Matthew Tommack, D.O. October 13, 2018 Chest radiography Anatomy, - PowerPoint PPT Presentation

Matthew Tommack, D.O. October 13, 2018

 Chest radiography ◦ Anatomy, pathology  Shoulder Radiography ◦ Anatomy, pathology  Knee Radiography ◦ Anatomy, pathology

Anatomy Consolidation Atelectasis Pulmonary Edema Pleural Effusion Pneumothorax

 Technique, type and quality  Ribs and spine  Upper abdomen  Soft tissues  Borders of the mediastinum/heart  Lungs ◦ Pneumothorax ◦ Consolidation ◦ Pleural effusion ◦ Interstitium/vessels

 When fluid/cells accumulate in lung ◦ Alveolar (airspace) compartment ◦ Interstitial compartment  In addition to increasing the lung density, the consolidation cancels the contrast between vessels and lung boundaries, and these structures disappear, ie silhouette sign  Air filled bronchi, normally invisible, will be contrasted by consolidation creating air bronchograms

 RUL: right superior mediastinum (SVC)  RML: right heart border  RLL: right hemidiaphragm or right heart border if medial RLL  LUL: left superior mediastinum (aortic arch)  Lingula: left heart border  LLL: left hemidiaphragm or descending aorta

 Obstructive / Resorptive ◦ Endobronchial Lesion  Passive / Relaxation ◦ Pleural Effusion, Pneumothorax  Compressive ◦ Bulla  Cicatricial/Scarring ◦ Radiation Fibrosis  Adhesive ◦ Neonatal Respiratory Distress Syndrome/Hyaline Membrane Dz

 Lobar  Segmental  Subsegmental (Plate/Streak)  Round

 Heart size on ideal PA film ◦ Heart width should be less than 50% of chest cavity width. ◦ Cardiac enlargement is common in CHF  Normal upright upper lung pulmonary vessels 1/3 the size of basilar vessels.  Early CHF ◦ Basilar edema causes shunt to upper lobe = cephalization of flow.  Interstitial edema ◦ Thin Kerley B lines (septal lines) and thick bronchi  Parahilar alveolar edema ◦ Usually symmetric and non-segmental

 Measurement of the Cardiothoracic ratio: [(MRD+MLD)/ID]  A value of <0.5 is normal (<0.6 in infants).  Enlargement may come from heart or pericardium.

 Pleural effusion is seen in many conditions ◦ Heart failure ◦ Tumor ◦ Pneumonia ◦ Trauma  Obscures and compresses underlying lung  Effusions are readily detected ◦ Can point to underlying problem that may not be seen on x-ray, ie infection, tumor  On routine upright chest x ray, need 200-300 mL of pleural fluid to blunt costophrenic angle  On lateral view, need only 75cc to blunt posterior costophrenic sulcus  Lateral decubitus is most sensitive and can be helpful to determine of fluid is loculated

 Injury to the lung, either trauma or iatrogenic  Air leakage into the pleural space  Spontaneous cases (idiopathic) also occur  Severity and duration of pneumothorax is made worse by increased airway pressure ◦ Obstructive airway disease or positive pressure ventilation  If a "flap valve" mechanism is present, progressive enlargement of space may compromise cardiac filling and ventilation (tension pneumothorax)  Expiratory films aid in detection

 Skin folds often simulate pleural lines ◦ True pleural line has air on both sides of a fine line ◦ Most pneumothorax look-alikes have air on only one side and are not real lines  Mastectomy  Bulla/blebs

 Discussed normal chest x ray with development of approach  Common clinical pathologies  Questions

 Anatomy  Pathology

Clavicle Acromion Coracoid process Greater tuberosity Glenoid Lesser Tuberosity

Glenohumeral Joint

coracoid Acromion Clavicle Glenoid

Clavicle Acromion Glenoid Face

Supraspinatus Tendon Footprint Labrum Cartilage

Bursa Supraspinatus footprint

Supraspinatus Infraspinatus Subscapularis Biceps Tendon

 Fractures  Dislocations  Arthritis  Calcific tendonosis  Avascular necrosis  Indirect signs of soft tissue injury  Tumors

Humeral Head Fracture -can be very subtle and CT or MRI may be needed -surgical management depends on amount of humeral head involved and degree of displacement

Anterior Dislocation -most common type of dislocation -complications include Hill sachs impaction fracture and Bankart lesions as well as rotator cuff injury

AC Joint Injury-High Grade -Grading depends on degree of diplacement which relates to degree of soft tissue involvement

Osteoarthritis and chronic rotator cuff tear

Calcific Tendonosis, HADD -may be incidental, but can acute cause pain -supraspinatus is one of the most common sites -Treatment is usually conservative, but ultrasound guided lavage can be performed, surgery rarely needed

Avascular Necrosis -humeral head is second most common site behind hip -can lead to subchondral collapse -MRI is most sensitive for early detection in high risk patients

Cartilage forming bone tumor -enchondroma, chondrosarcoma -predilection for metaphasis of long bones, tubular bones of hands and feet -treatment depends on aggressive features and many times symptoms may be the only deciding factor

 Anatomy  Common Pathology  Questions

 Anatomy  Pathology

Tibial PCL ACL MCL Spines Fibular Head Menisci

Quadriceps Suprapatellar Tendon Recess ACL PCL Patellar Tendon

Patellofemoral joint space Menisci Cartilage

 Fractures  Arthritis  Osteochondral Lesions  Signs of internal derangement  Soft tissue injuries  Tumors

Tibial Plateau Fractures -Treatment depends on severity of comminution, displacement, depression of subchondral bone, and associated soft tissue injuries -will generally go on to CT or MRI

Osteoarthritis -osteophyte formation, joint space loss, subchondral cyst, subchondral sclerosis

Transient dislocation of patella with joint effusion and osteochondral lesion