Radiographic Interpretation What’s Normal? Bucky Boaz, ARNP
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
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) • 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
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 bestseen on the odontoid view;
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, & limitedflexion, 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 bytransverse and alar ligaments;
Anatomy of C2 • lateral masses of C2 have aperture for accepting transversingvertebral 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;
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
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
AP Pelvis • Lateral part of the sacrum • Gas in colon • Ilium • Sacroiliac joint • Ischial spine • Superior ramus of pubis • Inferior ramus of pubis • Ischial tuberosity • Obturator foramen • Intertrochanteric crest • 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
AP Hip • Anterior superior iliac spine • Ilium • Anterior inferior iliac spine • Pelvic brim • Acetabular fossa • Head of femur • Fovea • Superior ramus of pubis • Obturator foramen • Inferior ramus of pubis • Pubic symphysis • Ischium • Lesser trochanter • Intertrochanteric crest • Greater trochanter • Neck of femur
Lateral Hip • Greater trochanter • Intertrochanteric crest • Lesser trochanter • Neck of femur • Head of femur • Acetabular fossa • Superior ramus of pubis • Obturator foramen • Inferior ramus of pubis • Ischium
AP Knee • Femur • Patella • Medial epicondyle of femur • Lateral epicondyle of femur • Medial condyle of femur • Lateral condyle of femur • Intercondylar eminence • Intercondylar notch • Knee joint • Lateral condyle of tibia • Medial condyle of tibia • Tibia • Fibula
Lateral Knee • Femur • Lateral condyle of femur • Medial condyle of femur • Fabella • Patella • Base of patella • Apex of patella • Intercondylar eminence • Apex of fibula • Fibula • Tibia • Tibial tuberosity
AP Ankle • Fibula • Tibia • Distal tibiofibular joint • Malleolar fossa • Lateral malleolus • Ankle joint • Medial malleolus • Talus
Lateral Ankle • Fibula • Tibia • Ankle joint • Promontory of tibia • Trochlear surface of talus • Talus • Posterior tubercle of talus • Calcaneus • Sustentaculum tali • Tarsal tunnel • Navicular • Cuneiforms • 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.
AP Foot A-E: Toes 1-5. (A:Great 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
Oblique Foot • Base of metatarsal • Cuneiforms • Navicular • Cuboid • Talus • Calcaneus • Tibia • Fibula • Tarsometatarsal joints • Transverse midtarsal joint A-E: Toes 1-5. (A:Great toe) 1,3. Distal phalax • Middle phalax 2,5. Proximal phalax • Interphalangeal joints • Metatarsophalangeal joints • Sesamoids • Head of metatarsal • Shaft (body) of metatarsal
AP Shoulder • Clavicle • Acromioclavicular joint • Acromion • Greater tubercle of humerus • Head of humerus • Lesser tubercle of humerus • Surgical neck of humerus • Coracoid process • Glenoid fossa • Shoulder joint • Lateral border of scapula
AP Elbow • Lateral supracondylar ridge • Medial supracondylar ridge • Olecranon fossa • Medial epicondyle • Lateral epicondyle • Capitulum • Olecranon • Trochlea • Coronoid process of ulna • Proximal radioulnar joint • Head of radius • Neck of radius • Tuberosity of radius • Ulna
Lateral Elbow • Supracondylar ridge • Trochlea • Olecranon • Trochlear notch • Coronoid process of ulna • Head of radius • Neck of radius • Tuberosity of radius • Ulna
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
Lateral Wrist • 1st metacarpal • Metacarpals II-V • Trapezium • Tubercle of scaphoid • Lunate • Triquetrum • Radiocarpal joint • Distal end of radius • 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 Hand • Metacarpophalangeal joint (V.) • Carpometacarpal joints • Trapezium • Trapezoid • Capitate • Hamate • Scaphoid • Lunate • Triquetrum • Pisiform • Radius • Ulna • 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)