Radiographic Interpretation

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Radiographic Interpretation
Whats Normal?
Bucky Boaz, ARNP
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Cervical Spine (Lateral)

• Anterior arch of the atlas?
• Dens of axis
• Posterior arch of the atlas?
• Soft palate
• Root of the tongue?
• Transverse process?
• Intervertebral disc?
• Inferior articular process?
• Superior articular process?
• Zygapophyseal (facet) joint?
• Spinous process of C7
• 2nd-7th The bodies of 2nd to 7th cervical
  vertebrae

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Lateral Cervical Spine
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Anterior soft tissue swelling

• soft tissue swelling is indirect indicator of
  significant trauma, esp. when the soft tissue
  swelling is above the epiglottis
• retropharyngeal soft tissue swelling should not
  exceed
• anterior to C3 should not exceed 3 mm.
• if gt than 5 mm at C3 consider minimally displaced
  C2 fracture
• w/ children, crying increases the C3 distance
• below C4 the thickness varies from 8 to 10 mm
  is less reliable

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Anterior soft tissue swelling

• distance between tracheal air column anterior
  aspect of vertebral body should be No greater
  than
• Adults no gt than 7 mm at C2 or 22 mm at C6
• Child no gt than 14 mm at C6
• during x-ray child should be in neutral or sl
  extension and w/ a full inspiration
• fullness and laxity of child's prevertbral soft
  tissues may simulate traumatic swelling if film
  is obtained during expiration or flexion

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Spinal Laminal Lines

• Three curves to follow
• Anterior aspect of vertebral bodies
• Posterior aspect of vertebral bodies
• Spinolaminar line
• Abnormalities in the curves
• posterior malalignment is more significant than
  anterior because of proximity of the spinal cord
• spinal canal diameter is significantly narrowed
  if lt 14 mm
• anterior subluxation is caused by facet
  dislocation
• lt 50 of vertebral body width unilateral
  dislocation
• gt 50 of vertebral body width bilateral
  dislocation

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Lateral Findings

• Examine bones for symmetry
• May provide evidence of fracture
• Abnormal symmetry is often due to compression
• compression of gt 40 of normal vertebral body
  height usually indicates a burst fracture with
  possibility of bone fragments in the spinal canal
• anterior compression may cause a teardrop shaped
  fracture

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Cervical Spine (Lateral)

• Bifid spinous process of C3?
• Superimposed articular processes?
• Uncinate processes?
• Air filled trachea?
• Transverse process of C7?
• Transverse process of T1?
• 1st rib?
• Clavicle
• 4th-7th The bodies of 4th to 7th cervical
  vertebrae

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AP Cervical Spine
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Odontoid View

• to evaluate
• C1 (Jefferson), Dens, superior facets of C2
• for evaluating dens fractures, body of C2,
  rotary C1-C2 dislocations
• mach lines - teeth, C1 arch
• open mouth view, along w/ lateral view, will
  reveal fractures of the dens
• atlantoaxial articulation integrity of dens and
  body of C2 are best seen on the odontoid view

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Odontoid View

• this is most technically most difficult film to
  obtain as it requires patient to open his mouth
  as wide as possible
• lateral masses of C1 should align over the
  lateral masses of C2
• lateral displacement of masses of C1 w/ respect
  to C2 may indicate Jefferson or burst fracture of
  the Atlas
• combined lateral mass displacement gt 7 mm
  suggests that transverse ligament is torn

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Anatomy of C2

• C2 provides rotation at its superior articulation
  w/ C1, limited flexion, tilt, rotation at its
  inferior articulation w/ C3
• body of C2 is the largest of the cervical
  vertebrae
• superior articulations are on the lateral masses
• superior projection of the odontoid is stabilized
  to the C1 ring by transverse and alar ligaments

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Anatomy of C2

• lateral masses of C2 have aperture for accepting
  transversing vertebral artery
• axis is transverse vertebra w/ its superior
  articular facets located anterior and its
  inferior facets located posterior
• prominent spinous process of C2 is palpable
  beneath of occiput

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Odontoid
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Thoracic Vertebra

• Each vertebra is composed of a body anteriorly
  and a neural arch posteriorly
• The arch encloses an opening, the vertebral
  foramen, which helps to form a canal in which the
  spinal cord is housed.
• Protruding from the posterior extreme of each
  neural arch is a spinous process and extending
  from the lateral edges of each arch are
  transverse processes.
• The parts of the neural arch between the spinous
  and transverse processes are known as the laminae
  and the parts of the arch between the transverse
  processes and the body are the pedicles.
• At the point where the laminae and pedicles meet,
  each vertebra contains two superior articular
  facets and two inferior articular facets.
• The pedicle of each vertebra is notched at its
  superior and inferior edges. Together the notches
  from two contiguous vertebra form an opening, the
  intervertebral foramen, through which spinal
  nerves pass

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Thoracic Spine

• Spinous process
• Pedicles
• Intervertebral disc space
• Ribs
• Vertebral body
• Neural foramen

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Lumbar Vertebra

• Lumbar vertebrae are characterized by massive
  bodies and robust spinous and transverse
  processes.
• Their articular facets are oriented somewhat
  parasagittally, which is thought to contribute
  the large range of anteroposterior bending
  possible between lumbar vertebrae.
• Lumbar vertebrae also contain small mammillary
  and accessory processes on their bodies.
• These bony protuberances are sites of attachment
  of deep back muscles

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Lateral Lumbar Spine
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Lateral Lumber Spine
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AP Lumbar Spine
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Vertebral Fractures
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Pelvis
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AP Pelvis

1. Lateral part of the sacrum
2. Gas in colon
3. Ilium
4. Sacroiliac joint
5. Ischial spine
6. Superior ramus of pubis
7. Inferior ramus of pubis
8. Ischial tuberosity
9. Obturator foramen
10. Intertrochanteric crest
11. Pubic symphysis

• Pubic tubercle
• Lesser trochanter
• Neck of femur
• Greater trochanter
• Head of femur
• Acetabular fossa
• Anterior inferior iliac spine
• Anterior superior iliac spine
• Posterior inferior iliac spine
• Posterior superior iliac spine
• Iliac crest

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AP Hip

1. Anterior superior iliac spine
2. Ilium
3. Anterior inferior iliac spine
4. Pelvic brim
5. Acetabular fossa
6. Head of femur
7. Fovea
8. Superior ramus of pubis
9. Obturator foramen
10. Inferior ramus of pubis
11. Pubic symphysis
12. Ischium
13. Lesser trochanter
14. Intertrochanteric crest
15. Greater trochanter
16. Neck of femur

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Lateral Hip

1. Greater trochanter
2. Intertrochanteric crest
3. Lesser trochanter
4. Neck of femur
5. Head of femur
6. Acetabular fossa
7. Superior ramus of pubis
8. Obturator foramen
9. Inferior ramus of pubis
10. Ischium

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AP Knee

1. Femur
2. Patella
3. Medial epicondyle of femur
4. Lateral epicondyle of femur
5. Medial condyle of femur
6. Lateral condyle of femur
7. Intercondylar eminence
8. Intercondylar notch
9. Knee joint
10. Lateral condyle of tibia
11. Medial condyle of tibia
12. Tibia
13. Fibula

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Lateral Knee

1. Femur
2. Lateral condyle of femur
3. Medial condyle of femur
4. Fabella
5. Patella
6. Base of patella
7. Apex of patella
8. Intercondylar eminence
9. Apex of fibula
10. Fibula
11. Tibia
12. Tibial tuberosity

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AP Ankle

1. Fibula
2. Tibia
3. Distal tibiofibular joint
4. Malleolar fossa
5. Lateral malleolus
6. Ankle joint
7. Medial malleolus
8. Talus

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Lateral Ankle

1. Fibula
2. Tibia
3. Ankle joint
4. Promontory of tibia
5. Trochlear surface of talus
6. Talus
7. Posterior tubercle of talus
8. Calcaneus
9. Sustentaculum tali
10. Tarsal tunnel
11. Navicular
12. Cuneiforms
13. Cuboid

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Talar Dome

• The talar dome should be scrutinised for a subtle
  indentation of the joint surface, or a small
  detached fragment.
• This is evidence of an osteochondral fracture.
• May be subtle, is often missed, but this injury
  is clinically significant.

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Boehlers Angle

• Compressive fractures occur after a fall from a
  height.
• Subtle fractures may only be identified by
  assessing Boehlers angle.
• This angle is measured by drawing a line from the
  highest point of the posterior tuberosity to the
  highest midpoint, and a 2nd line from the highest
  midpoint to the highest point of the anterior
  process.
• The angle, posteriorly, should be gt30 degrees.
• If there is flattening of the bone due to a
  fracture, this angle will be decreased, to lt30
  degrees.

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Boehlers Angle
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AP Foot

• A-E Toes 1-5. (AGreat toe)?
• I-V. Metatarsals
• 1,3. Distal phalax?
• 4. Middle phalax?
• 2,5. Proximal phalax
• Interphalangeal joints
• Metatarsophalangeal joints
• Sesamoids
• Head of metatarsal
• Shaft (body) of metatarsal
• Base of metatarsal

• Cuneiform
• Navicular
• Cuboid
• Talus
• Calcaneus
• Tibia
• Fibula
• Tarsometatarsal joints
• Transverse midtarsal joint

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Oblique Foot

• Base of metatarsal
• Cuneiforms
• Navicular
• Cuboid
• Talus
• Calcaneus
• Tibia
• Fibula
• Tarsometatarsal joints
• Transverse midtarsal joint

• A-E Toes 1-5. (AGreat toe)
• 1,3. Distal phalax?
• Middle phalax?
• 2,5. Proximal phalax
• Interphalangeal joints
• Metatarsophalangeal joints
• Sesamoids
• Head of metatarsal
• Shaft (body) of metatarsal

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AP Foot
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Oblique Foot
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Lateral Foot
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Lisfranc
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Lisfranc
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AP Shoulder

1. Clavicle
2. Acromioclavicular joint
3. Acromion
4. Greater tubercle of humerus
5. Head of humerus
6. Lesser tubercle of humerus
7. Surgical neck of humerus
8. Coracoid process
9. Glenoid fossa
10. Shoulder joint
11. Lateral border of scapula

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AP Elbow

1. Lateral supracondylar ridge
2. Medial supracondylar ridge
3. Olecranon fossa
4. Medial epicondyle
5. Lateral epicondyle
6. Capitulum
7. Olecranon
8. Trochlea
9. Coronoid process of ulna
10. Proximal radioulnar joint
11. Head of radius
12. Neck of radius
13. Tuberosity of radius
14. Ulna

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Lateral Elbow

1. Supracondylar ridge
2. Trochlea
3. Olecranon
4. Trochlear notch
5. Coronoid process of ulna
6. Head of radius
7. Neck of radius
8. Tuberosity of radius
9. Ulna

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PA Wrist

• I-V Metacarpals
• Trapezium
• Trapezoid
• Capitate
• Head of capitate
• Hamate
• Hook of hamate
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Styloid process of radius
• Head of ulna
• Styloid process of ulna
• Radiocarpal joint
• Distal radioulnar joint

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Lateral Wrist

1. 1st metacarpal
2. Metacarpals II-V
3. Trapezium
4. Tubercle of scaphoid
5. Lunate
6. Triquetrum
7. Radiocarpal joint
8. Distal end of radius
9. Distal end of ulna

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Rule of 11s

• Radial length or height
• Radial length is measured on the PA radiograph as
  the distance between one line perpendicular to
  the long axis of the radius passing through the
  distal tip of the radial styloid. ?
• A second line intersects distal articular surface
  of ulnar head. ?
• This measurement averages 10-13 mm.

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Rule of 11s

• Radial inclination or angle?
• Radial inclination represents the angle between
  one line connecting the radial styloid tip and
  the ulnar aspect of the distal radius and a
  second line perpendicular to the longitudinal
  axis of the radius. ?
• The radial inclination ranges between 21? and
  25?. ?Loss of radial inclination will increase
  the load across the lunate.

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Rule of 11s

• Radial tilt?
• Radial tilt is measured on a lateral radiograph.
  ?
• The radial tilt represents the angle between a
  line along the distal radial articular surface
  and the line perpendicular to the longitudinal
  axis of the radius at the joint margin.
• The normal volar tilt averages 11? and has a
  range of 2?-20?.

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PA Hand

• Thumb?
• Index
• Middle finger
• Ring finger
• Little finger
• I-V. Metacarpal bones
• 1,4. Distal phalanx?
• Middle phalanx?
• 3,5. Proximal phalanx?
• Sesamoid bones
• Distal interphalangeal joint (DIP)
• Proximal interphalangeal joint (PIP)?

1. Metacarpophalangeal joint (V.)
2. Carpometacarpal joints
3. Trapezium
4. Trapezoid
5. Capitate
6. Hamate
7. Scaphoid
8. Lunate
9. Triquetrum
10. Pisiform
11. Radius
12. Ulna

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QUESTIONS?