Unofficial Guide to Radiology

USS Scans Nuclear Medicine Scans

“Perhaps one of the biggest strengths of this book is the cases section, allowing you to practice not only interpreting high quality images but also to link them to a case history. The questions that follow not only test your radiology, but also your understanding of signs, symptoms, underlying pathophysiology and management of the condition. As well as detailed answers in each section, the book also shows you the best way to present each case, whether in an OSCE situation or on a ward round. The ease of use, detailed pictures and emphasis on key points of this one should cement it as the number one undergraduate book for radiology.”

James Brookes, Medical Student Fluoroscopy Bonus Chest X-Rays

“Which radiographs from each system are most likely to be presented in exams? This excellent book presents the classics, and at one level this makes it a high-yield textbook that will be extremely valuable to medical students and junior doctors. What is especially striking is the definition and clarity of the illustrations, with on-image labelling enabling one to be absolutely certain of which is the endotracheal tube, the nasogastric tube and the central line, for example.”

Bonus Abdominal X-Rays

Bob Clarke, Associate Dean, Professional Development, London. Director, Ask Doctor Clarke Ltd. ISBN: 978 0 9571499 4 6

Introduction Chest X-Rays Abdominal X-Rays Orthopaedic X-Rays CT Scans MRI Scans

MRI Scans

Simon Maxwell, Professor of Student Learning, University of Edinburgh

USS Scans

CT Scans

“Radiology is a constant challenge for students and doctors in busy clinical units: having a good command of the essentials is a real advantage. This book is well-presented and very accessible. The annotated examples provide realistic challenges with immediate feedback. It didn’t take long before I felt better prepared for my next ward round!”

Nuclear Medicine Scans

• Physicians Associates • Nurses • Advanced Nurse Practitioners

The Unofficial Guide to

Radiology: Chest, Abdominal and

Orthopaedic X-Rays, plus CTs, MRIs and Other Important Modalities

Bonus Orthopaedic X-Rays

Core Radiology Curriculum Covered: 100 Annotated X-Rays (including how to present them), 300 Multiple Choice Questions (with detailed explanations) RRP £39.99

Join Our Medical Book Writing Project (details inside)

FIRST EDITION

Mark Rodrigues and Zeshan Qureshi


Fluoroscopy

Orthopaedic X-Rays

• Medical Students • Radiographers • Nursing Students • Junior Doctors

Bonus Chest X-Rays

Abdominal X-Rays

This book is suitable for:

The Unofficial Guide to Radiology: Chest, Abdominal and Orthopaedic X-Rays, plus CTs, MRIs and Other Important Modalities

Chest X-Rays

‘The Unofficial Guide to Radiology’ follows on from the ‘The Unofficial Guide to Passing OSCEs’. This book teaches systematic analysis of the three main types of X-rays: chest, abdominal and orthopaedic, with additional chapters looking at all the other main radiology tests such as CT and MRI. The layout is designed to make the book as relevant to clinical practice as possible; the X-rays are presented in the context of a real life scenario. The reader is asked to interpret the X-ray before turning over the page to reveal a model report accompanied by a fully annotated version of the X-ray. To further enhance the clinical relevance, each case has 5 clinical and radiology-related multiple-choice questions with detailed answers. These test core knowledge for exams and working life, and illustrate how the X-ray findings will influence patient management.


The Unofficial Guide to Radiology


Introduction

Rodrigues QuresHi

The Unofficial Guide to Radiology FIRST EDITION Mark Rodrigues BSc (Hons) MBChB (Hons) Radiology Registrar, Royal Infirmary of Edinburgh; Honorary Clinical Tutor, University of Edinburgh, UK

Zeshan Qureshi BM BSc (Hons) Academic Clinical Fellow (International Child Health) Great Ormond Street and Institute for Global Health, London; Honorary Clinical Tutor, University of Edinburgh, UK

INTRODUCTION ‘The Unofficial Guide to Radiology’ is the fifth book in the Unofficial Guide to Medicine series. Almost every patient has some form of medical imaging performed during his or her investigations and management. The commonest form of imaging, and the modality which all doctors should be able to interpret, remains the X-ray. This important aspect of radiology is therefore the main focus of the book. Other imaging modalities are specialised investigations interpreted by radiologists. However, medical students, doctors, nurses, physician’s associates, and surgeons need to understand what these tests involve, when they are indicated and contraindicated, and how to best request them. Therefore, these aspects are also covered in the book.

Despite its universal importance, X-ray interpretation is often an overlooked subject in the medical school curriculum, which many medical students and junior doctors find difficult and daunting. I was no different when I started work as a junior doctor. However, since starting radiology training, I have realised X-ray interpretation should not be that way. The keys to interpreting X-rays are having a systematic method for assessing the X-ray and getting lots of practice at looking at and presenting X-rays. Occasionally, there may be a complex X-ray you find difficult, or a subtle finding you overlook, but that’s what keeps people like me in a job, so do not worry about it. The “4 Ds” are a useful framework for X-ray interpretation which underpins the approach used in this book. First, you need to Detect and Describe the abnormalities on the X-ray. You then need to form a Differential diagnosis based on clinical and X-ray findings before Deciding what further imaging and management is required. There are lots of radiology textbooks available, but I do not think there is one which is ideally suited for teaching medical students and junior doctors. Many have small, often poor quality images. Radiology is a visual subject and therefore such images are difficult to use to demonstrate key clinical findings. This is confounded by the fact that the findings are usually only described in a figure below the image, and it is often difficult to know exactly what part of the image corresponds to which finding! Another fundamental problem with many radiology textbooks is that they deal with X-rays in isolation. In reality, X-rays are part of the clinical assessment and management of patients, and thus they should be taught in a clinical context. The content, layout and approach used in this book are designed to make it as useful and clinically relevant as possible: • Over 200 large, high quality radiological images are used throughout the book and important findings are annotated on the images to highlight the key points and findings to the reader. • The chest, abdominal and orthopaedic X-ray chapters contain step-by-step approaches to interpreting and presenting X-rays. • Each of these chapters also covers 20 common and important X-ray cases/diagnoses. They are labelled as ‘Case X’ to not give away the diagnosis, but at the end of the book there is a list of all the diagnoses. • The X-rays are presented in the context of a clinical scenario. The reader is asked to “present their findings” before turning over the page to reveal a model X-ray report accompanied by a fully annotated version of the X-ray. This encourages the reader to look at the X-ray thoroughly, as if working on a ward, and come to their own conclusions about the X-ray findings and any further management required before seeing the answers. • To further enhance the clinical relevance, each case has 5 clinical and radiology-related multiplechoice questions with detailed answers. These are aimed to test core knowledge needed for exams and working life, and illustrate how the X-ray findings will influence patient management.

• 3

• The bonus X-ray chapter provides over 50 further X-ray cases to help consolidate the reader’s knowledge and provide an opportunity to practice the skills they have learnt. • Five chapters are devoted to other important imaging investigations: computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (USS), nuclear medicine, and fluoroscopy. These cover the details of what the examinations entail, their common indications, contraindications and key imaging findings. • The content is in line with the Royal College of Radiologists’ Undergraduate Radiology Curriculum 2012, making it up to date and relevant to today’s students and junior doctors. With this textbook, we hope you will become more confident and competent in these radiology competencies, both in exams and in clinical practice, and we also hope that this is just the beginning. We want you to get involved, this textbook has been a collaboration with junior doctors and students just like you. You have the power to contribute something valuable to medicine; we welcome your suggestions and would love for you to get in touch. A good starting point is our Facebook page, which is growing into a forum for medical education: Search for “The Unofficial Guide to Medicine” or enter the hyperlink below into your web browser.

Please get in touch and be part of the medical education project.

Mark Rodrigues, [email protected]

Zeshan Qureshi, [email protected], @DrZeshanQureshi

Facebook: http://www.facebook.com/TheUnofficialGuideToMedicine

4 •

FOREWORD Radiology is encountered every day by medical students. From the wards to OSCEs, from theatre to outpatient clinics, radiology is everywhere at the undergraduate level and beyond. The importance of understanding the principles of imaging, radiation doses and the clinical interpretation of results is paramount. Radiology is a key diagnostic and monitoring tool in modern medicine, so the ability to assess an X-ray in a systematic order is a vital skill. The vast range of techniques, and the complexity of the human body, means this is not a subject that can be learnt overnight, and this book aims to provide you with a grounding in this mammoth specialty. The authors have ensured they have included the basic scientific principles underlying radiology. The book covers many imaging modalities and presents them in a systematic James Brookes, order to give you a clear approach to interpreting what you see. Detailed pictures along Medical Student, University of Southampton the way point out normal anatomical features as well as deformities and anomalies. Perhaps one of the biggest strengths of this book is the cases section, which allows you to practice not only interpreting high quality images but also to link them to a case history. The questions that follow not only test your radiology knowledge, but also your understanding of signs, symptoms, underlying pathophysiology and management of the condition. As well as providing detailed answers in each section, the book also shows you the best way to present each case, whether in an OSCE situation or on a ward round.

“

The Unofficial Guide to OSCEs has quickly become established as one of the most useful undergraduate books. The ease of use, detailed pictures and emphasis on key points of this title should cement it as the number one undergraduate book for radiology. I hope you find it invaluable throughout your studies and it brings you success in all of your exams!

”

James Brookes

Which radiographs from each system are most likely to be presented in exams? This excellent book presents the classics, and at one level this makes it a high-yield textbook that will be extremely valuable to medical students and junior doctors. But it is much more than that. Not only does it teach pattern recognition, it also clearly and simply explains the underlying concepts which make such images easier to interpret and answers all those tricky questions that return to haunt clinicians on a regular basis. For example, when should I use CT and when would magnetic resonance imaging be more appropriate? Bob Clarke, Associate Dean, Professional Development, London. Director, Ask Doctor Clarke Ltd.

This book also teaches a systematic approach to reporting, with the bonus cases particularly useful in enabling readers to check that they have learnt from the core cases that have gone before. This interactivity is essential to its success and the skills acquired will transfer to life beyond the exams. What is especially striking is the definition and clarity of the illustrations, with onimage labelling enabling one to be absolutely certain of which is the endotracheal tube, the nasogastric tube and the central line, for example.

“

Mark Rodrigues and Zeshan Qureshi are to be congratulated on producing this excellent volume. As with the other books in this series, the multi-author collaborative approach works exceptionally well and the democratisation of the reviewing process ensures that this will meet the needs of medical students and junior doctors, both in their exams and in their day to day work. In summary, this is another classic in the “Unofficial Guide” series.

”

Bob Clarke

• 5

Abbreviations

A&E

accident and emergency

ENT

ear, nose and throat

AAA

abdominal aortic aneurysm

ERCP

endoscopic retrograde cholangiopancreatogram

ACE

angiotensin converting enzyme

ESR

erythrocyte sedimentation rate

ACJ

acromio-clavicular joint

ESWL

extracorporeal shock wave lithotripsy

ADEM

acute disseminated encephalomyelitis

ET

endo-tracheal

ADH

anti-diuretic hormone

EVAR

endovascular aneurysm repair

AIN

anterior interosseous nerve

FAST

focused assessment with sonography in trauma

AMT

abbreviated mental test

FDL

flexor pollicis longus

ANCA

anti-neutrophil cytoplasmic antibodies

FDP

flexor digitorum profundus

AP

anterior to posterior

FDS

flexor digitorum superficialis

ATLS

Advanced Trauma Life Support

FLAIR

fluid attenuation inversion recovery

AV

arteriovenous

FOOSH

falls onto an outstretched hand

AVN

avascular necrosis

G

gauge

AXR

abdominal X-ray

g/L

grams per litre

BTS

British Thoracic Society

G&S

group and save

CABG

coronary artery bypass graft

GCS

Glasgow coma scale

CBD

common bile duct

GI

gastrointestinal

CCAM

congenital cystic adenoid malformation

GTN

glyceryl trinitrate

cm

centimetre

HAS

human serum albumin

COPD

chronic obstructive pulmonary disease

HIDA

hepatobiliary iminodiacetic acid

CPAP

continuous positive airway pressure ventilation

HIP

heparin-induced thrombocytopaenia

CRP

C-reactive protein

HLA

human leukocyte antigen

CSF

cerebrospinal fluid

HPOA

hypertrophic pulmonary osteoarthropathy

CT

computer tomography

HRCT

high resolution CT

CTPA

computer tomography pulmonary angiogram

HRT

hormone replacement therapy

DDH

developmental dysplasia of the hip

HU

Hounsfield unit

DEXA

dual energy X-ray absorptiometry

DHS

dynamic hip screw

IRMER ionising radiation [medical exposure] regulations

DIPJ

distal interphalangeal joint

ITP

idiopathic thrombocytopenic purpura

DMSA

dimercaptosuccinic acid

ITU

intensive treatment unit

DTPA

diethylenetriaminepentaacetic acid

IU

international unit

DVT

deep venous thrombosis

IUCD

intrauterine contraceptive device

DWI

diffusion weighted image

IV

intra-venous

ECG

electrocardiogram

IVC

inferior vena cava

6 •

Abbreviations IVU

intravenous urogram

PET

positron emission tomography

JVP

jugular venous pressure

PFO

patent foramen ovale

kg

kilogram

PICC

peripherally inserted central catheter

KUB

kidneys, urethra, bladder

PIN

posterior interosseous nerve

LDH

lactate dehydrogenase

PIPJ

proximal interphalangeal joint

LIF

left iliac fossa

PR

per rectum

LLL

left lower lobe

RLL

right lower lobe

LUL

left upper lobe

RML

right middle lobe

m

metre

RUL

right upper lobe

MAG3

methyl-acetyl-gly-gly-gly

RUQ

right upper quadrant

MCPJ

metacarpophalangeal joint

MDP

methylene disphosphonate

SCIWORA spinal cord injury without radiological abnormality

MDT

multi-disciplinary team

SHO

senior house officer

MIRP

minimally invasive retroperitoneal pancreatic necrosectomy

SI

sacroiliac

SiADH

syndrome of inappropriate anti-diuretic hormone

SLE

systemic lupus erythematosus

mmol/L millimoles per litre

SMA

superior mesenteric artery

MRA

magnetic resonance angiography

SMV

superior mesenteric vein

MRCP

magnetic resonance cholangiopancreatogram

SP

spinous process

MRI

magnetic resonance imaging

STIR

short tau inversion recovery

MRSA

methicillin resistant Staphylococcus aureus

SUFE

slipped upper femoral epiphysis

mSv

milliSieverts

TB

tuberculosis

MTPJ

metatarsophalangeal joint

THR

total hip replacement

NAI

non-accidental injury

TNF

tumour necrosis factor

NG

naso-gastric

TNM

tumour, nodes, metastases

NSAID

non-steroidal anti-inflammatory drug

U&Es

urea and electrolytes

OA

osteoarthritis

USS

ultrasound scan

PA

posterior to anterior

VQ

ventilation/perfusion

PaCO2

partial pressure of carbon dioxide

VTE

venous thromboembolism

PaO2

partial pressure of oxygen

β-HCG

beta human chorionic gonadotrophin

PE

pulmonary embolus

PEA

pulseless electrical activity

PEG

percuntaneous endoscopic gastrostomy

mm

millimetre

mmHg

millimetres of mercury

• 7

Contributors Radiology Registrar, Edinburgh Royal Infirmary, Edinburgh, UK

Zeshan Qureshi

Academic Clinical Fellow, Great Ormond Street and Institute of Global Health, London, UK

Z.Qureshi

Mark Rodrigues

M.Rodrigues

Editors

Bijan Hedayati Chest X-rays

Radiology Consultant (Lewisham Hospital, London)

Chris Gee Orthopaedic X-rays

Orthopaedic Registrar, Trauma and Orthopaedics (Western Sussex Hospitals, Sussex)

Amanda Cheng Bonus X-rays

Radiology Registrar (Western General Hospital and Edinburgh Royal Infirmary, Edinburgh)

Kabir Varghese Bonus X-rays

Radiology Registrar (Chelsea and Westminster, London)

Reviewers

Brendan Kelly

University College Dublin

Chloe Thomson

University of Leicester

Marianna Christodoulou

University of Manchester

Madelaine Gimzewska

University of Edinburgh

Katherine Lattey

Brighton and Sussex Medical School

Jessica Spiteri Paris

University of Malta

8 •

C.Gee

Radiology Registrar (Edinburgh Royal Infirmary, Edinburgh)

K.Varghese

Mark Rodrigues Introduction Chest X-rays Abdominal X-rays CT MRI Ultrasound Nuclear Medicine Scans Fluroscopy

B.Hedayati

Radiology Registrar (Bristol Royal Infirmary, Bristol)

A.Cheng

Jonathan Rodrigues Chest X-rays Abdominal X-rays

J.Rodrigues

Authors

ConTENTS Introduction........................................................... 11

MRI Scans......................................................... 543

What are X-rays?........................................................................ 11

MRI Head....................................................................................544

How are X-rays used to produce images?......................... 12

MRI Spine....................................................................................549

The main densities on X-ray................................................... 12

MRCP............................................................................................553

Magnification.............................................................................. 12

MRI Small Bowel......................................................................554

The hazards of using X-rays................................................... 13

MRI Knee & Other Joints.......................................................555

Relevant legislation................................................................... 13 Pregnancy and X-rays............................................................... 14

Ultrasound Scan.............................................. 557

How to request radiology examinations........................... 14

Neck USS.....................................................................................558

When and how to discuss a patient with radiology...... 15

Chest USS...................................................................................558

Chest X-Rays* .....................................................17 Introduction................................................................................. 17 20 Clinical Cases......................................................................... 29

Abdominal X-Rays*......................................... 181 Introduction...............................................................................181 20 Clinical Cases.......................................................................189

Orthopaedic X-Rays*....................................... 335 Introduction...............................................................................335 Spine X-Ray Cases ...................................................................367 Shoulder X-Ray Cases ............................................................391 Elbow X-Ray Cases...................................................................399 Wrist X-Ray Cases ...................................................................407 Hip X-Ray Cases .......................................................................429 Knee X-Ray Cases ....................................................................473 Tibia/Fibular X-Ray Cases . ...................................................497 Ankle X-Ray Cases . .................................................................513

CT Scans............................................................ 521 CT Head.......................................................................................525 CT Cervical Spine......................................................................530 CT in Orthopaedics..................................................................530 CT Chest......................................................................................531 CT Abdomen and Pelvis.........................................................535

Abdominal USS.........................................................................560 Pelvic USS...................................................................................562 FAST Scanning...........................................................................563 Vascular USS..............................................................................563 Musculoskeletal USS..............................................................564 Ultrasound Guided Procedures...........................................564

Nuclear Medicine Scans................................. 565 VQ scan........................................................................................566 Myocardial perfusion scan...................................................567 Genitourinary scan..................................................................567 Bone imaging............................................................................568 PET/CT..........................................................................................569

Fluoroscopy...................................................... 571 Contrast Swallow.....................................................................572 Barium Follow Through.........................................................576 Contrast Enema........................................................................576 Tubogram...................................................................................576

Bonus Cases*.................................................... 579 Bonus Chest X-Rays.................................................................579 Advanced Chest X-Rays.........................................................603 Bonus Abdominal X-Rays......................................................613 Advanced Abdominal X-Rays...............................................625 Bonus Orthopaedic X-Rays...................................................637 Advanced Orthopaedic X-Rays............................................671

* For Chest X-Rays, Abdominal X-Rays, Orthopaedic X-Rays and the Bonus Cases, all cases have been labelled ‘Case X’ to mimic real life clinical situations/assessment. For reference, the X-rays are also all listed by diagnosis and clinical signs on p695.

• 9

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Chest X-Rays - Introduction • 17

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Figure 6: These three X-rays show how difficult it can be to diagnose free subdiaphragmatic gas. Image A: Is a normal chest X-ray with gas in the stomach. We know the gas is within the stomach, as it is under the left hemidiaphragm, and the soft tissue rim overlying the gas is a few millimetres thick, as it consists of the stomach wall and adjacent diaphragm. hi i s eshi resh u ursoft Q Qurea large pneumoperionteum. In this case, Q Image B: Contrast that appearance to the centre X-ray, which shows the n n n a a a h h h f Zes tissue rim between the lung and abdomen f Zeiss very thin, as it solely represents thehdiaphragm. f Zes o o o t t t h h g g g ri ri pyri the right hemidiaphragm Copy Image C: Is a mimic of free subdiaphragmatic Copy gas. In this case, inspection of the area Cobelow reveals bowel markings. These appearances are due to interposition of a loop of bowel between the liver and right hemidiaphragm, and is known as Chilaiditi’s sign.

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C IN Summary – This chest X-ray shows a large rightCpneumothorax. There is no evidence of associated tension. hi shi this X-ray, suggesting ureshi ThereanisQno uresunderlying cause discernible ureon Q n nQ esh esha esha Z Z Z f f f o o o ht spontaneous pneumothorax. that this is a oprimary ight ight pyrig opyr opyr

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30 • Chest X Rays - Case 1

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PRESENT hi ures Q n YOUR ha f Zes o t h rig Copy FINDINGS... •• This is a PA chest X-ray of an adult.

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1. Which of the following are risk factors for a primary spontaneous pneumothorax?

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precise cause of these pneumothoraces is uncertain. There is some evidence that they are due to the rupture of small sub-pleural blebs (small, air-filled eshi pleura). Patients are rvisceral u cysts just under the Q an han typically slim young men. Other risk factors f Zesh Zestall, f o o t t h righfor primary spontaneous pneumothoraces riginclude Copy smoking and family history. Copy B) Smoking – Correct. Smoking is a recognised risk factor for primary spontaneous pneumothoraces.

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ha f Zes o of Ze disorders t h htsystemic g g Most pneumothoraces are secondary, and a variety of lung and i i r r y y Cop Spontaneous primary pneumothoraces Cop typically occur in young, can be implicated. slim, tall male smokers.

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u Qu Accurate clinicalhassessment of the patient is a key part of n Qu practice, and is commonly assessed an Q haclinical han in s s s e e e Z Z Z of It is important to know the different of combinations of clinical findings associated of with a examinations. right right right y y y p p p o o o C pneumothorax, a pleural effusion, lobar C collapse, and pneumonia. Briefly, the chest C examination should follow the pattern of inspection, palpation, percussion, and auscultation. Look for symmetrical shape and chest expansion. Assess the position of the mediastinum (trachea and apex beat) and assess for chest expansion. Percuss and hiauscultate both lungs. Assessing routine shiobservations, such as oxygen shi ures Qure Qure saturations and hblood n n an Qpressure, is also important. a a h h f Zes

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Co Central trachea. Dull percussion and reduced Coair Co percussion and reduced A) D) Central trachea. Hyperresonant entry on the right side of the chest – Incorrect. This air entry on the left side of the chest – Incorrect. These combination of findings is suggestive of a right sided findings would be in keeping with a simple left sided pleural effusion. With a pleural h effusion you would pneumothorax. hi hi s i reexpansion, u ures ures expect to find reduced chest a very dull/ Q Qdeviated Q n n n a a a E) Trachea to the left. Hyperresonant h h h stony dull o percussion f Zes note, absent or reduced breathht of Zespercussion and reduced air entry onhthe f Zesside of oright t t h g g g i i i r r sounds, sounds pyr reduced vocal resonance, and no added the chest. Hypotensive, tachycardic Coon Copy Copy – Incorrect. This the side of the effusion. With large effusions there combination of clinical findings is worrying and should may be a shift of the mediastinum to the contralateral raise your suspicions of a tension pneumothorax. side. In addition to the usual findings associated with a i hi shand shi e e r r B) Central trachea. Dull percussion bronchial breathing simple pneumothorax, there is mediastinal shift to Qures u u Q Q n n n a a a h contralateral side and evidence of significantly sh right side of the chest – Incorrect. f Zesthe and cracklesf on ethe esh t o Z of clinical findings is in keeping with to t of Z cyanosis, h h h g g g i i i This combination impaired ventilation and circulation (hypoxia, r r r y opy opy Coapright sided pneumonia. Typically, there is C reduced hypotension, tachycardia,C reduced consciousness level). chest expansion, dull percussion, bronchial breathing Tension pneumothoraces are a medical emergency and with added crackles, and increased vocal resonance in need urgent treatment (there is a case covering tension pneumonia. pneumothorax i i more detail later in the chapter). sh shin shi Qure

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cardiac diseases, and systemic problems. It is important to be able to formulate an appropriate differential diagnosis from the history and examination to guide suitable investigations and initial management. Establishing the time frame of the onset of breathlessness is very helpful in formulating your differential hi hi eshi refers to breathlessness that develops diagnosis. Sudden uronset uresover seconds and includes pulmonary ures Q Q Q n n n a ha ha embolus, inhaled Zeshpneumonia, f Zespneumothorax, anaphylaxis, and f Zesforeign bodies. Dyspnoea associated f with o o o t t t h h h rig rig rig of asthma or COPD tendoto opyexacerbations Copy heart failure, metabolic acidosis,Cand C pydevelop more slowly, over minutes to hours. Other conditions, such as interstitial lung disease and anaemia, have a much more chronic onset.

i onset ofhbreathlessness is usually more subacute, eshi A) Pulmonary embolus r–eCorrect. hi Pulmonary embolus can r u s ures over hours rather than seconds. Other Qoccurring n Qbreathlessness. n n Qufeatures cause verysh sudden Other symptoms a a a h h s s e Ze f Ze sputum, a raised include a productive cough with t of Zpleuritic chest pain and dizziness. Clinical hinclude ht of ht ogreen g g g i i i r r r y y y p abnormal temperature, and appropriate clinical findings. examination of the chest often reveals Cop Cono Cop signs. There may be a swollen limb, suggesting an D) Heart failure – Incorrect. Heart failure is a common underlying deep venous thrombosis. The patient may cause of breathlessness, but usually its onset is more have had recent surgery or have other risk factors insidious. i h hi s shi Patients may also complain of orthopnoea present, such as being ureparoxysmal ubereas Qurepost-partum, or having an Qand Q nocturnal dyspnoea. There may n n n a a a underlying shmalignancy or a genetic prothromboticf Zesh Zesh examination previous history of cardiac disease. of Ze o of Clinical t t t h h h tendency. g g g i i i r r pyr jugular venous pulse and may demonstrate an Copy Copy Coelevated B) Pneumothorax – Correct. A pneumothorax often results evidence of pleural effusions. in a sudden onset of breathlessness and pleuritic chest E) Anaphylaxis – Correct. Anaphylaxis is a systemic and life pain. There may be a history of an underlying lung threatening i hi condition (see question shi allergic reaction. It usually occurs shortly res1hfor examples of conditions recontact u u ures after with the allergen (previous sensitisation Q Q Q n n n a a a which predispose to secondary pneumothoraces) or esh esh esh to the allergen is required). Symptoms t of Z The constellation of clinical findings t of Z t of Z develop rapidly trauma. associated h h h g g g i i i r r r over minutes and include opy 2. Copy with a pneumothorax is discussed inCquestion Copy facial swelling, wheezing, breathlessness, urticaria, and, potentially, shock. C) Pneumonia – Incorrect. Pneumonia and other infections Urgent management using the ABCDE approach and are common causes of breathlessness; however, the administration of intramuscular adrenaline is required. t of yrigh

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Use the history and examination findings to help formulate a differential diagnosis to guide appropriate investigations and management. But remember that some patients, such as those presenting with anaphylaxis, may need urgent treatment i hi hi resh and examination. In these patients, before ures you will be able to complete anfull uhistory ures Q Q Q n n sha use the ABCDE approach to assessment sha and management. sha of Ze of Ze of Ze

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i line imaging modality for suspected i The chest X-ray is rthe pneumothoraces. Imaging reshi hfirst hsimple u es ures Q Q Qu n n has a keysh role in confirming the diagnosis of a pneumothorax, assessing its size, and excluding a ha hanother s s e e e Z Z Z t of t of t of diagnoses. There are various types of chest X-ray, which are below. righdifferential righdifferent righdiscussed

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be a clearly discernible lung edge as seen in an erect accurate and reliable assessment for a pneumothorax. X-ray. Supine chest X-rays are thus not performed A well inspired PA X-ray allows a better assessment of routinely. Instead they are reserved for trauma patients the lungs and cardiac contours compared to an AP or i i shi on a chest X-ray is shsafely e who cannot moved. Features suggestive ofQ a uresh r expiratory X-ray. The key finding u urebe Q Q n n n a ha ha pneumothorax on a supine chest X-ray include displacement Zesha sharply f Zofesthe lung edge (visceral pleura) awayht of Zesoutlined dome of the hemidiaphragm, fdeep o o t t h h a lateral from ig ig pyrigthe chest wall, with no lung markingsCvisible opyr opyr Coperipheral costophrenic sulcus, and aChyperlucent upper quadrant to this. of the abdomen (due to the lucent gas within the B) PA and lateral chest X-rays – Incorrect. The lateral chest pleural space overlying the upper abdomen). X-ray can provide helpful information if a pneumothorax i CT is the most sensitive and E) CT – Incorrect. hi shi shWhilst is not visible on the PA X-ray. However, it is not part of ure urefor ures Q Q Q n n n specific test a pneumothorax, its high radiation dose routine practice. ha ha ha f Zes f Zes(approximately equivalent to 400 chest f Zes and the X-rays!) o o o t t t h h h rig rig C) o Expiratory X-rays pyrig chest X-ray – Incorrect. Expiratory satisfactory accuracy of standard C may Copy Copy PA chest X-rays mean make a subtle pneumothorax more readily visible. CT is not the first line imaging modality for suspected However, there are not performed in the first instance. pneumothoraces; instead, it is reserved for patients in Additionally, they can limit the assessment of the lungs whom there is continued suspicion of a pneumothorax and cardiac shadow. hi hi hi but no evidence s e r ures on a chest X-ray, or for assessing n Qures Qu Q n n a a a trauma patients. CT also provides the most reliable h h h f Zes f Zesassessment of pneumothorax size. ht of Zes o o t t h h g g g i i i

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shi shi shi 2. Pneumothoraces can be difficult to see on chest Qure QureX-rays. Inverting the image can an Qure n n a a Also, esh make the lung edge more obvious. esh your eyes tend to see horizontaloflines esh t of Z t of Z t Z h h h g g g i i i r r r better than vertical ones; it is thus sometimes useful to rotateothe chest X-ray by Copy Copy C py 90 degrees so that the lateral chest wall (and therefore the lung edge) is horizontal. 3. Always check the apices on an erect chest X-ray and around the lung bases on a i supinerechest shi X-ray for evidence of a pneumothorax. resh

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symptoms, to identify those patients with enlarging pneumothoraces. All patients with a pneumothorax should avoid air travel until hi complete resolution. ures Diving shouldnbeQpermanently avoided in most a have had a pneumothorax. h han s e patients who f Zes of Z

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Abdominal X-Rays

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Case 1...................189

Case 6...................225

Case 11.................263

Case 16.................299

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Case hi 7...................233

Case 12.................269 hi

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Abdominal X-Rays - Introduction • 181

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i i resh resh u u Q Q n to A&E with acute left sided loin pain, n A 38 year old manspresents haurinary e ha f Zhaematuria. f Zes X-ray is o o frequency and As part of his work up, an abdominal t t h h ig rig opyr Cperformed. Copy

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CASE 11

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Abdominal X-Rays


Abdominal X-Rays - Case 11 • 263

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264 • Abdominal X-Rays - Case 11

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IN Summary – This abdominal X-ray shows multiple small left sided renal calculi.

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C) Ultrasound – Incorrect. Ultrasound can occasionally identify renal calculi. However, this modality is not as sensitive as CT. Additionally, it is usually impossible to image the entire hi ureter due to overlying bowel hi ures ultrasound has a low sensitivity forn Qures Q gas. Therefore, n ha sha Zesdetecting f Zisegood urinary tract calculi. Ultrasound at o t h rig which may be y p identifying urinary tract obstruction o C caused by calculi. Furthermore, it can identify other causes of loin pain and haematuria such as renal tumours, as well as gynaecological pathology, such as hi hi ovarian cysts, ureswhich can present in a similar manner. ures

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helping to identify or exclude other differential diagnoses, such as appendicitis and diverticulitis (although the accuracy for this is limited by the low i dose nature of the and the lack of resh uexamination Q n acontrast). As discussed in Question 3, eshan h intravenous s e of Z t of Z ighnot righatsmall proportion of urinary tract calculi rare y y p p o o C C be secondary visible on CT; however, there may still signs of urinary tract calculi, such as perinephric and peri-ureteral stranding.

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The management of urinary tract calculi depends on the size and site of the stone and whether there is evidence of associated infection.

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h sh A) Urgent ureteroscopy spontaneously, particularly if they are located resh ures udistally. Qureand stone retrieval – Incorrect. Q Q n n n a a a Ureteroscopy Patients can therefore be treated conservatively sh is an invasive procedure reserved for sh sh of Zewith larger stones, persistent painigorht of Ze of Ze obstructed t t h h patients if there is no evidence of an infected, g g i i r r yr Copy those who fail to respond to conservative Copy therapy. Copabove). collecting system (see The mainstay of A ureteroscope is inserted via the urethra, through the treatment is analgesia (NSAIDs such as diclofenac bladder and into the appropriate ureter. Most ureteric are used as 1st line), anti-emetics and IV fluids if calculi are accessible. However, results are best for dehydrated. i Medications such as tamsulosin (an ealpha hi distal ureters. hi sthe shor e e r r those calculi located in blocker) nifedipine (a calcium channel blocker) u u ur s Q Q Q n n n a a a shthe stone. If can be used to facilitate the passage esh esh Zeof B) Urgent (ESWL) ofsuch t of Zextracorporeal shock wave lithotripsy t of Zt of h h h g g g visible on X-rays, the progress stones can be i i i r r r ESWL is another treatment modality reserved py opy oX-ray Copy Incorrect. C C monitored by serial KUBs. If the stone fails to for patients who fail conservative management or have pass after 4-6 weeks, the pain becomes intolerable, large stones. An external energy source causes shock or if the patient develops an infected, obstructed waves which are targeted towards the stone. The aim is collecting is i i system, an alternative treatment option to fragment stones toeallow hi them to pass through the r scan resh (see above). resh u u u required Q Q Q ureters. Theha fragments cause renal colic and ESWL n an han Zeins large and hard stones. Zesh ffail f Zes E) Percutaneous nephrolithotomy may –f Incorrect. o o o t t t h h h rig rig is used to fragment Percutaneous nephrolithotomy pyrig Copy C) Urgent percutaneous nephrostomyC–oIncorrect. Copy large renal calculi. It is usually reserved for large Urgent percutaneous nephrostomy is needed in or complex stones or patients in which ESWL and patients with an obstructed kidney and super-added ureteroscopy have failed. infection. It is usually performed under sedation i reduce the risk of h hi hi s with antibiotic coverage to e ur ures ures Q Q Q n n n a a ha septicaemia. Zesh Once the collecting system has t of Zesh f suitably f Zes o o t t been drained and the infection treated, h h h rig rig yrig Copy the access gained via the nephrostomy Copcan Copy be used for nephrolithotomy (procedure to remove the stone) if required. An alternative approach to draining an infected, obstructed collecting • Renahl ca hi shai retrograde fashion) s i lculi are common and can cause a e r system is from below (in u urvaerie ures Q Q Q n n n ty of symptoms, however, ha sha withfan placed ureteric stent esnehsaare mo Zeendoscopically f Zes fstZsto o o o t t t as ym h h h pt om atic. ig rig extending from the bladder, up the ureter rand rig Copy into the renal pelvis. Copy Copy • 75-90% of stones ar e visible on X-rays, whils t D) Conservative approach (supportive treatment almost all are visible on CT . with analgesia and anti-emetics and follow • Non-contrast low do se CT KUB is the imaging up with X-ray KUBs (ifsthe hi stone is visible on hi hi e r redaslit u has passed) - Correct. umo ures Q Q Q y of X-ray) untilhthe stone ch oic n n n e, wi th a a X-ray KUBs rese ersvehdafor Zes (<5 mm) stones in the ureter pass t of Zesh Most follow-up of radio t of small t of Z

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hi hi hi ures ures ures Q Q Q n n n a chapter is aimed at providing a systematic ha framework for approaching orthopaedic ha X-rays. This introduction shthe f Zeto f Zes f Zes o o o t t t h h h g Further and examples of the specific X-rays igfindings discussed below are coveredpmore ridetails rig extensively in the opyr Copy cases later in the chapter and theCbonus Co y example X-ray chapter.

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Orthopaedic X-Rays - Introduction • 335

Orthopaedic X-Rays

Knee Case 3..................489 i Hip Case 4.....................451 Wrist Case 2.................415 Spine Case 2.................375 shi shi sh e e r r u u Q Wrist Case 3.................423 Q5.....................457 Qure n n n a a a Tibia/Fibular Case 1....497 Hip Case Spine Case 3.................383 h h h es Zes Zes t of Z ht of ht of h g g g i i i r r r y y Hip Case 6.....................465CopyTibia/Fibular Case 2....505 Hip Case 1.....................429 Shoulder Case 1...........391 Cop Cop Ankle Case 1.................513 Knee Case 1.................. 473 Hip Case 2.....................435 Elbow Case 1................399

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The Gartland classification system is useful for categorising the severity of supracondylar fractures, and the X-ray features are summarised in Table 1. It relates to ‘extension type’ supracondylar injury, where the hi hi hi s s e e r r u u ures distal fragment is displaced 5% of supracondylar fractures, and Q posteriorly. Flexion type injuries comprise Q Q n n n a a a sh sh are classifiedofseparately. Zesh of Ze of Ze

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Orthopaedic X-Rays - Introduction • 353

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Orthopaedic X-Rays - Hip Case 5 • 457

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Intracapsular fractures often need surgery to have the femoral head replaced, but in certain cases this is not necessary, and in some cases conservative management might hi be considered. The Garden hi shi sintracapsular e e r r u u ures Classification is used to categorise the degree of displacement of an femoral neck fracture, Q Q Q n n n a sha esha Zesh and as such, of Zesupply to the femoral head has been t of Zalso defines how likely it is that the tblood t ofdisrupted.

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The subtle differences between 1/2 (undisplaced) and 3/4 (displaced) are best appreciated by looking at the trabeculation (lines seen within bone) in the different fractures. In Garden 1 fractures, the shi shi shi trabeculation lines in the to uthe Qurehead point vertically in comparison Q re normal. In Garden 2 fractures, an Qure n n a a h h they are all in sh In Garden 3 fractures, the trabeculation f Zeline. f Zes lines in the head are more horizontal f Zesthan o o o t t t h h h g g g normal. has rdisplaced but returned to its normal alignment and so the i ri pyri In Garden 4 fractures, the head Cotrabeculations Copy Copy are all in line. A) 1 – Incorrect. In Garden 1 fractures, there is an i at the fracture incomplete fracture withuimpaction resh Q n a site with the femoral sh head tilted into a valgus (more of Ze Therefore, the capsule is likely toight t upright) position. h g i pyr intact and the risk of AVN (avascular pyr Coremain Conecrosis) is reduced. Surgical fixation using screws prevents displacement of the fracture and is the best option for most patients. Keeping the patient’s own femoral hi ures head reduces the risknofQdislocation or need for a revision surgery. ZesIfhthe patient has little pain, this t f o t h fracture yrigh pyrig could potentially be treated without opsurgery Coand C with full weight bearing but follow-up X-rays are needed to ensure the fracture does not displace.

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2. “1, 2 give hiit a screw, 3, 4, Austin Moore” is anreaid himemoire for the treatment of hi ures ucansbe used in undisplaced fractures ures Q Q Q intracapsular fractures. Cannulated screws n n n ha ha ha f Zes (Garden 1 or 2), whereas anhtarthroplasty f Zes f Zes o o o is usually required for displaced t t h h rig rig rig opy4). Copy Copofy arthroplasty. fracture (Garden 3Cand Austin Moore is an outdated type

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axial, coronal and sagittal planes of the body A CT scanner essentially consists of an X-ray tube (figure 2). The standard CT image is the axial which spins around the CT table (figure 1). The (transverse) image hi and on this the left side of thereshi shi ure ures u X-ray tube is housedain the gantry, which is the Q Q image corresponds to the right side of thehbody n n an Q h ha s s s e e e Z Z Z donut shaped f part of the scanner. The patient lies of (for example in, figure 16, the iheart, ofwhich is a left ght o ritable right r ght y y y p p p on the (usually on his/her back). The couch o o o sided structure, is on the C C C right side of the image). travels through the centre of the gantry as the X-ray At first glance, this may appear counterintuitive. tube spins around the patient, taking hundreds of However, considering how we look at a frontal chest X-rays from different angles. The data are processed X-ray helps us why the CT images are shi i i shunderstand resh rethis by a computer to produce Quimages. Quin Qure displayed way. n n a a h h han

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Fluoroscopy • 571

CASE INDEX Orthopaedic X-Rays

Chest X-Rays

Abdominal X-Rays

Lumbar degenerative changes (case about cauda equina syndrome)............367 Anterior wedge compression fracture............375 Cervical spine fracture.........................................383 Anterior shoulder dislocation............................391 Supracondylar fracture........................................399 Salter Harris fracture............................................407 Scaphoid fracture..................................................415 Colles’ fracture........................................................423 Hip joint osteoarthritis........................................429 Perthes’ disease......................................................435 Pelvic fracture.........................................................443 Slipped upper femoral epiphysis......................451 Intracapsular fracture of the neck of femur....................................................................457 Extracapsular fracture of the neck of femur....................................................................465 Paediatric aggressive bone lesion....................473 Lipohaemarthrosis/Tibial plateau fracture/Fibular fracture.....................................481 Knee joint osteoarthritis.....................................489 Tibial and fibular shaft fractures......................497 Osteomyelitis/Periosteal reaction...................505 Bimalleolar fracture/Dislocation of the ankle joint.........................................................513

Primary spontaneous pneumothorax.............. 29 Tension pneumothorax......................................... 37 Normal CXR................................................................ 45 Collapsed right upper lobe................................... 53 Pleural effusion........................................................ 61 Hilar mass.................................................................. 69 Apical lung mass with rib destruction............. 77 Multiple pulmonary metastases........................ 85 Sarcoidosis................................................................. 91 Ingested foreign body............................................ 97 Left lower lobe consolidation............................105 Possible pulmonary embolism..........................113 Congestive cardiac failure...................................121 Free subdiaphragmatic gas................................129 Mediastinal mass..................................................137 Lung abscess and pneumonia...........................145 Left lower lobe collapse and humeral fracture......................................................................153 Incorrectly placed NG tube.................................161 Pericardial effusion...............................................169 Calcified pleural plaques.....................................175

Normal AXR.............................................................189 Small bowel obstruction.....................................195 Large bowel obstruction.....................................203 Sigmoid volvulus....................................................211 Pneumoperitoneum.............................................217 Thumbprinting.......................................................225 Pneumatosis intestinalis and pneumoperitoneum.............................................233 Constipation............................................................241 Splenomegaly.........................................................247 Gallstones................................................................255 Renal calculi.............................................................263 Chronic pancreatitis..............................................269 Uterine fibroid........................................................277 Splenic artery aneurysm.....................................285 Abdominal aortic aneurysm..............................293 Sclerotic bone metastases..................................299 Ankylosing spondylitis.........................................305 Ingested foreign bodies.......................................313 Duodenal atresia/Double-bubble sign...........321 Pneumatosis intestinalis.....................................327

Bonus Chest X-Rays


Apical pneumothorax..........................................579 Normal CXR..............................................................581 Free subdiaphragmatic gas................................583 Pleural effusion......................................................585 Misplaced NG tube...............................................587 Left lower lobe collapse.......................................589 Pericardial effusion...............................................591 Misplaced NG tube and dilated small bowel loops under the diaphragm........................................................593 Left lower lobe consolidation............................595 Right middle lobe consolidation.......................597 Right upper lobe collapse...................................599 Right upper lobe consolidation/Basal atelectasis................................................................601 Right lower lobe consolidation.........................603 Free subdiaphragmatic gas................................605 Lingula consolidation...........................................607 Left upper lobe collapse.......................................609 Pneumomediastinum..........................................611

Gallstones................................................................613 Migrated IUCD........................................................615 Large bowel obstruction.....................................617 Normal AXR.............................................................619 Small bowel obstruction/ Pneumoperitoneum.............................................621 Thumbprinting/Toxic dilatation of the transverse colon.............................................623 Bilateral nephrostomies......................................625 Thumbprinting.......................................................627 Necrotising enterocolitis.....................................629 Paget’s disease........................................................631 Splenomegaly.........................................................633 Intra-abdominal surgical swab/ Small bowel obstruction.....................................635

Bonus Orthopaedic X-Rays 5th metacarpal fracture......................................637 Normal foot X-ray..................................................639 Healed fractures (rib/clavicle/coracoid)/ Pneumothorax........................................................641 Normal elbow X-ray..............................................643 Slipped upper femoral epiphysis......................645 Lisfranc injury..........................................................647 Distal radial (with dorsal angulation) fracture......................................................................649 Weber C ankle fracture........................................651 5th metatarsal fracture.......................................653 Lipohaemarthosis..................................................655 Anterior shoulder dislocation............................657 Comminuted mid shaft femoral fracture......659 Comminuted humeral surgical neck fracture......................................................................661 Monteggia fracture...............................................663 Posterior shoulder dislocation..........................665 Rheumatoid arthritis............................................667 Distal radial (minimally displaced) fracture......................................................................669 Pathological shaft of femur fracture...............671 Acromio-clavicular joint disruption................673 5th metatarsal fracture.......................................675 Enchondroma (lytic bone lesion)......................677 Distal radial (buckle) fracture............................679 Intracapsular fracture of the femoral neck.... 681 Triquetral fracture.................................................683 Weber A ankle fracture........................................685 Radial head fracture.............................................687 Trimalleolar fracture.............................................689 Extracapsular (subtrochanteric) fracture of the femoral neck...............................................691 Supracondylar fracture........................................693

Case Index • 695

INDEX Page numbers followed by f indicate figures. AAA, see Abdominal aortic aneurysm ABCDD mnemonic, chest X-ray assessment airway, 19–20 breathing, 20 cardiac and mediastinum, 20, 21f delicates, 21 diaphragm, 20–21, 22f ABCDE assessment, pelvic fracture, 446 ABCDEF mnemonic, pulmonary oedema chest X-ray assessment, 25 Abdominal aorta, abdominal X-ray assessment, 185f Abdominal aortic aneurysm (AAA) abdominal X-ray, 293f, 294f causes, 296 clinical findings, 296 computed tomography angiography, . 542f diameter, 297 management, 297 rupture imaging, 298 Abdominal computed tomography colonoscopy, 539f haematuria, 541f haemorrhage, 537f indications, 535 renal tract calculi, 540f sepsis, 536f trauma, 535f tumour staging, 538f Abdominal ultrasound, 559f, 560f Abdominal X-ray adequacy, 181 case examples abdominal aortic aneurysm, 293f, . 294f, 295–298 ankylosing spondylitis, 305f, 306f, 307–312 bone metastasis, 299f, 300f, 301–304 bowel ischaemia, 233f, 234f, 235–240, 627f, 628f colitis, 225f, 226f, 227–232 constipation, 241f, 242f, 243–246 duodenal atresia, 321f, 322f, 323–326 foreign body ingestion, 313f, 314f, 315–320 gallstones, 255f, 256f, 257–262, 613f, 614f inflammatory bowel disease, 623f, 624f intrauterine contraceptive device migration, 615f, 616f

696 • • Index

large bowel obstruction, 203f, 204f, 205–210, 617f, 618f necrotising enterocolitis, 327f, 328f, 331–332, 629f, 630f nephrostomy complications, 625f, 626f Paget’s disease, 631f, 632f pancreatitis, 269f, 270f, 271–276 pneumoperitoneum, 217f, 218f, 219–224, 234f, 621f, 622f renal calculi, 263f, 264f, 265–268 sigmoid colon volvulus, 211f, 212f, 213–216 small bowel obstruction, 195f, 196f, 197–202, 635f, 636f splenic artery aneurysm, 285f, 286f, 287–292 splenomegaly, 247f, 248f, 249–254, 633f, 634f uterine fibroid, 277f, 278f, 279–284 checklist, 186 dose, 192–193, 523 indications, 192 normal findings, 189f, 190f, 191–194, 619f, 620f projection, 181 small/large bowel differences, 193 systematic review, 181–185 Abscess, see Lung abscess; Pancreatic abscess Achilles tendon, rupture, 517 Acute pancreatitis causes, 273 complications, 276 management, 275 pleural effusion induction, 66 ultrasound for gallstones, 274 Adhesions, small bowel obstruction, 200 Advance Trauma Life Support (ATLS), 446–447, 478 AIN, see Anterior interosseous nerve Alcoholism acute pancreatitis, 273 chronic pancreatitis, 272 lung abscess risk factor, 149 Allergy, contrast agents, 523 AMPLE assessment, 447 Anal fissure, constipation, 245 Anaphylaxis, breathlessness, 34 Anatomical snuff box, pain and scaphoid fracture, 418 Ankle medial clear space, 518 orthopaedic X-ray assessment, 362f, 363f fracture with talar shift, 651f, 652f malleolar fracture case examples, 513f, 514f, 515–520, 685f, 686f, 689f, 690f

Ottawa Ankle Rules, 516 Weber classification of lateral malleolus fractures, 363, 517 talar shift, 518–519 triplane fracture, 414 Ankle jerk, spinal injury assessment, 380 Ankylosing spondylitis abdominal X-ray, 305f, 306f, 309 clinical presentation, 308 extra-spinal joint involvement, 310 hepatic fibrosis, 311 treatment, 311–312 Anterior interosseous nerve (AIN) injury following supracondylar fracture, 404 testing, 427 Aortic dissection, chest computed tomography, 534f Appendicitis, foreign body ingestion, 430 Asbestos exposure, case example with chest X-ray of pleural plaques, 175f, 176f, 177–180 Ascites, portal hypertension, 290 Aspirin, pericardial effusion management, 174 Atherosclerosis, abdominal aortic aneurysm, 296 ATLS, see Advance Trauma Life Support Avascular necrosis hip, see Perthes’ disease scaphoid, 419 Axillary nerve, injury in shoulder dislocation, 396 Babinski sign, 304 Back pain management, 374 red flags, 308 Bamboo spine, ankylosing spondylitis, 309 Barium follow-through, 576 Barium swallow constipation induction, 246 principles, 572 small bowel obstruction diagnosis, 202 views, 573f, 574f, 575f Bat’s wing consolidation, 122f Bell classification, necrotising enterocolitis, 332 Bennett’s fracture, 364 Biliary colic, gallstone presentation, 259 Blood culture, necrotising enterocolitis, 331 Blood gas, venous central line, 167–168 Bone metastasis abdominal X-ray, 299f, 300f causes, 302 clinical findings, 302 spinal cord compression management, 304

INDEX Bone scan principles, 565, 568f, 569 prostate cancer staging, 302–303 radiation dose, 566 Bony Bankart lesion, 397 Bowel ischaemia abdominal X-ray, 233f, 234f, 235–240 acute versus chronic, 240 case examples with abdominal X-ray, 233f, 234f, 235–240, 627f, 628f computed tomography, 237, 239 management of acute disease, 237 pneumatosis intestinalis, 236, 238 Bowel obstruction abdominal X-ray assessment, 182, 183f case examples with abdominal X-rays large bowel obstruction, 203f, 204f, 205–210, 617f, 618f small bowel obstruction, 195f, 196f, 197–202, 621f, 622f, 635f, 636f central loops in small bowel obstruction, 198 foreign body ingestion, 320 pseudo-obstruction versus mechanical large bowel obstruction, 206 small/large bowel differences on X-ray, 193 stenting of large bowel Breast cancer lobar lung collapse, 156 sclerotic bone metastasis, 302 Breathlessness, differential diagnosis, 34 Bronchiectasis, pneumonia complication, 111–112 Bronchoscopy, foreign body retrieval, 104 Burst fracture, 364

placement verification, 167–168 Chance fracture, 364, 379 Chest computed tomography, see also Computed tomography pulmonary angiography aortic dissection, 534f indications, 531 lobar lung collapse, 532 lung parenchyma assessment, 532f pulmonary nodule, 531f trauma, 533f Chest drain Seldinger technique, 68 tension pneumothorax, 44 Chest ultrasound, 558, 559f Chest X-ray abnormality assessment, 19 calcification causes, 180 case examples asbestos exposure and pleural plaques, 175f, 176f, 177–180 foreign body ingestion, 97f, 98f, 99–104 lobar collapse right upper lobe collapse, 53, 54f, 55–60, 599f, 600f left lower lobe collapse, 153f, 154f, 155–160, 589f, 590f lung abscess, 145f, 146f, 147–152 lung cancer hilar mass, 69f, 70f, 71–76 metastasis sites, 74–75 Pancoast tumour, 77f, 78f, 79–84 pulmonary metastases, 85f, 86f, 87–90 mediastinal mass, 137f, 138f, 139–141 normal findings, 46f, 47–52 Caecum, volvulus, 213–214, 216 pericardial effusion, 169f, 170f, CAP, see Community acquired pneumonia 591f, 592f Cardiothoracic ratio pleural effusion, 61f, 62f, 63–68, congestive cardiac failure, 125 585f, 586f measurement, 50–51 pneumomediastinum, 611f, 612f Carotid artery, Doppler ultrasound, 558, pneumonia, 105f, 106f, 107–112, 559f 595f, 596f, 597f, 598f, 601f, 602f, Carpal tunnel, anatomy, 422 603f, 604f, 607f, 608f Cauda equina syndrome pneumoperitoneum, 129f, 130f, clinical features, 370 131–136, 583f, 584f decompression surgery, 373 pneumothorax lumbar spine X-ray, 367f, 368f primary spontaneous, 29f, 30f, magnetic resonance imaging, 372, 31–36 550f small left apical pneumothorax, physical examination, 371 579f, 580f Cavitating tumour, lung, 148 tension pneumothorax, 37f, 38f, Central cord syndrome, 382 39–44 Central line pulmonary embolism, 113f, 114f, chest X-ray, 22f 115–120, 581f, 582f insertion, 166–167

pulmonary oedema, 121f, 122f, 123–128 sarcoidosis of lung, 91f, 92f, 93–96 tube and line displacement, 161f, 162f, 163–168, 587f, 588f, 593f, 594f checklist, 28 consolidation causes, 108, 117, 122f, 162f dose, 48–49 indications, 48 inspiration during, 18–19 lines and tubes, 22f lung collapse, see Lobar lung collapse lymphadenopathy, 94 patient details, 18 penetration assessment, 19 pleural effusion, 25f pneumonia, 23, 24f, 25 pneumothorax, 25f projection, 17f, 18 pulmonary oedema, 25f review ABCDD mnemonic airway, 19–20 breathing, 20 cardiac and mediastinum, 20, 21f delicates, 21 diaphragm, 20–21, 22f summarisation, 23 rotation, 18f Cholecystitis, gallstone presentation, 259 Chronic myeloid leukaemia, splenomegaly, 252 Chronic obstructive pulmonary disease (COPD), 20, 603f, 604f Chronic pancreatitis, abdominal X-ray, 269f, 270f Clavicle, see Shoulder Clips, see Sterilisation clips Cocksackie virus, pericardial effusion induction, 172 Coffee bean sign, sigmoid colon volvulus, 215 Colchicine, pericardial effusion management, 174 Colitis case example with abdominal X-ray, 225f, 226f, 227–232 causes, 228 ulcerative colitis, see Inflammatory bowel disease Colles’ fracture, 364, 423f, 424f, 425–428 Colon cancer colonoscopy, 209 large bowel obstruction, 207 lobar lung collapse, 156 Colon, see Large bowel

Index • 697

INDEX Colonoscopy, 209, 539f Community acquired pneumonia (CAP) case examples, 595f, 596f, 601f, 602f pathogens, 110 scoring, 111 Compartment syndrome, 402, 486, 503 Computed tomography (CT) abdominal aortic aneurysm rupture imaging, 298 abdominal CT, 535f, 536f, 537f, 538f, 539f, 540f, 541f angiography, 542f bone tumour, 479 bowel ischaemia, 237, 239 cancer staging, 159 cervical spine, 344f, 388–389, 530f chest CT, 531f, 532f, 533f, 534f contraindications, 524 contrast agents allergy, 523 metformin patient precautions, 524 nephropathy induction, 523–524 types, 523 dose, 523 foreign body ingestion, 101 head CT, 525, 526f, 527f, 528f, 529f indications, 524 lung abscess, 150–151 lung cancer, 75 orthopaedic CT, 530f, 531 pancreatic abscess, 276 pelvis fracture, 446 PET/CT, see Positron emission tomography pleural calcification, 179 pneumoperitoneum, 132–133, 223–224 principles, 521f pulmonary metastases, 90 scanner, 521f sigmoid colon volvulus, 216 tibial plateau fracture, 488 windowing, 522f, 523 Computed tomography pulmonary angiography (CTPA) pleural effusion, 67 pulmonary embolism, 531f Congestive cardiac failure assessment, 117 chest X-ray findings, 114–115 clinical features, 114 Constipation ankylosing spondylitis, 306f bone metastasis, 302 causes, 244–245 complications, 246 imaging, 241f, 242f, 245–246 management, 245 tenesmus, 244

698 • • Index

Continuous positive airway pressure (CPAP), pulmonary oedema management, 128 Contrast agents computed tomography allergy, 523 metformin patient precautions, 524 nephropathy induction, 523–524 types, 523 gadolinium for magnetic resonance imaging, 544 Contrast enema, 576f Contrast swallow, see Barium swallow COPD, see Chronic obstructive pulmonary disease Costophrenic angle, blunting, 30f, 62f CPAP, see Continuous positive airway pressure Cremasteric reflex, spinal injury assessment, 380 CRITOE acronym, ossification centres, 351, 353f Crohn’s disease, see Inflammatory bowel disease CTPA, see Computed tomography pulmonary angiography Cubitus varus, supracondylar fracture, 406 CURB 65, pneumonia scoring, 111 Danozol, uterine fibroid management, 283 Deep vein thrombosis (DVT) complications, 119–120 pneumonia complication, 111–112 prophylaxis in ulcerative colitis flare management, 232 ultrasound, 118 Demyelination, magnetic resonance imaging, 547f Dermatome, spinal injury assessment, 380, 389–390 Diarrhoea, bloody diarrhoea assessment, 229 Dislocation, 339, 340f Disseminated intravascular coagulation, necrotising enterocolitis, 334 Diverticulitis, stricture formation, 208 Docusate sodium, constipation management, 245 Double bubble sign, 322f Down’s syndrome, duodenal atresia, 325 Duodenal atresia abdominal X-ray, 321f, 322f, 325 associated conditions, 325 case example with abdominal X-ray, 321f, 322f, 323–326 double bubble sign, 322f management, 326 signs and symptoms, 324 stenosis similarity, 324

Duodenum, volvulus, 213 DVT, see Deep vein thrombosis Dysmenorrhoea, uterine fibroids, 281 ECG, see Electrocardiogram Elbow anatomy, 405 anterior interosseous nerve injury, 404 effusion X-ray, 337f, 687f, 688f, 693f, 694f orthopaedic X-ray assessment, 350, 351f, 352f, 353f, 403 normal findings, 643f, 644f radial head fracture, 687f, 688f supracondylar fracture case examples, 399f, 400f, 401–406, 693f, 694f deformities following, 405–406 Gartland classification, 353, 403 ossification centres, 351, 353f Electrocardiogram (ECG), congestive cardiac failure, 127 Emergency surgery, prerequisites, 463–464 Emphysema, lung abscess risk factor, 149 Empyema pleural calcification, 178 pneumonia complication, 111–112 Enchondroma, location and age, 480 Endoscopic retrograde cholangiopancreatography (ERCP), acute pancreatitis, 273 Endoscopy battery stuck in mid-oesophagus, 319 complications, 320 Endotracheal tube (ET) chest X-ray, 22f positioning, 166 Enema, sigmoid colon volvulus management, 216 Enterocolic fistulae, necrotising enterocolitis, 334 Epilepsy, magnetic resonance imaging, 548 ERCP, see Endoscopic retrograde cholangiopancreatography ET, see Endotracheal tube Ewing’s sarcoma differential diagnosis, 477 location and age, 480 Faecal loading, see Constipation FAST, see Focused assessment with sonography in trauma Femoral vein, ultrasound, 563f Femur neck fracture, see Hip shaft fracture X-rays, 339f, 659f, 660f, 671f, 672f

INDEX Fibula, see also Knee shaft fracture case example, 497f, 498f, 499–504 Finger, X-ray bone lesion in proximal phalanx, 677f, 678f lucent lesion, 338f subluxation versus dislocation, 339, 340f views, 335f Fish bone, X-ray findings of ingestion, 103 Fistula, Crohn’s disease, 230 FLAIR, see Fluid attenuation recovery Fluid attenuation recovery (FLAIR), 547f Fluid resuscitation, ulcerative colitis flare management, 232 Fluid therapy duodenal atresia, 26 necrotising enterocolitis, 332–333 Fluoroscopy barium follow-through, 576 barium swallow, see also Barium swallow principles, 572 views, 573f, 574f, 575f contraindications, 572 contrast enema, 576f indications, 572 principles, 571 radiation dose, 572 tubogram, 576, 577f Focused assessment with sonography in trauma (FAST), 448, 563 Foot, metatarsal fracture, 639f, 640f, 647f, 648f, 653f, 654f, 675f, 676f Foreign body ingestion abdominal X-ray, 313f, 314f age groups, 316 battery stuck in mid-oesophagus, 319 case examples abdominal X-ray, 313f, 314f, 315–320 chest X-ray, 97f, 98f, 99–104 oropharynx trapping, 317 physical examination, 318 pneumoperitoneum induction, 135 Foreign body inhalation, lobar lung collapse, 157 Functional ileus, small bowel obstruction differentiation, 199

cholecystitis management, 262 clinical presentation, 259 risk factors, 258 ultrasound, 274, 560f, 561f Garden classification, hip fractures, 359, 461 Garland’s triad (1, 2, 3 sign), 96 Gartland classification, supracondylar fracture, 353, 403 Gas, see also Pneumoperitoneum; Pneumothorax pneumatosis intestinalis, 236, 238 subdiaphragmatic, 22f, 129f, 130f, 131–136, 605f, 606f Gastric tube, duodenal atresia, 326 Genitourinary scan principles, 565 radiation dose, 566 renal cortex assessment, 567–568 Glenohumeral joint, see Shoulder Globular heart, pericardial effusion chest X-ray, 174 Glycerol suppository, constipation management, 245 Glyceryl trinitrate (GTN), pulmonary oedema management, 128 Goitre mediastinal mass differential diagnosis, 142 ultrasound, 558f Golden S sign, 26f, 54f, 59 Growth plate fracture growth disturbances, 412 management, 413 Salter Harris classification, 364, 408f, 411–412 physis components, 410 GTN, see Glyceryl trinitrate Gunstock deformity, supracondylar fracture, 406 Gustilo classification, open fractures, 504

haemorrhage, 525, 526f, 527 hydrocephalus, 526f, 528 indications, 525, 527 mass effect, 527 space-occupying lesions, 527f Head magnetic resonance imaging congenital abnormalities, 549 demyelination, 547f epilepsy, 548 indications, 544 pituitary, 548 space occupying lesions, 548f stroke, 546f vascular abnormalities, 549 weighted images, 545f Heparin-induced thrombocytopaenia (HIP), 119 Hepatic fibrosis, ankylosing spondylitis, 311 Hereditary spherocytosis, splenectomy, 253 Hilar mass, case example, 69f, 70f, 71–76 Hill Sachs lesion, 365, 397 Hilum overlay sign, mediastinal mass, 142 HIP, see Heparin-induced thrombocytopaenia Hip ankylosing spondylitis, 310–311 avascular necrosis case example, 435f, 436f, 437–442 femur neck fracture case examples extracapsular fracture, 465f, 466f, 691f, 692f intracapsular fracture, 457f, 458f, 459–464, 681f, 682f Garden classification, 359, 461 management, 462–463, 470–471 mechanism of injury, 468 mortality, 471–472 overview, 462 2 to 4 parts classification, 360, 470 indications, 433–434 orthopaedic X-ray assessment, 357f, 358f, 359f, 360 Haematuria, abdominal computed osteoarthritis tomography, 541f case example, 336f, 429f, 430f, Haemolytic anaemia, gallstone risks, 258 431–434 Haemoptysis, differential diagnosis, 72 X-ray, 336f Haemorrhoids, constipation association, parts classification of neck of femur 246 fractures, 360 Haemothorax, pleural calcification, 18 Perthes’ disease, 442 Hampton’s hump, 117 septic arthritis distinguishing from Gadolinium, precautions, 544 Hand, see also Finger irritable hip, 512 Galeazzi fracture, 364 erosive arthropathy, 667f, 668f slipped upper femoral epiphysis case Gallbladder, abdominal X-ray metacarpal fracture, 637f, 638f examples, 451f, 452f, 453–456, 645f, assessment, 185 Hangman’s fracture, 364 646f Gallstones Hartmann’s procedure, 210 surgical approaches, 434 acute pancreatitis, 273 Head computed tomography Trendelenburg sign, 432–433 case examples with abdominal X-ray, contrast enhanced imaging, 528, 529f Hippocratic method, shoulder dislocation grey-white matter differentiation, 528f reduction, 395 255f, 256f, 257–262, 613f, 614f

Index • 699

INDEX Holstein Lewis fracture, 365 Hormone replacement therapy (HRT), pulmonary embolism risks, 116 Horner’s syndrome, lung cancer, 80–81 Hounsfeld unit (HU), 522 HPOA, see Hypertrophic pulmonary osteoarthropathy HRT, see Hormone replacement therapy HU, see Hounsfeld unit Hydronephrosis, abdominal aortic aneurysm, 296 Hypercalcaemia constipation, 244 renal calculi, 266 Hypertension, splenic artery aneurysm risks, 290 Hypertrophic pulmonary osteoarthropathy (HPOA), lung cancer, 74 Hypotension pericardial effusion, 173 tension pneumothorax, 41 Hypoxia, tension pneumothorax, 41 Hysterectomy, uterine fibroid management, 284

right upper lobe, 26, 53, 54f, 55–60, 599f, 600f clinical presentation, 56 computed tomography, 532 foreign body induction, 102 Low-molecular-weight heparin, pulmonary embolism management, 119 Luftsichel sign, 26f Lumbar spine, see Cauda equina syndrome; Spine Lung parenchyma assessment with chest computed tomography, 532f X-ray, see Chest X-ray Lung abscess aetiology, 150–151 chest X-ray findings, 145f, 146f differential diagnosis, 148 risk factors, 149 treatment, 151–152 Lactulose, constipation management, 245 Lung cancer Large bowel case examples with chest X-rays abdominal X-ray assessment, 182f hilar mass, 69f, 70f, 71–76 abscess, 334 metastasis sites, 74–75 constipation and perforation, 246 Pancoast tumour, 77f, 78f, 79–84 Idiopathic thrombocytopaenic purpura, obstruction, 182, 183f, 617f, 618f pulmonary metastases, 85f, 86f, Splenectomy, 253 obstruction, see Bowel obstruction 87–90 Inflammatory bowel disease sigmoid colon volvulus, 211f, 212f, consolidation on chest X-ray, 108 abdominal X-ray findings, 623f, 624f 213–216 lobar lung collapse, 156 Crohn’s disease versus ulcerative small bowel differences on X-ray, 193 Lung collapse, see Lobar lung collapse colitis, 230 thumbprinting, 185f, 185 Lung ventilation/perfusion scan flares Laryngeal cancer, asbestos exposure, 179 principles, 565 toxic megacolon assessment, 231 Left lower lobe collapse, 26f, 153f, 154f, pulmonary embolism, 566, 567f ulcerative colitis management, 232 155–160 radiation dose, 566 gallstone risks with Crohn’s disease, 258 Left upper lobe collapse, 26, 58, 609f, 610f Lymphadenopathy pneumoperitoneum induction, 135 Levonorgestrel intrauterine device, chest X-ray findings, 94 renal calculi, 266 uterine fibroid management, 283 sarcoidosis of lung, 91f, 92f, 94 stricture formation, 208 Lipohaemarthrosis Lymph node, calcification in upper left Infliximab, ankylosing spondylitis fracture association, 484 quadrant of abdominal X-ray, 288 management, 312 tibial plateau fracture case studies, Lymphoma Interosseus nerve, testing, 427 481f, 482f, 483–488, 655f, 656f hilar mass, 73 Interventional radiology, bowel Lisfranc injury, 365 mediastinal mass differential ischaemia, 237 Liver diagnosis, 142–143 Intra-aortic balloon pump, pulmonary abdominal X-ray assessment, 185 splenomegaly, 252–253 oedema management, 128 ultrasound, 560f, 561f Intrauterine contraceptive device (IUCD), Liver transplantation, splenic artery Magnetic resonance X-ray of migration, 615f, 616f aneurysm risks, 290 cholangiopancreatography (MRCP), 261, IUCD, see Intrauterine contraceptive Lobar lung collapse 553f device cancer association, 156 Magnetic resonance imaging (MRI) causes, 57 bone tumour of knee, 479 Jaundice, gallstone presentation, 259 chest physiotherapy, 60 cauda equina syndrome, 372 Jefferson fracture, 365, 388 chest X-ray cervical spine, 388–389 Jones fracture, 365 left lower lobe, 26f, 153f, 154f, contraindications, 544 155–160, 589f, 590f gadolinium contrast agent, 544 Kerley B lines, 25f left upper lobe, 26, 58, 609f, 610f head MRI Kidney right lower lobe, 27f congenital abnormalities, 549 abdominal X-ray assessment, 185 right middle lobe, 27f demyelination, 547f

700 • • Index

failure, see Renal failure stones, see Renal calculi ultrasound, 560, 561f Klein’s line, 366 Knee aspiration, 487 bone tumour case study, 473f, 474f, 475–480 magnetic resonance imaging, 555f orthopaedic X-ray assessment, 360, 361f osteoarthritis case example, 489f, 490f, 491–496 tibial plateau fracture case studies, 481f, 482f, 483–488, 655f, 656f X-ray features, 494–495 Knee replacement, 496 Kocher’s method, shoulder dislocation reduction, 395

INDEX epilepsy, 548 indications, 544 pituitary, 548 space occupying lesions, 548f stroke, 546f vascular abnormalities, 549 weighted images, 545f indications, 544 knee, 555f osteomyelitis, 510 Pancoast tumour, 83 principles, 543 safety, 543 scanner, 543f small bowel, 554f spinal cord compression, 303 spine MRI cauda equina syndrome, 550f indications, 549 normal findings, 549f spinal canal stenosis, 552f spinal cord compression, 550, 551f spinal cord trauma, 553f uterine fibroids, 282 weighted sequences, 544 Maissonneuve injury, 365 Malaria, splenomegaly, 252 Malleolus, see Ankle Malrotation, duodenal atresia, 325 Medial clear space, 518 Median nerve, injury in Colles’ fracture, 426–427 Mediastinum chest X-ray assessment, 20, 21f, 140 gas, see Pneumomediastinum mass, case example with chest X-ray, 137f, 138f, 139–141 mediastinitis and oesophagus foreign body induction, 100 Menorrhagia, uterine fibroids, 281 Mesothelioma, asbestos exposure, 179 Metacarpal, fracture, 637f, 638f Metal detector, ingested coin detection, 100 Metastasis, lung cancer, 74–75 Metatarsal, fracture, 639f, 640f, 647f, 648f, 653f, 654f, 675f, 676f Mitral regurgitation calcification on X-ray, 180 pulmonary oedema, 126 Metformin, contrast agent precautions, 524 Monteggia fracture, 365 MRCP, see Magnetic resonance cholangiopancreatography MRI, see Magnetic resonance imaging Mucus plug, lobar lung collapse, 157 Multiple myeloma, 158, 480 Myasthenia, lung cancer, 74

Myelofibrosis, splenomegaly, 252 Myocardial infarction, pericardial effusion induction, 172 Myocardial perfusion scan principles, 565, 567 radiation dose, 566 Myomectomy, uterine fibroid management, 284 Myotome, spinal injury assessment, 380, 390 Nasendoscopy, foreign body retrieval, 104 Nasogastric (NG) tube acute pancreatitis, 275 chest X-rays, 22f, 161f, 162f, 165, 587f, 588f, 593f, 594f placement, 164 small bowel obstruction management, 201 Necrotising enterocolitis abdominal X-ray, 327f, 328f, 331–332, 629f, 630f Bell classification system, 332 complications, 333–334 management, 332–333 risk factors, 330 stricture formation, 208 Needle decompression, tension pneumothorax, 38, 42, 44 Nephrostomy, complications, 625f, 626f NG tube, see Nasogastric tube Nuclear medicine, see Bone scan; Genitourinary scan; Lung ventilation/ perfusion scan; Myocardial perfusion scan; Positron emission tomography Obesity, gallstone risks, 258 Oesophageal varices, portal hypertension as cause, 291 Oesophagus battery stuck in mid-oesophagus, 319 fistula from foreign body ingestion, 320 perforation from foreign body ingestion, 320 Open fracture Gustilo classification, 504 management, 501–502 Opioids, constipation, 244 Orthopaedic computed tomography, 530–531 Orthopaedic X-rays, see also specific bones and joints ankle assessment, 362f, 363f checklist, 366 elbow assessment, 350, 351f, 352f, 353f Gartland classification of supracondylar fracture, 353

fracture appearance, 336f descriptors, 338–339 names, 364–366 hip assessment, 357f, 358f, 359f, 360 knee assessment, 360, 361f pelvis assessment, 357f, 358f, 359f, 360 projection, 335f shoulder assessment, 348, 349f, 350f spine cervical spine assessment, 340–341, 342f, 343f, 344f, 345f thoracolumbar spine assessment, 345, 346f, 347f subluxation versus dislocation, 339, 340f systematic review, 336f, 337f, 338f technical adequacy, 336 wrist assessment, 354f, 355f, 356f Ossification centres, elbow, 351, 353f Osteoarthritis hip case example, 336f, 429f, 430f, 431–434 knee case example, 489f, 490f, 491–496 severity assessment, 433 X-ray features, 432 Osteomyelitis clinical findings, 508 differential diagnosis, 477 magnetic resonance imaging, 510 management, 511 pathogens, 509 tibia case example, 505f, 506f, 507–512 Osteophyte, knee arthritis, 494–496 Osteosarcoma location and age, 480 pathological fracture, 158 Ottawa Ankle Rules, 516 Ovarian cyst, ultrasound, 562f Paget’s disease, X-ray findings, 631f, 632f Pancoast tumour, see Lung cancer Pancreas abdominal X-ray assessment, 185 annular pancreas, 324–325 ultrasound, 560 Pancreatic abscess, acute pancreatitis association, 276 Pancreatitis, see Acute pancreatitis; Chronic pancreatitis Patella reflex, spinal injury assessment, 380 Pelvic ultrasound, 562f Pelvis fracture bladder and urethral injuries, 449 case example, 443f, 444f, 445–450 computed tomography, 446

Index • 701

INDEX management, 450 mortality, 449 types, 448–449 orthopaedic X-ray assessment, 357f, 358f, 359f, 360 tumour staging with computed tomography, 538f Pericardial effusion, case examples with chest X-ray, 169f, 170f, 591f, 592f Periosteal reaction aggressive bone lesion, 476 osteomyelitis, 505f, 506f Peritonitis, pneumoperitoneum induction, 136 Perthes’ disease differential diagnosis, 440 severity assessment, 441 treatment, 441–442 X-ray case example, 435f, 436f, 437–442 PET, see Positron emission tomography Phlebolith, 278f Physis, see Growth plate Pituitary, magnetic resonance imaging, 548 Pleural calcification causes, 178 imaging, 177f, 179 Pleural effusion case examples with chest X-ray, 61f, 62f, 63–68, 585f, 586f chest X-ray findings, 25f clinical signs and symptoms, 64 congestive cardiac failure, 125 draining, 68 exudate analysis, 64–65 exudative effusion aetiology, 65–66 pneumonia complication, 111–112 transudate versus exudate effusions, 66 ultrasound, 559f Pneumatosis intestinalis, differential diagnosis, 236, 238 Pneumomediastinum, case example, 611f, 612f Pneumonia case examples with chest X-rays, 105f, 106f, 107–112, 595f, 596f, 597, 598f, 601f, 602f, 603f, 604f, 607f, 608f chest X-ray findings, 23, 24f, 25 community acquired pneumonia case examples, 595f, 596f, 601f, 602f pathogens, 110 scoring, 111 complications, 111–112 consolidation on chest X-ray, 108–109 pleural effusion induction, 65 Pneumoperitoneum abdominal X-ray assessment, 184f, 185f

702 • • Index

case examples with abdominal X-ray, 217f, 218f, 219–224, 234f, 583f, 584f, 621f, 622f causes, 134–135, 220 chest X-ray findings, 129f, 130f, 131–136 post-operative, 136 Pneumothorax breathlessness, 34 case examples with chest X-rays primary spontaneous, 29f, 30f, 31–36 small left apical pneumothorax, 579f, 580f tension pneumothorax, 37f, 38f, 39–44 chest X-ray findings, 25f evolution from simple pneumothorax, 40 pneumonia complication, 111–112 shoulder X-ray, 641f, 642f tension pneumothorax, 20 Portal hypertension, 290–291, 560 Positron emission tomography (PET) indications, 420 PET/CT principles, 565 radiation dose, 566 tumours, 569f Posterior interosseus nerve, testing, 427 Pregnancy pulmonary embolism evaluation, 118 splenic artery aneurysm risks, 290 X-ray safety, 14 Premature infants, necrotising enterocolitis, 330 Prostate cancer bone metastasis, 299f, 300f, 301–304 staging, 302–303 Pulmonary artery hypertension hilar mass, 73 pulmonary embolism complication, 119–120 Pulmonary embolism breathlessness, 34 case examples with chest X-ray, 113f, . 114f, 115–120, 581f, 582f complications, 119–120 lung ventilation/perfusion scan, 566, 567f pregnant patient evaluation, 118 risk factors, 116 treatment, 119 Pulmonary fibrosis, 96, 179 Pulmonary oedema case example with chest X-ray, 121f, 122f, 123–128 causes, 126

chest X-ray findings, 25f, 108 treatment, 128 Pulmory infarction haemoptysis, 72 lung abscess differential diagnosis, 148 pleural effusion induction, 66 Radial inclination, 355 Radial nerve, testing, 427 Radius, see Elbow; Wrist Renal artery stenosis, pulmonary oedema, 126 Renal calculi abdominal X-ray, 263f, 264f calcification in upper left quadrant of abdominal X-ray, 288 computed tomography, 267–268, 540f management, 268 risk factors, 266 symptoms, 266 uric acid stones, 267 Renal failure contrast agent nephropathy induction, 523–524 pericardial effusion induction, 172 pulmonary oedema, 126 Renal tubular acidosis, renal calculi, 266 Retroperitoneal fibrosis, abdominal aortic aneurysm, 296 Rheumatoid arthritis, hand X-ray, 667f, 668f Right lower lobe collapse, 27f Right middle lobe collapse, 27f Right upper lobe collapse, 26, 53, 54f, 55–60, 599f, 600f Rigler’s sign, 234f Rolando’s fracture, 365 Round atelectasis, asbestos exposure, 179 Sacroiliac joint, abdominal X-ray, 194 Saddle anaesthesia, cauda equina syndrome, 371 Sail sign, 26, 27f, 154f Salter Harris classification, growth plate fractures, 364, 408f, 411–412 Sarcoidosis clinical presentation, 95–96 differential diagnosis in lung, 78 hilar mass, 73 lung, 91f, 92f, 93–96 risk factors, 94–95 Scaphoid, see Wrist SCIWORA, see Spinal cord injury without radiological abnormality Segond fracture, 365 Seldinger technique, 68 Senna, constipation management, 245 Septic arthritis, distinguishing from irritable hip, 512

INDEX Shenton’s line, 366 Short bowel syndrome, necrotising enterocolitis, 334 Shoulder ankylosing spondylitis, 310 dislocation axillary nerve injury, 396 bony abnormalities with anterior dislocations, 397 instability following injury, 397–398 reduction, 395 types, 394 orthopaedic X-ray acromio-clavicular joint disruption, 673f, 674f assessment, 348, 349f, 350f glenohumeral joint dislocation, 391f, 392f, 393–398, 657f, 658f humeral neck fracture, 661f, 662f posterior dislocation, 665f, 666f SiADH, see Syndrome of inappropriate antidiuretic hormone secretion Sickle cell anaemia, calcification in upper left quadrant of abdominal X-ray, 288 Sigmoid colon volvulus abdominal X-ray, 211f, 212f, 213–216 contrast enema, 576f Sigmoidoscopy, sigmoid colon volvulus management, 216 Silhouette sign mediastinal mass, 142 pneumonia chest X-ray, 24f, 109 Silicosis, calcification on X-ray, 180 Slipped upper femoral epiphysis (SUFE) case examples, 451f, 452f, 453–456, 645f, 646f clinical presentation, 454 contralateral slippage incidence, 455 management, 456 pathology, 454 Trethowan’s sign, 455 Small bowel abdominal X-ray assessment, 182f barium follow-through, 576 dilation in necrotising enterocolitis, 331–332 large bowel differences on X-ray, 193 magnetic resonance imaging, 554f obstruction, see Bowel obstruction ultrasound, 561f Smith’s fracture, 365, 427–428 Spinal canal stenosis, magnetic resonance imaging, 552f Spinal cord compression bone metastasis, 302–304 cauda equina syndrome decompression surgery, 373

magnetic resonance imaging, 550, 551f Spinal cord injury without radiological abnormality (SCIWORA), 384 Spinal cord trauma, magnetic resonance imaging, 553f Spinal shock, 381 Spine, see also Cauda equina syndrome back pain management, 374 cauda equina syndrome decompression surgery, 373 cervical spine computed tomography, 530f computed tomography of cervical spine, 388–389 magnetic resonance imaging of cervical spine, 388–389 orthopaedic X-ray central cord syndrome, 382 cervical spine assessment, 340–341, 342f, 343f, 344f, 345f case example of fracture without trauma, 382f, 383f, 384–390 lines for lateral X-ray assessment, 387 Chance fracture-associated injuries, 379 Jefferson fracture, 388 L1 fracture, 375f, 376f level of sensation and fracture location, 380, 389–390 stable fracture, 376 thoracolumbar spine assessment, 345, 346f, 347f Spine magnetic resonance imaging cauda equina syndrome, 550f indications, 549 normal findings, 549f spinal canal stenosis, 552f spinal cord compression, 550, 551f spinal cord trauma, 553f Spleen abdominal X-ray assessment, 185f congenital asplenia, 251 erythrocytes, 251 lymphocyte production, 251 size, 251 Splenectomy indications, 253 management in post-operative period, 254 splenic artery aneurysm, 292 Splenic artery aneurysm abdominal X-ray of calcification, 285f, 286f, 288 pseudoaneurysm differentiation, 289

risk factors, 290 treatment, 292 Splenomegaly case examples with abdominal X-ray, 247f, 248f, 249–254, 633f, 634f causes, 252 physical examination, 250 portal hypertension, 290 splenic artery aneurysm, 286f ultrasound, 560 Staphylococcus aureus, osteomyelitis association, 509 Sterilisation clips abdominal X-ray assessment, 186 displacement, 248f Stomach, volvulus, 213 Streptococcus pneumoniae, community acquired pneumonia, 110 Stroke computed tomography of haemorrhage, 525, 526f, 527 magnetic resonance imaging, 546f Subluxation, 339, 340f SUFE, see Slipped upper femoral epiphysis Superior vena cava, stenting in Pancoast tumour, 84 Supracondylar fracture, see Elbow Syndrome of inappropriate antidiuretic hormone secretion (SiADH), lung cancer, 74 Tachycardia, tension pneumothorax, 41 Talus, shift, 518–519 TB, see Tuberculosis Tenesmus, constipation, 244 Teratoma, mediastinal mass differential diagnosis, 142–143 Thrombolysis, pulmonary embolism management, 119 Thumbprinting, colitis, 218 Thurstand Holland fragment, 365 Thymoma, mediastinal mass differential diagnosis, 142–143 Thyroid cancer, lobar lung collapse, 156 Tibia, see also Knee osteomyelitis case example, 505f, 506f, 507–512 shaft fracture case example, 497f, 498f, 499–504 Toxic megacolon, 231 Tranexamic acid, uterine fibroid management, 283 Trauma, initial series X-rays, 447 Trendelenburg sign, 432–433 Trethowan’s sign, 366, 455 Triplane fracture, 414 Triquetral bone, see Wrist Tuberculosis (TB) differential diagnosis, 89

Index • 703

INDEX hilar mass, 73 pleural effusion induction, 66 Tubogram, 576, 577f Ulcerative colitis, see Inflammatory bowel disease Ulna distal fracture, see Wrist shaft fracture, 663f, 664f Ulna variance, 355 Ultrasound scans abdominal aortic aneurysm, 297 abdominal ultrasound, 559f, 560f B-mode, 557 chest ultrasound, 558, 559f colour flow imaging, 557, 563f congestive cardiac failure echocardiogram, 127 contraindications, 558 deep vein thrombosis, 118 Doppler imaging, 557–558, 559f focused assessment with sonography in trauma, 448, 563 gallstones, 260, 274 guided procedures, 564 indications, 557 musculoskeletal ultrasound, 564 neck, 558f, 559f pelvic ultrasound, 562f pleural effusion, 67–68 principles, 557 reflection of waves, 558 safety, 557 vascular ultrasound, 563f Ultrasound therapy, uterine fibroid management, 284 Urinary incontinence, cauda equina syndrome, 370 Urinary tract infection, renal calculi, 266 Uterine fibroid abdominal X-ray of calcification, 277f, 278f case example with abdominal X-ray, 277f, 278f, 279–284 magnetic resonance imaging, 282 management, 283–284 sites, 281 symptoms, 280 VACTERL, duodenal atresia, 325 Varicella pneumonia, calcification on X-ray, 180 Veil sign, 26f Ventilation/perfusion scan, see Lung ventilation/perfusion scan Vertebral body osteitis, ankylosing spondylitis, 309

704 • • Index

Volar angulation, 355 Volar Barton’s fracture, 365 Volvulus sigmoid colon volvulus, 211f, 212f, 213–216 sites, 213 Wackenheim’s line, 366 Wall test, 308 Warfarin initial prothrombotic effects, 119 pulmonary embolism management, 119 Water skiing, pneumoperitoneum induction, 135 Weber classification, malleolus fractures, 363, 517, 686f Wegener’s granulomatosis, 148 Westermark’s sign, 114f Wilm’s tumour, 89 Wrist carpal tunnel anatomy, 422 orthopaedic X-ray assessment, 354f, 355f, 356f case examples Colles’ fracture, 423f, 424f, 425–428 distal radius fracture, 407f, 408f, 409–414, 649f, 650f, 669f, 670f, 679f, 680f scaphoid fracture, 415f, 416f triquetral fracture, 356f, 683f, 684f distal radius radiological measurements, 428 radial inclination, 355 radius fracture, 356f Smith’s fracture, 365, 427–428 ulna variance, 355 volar angulation, 355 X-ray, see also specific areas and structures densities, 12f dose, 192–193, 523 generation, 11f hazards, 13 image production, 12 magnification of anteroposterior view, 12, 13f pregnancy, 14 regulatory legislation, 13–14 requesting form, 14–15 radiology team interactions, 15–16

USS Scans Nuclear Medicine Scans

“Perhaps one of the biggest strengths of this book is the cases section, allowing you to practice not only interpreting high quality images but also to link them to a case history. The questions that follow not only test your radiology, but also your understanding of signs, symptoms, underlying pathophysiology and management of the condition. As well as detailed answers in each section, the book also shows you the best way to present each case, whether in an OSCE situation or on a ward round. The ease of use, detailed pictures and emphasis on key points of this one should cement it as the number one undergraduate book for radiology.”

James Brookes, Medical Student Fluoroscopy Bonus Chest X-Rays

“Which radiographs from each system are most likely to be presented in exams? This excellent book presents the classics, and at one level this makes it a high-yield textbook that will be extremely valuable to medical students and junior doctors. What is especially striking is the definition and clarity of the illustrations, with on-image labelling enabling one to be absolutely certain of which is the endotracheal tube, the nasogastric tube and the central line, for example.”


Bob Clarke, Associate Dean, Professional Development, London. Director, Ask Doctor Clarke Ltd. ISBN: 978 0 9571499 4 6

Introduction Chest X-Rays Abdominal X-Rays Orthopaedic X-Rays CT Scans MRI Scans

MRI Scans

Simon Maxwell, Professor of Student Learning, University of Edinburgh

USS Scans

CT Scans

“Radiology is a constant challenge for students and doctors in busy clinical units: having a good command of the essentials is a real advantage. This book is well-presented and very accessible. The annotated examples provide realistic challenges with immediate feedback. It didn’t take long before I felt better prepared for my next ward round!”


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The Unofficial Guide to Radiology: Chest, Abdominal and Orthopaedic X-Rays, plus CTs, MRIs and Other Important Modalities

Chest X-Rays

‘The Unofficial Guide to Radiology’ follows on from the ‘The Unofficial Guide to Passing OSCEs’. This book teaches systematic analysis of the three main types of X-rays: chest, abdominal and orthopaedic, with additional chapters looking at all the other main radiology tests such as CT and MRI. The layout is designed to make the book as relevant to clinical practice as possible; the X-rays are presented in the context of a real life scenario. The reader is asked to interpret the X-ray before turning over the page to reveal a model report accompanied by a fully annotated version of the X-ray. To further enhance the clinical relevance, each case has 5 clinical and radiology-related multiple-choice questions with detailed answers. These test core knowledge for exams and working life, and illustrate how the X-ray findings will influence patient management.


The Unofficial Guide to Radiology


Introduction

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Unofficial Guide to Radiology

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