Radiographic Interpretation Bucky Boaz, ARNP What’s Normal?

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Radiographic Interpretation

Bucky Boaz, ARNP

What’s Normal?

Cervical Spine (Lateral)

1. Anterior arch of the atlas2. Dens of axis3. Posterior arch of the atlas4. Soft palate5. Root of the tongue 6. Transverse process7. Intervertebral disc8. Inferior articular process9. Superior articular process10. Zygapophyseal (facet) joint11. Spinous process of C72nd-7th: The bodies of 2nd to 7th

cervical vertebrae



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 > 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;



Anterior soft tissue swelling

• distance between tracheal air column & anterior aspect of vertebral body should be No greater than:

– Adults: no > than 7 mm at C2 or 22 mm at C6;

– Child: no > 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;



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 < 14 mm

• anterior subluxation is caused by facet dislocation

– < 50% of vertebral body width = unilateral dislocation

– > 50% of vertebral body width = bilateral dislocation



Lateral Findings

• Examine bones for symmetry• May provide evidence of

fracture• Abnormal symmetry is often

due to compression• compression of > 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



Cervical Spine (Lateral)

1. Bifid spinous process of C32. Superimposed articular

processes3. Uncinate processes4. Air filled trachea5. Transverse process of C76. Transverse process of T17. 1st rib8. Clavicle4th-7th: The bodies of 4th to 7th

cervical vertebrae



AP Cervical Spine





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;



http://www.wheelessonline.com/ortho/anatomy_of_atlas

http://www.wheelessonline.com/ortho/atlas_frx_jefferson_fracture

http://www.wheelessonline.com/ortho/anatomy_of_the_axis

http://www.wheelessonline.com/ortho/dens_fracture

http://www.wheelessonline.com/ortho/anatomy_of_the_axis

http://www.wheelessonline.com/ortho/anatomy_of_atlas

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 > 7 mm suggests that transverse ligament is torn;



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;



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;



Odontoid





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



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



Lateral Lumbar Spine





Lateral Lumber Spine





AP Lumbar Spine





Vertebral Fractures



Pelvis





AP Pelvis

1. Lateral part of the sacrum

2. Gas in colon3. Ilium4. Sacroiliac joint5. Ischial spine6. Superior ramus of

pubis7. Inferior ramus of

pubis8. Ischial tuberosity9. Obturator foramen10. Intertrochanteric

crest11. Pubic symphysis



12. Pubic tubercle

13. Lesser trochanter

14. Neck of femur

15. Greater trochanter

16. Head of femur

17. Acetabular fossa

18. Anterior inferior iliac spine

19. Anterior superior iliac spine

20. Posterior inferior iliac spine

21. Posterior superior iliac spine

22. Iliac crest

AP Hip

1. Anterior superior iliac spine2. Ilium3. Anterior inferior iliac spine4. Pelvic brim5. Acetabular fossa6. Head of femur7. Fovea8. Superior ramus of pubis9. Obturator foramen10. Inferior ramus of pubis11. Pubic symphysis12. Ischium13. Lesser trochanter14. Intertrochanteric crest15. Greater trochanter16. Neck of femur



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



AP Knee

1. Femur2. Patella3. Medial epicondyle of femur4. Lateral epicondyle of femur5. Medial condyle of femur6. Lateral condyle of femur7. Intercondylar eminence8. Intercondylar notch9. Knee joint10. Lateral condyle of tibia11. Medial condyle of tibia12. Tibia13. Fibula



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



AP Ankle

1. Fibula

2. Tibia

3. Distal tibiofibular joint

4. Malleolar fossa

5. Lateral malleolus

6. Ankle joint

7. Medial malleolus

8. Talus



Lateral Ankle

1. Fibula2. Tibia3. Ankle joint4. Promontory of tibia5. Trochlear surface of talus6. Talus7. Posterior tubercle of talus8. Calcaneus9. Sustentaculum tali10. Tarsal tunnel11. Navicular12. Cuneiforms13. Cuboid



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.



Boehler’s Angle

• Compressive fractures occur after a fall from a height.

• Subtle fractures may only be identified by assessing Boehler’s 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 >30 degrees.

– If there is flattening of the bone due to a fracture, this angle will be decreased, to <30 degrees.



Boehler’s Angle



AP Foot

A-E: Toes 1-5. (A:Great toe)

I-V. Metatarsals

1,3. Distal phalax

4. Middle phalax

2,5. Proximal phalax

6. Interphalangeal joints

7. Metatarsophalangeal joints

8. Sesamoids

9. Head of metatarsal

10. Shaft (body) of metatarsal

11. Base of metatarsal



12. Cuneiform13. Navicular14. Cuboid15. Talus16. Calcaneus17. Tibia18. Fibula19. Tarsometatarsal joints20. Transverse midtarsal joint

Oblique Foot

11. Base of metatarsal12. Cuneiforms13. Navicular14. Cuboid15. Talus16. Calcaneus17. Tibia18. Fibula19. Tarsometatarsal

joints20. Transverse midtarsal

joint



A-E: Toes 1-5. (A:Great toe)1,3. Distal phalax4. Middle phalax2,5. Proximal phalax6. Interphalangeal joints7. Metatarsophalangeal

joints8. Sesamoids9. Head of metatarsal10. Shaft (body) of

metatarsal

AP Foot





Oblique Foot

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Lateral Foot





Lisfranc





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



AP Elbow

1. Lateral supracondylar ridge2. Medial supracondylar ridge3. Olecranon fossa4. Medial epicondyle5. Lateral epicondyle6. Capitulum7. Olecranon8. Trochlea9. Coronoid process of ulna10. Proximal radioulnar joint11. Head of radius12. Neck of radius13. Tuberosity of radius14. Ulna



Lateral Elbow

1. Supracondylar ridge2. Trochlea3. Olecranon4. Trochlear notch5. Coronoid process of

ulna6. Head of radius7. Neck of radius8. Tuberosity of radius9. Ulna



PA WristI-V: Metacarpals1. Trapezium2. Trapezoid3. Capitate4. Head of capitate5. Hamate6. Hook of hamate7. Scaphoid8. Lunate9. Triquetrum10. Pisiform11. Styloid process of radius12. Head of ulna13. Styloid process of ulna14. Radiocarpal joint15. Distal radioulnar joint



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



Rule of 11’s

• 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.



Rule of 11’s

• 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.



Rule of 11’s

• 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 ｡ .



PA HandA. ThumbB. IndexC. Middle fingerD. Ring fingerE. Little fingerI-V. Metacarpal bones1,4. Distal phalanx2. Middle phalanx3,5. Proximal phalanx6. Sesamoid bones7. Distal interphalangeal

joint (DIP)8. Proximal

interphalangeal joint (PIP)



9. Metacarpophalangeal joint (V.)

10. Carpometacarpal joints

11. Trapezium

12. Trapezoid

13. Capitate

14. Hamate

15. Scaphoid

16. Lunate

17. Triquetrum

18. Pisiform

19. Radius

20. Ulna

QUESTIONS?

Radiographic Interpretation Bucky Boaz, ARNP What’s Normal?

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