1. Orthopedic Radiology Dr. W. Pacheco 2 XI 2010
Joyce and Cedes

2. Principles Orthogonal (90 degrees from last view- DEPTH)
Joint above and below
Contralateral view for children
Splint! Because of pain. Secondary na ang prevention of further injury
Weight-bearing vs. Dynamic joints
Primum non nocere.

3. Reporting View, laterality, date Quality of X-ray (exposure, etc)
Quality of bone and alignment (You’ll see bone trabeculae dapat)
Assess joint surfaces
Assess soft tissues

4. Common Views for Upper Extremities
Shoulder: AP, Scapular Y view
Humerus :AP, Lateral
Elbow: AP, Lateral
Forearm: AP, Lateral
Wrist: PA ,Lateral
Hand: oblique, AP, Lateral

5. Shoulder routine: AP, axillary, transcapular,
scapular Y view
Avoid manoeuvring patient esp if masakit (hx of trauma). Kaya you move the film and beam instead.

6. SHOULDER AP
Indications for imaging Trauma - dislocations, fractures, tendon calcifications Arthritis survey Bone pain.
Usong-uso ang dislocations.

7. SHOULDER AP Shoulder X-ray, AP projection 1, Clavicle. 2, Acromion.
3, Greater tubercle. 
4,Lesser tubercle. 
5, Neck of Humerus
. 6, Humerus.
7, Coracoid Process. 
8, Axillary border of scapula.
9, Rib.

8. SHOULDER AP
Shoulder dislocation

9. SHOULDER
axillary

10. SHOULDER scapular Y view
Anatomy  Demonstrated Demonstrates relationship of humeral  head to glenoid, spine of scapula and head of humerus in lateral profile.
Indications for imaging Trauma - dislocations, fractures, 

11. SHOULDER scapular Y view Shoulder X-ray: lateral view
1, Coracoid Process.
 2, Clavicle.
 3, Acromion. 
4,Head of Humerus. 
5, Humerus. 
6, Axillary border of scapula.

12. SHOULDER
scapular Y view
A shows anterior dislocation

13. SHOULDER
scapular Y view
B shows posterior dislocation

14. SHOULDER
recap
Between anterior and posterior dislocations, ano ang mas madalas mangyari?

15. Abnormalities
1) Inferior Dislocation can’t say if it’s an anterior or posterior dislocation (xray has no depth)
2) Greater Tuberosity fracture: with humeral dislocation
Which view will you request? Scapular Y View (so you don’t need to move the patient who’s in pain)
3) Problem in scapular body w/ multiple rib fractures
 The Scapula is wrapped around muscle, so It’ll take a very large amount of energy to fracture it. Following such fracture, the rib cage is affected  rib cage fracture  pulmonary problems then arise (ex. pneumothorax…)

16. Humerus routine: AP and lateral
Translateral!

17. HUMERUS AP Indications for imaging Trauma - dislocations, fractures,
soft tissue calcifications Arthritis survey Bone pain. 

18. HUMERUS WALA AKONG MAKITANG HUMERUS LATERAL SA NET lateral
Indications for imaging Trauma - dislocations, fractures, soft tissue calcifications Arthritis survey Bone pain.
WALA AKONG MAKITANG HUMERUS LATERAL SA NET

19. Elbow routine: AP and lateral
In any view (AP, Lat, Oblique), radial head must always be centered sa capitulum (“capitellem”).

20. ELBOW AP
Indications for imaging Trauma, loose bodies, bone pain

21. ELBOW AP Elbow Radiograph - AP projection 1, Humerus.
2, Medial epicondyle. 
3, Lateral epicondyle. 
4, Olecranon fossa. 
5, capitellum. 
6, Radius. 
7, Radial Head. 
8, Ulna. 
9, Olecranon process. 
10, Coronoid process.

22. ELBOW
lateral
Indications for imaging Trauma, loose bodies, bone pain

23. ELBOW lateral Elbow Radiograph - AP projection 1, Humerus.
2, Medial epicondyle. 
3, Lateral epicondyle. 
4, Olecranon fossa. 
5, capitellum. 
6, Radius. 
7, Radial Head. 
8, Ulna. 
9, Olecranon process. 
10, Coronoid process.
11, anterior fat pad

24. ELBOW lateral Middle is normal
This is an invaluable soft tissue finding in cases of intra-articular injury of the elbow. Fat is normally present within the joint capsule of the elbow, but outside the synovium. Typically "hidden" in the concavity of the olecranon and coronoid fossae, the fat is usually not visible on the lateral radiograph. However, injuries that produce intra-articular hemorrhage cause distension of the synovium and forces the fat out of the fossa, producing triangular radiolucent shadows anterior and posterior to the distal end of the humerus. When present in a patient with a history of acute trauma to the elbow, the fat pad sign indicates the presence of an intra-articular hemorrhage, which in turn is often associated with an intra-articular skeletal injury (usually the radial head in an adult).

25. Forearm routine: AP and lateral
Always get 2 joints in view

26. FOREARM AP
Indications for imaging Trauma*, metastases, bone pain. (*Monteggia's fracture, fracture of the ulna with dislocation of the head of the radius.

27. FOREARM AP 1, Humerus. 2, Radius. 3, Ulna. 4 Navicular Bone
5 Lunate Bone. 
6 Triquetrum. 
7 Capitatum bone. 
8, Metacarpal bone. 
9 Metacarpophalangeal joint. 
 Proximal phalangeal joint. 
11 Proximal Phalanx. 
12 Distal phalanx. Arrow, Fracture.  *, Epiphysial plate.

28. FOREARM
lateral
Indications for imaging Trauma*, metastases, bone pain. (*Monteggia's fracture, fracture of the ulna with dislocation of the head of the radius.)

29. FOREARM
lateral

30. FOREARM AP MONTEGGIA’s FRACTURE
    - Giovanni Monteggia (1814) first described frx of proximal 1/3 of ulna in association w/ anterior dislocation of radial head;           - hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity.
    - Mechanism:            - proposed mechanisms include direct blow & hyperpronation injuries as well- as the hyperextension theory;
Monteggia Fracture - fracture of the proximal ulna with a dislocation of the radial head.

31. FOREARM AP GALEAZZI’S FRACTURE
  The combination of a fracture near the junction of the mid to distal third of the radius with disruption of the distal radioulnar joint (DRUJ) is a Galeazzi fracture.  Ricardo Galeazzi described his experience of 18 such cases in 1934.  The fracture has taken his name since then, although it was initially described by Cooper in 1842.  The main ED priorities are accurate diagnosis and identification of early complications. 

32. Fat Pad Sign
More radiolucent area (less dense); seen in fractures wherein hematoma and bleeding pushes fat.
Fracture  hematomoa  push out the normal fat  visible radiolucent area

33. Wrist routine: PA and lateral
Special: carpal tunnel view
Usually missed fracture: SCAPHOID (boat-shaped). Manifests as wrist pain. Where to palpate it? Look for your radial snuffbox.
Nice to know: Terry Thomas Scapholunate dissociation (Madonna sign)- Clenched fist view: scaphoid and lunate could be seen dissociating

34. WRIST PA
Indications for imaging Injury, pain, carpal tunnel syndrome,

35. WRIST
lateral
Indications for imaging Injury, pain, carpal tunnel syndrome,

36. WRIST
carpal tunnel view

37. WRIST
others
COLLES’ FRACTURE

38. Hand routine: AP and oblique
Kung lat, magpapatong-patong sila, malaking kabobohan. Palpakis!

39. HAND AP
Indications for imaging Injury, ? rheumatoid arthritis, ?acromegaly, bone pain

40. HAND AP Hand X-ray - AP 1, Distal phalanx.
2, Distal interphalangeal joint.
 3, Middle phalanx. 
4, Proximal interphalangeal joint.
 5, Proximal phalanx. 
6, Metacarpophalangeal joint.
 7, Head of 5th metacarpal.
 8, Sesamoid bone. 

41. HAND
oblique

42. HAND
others
Left – RA
Right - Scleroderma

43. Common Views for Lower Extremities
Both hips AP, frog leg lateral (for children, congenital problems)
Cross table lateral (for hip fractures)
Femur AP, lateral
Knee AP, Lateral
Leg AP, Lateral
Ankle mortise, AP, Lateral
Foot AP, oblique, lateral
Pelvis AP

44. Pelvis routine: AP only
Special: Pelvic Inlet, Pelvic Outlet
Acetabulum: Judets view (obturator & iliac)
Check for symmetry, holes, SI joints, pub. Symphysis, acetabulum

45. PELVIS AP

46. PELVIS AP
Anatomy  Demonstrated Iliac bones, femoral heads and necks, ishium, pubis and scrum.
Indications for imaging Congenital abnormalities, Trauma, degenerative disease, carcinoma primary and secondary, pathologies e.g. Perthes disease, slipped femoral epiphyses. 

47. PELVIS AP
1 Superior Ramus of Right Pubis 2 Symphysis Pubis 3 Inferior Ramus of Left Pubis 4 Left obturator foramen 5 Left lesser Trochanter 6 Left Greater Trochanter 7 Left iliac wing 8 Iliac crest 9 Vertebral Pedicle (Lumbar Spine) 10 Right Sacro-iliac joint  11 Head of right femur 
1 Superior Ramus of Right Pubis 2 Symphysis Pubis 3 Inferior Ramus of Left Pubis 4 Left obturator foramen 5 Left lesser Trochanter 6 Left Greater Trochanter 7 Left iliac wing 8 Iliac crest 9 Vertebral Pedicle (Lumbar Spine) 10 Right Sacro-iliac joint  11 Head of right femur 

48. PELVIS AP

49. PELVIS inlet vs outlet view
1) Pelvic Inlet: Normally inclined about 45 deg. (”Kitang kita yung butas”); patient supine, xray beneath, beam points to the foot at 45 deg, sacroiliac widening and displacement of hemipelviscan be seen; donut shaped
2) Pelvic Outlet: View from the bottom - useful for those with pelvic fractures; beam directed cephalad; whole sacrum and superior and inferior pubic rami can be seen; butterfly-like

50. PELVIS
male vs female

51. PELVIS AP
Female pelvis. Note the sacro-iliac joints, the subpubic angle, and the continuous curvature of the margin of the obturator foramen and the neck of the femur (Shenton's line)
NORMAL

52. PELVIS AP
This pelvis is of an 11 month old. To draw Shenton's line, the inferior border of the superior pubic ramus is traced laterally and should smoothly extend to the inferomedial border of the proximal femur.
Developmental Dysplasia of the Hip (DDH)

53. PELVIS
acetabulum
1,Acetabular fossa. 2, Head femoral. 3, Greater trochanter. 4, Lesser trochanter. 5, Femur. 6, Obturator foramen. 7, Inferior pubic ramus. 8, Superior pubic ramus. 9, Sacrum. 10, Iliac wing.
Take oblique views, Lateral is “walang kwenta”
1,Acetabular fossa. 2, Head femoral. 3, Greater trochanter. 4, Lesser trochanter. 5, Femur. 6, Obturator foramen. 7, Inferior pubic ramus. 8, Superior pubic ramus. 9, Sacrum. 10, Iliac wing.

54. Sample Case
Asymmetrical (imagine picture- may obvious rami fracture and a subtle SI fracture which John/.Joshua/Roel spotted)
Hole: symmetrical?
SI joint: normal? Widened? (if widened = Ala fracture)
Request other views: outlet is dislocation up or down? Inlet did disloc hemipelvis move pa-front of back?
*Sacral Wing problems involve Nerves S1-5 (which innervate the bladder, I.e. urinary and sexual function implications)
True leg length (ASIS to medial malleolus), is it equal? Yes.
Apparent leg length (umbilicus [fixed portion in midline] to medial malleolus) equal? No
hemi pelvis moved upwards and posteriorly

55. PELVIS
frog’s view
Anatomy  Demonstrated Femoral heads and necks, acetabulum
Indications for imaging Congenital abnormalities, Perthes disease, slipped femoral epiphyses. 

56. PELVIS
frog’s view
1, Symphysis pubis. 2, Obturator foramen. 3, Ischium. 4, Lesser trochanter. 5, Femur. 6, Femoral head. 7, Anterior inferior iliac spine. 8, Acetabular fossa. 9, Anterior superior iliac spine.
1, Symphysis pubis. 2, Obturator foramen. 3, Ischium. 4, Lesser trochanter. 5, Femur. 6, Femoral head. 7, Anterior inferior iliac spine. 8, Acetabular fossa. 9, Anterior superior iliac spine.

57. PELVIS- acetabulum visualization
obturator vs iliac view
Obturator view  obturator would be clearly defined, anterior column of acetabulum (anterior pelvic, posterior rim) is seen
Iliac internal Oblique View posterior column of the acetabulum is seen; can see the iliac wing

58. PELVIS
obturator vs iliac

59. PELVIS
obturator vs illac
Hoho. Illac Diaz, hello!

60. Additional Info
Cross table lateral viewpatient’s opposite/unaffected limb is raised, plate is beside the involved hip, beam is at 30 degrees
Frog leg view soles of the feet together then ask patient to make bukaka. Can see the relationship of the hip joint to the acetabulum. In kids, you can see if may dysplastic hip or a slipped capital femoral epiphysis.

61. Cervical Spine Routine: AP and lateral Special: Swimmer’s, Open Mouth
Open-mouth: to see C1 and C2
Get Obliques to check for nerve impingement

62. CERVICAL SPINE lateral Indications for imaging Trauma, pain,
rheumatoid arthritis,
 upper limb paraethesia,
vertebral artery syndrome.
Check for normal curvature, visualize 7 vertebrae

63. CERVICAL SPINE
lateral

64. CERVICAL SPINE lateral Cervical Spine X-ray: Lateral view.
1, Vertebral body (TH1). 
2, Spinous process of C7. 
3, Lamina. 
4, Inferior articular process. 
5, Superior articular process. 
6,Spinous process of C2. 
7, Odontoid process. 
8, Anterior arch of C1 (Atlas). 
9,Trachea.

65. CERVICAL SPINE
lateral 1 2 3 4 5 6 7

66. CERVICAL SPINE
lateral
Normal cervical spine? 1 2 3 4 5 6 7

67. CERVICAL SPINE lateral
A lateral radiograph of the cervical spine demonstrates a fracture through the posterior elements of C2 (yellow arrow) with forward subluxation of the anterior aspect of C2 on C3 (white arrow). This injury is caused by a combination of extension and compression
Hangman’s fracture

68. CERVICAL SPINE
lateral
Teardrop fracture

69. CERVICAL SPINE lateral
A lateral radiograph of the cervical spine demonstrates subluxation of C1 on C2, in this instance anterior subluxation most likely caused by severe hyperflexion (white arrow).
Atlantoaxial subluxation

70. CERVICAL SPINE AP Cervical vertebrae 3 to 7, vertebral bodies,
spinous processes
intervertebral spaces

71. CERVICAL SPINE AP T1 Cervical vertebrae 3 to 7, vertebral bodies,
spinous processes
intervertebral spaces T1

72. CERVICAL SPINE open mouth
- to view odontoid process should be centered
- check space between odontoid and C1--> space should be equal on both sides (& symmetrical)
*also check if disk space and alignment on both sides are equal
JEFFERSON’S fracture - burst fracture of C1 (multiple fracture); (+) overhang of C1 over C2

73. CERVICAL SPINE open mouth
Anatomy  Demonstrated Cervical vertebrae 1 & 2,
odontoid process
intervertebral space,
posterior arch of atlas and
lateral masses.
Indications for imaging Trauma,
pain,
rheumatoid arthritis,  

74. CERVICAL SPINE open mouth Atlas and odontoid process:
AP view (Mouth wide open). 
1, Transverse process of C1. 
2, Lateral mass of C1. 
3, Odontoid. 
4, Inferior articular process of C1.
5, Superior articular process of C2.
... Water’s view? Joke lang.

75. CERVICAL SPINE open mouth Jefferson Fracture.
There is bilateral offset of both the right and left lateral masses of C1 relative to the lateral masses of C2 on the open-mouth cervical spine view (above-white arrows).
This indicates a burst-type injury to the ring of C1. A single axial CT scan through the level of C1 shows fractures involving the right and left anterior ring of C1 and the right posterior ring (yellow arrows).
Jefferson, i.e. Burst fracture.

76. CERVICAL SPINE oblique
Anatomy  Demonstrated Cervical vertebra bodies, intervertebral foramina, articular pillars apophysial  joints and spinous processes. The  intervertebral foramina demonstrated are those furthest from the film.
Indications for imaging Trauma,
pain,
rheumatoid arthritis, 
upper limb paraethesia,
vertebral artery syndrome.

77. CERVICAL SPINE oblique Anatomy Demonstrated Cervical vertebra bodies,
intervertebral foramina,
articular pillars
apophysial  joints
spinous processes. 
- to view intervertebral foramina (a.k.a. Mga butas) where cervical nerve roots pass
- done when suspecting encroachment of nerve roots; radiculopathies
- notes: there are 8 cervical roots and 7 cervical vertebra

78. CERVICAL SPINE oblique Cervical Spine X-ray, (Left Neural Foramina).
 1, Rib. 
2, Clavicle. 
3, Neural Foramina. 
4, Pedicle. 
5, Trachea.

79. CERVICAL SPINE
swimmer’s view
to reveal lower cervical spine

80. CERVICAL SPINE
swimmer’s view

81. Thoracic Spine routine: AP and lateral

82. THORACIC SPINE AP AP VIEW
Anatomy  Demonstrated Thoracic vertebra, medial ends of ribs.
Indications for imaging Congenital abnormalities,
scoliosis,
trauma,
pain,
metastasis's. 

83. THORACIC SPINE AP
This is an inadequate radiograph of the thoracic spine although all thoracic vertebrae (T1-T12) are seen on this AP view. For trauma imaging, C7 and L1 must be entirely demonstrated to evaluate potential dislocation at the cervical and lumbar junctions. As for the radiograph technique, it is adequate for the upper vertebrae but the lower thoracic vertebrae are poorly penetrated. This is because the exposure favors high contrast rather than low contrast and good penetration. To correct for this you should use the anode-heel-effect or a wedge filter to even out the density difference between the upper and lower thoracic spine. When using anode-heel-effect place the thicker part under the cathode end of the anode. This will provide a greater number of photons with greater energy to that area. Using the 50/15 rule to create a radiograph with a slightly lower contrast is recommended to make this an optimal film.

84. THORACIC SPINE AP

85. THORACIC SPINE AP pedicles Thoracic Spine X-ray: AP projection.
1, Left ventricle. 
2, Gas in stomach.
 3, Right hemidiaphragm. 
4, Posterior rib. 
5,Clavicle.
pedicles

86. THORACIC SPINE AP Thoracic Spine X-ray: AP projection.
1, Gas in Colon (Splenic flexure). 
2, Gas in stomach. 
3, Left hemidiaphragm. 
4, Posterior rib. 
5, Pedicle. 
6, Spinous process. 
7, Transverse process.

87. THORACIC SPINE AP Di pala thoracic to sorry! HEHE!
Just to show scoliosis!

88. THORACIC SPINE AP Spot the Winking Owl!
Mets! If nakain na ang pedicles.

89. THORACIC SPINE AP

90. THORACIC SPINE lateral Anatomy Demonstrated Thoracic vertebra,
Indications for imaging Congenital abnormalities,
scoliosis,
trauma,
pain,
metastasis's. 

91. THORACIC SPINE lateral Thoracic Spine X-ray: Lateral view.
1, Right hemidiaphragm. 
2, Left hemidiaphragm. 
3, Vertebral body. 
4, Rib

92. THORACIC SPINE lateral Thoracic Spine X-ray: Lateral view.
1,Posterior rib.
 2, Vertebral body. 
3, Intervertebral discal space.

93. THORACIC SPINE
lateral
kyphosis

94. THORACIC SPINE lateral
A 73-year-old female with L1 vertebral compression fracture treated with kyphoplasty 6 weeks after fracture. The focal kyphosis was corrected from 16° to 5°.

95. Lumbosacral Spine routine: AP and lateral

96. LUMBOSACRAL SPINE AP Indications for imaging Congenital abnormalities,
trauma,
pain,
metastasis's. 
Anatomy  Demonstrated Lumbar vertebra,
sacro iliac joints,
Sacrum
coccyx

97. LUMBOSACRAL SPINE AP Lumbar spine X-ray, AP projection 1, rib.
 2, Transverse process. 
3, Pedicle. 
4, Spinous Process. 
5, Sacrum. 
6, Sacroiliac joint

98. LUMBOSACRAL SPINE AP
Spina bifida occulta

99. LUMBOSACRAL SPINE AP
Winking owl sign- Mets! Mawalala ang lateral processes

100. LUMBOSACRAL SPINE AP
Spina bifida occulta

101. LUMBOSACRAL SPINE lateral Anatomy Demonstrated Lumbar vertebra.
Indications for imaging Congenital abnormalities, trauma, pain, metastasis's. 
Spina bifida occulta

102. LUMBOSACRAL SPINE lateral Lumbar spine X-ray, lateral view 1, Sacrum.
 2, Spinous Process. 
3, Vertebral body.
4, Intervertebral disc space.
 5, Intervertebral foramina. 
, Pedicle. 
7, Inferior articulating facet. 
8,Superior articulating facet. 
9, Rib .

103. LUMBOSACRAL SPINE oblique Scotty Dog/Pars Defect- oblique!
The parts of the dog are as follows:
the transverse process-the nose;
the pedicle-the eye;
the pars interarticularis-the neck;
the superior articular facet-the ear;
the inferior articular facet-the front leg.
If pars interarticularis is broken- Spondylolysis
If pars is borken AND has moved/slipped- Spondylolisthesis (beheaded Scotty Dog)

104. LUMBOSACRAL SPINE lateral Spondylolysis L Spondylolisthesis R
Fracture in pars interarticularis

105. Knee routine: AP and lateral
Special: patella’s skyline view s

106. KNEE AP AP

107. KNEE AP
Standing AP 1 2 3 4

108. KNEE
lateral
LAT

109. KNEE
skyline view
Laterality? Steeper slope sa medial side.

110. KNEE merchant’s view Merchant’s- for dislocated patella.
Bipartite patella: bilateral

111. Ankle routine: AP, mortise and lateral

112. ANKLE AP

113. ANKLE
mortise view
Naka rotate interiorly (view medial and lateral malleoli)

114. ANKLE
lateral view
Check for ankle syndesmosis

115. LAT

116. Axial , lateral, axial view
Calcaneus
Axial , lateral, axial view s

117. CALCANEUS lateral view
Usually injured c/o falls. Trying to stop moving motorcycle. Pero mas common ang falls.

118. CALCANEUS lateral view
Don’t forget Talus! Talar neck fractures- obvious naman.

119. Foot
AP and oblique s

120. FOOT AP

121. FOOT
lateral

122. FOOT
oblique

123. Lisfranc’s Fracture

124. The end.