An Introduction to Radiographic Views & Anatomy
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1 An Introduction to Radiographic Views & Anatomy Morey J. Kolber, PT, PhD, OCS, Cert MDT, CSCS*D An Introduction to Radiographic Views & Anatomy M.S.P.T University of Miami Nova Southeastern University Associate Professor Department of Physical Therapy Fort Lauderdale, Florida Boca Raton Orthopaedic Group Director of Physical Therapy Boca Raton, Florida 1
2 Topics Indications overview The basics of viewing Two dimensions & added distortion Density & Interpreting the grey Radiographic views & anatomy Spine (Cervical and Lumbar) Knee Ankle Foot Introduction Nice to Know or Need to Know? 2
3 Does Your Patient Need a Radiograph? Indications. Risk for more serious pathology e.g. Fracture, Cancer, Infection Condition not immediately amenable to rehab Therapeutically informative vs. uninformative Kolber, MJ. Does Your Patient Need a Radiograph? On-Demand Webinar Does Your Patient Need a Radiograph? Indications.Suspicion of fracture Trauma Reduced weight-bearing (lower extremity) Bone tenderness e.g. Ankle-malleolus; Midfoot-navicular/base 5 th MT e.g. Spine-midline tenderness; Knee-patella/fib. head Acute motion loss e.g. Knee-flexion 90 ; Elbow-incomplete extension e.g. Cervical rotation < 45 bilaterally Other: risk profile, medications, etc. Kolber, MJ. Does Your Patient Need a Radiograph? On-Demand Webinar 3
4 Does Your Patient Need a Radiograph? CPRs Examples Ottawa Ankle CPR Malleolar pain plus either of the 2 below: Tenderness malleolar zone (not anterior) Limited WB Pittsburgh decision rules Blunt trauma/fall MOI plus either of the following: Age younger than 12 years or older than 50 years Inability to walk four weight-bearing steps immediately & in ER Kolber, MJ. Does Your Patient Need a Radiograph? On-Demand Webinar Nomenclature X-ray or Radiograph 4
5 X-ray Computed tomography (CT) Bone densitometry (DEXA) Radiography Fluoroscopy Plain film radiography Digital radiography Digital vs. Plain Film 5
6 Basic Science X-ray tube generates x-rays that exit tube & enter body: some absorbed & others pass through. What passes through is intercepted by a film cassette or image receptor creating visual image (various shades of gray) X-rays produce a radiographic image dependent upon: Radiographic Density *Structural density of the area of interest Image Quality Optical density, distortion, & detail Basic Science Structural density: x-ray absorption determined by a structures density & thickness: Lead 11g/cm 3 Ca 1.54 g/cm 3 Greater density/thickness: x-ray absorption = opacity *Radiopaque: substance impermeable to x-ray. Thicker & more dense (metal, sclerosed bone, contrast) Less density/thickness: x-ray absorption = lucency *Radiolucent: a substance readily permeable to x-rays. Less dense & thin ( i.e. air, adipose, fracture line) 6
7 Increasing Structural Density Radiolucent Image Air (lungs, digestive track) Adipose (around muscle/organs) Water (muscle, vessels) Bone (normal bone) Contrast (barium, gadolinium) Heavy metal (lead, hardware) Radiopaque Image Decreasing Structural Density Air (lungs) Adipose (around muscle) Water (muscle) Bone (cortical is more opaque) Contrast media (Isovue) Heavy metal (fillings) 7
8 Shapes & Images Radiographs are 2-dimensional Shape and image are density dependent 8
9 Distortion Distortion vs. object positioning Radiation beam Radiation beam Objects Solid wooden stick Films Distortion 9
10 Viewing Radiographs R vs. L Minimum Views 2 film projections (views) minimum (90 to each other) are required to examine the body part for all three anatomical dimensions (length, depth, width) 10
11 Minimum 2 Views Radiographic Views AP: X- ray beam enters anterior part of body & exits posterior to contact cassette. Posterior contacts cassette PA: Beam enters posterior and exits anterior. Used for chest films because heart & lungs are more anterior. Also used with hand/wrist films (Why?) Oblique: rotate body 45 from AP or PA position Lateral: at a right angle to the AP or PA position. Left lateral beam enters right & exits left to cassette Axial: superior to inferior or inferior to superior Ex. Knee: skyline/sunrise 11
12 Radiograph Views Standard views (at minimum) AP Lateral PA (chest and hand) Standard views* Oblique (spine) Oblique (knee, ankle (mortise), foot) AP Open-mouth (cervical spine) Radiograph Specialty Views Axial PFJ (sunrise/sunset/skyline) Stress Cervical/Lumbar: instability Spot Lumbar: L5-S1 Cross table lateral Knee: trauma 12
13 Radiographic Views: Cervical Spine AP Cervical Spine Radiographic Views: Cervical Spine AP Cervical Spine C3 body C4 spinous process (SP) Intervertebral space C3-4 C3-4 uncovertebral joints Pedicle and SP C7 T1 SP T1 transverse process First rib 13
14 Radiographic Views: Cervical Spine Lateral Cervical Spine Radiographic Views: Cervical Spine Lateral Cervical Spine C3 Vertebral body* Intervertebral disc space* Pedicle Facet Joint* (SAP & IAP) C4 Lamina C4 Spinous process 14
15 Radiographic Views: Cervical Spine Lateral Cervical Spine Spinous process Post arch atlas Dens Atlanto-dens interval (ADI) Radiographic Views: Cervical Spine Anterior Oblique Cervical Spine (RAO) 15
16 Radiographic Views: Cervical Spine Anterior Oblique Cervical Spine (RAO) Anterior Oblique usually RAO = Right anterior oblique Image gets flipped Image quality? Intervertebral foramen* Radiographic Views: Cervical Spine Open Mouth 16
17 Radiographic Views: Cervical Spine Open Mouth Dens Position Lateral Mass C1 Space between mass C1-2 Joint C1 transverse process AO joint C2 spinous process C2 body Radiographic Views: Cervical Spine Stress Views-Instability 17
18 Radiographic Views: Lumbar Spine AP Lumbar Spine Radiographic Views: Lumbar Spine AP Lumbar Spine L4-5 disc space L4 Spinous process L3 Vertebral body L3 TP Lamina Pedicle 18
19 Radiographic Views: Lumbar Spine Lateral Lumbar Spine Radiographic Views: Lumbar Spine Lateral Lumbar Spine 19
20 Radiographic Views: Lumbar Spine Lateral Lumbar Spine (Spot View) Radiographic Views: Lumbar Spine Right Posterior Oblique Lumbar Spine 20
21 Radiographic Views: Lumbar Spine Right Posterior Oblique Lumbar Spine Radiographic Views: Lumbar Spine Right Posterior Oblique Lumbar Spine 21
22 Radiographic Views: Lumbar Spine Stress Views Lumbar Spine Radiographic Views: Knee AP Knee 22
23 Radiographic Views: Knee AP Knee Patella Intercondylar notch/fossa Medial joint line Lateral joint line Tibial spines (intercondylar tubercles) Fibular head Neck of fibula Radiographic Views: Knee Lateral Knee 23
24 Radiographic Views: Knee Lateral Knee Retropatellar compartment Femoral condyles Post. aspect lat. tibial plateau Region of inferior pole Radiographic Views: Knee Lateral Cross-Table (Trauma) Knee 24
25 Radiographic Views: Knee Lateral Cross-Table (Trauma) Knee Radiographic Views: Knee Oblique Knee **Fibular head/neck 25
26 Radiographic Views: Knee Sunrise/Sunset/Skyline Knee Radiographic Views: Knee Sunrise/Sunset/Skyline Knee Considered an axial view Knee flexed Medial facet - patella Lateral facet - patella Trochlear groove Sulcus angle Congruence angle (a) 26
27 Radiographic Views: Ankle AP Ankle Radiographic Views: Ankle AP Ankle *Medial malleolus *Lateral malleolus *Talus 27
28 Radiographic Views: Ankle Lateral Ankle Radiographic Views: Ankle Lateral Ankle *Lateral malleolus *Medial malleolus *Talus *Navicular *Calcaneus 28
29 Radiographic Views: Ankle Oblique Ankle (Mortise-Medial Oblique (20 ) Radiographic Views: Ankle Oblique Ankle (Mortise-Medial Oblique (15-20 ) 29
30 Radiographic Views: Foot AP Foot Radiographic Views: Foot AP Foot 1 st MTP joint Sesamoid bones Cuboid 3 Cuneiforms 3 rd cuneiform & cuboid? Navicular 5th metatarsal 30
31 Radiographic Views: Foot Lateral Foot Radiographic Views: Foot Lateral Foot Navicular Talus Calcaneus Sesamoid 5 th Metatarsal Cuneiform region 31
32 Radiographic Views: Foot Oblique Foot Radiographic Views: Foot Oblique Foot 1 st & 2nd Cuneiform 3 rd Cuneiform* 5th MT Cuboid* Talus Navicular Calcaneus Sesamoid 32
33 Questions? Thank You References Stiell IG et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med Dec 25;349(26): Stiell IG et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA Feb 28;275(8): Bachmann LM et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ Feb 22;326(7386):417. Weber JE et al. Clinical decision rules discriminate between fractures and nonfractures in acute isolated knee trauma. Ann Emerg Med Oct;26(4): Seaberg DC & Jackson R. Clinical decision rule for knee radiographs. J Emerg Med Sep;12(5): Dalinka MK et al. Imaging evaluation of suspected ankle fractures. American College of Radiology. ACR Appropriateness Criteria Radiology Jun;215 Suppl: Pavlov H et al. Acute trauma to the knee. American College of Radiology. ACR Appropriateness Criteria. Radiology Jun;215 Suppl: **Bontrager and Lampignano. Textbook of Radiographic Positioning and Related Anatomy 8th ed. Elsevier-Mosby, St. Louis, Missouri
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