DIAGNOSTIC IMAGING METHODS

HISTORY

1895-Wilhem Roentegen

Produced the 1st X ray film image of his wifes hands

X RAY

Form of radiant energy similar to visible light

Has very short wavelength
Penetrates many substances that are opaque to light
Produced by bombarding a tungsten target with an electron beam with an x-
ray tube.

FILM RADIOGRAPHY

Utilize a screen film system within a film cassette ( x-ray detector)

COMPUTED RADIOGRAPHY (CR)

Filmless system
No processing
Produces A DIGITAL RADIOGRAPHIC IMAGES

DIGITAL RADIOGRAPHY

Filmless system
Substitutes a fixed electronic detector on charge-coupled device for the film
screen cassette or phosphor imaging plate.
CONVENTIONAL TOMOGRAPHY

Provides radiographic images of slices of the

patient
Done by simultaneously moving
both x-ray tube and x-ray detector around a
pivot point center to the patient
Improved detail

FLUOROSCOPY

Real time radiographic visualization of moving anatomic structures

Useful in evaluating motion such as gastrointestinal peristalsis, movement of
diaphragm during respiration and cardiac action

PRINCIPLES OF INTERPRETATION

5 basic radio densities

Air density
Fat density
Soft tissue density
Bone density
Metal/contrast agent density
Air attenuates very little of the x ray beam-most are transmitted-> black on
radiograph
Bone, metal, contrast agent attenuates a large proportion of x ray beam-> white
on radiograph.
Fat and soft tissue intermediate amt. of x ray beam-> shades of gray on
radiograph
Anatomic structures are seen when outlined by tissues.
Contrast agents- suspensions of iodine or barium
 Disease states may obscure normally visualize structures by silhouetting their
outline.

CROSS SECTIONAL IMAGING TECHNIQUES

CT, MR, AND ULTRASOUND

Produced 2 dimensional image
Resulting image is made up of pixels which represent a voxel of patient
tissue

COMPUTED TOMOGRAPHY

Displays each splice separately

No superimposed blurred structures seen.
Hounsfield unit (H) scale

o Air:1,000H
o Lung tissue :-400 to -600 H
o Fat:- 60 to -100 H
o Water: value of 0 H
o Soft tissue:+40 - +80 H
o Bone:+400 to + 1000 H
Most CT units allow slice thickness between 0.5 to .10mm
Advantages of CT compared to MRI:
o Rapid scan acquisition
o Superior bone detail and demonstration of calcification.

TYPES OF CT SCAN:

Conventional CT (non helical)

- Obtain image data one slice at a time- one slice per breath hold.
- Requires at least 2-3x the total scanning time of helical CT.
Helical CT (spiral)
- Improved speed of image acquisition.
- Improved visualization of small lesions.
- Scans entire abdomen, pelvis in 2-3 breaths.
Multidetector helical CT
- Latest technical advance in CT imaging
- Obtains multiple slices per tube rotation
- 5-8x faster than single slice helical CT.
- DA: radiation dose, 3-5x higher than single slice CT.
Contrast administration in CT
- Intervenous iodine based contrast agents are administered in CT to:
o Enhance density differences between lesions surrounding the
parenchyma.
 o To demonstrate vascular anatomy and vessel patency.

PRINCIPLES OF CT INTERPRETATION

Images are oriented so that the observer is looking at the patient below.
Patients right side is oriented on the left side of the image.
Optimal bone detail is viewed at bone windows
Lungs are viewed at lung windows
Window width of 2,000 H, window level of 400-600H
Soft tissues
Window width of 400 -500 H, window level of 20-40H.

MAGNETIC RESONANCE IMAGING (MRI)

Produces images by means of magnetic fields and radio waves

Analyzes multiple tissue characteristics :
Hydrogen
T1 and T2 relaxation times of tissue
Blood flow within tissue
Provides the best tissue contrast.
Most tissues can be differentiated by differences in their T1 and T2 relaxation
times.
Blood flow has a complex effect on MR signal that may decrease or increase
signal intensity within blood vessel.
Because the MR signal is very weak, prolonged imaging time is often required
for optimal changes.

ADVANTAGES OF MRI DISADVANTAGES OF MRI

Outstanding soft tissue contrast
resolution
Provides images in any anatomic plate
Absence of ionizing radiation
Limited in its ability to demonstrate
dense bone detail or calcifications
Involves long imaging of many pulse
sequences
Possesses limited spatial resolution
compared with CT

CONTRAST ADMINISTRATION IN MRI:

Gadolinium chelates
- A heavy metal ion with paramagnetic effect that shortens T1 and T2
relaxation times of hydrogen nuclei within its local magnetic field.
- Essential in providing high quality MR angiographic studies by
enhancing the signal differences between blood vessel and
surrounding tissues.
 - If very high tissue concentrations, such as the renal collecting system,
T2 shortening causes a significantly loss of signal intensity best seen
on T2WIs.

SAFTETY CONSIDERATIONS:

MR is contraindicated in patients who have electrically, magnetically or

mechanically activated implants.
Cardiac pacemakers, insulin pumps, cochlear implants,
neurostimulators, bone- growth stimulators, and implantable
drug infusion pumps.
Intracardiac pacing wires or Swan-Ganz catheters
Ferromagnetic implants such as cerebral aneurysm clips,
vascular clips, and skin staples.
Bullets, shrapnel, and metallic fragments may move and cause
additional injury or become projectiles in the magnetic field.
Metal workers and patients with heinous story of penetrating
eye injuries should be screened with radiographs of the orbit to
detect intraocular metallic foreign bodies that may dislodge,
tear the retina and cause blindness.
SAFE FOR MRI
No ferromagnetic vascular clips and staples and orthopedic
devices.
Prosthetic heart valves with metal components and stainless
steel greenfield filters
Pregnant patients can be scanned, provided the study is medically
indicated.

Principles of Interpretation:

Soft tissue contrast is obtained through imaging sequences that accentuate

differences in T1 and T2 tissue relaxation times.
Water is the major source of the MR signal in tissues other than fat.
Mineral rich structures, such as bone and calculi, and collagenous tissue such
as ligaments, tendons, fibrocartilage and tissue fibrosis are low in water
contents and lack mobile protons to produce an MR signal.
Low in signal intensity on all MR sequence
Free Water
Long T1 (low signal) and long T2 (high signal)
Found mainly as extracellular fluid, also as intracellular free water
Organs with extracellular fluid (free water)
 Kidneys (Urine); ovaries and thyroid (fluid-filled follicles); spleen and
penis (stagnant blood); and prostate, testes and seminal vesicles (fluid
and tubules)
Edema (increase in extracellular fluid) - prolongs T1 and T2 relaxation times.
Most neoplastic tissues have increase in extracellular fluid as well as an
increase in the proportion of intracellular free water bright signal intensity
on T2WIs.

Proteinaceous fluids
Addition of protein and free water shortens T1 relaxation time bright.
T2 relaxation is also shortened, but the T1 shortening effect is
dominant even on T2WIs- remain bright on T2WIs.
Synovial fluid, complicated cysts, abscesses, many pathologic fluid
collections, and necrotic areas within tumors.
Soft tissues
Soft tissues that have a predominance of intracellular bound water
have shorter t1 and t2 times than do tissues with large amounts of
extracellular water.
Include the liver, pancreas, adrenal glands and muscle-
intermediate signal intensities on both t1wis and t2wis
Intracellular protein synthesis shortens t1 more.
Muscle (less active protein synthesis) is lower in signal
intensity on t1wis than are organs with more active
protein synthesis
Benign tumors with a predominance of normal cells, such as
focal nodular hyperplasia in the liver, tend to remain isointense
with their surrounding normal parenchyma on all imaging
sequences.
Hyaline cartilage has a predominance of extracellular water but
extensively bound to mucopolysaccharide matrix
Signal resembles cellular soft tissues intermediate on
most imaging sequences.
Fat
Protons in fat are bound to hydrophobic intermediate sized
molecules and exchange energy efficiently within their chemical
environment.
T1 relaxation time is short resulting in a bright signal.
T2 is shorter than t2 of water lower signal intensity for fat, relative
to water.
On images with lesser degrees of t2 weighting, t1 effect
predominates and fat appears isointense or slightly hyper intense
compared with water.
 Specialized fat saturation imaging sequences may be used to
reduce the signal intensity of fat and enhance the visibility of
edema and pathologic processes within fat.
STIR sequences suppress signals from all tissues with short t1
times, including fat.

Flowing blood
The MR signal of slow moving blood, such as in the spleen, venous
plexuses and cavernous hemangiomas is dominated by the large amount
of extracellular water present.
Low signal on t1WIs and high signal on t2WIs

Ultrasonography

Utilizes pulse echo technique

Transducer converts electrical energy to a brief pulse of high frequency sound
energy transmitted into patient- transducer becomes a received detecting
echoes of sound energy reflected from tissue composite image is produced.
Produces nearly real time images of moving patient tissue.
Enables assessment of respiratory and cardiac movement vascular
pulsations, peristalsis and moving fetus.
Images may be produced in any anatomic plane by adjusting the orientation
and angulation of the transducer and the position of the patient.
Standard orthogonal planes: axial, sagittal and coronal.
Visualization of structures by US is limited by bone and gas contaminating
structures (e.g. bowel and lung)
Sound energy is nearly completely absorbed at interfaces between soft
tissue and bone causing an acoustic shadow limiting visualization of
structures deep to the bone surface.
Soft tissue gas interfaces cause nearly complete reflection of the sound
beam, preventing visualization of deeper structures.

Doppler US:

Adjunct to real time gray scale imaging.

Detects reflection of the sound wave from a moving object RBC in
flowing blood.
 Can detect presence of blood flow and its direction and velocity.
Color Doppler
Gray scale + color coded Doppler information in a single image.
Stationary tissue shades of gray.
Blood flow and moving tissue colored.
Blood flow relatively toward the transducer face shades of red.
Blood flow relatively away from the transducer face shades of
blue.
Lighter shades of color imply higher glow velocities

US Artifacts

Must be recognized to avoid diagnostic errors.

Acoustic shadowing
Produced by nearly complete absorption or reflection of the beam,
obscuring deeper tissue structures.
Produced by gallstones, urinary tract stones, bone, metallic objects,
and gas bubbles.
Acoustic enhancement
Increased intensity of echoes deep to structures that transmit sound
exceptionally well.
Such as cysts, fluid filled bladder and gallbladder.
Presence of acoustic enhancement aids in the identification of cystic
masses.
Comet tall artifact is seen as pattern of tapering bright echoes trailing from
small bright reflectors

Such as air bubbles and cholesterol crystals.

PRINCIPLES OF ULTRASOUND INTERPRETATION

Fluid containing structures (cysts, dilated calyces and ureters, bladder and
gallbladder
Well defined walls, absence of internal echoes, and distal acoustic
enhancement
Solid tissue
Speckled pattern of tissue texture and definable blood vessels.
Fat: usually highly echogenic.
 Solid organs (liver, pancreas, and kidney): lower degrees of echogenic.
Terminologies
Hypo echoic: lesions of lower echogenicity than surrounding
parenchyma
Hyperopic: lesions of greater echogenicity than surrounding
parenchyma
Anechoic: complete absence of echoes

E.g. simple cysts

RADIOGRAPH ULTRASOUND CT SCAN MRI

TERMINOLOG DENSITY ECHOLGENICITY DENSITY INTENSITY
Y Radiolucent Anechoic black Hypodense Hypointense darker
black Hypoechoic darker Hyperintense whiter
Radio darker than Hyperdense Isointense same as
opaque/radio parenchyma whiter parenchyma
dense white Hyperechoic Isodense
whiter than same as
parenchyma parenchyma
Isoechoic
same as
parenchyma
AIR radiolucent Not visualized Black T1 T2
FAT Moderately Hyperecholic Hypodense Hypointen Hyperinte
radiolucent se nse
WATER/FLUID Moderately Anechoic hyperdense Hypointen Lower
S radio opaque se intensity
than
water
SOFT TISSUE Moderately Varying Varying hypointen hyperinten
 radiopaque echogenicity hyperdenseit se se
y
BONE/METAL Very radio Not visualized Very Intermedi Intermedi
opaque hyperdense ate ate
intensity intensity
Hypointen Hypointen
se se

PULMONARY RADIOLOGY

IMAGING MODALITIES:

Conventional Chest Radiography:

Posteroanterior (PA) and lateral chest radiographs are the mainstays of

thoracic imaging
Initial imaging study in all patients with thoracic disease.
Proper radiographic technique on frontal radiographs involves assessment of
four basic features:
Penetration faint visualization of the intevertebal disc spaces of the
thoracic spine: discrete branching vessels can be identified through the
cardiac shadow and the diaphragms.
Rotation note the relationship between the medial cortical margins of
the clavicular heads and the spinous processes of the thoracic
vertebrae.
Inspiration apex of the right hemidiaphragm is visible below the tenth
posterior rib.
Motion cardiac margin, diaphragm and pulmonary vessels should be
sharply marginated in a completely still patient.

Portable Radiograph:

Obtained when patients cannot be safely mobilized.

There is magnification of intra thoracic structures.
Normal gravitational effect evens out the blood flow between upper and
lower zones in supine patients.
Widened upper mediastinum.

Special techniques:

Lateral decubitus
 Used to detect small effusions and characterize free-flowing effusions
on the decubitus side, or to detect a small pneumothorax on the
contralateral side.
Expiratory radiograph
Detection of a small pneumothorax.
Apical lordotic view
Improves visualization of the lung apices
Chest fluoroscopy
Assess chest dynamics on patients with suspected diaphragmatic
paralysis.

CT and HRCT

Long windows: window width of 1000 to 2000 H and window levels of about
500 to 600 H
Routine settings for CT display of mediastinal structures are WW = 400 and
WL = 40 and for the lungs are WW = 1500 and WL = 700
Advantages of CT scan:
Superior contrast resolution
Cross-sectional display format

Indication for thoracic CT

Indication
Evaluation of an abnormality identified
on conventional radiographs
Staging of lung cancer
Detection of occult pulmonary
metastases
Detection of mediastinal nodes
Distinction of empyema from lung
abscess
Detection of central pulmonary
embolism
Detection and evaluation of aortic
disease: aneurysm, dissection,
intramural hematoma, aortitis, trauma
example
Assessment of extent of the primary
tumor and the relationship of the tumor
to the pleura, chest wall
Extrathoracic
Lymphoma metastases infections
Contrast-enhanced CT can usually
distinguish a peripheral lung abscess
from loculated empyema
Anglo-CT with high inje
Detection and localization of extent,
including aortic branch involvement
 HRCT technique involves incremental thinly collimated scans (1.0 to 1.5mm)
obtained at evenly spaced intervals through the thorax for the evaluation of
diffuse bronchial or parenchymal lung disease.
Image acquisition time is limited to minimize the effects of respiratory and
cardiac motion.

Indication of Thoracic HRCT

Indications Examples
Solitary pulmonary nodule Breath-hold volumetric exam with thin
collimation for accurate density
determination without respiratory
misregistration
Detection of lung disease in a patient Emphysema
with pulmonary symptoms or abnormal Extrinsic allergic alveolitis
pulmonary function studies and a Small airways disease
normal or equivocal chest film Immunocompromised patient
Evaluation of diffusely abnormal chest film
A baseline for evaluation of patients Cystic fibrosis
with chronic diffuse infiltrative lung Sarcoidosis
disease for follow-up changes with Interstitial lung disease
therapy Histiocytosis x
Adult respiratory distress syndrome
To determine approach (type and Bronchoscopy versus VATS or needle
location) of biopsy biopsy

MRI

Morphologic studies usually require only spin echo T1W and T2W sequences
in the axial plane.
Advantages of MRI:
Superior contrast resolution between tumor and fat
Ability to characterize tissues based on T1 and T2 relaxation times
Ability to scan in direct sagittal and coronal planes
Lack of need for intravenous iodinated contrast
Disadvantages of MRI
Limited spatial resolution
Inability to detect calcium
Difficulties in imaging the pulmonary parenchyma
More time-consuming and expensive than CT

Indications for MR of the Thorax

Evaluation of aortic disease in stable patients: dissection, ancurysm, intramural
hematoma, aortitis
Assessment of superior sulcus tumors
Evaluation of mediastinal, vascular and chest wall invasion of lung cancer
Staging of lung cancer patients unable to receive intravenous iodinated contrast
Evaluation of posterior mediastinal masses

Ultrasound

Used for the detection, characterization and sampling of pleural, peripheral

parenchymal and mediastinal lesions
Can also confirm phrenic nerve paralysis without the use of ionizing radiation
Detects subpulmonic and subphrenic fluid collections

NORMAL LUNG ANATOMY

Tracheobronchial Tree

Trachea
Hollow cylinder composed of a series of c-shaped cartilaginous rings
 Seen as a vertically oriented cylindric lucency extending from the
cricoid cartilage superiorly to the main bronchi inferiorly on chest
radiographs.
Bronchial system
Exhibits a branching pattern of asymmetric dichotomy
Main bronchi arise from the trachea at the carina
Right bronchus forms a more obtuse angle with the long axis of the
trachea and is considerably shorter than the left main bronchus
Bronchi on the end can be seen as a ring shadow on the chest
radiographs
Tracheal and main, lobar and segmental bronchial anatomy are easily
seen on CT

Pulmonary arteries

Arises from the right ventricle

Left pulmonary artery is a direct continuation of the main pulmonary artery
Right artery divides into the truncus anterior and interlobar arteries

Bronchial arteries

Primary nutrient vessels of the lung

Usually arise from the proximal descending thoracic aorta at the level of the
carina

Pulmonary veins

Arise within the interlobular septa from the alveolar and visceral pleural
capillaries

Lobar and segmental anatomy

Interlobar fissures
Invaginations of the visceral pleura
Completely or incompletely separate the lobes from one another
There are two interlobar fissures on the right and one on the left
Right minor fissure separates the middle from the upper lobe
Projects as a thin undulating line on frontal radiographs
and as a thin curvilinear line with a convex superior
margin on lateral radiograph
Right and left major fissure separates the lower lobe from the
upper lobe superiorly and from the middle lobe inferiorly
 Not usually visualized on frontal radiographs because of
the oblique course relative to the x-ray beam
The upper lobe bronchus and its artery arising from the truncus anterior
branch into three segmental branches: anterior apical and posterior.
The middle lobe bronchus arises from the intermediate bronchus and divides
into medial and lateral segment branches, with its blood supplied by a branch
of the right interlobar pulmonary artery.
The lower lobe (RLL) is supplied by the RLL bronchus and pulmonary artery. It
is subdivided into a superior segment and four basal segments: anterior,
lateral, posterior and medial.
Left upper lobe is subdivided into four segments: anterior, apicoposterior, and
the superior and inferior lingular segments.
The superior and inferior lingular arteries are proximal branches of the left
inter-lobar pulmonary artery analogous to the middle lobes blood supply.
Arterial supply to the anterior and apicoposterior segments parallels the
bronchi and is via branches of the upper division of the left main pulmonary
artery.
The left lower lobe has a superior segment and three basal segments:
anteromedial, lateral and posterior.

Pulmonary lymphatics

Visceral pleural lymphtics

Reside in the vascular layer of the visceral pleura
Form a network over the surface of the lung that roughly parallels the
margins of the secondary pulmonary lobules
Penetrate the lung to course centrally within interlobular septa, along
with the pulmonary veins toward the hilum

Parenchymal lymphatics
Originate in proximity to the alveolar septa (juxta-alveolar lymphatics)
Course centrally with the Broncho arterial bundle

Perivenous and bronchoarterial lymphatics

Communicate via obliquely oriented lymphatics located within the
central regions of the lung.
The perivenous lymphatics and their surrounding connective tissue
when distended by fluid account for the radiographic appearance of
kerley a lines.

Pulmonary interstitium

Provides support for the airways and pulmonary vessels

Begins within the hilium and extends peripherally to the visceral pleura
Axial interstitium
 Extends from the mediastinum and envelopes the bronchovascular
bundles
edema within is recognized radio graphically as per bronchial cuffing.
Centrilobular interstitium
These are axial fiber system continues distally along with the
arterioles, capillaries, and bronchioles to provide support for the air
exchanging portions of the lung.
Peripheral interstitium
Where the pulmonary veins and lymphatics lie within
subpleural interstitium (and interlobular septa)
Parts of the peripheral inerstitium which divides secondary
pulmonary lobules
Radio graphically, edema of the peripheral and supleural interstitium
accounts for kerley b lines (or interlobular lines on HRCT) and
thickened fissures on chest radiographs.
Intralobular interstitium
Bridges the gap between the centrilobular and peripheral
compartments.
Pathologic involvement may account for some cases of so called
ground glass opacity on chest radiographs and HRCT scans.
Respiratory bronchioles contain a few alveoli along their walls and give rise to
the gas-exchanging units of the lung:
Alveolar ducts
Alveolar sacs
Type 1 pneumocyte
Flattened squamous cells
Incapable of mitosis or repair
Type2 pneumocyte
Cuboidal cells
Course of new type 1 pneumocytes and provide a
mechanism for repair following alveolar damage
Source of alveolar surfactant

Posterioranterior chest radiograph

Soft tissues
 Consist of the skin, subcutaneous fat and muscles
Visualization of normal fat in the supraclavicular fossae and the
companion shadows of skin and subcutaneous fat paralleling the
clavicles helps exclude mass, adenopathy or edema in his region.
The inferolateral edge of the pectoralis major muscle is normally seen
curving towards the axilla
Breast shadows should be evaluated routinely to detect evidence of
prior mastectomy or distorting mass.
Bones
Thoracic spine, ribs and costal cartilages, clavicles, and scapulae are
routinely visible on frontal chest radiographs.
The bodies of the thoracic vertebrae should be vertically aligned, with
endplates, pedicles, and spinous processes visualized.
Coastal cartilage calcification is seen in a majority of adults, increase in
prevalence with advancing age. Men typically show calcification at the
upper and lower margins (vaginal sign). While the majority of women
develop central cartilaginous calcification (penile sign).
Lungs
Opacity of the lungs as visualized radiographically is attributable solely
to th4 presence of the pulmonary vasculature and enveloping
interstitial structures.
Arteries are solid cylinders branching along the airways and both
gradually diminish in caliber as they divide.
Pulmonary veins can often be traced horizontally to the left atrium,
whereas the arteries caqn be followed to their hilar origin, which lies
more cephalad than the left atrium.
The effects of gravity explain the basal predominance of vasculature in
an upright patient, as well as isodistribution of vessels in the supine
patient.
Lung mediastinal interfaces
Superior vena cava
Straight or slightly concave interface with the right upper lobe
extending from the level of the clavicle to the superior margin of
the right atrium.
Lateral margin of the right atrium
Projects just to the lateral margin of the thoracic spine on a
normal PA radiograph.
Smooth convex inter with the medial segment of the middle
lobe.
Pectus excavatum- displaces the cardiac shadow leftward and
may not demonstrate this interface.
Right lateral border of the inferior vena cava
Concave lateral interface at the level of the right
hemidiaphragm
Best visualized on lateral radiographs
 Aortic knob
Small convex indentation on the left lung
Aortopulmonary window
Inferior to the aortic arch
Usually straight or concave toward the lung.
Left lateral border of the main pulmonary artery
Inferior to the aortopulmonary window
This structure may be convex, straight, or concave toward the
lung.
Enlargement is seen in diopathic condition in young women,
poststenotic dilatation in valvular pulmonic stenosis, conditions
where there is increased flow or pressure in the pulmonary
arterial system.
Left atrial appendage
Forms a concave interface immediately below the main
pulmonary artery.
Lateral border of the left ventricle
Comprises most of the left heart border as a gentle convex
margin with the lingua.
Diaphragm
Major inspiratory muscle comprised of muscular origins along the
costal margins and insertions into the membranousdome
Right hemidiaphragm
Overlies the liver
Apex typically lies at the level of the sixth anterior rib on frontal
radiographs exposed in deep inspiration, approximately one half
interspace above the apex of the left hemidiaphragm.
Left hemidiaphragm
Overlies the stomach and spleen

Lateral chest radiograph

Summation of the right hemi thorax over the left.

Knowledge of normal lateral radiographic anatomy can greatly aid in
detection and localization of parenchymal and cardiomediastinal processes.

Parenchymal lung disease:

Pulmonary opacity abnormal increase in lung density

Pulmonary lucency abnormal decrease in lung density

Pulmonary opacity
Airspace disease:

Develop when air normally present within the terminal spaces are replaced
by material of soft tissue density such as blood transudate, exudates or
neoplastic cells.
Radiographic characteristics of airspace disease:
Lobar or segmental distribution
Poorly marginated
Airspace nodules
Tendency to coalesce
Bats wing or butterfly distribution
Rapidly changing over time
CT findings of airspace disease:
Lobar or segmental distribution
Poorly marginated that tend to coalesce
Airspace nodules
Air bronchogram
Differential diagnosis:
Pneumonia
Pulmonary edema
Hemorrhage
Neoplasm
Alveolar proteinosis

Interstitial disease:

Produced by processes that thicken the interstitial compartments of the lung

with water bleed tumor, cells, fibrous tissue or any combination of these
Patterns of interstitial disease are divided into:
Reticular network of curvilinear opacities
Fine reticular or ground glass pattern
1 to 2 mm of intervening lucent spaces
Seen in interstitial pulmonary edema and interstitial
pneumonitis
Medium reticulation or honeycombing
3 to 10 mm
Seen in pulmonary interstitial fibrosis
Coarse reticular pattern
<1 cm
Seen langerhanscell histiocytosis of the lung, sarcoidosis
and idiopathic pulmonary fibrosis.
Reticulonodular
May be produced by overlap of reticular shadows or
presence of both nodular and reticular opacities.
Silicosis, sarcoldosis and lymphangitic carcinomatosis give
rise to true reticulonodular pattern.
 Nodular homogenous, well defined, small rounded lesions
within the pulmonary interstitium.
Military < 2 mm
Micro nodules 2 to 7 mm
Nodules 7 to 30 mm
Masses 30 mm
Military or mironodular pattern are seen in granulomatous
processes (military or histoplasmosis) hematogenous
pulmonary metastasis (thyroid and renal cell
And pneumoconiosis (silicosis)
Nodules and masses are seen in metastatic disease to the
lung
Linear processes that thickens the axial (Broncho vascular) or
peripheral interstitium of the lung. Produce parallel linear
opacities radiating from the hila when visualized in length or
peribronchial cuffing when visualized end on.
Kerley A lines - < 1 mm thick lines obliquely oriented and
course through the lung toward the hila 2 to 6 cm long.
Corresponds connective tissue within the lung
Kerley B lines peripheral lines that course perpendicular
to and contact the pleural space 1 to 2 cm long.
Represent thickened peripheral subpleural
interlobular septa.

Atelectasis:

Incomplete expansion of the lungs

4 mechanisms of atelectasis:
Obstructive/resorptive atelectasis
Most common form
Secondary to complete endobronchial obstruction of lobar
bronchus with resorption of gas distally
Common causes are bronchogenic carcinoma foreign bodies
mucous plugs and malpositioned endotracheal tube.
Passive/relaxation atelectasis
Result from mass effect of an air or fluid collection within the
pleural space on the adjacent lung.
Causes are pneumothorax and pleural effusion.
Compressive atelectasis
Form of passive atelectasis in which intrapulmonary mass
compresses adjacent lung parenchyma.
Causes include bullae, abscess and tumors.
 Cicatricial atelectasis
Produced by processes resulting in parenchymal fibrosis and
reduce alveolar volume.
Most often seen in chronic upper lobe fibrotic tuberculosis.
Adhesive atelectasis
Occurs in association with surfactant deficiency disease.
Radiograph show diminution in lung volume.

Pulmonary lucency

Abnormal lucency of the lung may be localized or diffuse

Diffuse lung lucency
Unilateral hyperlucency
Result in decrease in blood flow to the lung.
Hypoplasia of the right or left pulmonary artery.
Lobar resection or atelectasis
Pulmonary arterial obstruction
Swyer james syndrome
Emphysema most common with severe disease
Bilateral hyperlucent lung:
May be simulated by an over penetrated film or by a thin
patient
Result of diminished pulmonary blood flow
Congenital pulmonary stenosis
Pulmonary emphysema
Asthma
Focal radiolucent lesions
Includes cavities, cysts, bullae, blebs and pneumatoceles
Cavities
Form when a pulmonary mass undergoes necrosis and
communicates with an airway
The wall of a cavity is usually irregular or lobulated
Wall is greater than 1 mm thick
Lung abscess and necrotic neoplasm are the most
common cavitary pulmonary lesions

Bulla
Gas collection within the pulmonary parenchyma
>1 cm in diameter and has a thin wall <1 mm thick
Represents a focal area of parenchymal destruction
(emphysema) and may contain fibrous strands, residual
blood vessels or alveolar septa

Air cyst
 Well-circumscribed intrapulmonary gas collection
Smooth thin wall >1 mm thick
Bleb
Collection of gas <1 cm in size within the lawyers of the
visceral pleura
Usually found in the apical portion
Not seen on plain radiographs but may be visualized on
chest CT
Rupture can lead to spontaneous pneumothorax
Pneumatoceles
Thin-walled, gas-containing structures
Represent distended airspaces distal to a check-value
obstruction of a bronchus or bronchiole
Most commonly secondary to staphylococcal pneumonia

Pneumonia:

Microorganisms enter the lung via three potential routes:

Tracheobronchial tree
Pulmonary vasculature
Direct spread from infection in the mediastinum, chest wall or upper
abdomen.

1. Lobar pneumonia:
Typical of pneumococcal pulmonary infection.
The inflammatory exudate begins within the distal airspaces.
Airways are usually spared, air bronchograms are common and significant
volume loss is unusual.

2.Bronchopneumonia:
Most common patterns
Most typical staphylococcal pneumonia
Early stages of inflammation is centered primarily in and around lobular
bronchi
As the inflammation progresses, exudative fluid extends peripherally along
the bronchus to involve the entire pulmonary lobule.
Radio graphically, multifocal opacities that are roughly lobular in
configuration produce a patchwork quilt appearance.
Exudate within the bronchi accounts for the absence of air bronchograms in
bronchopneumonia

3. Interstitial pneumonia
Seen in viral and mycoplasma infection
There is inflammatory thickening of bronchial and bronchiolar walls and the
pulmonary interstitium
 Radiographic findings pattern of airways thickening and reticulonodular
opacities
Segmental and sub segmental atelectasis from small airways obstruction is
common.

Pulmonary tuberculosis:

Mycobacterium tuberculosis is an aerobic acid fast bacillus

Two principal forms of tuberculous pulmonary disease are recognized
clinically and radiographically
Primary tuberculosis (TB)
Reactivation or post-primary disease
Involves cell-mediated immunity (delayed hypersensitivity)
Primary PTB:
Has classically been a disease of childhood
Ranke complex: calcified parenchymal focus (the ghon lesion) and
nodal calcification.
Nonspecific focal pneumonitis seen as small ill-defined areas of
segmental or lobar opacification.
Unllateral/ollateral hilar or mediastinal lymph node enlargement.
Post-primary PTB:
Tends to occur in the apical and posterior segments of the upper lobes
and the superior segments of the lower lobes as ill-defined patchy and
nodular opacities.
Cavitation: may lead to transbronchial spread of organisms and result
in a multifocal bronchopneumonia.
Rasmussen aneurysm erosion of a cavitary focus into a branch of the
pulmonary artery can produce an aneurysm and cause hemoptysis.
Parenchymal healing is associated with fibrosis, bronchiectasis and volume
loss (cicatrizing atelectasis) in the upper lobes.

Milliary TB:
May complicate either primary or reactivation disease.
Results from hematogenous dissemination of tubercle bacilli and
produces diffuse bilateral 2 to 3 mm pulmonary nodules.

Asthma:

An airway disorder characterized by the rapid onset of bronchial

narrowing with spontaneous resolution or improvement as a result of
therapy.
Radiographic findings include:
Hyperinflation
 Bronchial wall inflammation and thickening (peribronchial cuffing and
tram tracking)
In some patients the hila are prominent from transient pulmonary
arterial hypertension.

Emphysema:

Defined as an abnormal permanent enlargement of the airspaces distal to the

terminal bronchioles accompanied by destruction of alveolar walls and
without obvious fibrosis.
Frontal and lateral chest radiographs are the initial radiographic examinations
obtained in patients with suspected emphysema.
Hyperinflation most important plain radiographic finding.

1. Centrilobular emphysema
Most common affects the upper lobes to a greater extent than the lower
lobes
Airspaces distention in the central portion of the lobule sparing of the more
distal portions of the lobule.

2. Panlobular emphysema
Affects lower lobes more than the upper lobes.
Uniform distention of the airspaces throughout the substance of the lobule
from the central respiratory bronchioles to the peripheral alveolar sacs and
alveoli.

3. Paraseptal emphysema
Most often seen in the immediate subpleural regions of the upper lobes.
Selective distention of peripheral airspaces adjacent to the interlobular septa
with sparing of the centrilobular region.
May coalesce to form apical bullae.

4. Paracicatricial or irregular emphysema

Destruction of lung tissue associated with fibrosis; has no consistent
relationship to a given portion of the lobule.
Often seen in association with old granulomatous inflammation.

Bronchogenic carcinoma:

Majority of patients are cigarette smokers who are over 40 yrs of age.
Men are more affected.
Solitary pulmonary nodule or mass and a hilar mass with or without bronchial
obstructionare the most common radiographic findings.
Obstruction of the bronchial lumen can result into resorptive atelectasis or
obstructive pneumonitis
 Pancoast tumor (superior sulcus) peripheral neoplasm arising in the lung
apex indented superior by the subclavian artery.
Majority are squamous cell carcinomas or adenocaricinomas.
Apical thickness of >5 mm asymmetry of the apical opacities of >5 mm or
evidence of rib destruction should prompt further evaluation with helical CT
or MR.

Subtypes of bronchogenic carcinoma:

adenocarcinoma
Most common type of lung cancer (35% of bronchogenic carcinoma)
Usually located in the lung periphery; of cases found in central
portions.
Arise from the bronchiolar or alveolar epithelium.
They have irregular or speculated appearance where they invade
adjacent lung
5 year survival rate of 17%
Squamous cell carcinoma
2nd most common subtype of bronchogenic carcinoma (25%)
Arises centrally within a lobar or segmental bronchus.
Usually present as hilar mass with or without obstructive pneumonitis
or atelectasis
5 year survival rate 15%
Small cell carcinoma
25% of bronchogenic carcinomas and arise centrally within the main or
lobar bronchi.
Most malignant neoplasm arising from neuroendocrine (kultchitsky)
cells.
Produces a hilar or mediastinal mass with extrinsic bronchial
compression.
5 year survival rate 5%
Large cell carcinoma
15% of bronchogenic carcinomas
Present as a large peripheral mass usually peripherally located
5 year survival rate of 11%

TMN classification of lung cancer

Primary tumor (T)
Tx Malignant cells in sputum without
identifiable tumor.
T0 No evidence of primary tumor.
T1 Tumor <3.0 cm in diameter surrounded
by lung or visceral pleura arising distal
to a main bronchus.
T2 Tumor >3.0 cm in diameter any tumor
invading the visceral pleura any tumor
 with atelectasis or obstructive
pneumonitis of less than an entire lung;
tumor must be >2 cm from the tracheal
carina.
T3 Any tumor with localized chest wall
diaphragmatic mediastinal pleural or
pericardial invasion the tumor may be,
2 cm from the carina but cannot involve
the carina.
T4 Any tumor that invades the
mediastinum or vital mediastinal
structures including the heart, great
vessels trachea carina or vertebral
body; separate tumor nodules in the
same lobe; presence of a malignant
pleural effusion.
Nodal metastases (N)
N0 No evidence of nodal metastases
N1 Metastasis to ipsilateral peribronchial or
hilar nodes including involvement by
contiguous spread of tumor.
N2 Metastasis to ipsilateral mediastinal or
subcarinal
nodes.
N3 Metastasis to contralateral mediastinal
or hilar nodes or scalene or
supraclavicular nodes.
Distant metastases (M)
M0 No evidence of distant metastases.
M1 Distant metastases separate tumor
nodules in different lobes.

Clinical staging of lung cancer based on TNM classification

Ia T1 N0 M0

Ib T2 N0 M0

IIa T1 N1 M0

IIb T2 N1 M0

T3 N0 M0

IIIa T1 or T2 N2 M0
 T3 N1 or N2 M0

IIIb any T N3 M0

T4 Any N M0

IV any T any N M1

Pulmonary vascular disease:

Pulmonary venous hypertension

Elevation in pulmonary venous pressure

Causes: obstruction to left ventricular inflow left ventricular systolic
dysfunction mitral valve regurgitation.
Radiographic findings include: enlargement of pulmonary veins and
redistribution of pulmonary blood flow to nondependent lung zones.

Pulmonary arterial hypertension:

Defined as systolic pressure in the pulmonary artery of 30 mm Hg

Causes: increase resistance to pulmonary blood flow (emphysema, chronic
hypoventilation cystic lung disease constrictive bronchiolitis cystic fibrosis)
Typical radiographic findings are enlarged main and hilar pulmonary arteries
that taper rapidly toward the lung periphery.
There may be associated right ventricular enlargement.
Enlarged pulmonary artery a transverse diameter of the proximal interlobar
pulmonary artery on PA chest radiograph exceeding 16 mm

Pulmonary edema:

The interstitial spaces of the lungs are kept dry by pulmonary lymphatic
located within the axialand peripheral interstitium of the lung.
There are no lymphatic structures immediately within the alveolar walls,
alveolar interstitial fluid is drawn to the lymphatics by pressure gradient.
When the rate of fluid accumulation exceeds the lymphatic drainage
capabilities of the lungs fluid accumulate first within the interstitial space
Progressive fluid accumulation eventually produces flooding of the alveolar
spaces.
Hydrostatic pulmonary edema most common cause.

Interstitial edema:

Radiologic appearance of results from thickening of the components of the

interstitial spaces by fluid.
 Peribronchial cuffing and tram tracking thickening of the peribronchovascular
interstitium.
Loss of definition of the intrapulmonary vascular shadows thickening of the
axial interstitium.
Kerley lines.

Airspace edema:

Occurs when fluid from the interstitum spills into the alveoli
Upright radiograph show bilateral symmetrical airspace opacities
predominantly in the mid to lower lobes.

Pleura:

The pleura is a serous membrane subdivided into:

Visceral pleura covers the lungs and forms the interlobar fissure.
Parietal pleura lines the mediastinum diaphragm and thoracic cage
The potential space between the visceral and parietal pleura is the pleural
space which contains 2 to 5 ml of fluid which serves as a lubricant during
breathing.
Under normal conditions, pleural fluid is formed by filtration form systemic
capillaries in the parietal pleura and resorbed via the parietal pleural
lymphatics.

Pleural effusion:

Occurs when there is imbalance between the formation and resorption of

pleural fluid.
Pleural effusions may be classified by:
Gross appearance (bloody, chylous, purulent, serous)
Causative disease
Pathophysiology of abnormal pleural fluid formation (transudative
versus exudative)
The radiographic appearance of pleural effusions depends upon:
Amount of fluid present
Patients position during the radiographic examination
Presence or absence of adhesions between the visceral and parietal
pleura
Small amounts of pleural fluid initially collect between the lower lobe and
diaphragm in a subpulmonic location as more fluid accumulates, it spills
into the posterior and lateral costophrenic sulci.
On upright PA chest radiographs
Moderate amount of pleural fluid (>175 ml) in the erect patient will
have homogeneous lower zone opacity.
The lateral costopherenic sulcus will show a concave interface towards
the lung (meniscus sign)
Pleural fluid may extend into the interlobar fissures
 Free fluid within the minor fissure is usually seen as smooth, symmetric
thickening on a frontal radiograph.
In patients with suspected pleural effusion, a lateral decubitus film with the
affected side down is the sensitive technique to detect small amounts of fluid.
There will be fluid shifting to the dependent portion of the thorax
A large pleural effusions can cause passive atelectasis of the entire lung
producing an opaque hemithorax.
The radiographic detection of pleural effusion in the supine patient can be
difficult because fluid accumulates in a dependent location posteriorly.
The most common findings is a hazy opacification of the affected hemithorax
with obscuration of the hemidiaphragm and blunting of the lateral
costophrenic angle.
On axial CT scans pleural fluid layers posteriorly with a characteristic
meniscoid appearance and has a CT attenuation value of 0 to 20 H.

MEDIASTINUM

A narrow vertically oriented structure that resides between the medial parietal
pleuraol layers of the lungs.

Contains central cardiovascular tracheobronchial structures and the esophagus

enveloped in fat with intermixed lymph nodes

Divided into superior (thoracic inlet) and inferior components with the inferior
mediastinum subdivided into anterior middle and posterior compartments.

A line drawn through the sternal angel anteriorly and fourth thoracic intervertebral
space posteriorly divides the mediastinum into superior and inferior compartments.

Contents of the thoracic inlet and mediastinum

compartments contents
Thoracic inlet Thymus
Confluence of the right and left internal
jugular and subclavian veins

Right and left carotid arteries

Right and left subclavian arteries
Trachea
Esophagus
Prevertebral fascia
Phrenic, vagus, recurrent laryngeal
nerves
muscles
Anterior mediastinum Internal mammary vessels
Internal mammary and prevascular
lymph nodes
thymus
Middle mediastinum Heart and pericardium
Ascending and transverse aorta
Main and proximal right and left
pulmonary arteries
Confluence of pulmonary veins
Superior and inferior vena cava
Trachea and main bronchi
Lymph nodes and fat within mediastinal
spaces
Posterior mediastinum Esophagus
Azygos and hemiazygos veins
Thoracic duct sympathetic ganglia and
intercostal nerves
Lymph nodes

Mediastinal mass:

Patients with mediastinal masses tends to present in one of two fashions:

With symptoms related to local mass effect or invasion of adjacent mediastinal

structures (stridor in a patient with thyroid goiter)

Incidentally with an abnormality on a routine chest radiograph

Thoracic inlet masses

Marginated by the first rib and represents the junction between the neck and thorax

Commonly present as neck masses or with symptoms of upper airway obstruction

resulting from tracheal compression.

Thyroid masses lymphomatous nodes and lymphangiomas are the most common
thoracic masses

Thoracic lnlet masses

Thyroid mass Goiter
Malignancy
 Thyromegaly resulting from thyroiditis
Parathyroid mass Hyperplasia
Adenoma
carcinoma
Lymph node mass Lymphoma
Hodgkin
Non-Hodgkin
Matastases
Inflammatory
tuberculosis
lymphangioma
 - aed and fails to increase with raised intraabdominal pressure
increase in intrabdominal pressure exceed LES pressure and gastric
contents are allowed to reflux into the esophagus

Symptoms:

Substernal burning pain (heartburn)

Postural regurgitation (in the supine position)
Reflux esophagitis
Dysphagia
Odynophagia

Complications:

Reflux esophagitis
Stricture
Barrett esophagus
Radiographic diagnosis of GERD
Difficult to diagnose
20% of normal individuals show spontaneous reflux on UGI
examination and patients with pathologic GERD may not
demonstrate reflux without provocative tests
Zenker diverticulum
- Arises in the hypopharynx just proximal to the upper esophageal
sphincter (UES)
 -Located in the posterior midline at the cleavage plane (known as Killian
dehiscence) between the circular and oblique fibers of the
cricopharyngeus muscle
- Has a small neck that is higher than the sac, resulting in the trapping
of food and liquid within the sac.
- The distended sac may compress the cervical esophagus and cause
symptoms of:
Dysphagia
Halitosis
Regurgitation of food
Esophagitis
- A common disease with many causes
- Radiologic evaluation will detect most cases of moderate to severe
esophagitis but will demonstrate fewer than half the cases of mild
esophagitis

Radiographic signs of esophagitis:

1. Thickened esophageal folds (>3 mm)

2. Limited esophageal distensibility (asymmetric flattening)
3. Abnormal motility
4. Mucosal plaques and nodules
5. Erosions and ulcerations
6. Localized stricture
7. Intramural pseudodiverticulosis (barium filling of dilated to 1-
3mm submucosal glands)
- CT usually reveals nonspecific thickening of the wall (>5mm) and
target sign with hypoattenuating thickened wall and high-attenuation
enhancing mucosa.

Types of Esophagitis:

Reflux esophagitis Complication: Barrett esophagus

Infectious esophagitis
o Tuberculosis
o Cytomegalovirus
o Herpes simplex
o Candida albicans most common
Drug Induced esophagitis
o Tetracycline, doxycycline, quinidine, aspirin, indomethacin,
ascorbic acid, potassium chloride and theophylline
Radiation esophagitis
Esophageal achalasia
a disease of unknown etiology characterized by:
Absence ofperistalsis in the body of esophagus
Marked increase in resting pressure of the LES
Failure of the LES to relax with swallowing
 The abnormal peristalsis and LES spasm result in a failure of the
esophagus to empty
There is deficiency of ganglion cells in the myenteric plexus (Auerbach
plexus) throughout the esophagus.
Insidious in onset
30-50 years old
Signs and symptoms: dysphagia, regurgitation, foul breath, aspiration
Radiographic signs:
Uniform dilatation of the esophagus usually with an air fluid level
present
Absence of peristalsis with tertiary waves common in the early
stages of the disease
Tapered beak deformity at the LES because of failure of
relaxation
Increased incidence of epiphrenic diverticula and
esophageal carcinoma
Treatment:
Balloon dilatation or Heller myotomy

STOMACH

- A wide muscular bag and represents the widest part of the gut
- Variable in shape and lie depending on the build of the individual
- Has a roughly J shape in the erect position
- Proximal part lies posteriorly, with the distal stomach curving anteriorly as it
passes downwards and to the right
- If empty, it is flattened antero-posteriorly
- The inferior edge is referred to as the greater curve and the superior edge is
the lesser curve
- Inferiorly on the lesser curve is a variably defined notch called the incisura
angularis.
- Terms used to describe the anatomic divisions of the stomach
o Cardia region of the gastroesophageal junction (GEJ)
o Fundus portion of the stomach above the level of the GEJ
o Body of the stomach central two thirds, from the cardia to the
incisura angularis
o Incisura angularis - an acute angle formed on the lesser curvature that
marks the boundary between the body and the antrum
Parietal cells hydrochloric acid
Chief cells pepsin precursors
Antrum distal third of the stomach, contains gastrin-producing
cells but no acid-secreting cells
Pylorus junction of the stomach with the duodenum and the
pyloric canal is the channel through the pylorus.
Gastric ulcers full thickness defect in the mucosa
- Frequently extends to the deeper layers of the stomach
including the submucosa and muscularis propria.
 - 95% of ulcerating gastric lesions are benign
- All gastric ulcers should be examined endoscopically or be
followed to complete radiographic healing
- Signs of an ulcer as demonstrated by double-contrast UGI series
include:
A barium-filled crater on the dependent wall
A ring shadow caused by barium coating the edge of the
crater on the nondependent wall
A double ring shadow if the base of the ulcer is broader
than the neck
A crescentic or semilunar line when the ulcer is seen on
tangent oblique view
- Some ulcers may be linear or rod-shaped
- Ulcers are multiple in about 20% of patients
Peptic Ulcer Disease
Benign gastric ulcers caused by H.pylori infection (70%) or
nonsteroidal anti-inflammatory medications (30%)
- Duodenal ulcers are usually associated with increased
production of acid
- Gastric ulcers occur with normal or even decreased acid levels.
However, hydrochloric acid must be present for peptic ulceration
to occur
- Signs and symptoms:
Asymptomatic
Aching or burning pain within several hours after eating,
melena, hematemesis, hematochezia
- Complications:
Bleeding (15-20%)
Obstruction
Perforation
Gastric outlet obstruction (5% of cases)
Gastric carcinoma 3rd most common GI malignancy
- Adenocarcinomas (95%)
- Diffuse anaplastic (signet-ring) carcinoma
- SCC
- Predisposing factors:
Smoking
Pernicious anemia
Atrophic gastritis
Gastrojejunostomy
- H.pylori infection increases the risk of gastric carcinoma sixfold
and is the cause of approximately half of gastric
adenocarcinoma cases
- Peak age is from 50-70 years, with men predominating (2:1)

DUODENUM rough C-shaped tube which runs from the pyloric canal to the jejunum
 - For most of its curved course it has the pancreas on its inner margin
- Divided into four parts:
o First part passes posterosuperiorly from the pylorus
Distensible on barium studies and is known as the duodenal cap
o Second part runs in a vertical orientation
Where the common bile duct and pancreatic duct open, usually
together at the ampulla of Vater
o Third part longest and most posterior
o Fourth part shortest part of the duodenum
Duodenal ulcers
- Causes:
o H.pylori infection in 95% of cases
o Anti-inflammatory medications
o Crohn disease
o Zollinger-Ellison syndrome
o Viral infection
o Penetrating pancreatic CA
- Associated with acid hypersecretion
- In the duodenal bulb (95% of the case)
- Radiographic diagnosis:
o Demonstration of the ulcer crater or niche
o Giant ulcers larger than 2cm resemble diverticula or a deformed bulb

JEJUNUM AND ILEUM

- Tube approximately 7m long that lies totally within the greater

peritoneal cavity
- The jejunum is arbitrarily defined as the proximal two fifths of the
mesenteric intestine while the ileum is the distal three fifths
- Comprise the most important part of the alimentary tract for
absorption of nutrients and form the longest section.
The transition from jejunum to ileum is a gradual one, the
jejunum being the initial two-fifths of this length of bowel.
- Chest PA view for optimal detection of pneumoperitoneum and
intrathoracic disease that may present with abdominal complaints.
- Abdomen supine view most commonly requested
- Abdomen upright or decubitus view (other name cross table lateral)
- For definitive diagnosis ultrasound and/or CT scan are routinely
obtained

Normal abdominal gas pattern

- Plain abdominal radiograph interpretation

- Assessment of:
o Gas
o Fluid
o Soft tissue
o Fat
 o Calcium densities
- Normal gas in the abdomen is predominantly swallowed air.
- Air fluid levels are seen in normal patients, commonly in stomach,
often in small bowel, but never in the colon distal to the hepatic flexure
- Normal air fluid levels in the small bowel should not exceed 2.5cm in
length.
- A normal intestinal gas pattern varies from no intestinal gas to gas
within three to four variably shaped intestinal loops measuring less
than 2.5-3.0 cm diameter
- The normal colon contains some gas and fecal materials and varies in
diameter from 3-8cm with the cecum having the largest diameter.
Dilated bowels
- Small bowel is dilated when it exceeds 2.5-3.0 cm diameter.
- The colon is dilated when it exceeds 5.0 cm in diameter and the cecum
is dilated when it exceeds 8.0 cm in diameter.

Small bowel Large bowel

Location
Characteristics
Normal lumen diameter
Central Peripheral
Valvulae conniventes are Haustral markings
finer and closer together extend only part across
(extend wall to wall) the lumen (do not extend
from wall to wall)
Less than 3cm Less than 6cm except for
cecum that can extend to
9cm and maximum of
12cm

Adynamic ileus
- Other names: Paralytic ileus and non obstructive ileus
- Ileus means stasis
- Does not differentiate mechanical obstruction from non mechanical
stasis
- Stasis of bowel contents because of absent or decreased peristalsis
- Typically demonstrates diffuse symmetric predominantly gaseous
distention of bowel
- Stomach, small bowel and colon are proportionally dilated without an
abrupt termination
- Occasionally, adynamic ileus may result in a gasless abdomen with
dilated loops of bowel that are filled only with fluids.
- Seen in incarcerated hernia and volvulus.
Small bowel obstruction
- 20% of surgical admission for acute abdominal pain
- 80% of all intestinal tract obstruction
- The level of obstruction is determined by dilated loops above the
obstruction and normal or empty loops below the obstruction
- Step ladder or hairpin loops of small bowel are most characteristic
Causes:
 - Adhesions post surgical (75%) and post inflammatory
- Incarcerated hernia
- Malignancy, metastatic usually
- Intussusceptions
- Volvulus
- Gallstone ileus
- Parasites bolus of ascariasis
- Foreign body

Signs and symptoms crampy abdominal pain, abdominal distention,

vomiting

Radiographic plain films diagnostic only in 50-60% of cases

Findings:

- Dilated loops of small bowel (>3cm) disproportionate to more distal

small bowel or colon.
- Small bowel air fluid level that exceeds 2.5cm in length.
- Air fluid levels at differing heights within the same loop (strong
evidence of obstruction)
- Small bubbles of gas trapped between folds in dilated fluid filled loops
producing string of pearl sign
o A row of small bubbles of gas oriented horizontally or obliquely
across the abdomen.

Abdominal CT Scan

- Imaging method of choice when the diagnosis is equivocal.

- Reveals cause obstruction in 70-90% of cases.
- Finding:
o Demonstration of a transition site between small bowel loops
dilated with fluid or air and collapsed bowel loops distal to
obstruction
o Small bowel feces sign definitive evidence of bowel obstruction
Particulate feculent matter mixed with gas bubbles is seen
within dilated small bowel loops
Abrupt beaklike narrowing commonly seen in adhesion
cause of SBO.
Acute Appendicitis most common cause of acute abdomen
- Results from the obstruction of the appendiceal lumen
Plain abdomen 14% of cases demonstrate appendiceal calculus on
plain film (Appendicolith or Fecolith)
o Appendicolith is formed by calcium deposition around a nidus of
inspissated feces.
- Localized ileus may be evident in the right lower quadrant.
Ultrasound noncompressible appendix larger than 5mm in diameter.
 o Concentric rings may be seen representing layers of edematous
intestines with alternating layers of mesentery
o Often anechoic fluid echogenic mesentery, mesenteric fat and
small lymph node can be identified in the center of the
intussusceptions.
o donut configuration of alternating hyperechoic and
hypoechoic rings representing alternating mucosa, muscular
wall and mesenteric fat tissues.
CT Scan diagnostic
o Demonstrating a characteristic target like intestinal mass.
o the inner central density is the invaginating loop, surrounded
by fat density mesentery that is enveloped by receiving loop
Hirschprung disease is the result of absence of ganglion cells in the distal
colon resulting in abnormal peristalsis and inability to effectively evacuate
the colon.
- Functional colonic obstruction is caused by congenital absence of
ganglion cells in the distal colon resulting in abnormal peristalsis.
- Rectum is always involved but the extent of proximal involvement
varies.
- The aganglionic segment is characteriscally contracted.
- In older infants, a well defined change in calibre at the zone of
transition is characteristic.
- Rectal biopsy is suggested for definitive diagnosis.
Necrotizing enterocolitis
- Etiology: hypoperfusion and hypoxia of the gut
- Radiograph
Initially dilated loops of small bowel or colon
Hallmark: Pneumatosis cystoides intestinalis appears as
linear, curvilinear or bubbly to granular collection of air.
- Ultrasound
Echogenic punctuate foci in the liver vessels and bowels
Thickening of the bowel wall and decrease blood flow within the
bowel wall with color Doppler imaging suggestive of necrosis.
Sigmoid volvulus
- Most common in the elderly and in individuals on high residue diet.
- The sigmoid colon twist around its mesentery resulting in closed loop
obstruction.
- Proximal colon dilates while the rectum empties.
- 3-8% of large bowel obstruction in adults.
- Plain radiograph:
Usually diagnostic
The sigmoid colon appears as a large gas filled loop without
haustral arising from the pelvis and extending high into the
abdomen and often to the diaphragm
 The three white lines formed by the lateral walls of the loop and
the summation of the two opposed medial walls of the loop
converge inferiorly into the iliac fossa
Fecal impaction most common cause of large bowel obstruction in elderly
and in bedridden patients.
- Plain radiograph demonsrates a large mass of stool with a
characteristics mottled appearances in the distal colon.
Pneumoperitoneum
- Free air within the peritoneal cavity
- Sign of bowel perforation
- Causes:
Duodenal or gastric ulcer perforation (most common).
Trauma
Recent surgery or laparoscopy.
Infection
- Post operative pneumoperitoneum usually resolves in 3-4 days.
- Radiography: Plain Film
Upright chest radiograph most sensitive for free air.
Small amount of air are clearly demonstrated beneath
the domes of the diaphragm.
Left lateral decubitus or crosstable lateral view demonstrate
air outlining the liver.
Supine radiograph
Gas on both sides of the bowel wall (RIGLER SIGN)
Gas outlining the falciform ligament
Gas outlining the peritoneal cavity (FOOTBALL SIGN)
Triangular or linear localized extraluminal gas in the right
upper quadrant.
Ascites
- Serous fluid in the peritoneal cavity
- Causes:
Cirrhosis
Hypoprotenemia
Congestive heart failure
- Exudative ascites results from inflammatory processes
Cause: abscess, pancreatitis, peritonitis, bowel perforation
- Hemoperitoneum
Cause: trauma, surgery, spontaneous haemorrhages
- Neoplastic ascites is associated with intraperitoneal tumors
- Urine, bile and chyle may also spread freely within the peritoneal
cavity
- Plain film diagnosis of ascites requires at least 500ml of fluid to be
present
Diffuse increase in density of the abdomen
Indistinct margins of the liver, spleen and psoas muscle.
Medial displacement of gas filled colon, liver and spleen away
from the properitoneal flank stripe.
 Bulging of the flanks.
Increase separation of gas filled bowel loops.
dog ears appearance of symmetric densities in the pelvis
caused by fluid spilling out of the cul de sac or either side of the
bladder.
- Ultrasound
Sensitive to small amounts of fluid in the peritoneal recesses.
Most gravity-dependent portions of the abdominal cavity
Morison pouch and the pelvis
Simple ascites is anechoic
Exudative, hemorrhagic or neoplastic ascites appear anechoic
with floating debri
Septation in ascites are associated with inflammatory or
malignant process
- CT Scan
Demonstrate fluid density in the recesses of peritoneal cavity
Serous ascites Hu= -10 to +10
Exudative Hu = +15 above
Bleeding Hu= +45
- MRI
Serous fluid is low intensity on T1W1 and markedly increase in
intensity on T2W1
Hemorrhagic fluid high signal intensity on both T1W1 and T2W1
Serous ascites is commonly bright on gradient echo images
because of fluid motion.
DIFFUSE LIVER DISEASE
HEPATOMEGALY
- rounding of the inferior border of the liver
- extension of the right lobe of the liver inferior to the lower pole of the
right kidney
- liver length: 15.5 cm midclavicular line
- Reidel lobe
An elongated inferior tip of the right lobe of the liver
Normal variant most often in female
When present, left lobe of liver is smaller in size
- Causes:
Vascular congestion
Congestive heart failure
Hepatic vein thrombosis
Metabolic/Diffuse infiltration
Fatty infiltration: alcohol, drugs/chemotherapy, hepatic
toxins, Gaucher disease and lipidoses
Carbohydrates Glycogen storage disease and DM.
Iron hemochromatosis
Amyloid amyloidosis
Tumor/Cellular infiltration
 Diffuse metastases
Diffuse hepatocellular ca
Lymphoma
Extramedullary hematopoiesis
Inflammation/infection
Hepatitis
Sarcoidosis
Tuberculosis
Cysts Polycystic disease
FATTY INFILTRATION
- common and non-specific responses of hepatocytes to injury and
toxins
- hepatocytes becomes filled with cholesterol and triglycerides
- Causes: alcoholism, obesity, malnutrition, hyperalimentation, steroid
therapy, DM, pancreatitis, glycogen storage disease, chemotherapy
- Ultrasound increase in echogenicity in areas of fat infiltration
Echogenicity of the fatty liver is significantly greater than the
echogenicity of the normal kidney parenchyma
Flip flop sign density difference in fat which is bright on US and
dark on CT
CT scan fat infiltration lowers the attenuation of the hepatic
parenchyma and makes the liver appear dense
Fat infiltrated liver enhances less than normal liver
- Characteristics features of fatty infiltration:
Lack of mass effect (no bulging of the liver contour or
displacement of intrahepatic blood vessels)
Angulated geometric boundaries between involved and
uninvolved parenchyma
Areas of fat infiltration may be multifocal with interdigitating
fingers of normal and abnormal parenchyma
Fatty changes can develop within 3 weeks of hepatocyte insult
and may resolve within 6 days of removing insult
Diffuse fatty infiltration involving the entire liver is the most
common pattern
Degree of fat infiltration is commonly not uniform throughout
the liver
Focal fatty infiltration geographic or fan shaped portion of the liver
- May stimulate a liver tumor however the area of involvement has a
density characteristics of fat
- Most commonly adjacent to the falciform ligament, gallbladder and
porta hepatis
Focal sparing diffusely infiltrated liver with spared areas of normal
parenchyma
- Simulates a liver tumor
- Most commonly located in segment IV
- Fat spared area
 US hypoechoic relative to the rest of the liver
CT higher density than the rest of the liver
Non-alcoholic steatohepatitis (NASH)
- Described fatty liver caused by an inflammatory response that is not
caused by excessive alcohol intake.
- Cause: Obesity, DM2, Hyperlipidemia, Anorexia nervosa
Acute hepatitis most commonly causes no abnormalities on hepatic imaging
- US in some patients, diffuse edema lowers the parenchymal
echogenecity and causes the portal venules to appear usually bright.
- CT in acute fulminant hepatits, areas of necrosis show as ill defined
areas of low density.
Chronic hepatitis characterized pathologically by portal and perilobular
inflammation and fibrosis
- Fatty changes are minimal and the liver is usually not enlarged.
- Perihepatic lymph node are commonly visualized.

URINARY TRACT RADIOLOGY

KIDNEYS:

IMAGING METHODS:

Plain KUB (kidneys, ureter, urinary bladder) radiograph

Conventional radiograph IVP (intravenous pyelogram or excretory
urograph)
o Procedure
A plain radiograph is obtained first
Iodinated contrast media is given intravenously
X-ray films are taken until the collecting system is
visualized adequately
o Not used commonly anymore due to wide availability of CT
o Offers higher spatial resolution in demonstrating contrast-filled
pelvicalyceal systems and ureters
o However, limited assessment of renal parenchyma and collecting
system that is not filled with contrast
CT-IVP (CT Urogram)
o Procedure
A plain, precontrast scan is obtained first
Intravenous iodinated contrast media is given
Scans are again obtained at different times
o Precontrast scans
To detect stones and calcifications
Provide baseline
o Arterial phase scan
 Enhances the cortex
Shows early enhancement of renal tumors
o Nephrogram phase
2 minutes post contrast administration
renal parenchyma is uniformly enhanced
o pyelogram phase scan
3-5 minutes post contrast
contrast-filling of collecting system and ureters
Ultrasound
o Used to characterize lesions thought to be cysts
o To detect hydronephrosis
o Assess kidney size
o Color Doppler assess tumor vascularity and assess tumor
expression to venous system

ANATOMY

Located within the Gerotas fascia

Surrounded by perirenal fat
Composed of:
o Medullary pyramids
o Cortex including the peripheral cortex and columns of Bertin
Main renal arteries originate from the aorta
o Right passes posterior to the IVC
o Left course posterior to the left renal vein
o Main renal artery -> divides into dorsal and ventral branches ->
into segmental arteries -> interlobar arteries -> arcuate arteries
-> interlobular arteries

CONGENITAL RENAL ANOMALIES

Renal agenesis

Compensatory hypertrophy of the opposite kidney

Horseshoe kidney

Most common renal fusion anomaly

Lower poles of the kidneys are joined across the midline by a fibrous or
parenchymal band
Kidneys are malrotated and is located in the abdomen prone to
trauma
Also prone to infection and stones due to urinary stasis
Crossed-fused renal ectopia

Two kidneys are fused on the same side while their ureters insert
normally into the bladder

RENAL MASS

Most common renal neoplasm: renal cell carcinoma

Most common renal mass: simple cyst

Renal cell carcinoma

Accounts for 85% of renal neoplasms

Radiologic evaluation is done for tumor detection and characterization
and staging
CT scan with and without contrast is the imaging of choice
CT scan shows heterogeneous tumor enhancement
Ultrasound heterogeneous hypo or mildly hyperechoic mass
o Doppler may show thrombus in IVC and renal vein

Renal cyst

Found in >50% of the population older than 55 years old

Small cyst are asymptomatic while large cyst (>4cm) may cause
symptoms
May be diagnosed thru CT, MRI, US
US: round or oval anechoic mass with acoustic enhancement, thin or
imperceptible wall and sharply defined far wall
CT: sharply marginated homogenous mass with imperceptible wall (HU:
-10 to +10)

PELVICALYCEAL SYSTEM, URETERS, BLADDER AND URETHRA:

IMAGING METHODS:

CT urogram: imaging method of choice for evaluation of hematuria and

screening examination of the pelvicalyceal system and ureters
Retrograde pyelography:
o Ureteral orifice is catheterized cystoscopically -> contrast is
injected
o Provides a method of visualization of the ureter and collecting
system independent of the renal function
US: imaging method of choice for screening of hydronephrosis

ANATOMY
 Collecting tubules of medullary pyramids -> papillary ducts -> minor
calyx -> major calyx -> pelvis -> ureter -> urinary bladder
3 main points of ureteral narrowing where calculi are likely to become
impacted
o ureteropelvic junction
o site where the ureter crosses the pelvic bone
o ureterovesical junction

CONGENITAL ANOMALIES

Ureteral duplications

Weigert-Meyer rule: with complete ureteral duplication, the ureter

draining the upper pole passes through the bladder wall to insert
medial and inferior to the normally placed draining the lower pole
The upper pole ureter often ends as an ectopic ureterocele
The lower pole ureter inserts normally into the bladder but is prone to
vesicoureteral reflux

Nephrolithiasis

Acute flank pain is the most common complaint and is due to renal
colic caused by a stone obstructing the ureter
Calcium oxalate is the most common type of stone (40-60%)
Plain radiograph
o 80% are radioopaque: calcium oxalate, calcium phosphate,
struvite (staghorn)
o cystine stones are mildly radioopaque
o uric acid and xanthine stones are radioluscent and, therefore,
cannot be seen on radiographs
o difficult to localize the calcification for the ureter and
differentiation from other calcifications through plain radiographs
o 45% sensitivity, 77% specificity
US
o 24% sensitivity
plain CT scna/CT stonogram
o all stones are detected on CT scan (>200 HU)
o 97% sensitivity, 96% specificity
o nephrolithiasis appears as white dots within the ureter
associated with the proximal dilatation and distal contraction of
the ureter
a halo of soft tissue surrounding the calculus (tissue rim
sign) confirms a stone within the ureter

Hydronephrosis
 dilatation of the upper urinary tract
US is an excellent screening modality
o Calyces and pelvis are distended by anechoic urine
o Medullary pyramids may be hypoechoic
Causes:
o Obstruction
May be due to stone, stricture, tumor and extrinsic
compression
CT:
Increasingly dense nephrogram
Delay in appearance of contrast in the collecting
system
Dilated pelvicalyceal system and ureter up to the
point of obstruction
o Vesicoureteral reflux
A common cause of hydronephrosis in children
Prone to infection
Demonstrated by retrograde filling of the ureters on
voiding cystourethrography (VCUG)

Transitional Cell Carcinoma

Accounts for 85-90% of uroepithelial tumors

2nd most common primary renal malignancy
85% have papillary growth pattern which are exophytic, polypoid and
attached to the mucous by a stalk -> stippled pattern of contrast
material
Non-papillary tumors nodular or flat, tends to be infiltrating and
aggressive
CT:
o Focal intraluminal mass
o Thickening of the wall and narrowing of the lumen of the ureter
or collecting system
o Mass infiltrating the renal sinus and renal parenchyma
o 8-30 HU (blood clots >40-80 HU, stone >200 HU)
o used for staging by demonstrating extent of tumor, invasion of
kidneys or surrounding structures, lymphadenopathy and distant
metastasis
US:
o Discrete slightly hypo or hyperechoic mass within the renal sinus
o Less sensitive than CT or MR

BLADDER
 CT urogram demonstrates many bladder lesions
o Small lesions, <5mm, and lesions at the bladder base near the
prostate and urethra are easily missed
o Direct cystoscopy is usually required for complete evaluation
o Cystoscopic-guided biopsy provides definitive diagnosis
CT and MRI are used to stage bladder carcinoma
Traditional cystogram
o Done by instilling contrast agent into the bladder through a
catheter and taking a series of radiographs
o Provides a more detailed exam
o Fluoroscopic exam is done during bladder filling to detect reflux
o Radiographs obtained during voiding demonstrate bladder outlet
and the urethra
o Post-void films document residual urine
CT pyelogram
o Performed similar to traditional cystogram
o Minimum of 250cc of contrast agent is instilled into the bladder
through a catheter
o CT is sensitive to small amounts of contrast that may leak into
the perivesical tissue
Ultrasound
o Routinely performed using the urne-filled bladder
o Intraluminal masses, calculi, bladder wall thickness and bladder
emptying can be reliably assessed

ANATOMY

Oval in shape
Floor is parallel to and 5-10mm above the superior aspect of the
symphysis pubis
Superior surface covered by peritoneum while inferior surface is
extraperitoneal
Anteriorly, the bladder is separated from the symphysis pubis by fat in
the extraperitoneal space of Retzius
Posteriorly separated from the uterus by the uterovesical peritoneal
recess in females and from the rectum by the rectovesical peritoneal
recess in males
Has 4 layers: outer adventitia, inner longitudinal, circular and outer
longitudinal muscle, submucosal connective tissue, mucosa of
transitional epithelium
Trigone: triangle at the floor of the bladder formed by the 2 ureteral
orifice and an internal urethral orifice
The normal wall of a well-distended bladder should not exceed 5-6mm
thickness
CONGENITAL ANOMALIES

Urachal remnant disease

May be discovered in asymptomatic adult patients on CT and US

examinations incidentally
The urachus is the vestigial remnant of the urogenital sinus and
allantois
o Tubular structures that extends from the bladder dome to the
umbilicus along the anterior abdominal wall
o Median umbilical ligament is its obliterated residual
Patent urachus: 50%
o Persistent communication between the bladder and the umbilicus
o Causes urine to leak into the umbilicus
Umbilical-urachal sinus: 15%
o A blind-ended dilatation of the urachus at the umbilical end that
may cause a persistent umbilical discharge
o Imaging shows a tubular structure in the midline abdominal wall
extending caudally from the umbilicus
Vesical-urachal diverticulum: 5%
o Outpouching of the bladder in the anterior midline location of the
urachus
o Seen in adults with the bladder outlet obstruction as a fluid-filled
sac extending cranially from the bladder in the midline
abdominal wall
o Stasis of urine in the putpouching may result in infection, stone
formation and risk of carcinoma
Urachal cyst: 30%
o Urachus is closed at both umbilicus and bladder ends but remain
patent in the middle
o Imaging shows a fluid-filled cyst in the midline abdominal wall
usually in the lower third region of the urachus
o May have calcifications because of infection

Cystitis

Inflammation of the bladder which may be due to infection (bacteria,

adenovirus, tuberculosis, schistosomiasis), drugs (cyclophosphamide),
radiation, and autoimmune reaction
CT: bladder wall thickening and perivesical edema
Emphysematous cystitis is a form of inflammation with gas within the
bladder wall
o Associated with uncontrolled diabetes, bladder outlet obstruction
and E. coli infection
Bladder wall mass

Simple ureterocele
Caused by congenital prolapse of the distal ureter into the bladder
lumen resulting in a cystic dilatation of the distal ureter
Usually an incidental finding
May be associated with obstruction, infection, and stone formation
Contrast studies: rounded filling defect in the bladder wall at the
ureteral insertion described as cobra head or spring onion
appearance
Ultrasound: cystic mass at the ureteral orifice

Ectopic ureterocele

Usually associated with ureteral duplication

Ectopic ureter may insert anywhere such as the vestibule, uterus or
vagina in females causing incontinence
o In males, ectopic ureter usually inserts proximal to the external
sphincter causing no incontinence
Appears as a cystic mass at the ectopic site of the ureter

Transitional cell carcinoma

Most common urinary tract neoplasm

Hallmark: multiplicity and recurrence
CT and MR are capable of staging bladder CA
CT:
o Soft tissue nodule or papillary mass projecting into the bladder
lumen or focal thickening of the bladder wall
o Tumor enhances after contrast injection
MRI:
o Intermediate signal to muscle and higher signal than urine in T1
o Lower signal than bright urine and higher signal than normal
bladder muscle on T2
US:
o Exophytic tumors as polypoid masses extending from the bladder
wall
o Infiltrating tumors may be seen as focal thickening of the bladder
wall

Bladder trauma

Susceptibility of the bladder to traumatic injury depends largely on the

degree of bladder filling at the time of injury
Distended bladder is more prone to injury than a collapsed bladder
 Extraperitoneal bladder rupture: (80%)
o Results from puncture of the bladder by a spicule of bone from a
pelvic fracture
o Contrast extravasates into the extraperitoneal compartments,
most commonly in the retropubic space of Reitzus and may
extend into the anterior abdominal wall, thigh, and scrotum
o Conventional or CT cystography requires distention of bladder to
at least 250ml to exclude bladder rupture
Intraperitoneal bladder rupture: (20%)
o Results from blunt trauma
Contrast material flows into the paracolic gutters and
outlines the loops of the bowel

SKELETAL RADIOLOGY

SKELETAL TRAUMA

Concerns on radiograph of trauma are:

o High index of suspicion
o Two radiographs at 50 degree to each other in every case
o Once a fracture is identified, do not forget to look at the rest of
the film

Skull fracture

Demonstration of skull fractures does not indicate presence of

intracranial injury or the other way around
Pertinent findings in plain film:
o Shift in the calcified pineal gland
o Depressed skull fracture
Types:
o Linear sharp, dark, translucent line, irregular or jagged,
branching character
Often extends into the base
Versus vascular groove: smooth, curving course
Versus suture lines: serrated edges
o Depressed stellate with multiple fracture lines radiating
outward from a central point
Secondary to severe trauma
o Diastatic linear fracture extends into the suture and seperates
it
Infancy and children most commonly seen
Lamboid and sagittal suture most commonly involved

Facial fractures
 Le Fort 1
o Guerin fracture
o Transverse fracture that transects the inferior aspect maxilla,
nasal septum and most inferior portions of the pterygoid plate
o Floating palate
Le Fort 2
o Fracture is pyramidal in shape
o Nasal bone, frontal process of maxilla, medial orbital wall, inerior
orbital wall, maxillary sinus, pterygoid plate
o Floating maxilla
Le Fort 3
o Produces craniofacial separation
o Horizontal fracture that transects the nasofrontal suture, medial,
inferior and lateral orbital walls, zygomatic arches and pterygoid
plate base
o Floating face
Zygomaticomaxillary fracture (tripod)
o Zygoma 2nd most commonly fractured bone of the midline
(nasal bone is the most commonly fractured bone of the midface)
o Zygomatic sutures separation
Zygomaticosphenoidal
Zygomaticofrontal
Zygomaticotemporal

Spine fracture

Cervical spine is one of the most commonly radiographed parts of the

body
Make sure all seven cervical vertebral bodies are visualized
Cervical spine fracture:
o Jefferson fracture
MOI: blow to the top of the head
Causing the lateral masses of the C1 to slide apart,
splitting the bony ring of C1
Lateral masses of C1 must extend beyond the margins of
the C2 body
o Hangmans fracture
MOI: secondary hyperextension and distraction
Unstable and serious fracture of the posterior elements of
C2 with displacement of the C2 body anterior to C3
o Clay-Shovelers fracture
Fracture of the C6 or C7 spinous process
Lumbar spine fracture
o MOI: compression secondary to anterior and lateral flexion
 o Wedge fracture anterior wedging of the affected vertebra
(anterior body)
o Burst fracture fracture involving the anterior and posterior part
of the vertebral body with extension into the posterior elements
o Chance fracture Seatbelt injury
MOI: hyperflexion and distraction
Anterior, middle and posterior columns are involved
Unstable injury perpendicular to the spinal axis
Spondilolysis break in the pars interarticularis
Spondylolisthesis anterior slippage of a vertebral body in relation to
its inferior vertebra
Retrolistheis posterior slippage of a vertebra over another
Scoliosis
o Abnormal curving of the physiologic thoracic and lumbar spine
Dextroscoliosis towards to the right
Levoscoliosis towards the left
o Grading
10-20 mild
>20-40 moderate
>40 severe

Hand and Wrist

Bennett fracture
o Fracture at the base of the thumb
Rolando fracture
o Comminuted fracture of the base of the thumb
Boxers fracture
Fracture of the 2nd to 5th metacarpals

Arm and Forearm

Colles fracture
o MOI: fall on an outstretched hand
o Fracture of the distal radius and ulna with dorsal angulation
Smith fracture
o MOI: fall on an outstretched hand
o Fracture of the distal radius and ulna with a ventral angulation
Monteggia fracture
o Fracture of the ulna with distal radial dislocation
Galleazzi fracture
o Fracture of the radius with distal ulnar dislocation
Supracondylar fracture
o Most common in children
Shoulder

Dislocation
o Anterior most common
Occurs when arm is forcibly externally rotated and
abducted
AP film humeral head lie inferiorly and mentally to the
glenoid
Hill Sachs deformity
Indentation on the posterosuperior portion of the
head
Indicates repetitive shoulder dislocation
Bankart deformity
Bony irregularity or fragment off the inferior glenoid
fossa
o Posterior difficult to diagnose
AP film humeral head slightly overlaps the glenoid,
forming the crescent sign
o Subluxio

Hip/Pelvis

Dislocation
o Anterior
o Posterior most common with associated fracture of the
posterior rim of the acetabulum

Leg and Foot

Femoral neck fracture

o Common in the elderly
o Resulting from a simple fall
o Subcapital and intertrochanteric fractures most common
Lisfrancs fracture
o Serious fracture in the foot
o Fracture-dislocations of the tarsometatarsal joints

ARTHRITIDES

Osteoarthritis or degenerative joint disease (DJD)

The most common arthritide

Caused by trauma either overt or as an accumulation of microtrauma
over years
Affects women more commonly than men
 The large joints such as the hips or knee and the small joints such as
the interphalangeal joints of the hand are the most often affected, the
spine, however, is just as frequently involved in the degenerative
process
Hallmarks of DJD
o Joint space narrowing result of thinning of the articular cartilage
o Sclerosis caused by reparative processes (remodeling)
o Osteophytosis result of reparative processes in sites not
subjected to stress (so-called low-stress areas), which are usually
marginal (peripheral) in distribution
Two types:
o Primary (idiopathic)
Affects individuals age 50 and older
Related to the aging process
Wear and tear
Related to genetic factors, gender, race and obesity
o Secondary form
Much younger age group
Have underlying conditionsleading to the development of
degenerative joint disease
Highlights of primary osteoarthritis
o Large joints (most commonly seen in knee and hips)
Narrowing of the joint space
Subchondral sclerosis
Osteophyte formation (osteophytosis)
Cyst or pseudocyst
o Small joints (hands)
Heberden nodes
Bouchards nodes
Joint space narrowing
Subchondral sclerosis
o Spine
Facet narrowing and eburnation
Foraminal stenosis
Spinal canal stenosis

Rheumatoid arthritis

Is a connective tissue disorder of unknown etiology that can affect any

synovial joint in the body
Affects women more commonly than men
Positive for rheumatoid factors in the patients serum
Radiographic hallmarks
o Soft tissue swelling
 o Osteoperosis
o Joint space narrowing
o Marginal erosions
o Boutonnieres deformity
o Swan neck deformity
o Subluxation of the affected joints

Gout

Metabolic disorder that results hyperuricemia and leads to deposition

of monosodium urate crystals in various sites in the body especially in
the joint cartilage
4 to 6 years of gout is entailed to cause radiographically evident
Typically affects metatarsophalangeal joint of the
Classic radiographic findings:
o Well delineated erosions with sclerotic borders and
o Soft tissue nodules
o Random distribution
o No osteoperosis