The radiologist and the raiders of the lost image
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1 The radiologist and the raiders of the lost image Poster No.: P-0072 Congress: ESSR 2014 Type: Educational Poster Authors: M. J. Ereño Ealo, E. Montejo Rodrigo, B. Sancho, E. Pastor; Galdakao/ES Keywords: Musculoskeletal system, Extremities, Radiation physics, Conventional radiography, Digital radiography, Diagnostic procedure, Technical aspects, Artifacts, Education and training, Quality assurance DOI: /essr2014/P-0072 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 76
2 Learning objectives *To describe the basics of the main radiographic projections of the extremities * To show the radiological findings we must study and clinical cases of the most common diseases. * To identify the common errors by clinical cases Page 2 of 76
3 Background Currently the CT and MRI have sometimes supplanted plain radiography in the assessment of urgent orthopedic injuries. Plain radiography is the first diagnostic approach technique in urgent traumatological pathology of the extremities. Radiologists must understand and nimbly manage the appropriate projections for the different conditions in order to respond to the questions and issues of other specialists, particularly orthopedic surgeons For it we will develop some key points to consider in the radiological study of the lower limbs: 1. MAIN PROJECTIONS FOR THE STUDY OF THE LOWER LIMBS 1.1. PELVIC VIEWS: - Anteroposterior (A/P) - Inlet View - Outlet View 1.2. KNEE VIEWS: - Anteroposterior (A/P) - Lateral View 1.3. ANKLE VIEWS: - Anteroposterior (A/P) - Lateral View - Mortise View 1.4. FOOT VIEWS: Page 3 of 76
4 - Anteroposterior (A/P) - Lateral View - Oblique View 2. OPTIMAL RADIOLOGICAL STUDY. How can I know that my Xray is well done? 2.1. PELVIS 2.2. KNEE 2.3. ANKLE 2.4. FOOT - Examples 3. MOST FREQUENT DIAGNOSIS. CLINICAL CASES 3.1. Pelvic Fractures 3.2. Metastasis 3.3. Gout 3.4. Chondrocalcinosis 3.5. Multiple Myeloma 3.6. Paget's Disease 3.7. Sacroiliitis 3.8. Ankle and Foot Fractures 3.9. Chronic osteomyelitis 4. VARIANTS 4.1. Accessory navicular bone 4.2. Accessory bone Page 4 of 76
5 4.3. Unfused ossification center Page 5 of 76
6 Imaging findings OR Procedure Details We analyzed plain radiographs performed in our Hospital in recent years. We refer more specifically to the extremities radiographs performed in the Emergency Department and we analyze its technical characteristics. First will carry out a review of basic radiographic projections of the lower extremities, the requirements to be met for the successful completion and their indications. 1. MAIN PROJECTIONS FOR THE STUDY OF THE LOWER LIMBS 1.1. PELVIC VIEWS: - Anteroposterior (A/P) - Inlet View - Outlet View Page 6 of 76
7 Fig. 1 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 7 of 76
8 Fig. 2 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 8 of 76
9 Fig. 3 References: Radiology, Hospital of Galdácano - Galdakao/ES 1.2. KNEE VIEWS: - Anteroposterior (A/P) - Lateral View Page 9 of 76
10 Fig. 4 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 10 of 76
11 Fig. 5 References: Radiology, Hospital of Galdácano - Galdakao/ES 1.3. ANKLE VIEWS: - Anteroposterior (A/P) - Lateral View - Mortise View Page 11 of 76
12 Fig. 6 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 12 of 76
13 Fig. 7 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 13 of 76
14 Fig. 8 References: Radiology, Hospital of Galdácano - Galdakao/ES 1.4. FOOT VIEWS: - Anteroposterior (A/P) - Lateral View - Oblique View Page 14 of 76
15 Fig. 9 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 15 of 76
16 Fig. 10 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 16 of 76
17 Fig. 11 References: Radiology, Hospital of Galdácano - Galdakao/ES 2. OPTIMAL RADIOLOGICAL STUDY. How can I know that my Xray is well done? 2.1 PELVIS - The pelvis MUST NOT be rotated (check for symmetry and equal size of both iliac blades) - Whole pelvis and the proximal portions of both femurs should be included - Both femoral heads should be seen - The obturators foramina have to appear symmetrical (in form and size) Page 17 of 76
18 - The greater trochanters should be seen of the same size without overlaps - Minor trochanters MUST NOT be viewed - The X-ray must include the L5 vertebra and partially L4. Some examples: Fig. 12 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 18 of 76
19 Fig. 13 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 19 of 76
20 Fig. 14 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 20 of 76
21 Fig. 15 References: Radiology, Hospital of Galdácano - Galdakao/ES 2.2. KNEE Anteroposterior (A/P) Knee View: - Knee should be observed without rotation (medial and lateral joint space should be the same amplitude, unless there is a pathological change.) - The patella has to be superimposed over the distal femur - The distal femur should be displayed - The proximal tibia should appear superimposed on the fibular head. Page 21 of 76
22 Lateral Knee View: - Overlapping of both femoral condyles confirms the lateral position of the Knee - The proximal tibia should slightly overlap the head of the fibula. - It should be noted patellar profile (patellofemoral joint space) Fig. 16 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 22 of 76
23 Fig. 17 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 23 of 76
24 Fig. 18 References: Radiology, Hospital of Galdácano - Galdakao/ES 2.3. ANKLE Anteroposterior (A/P) Ankle View: - The distal ends of the tibia and fibula should be observed with distal tibiofibular joint partially superimposed -The center of the ankle is centered on the plate with freee tibio talar joint space -The medial malleolus (tibial) has to be free of overlaps -The lateral malleolus (peroneal) must appear partially overlapped the talus. Page 24 of 76
25 Lateral Ankle View: -The posterior área of the distal tibia should be superimposed over distal fibula. -The ankle joint shall be centered on the plate. -The tibio talar joint must be correctly displayed, superimposed on the malleoli -The talus and adjacent tarsal bones (navicular, cuboid and calcaneus) should be displayed. Internal Oblique Ankle View: -The talus and its articulation with the lateral and medial malleolus must be complied without overlapping Page 25 of 76
26 Fig. 19 References: Radiology, Hospital of Galdácano - Galdakao/ES 2.4. FOOT Anteroposterior (A / P) Foot View -The entire foot must be observed from distal phalanges to the tarsus, without rotation (check by equidistance between the bodies of the 2nd to the 5th metatarsal) -The cuboid bone, the navicular and the Three cuneiform bones should be displayed Lateral Foot view -Whole foot (from distal phalanges to the tarsus) and distal portion of the leg should be observed -The tibia and fibula are to be superimposed and also the metatarsals and phalanges. Oblique projection - Whole foot should be displayed -There must be equidistant between the metatarsal 2nd to 5th -The 1st and 2nd metatarsals seem partially overlapping -Absence of overlapping from the 3rd to the 5th metatarsal -Tarsometatarsal and intertarsal joints must be displayed -The tuberosity of the 5th metatarsal appears in lateral view 3. MOST FREQUENT DIAGNOSIS. CLINICAL CASES 3.1. Pelvic Fractures Page 26 of 76
27 Fig. 20 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 27 of 76
28 Fig. 21 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 28 of 76
29 Fig. 22 References: Radiology, Hospital of Galdácano - Galdakao/ES 3.2. Metastasis Page 29 of 76
30 Fig. 23 References: Radiology, Hospital of Galdácano - Galdakao/ES 3.3. Gout Page 30 of 76
31 Fig. 24 References: Radiology, Hospital of Galdácano - Galdakao/ES 3.4. Chondrocalcinosis Page 31 of 76
32 Fig. 25 References: Radiology, Hospital of Galdácano - Galdakao/ES 3.5. Multiple Myeloma Page 32 of 76
33 Fig. 26 References: Radiology, Hospital of Galdácano - Galdakao/ES 3.6. Paget's Disease Page 33 of 76
34 Fig. 27 References: Radiology, Hospital of Galdácano - Galdakao/ES 3.7. Sacroiliitis Page 34 of 76
35 Fig. 28 References: Radiology, Hospital of Galdácano - Galdakao/ES 3.8. Ankle and Foot Fractures Page 35 of 76
36 Fig. 29 References: Radiology, Hospital of Galdácano - Galdakao/ES 3.9. Chronic osteomyelitis Page 36 of 76
37 Fig. 30 References: Radiology, Hospital of Galdácano - Galdakao/ES 4. VARIANTS 4.1. Accessory navicular bone Page 37 of 76
38 Fig. 31 References: Radiology, Hospital of Galdácano - Galdakao/ES 4.2. Accessory bone Page 38 of 76
39 Fig. 32 References: Radiology, Hospital of Galdácano - Galdakao/ES 4.3. Unfused ossification center Page 39 of 76
40 Fig. 33 References: Radiology, Hospital of Galdácano - Galdakao/ES Page 40 of 76
41 Images for this section: Fig. 1 Radiology, Hospital of Galdácano - Galdakao/ES Page 41 of 76
42 Fig. 2 Radiology, Hospital of Galdácano - Galdakao/ES Page 42 of 76
43 Fig. 3 Radiology, Hospital of Galdácano - Galdakao/ES Page 43 of 76
44 Fig. 4 Radiology, Hospital of Galdácano - Galdakao/ES Page 44 of 76
45 Fig. 5 Radiology, Hospital of Galdácano - Galdakao/ES Page 45 of 76
46 Fig. 6 Radiology, Hospital of Galdácano - Galdakao/ES Page 46 of 76
47 Fig. 7 Radiology, Hospital of Galdácano - Galdakao/ES Page 47 of 76
48 Fig. 8 Radiology, Hospital of Galdácano - Galdakao/ES Page 48 of 76
49 Fig. 9 Radiology, Hospital of Galdácano - Galdakao/ES Page 49 of 76
50 Fig. 10 Radiology, Hospital of Galdácano - Galdakao/ES Page 50 of 76
51 Fig. 11 Radiology, Hospital of Galdácano - Galdakao/ES Page 51 of 76
52 Fig. 12 Radiology, Hospital of Galdácano - Galdakao/ES Page 52 of 76
53 Fig. 13 Radiology, Hospital of Galdácano - Galdakao/ES Page 53 of 76
54 Fig. 14 Radiology, Hospital of Galdácano - Galdakao/ES Page 54 of 76
55 Fig. 15 Radiology, Hospital of Galdácano - Galdakao/ES Page 55 of 76
56 Fig. 16 Radiology, Hospital of Galdácano - Galdakao/ES Page 56 of 76
57 Fig. 17 Radiology, Hospital of Galdácano - Galdakao/ES Page 57 of 76
58 Fig. 18 Radiology, Hospital of Galdácano - Galdakao/ES Page 58 of 76
59 Fig. 19 Radiology, Hospital of Galdácano - Galdakao/ES Page 59 of 76
60 Fig. 20 Radiology, Hospital of Galdácano - Galdakao/ES Page 60 of 76
61 Fig. 21 Radiology, Hospital of Galdácano - Galdakao/ES Page 61 of 76
62 Fig. 22 Radiology, Hospital of Galdácano - Galdakao/ES Page 62 of 76
63 Fig. 23 Radiology, Hospital of Galdácano - Galdakao/ES Page 63 of 76
64 Fig. 24 Radiology, Hospital of Galdácano - Galdakao/ES Page 64 of 76
65 Fig. 25 Radiology, Hospital of Galdácano - Galdakao/ES Page 65 of 76
66 Fig. 26 Radiology, Hospital of Galdácano - Galdakao/ES Page 66 of 76
67 Fig. 27 Radiology, Hospital of Galdácano - Galdakao/ES Page 67 of 76
68 Fig. 28 Radiology, Hospital of Galdácano - Galdakao/ES Page 68 of 76
69 Fig. 29 Radiology, Hospital of Galdácano - Galdakao/ES Page 69 of 76
70 Fig. 30 Radiology, Hospital of Galdácano - Galdakao/ES Page 70 of 76
71 Fig. 31 Radiology, Hospital of Galdácano - Galdakao/ES Page 71 of 76
72 Fig. 32 Radiology, Hospital of Galdácano - Galdakao/ES Page 72 of 76
73 Fig. 33 Radiology, Hospital of Galdácano - Galdakao/ES Page 73 of 76
74 Conclusion * Plain radiography remains the first-line diagnostic tool in the evaluation of trauma pathology. * It is necessary for us to perform a systematic reading of radiographs and know the common mistakes. Page 74 of 76
75 References 1] Delaunay S, Dussault RG, Kaplan PA, et al. Radiographic measurements of dysplastic adult hips. Skeletal Radiol 1997;26: [2] Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis-what the radiologist should know. Am J Roentgenol 2007;188(6): [3] Kalberer F, Sierra RJ, Madan SS, et al. Ischial spine projection into the pelvis: a new sign for acetabular retroversion. Clin Orthop Relat Res 2008;466: [4] Banks KP, Grayson DE. Acetabular retroversion as a rare cause of chronic hip pain: recognition of the "Fig.-eight" sign. Skeletal Radiol 2007;36(Jun (Suppl. 1)):S [5] Armfield DR et al. Radiographic and MR Imaging of the Athletic Hip. Clin Sports Med 25 (2006) Page 75 of 76
76 Personal Information Maria José Ereño Ealo Diagnostic Imaging Hospital of Galdacano Vizcaya. SPAIN Page 76 of 76
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Shear Wave Elastography in diagnostics of supraspinatus tendon.
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Imaging acute knee trauma: Are referral criteria and clinical guidelines used in Belgium?
Imaging acute knee trauma: Are referral criteria and clinical guidelines used in Belgium? Poster No.: C-2209 Congress: ECR 2010 Type: Scientific Exhibit Topic: Musculoskeletal Authors: M. A. T. Vergauwen,
Dynamic CT Assessment of Distal Radioulnar Instability
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Ultrasound and radiography findings in developmental dysplasia of the hip: a pictorial review
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Standardizing mammographic breast compression: Pressure rather than force?
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Computed tomography for the detection of thumb base osteoarthritis, comparison with digital radiography.
Computed tomography for the detection of thumb base osteoarthritis, comparison with digital radiography. Poster No.: C-1981 Congress: ECR 2012 Type: Scientific Exhibit Authors: M. S. Saltzherr, J. W. van
Slowly growing malignant nodules and rapidly growing benign nodules: Evaluation of the value of volume doubling time
Slowly growing malignant nodules and rapidly growing benign nodules: Evaluation of the value of volume doubling time Poster No.: C-208 Congress: ECR 2009 Type: Educational Exhibit Topic: Chest Authors:
BI-RADS 3, 4 and 5 lesions on US: Five categories and their diagnostic efficacy and pitfalls in interpretation
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CT assessment of children with in-toeing gait
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MR measurements of subcoracoid impingement using a new method and its relationship to rotator cuff pathology at MR arthrography
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Idiopathic dilatation of the pulmonary artery : radiographic and MDCT features in 6 cases
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Acute pelvic pain in female patient: Clinical and Radiological evaluation
Acute pelvic pain in female patient: Clinical and Radiological evaluation Poster No.: C-0909 Congress: ECR 2014 Type: Authors: Keywords: DOI: Educational Exhibit N. Ramesh 1, T. Simelane 2 ; 1 Portlaoise/IE,
Acute pelvic pain in female patient: Clinical and Radiological evaluation
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Essure Permanent Birth Control Device: Radiological followup results at our center
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Accessory Ossicles of the Foot and Ankle
Accessory Ossicles of the Foot and Ankle Poster No.: C-0978 Congress: ECR 2016 Type: Educational Exhibit Authors: U. Kesimal, M. OYNAK, C. Cevikol; Antalya/TR Keywords: Anatomy, Musculoskeletal bone, Musculoskeletal
Single cold nodule in Graves' disease: benign vs malignant
Single cold nodule in Graves' disease: benign vs malignant Poster No.: C-0073 Congress: ECR 2011 Type: Authors: Keywords: DOI: Scientific Paper L. I. Sonoda, M. Halim, K. Balan; Cambridge/UK Head and neck,
A pictorial review of normal anatomical appearences of Pericardial recesses on multislice Computed Tomography.
A pictorial review of normal anatomical appearences of Pericardial recesses on multislice Computed Tomography. Poster No.: C-1787 Congress: ECR 2012 Type: Educational Exhibit Authors: N. Ahmed 1, G. Avery
Spinal injury is very common in Ireland: 19 per 100,000 (1). It poses a significant disease burden.
MRI in traumatic spinal cord injury: a single national spinal centre experience and study of imaging features with clinical correlation with ASIA score and outcome Poster No.: C-1235 Congress: ECR 2011
Complications in amputees
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MRI Findings of Posterolateral Corner Injury on Threedimensional
MRI Findings of Posterolateral Corner Injury on Threedimensional Isotropic SPACE. Poster No.: C-1792 Congress: ECR 2013 Type: Scientific Exhibit Authors: S.-W. Lee, Y. M. Jeong, J. A. Sim, S. Ahn; Incheon/KR
Suprapatellar fat-pad impingement:mri findings
Suprapatellar fat-pad impingement:mri findings Poster No.: C-1672 Congress: ECR 2017 Type: Scientific Exhibit Authors: A. Arslan, S. Ulus, S. A. Kara, O. SAYG#L#; istanbul/tr Keywords: Trauma, Diagnostic
Calcaneal Apophysitis (Sever s Disease) a Poorly Identified Pathology: Easy Radiological Evaluation.
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Synovial hemangioma of the suprapatellar bursa
Synovial hemangioma of the suprapatellar bursa Poster No.: P-0040 Congress: ESSR 2013 Type: Authors: Keywords: DOI: Scientific Exhibit A. YESILDAG, S. Keskin, H. Kalkan, S. Kucuksen, U. Kerimoglu; Konya/TR
Value of shear wave ultrasound elastography in the myofascial pain syndrome diagnosis in sportsmen
Value of shear wave ultrasound elastography in the myofascial pain syndrome diagnosis in sportsmen Poster No.: C-1202 Congress: ECR 2014 Type: Authors: Keywords: DOI: Scientific Exhibit V. Saltykova; Moscow/RU
Unenhanced and dynamic contrast enhanced (DCE) MRI in assessment of scaphoid fracture non-union revisited: role in pre-operative planning
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Hyperechoic breast lesions can be malignant.
Hyperechoic breast lesions can be malignant. Poster No.: C-0041 Congress: ECR 2015 Type: Educational Exhibit Authors: G. Babu, R. bradley; Edinburgh/UK Keywords: Breast, Ultrasound, Biopsy, Cancer DOI:
Radiographic Signs Predicting Rotator Cuff Tears
Radiographic Signs Predicting Rotator Cuff Tears Poster No.: P-0051 Congress: ESSR 2015 Type: Scientific Poster Authors: J. J. van der Reijden, M. van den Bekerom, M. Somford, J. 1 2 2 4 1 3 2 Doornberg,
Chronology of normal brain myelination in newborns with MR imaging
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MRI of scapholunate ligament- comparison between direct MR arthrography and non-contrast examination with highresolution
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How to plan a Zenith AAA stent-graft from a CTA: Basic measurements and concepts explained
How to plan a Zenith AAA stent-graft from a CTA: Basic measurements and concepts explained Poster No.: C-3077 Congress: ECR 2010 Type: Educational Exhibit Topic: Vascular Authors: D. V. Thomas; Northampton/UK
Diagnostic accuracy of MRI in detecting posterior ligamentous complex injury in thoracolumbar vertebral fractures
Diagnostic accuracy of MRI in detecting posterior ligamentous complex injury in thoracolumbar vertebral fractures Poster No.: C-1726 Congress: ECR 2011 Type: Scientific Exhibit Authors: E. Aguirre, P.
User Guide for Dental and Maxillofacial Cone Beam Computed Tomography (CBCT)
User Guide for Dental and Maxillofacial Cone Beam Computed Tomography (CBCT) Poster No.: C-0756 Congress: ECR 2014 Type: Educational Exhibit Authors: J. Ukkonen, J. Asp; Helsinki/FI Keywords: Education
The "whirl sign". Diagnostic accuracy for intestinal volvulus.
The "whirl sign". Diagnostic accuracy for intestinal volvulus. Poster No.: C-0670 Congress: ECR 2014 Type: Scientific Exhibit Authors: M. Pire, M. Marti, A. Borobia, A. Verón; Madrid/ES Keywords: Abdomen,
Comparison of radiation doses of various approaches of MR arthrograms with fluoroscopic guided contrast injection
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Carpal bossing - review and an unrecognized variation.
Carpal bossing - review and an unrecognized variation. Poster No.: P-0053 Congress: ESSR 2014 Type: Authors: Keywords: DOI: Educational Poster K. B. Puhakka, L. Roemer, B. Munk; Aarhus C/DK Developmental
Valsalva-manoeuvre or prone belly position for computed tomography (CT) scan when an orbita varix is suspected: a single-case study.
Valsalva-manoeuvre or prone belly position for computed tomography (CT) scan when an orbita varix is suspected: a single-case study. Poster No.: C-0512 Congress: ECR 2012 Type: Authors: Keywords: DOI:
PGMI classification of screening mammograms prior to interval cancer. Comparison with radiologists' consensus classification.
PGMI classification of screening mammograms prior to interval cancer. Comparison with radiologists' consensus classification. Poster No.: C-0673 Congress: ECR 2016 Type: Authors: Keywords: DOI: Scientific
Diffuse high-attenuation within mediastinal lymph nodes on non-enhanced CT scan: Usefulness in the prediction of benignancy
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Lumbosacral Transitional Vertebrae
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Trabecular bone analysis with tomosynthesis in diabetic patients: comparison with CT-based finite-element method
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Ultrasound and MRI Findings of Tennis Leg with Differential Diagnosis.
Ultrasound and MRI Findings of Tennis Leg with Differential Diagnosis. Poster No.: R-0057 Congress: 2015 ASM Type: Educational Exhibit Authors: M. George, A. Thomas, R. Dutta, K. Gummalla; Singapore/SG
Purpose. Methods and Materials. Results
Prevalence and significance of hypoattenuating hepatic lesions deemed too small to characterise: How are we following up these lesions and what are the outcomes? Poster No.: C-014 Congress: ECR 2009 Type:
The Role of Radionuclide Lymphoscintigraphy in the Diagnosis of Lymphedema of the Extremities
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Cavitary lung lesion: Two different diagnosis with similar appearence
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Computed tomography for pulmonary embolism: scan assessment of a one-year cohort and estimated cancer risk associated with diagnostic irradiation.
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The iliotibial band syndrome : MR Imaging findings
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