poor definition of the the soft tissue shadows, such as the psoas muscles, liver and spleen medial displacement of bowel and solid viscera (away from properitoneal fat stripe) bulging of the flanks increased separation of small bowel loops The fluid causes a generalized haziness or "ground glass" appearance to the abdomen.

The bowel loops may be separated by interposed fluid and bowel loops assume a central location as they float to the highest point of the abdomen. 5. Sebutkan diagnosis banding mekoneum plug syndrome On conventional radiographs o Meconium, being fluid density, is normally invisible on radiographs o In meconium ileus, there may be dilated loops of bowel (small bowel) typically without air-fluid levels because of the viscosity of the secretions Bowel distension can achieve very large sizes o Bubbly appearance of intestinal contents in the right lower quadrant On contrast enema o Required to establish the diagnosis Nonionic contrast agents (e.g. Omnipaque or Hypaque) or dilute Gastrografin Fluid shifts have been reported with Gastrografin o Microcolon Underused colon in antenatal obstruction May be seen with other causes of distal small bowel obstruction o Multiple oval filling defects in distal ileum and colon from inspissated meconium On ultrasound o Enlarged loops of bowel o Possible RLQ mass representing inspissated meconium Differential Diagnosis Hirschsprungs disease Small bowel atresia with meconium ileus Meconium plug syndrome o Functional immaturity of the ganglion cells in the colon leading to failure to pass meconium o Considered same as small left colon syndrome Imperforate anus Other radiology imaging for Meconium Plug Syndrome

Supine frontal view of the abdomen in a newborn with meconium plug syndrome demonstrates multiple dilated loops of bowel but no rectal gas.

A lateral view from contrast enema in a newborn demonstrates a normal-to-decreased caliber "empty" distal colon and dilated proximal bowel containing multiple plugs. The child responded clinically and radiographically to a single enema.

A frontal view from contrast enema in a patient initially given a diagnosis of small left colon syndrome. A long filling defect is seen in the rectosigmoid with gradual transition to a more dilated proximal bowel. The infant failed to improve, and rectal biopsy confirmed Hirschsprung disease Dibedakan dengan barium enema. Dan CIL 6. Apa persamaan gambaran radiografi plain foto pada kasus megacolon konginetal, ileus fungsional, left small colon sysndroma? Gambaran plain radiography sama-sama menunjukkan obstruksi letak rendah pada megacolon congenital dan left small colon syndrome. Gambaran plain radiography pada ketiganya menunjukkan distensi usus, multiple air fluid level (stepladder appearance). Pada umumnya distensi usus dapat dilihat di usus halus dan usus besar, memberikan gambaran coiled spring dan hering bone appearance. 7. Pada systema colorectal sebutkan segmen/ bagian colorectal yang termasuk intraperitoneal dan retroperitoneal Intraperitoneal= caecum, colon transversum, kolon sigmoid Retroperitoneum= kolon asenden, desenden dan regtum Implikasi pada volvulus sigmoid 8. Per definisi apa yang dimaksud ileus obstruksi letak tinggi dan letak rendah? Ileus obstruksi letak tinggi ialah keadaan di mana penderita mengalami obstruksi passage makanan yang terjadi pada usus yang berasal dari foregut, iaitu dari pylorus gaster sampai duodenum

Ileus letak rendah ialah keadaan di mana penderita mengalami obstruksi passage makanan yang terjadi pada usus yang berasal dari hindgut, iaitu dari 1/3 distal transverse colon, descending colon, sigmoid, rektum,upper part anus. (ileus letak tengah ialah keadaan di mana penderita mengalami obstruksi passage makanan yang terjadi pada usus yang berasal dari midgut, iaitu dari jejunum, ileum, coecum, ver miform appendix, ascending colon, 2/3 proximal tranversecolon) Small bowel (upper: muntah non profuse, mid, lower) 9. Apa gambaran yang bisa dilihat pada plain abdomen pasien dengan volvulus sigmoid? Coffee been sign 10. Banana sign ditemukan pada plain abdomen pada kasus apa? intususepsi 11. Sebutkan jenis periosteal reaktion proses 1) With slow-growing processes, the periosteum has plenty of time to respond to the process. That is, it can produce new bone just as fast as the lesion is growing. Therefore, one would expect to see solid, uninterrupted periosteal new bone along the margin of the affected bone. 2) However, with rapidly growing processes, the periosteum cannot produce new bone as fast as the lesion is growing. Therefore, rather than a solid pattern of new bone formation, we see an interrupted pattern. This interrupted pattern can manifest itself in several ways, depending on just how steadily the lesion grows. If the lesion grows unevenly in fits and starts, then the periosteum may have time to lay down a thin shell of calcified new bone before the lesion takes off again on its next growth spurt. This may result in a pattern of one or more concentric shells of new bone over the lesion. This pattern is sometimes called lamellated or "onion-skin" periosteal reaction 3) If the lesion grows rapidly but steadily, the periosteum will not have enough time to lay down even a thin shell of bone, and the pattern may appear quite different. In such cases, the tiny fibers that connect the periosteum to the bone (Sharpey's fibers) become stretched out perpendicular to the bone. When these fibers ossify, they produce a pattern sometimes called "sunburst" or "hair-on-end" periosteal reaction, depending of how much of the bone is involved by the process. (pict:"sunburst" and "hair-on-end" periosteal reaction) 4) codmans triangle We can usually differentiate lesions into one of two categories: benign vs. aggressive processes. If we see a solid pattern of periosteal reaction, we can be fairly confident that we are dealing with a benign process. How confident? In normal everyday practice, my estimate is that you can be about 90 - 95 % confident in this rule(9), but your mileage may vary. As with many rules in medicine, there are some caveats associated with the use of this rule. The main caveat with this rule is that benign processes and malignant processes may coexist. The usual way that this may manifest is when there is a fracture or infection in the same area as a tumor. In this case, you may see a fairly complex pattern of periosteal reaction that demonstrates some elements that look benign and some that look very aggressive.

12. Apa tujuan pemeriksaan colon in loop pada kasus invaginasi? Colon In loop berfungsi sebagai diagnosis cupping sign, letak invaginasi. Pada orang dewasa diagnosis preoperatif keadaan intususepsi sangatlah sulit, meskipun pada umumnya diagnoasis preoperatifnya adalah obstruksi usus tanpa dapat memastikan kausanya adalah intususepsi. Diagnosis dapat ditegakkan berdasarkan riwayat yang khas dan pemeriksaan fisik. Pada penderita dengan intususepsi yang mengenai kolon, barium enema mungkin dapat memberi konfirmasi diagnosis. Mungkin akan didapatkan obstruksi aliran barium pada apex dari intususepsi dan suatu cupshaped appearance pada barium di tempat ini. Ketika tekanan ditingkatkan, sebagian atau keseluruhan intususepsi mungkin akan tereduksi. Jika barium dapat melewati tempat obstruksi, mungkin akan diperoleh suatu coil spring appearance yang merupakan diagnostik untuk ileus. Pemeriksaan penunjang lainnya ( Ultra sonography, Barium Enema dan Computed Tomography) 13. Apa gambaran radiologi yang bisa dilihat pada periksaan head ct-scan pada kasus subarachnoid bleeding? High attenuated, mengikuti lekuk dari gyrus dan sulci 14. Apa keunggulan modalitas pemeriksaan USG saat dipakai untuk memeriksa softisue tumor dibanding pemeriksaan radiografi? Kelebihan usg untuk tumor : memberi informasi dengan batas struktur organ; semua organ kecuali yg mengandung udara dapat ditentukan bentuk,ukuran,posisi,dan ruang interspasial; membedakan kista dengan massa solid; dapat membedakan jenis jaringan dengan melihat perbedaan interaksi dengan gelombang suara 15. Pada kasus abdomen distended dengan muntah muntah bila difikirkan diperlukan pemeriksaan penunjang radiologi, pemeriksaan apa yang akan anda minta, apa alasannya? Pemeriksaan Rontgen Abdomen 3 posisi : (posisi supine, semi-erek dan left lateral decubitus) Untuk mengetahui adanya sumbatan dan letaknya. Contohnya, pada penderita ileus, flatus bisa sedikit atau tidak ada. Akibatnya terjadi penumpukan udara di dalam usus. o Pada rontgen bagian yang berisi udara :- radiolusen o Kalau udaranya ada di usus halus, berarti kemungkinan sumbatannya terjadi di colon o Pada usus halus, ada plica semicircularis yang merupakan suatu pelipatan mukosa berbentuk (setengah) lingkaran. o Kolon, plica semilunaris bentuknya seperti bulan sabit. o Usus besar terlihat gambaran bulan sabit yang berjejer sehingga berbentuk seperti tulang ikan herring (hering bone appearance) pada ileus. Contrast X-ray, bisa berupa : Foto traktus GI atas dengan OMD (oesophagus, magh, duodenum) Barium enema, dengan colon inloop, o Dari pemeriksaan ini ditemukan ladder symptom foto abdomen tampak gambaran seperti anak tangga, bagian paling atas : udara, bagian tengah : cairan, bagian bawah : sumbatan. 16. Apa perbedaan dan persamaan gambaran radiografi antara atelektasis dengan pnemothorax? PNEUMOTHORAX X-ray of a collapsed lung (specifically a pneumothorax) The darker area you see on the left is air which has escaped the lung and is now trapped in the thoracic cavity.

The diagnosis of pneumothorax is established by demonstrating the outer margin of the visceral pleura (and lung), known as the pleural line, separated from the parietal pleura (and chest wall) by a lucent gas space devoid of pulmonary vessels. The pleural line appears in the image below). A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the pleural line. The pleural line may be difficult to detect with a small pneumothorax unless high-quality posteroanterior and lateral chest films are obtained and viewed under a bright light. A skin fold may mimic the pleural line; usually, the patient is asymptomatic (see the image below). Note that although a skin fold can mimic a subtle pneumothorax, lung markings are visible beyond the skin fold. In erect patients, pleural gas collects over the apex, and the space between the lung and the chest wall is most notable at that point (see the image below). A large, right-sided pneumothorax has occurred from a rupture of a subpleural bleb. In the supine position, the juxtacardiac area, the lateral chest wall, and the subpulmonic region are the best areas to search for evidence of pneumothorax (see the image below). The presence of a deep costophrenic angle on a supine film may be the only sign of pneumothorax; this has been termed the deep sulcus sign. Deep sulcus sign in a supine patient in the ICU. The pneumothorax is subpulmonic. When a suggested pneumothorax is not definitively observed on an inspiratory film, an expiratory film may be helpful. At end expiration, the constant volume of the pneumothorax gas is accentuated by the reduction of the hemithorax, and the pneumothorax is recognized more easily. Similar accentuation may be obtained with lateral decubitus studies of the appropriate side (for a possible left pneumothorax, a right lateral decubitus film of the chest should be obtained, with the beam centered over the left lung). The most common radiographic manifestations of tension pneumothorax are mediastinal shift, diaphragmatic depression, and rib cage expansion (see the image below). An older man admitted to ICU postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position. Any significant degree of displacement of the mediastinum from the midline position on maximum inspiration, as well as any depression of the diaphragm, should be taken as evidence of tension (see the image below), although a definite diagnosis of tension pneumothorax is difficult to make on the basis of

radiographic findings. The degree of lung collapse is an unreliable sign of tension, since underlying lung disease may prevent collapse even in the presence of tension. Right main stem intubation resulting in left-sided tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax Pleural effusions occur coincident with pneumothorax in 2025% of patients, but they usually are quite small. Hemopneumothorax occurs in 23% of patients with spontaneous pneumothorax. Bleeding is believed to represent rupture or tearing of vascular adhesions between the visceral and parietal pleura as the lung collapses

ATELECTASIS Atelectasis is the collapse of part or (much less commonly) all of a lung. Findings A. Mediastinal shift 1. Massive whole lung collapse 2. Lower lobe collapse B. Tracheal Deviation 1. Whole lung collapse C. Upward hilar displacement 1. Upper lobe collapse D. Downward hilar displacement 1. Lower lobe collapse E. Shift of fissures 1. Affects any segment F. Narrowing of costal interspaces 1. Massive Atelectasis Complete atelectasis of an entire lung (see images below) is when (1) complete collapse of a lung leads to opacification of the entire hemithorax and an ipsilateral shift of the mediastinum and (2) the mediastinal shift separates atelectasis from massive pleural effusion. Complete atelectasis of the left lung. Mediastinal displacement, opacification, and loss of volume are present in the left hemithorax. With right upper lobe (RUL) collapse, the collapsed RUL shifts medially and superiorly, resulting in elevation of the right hilum and the minor fissure. Rarely, the RUL may collapse laterally, producing a masslike opacity that may look like a loculated pleural effusion. The minor fissure in RUL collapse is usually convex superiorly but may appear concave because of an underlying mass lesion. This is called the sign of Golden S. Tenting of the diaphragmatic pleura juxtaphrenic peak is another helpful sign of RUL atelectasis middle lobe (RML) collapse (see images below) obscures the right border on a posteroanterior (PA) film. Occasionally, a triangular

Right heart

opacity may be observed. The lateral view shows a triangular opacity overlying the heart because the major fissure shifts upward and the minor fissure shifts downward. Upon CT scanning, the atelectatic RML appears as a triangular opacity against the right heart border with the apex pointing laterally and is termed the "tilted ice cream cone sign."

Perbedaannya: atelektasis tertarik ke hilus, pneumothorak terdorong 17. Mengapa di perlukan foto radiografi AP view dan Lateral view pada kasus kecurigaan fraktur ekstremitas? Karena fraktur mungkin tidak terlihat pada sinar X tunggal dan dapat lebih mendiskripsikan karakteristik dari fraktur tersebut. Sehingga diperlukan sekurang-kurangnya dilakukan dua sudut pandang 18. Apa tujuan perubahan posisi pada foto abdomen plain 3 posisi? Tujuan perubahan posisi pada foto abdomen 3 posisi adalah untuk memvisualisasi secara maksimal area-area yang dapat memberi gambaran khas untuk diagnosis kelainan di abdomen. Area area yang penting tersebut adalah: - Posisi Left Lateral Decubitusmemvisualisasi gambaran air fluid level yang panjang di kolon/ air fluid level pendek-pendek (step ladder appearance) pada kasus ileus; udara bebas pada kasus perforasi organ berongga - Posisi supinasimemvisualisasi gambaran udara usus(prominent atau normal). Pada kasus ileus obstruksi, tampak segmen usus yang terdistensi dengan segmen disebelah distal dari obstruksi yang kolaps. Usus yang sangat terdistensi dapat membentuk gambaran Hearing bone appearance. - Posisi Semi Erect/ APmemvisualisasi area-area seperti di infra diafragma dan sub hepatal. Pada kasus perforasi organ berongga, area ini akan menjadi tempat terkumpulnya udara bebas di rongga abdomen yang mudah dideteksi. 19. Sebutkan temuan radiografi pada kasus dislokasi -disaligment antar sendi, pelebaran jarak -abnormal rotasi !!! balajar cubiti anak 20. Doble bubble sign di temukan pada kasus? Single bubble pada kasus? Double bubble sign: atresia duodenal; single bubble sign: stenosis pilorus 21. Apa yang dimaksud atresia ani letak tinggi? Atresia ani letak tinggi adalah atresia ani dimana rectum tidak menembus musculus levator ani, sehingga ujung buntu rectum dengan kulit luar berjarak lebih dari 1 cm. 22. Modalitas/ alat pemeriksaan radiologi apa yang paling tepat untuk menilai kecurigaan fraktur cervical? CT scan

23. Pada trauma abdomen dengan kecurigaan kontusio dengan lacerasi lien modalitas/alat pemeriksaan radiologi apa yang paling tepat? FAST-USG 24. Apa yang dimaksud dengan greenstick fraktur? Fraktur greenstick adalah patah tulang parsial di mana salah satu sisi tulang patah dan sisi lain melengkung.D e n g a n m e n i n g k a t n y a u m u r , m a k a tulang seseorang akan m e n j a d i l e b i h k e r a s ( k a k u ) d a n l e b i h r a p u h . S e h i n g g a fraktur greenstick hanya terjadi pada bayi dan anak-anak saja dimana struktur t u l a n g n y a m a s i h l e m b u t dan periosteumnya masih tebal. 25. Apa perbedaan vaskuler groove pada calvaria dengan fraktur calvaria? vasukular biasanya berbentuk seperti busur semntara fraktur terlihat sebagai garis yang lurus atau bersudut tajam yang lebih lucen disbanding vascular grooves. Fraktur membagi/membelah seluruh ketebalan tulang, sementara vascular groove hanya menempati sebagian ketebalan tulang. Fraktur linear cranial biasanya tampak sebagai garis hitam yang Nampak tegas, sedangkan vascular groove sering bercabang, memiliki margin sclerotic dan tempatnya tipikal.