General Considerations for Patient Management in Radiology PDF

General Considerations Regs Alunan, RRT Patient Management Try to appear confident Explain what/why Answer questions Dont volunteer unnecesary information Take more anterior films first Work Quickly but efficiently Empathize Compliment patient Patient Identific...

General Considerations Regs Alunan, RRT Patient Management Try to appear confident Explain what/why Answer questions Dont volunteer unnecesary information Take more anterior films first Work Quickly but efficiently Empathize Compliment patient Patient Identification Verification of patient information on arrival – What is your name? What is your date of birth? – What is your address? What are you here for? Matching information Ensure the request/consent form is clear and legible and contains: – Patient’s first and family name, date of birth and medical record number or full address – Procedure requested including side (if applicable) Clinical history Time out Correct patient is present Correct examination is being performed Clinical history corresponds to the requested examination Correct side/site is being examined Right or left side markers are being used and are correct to the side/extremity Post procedure Patient details and the side marker attached to the post-processed image are correct Role of the radiographer Radiographers are primarily responsible for operating X- ray equipment to produce high-quality diagnostic images that aid in the diagnosis of various patient conditions. They can specialize in certain areas of imaging, including sonography, MRI, mammography, computed tomography, and vascular interventional radiography. What does a radiologic technologist do? Radiologic technologists, also known as radiographers, perform medical exams using X-rays on patients to create images of specific parts of the body. The images are then interpreted by a doctor for diagnosis and monitoring of disease. Radiographers prepare patients for the exams, move patients to the correct position, operate the equipment, and use their knowledge and skill to minimize the radiation dose to the patient. Scope of practice Assessing, evaluating, and testing patients Preparing and positioning patients for imaging Attending to patient needs during imaging procedures Applying and maintaining up-to-date knowledge of radiation protection and safety practices  Independently performing or assisting a licensed practitioner in performing procedures such as mammograms, X-ray exams, MRIs, or administering radiation to cancer patients Preparing, administering, and documenting activities related to medications in accordance with state and federal regulations and institutional policy Specializations Bone densitometry Cardiac-interventional radiography Computed tomography (CT) Magnetic resonance imaging (MRI) Mammography Vascular interventional radiography Nuclear medicine Sonography Work environment Radiographers work in hospitals, medical labs, doctors’ offices, and outpatient centers. They may work a full-time, part-time, or as-needed schedule, which may include evening, weekend, or on-call hours  Radiographers may specialize and provide imaging in operating rooms, emergency departments, procedural suites, and specialized imaging departments. Chief complaint A chief complaint is a concise statement in English or other natural language of the symptoms that caused a patient to seek medical care. DO DON’T Specify reason for the visit Fail to specify reason for visit “Patient presents for follow-up evaluation of ankle “Patient presents for follow-up.” sprain.” Specify who requested a consult and why Fail to specify as a consult (who requested and “Consult requested by Dr. Jones for evaluation of why). Imply chronic abdominal referral or transfer of care pain.” “Patient referred by Dr. Jones.” History of Present Illness (HPI) DO DON’T Give specific details regarding the presenting illness Fail to give details regarding presenting illness. “Patient presents for evaluation of left ankle pain. “Ankle pain.” Slipped on ice yesterday. Felt a pop. Pain currently 6 of 10.” Document your own HPI Reference a nurse, clinical tech, or medical student’s HPI Allergy History what the suspected allergen is Any personal history of atopic disease (asthma, eczema or allergic rhinitis) Any individual and family history of atopic disease (such as asthma, eczema or allergic rhinitis) or food allergy in parents or siblings cultural and religious factors that affect the foods eaten details of any foods that are avoided and the reasons why who has raised the concern and suspects a food allerg Pain Assessment Precise and systematic pain assessment is required to make the correct diagnosis and determine the most efficacious treatment plan for patients presenting with pain. – Onset: Mechanism of injury or etiology of pain, if identifiable – Location/Distribution – Duration – Course or Temporal Pattern  Character & Quality of the pain Aggravating/Provoking factors Alleviating factors Associated symptoms Severity: Intensity or impact on function, sleep, mood Barriers to pain assessment Pain scales Single-dimensional scales – These scales assess a single dimension of pain, typically pain intensity, and through patient self-reporting. These scales are useful in acute pain when the etiology is clear Multidimensional scales These measure the intensity, nature, and location of pain, as well as, in some cases, the impact that pain is having on a patient’s activity or mood; multidimensional scales are useful in complex or persistent acute or chronic pain Pain assessment in the elderly Underreporting of discomfort because the patient does not want to complain or due to communication or cognitive impairment Other medical comorbidities may overshadow pain complaints Decreases in hearing and visual acuity, so that pain assessment tools that require extensive explanation or visualization to perform will be more difficult and possibly less reliable Pain assessment in infants CRIES - Uses 5 variables (ie, crying, requires oxygen, increased vital signs, expression, sleeplessness) Modified Behavioral Pain Scale - Uses 3 factors (facial expression, cry, movements); has been validated for children aged 2-6 months Pain assessment in young children Limited cognitive or language skills may influence pain measures, as may the positive or negative consequences of a child’s behaviors associated with pain. In children older than 3-4 years, self-report measures may be used. However, children may underreport their pain to avoid future injections or other procedures aimed at alleviating the pain. Aggravating/alleviating factors Asking the patient to describe the factors that aggravate or alleviate the pain will help plan interventions – “What makes the pain better or worse?” Other things to include in the pain assessment are the presence of contributing symptoms or side effects associated with pain and its treatment. These include nausea, vomiting, constipation, sleepiness, confusion, urinary retention, and weakness. Special Consideration in Pediatric Imaging Imaging examinations that are easily carried out in adults require special adjustments to be successfully achieved in children. – The attitude and approach of radio technologists to a child. – The radiographer must have good knowledge of radiologic equipment and its use. While coming for an examination most children are accompanied by parents. It is important to follow the protocol: Proper introduction of yourself as the technologist. Proper instructions should be followed given by the pediatrician or physician. Explain the proper procedure and what your needs will be during an examination. Preliminary Steps in Radiology 1. Cassette with film: A device that contains special intensifying screens that glow when struck by x-rays and imprints the x-ray image on film  Image plate (IP): A device, used for computed radiography (CR Solid-state detectors: A flat panel thin-film transistor (TFT) detector Portable digital radiography Fluoroscopic screen Radiograph The radiographer must be thoroughly familiar with the radiographic attenuation patterns cast by normal anatomy structures. – Superimposition – Adjacent structures – Optical density (OD – Contrast – Recorded detail – Shape distortion ANATOMIC POSITION The anatomic position refers to the patient standing erect with the face and eyes directed forward, arms extended by the sides with the palms of the hands facing forward, heels together, and toes pointing anteriorly DISPLAY OF RADIOGRAPHS Radiographs are generally oriented on the display device according to the preference of the interpreting physician. Because methods of displaying radiographic images have developed largely through custom, no fixed rules have been established Posteroanterior(PA) and anteroposterior (AP) radiographs A, Patient positioned for PA projection of the chest. Anterior aspect of the chest is closest to IR. B, Patient positioned for AP projection of the chest. Posterior aspect of the chest is closest to IR.  Exceptions to these guidelines include the hands, fingers, wrists, feet, and toes. Hand, finger, and wrist radiographs are routinely displayed with the digits (fingers) pointed to the ceiling. Foot and toe radiographs are also placed on the illuminator with the toes pointing to the ceiling.  Lateral radiographs are obtained with the patient’s right or left side placed against the IR  Oblique radiographs are obtained when the patient’s body is rotated so that the projection obtained is not frontal, posterior, or lateral Clinical History Normal anatomy and normal anatomic variations so that the patient can be accurately positioned The radiographic characteristics of numerous common abnormalities the radiographer’s professional responsibility is to produce an image that clearly shows the abnormality. Initial Examination The radiographs obtained for the initial examination are usually the minimum required to detect any demonstrable abnormality in the region. Supplemental studies for further investigation are made as needed. This method saves time, eliminates unnecessary radiographs, and reduces patient exposure to radiation. Diagnosis and the Radiographer A patient is naturally anxious about examination results and is likely to ask questions. The radiographer should tactfully advise the patient that the referring physician will receive the report as soon as the radiographs have been interpreted by the radiologist Care of the Radiographic Examining Room The radiographic examining room should be as scrupulously clean as any other room used for medical purposes. The mechanical parts of the x-ray machine, such as the tableside, supporting structure, and collimator, should be wiped with a clean, damp (not soaked) cloth daily. The metal parts of the machine should be periodically cleaned with a disinfectant Standard Precautions They should know the way to handle patients who are on isolation status without contaminating their hands, clothing, or apparatus, and radiographers must know the method of disinfecting these items when they become contaminated. Standard precautions apply to: Blood All body fluids Secretions and excretions (except sweat) Nonintact skin Mucous membranes Handwashing is the easiest and most convenient method of preventing the spread of microorganisms After examining patients with known communicable diseases After coming in contact with blood or body fluids Before beginning invasive procedures Before touching patients who are at risk of infections Disinfectants and Antiseptics Chemical substances that kill pathogenic bacteria are classified as germicides and disinfectants Disinfection is the process of killing only microorganisms that are pathogenic. Chemical substances that inhibit the growth of but without killing pathogenic microorganisms are called antiseptics Alcohol, which is commonly used for medical or practical asepsis in medical facilities, has antiseptic but not disinfectant properties. Sterilization, which is usually performed by means of heat or chemicals, is the destruction of all microorganisms.  Centers for Disease Control and Prevention For the protection of health care workers, the U.S. Centers for Disease Control and Prevention (CDC) has issued recommendations for handling blood and other body fluids. According to the CDC, all human blood and certain body fluids should be treated as if they contain pathogenic microorganisms These precautions should apply to all contacts involving patients. Health care workers should wear gloves whenever they come into contact with blood, mucous membranes, wounds, and any surface or body fluid containing blood. Body fluids that may contain pathogenic microorganisms Blood Any fluid containing blood Amniotic fluid Pericardial fluid Pleural fluid Synovial fluid Cerebrospinal fluid Seminal fluid Vaginal fluid Urine Sputum  Health care workers must be cautious to prevent needle stick injuries. Needles should never be recapped, bent, broken, or clipped. Instead, they should be placed in a puncture-proof container and properly discarded Operating Room Must exercise extreme caution to prevent contaminating sterile objects in the OR. After checking the room setup, the radiographer should thoroughly wipe the x-ray equipment with a damp (not soaked) cloth before taking it into the OR.  Radiographer must exercise extreme caution to prevent contaminating sterile objects in OR.  Bowel Preparation Radiologic examinations Limited diet involving the abdomen Laxatives often require that the entire colon be cleansed Enemas before the examination so that diagnostic-quality radiographs can be obtained. The patient’s colon may be cleansed by one or any combination of the following Motion and Its Control Patient motion plays a large role in radiography A, Forearm radiograph of a patient who moved during the exposure. Note the fuzzy appearance of the edges of the bones. B, Radiograph of patient without motion.  Smooth (involuntary) Cardiac (involuntary) Striated (voluntary) INVOLUNTARY MUSCLES Involuntary motion is The primary method of caused by the following: reducing involuntary motion is to control the Heart pulsation length of exposure time – the less exposure time to Chill the patient, the better. Peristalsis Tremor Spasm Pain Anatomic and Radiographic Positioning Terminology JOHN REGNER S. ALUNAN, RRT  Understanding patient positioning requires a knowledge of the basic terminology relating to radiographic positioning: Anterior denotes the front of a body part, while the posterior denotes the back. Superior denotes the top of a body part, while inferior denotes the bottom. Medial indicates towards the midline. Body planes and positions Imaging of the body is often complicated by the fact that anatomic structures overlap each other. Diagnostic accuracy of radiographs generally refers to how well an exam can predict the presence (or absence) of a disease or condition.  Anterior denotes the front of a body part, while the posterior denotes the back. Superior denotes the top of a body part, while inferior denotes the bottom. Medial indicates towards the midline. Lateral indicates a location away from the midline. Proximal is towards the body’s center. Distal denotes being away from the body’s center. Cranial indicates towards the head and caudal towards the feet.  The sagittal plane indicates the vertical plane that is parallel to the midsaggital plane. The coronal plane is the vertical plane that is perpendicular to the median plane. Prone denotes lying face-down, while supine denotes lying on one’s back. 1. Anatomic position 2. Divisions of the Abdomen Quadrants of the Abdomen 3. Surface landmarks Surface landmarks are parts of the patient that can be palpated whatever the size or conformation of the patient. These landmarks should not change from patient to patient unless there is a specific anatomical variation. Surface landmarks 4. Body habitus Body habitus (or "bodily habitus") is the medical term for physique, and is categorized as either endomorphic (relatively short and stout), ectomorphic (relatively long and thin) or mesomorphic (muscular proportions). The four major types of body habitus are as follows Sthenic. Also known as average, mesomorphic. It is a moderately heavy build with the organs oriented as such: heart – moderately transverse lungs – moderate in length diaphragm – moderately high colon – spread evenly with a slight dip in the transverse colon gallbladder – right upper abdomen  Asthenic Also known as very slender, ectomorphic. It is a frail build with the organs oriented as such: heart – nearly vertical and in the midline lungs – long – apices above clavicles – may be broader above base diaphragm – low stomach – low – near the midline colon – low – folds on itself gallbladder – relatively lower – close to the midline Hyposthenic intermediate between the sthenic and asthenic body habitus types also known as slender similar to asthenic but the stomach, intestines and gallbladder are situated relatively higher in the abdomen  Hypersthenic Also known as endomorphic. It is a largerbuild with the organs oriented as such: heart – axis is almost transverse lungs – short – apices lie near the clavicles diaphragm – high stomach – high – transverse and in the middle colon – around the periphery of the abdomen gallbladder – high Body habitus Anatomical Terminology Directional Terms Directional terms describe Inferior or caudal - away the positions of structures from the head; lower relative to other structures (example, the foot is part or locations in the body. of the inferior extremity). Superior or cranial - toward the head end of the body; upper (example, the hand is part of the superior extremity).  Anterior or ventral - front (example, the kneecap is located on the anterior side of the leg). Posterior or dorsal - back (example, the shoulder blades are located on the posterior side of the body).  Medial - toward the midline of the body (example, the middle toe is located at the medial side of the foot). Lateral - away from the midline of the body (example, the little toe is located at the lateral side of the foot).  Proximal - toward or nearest the trunk or the point of origin of a part (example, the proximal end of the femur joins with the pelvic bone). Distal - away from or farthest from the trunk or the point or origin of a part (example, the hand is located at the distal end of the forearm). Body Cavities The cavities, or spaces, of The upper ventral, thoracic, or the body contain the chest cavity contains the heart, internal organs, or viscera. lungs, trachea, esophagus, large blood vessels, and nerves. The thoracic cavity is bound laterally by the ribs (covered by costal pleura) and the diaphragm caudally (covered by diaphragmatic pleura). Abdominal Cavity Contains most of the gastrointestinal tract as well as the kidneys and adrenal glands. The abdominal cavity is bound cranially by the diaphragm, laterally by the body wall, and caudally by the pelvic cavity. Pelvic Cavity The pelvic cavity contains most of the urogenital system as well as the rectum. The pelvic cavity is bounded cranially by the abdominal cavity, dorsally by the sacrum, and laterally by the pelvis. Cranial Cavity The upper portion, or the cranial cavity, houses the brain, and the lower portion, or vertebral canal houses the spinal cord. 6. Radiographic positioning terms: Body Positions Erect: either standing or sitting Recumbent: lying down Supine: lying on back Trendelenburg position: the patient is supine (on an inclined radiographic table) with the head lower than the feet Prone: lying face-down Lateral: side touches the cassette – right lateral: right side touches the cassette – left lateral: left side touches the cassette Lateral decubitus lying on one side, cassette is anterior/posterior Right lateral decubitus: lying on right side Left lateral decubitus: lying left side Movement Flexion: decrease in the angle of the joint Extension: increase in the angle of the joint  Abduction: movement of limb away from midline Adduction: movement of limb towards the midline  Pronation: movement of hand and forearm to bring the palm facing posterior Supination: movement of hand and forearm to bring the palm facing anterior Circumduction: circular movement of a joint using a combination of flexion, abduction, extension and adduction such that the distal limb describes a circle  Opposition: thumb brought to oppose another digit Reposition: thumb repositioned back to the anatomic position  Elevation: movement of the scapular superiorly Depression: movement of the scapular inferiorly  Eversion: movement of the sole of the foot away from the median plane Inversion: movement of the sole of the foot towards from the median plane  Protrusion: movement of the mandible, lips or tongue anteriorly Retraction: movement of the mandible, lips or tongue posteriorly Projections Depending on patient presentation, a single view or orthogonal projections comprising of the list projections below may be performed to visualize the region of interest.  Antero-posterior (AP): central ray passes, perpendicular to the coronal plane, from anterior to posterior Postero-anterior (PA): central ray passes, perpendicular to the coronal plane, from posterior to anterior – depending on the anatomic segment to radiograph, synonyms can be used, for example: occipito-frontal (skull); dorso-ventral (thorax); dorso-palmar (hand) Lateral Position Central ray, perpendicular to the sagittal plane and parallel to the coronal plane, passes from one side of body to the other Oblique Position Central ray passes through the body/body part through a plane which is at an angle to the transverse plane/coronal plane Axial Projection Central ray passes through (or parallel) to the long axis of the body – in some cases, however, the central ray runs through (or parallel) to the long axis of the skeletal segment studied (for example, the axial view of the calcaneus) 7. Source-image-receptor distance SID is the distance between the X-ray tube and the image receptor and is inversely proportional to magnification/distortion. In other words, the greater the SID, the less magnification/distortion will be apparent in the image.  For most radiographic examinations, the source-to-image distance (SID) is fixed at 100 cm (40 inches), and there are usually detents in the radiographic equipment that help the technologists to set this distance. Upright chest radiography is an exception, where the SID is typically set to 183 cm (72 inches). 8. Tube film alignment Alignment helps control geometric distortion and grid cutoff, resulting in more consistent radiographic image quality. While there is some variability in the implementation of these tools, most systems essentially operate in a similar way. Longitudinal Alignment: Longitudinal alignment is done manually by the radiographer. The tubestand and bucky can both be moved in the longitudinal direction. Lateral Alignment: While the bucky can move in the longitudinal direction in the table, its lateral position is fixed. Even when the table top is moved the lateral bucky position does not change. Vertical Alignment: Another tubestand switch is engaged when the focal spot is at the desired vertical distance from the image receptor, usually at a 40 inch source to image distance (SID) 9. Positioning aids Positioning aids help to hold patients in place and allow practitioners to move away to avoid scatter radiation. Sandbags – These are used to weigh down patients' limbs, to help keep them in position. Foam wedges and blocks These can be placed under a patients' sternum to prevent rotation of the spine. They may also be placed between limbs to raise one or the other. Rope ties These can be used to pull limbs forward and tie them so they are out of the collimated field Calipers We have been using an x-ray ruler called calipers to help the technologist measure the thickness of the body part they are imaging.  10. Accessory equipment Radiology accessories are widely used in a variety of facilities, including hospitals, doctor's offices, radiology clinics, dental offices, nursing homes, hospitals, and emergency rooms. These state-of-the-art radiology accessories assist certified X-Ray technologist in obtaining the necessary images for accurate diagnosis. X-Ray Viewer Designed for viewing dry and wet X-ray images. X-Ray Protective Glasses The glasses are available for protecting the eyes of the practitioner against X- ray during the Radio Graphic Diagnosis and Interventional Treatment. Lead Gloves Lead Gloves have seamless surface that does not allow any radiation to leak in. Convenient to wear and discard. Lead Apron - Wrap Around Used in medical facilities to protect workers and patients from unnecessary x-ray radiation exposure from diagnostic radiology procedures  Lead Apron - Velcro Type Used in medical facilities to protect workers and patients from unnecessary x-ray radiation exposure from diagnostic radiology procedures Thyroid Collars Thyroid collars provide protection for the neck and thyroid area. It helps to reduce patient exposure during intraoral radiography. Gonad Shield Ideal to protect the Male/Female reproductive organ Ovary Shield Ideal to protect the female reproductive organ  X-Ray Cassettes Made of specified aluminum alloy frame, specified engineering plastics and high-stamina aluminum plate. Size 6.5"X8.5" 8"X10" 10"X12" 14"X17" 12"X15" 14"X14" X-Ray Hangers Made of Stainless Steel Size 6.5"X8.5" 8"X10" 10"X12" 14"X17" 12"X15" 14"X14" Apron Stand for 5 Aprons Made of Stainless Steel, Floor Type with wheels Apron Stand also available for 3, 7 Aprons. Wall mounted type Apron Stand also available Chest Stand Floor Model Made of Steel Wall mounted Chest Stand also available. Safe Light for Dark Room Protection Screen Single Panel with Lead Glass Lead Letters Bony Thorax Regs Alunan, RRT Bony Thorax The bony thorax supports the walls of the pleural cavity and diaphragm used in respiration. The thorax is constructed so that the volume of the thoracic cavity can be varied during respiration. The thorax also protects the heart and lungs.  The bony thorax is formed by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae. The bony thorax protects the heart and lungs. Conical in shape, the bony thorax is narrower above than below, more wide than deep, and longer posteriorly than anteriorly. Sternum The sternum, or breastbone, is directed anteriorly and inferiorly and is centered over the midline of the anterior thorax A narrow, flat bone about 6 inches (15 cm) in length, the sternum consists of three parts: manubrium, body, and xiphoid process.  The sternum supports the clavicles at the superior manubrial angles and provides attachment to the costal cartilages of the first seven pairs of ribs at the lateral borders. Anterior aspect of bony thorax.  Anterior aspect of sternum and sternoclavicular joints Anterolateral Lateral sternum. oblique aspect of bony thorax.  The manubrium, the superior portion of the sternum, is quadrilateral in shape and is the widest portion of the sternum. At its center, the superior border of the manubrium has an easily palpable concavity termed the jugular notch.  The body is the longest part of the sternum (4 inches [10.2 cm]) and is joined to the manubrium at the sternal angle  The xiphoid process, the distal and smallest part of the sternum, is cartilaginous in early life and partially or completely ossifies, particularly the superior portion Ribs The 12 pairs of ribs are numbered consecutively from superiorly to inferiorly The rib number corresponds to the thoracic vertebra to which it attaches.  A typical rib consists of a head, a flattened neck, a tubercle, and a body The ribs have facets on their heads for articulation with the vertebrae.  A, Superior aspect of rib articulating with thoracic vertebra and sternum. B, Enlarged image of costovertebral and costotransverse articulations. C, MRI transverse image showing costovertebral Bony Thorax Articulations The sternoclavicular joints are the only points of articulation between the upper limbs and the trunk Articulation between the sternal extremity of the clavicles and the clavicular notches of the manubrium, these synovial gliding joints permit free movement  A, Anterior aspect of thoracic spine, showing costovertebral articulations. B, Anterior aspect of manubrium, sternum, and first two ribs, showing articulations. SC, sternoclavicular. C, Lower sternum and ribs, showing intercostal, costochondral, and sternocostal joints. D, CT cross-section image of upper thorax showing manubrium and angulation of sternoclavicular joints (arrows).  The tubercle of a rib articulates with the anterior surface of the transverse process of the lower vertebra at the costotransverse joint The costotransverse articulation is also a synovial gliding articulation  Costochondral articulations are found between the anterior extremities of the ribs and the costal cartilages These articulations are cartilaginous synchondroses and allow no movement.  The manubriosternal joint is a cartilaginous symphysis joint, and the xiphisternal joints are cartilaginous synchondrosis joints that allow little or no movement RESPIRATORY MOVEMENT The normal oblique On deep inspiration, the orientation of the ribs anterior ends of the ribs changes little during quiet are carried anteriorly, respiratory movements superiorly, and laterally The degree of obliquity while the necks are rotated decreases with deep inferiorly inspiration and increases with deep expiration.  A, Full inspiration with posterior ribs numbered. B, Full expiration with ribs numbered. Anterior ribs are labeled with A. DIAPHRAGM The ribs located above the The position of the diaphragm are best diaphragm varies with examined radiographically body habitus: It is at a through the air-filled lungs, higher level in whereas the ribs situated hypersthenic patients and below the diaphragm must at a lower level in asthenic be examined through the patients upper abdomen.  A, A hypersthenic patient has a diaphragm positioned higher. B, An asthenic patient has a diaphragm positioned lower. C, Chest radiograph of a hypersthenic patient. D, Chest radiograph of an asthenic patient.  The position of the it is desirable to place the diaphragm changes patient in the upright considerably with the body position for examination of position, reaching its the ribs lowest level when the body is upright and its highest level when the body is supine TRAUMA PATIENTS The first and usually the To show the site and only requirement in the extent of rib injury, but also initial radiographic to investigate the examination of a patient possibility of injury to the who has sustained severe underlying structures by trauma to the rib cage is to depressed rib fractures. take AP and lateral projections of the chest.  Ribs SUMMARY OF ANATOMY – Costal cartilage Bony thorax – True ribs – False ribs – Sternum – Floating ribs – Ribs (12) – Cervical ribs – Thoracic vertebrae (12) – Lumbar ribs Sternum – Intercostal spaces – Head – Manubrium – Neck – Jugular notch – Tubercle – Clavicular notch – Body – Body – Facets – Vertebral end – Sternal angle – Sternal end – Xiphoid process – Angle – Costal groove  Bony thorax articulations – Sternoclavicular – Costovertebral – Costotransverse – Costochondral – Sternocostal – Interchondral – Manubriosternal – Xiphisternal SUMMARY OF PATHOLOGY Condition Definition Fracture Disruption of the continuity of bone Metastases Transfer of a cancerous lesion from one area to another Osteomyelitis Inflammation of bone owing to a pyogenic infection Osteopetrosis Increased density of atypically soft bone Osteoporosis Loss of bone density Paget disease Thick, soft bone marked by bowing and fractures Tumor New tissue growth where cell proliferation is uncontrolled Chondrosarcoma Malignant tumor arising from cartilage cells Multiple myeloma Malignant neoplasm of plasma cells involving the bone marrow and causing destruction of bone EXPOSURE TECHNIQUE CHART ESSENTIAL PROJECTIONS BONY THORAX Bony Thorax—Positioning Considerations Sternum 15°–20° RAO achieves – The routine for a sternum this best. generally includes a lateral breathing technique and an oblique wherein the generally is used to blur sternum is shifted to the left of the spine and is out the lung markings and superimposed over the the ribs overlying the homogeneous heart sternum. shadow. Right Anterior Oblique (RAO) Sternum Erect (preferred) or semiprone, turned 15°–20° with right side down. (A thin-chested patient requires slightly more obliquity than a thick-chested patient.) Center sternum to CR at midline of table or IR holder Central Ray: CR ⊥, to midsternum (midway between jugular notch and xiphoid process) SID: 40-44″ (102-113 cm) Lateral Sternum Erect (seated or standing), or recumbent lying on side with vertical CR; or supine with cross-table CR for severe trauma Draw shoulders and arms back. Align sternum to CR at midline of IR holder. Top of IR 1.5″ (4 cm) superior to level of jugular notch  Evaluation Criteria: Oblique (RAO) Sternum Anatomy Demonstrated: Entire sternum superimposed on heart shadow Position: Correct rotation, sternum visualized alongside vertebral column Exposure: 2- to 3-second exposure using breathing technique; lung markings appear blurred Optimal contrast and density (brightness) to visualize entire sternum Ribs (AP) The ribs AP view is a specific projection employed in the assessment of the posterior ribs. Patient position the patient is erect facing the x-ray tube, posterior portion resting on the upright detector the chin is raised as to be out of the image field hands are placed by the patient's side  Technical factors orientation Anteroposterior projection – portrait suspended inspiration (ribs above exposure the diaphragm) – 60-70 kVp centering point (above the – 30-40 mAs diaphragm) SID 10 cm below the jugular notch at the midsagittal plane – 100 cm centering point (below the grid diaphragm) – yes midway between the xiphoid process and the 12th rib  Image technical evaluation the chin should not be superimposing any structures minimal to no superimposition of the scapulae borders on the lung fields sternoclavicular joints are equal distant apart the clavicle is in the same horizontal plane a minimum of ten posterior ribs is visualized above the diaphragm the ribs and thoracic cage are seen only faintly over the heart clear vascular markings of the lungs should be visible Ribs (AP oblique view) The AP oblique rib projection is performed to best demonstrate the axillary ribs. Oblique ribs may be conducted either as an anterior oblique or posterior oblique view.  Patient position The patient may be erect or supine with their right (RPO) or left posterior (LPO) side closest to the image receptor 2 affected side is rotated 45 degrees towards the IR 2 the patient’s arm closest to the receptor is raised and placed on their head, with the other on their hip Transthoracic supine lateral scapula Indication – The modified supine lateral view is performed to identify dislocations and scapula fractures when patients are unable to move and are supine. Patient position – patient is supine Technical factors respiration exposure – suspended inspiration – 110 – 125 kVp 2 centering point – 12 – 20 mAs – above diaphragm: level of SID T7 – 183 cm 2 grid – yes Clavicle The clavicle (collarbone) extends between the manubrium of the sternum and the acromion of the scapula. It is classed as a long bone and can be palpated along its length The clavicle has three main functions: 1. Attaches the upper limb to the trunk as part of the ‘shoulder girdle’. 2. Protects the underlying neurovascular structures supplying the upper limb. 3. Transmits force from the upper limb to the axial skeleton. Bony Landmarks and Articulations The clavicle is a slender bone with an ‘S’ shape. Facing forward, the medial aspect is convex, and the lateral aspect concave. It can be divided into a sternal end, a shaft and an acromial end. Sternal (medial) End The sternal end contains a large facet – for articulation with the manubrium of the sternum at the sternoclavicular joint. The inferior surface of the sternal end is marked by a rough oval depression for the costoclavicular ligament (a ligament of the SC joint). Shaft The shaft of the clavicle acts a point of origin and attachment for several muscles – deltoid, trapezius, subclavius, pectoralis major, sternocleidomastoid and sternohyoid Acromial (lateral) End The acromial end houses a Conoid tubercle – attachment small facet for articulation with point of the conoid ligament, the acromion of the scapula at the medial part of the the acromioclavicular joint. coracoclavicular ligament. It also serves as an attachment Trapezoid line – attachment point of the trapezoid ligament, point for two ligaments: the lateral part of the coracoclavicular ligament. The coracoclavicular ligament is a very strong structure, effectively suspending the weight of the upper limb from the clavicle. Clavicle series The radiographic series of Indications the clavicle is utilized in – Trauma emergency departments to – Bony tenderness assess the clavicle, – Suspected fracture acromioclavicular and – Congenital abnormalities sternoclavicular joint. – Obvious deformity Clavicle AP The projection demonstrates the shoulder in its natural anatomical position. Patient position – patient is preferably erect – the midcoronal plane of the patient is parallel to the image receptor, in other words, the patient's back is against the image receptor – the clavicle of the affected side is at the center of the image receptor – affected arm is in a neutral position by the patient side Technical factors Centering point – mid clavicle Orientation – landscape Exposure – 60-70 kVp – 10-18 mAs Clavicle Tangential AP 'straightens' out the Indication clavicle – This projection straightens often used to better out the clavicle and projects most of it above the scapula visualize occult clavicle and second and third rib. It fractures can help to determine angulation of fractures and dislocation  centering point – just below mid clavicle – angled cephalic 15-30° orientation – landscape Sternoclavicular joint (serendipity view) The serendipity view is a Indications specialized radiographic – The serendipity view is projection utilized in the often requested in the setting of suspect context of significant trauma dislocations of the that can result in sternoclavicular joint sternoclavicular joint dislocation or medial end clavicular fractures.  Patient position – supine on the radiographic examination table – axial projection centering point – at the level of the sternoclavicular joint with a 40-degree cephalic angle Acromioclavicular joint (AP weight-bearing view) The acromioclavicular joint Indications AP weight-bearing view, – This view is used in the often performed together assessment of possible with the normal non- acromioclavicular joint weight-bearing AP view, separation and may be done bilaterally to allow comparison of joint spaces Patient position – the patient is erect holding a weight in the hand of the affected side – the patient's back is against the image receptor – the acromioclavicular joint of the affected side is at the center of the image receptor – affected arm is in a neutral position by the patient side  Centering point – at the acromioclavicular joint Acromioclavicular joint (Zanca view) The Zanca view is a Indications – The Zanca view is used in the specialized projection of assessment of acute and chronic the acromioclavicular joint acromioclavicular joint injuries. The (ACJ), which will better view optimizes visualization of the acromioclavicular joint, as overlying demonstrate the structures can limit assessment in acromioclavicular joint free an AP projection, with distal osteophytes better visualized. from superimposition  Patient position – patient is erect – midcoronal plane of the patient is parallel to the image receptor, in other words, the patient's back is against the image receptor – acromioclavicular joint of the affected side is at the center of the image receptor – affected arm is in a neutral position by the patient side Centering point – at the acromioclavicular joint with a 10-15 cephalad angle Modified Alexander view (AC) joint In the Alexander method (AP axial projection), which is superior in delineating abnormalities of AC joint, the CR is directed to the coracoid process at a cephalic angle of 15°. This angulation projects the AC joint above the acromion Scapula The scapula is also known as It is a triangular, flat bone, the shoulder blade. which serves as a site for It articulates with the humerus attachment for many muscles. at the glenohumeral joint, and with the clavicle at the acromioclavicular joint. In doing so, the scapula connects the upper limb to the trunk. Costal Surface Originating from the superolateral surface of the costal scapula is the coracoid The costal (anterior) surface of process. the scapula faces the ribcage. It is a hook-like projection, It contains a large concave which lies just underneath the depression over most of its clavicle. surface, known as the subscapular fossa. – The subscapularis (rotator cuff muscle) originates from this fossa. Lateral Surface Infraglenoid tubercle – a The lateral surface of the roughening immediately inferior scapula faces the humerus. It is to the glenoid fossa. the site of the glenohumeral joint Important bony landmarks include: – Glenoid fossa – a shallow cavity, located superiorly on the lateral border. – Supraglenoid tubercle – a roughening immediately superior to the glenoid fossa.  Infraspinous fossa – the area below Posterior Surface the spine of the scapula, it displays a The posterior surface of the scapula convex shape. faces outwards. It is a site of origin Supraspinous fossa – the area for the majority of the rotator cuff above the spine of the scapula, it is muscles of the shoulder much smaller than the infraspinous fossa, and is more convex in shape. It is marked by: – Spine – the most prominent feature of the posterior scapula. – Acromion – projection of the spine that arches over the glenohumeral joint and articulates with the clavicle at the acromioclavicular joint  Articulations The scapula has two main articulations: Glenohumeral joint – between the glenoid fossa of the scapula and the head of the humerus. Acromioclavicular joint – between the acromion of the scapula and the clavicle. Scapula Indications – trauma Radiographic assessment of the scapular bone of the – suspected primary or shoulder girdle. metastatic lesions Scapula AP The scapula AP view is a specialized projection of the scapular bone, performed in conjunction with the lateral scapular view This projection can be performed erect or supine, involving 90- degree abduction of the affected arm.  centering point – 5 cm inferior to the coracoid process breathing – a breathing technique is the most effective way to perform this projection Shoulder (lateral scapula view) This view is a pertinent projection to assess suspected dislocations, scapula fractures, and degenerative changes. Useful in seeing both the coracoid and acromion process in profile.  Patient position – erect or sitting, facing the upright detector – rotated in an anterior oblique position so the anterior portion of the shoulder is touching the upright detector – the hand is placed on the patient's abdomen with the arm flexed – degree of anterior rotation can vary from patient to patient – scapula should be end-on to the upright detector, and this can be done via palpation of the scapula border  Centering point – the level of the glenohumeral joint on the posterior aspect of the patient (5 cm below the top of the shoulder) – central to the medial scapula border