Radiology Exam 1 Outline - PDF

Ppt 1 - The Basics (01/13) I. Imaging Modalities - overview A. Radiography 1. "conventional radiograph" 2. "Plain films" 3. "Standard film" B. Fluoroscopy C. Computed axial tomography "CT" D. Magnetic resonance imaging "MRI" E. Ultrasound...

Ppt 1 - The Basics (01/13) I. Imaging Modalities - overview A. Radiography 1. "conventional radiograph" 2. "Plain films" 3. "Standard film" B. Fluoroscopy C. Computed axial tomography "CT" D. Magnetic resonance imaging "MRI" E. Ultrasound "US" F. Nuclear imaging G. Interventional radiology "angio" H. Clinical justification 4. ex) diagnosis on the order I. Patient information 5. Name 6. DOB 7. ID \# J. Imaging modality selection K. Specific instructions 8. Body part to be imaged a. ex) AP & Lateral of Right Hand 9. Positioning 10. Contrast administration as needed 11. Necessary steps for the patient b. Where does pt go for this image? Which facility? L. Consult guidelines 12. Refer to American College of Radiology (ACR) criteria to ensure an imaging study is clinically indicated - **Discovered by: Wilhelm Conrad Roentgen** in 1895 - Most common imaging - chest xray especially - Related to subjects' density - "Wet reading" aka "STAT" interpretation - Digital Radiography - **PACS - picture archiving and communication system** - Benefits - images can be viewed by anyone anytime (sent to PCP) - Can enhance images by processing - Indications/Uses - Bone injuries, help diagnose arthritis, osteoporosis, tooth decay, etc - Strong xrays can be used to treat tumors (destroys cell DNA) - radiation - Dangers/Risks/Contraindications - Ionizing radiation → large doses produce free radicals & cell mutations - Radiation associated cancers - Breast cancer - Thyroid cancer - Brain cancer/leukemia - association with pts under age of 20 exposed - Contraindications - Pregnancy → teratogenic times - Prenatal exposure → highest risks gestational weeks 8-15 weeks - Mental retardation & Reduced head circumference (microcephaly) - Ionizing radiation → most dangerous - from ultraviolet → x rays → gamma rays - **ALARA → "As Low as Reasonably Achievable"** - It is a standard/protocol/concept we utilize to increase safety - **Time** → Shortest amount of time - **Distance** → Far from radiation as possible - **Shielding** - Thyroid shield!!! - **ESPECIALLY in children,** cause their metabolism/cells are growing so fast they are at greater risk (20x) for cancer than an adult - **Use US/MRI (safer) & avoid repeat testing** - w/ contrast! - Paste, drink, pill, IV - - - - Indications - Find, locate, identify foreign object - Diseases in GI tract - Procedures → like spinal taps - **ex) Cervical Facet injections → steroid put into joint of cervical spine of pt with chronic pain** - - - - **"BONE AND BLOOD"** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Determining if a tumor has transfissural growth or has spread into lymph node - **great for SOFT TISSUES!!! Specifically small changes** - Still do the 3 planes - axial, sagittal, coronal planes - **Not exposed to radiation! (safer for preg. & kids)** - Instead → pt is exposed to external magnetic fields and radio frequency waves - **Uses hydrogen ions to work!!!** - **Atoms spin randomly in our body** - **Magnetic field causes the hydrogen ions to go in the same direction!** - Concerns - Magnetism - ex) ear implants, pacemakers, Cerebral aneurysm clipped by ferromagnetic clips - We use **titanium in brain and spine** → much safer now! - Noise - If someone is claustrophobic (ex: Autism) - Sensitivity to loud noise can trigger the patient - Pt must be still!!! - No pregnancy - Still safer than CT - **Gadolinium → this is the contrast!!!** - ONLY used in MRI! - Safe on kidneys - - - - - - - - - - - - Benefits - **Safe - no x rays or radiation** - **Inexpensive** - Produces 2D or 3D sectional images in anatomical planes - **3 types** - **2D Sonogram** - **3D Sonogram** - **Doppler →** Seeing live version - doppler during pregnancy - Can be used in ER - ex) view how deep/wide a pressure ulcer goes - Echogenicity - **Echogenic - aka hyperechoic** - Bright white = solid areas - US waves are bouncing off something - **Sonolucent - aka hypoechoic or anechoic** - Dark or black = waves that continue to keep going/nothing makes it bounce back - Indications - Testicle & prostate - Solid mass/tumor - Appears white - Full of fluid - ex) hydrocele → darker image, filled with fluid - Chest for pleural fluid - Distinguish between fluid vs air - Fluid = white - Waves reflect - Air = dark - Waves keep going - Abdomen - Appendicitis - Infants for several conditions - Concerns - Decreased birth weight with increased US use due to Direct heat / bubble - No substantial ill effects but only use if necessary - Indications - Diagnose disease - **Stage disease** - ex) staging **cancers** → did they travel to lymph nodes or metastasize? - Monitor disease - Types - **Scintigraphy** - gamma waves are far right on scale - Gamma cameras detect internal radiation - **Radioisotopes - aka tracers** are injected and we watch where they go - **Used to assess organ function** - Areas of high metabolism pick up the tracers more (blood travels to areas that are more highly metabolic) - **Increased absorption = bright or hot spot** - This is an area of high metabolism/high blood flow - **Normal absorption = warm spot** - Good blood flow - **Decreased absorption = cold spot** - Low blood supply - ex) fracture with scar tissue - ex) osteonecrosis - Types - Bone scan - Thyroid scan - Liver scan - **Single Photon Emission Computed Tomography (SPECT)** - Good for bleeding - ex) Intestinal bleeding - Also good for: - Bone - Gallbladder - Decreased resolution/images not as clear but more available - SPECT = top image ---\-\-\--\> - **Positron emission tomography (PET) scan** - **Good for cancer to detect metastasis** - **More expensive** - PET → bottom image ---\-\-\-\-\-\-\-\-\--\> **[Interventional radiology "angio"]** - Overview - Diagnose, **[Intervene]** & **Treat** - **Interventional Radiology (IR) = image-guided** ***therapy*** - Types - Angiography - Stenting - Embolization - Biopsy - Abscess drainage - Foreign body retrieval - ex) ablation **[Reading an Image]** "IDS body positioning penetrates contrast artifacts" - Identification - Date of study - **COMPARE TO PREVIOUS STUDIES!!!** - Study ordered - **Correct view → direction of the waves coming from the machine** - **Whatever we want to see clearly → put closest to plate** - **PA = posterior to anterior** - Preferred for heart & chest xray - We see heart is more defined - **AP = anterior to posterior** - Heart looks bigger because heart is anterior organ since it is not against the plate - We can see the scapulae on this view - **Lateral** - **NOTE: color of plate = white, so the rays will project through the body to the white plate** - **Whatever is directly on the plate is going to be more visible** - **Further away from the plate = object appears bigger** - **Closer away from the plate = accurate size & darker** - Body part - PA view → x ray goes through back first and then front and then plate - Anatomical position so palm facing forward - So the palm of the hand is on the plate - For a view of sternum → take PA view - We flip PA view to read chest to see better! - This is why the heart is consistently on the same side for each AP and PA views - For systematic review! - This is the right hand! - L image = PA view , R = AP view - AP - Rays are going through anterior → then posterior → then plate - Posterior is ON the plate - For checking vertebrae → AP is best - Positioning - Supine - Upright - standing upright - Rotation - Pt is in pain and cant rotate - Pt is breathing in - Non-rotated or neutral positon - **Left rotation → it brings the clavicles further out** - **You see a gap toward the side that is rotated** - In an AP view: - R shoulder = forward - L shoulder = goes backwards a bit - Penetration - aka exposure - 5 densities increasing brightness - Radioopaque aka opacity = lighter - Rays cannot pass through - **metal** - Radioluscent aka lucency = darker - Rays can pass through - Lower density = darker the object appears - Decreased attenuation (blacker densities) - ex) AIR in the lungs & stomach - Picture to right = gas bubble - **"Loss of attenuation" = image gets darker** - Higher density = lighter the object appears - Increased attenuation (whiter densities) - ex) bone - **Requirements for a good film** - **Adequate penetration** - **Thoracic spine disc spaces slightly visible through the heart** - **See the vertebrae through the heart** - **But not see the pedicles/spinous processes** - **Bronchovascular structures can be seen through the heart** - **Not too much noise aka cloudiness** - **Underexposed (soft) = very white image** - **Thinking you see a tumor when there is none** - **Artifacts = reflection of something that looks like a bright white shape** - **Overexposure (hard) = very dark image** - **Miss things** - Contrast - IV contrast required for: - Angiography - ex) what you can check for - Aneurysms - Aortic dissections - Chest (malignant lesions) - Suspecting lung cancer - All abdominal work for: - Liver - Pancreas - Kidney - Bladder - Not used for intestines or stomach - Contrast Agents - Iodine - Great because it is water soluble - Safe (unless you are allergic) - Typically IV - Barium - Typically swallowed - Barium sulfate - **Gastrofin** - **Best option** - **Very safe , not many allergies** - Oral delivery - 4 delivery methods - IV - Blood vessels - Organs - Brain - Spine - Liver - Kidney - Oral - GI organs - Fast, used for constipation - Rectal - Large intestine - Lower GI - enemas - Inhalation - Lung - Brain - Artifacts - Unwanted or sometimes unexpected & ***often misleading*** features/structures that appear on xray images - ex) movement artifacts → may look like scoliosis on xray **[Lecture 3 → Limbs Part 1 (01/23)]** I. Approach to Radiograph of the Limbs A. AP & lateral views B. **Must see joint above and below of the fracture** 1. ex) humerus fx → must see shoulder & elbow C. **Looking for:** 2. **Black lines = stress fractures** 3. **Cortex of the joint = intraarticular fracture** a. **Borders should be smooth** 4. **Joint space** b. **Narrowing** c. **Widening** 5. **Soft tissues** d. **Enlargement = swelling** e. **Displaced fat pads = radial head** D. Describe 6. Area 7. Views, f. AP g. Lateral h. Clavicle 8. location i. Proximal j. Middle k. Distal 9. Pattern 10. Type l. Intraarticular m. Subcondylar n. etc II. Fracture Patterns E. Transverse → straight across F. Oblique → oblique to axis of the bone G. Spiral → wraps arond the bone 11. Usually twisting type MOA H. Segmental → several large fractures involved I. Avulsed → pulling 12. Usually at point of tendon attachment 13. Tendon tries to hang on to the bone → traction that occurs during injury pulls that segment of the bone off of the body J. Impacted → ramming pieces of bone into eachother 14. Wedged in there K. Torus 15. Incomplete fracture 16. Swelling or protuberance due to fracture in the bone that doesnt reach the outer edges of the bone 17. Aka "buckle" 18. More common w/ children L. **Greenstick** 19. **Associated w/ children** 20. **One side is bent** 21. **One side is snapped/broken** M. Simple → broken into 2 pieces 22. Aka "Closed" N. Comminuted → more than 2 pieces 23. Multiple fractures involved 24. Splintered or crushed into several pieces O. **Compound → breaking through skin** or penetrating another organ 25. Can cause more complications 26. ex) rib penetrating the lungs 27. ex) piercing through the skin P. Complete Q. Fracture Dislocation → fracture with misalignment of joint 28. Look at distal bone for direction R. Pathologic fracture → **due to metabolically weakened bone** 29. Small, low speed fall, yet it still fractures 30. Consider especially in **older population** 31. ex) osteoporosis causes demineralization S. Stress → small crack due to repetitive small trauma 32. ex) marathon runners in their tibia T. Displacement → fragments have moved out of place 33. Broad term that includes: o. Translation → sideways movement of a fractured bone away from the other fragments p. Rotated → fragment rotated/twisted in relation to proximal one q. Angulation → fragments form an angle 1. Normal alignment of the bone = off, no longer straight 2. ex) in fingers 34. Look at proximal piece for direction U. Shortened → distal fracture component moving proximally 35. ex) femur    💪 Limbs Part 2 (01/23) **[Lecture 3 → Limbs Part 2 (01/23)]** Anatomy Getting a good view Shoulder Arm Upper Arm Fractures Shoulder Anatomy   I. Shoulder Views A. Should minimally include: 1. AP view 2. **Trascupular (Y) view → done for shoulder dislocations** 3. Axillary views B. Additional views: 4. Stress views of the AC joint  Proximal Humeral Fracture **[Proximal Humeral Fracture]** A. H&P 1. FOOSH - fall on outstretched hand 2. MVA 3. Swelling, Pain, Restricted shoulder movement B. **NEER Classification → based on 4 fracture segments** C. Complications 4. Adhesive capsulitis 5. **Axillary nerve damage** 6. Ischemia = loss of blood supply resulting in necrosis (looks dark on xray) 7. Loss of function/ROM D. Dx = xray or CT 8. AP/lateral views Shoulder Dislocations Shoulder Dislocations - **Most common shoulder dislocation = [ANTERIOR!]** Anterior Shoulder Dislocation Anterior Shoulder Dislocation - aka "Anterior Glenohumeral Joint Dislocation" I. H&P A. FOOSH B. MVA C. Seizure D. "Shoulder popping out" → bump E. **90% of all shoulder dislocations = anterior!!!** II. Dx F. Scapular Y view G. Hillsachs and Bankart lesions - In pic above mercedes benz sign is disfigured → **[it is inferior and medial]** (displaced anteriorly) III. Associated Injuries H. [Hillsachs lesion] → **humeral head has a groove or indentation** at the site of impact (aka on the posterior side, since its an anterior dislocation) 1. Blue arrow top pic → I. [Bankart lesion] → **inferior glenoid rim** is broken 2. Avulsion of glenoid labrum 3. Red arrow bottom pic → Posterior Shoulder Dislocation Posterior Shoulder Dislocation - aka "Posterior Glenohumeral Joint Dislocation" I. H&P A. Anterior directed trauma B. Electrical shock C. Seizure D. **Arm held in adduction & internal rotation** \