1. 35 things you really don’t want to miss on an XRAY
Micelle Haydel, MD
LSUEM 2008
Learningradiology.com

2. Two patients with n/v B A

3. Large vs. Small Bowel Large Bowel Small Bowel Peripheral
Haustral markings don't extend from wall to wall
Max diameter 6cm (9cm cecum)
Small Bowel
Central
Plica extend across lumen
Maximum diameter of 3cm

4. Patient A: SBO
Upright
Flat
Small bowel:<3cm

5. Radiology Report: Plain abdominal radiograph.
Multiple dilated loops of small bowel within the central abdomen. Gas is not seen in the large bowel.
The three most common causes of small bowel obstruction are:
Surgical adhesions
Herniae
Intraluminal mass eg, small bowel lymphoma or gallstone (in gallstone ileus)

6. Patient B: LBO
The Cecum is considered dilated if >9cm; other if >6cm.

7. Radiology Report: Plain abdominal radiograph.
Multiple dilated loops of large bowel across the abdomen. Gas is not seen in the large bowel.
The three most common causes of large bowel obstruction are: Ca
Diverticular disease
Volvulus

8. Two more patients with n/vB

9. A: Sigmoid Volvulus B: Cecal Volvulus
A volvulus always extends away from the area of bowel twist.
Sigmoid volvulus can only move upwards and usually goes to the right upper quadrant.
Cecal volvulus can go almost anywhere.

10. Sentinel
LOOPS
Cholecystitis
Pancreatitis
Appendicitis
Diverticulitis

11. Sentinel Loops
Supine

12. Abdominal Pain, NV

13. Mesenteric Ischemia/Infarction
Thumbprinting
Pneumatosis intestinalis
Mortality 75%

14. Why this patient is short of breath?
Why this patient is short of breath?

15. Tension pneumothorax Shift of heart and trachea to left
Tension pneumothorax
Shift of heart and trachea to left
Complete right-sided pneumothorax
Lung is compressed against mediastinum

16. A smaller Pneumothorax on CT
A smaller Pneumothorax on CT
Ant
Air in pleural space rises to top and displaces normal lung
Post

17. Another patient with SOB:
Skin Fold
Pneumothorax
A skin fold consists of a density (light) and then a lucency (dark),
A pneumothorax has a thin white line with similar densities on both sides of it.

18. Bleb

19. URD, front end collision, high speed MVA
Now, same patient, upright cxr…
You are looking for a marker of aortic injury: mediastinal hematoma
 Mediastinal widening >8cm
Left paratracheal stripe
Displacement of intimal calcifications
Apical pleural cap
Left pleural effusion
Displacement of endotracheal tube or nasogastric tube
About 10% will have a normal CXR!

20. Apical Cap
Wide Lt Paratracheal stripe that extends above the knob

21. Traumatic aortic injury

22. Ruptured Diaphragm

23. Newborn with tachypnea

24. This person reports severe N/V and now has chest pain, fever and SOB…
This person reports severe N/V and now has chest pain, fever and SOB…

25. He sick!
Streaky, linear densities due to air in the mediastinum
Pleural effusion
Boerhaave’s

26. Air, air, everywhere

27. 57 year-old female with shortness of breath
57 year-old female with shortness of breath

28. Meniscus-shaped density at bases from a pleural effusion
Where are the diaphragms?
Pleural Effusions

29. Meniscus-shaped density at right & left base from a pleural effusion
Pleural Effusions

30. Effect of Position - Layering
Effect of Position - Layering
Supine
Erect

31. Pneumonias
Rt Lower lobe
Rt Upper lobe
Rt Mid lobe
Spine sign

32. Pneumonias
Left upper lobe
Lt Lower Lobe
Lt Lingula
Lt Lower Lobe

33. Cavitary Lesions
Thin wall: TB
Thick: CA or abscess

34. NV, Fever, RUQ pain

35. Gallbladder bad (aka, emphysematous gallbladder)

36. Chief complaint: Abdominal Pain
Chief complaint: Abdominal Pain

37. Pneumoperitoneum
Air outlines both sides of the wall of the stomach-a sign of free air in the peritoneal cavity

38. Pneumoperitoneum on CT
Free air
Free air
CT scans on 2 different people show a small and large amount of free air in the peritoneal cavity which rises to the highest point (anterior abdomen with the person lying on their back) and is not contained within bowel

39. SOB

40. Size (not number) of vessels at the apex exceeds size of vessels at the base in this upright person. This is “cephalization.” Normally the vessels at the base exceed the size of the vessels at the apex

41. Sudden, severe Chest Pain, pale diaphoretic…

42. Widened mediastinum
Neuro findings
Chest pain: sharp, sudden, severe, radiating to back
Sudden Pain, at its max immediately should make you think of an aortic dissection

43. 63 year-old man with chest pain
63 year-old man with chest pain

44. 68 y/o w/Flank pain

45. Even if you’ve already called the surgeons and the OR, you can start writing up your m&m…

46. Triple A: Aortic rupture
Red arrows point to active extravasation of contrast from the aorta into the retroperitoneum
Aorta
Aorta
Thrombus inside the lumen of the aorta
Triple A: Aortic rupture

47. Post-intubation CXR

48. Tip of endotracheal tube is in right mainstem bronchus (red arrow) leading to atelectasis of the right upper lobe and entire left lung

49. Endotracheal Tubes Where
Tip should be at least 5cm above carina
Between clavicles and carina
Carina usually at level of T4
Balloon should never distend tracheal walls; if >2.8 cm, suspect laceration

50. Central Venous Catheters Where
Subclavian joins brachiocephalic vein behind medial end of clavicle
Catheter should reach this point before descending
Catheter should descend lateral to spine and tip should be in the SVC

52. Pacemakers Where Tip positioned at apex of right ventricle
Tip may have slight bend as it abuts wall of right ventricle
Not a sharp bend
Some pacers may also have lead(s) in right atrium and/or coronary sinus

53. Two-lead pacemaker (red circle) shows one lead in right atrium (green arrow) and the second in the right ventricle (red arrow).

54. The End.

55. Two different people who fell & complain of neck painB
Two different people who fell & complain of neck pain

56. A A Fracture of C2 - “Hangman’s Fracture”A A
Spinolaminar white line of C2 does not align with other vertebral bodies
Fracture through posterior elements of C2
Forward displacement of the body of C2 (red arrows)
Fracture of C2 - “Hangman’s Fracture”

57. The inferior articular facet of C5 (red arrow) has slipped forward and lies anterior to the superior articular facet of C6 (green arrow) — a condition known as a “locked facet” B C5 C6
Locked facets

58. Two patients-one with pain in the ankle, the other with pain in the wrist

59. Fractures extending into joints
Fracture of radial styloid (yellow arrows) extends into wrist joint
Fractures of the metaphysis (red arrow) and epiphysis (green arrow) (Salter-Harris IV) extend into joint
Fractures extending into joints

60. 27 year-old fell on elbow

61. Fracture of the radial head with traumatic joint effusion
Fracture of radial head
Posterior “fat-pad sign” indicates fluid in the joint
Fracture of the radial head with traumatic joint effusion

62. Two different patients with acute shoulder pain1 2
Two different patients with acute shoulder pain

63. Anterior Dislocation of the Shoulder
Humeral head (red arrow) lies inferior to the coracoid process of the scapula (green arrow) and anterior to the glenoid (yellow oval)
Humeral head (red arrow) lies inferior to the coracoid process of the scapula (green arrow)
Humeral head (red arrow) lies inferior to the glenoid fossa of the scapula (yellow arrow) 2
Anterior Dislocation of the Shoulder

64. Posterior Dislocation of the Shoulder1
Humeral head (red arrow) lies beneath the acromion process of the scapula (green arrow) and posterior to glenoid (yellow oval)
Humeral head (red arrow) assumes the shape of a “lightbulb” because it is fixed in internal rotation
Humeral head (red arrow) lies posterior to the glenoid fossa of the humerus (yellow arrow)
Posterior Dislocation of the Shoulder

65. 37 year-old hit in the head with a brick

66. Traumatic intracranial hemorrhage Subdural hematoma
Crescentic low attenuation lesion at periphery of brain containing a fluid-fluid level from blood
Traumatic intracranial hemorrhage Subdural hematoma

67. Sudden Headache

68. Staggering gait & incontinence

69. Large ventricles due to Cerebral Atrophy
Lateral ventricles – anterior and posterior horns
Large ventricles due to Cerebral Atrophy

70. MVA, H/A