Diagnostic Radiology Notes

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Elbow CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Elbow using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic INRODUCTION Elbow Note 1.LATERAL Direction and Centring of X-ray Beam Essential Image Characteristics Notes 2.Antero-posterior Direction and Centering of X-ray Beam MODIFIED TECHNIQUE ELBOW These are ; 1.Antero-posterior – partial flexion a.Antero-posterior – forearm in Direction and location of X-ray beam b.Antero-posterior – upper arm in 2.Antero-posterior – full flexion a.Axial – upper arm in contact b.Axial – forearm in contact Lateral head of radius Position of patient and image receptor Proximal radio-ulnar joint – oblique Ulnar groove – axial Radiological considerations ELBOW INRODUCTION Optimum projections of the elbow joint are obtained when the upper arm is in the same plane as the forearm. For many examinations, the patient will be seated at the table with the shoulder lowered, so that the upper arm, elbow and forearm are on the same horizontal level. Elbow To gain the patient’s confidence, the lateral projection is taken first, because the patient will find it easier to adopt this position. The humerus must be rotated through 90° to make sure that two projections at right-angles are obtained of the humerus as well as the ulna and radius. Alternatively, if the limb cannot be moved, two projections at right-angles to each other can be taken by keeping the limb in the same position and moving the tube through 90° between projections. If the patient cannot extend the elbow fully, modified positioning is necessary for the antero-posterior projection. Note Special care should be taken with a child suspected of having a supracondylar fracture of the humerus. Modified projections must be obtained without moving the arm from the collar and cuff that should be used to immobilize the arm. 1.LATERAL Position of Patient and Image Receptor The patient is seated alongside the table, with the affected side nearest to the table. The elbow is flexed to 90 degrees and the palm of the hand is rotated so that it is at 90 degrees to the tabletop. The shoulder is lowered so that it is at the same height as the elbow and wrist, such that the medial aspect of the entire arm is in contact with the tabletop. The image receptor is placed under the patient’s elbow, with its centre to the elbow joint. The limb is immobilized using sandbags. Direction and Centring of X-ray Beam The vertical central ray is centered over the lateral epicondyle of the humerus. Essential Image Characteristics The central ray must pass through the joint space at 90 degrees to the humerus, i.e. the epicondyles should be superimposed. The image should demonstrate the distal third of humerus and the proximal third of the radius and ulna. Notes Care should be taken when a supracondylar fracture of the humerus is suspected. In such cases, no attempt should be made to extend the elbow joint, and a modified technique must be employed RADIOGRAPHIC ANATOMY -LATERAL 2.Antero-posterior Position of Patient and Image Receptor The patient is seated alongside the table with the affected arm nearest to the table. The arm is extended fully, such that the posterior aspect of the entire limb is in contact with the tabletop and the palm of the hand is facing upwards. The image receptor is positioned under the elbow joint. The arm is adjusted such that the medial and lateral epicondyles are equidistant from the image receptor. The limb is immobilized using sandbags. Direction and Centering of X-ray Beam The vertical central ray is centered through the joint space 2.5 cm distal to the point midway between the medial and lateral epicondyles of the humerus. Essential Image Characteristics The central ray must pass through the joint space at 90 degrees to the humerus to provide a satisfactory view of the joint space. The image should demonstrate the distal third of humerus and the proximal third of the radius and ulna. RADIOGRAPHIC ANATOMY-AP Notes When the patient is unable to extend the elbow to 90 degrees, a modified technique is used for the antero-posterior projection. If the limb cannot be moved, two projections at right-angles to each other can be taken by keeping the limb in the same position and rotating the X-ray tube through 90 degrees. MODIFIED TECHNIQUE ELBOW These projections may be useful in cases of trauma when the patient is unable to extend the elbow joint. These are ; Forearm in contact with image receptor fosuspected radial head and olecranon fractures. Upper arm in contact with image receptor for suspectedsupracondylar fractures. Axial projection when the patient cannot extend their arm to any extent. 1.Antero-posterior – partial flexion Adaptation of technique If the patient is unable to extend the elbow fully, the positioning for the AP projection may be modified. For a general survey of the elbow, or if the main area of interest is the proximal end of the radius and ulna, then the posterior aspect of the forearm should be in contact with the image detector. If the main area of interest is the distal end of the humerus, however, then the posterior aspect of the humerus should be in contact with the image detector. If the elbow is immobilized in the fully flexed position, then an axial projection must be used instead of the AP projection. Notes In both of the above cases, some superimposition of the bones will occur. However, gross injury and general alignment can be demonstrated. a.Antero-posterior – forearm in contact Position of patient and image receptor The patient is seated alongside the table, with the affected side nearest to the table. The posterior aspect of the forearm is placed on the table, with the palm of the hand facing upwards. The image receptor is placed under the forearm, with its centre under the elbow joint. The arm is adjusted such that the medial and lateral epicondyles of the humerus are

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Facial Bones CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Facial Bones using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic These are the bones which form the face. ANATOMY Facial Bones • Sphenoid sinus: this structure lies immediately beneath the sella turcica and posterior to the Ethmoid sinuses. Radiological considerations Assessment tools The basic views The examination of the facial bones is guided by the indication of the examination. Occipito-mental (OM) (chin nose) view Positioning the patient Essential image characteristics (Figs 8.28b, 8.28c) Common faults and solutions LATERAL Position of patient and cassette Supine Direction and centring of the X-ray beam Essential image characteristics ZYGOMATIC ARCHES NASAL BONES A view at right angles to this is obtained by using:- MANDIBLE Postero-anterior (PA) Lateral oblique Additional view TEMPORAL-MANDIBULAR JOINTS An additional projection may be required with the teeth clenched. Paranasal sinuses Occipito-mental FACIAL BONES These are the bones which form the face. These are composed of the maxilla (upper jaw), the nasal, lacrimal, vomer, palatine and zygomatic bones and the mandible. The mandible is mostly examined separately. ANATOMY The facial skeleton is complex and the series of images produced are difficult to assess radiologically for diagnosis; optimal projections are therefore extremely important. The facial bones are a series of 14 irregular bones that collectively are attached to the antero-inferior aspect of the skull. Within these bones, and some of the bones forming the cranial base, are a series of air-filled cavities known as the paranasal air sinuses. Facial Bones These communicate with the nasal cavity and the margins of them appear of higher radiographic density than surrounding bones, as the air within them offers little attenuation to the X-ray beam. If the sinuses become filled with fluid due to pathology, e.g. blood in trauma or chronic infection, this results in a decrease in radiographic density and increase in radio-opacity. The sinuses are therefore best imaged by using a horizontal beam, with the patient in the erect position thus demonstrating fluid levels. Facial Bones Maxillary sinuses (maxillary antra): paired, pyramidal shaped structures located within the maxillary bone either side of the nasal cavity. These are the largest of the sinuses. Frontal sinuses: these are paired structures located within the frontal bone adjacent to the fronto-nasal junction (acanthion). They are very variable in size and shape and in some individuals they may be absent. • Sphenoid sinus: this structure lies immediately beneath the sella turcica and posterior to the Ethmoid sinuses. Ethmoid sinuses: a labyrinth of small air spaces that collectively form part of the medial wall of the orbit and the supero-lateral walls of the nasal cavity Radiological considerations The facial bones and sinuses are complicated structures and the radiographer must be aware of their anatomical position and radiographic appearances in order to assess the diagnostic suitability of an image. The accompanying diagrams and radiographs outline the position of the major structures and landmarks used for image assessment. If serious facial injury is suspected clinically, CT will give more detailed information, with the ability to perform 3D reconstructions. Facial Bones Due to the complexity of facial fracture patterns there are some well-known fracture classifications and assessment models to allow radiographers and clinicians viewing/reporting upon plain facial images to demonstrate the severity and involvement of the facial skeleton. Assessment tools McGrigors’ lines are lines on the facial skeleton that can be followed to exclude or confirm any breach in continuity and thus a facial fracture. The lines are visible on any OM image.6 Follow all 3 lines: Line 1: fronto-zygomatic suture across the superior orbital margin, nasion and opposing side. Line 2: superior aspect of zygomatic arch, frontal process of zygoma, inferior orbital margin, nasal bones and opposing side. Line 3: inferior aspect zygomatic arch, base of maxillary sinuses, maxilla at base of upper teeth and opposing side. The basic views Occipito-mental (OM) Lateral OM 30⁰ caudad The examination of the facial bones is guided by the indication of the examination. The above routine views are for the general facial radiographs but depending on indication, views likeTowne’s view may be included. Occipito-mental (OM) (chin nose) view This projection shows the orbits, nasal region, the maxillae and the zygomatic bones. Positioning the patient The patient is preferably seated facing an erect-Bucky but the examination can be carried out with the patient lying prone on the Bucky table if necessary. The patient’s nose and chin are in contact with the mid-line of the Bucky and then the head adjusted to bring orbito-meatal line at 45⁰ to the central ray directed perpendicular to the film. Facial Bones Centre:- towards the mid-line at the level of the lower border of the orbits with the central ray perpendicular to the film. Essential image characteristics (Figs 8.28b, 8.28c) The petrous ridges should be demonstrated inferior to the floors of the maxillary sinuses. There should be no rotation. This can be checked by ensuring the distance from the lateral orbital wall to the outer skull margins is equidistant on both sides. Facial Bones In case of injury to the face, better results may be obtained by raising the chin still further so that the central ray makes an angle of 60⁰ with the mid-line. As this tilt is too great for the patient to attain the tube placed high and tilted towards the feet i.e tilt the Orbito-meatal line 40⁰ and tilt the tube 20⁰ Centre as before. Occasionally accident cases are unable to lie prone and film can be taken in the reverse direction (Mento-Occipital). The patient is supine the OM line 65⁰ to the film, tube tilted approximately 20⁰ so that the incident beam makes an angle of 45⁰ with the Orbito-meatal line. Centre over the mouth Common faults and solutions Petrous ridges superimposed over the inferior part of the maxillary sinuses. In this case several faults may have occurred. The orbito-meatal baseline may not

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Fingers CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Fingers using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic FINGERS Clinical indications BASIC PROJECTION/VIEWS Dorsi-palmar (DP)- postero-anterior Direction and location of X-ray beam Essential image characteristics Radiological considerations Lateral- index and middle fingers Thumb Lateral Antero-posterior (AP) Postero-anterior foreign body Note FINGERS SESSION: 04 Clinical indications Fractures and dislocations of the distal, middle, and proximal phalanges; distal metacarpal; and associated joints Pathologic processes, such as osteoporosis and osteoarthritis BASIC PROJECTION/VIEWS Two projections are routinely taken, a postero-anterior a lateral. The adjacent finger is routinely imaged unless the injury is very localized, e.g. a crush injury to the distal phalanx. Each image is acquired using an 18cm × 24 cm Dorsi-palmar (DP)- postero-anterior Position of patient and image receptor The patient is positioned seated alongside the table as for a postero-anterior projection of the hand. The forearm is pronated with the anterior (palmer) aspect of the finger(s) in contact with the image receptor. The finger(s) are extended and separated. A sandbag may be placed across the dorsal surface of the wrist for immobilization. Direction and location of X-ray beam The collimated vertical beam is centered over the proximal interphalangeal joint of the affected and adjacent finger PA OF SECOND DIGIT PA OF FOURTH DIGIT Essential image characteristics The image should include the fingertips, including soft tissue, and distal 3rd of the metacarpal bone(s). It is necessary to include adjacent finger(s), i.e. the 2nd and 3rd or 4th and 5th to aid in identifying the relevant anatomy. If this is the case, then care should be taken to avoid superimposition, particularly in the lateral projection, by fully extending one finger and partly flexing the other. PA OF THE FOURTH FINGER Radiological considerations The image should include the fingertip and the distal 3rd of the metacarpal bone. Lateral- index and middle fingers Position of patient and image receptor The patient is seated alongside the table with the arm abducted and medially rotated to bring the lateral aspect of the index finger into contact with the image detector. The raised forearm is supported. The index finger is fully extended and the middle finger slightly flexed to avoid superimposition. The middle finger is supported on a non-opaque pad. The remaining fingers are fully flexed into the palm of the hand and held there by the thumb. Direction and location of X-ray beam The collimated vertical central ray is centred over the proximal interphalangeal joint of the affected finger. Essential image characteristics The image should include the fingertip and the distal 3rd of the metacarpal bone. Thumb Basic projections/VIEWS Two projections are routinely taken, a lateral an antero-posterior. Occasionally a postero-anterior may be undertaken if the patient is unable to get into position because of a painful fracture 18 × 24 CM CASSETES Lateral Position of patient and image receptor The patient is seated alongside the table with the arm abducted, the elbow flexed and the anterior aspect of the forearm resting on the table. The thumb is flexed slightly and the palm of the hand is placed on the image receptor. The palm of the hand is raised slightly with the fingers partially flexed and may be supported on a non-opaque pad, such that the lateral aspect of the thumb is in contact with the image receptor. Direction and location of X-ray beam The collimated vertical beam is centered over the 1st MCPJ. Essential image characteristics The image should include the fingertip and the distal 1/3 of the metacarpal bone. Where there is a possibility of injury to the base of the 1st metacarpal, the carpo-metacarpal joint must be included on the image. Antero-posterior (AP) Position of patient and image receptor The patient is seated facing away from the table with the arm extended backwards and medially rotated at the shoulder. The hand may be slightly rotated to ensure that the 2nd, 3rd and 4rth metacarpals are not superimposed on the base of the 1st metacarpal. The patient leans forward, lowering the shoulder so that the 1st metacarpal is parallel to the tabletop. The image receptor is placed under the wrist and thumb and oriented to the long axis of the metacarpal. Direction and location of X-ray beam The collimated vertical central ray is centred over the 1st MCPJ. Postero-anterior foreign body Position of patient and image receptor With the hand in the postero-anterior position, the palm of the hand is rotated through 90° to bring the medial aspect of the hand in contact with the table and the palm vertical. The image receptor is placed under the hand and wrist, with its long axis along the line of the thumb. The fingers are extended and the hand is rotated slightly forwards until the anterior aspect of the thumb is parallel to the image receptor. The thumb is supported in position on a non-opaque pad. Direction and location of X-ray beam The collimated vertical beam is centered over the base of the 1st metacarpal. Note The use of the postero-anterior projection maintains the relationship of the adjacent bones, i.e. the radius and ulna, which is essential in cases of suspected foreign body in the thenar eminence. When undertaking a PA projection there is an increased object to detector distance. This will lead to magnification of the image and any associated unsharpness. To prevent this, increase the focus receptor distance (ffd). Radiological considerations Fracture of the base of the 1st metacarpal through the joint surface may be associated with dislocation due to the pull of the abductor and extensor tendons of the thumb. This is known as Bennett’s fracture and may cause functional impairment and early degenerative disease if not corrected. In contrast, a fracture that does not transgress the articular surface does not dislocate and does not have the same significance (Rolando fracture). ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Forearm Radiography CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Forearm Radiography using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic Two projections are routinely taken, an antero-posterior and lateral. Antero-posterior Direction and Centring of X-ray Beam Essential Image Characteristics Note Radiation protection Lateral (MEDIAL PROJECTION) Direction and Centering of X-ray Beam Radiological considerations FOREARM Two projections are routinely taken, an antero-posterior and lateral. The projections must be at right-angles to each other and demonstrate the full length of the radius and ulna including both the elbow and the wrist joint. The antero-posterior projection with the forearm supinated demonstrates the radius and ulna lying side by side. Poor quality images have superimposition of the radius and ulna and this may obscure pathology(pronation of the fore arm). 24 × 30 cm image receptor is recomended Antero-posterior Position of patient and image receptor The patient is seated alongside the table, with the affected side nearest to the table. The arm is abducted and the elbow joint is fully extended, with the supinated forearm resting on the table. The shoulder is lowered to the same level as the elbow joint. The image receptor is placed under the forearm to include the wrist joint and the elbow joint. The arm is adjusted such that the radial and ulnar styloid processes and the medial and lateral epicondyles are equidistant from the image receptor. The lower end of the humerus and the hand may be immobilized using sandbags. Direction and Centring of X-ray Beam The vertical central ray is centred in the midline of the forearm to a point midway between the wrist and elbow joints. Essential Image Characteristics Both the elbow and the wrist joint must be demonstrated on the radiograph. Both joints should be seen in the true antero-posterior position, with the radial and ulnar styloid processes and the epicondyles of the humerus equidistant from the image receptor. Note The postero-anterior projection of the forearm with the wrist pronated is not satisfactory because, in this projection, the radius is superimposed over the ulna for part of its length Radiation protection Careful technique and close collimation will assist in reducing the patient dose. Lateral (MEDIAL PROJECTION) Position of Patient and Image Receptor From the antero-posterior position, the elbow is flexed to 90 degrees. The humerus is internally rotated to 90 degrees to bring the medial aspect of the upper arm, elbow, forearm, wrist and hand into contact with the table. The image receptor is placed under the forearm to include the wrist joint and the elbow joint. The arm is adjusted such that the radial and ulnar styloid processes and the medial and lateral epicondyles are superimposed. The lower end of the humerus and the hand are immobilized using sandbags. Direction and Centering of X-ray Beam The vertical central ray is centred in the midline of the forearm to a point midway between the wrist and elbow joints. Essential image characteristics Both the elbow and the wrist joint must be demonstrated on the image. Both joints should be seen in the true lateral position, with the radial and ulnar styloid processes and the epicondyles of the humerus superimposed. Note In trauma cases, it may be impossible to move the arm into the positions described, and a modified technique may need to be employed to ensure that diagnostic images are obtained. If the limb cannot be moved through 90°, then a horizontal beam should be used Both joints should be included on each image. No attempt should be made to rotate the patient’s hand. Radiological considerations When two or more bones such as the radius and ulna form a ring, fracture of one of the bones is often associated with fracture or dislocation elsewhere in the ring, especially if the fracture is displaced or the bone ends overlap. In Galeazzi fracture there is a fracture of the radius with dislocation of the distal ulna, while in Monteggia fracture there is fracture of the ulna with dislocation of the head of the radius. In forearm fracture, therefore, both ends of both bones, as well as the proximal and distal radio-ulnar joints, must be demonstrated. Basic forearm projections do not give adequate views of the elbow and should not be relied upon for diagnosis of radial head injury. If an elbow joint effusion is shown, formal projections of the elbow joint will be required. ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW ALL LEVEL NOTESALL DIAGNOSTIC RADIOLOGY NOTES Need These Notes as PDF? Need a clean, well-formatted PDF copy for offline study, revision or printing? Request the complete notes directly through WhatsApp. GET WELL-FORMATTED PDF NOTES

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Hand Part 1 CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Hand Part 1 using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic RADIOGRAPHY OF THE UPPER LIMB Introduction HAND Basic projections/VIEWS Dorsi-palmar (DP) Direction and Centering of X-ray Beam Esseimage characteristicsntial 2.Anterior oblique (DP oblique) Direction and centering of the X-ray beam Essential image characteristics Common faults and remedies Note RADIOGRAPHY OF THE UPPER LIMB SESSION: 04 PART: 1 Introduction Although radiographic examinations of the upper limb are routine a high standard of radiography must be maintained. The importance of registering the correct right or left marker at the time of the exposure cannot be over emphasised nor can the importance of recording the correct patient identification and date of the examination. To ensure maximum radiation protection when using computed radiography (CR) cassettes, the patient should be seated at the side or end of the table with the lower limbs and gonads away from the primary beam, i.e. with the legs to the side of the table not under it and the beam should be collimated within the margins of the image receptor HAND Clinical Indications Fractures, dislocations. Foreign bodies of the phalange metacarpals, and all joints of the hand Pathologic processes such as osteoporosis and osteoarthritis Basic projections/VIEWS Two projections are routinely taken, Dorsi-palmar (DP) Anterior oblique (DP oblique) (18 cm × 24 cm) cassette size. Dorsi-palmar (DP) Position of patient and image receptor The patient is seated alongside the table with the affected arm nearest to the table. The forearm is pronated and placed on the table with the palmer surface of the hand in contact with the image receptor. The fingers are separated and extended but relaxed to ensure that they remain in contact with the image receptor. The wrist is adjusted so that the radial and ulna styloid processes are equidistant from the image receptor. A sandbag is placed over the lower forearm for immobilization. Direction and Centering of X-ray Beam The collimated vertical beam is centered over the head of the 3rd metacarpal. Esseimage characteristicsntial The image should demonstrate all the phalanges, including the soft-tissue fingertips, the carpal and metacarpal bones, and the distal end of the radius and ulna. The interphalangeal and metacarpo-phalangeal and carpo-metacarpal joints should be demonstrated clearly. No rotation. Radiographic anatomy 2.Anterior oblique (DP oblique) Position of patient and image receptor From the basic postero-anterior position, the hand is externally rotated 45° with the fingers extended. The fingers should be separated slightly and the hand supported on a 45° non-opaque pad. A sandbag is placed over the lower end of the forearm for immobilisation. Direction and centering of the X-ray beam The collimated vertical beam is centred over the head of the 5th metacarpal. The tube is then angled so that the central ray passes through the head of the 3rd metacarpal, enabling a reduction in the size of the field Essential image characteristics The image should demonstrate all the phalanges, including the soft tissue of the fingertips, the carpal and metacarpal bones and the distal end of the radius and ulna. The correct degree of rotation has been achieved when the heads of the 1st and 2nd metacarpals are seen separated whilst those of the 4th and 5th are just superimposed Common faults and remedies Over rotation will project the metacarpals and digits on top of each other Under rotation will fail to open out the metacarpals. Note The exposure should provide adequate penetration too visualize the metacarpal bones 10 point plan image quality ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW ALL LEVEL NOTESALL DIAGNOSTIC RADIOLOGY NOTES Need These Notes as PDF? Need a clean, well-formatted PDF copy for offline study, revision or printing? Request the complete notes directly through WhatsApp. GET WELL-FORMATTED PDF NOTES

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Hand Part 2 CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Hand Part 2 using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic RADIOGRAPHIC OF THE HAND PART 2 (special consideration) BOTH HANDS Dorsi-palmar Direction and location of the X-ray beam Essential image characteristics Antero-posterior oblique both Position of the patient and image receptor Direction and location of X-ray beam Radiation protection Lateral – hand Position of patient and image receptor Radiological considerations RADIOGRAPHIC OF THE HAND PART 2 (special consideration) PART: 2 BOTH HANDS dorsi-Palmar-BOTH HANDS This projection is often used to demonstrate subtle radiographic changes associated with early rheumatoid arthritis and to monitor the progress of the disease. Dorsi-palmar Position of patient and cassette Ideally, the patient is seated alongside the table. However, if this is not possible due to the patient’s condition, the patient may be seated facing the table Both forearms are pronated and placed on the table with the palmer surface of the hands in contact with the cassette The fingers are separated and extended but relaxed to ensure that they remain in contact with the cassette The wrists are adjusted so that the radial and ulna styloid processes are equidistant from the cassette. A sandbag is placed over the lower forearms for immobilization. Direction and centering of the X-ray beam Direction and location of the X-ray beam The vertical central is centered over a point midway between the inter-phalangeal joints of both thumbs. Essential image characteristics The image should demonstrate all the phalanges, including the soft tissue of the fingertips, the carpal and metacarpal bones and the distal end of the radius and ulna. The exposure factors selected must produce an accurate EI and optimally demonstrate joint detail. Antero-posterior oblique both hands (ball catcher’s or Norgaard projection) This projection may be used in the diagnosis of rheumatoid arthritis. It can also be used to demonstrate fractures of the base of the 5th metacarpals. CR a 24 × 30 cm cassette is employed. Position of the patient and image receptor Ideally the patient is seated alongside the table. However, if this is not possible, due to the patient’s condition, the patient may be seated facing the table Both forearms are supinated and placed on the table with the dorsal surface of the hands in contact with the image receptor. From this position both hands are rotated internally (medially) 45° into a ‘ball catching’ position. The fingers and thumbs are separated and extended but relaxed to ensure that they remain in contact with the image receptor. The hands may be supported using 45° non-opaque pads. A sandbag is placed over the lower forearms for immobilisation. Direction and location of X-ray beam The collimated vertical beam is centered to a point midway between the hands at the level of the 5th metacarpophalangeal joints (MCPJ). Essential image characteristics The image should demonstrate all the phalanges, including the soft tissue of the finger tips, the carpal and metacarpal bones and the distal end of the radius and ulna. The exposure factors selected must produce an accurate EI and optimally demonstrate joint detail. The heads of the metacarpals should not be superimposed. Radiation protection If it has been necessary to position the patient facing the table it is essential to provide radiation protection for the lower limbs and gonads. This may be achieved by placing a lead-rubbersheet on the table underneath the image receptor to attenuate the primary beam Lateral – hand In the lateral position the metacarpals overshadow and obscure each other. However, this projection is essential to demonstrate anterior or posterior displacements of fracture fragments. This projection is also used to determine the position of foreign bodies in the palmar or dorsal aspect of the hand. Position of patient and image receptor From the postero-anterior (DP) position, the hand is externally rotated 90°. The palm of the hand is perpendicular to the image receptor, with the fingers extended and the thumb abducted and supported parallel to the image receptor on a non-opaque pad. The radial and ulnar styloid processes are superimposed. Direction and location of the X-ray beam The collimated vertical beam is centered over the head of the 2nd metacarpal. Essential image characteristics The image should include the fingertips, including soft tissue, and the radial and ulnar styloid processes. The heads of the metacarpals should be superimposed. The thumb should be demonstrated clearly without superimposition of other structures Radiological considerations The hand and wrist (like the ankle and foot) have many accessory ossicles, which may trap the unwary into a false diagnosis of pathology. ‘Boxer’s fracture’ of the neck of the 5th metacarpal is seen easily, but conspicuity of fractures of the bases of the metacarpals is reduced by over-rotation and underexposure. ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW ALL LEVEL NOTESALL DIAGNOSTIC RADIOLOGY NOTES Need These Notes as PDF? Need a clean, well-formatted PDF copy for offline study, revision or printing? Request the complete notes directly through WhatsApp. GET WELL-FORMATTED PDF NOTES

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Humerus – shaft CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Humerus – shaft using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic Position of patient and image receptor Direction and location of X-ray beam Lateral – erect Essential image characteristics Positioning the patient supine allows greater stability than positioning the patient standing. Humerus – shaft Lateral – supine Radiation protection/dose Humerus – shaft Position of patient and image receptor A 35 × 43 cm CR cassette is positioned in an erect cassette holder or alternatively a vertical DDR receptor is selected. The patient sits or stands with their back in contact with the image receptor. The patient is rotated towards the affected side to bring the posterior aspect of the shoulder, upper arm, and elbow into contact with the image receptor. The patient’s position is adjusted to ensure that the medial and lateral epicondyles of the humerus are equidistant from the receptor. The forearm maybe immobilized using a sandbag. Direction and location of X-ray beam The vertical collimated X-ray beam is centred to a point midway between the shoulder and elbow joints at rightangles to the image receptor. Lateral – erect Position of patient and image receptor A 35 × 43 cm CR cassette is positioned in an erect cassette holder or a vertical DDR receptor is selected. From the anterior position, the elbow joint is flexed to 90°. the patient is rotated through 90° until the lateral aspect of the injured arm is in contact with the image receptor. The patient is rotated further until the arm is clear of the rib cage but still in contact with the image receptor. Direction and location of X-ray beam The horizontal collimated X-ray beam is centred to a point midway between the shoulder and elbow joints at right angles to the shaft. Essential image characteristics The exposure should be optimised to ensure that the area of interest is clearly visualised. Positioning the patient supine allows greater stability than positioning the patient standing. Position of patient and image receptor The patient lies supine on the X-ray table, with the unaffected side raised and supported on pads. A 35 × 43 cm CR cassette is positioned under the affected limb and adjusted to include the shoulder and elbow joints Humerus – shaft The arm is slightly abducted and the elbow joint is full extended, so that the posterior aspect of the upper arm is in contact with the image receptor. The arm is adjusted to ensure that the medial and lateral epicondyles are equidistant from the image detector. The forearm may be immobilised using a sandbag. Lateral – supine Position of patient and image receptor From the antero-posterior position, the elbow joint is flexed to 90°. The arm is abducted and then medially rotated through 90° to bring the medial aspect of the arm, elbow and forearm in contact with the table. A 35 × 43 cm CR cassette is placed under the arm and adjusted to include both the shoulder and the elbow joints. The humerus is adjusted to ensure that the medial and lateral epicondyles of the humerus are superimposed. The forearm may be immobilised using a sandbag. Direction and location of X-ray beam The vertical collimated X-ray beam is centred to a point midway between the shoulder and elbow joints. Essential image characteristics Both joints should be seen on the image. The elbow joint should be seen in the true lateral and antero-posterior positions. Radiation protection/dose Careful technique and close collimation will assist in reducing the patient dose. ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW ALL LEVEL NOTESALL DIAGNOSTIC RADIOLOGY NOTES Need These Notes as PDF? Need a clean, well-formatted PDF copy for offline study, revision or printing? Request the complete notes directly through WhatsApp. GET WELL-FORMATTED PDF NOTES

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Hysterosalpingography CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Hysterosalpingography using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic Lesson objectives defination Uterus Hysterosalpingography The fallopian tubes Indications Contra indications Patient preparations Contrast medium Equipment LOWERSHELF (unsterile) procedure aftercare complications Venous intravasation HISTEROSALPINGOGRAPHY Lesson objectives Defination Anatomy Indication Contraindication Patient preparation Equipment Procedure Complications Radiographic anatomy Common pathology reference defination Hysterosalpingography is a radiological examination of the uterine cavity and the fallopian tubes following injection of a suitable contrast agent through the cervical canal under fluoroscopy. Anatomy Uterus The uterus is located inside the pelvis immediately dorsal to the urinary bladder and ventral to the rectum. The human uterus is pear-shaped and is about 3 in. (7.6 cm) long. The uterus can be divided anatomically into four segments: The fundus, body, cervix and the vaginal canal. The layers of the uterus from innermost to outermost include the endometrium,myometrium and the parametrium The endometrium is the inner most layer and it consist of the outer layer which is the basal layer known as the stratum basalis and the inner layer is the functional layer which is the stratum functionalis made up of stratum compactum and stratum spongiosum. The functional layer is shade of during menses and damage to the basal endometrium results in adhesion formation and/or fibrosis (Asherman's syndrome). Hysterosalpingography The uterus mostly consists of smooth muscle, known as "myometrium." The innermost layer of myometrium is known as the junctional zone, which becomes thickened in adenomyosis. Parametrium is the outermost layer which is the loose connective tissue around the uterus. Perimetrium The peritoneum covering of the fundus and ventral and dorsal aspects of the uterus The fallopian tubes The fallopian tubes are uterine appendages located bilaterally at the superior portion of the uterine cavity. These tubes exit the uterus through an area referred to as the cornua, forming a connection between the endometrial and peritoneal cavities. Each uterine tube is approximately 10 cm in length and 1 cm in diameter and is situated within the mesosalpinx Hysterosalpingography A uterine tube contains 3 parts. The first segment, closest to the uterus, is called the isthmus. The second segment is the ampulla; it is more dilated in diameter and is the most common site for fertilization. The final segment, located farthest from the uterus, is the infundibulum. The infundibulum gives rise to the fimbriae, fingerlike projections that are responsible for picking up the egg released by the ovary (Marieb, 2010). Indications Congenital abnormalities. Primary infertility Recurrent spontaneous abortions Previous ectopic pregnancy ?Presence of mass -intraluminal mass -intrauterine mass -polyps To monitor the effects of tubal surgery Contra indications Suspected pregnancy, ectopic pregnancy Recent birth Known ruptured tube Inflammation- salpingitis, vagnitis, cervitis Acute vaginal bleeding Recent gyneological surgery Immediate pre and post ovulation phase- the examination is best performed at about the mid menstrual cycle Patient preparations Performed in the first half of the menstrual cycle following cessation of bleeding ,on the 10th day from the onset of menses,proliferation phase Patient should do ultrasound examinations and lab test before the examination. Explanation of the procedure to the pt. Pt asked to refrain from unprotected sex from onset of menses to before investigation Pt is asked to shave the pubic region if necessary Upon arrival patient should sign consent form Premedication in anxious pts; 5-10 mg of Diazepan given 30min before examination. Ask pt to empty bladder immediately before exam and change into hospital gown Contrast medium Isovue 200 mg/mls Optiray 320 / 350mg/mls Urografin 76% – (10-20ml) Equipment UPPERSHELF (sterile) Casco-vaginal speculum (Duck-bill / sims speculum ) Vulsellum forceps Uterine sound Uterine cannula (Lisch Wilkinson cannula) Sponge holding forceps /Tissue forceps Syringes (10-20ml) and needle Gallipot Gauze swabs Surgical gloves LOWERSHELF (unsterile) Antiseptic solution e.g hibitane lubricating gel/ cream Ampoules of contrast media in warm water File for opening ampoules Pads/ tampon Emergency drugs Torch procedure The patient should empty the bladder immediately prior to the investigation as a full bladder elevates the fallopian tubes and causes spurious appearance of tubal blockage. The patient is placed in lithotomy position on the screening table before the examination. A prelimary ap film is taken The vulva is cleaned with antiseptic solution Vaginal speculum lubricated with gel is inserted, vagina and cervix are swabbed Anterior cervical lip is grasped using valsellum forceps A uterine sound is then inserted to check for direction and depth of uterine cavity A uterine cannula is placed within the cervical canal and 10-20ml of contrast media is injected to outline the uterine cavity and tubes under fluoroscopy. Care must be taken to expel all air bubbles from the syringe and cannula. Hysterosalpingography Between 15-20mls of water soluble contrast media is introduced into the uterine cavity via a metallic canula and spot films taken. An AP view of the pelvis is taken after 5-10mls was injected, during uterine filling, before the contrast opacification becomes too dense, in order to demonstrate small uterine filling defects and abnormalities Hysterosalpingography A second film is taken after another 5mls of contrast media was injected when the uterus and fallopian tubes are delineated and peritoneal spill is just occurring from the fimbrial ends. A further radiograph can be taken to show the pattern of peritoneal spillage after another 5mls of water soluble contrast media. Additional views are done when necessary including oblique’s or lateral aftercare Tell patient that exam is over and give them a pad/ tampoon Insure pt is in no serious discomfort nor has significant bleeding before she leaves the department Patient is advised that she may have PV bleeding 1-2 days & pain may persist for upto 2weeks. Ensure that patient recieves there results complications Slight risk of pelvic inflammatory disease (PID) resulting from bacteria introduced into the body through the procedure itself. Uncommon risk of allergic reaction to contrast medium (hives, itching, low blood pressure) and very uncommon risk of uterine perforation.

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Intravenous Urography CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Intravenous Urography using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic IVU CONTENT INTRODUCTION Kidney s Renal structure Blood supply Ureters and urinary bladder Blood supply of the ureters Urinary bladder Blood supply u bladder INDICATION Contraindications Preparations of the patient Checking serum cretinine/blood urea Equipment used Procedure /technique + contrast medium Intravenous Urography procedure Injection of a contrast media Timing after injection 5 MINUTE FILM(AP-RENAL AREAS 15 MINUTES FILM 30 MINUTES POST MICTURATION Additional films Adverse reaction of the contrast media AFTER CARE OF THE PATIENT Common pathologies Hydronephrosis Acute pyelonephritis Chronic pyelonephritis . Duplex kidneys and double ureter Bladder calculi Bladder tumours Ureteric displacement COMPRESSION It is applied between the ASIS Dangers of compression Other imaging modalities INTRAVENOUS UROGRAPHY IVU CONTENT DEFINITION/INTRODUCTION ANATOMY Of THE URINARY SYSTEM INDICATION CONTRAINDICATIONS PREPARATIONS EQUIPMENT USED PROCEDURE /TECHNIQUE+CONT MEDIA RADIOLOGICAL ANATOMY COMMON PATHOLOGY RELATED IN IVU EXAM ADVERSE EFFECTS OTHER IMAGING MODALITIES INTRODUCTION INTRAVENOUS UROGRAPHY(IVU)/IVP/EU Refers to radiological examination of the urinary tract(kidneys, ureters and urinary bladder)following injection of the contrast medium via vein (of the arm) and excreted by the kidney as urine. is indicated in suspected urinary tract pathology when ultrasound has failed to make a diagnosis Kidney s Are paired organs approximately 8-13 cm in lengh,2-3 cm in AP diameter and 4-5cm in width . Lie obliquely in the retroperitoneal cavity Have concave media border that houses the hilum Left kidney is typically larger than the right kidney is positioned lower because of the size of the liver (1-2 higher) Kidneys moves approximately 2 cm with respiration Renal structure The layers of tissue that enclose the kidney are gerottas fascia(outer),per nephric fat(middle),true fibrous renal capsule (inner) Parenchyma of the kidney contain the cortex and medulla Cortex contains the renal corpuscles and glomeruli Medulla is the inner portion of the kidney adjacent to the calyces contains loop of henle ,renal pyramids and collecting tubules Blood supply Renal veins, arteries ureters and lymph vessels enter and leave the kidneys at renal hilum The main renal arteries branch off the aorta Once in the renal pelvic,a renal artery becomes segmental artery segmental artery continues branch into the inter lobar arteries ,inter lobar arteries eventually become the arcuate arteries Renal veins drains the kidneys and empty into ivc Ureters and urinary bladder Two muscular tubes, 25 cm long that extend from the pelvis to the bladder Propel urine from the ureters to the bladder Narrowing's of the ureters At the beginning ( renal pelvis) At the pelvic brim, (crossing common iliac) At the end where it enters the bladder Blood supply of the ureters Upper part: renal artery Middle part: ovarian/ testicular artery Lower part: superior vesicle artery branch of internal iliac artery Urinary bladder Bladder: lies behind the pubic bones Apex lies behind symphysis pubis Base is posterior and is related to the vagina and uterus in females and rectum and sigmoid in males Superior surface is above and related to uterus in females and sigmoid colon in males Infero lateral surfaces related to pubic bones. Neck lies on prostate in males, and urogenital diaphragm in females. Blood supply u bladder Blood supply: superior and inferior vesicle arteries from internal iliac INDICATION Check for normal function of the kidneys Hematuria Suspected renal calculi Check the course of the ureters Check for anatomical variants or congenital anomalies (e.g.horse-shoe kidney Persistent pyuria renal colic with a normal scan suspected renal disease that is likely to cause calyceal deformity such as tuberculosis, papillary necrosis and chronic pyelonephritis Contraindications Advanced renal failure – use ultrasound Polycystic renal disease – better seen on ultrasound Vague abdominal pain Acute urinary tract infection Not diagnostic for renal artery stenosis Patients with history of reaction to water-soluble contrast media Pregnancy Preparations of the patient This is of a great importance the aim is to rid the bowel of all fecal material without producing gas shadows By giving purgatives drugs like bisacodyl or castor oil before examination perfomed Low residual diet during previous day,it is an advantage to stop all food and drink for 12 hours Some times enema as high colonic wash out should be used. Checking serum cretinine/blood urea If the blood urea is more than a little elevated, IVP will seldom be of value, , especially if standard amount of contrast is used If an IVP is considered to be necessary an increased amount of contrast should be used If urea is very high IVP will not be diagnostic and may be harmful Main is to check physiological function of the kidney Equipment used 2 or 3cc Syringes Cotton swabs (2-3) 4 x 4cm Gauze pads Cannulae – varying sizes & designs Sterile gloves Cassete of varying in size Emergence drugs ie hydrocortisone and adrenaline Contrast medium of choice Procedure /technique + contrast medium Intravenous urography involves an intravenous injection of a water soluble iodinated contrast agent. These agents are classed as IONIC (HIGH OSMOLAR) and NON- IONIC (LOW OSMOLAR). The non- ionic contrast agents are safer to use and cause less severe reactions than those encountered with the cheaper ionic agents. These are iopamidol,iopromide(ultra visit),hypaque,urovsion,or conray Intravenous Urography As there is a risk of producing a severe reaction even with non- ionic contrast, an IVP should only be performed if there is a valid clinical indication The standard dose of contrast for an adult is 50cc but this can be increased to 100cc in very large patients or patients with an elevated blood urea. In children a guide to dosage is 1ml per kg of body weight up to age 15yrs There should always be adrenaline & hydrocortisone immediately available in case of a severe reaction. procedure A plain film is always taken before injection of the contrast medium. This is because calculi are masked by the contrast and would not be seen once the

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE Knee joint CRT04103 · Radiographic Techniques and Procedures START READING NOTES Study Knee joint using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures. Contents of This Topic Two projections are taken routinely: Knee joint Antero-posterior – weight-bearing Direction and location of the X-ray beam Essential image characteristics (Figs above) Antero-posterior – supine Lateral (Basic) Essential image characteristics (Fig. above) Femur – shaft Antero-posterior (Basic) Essential image characteristics Radiation protection/dose Knee joint Two projections are taken routinely: anterio-posterior (AP) lateral. Knee joint The AP projection is frequently obtained in the weight-bearing/standing position as it provides more meaningful information on the condition of the joint when compared to the traditional (supine) non-weight-bearing technique Antero-posterior – weight-bearing Position of patient and image receptor The patient stands with their back against the vertical Bucky or DDR receptor (grid removed) using it for support if necessary. The patient’s weight is distributed equally. The knee is rotated so that the patella lies equally between the femoral condyles. The centre of the image receptor is level with the palpable upper borders of the tibial condyles. This projection is useful to demonstrate alignment of the femur and tibia in the investigation of valgus (bow-leg) or varus (knock-knee) deformity. Any such deformity will be accentuated when weight-bearing, which more closely resembles the real-life situation. It is commonly requested to assess alignment prior to joint replacement, as narrowing of one side to the joint space more than the other will produce varus or valgus tilt. Direction and location of the X-ray beam The collimated horizontal beam is centred 1 cm below the apex of the patella through the joint space, with the central ray at 90° to the long axis of the tibia (midway between the palpable upper borders of the tibial condyles). Essential image characteristics (Figs above) The patella must be centralised over the femur. The image should include the proximal 1/3 of the tibia and fibula and distal 1/3 of the femur. Antero-posterior – supine Position of patient and image receptor The patient is either supine or seated on the X-ray table or trolley, with both legs extended. The affected limb is rotated to centralise the patella between the femoral condyles, and sandbags are placed against the ankle to help maintain this position. The image receptor, i.e. 18 × 24 CR cassette should be in close contact with the posterior aspect of the knee joint, with its centre level with the upper borders of the tibial condyles. Direction and location of the X-ray beam The vertical collimated central beam is centred 1 cm below the apex of the patella through the joint space, with the central ray at 90° to the long axis of the tibia (midway between the palpable upper borders of the tibial condyles). Lateral (Basic) Position of patient and image receptor The patient lies on the side to be examined, with the knee flexed at 45° or 90°. The other limb is brought forward in front of the one being examined and supported on a sandbag. A pad is placed under the ankle of the affected side to bring the long axis of the tibia parallel to the image receptor. Dorsiflexion of the foot helps maintain this position. The position of the limb is now adjusted to ensure that the femoral condyles are superimposed vertically. The medial tibial condyle is placed level with the centre of the receptor. An alternative method is to keep the unaffected limb behind the knee being examined with the ankle flexed and the heel resting on the lower shaft of the unaffected leg. Direction and location of the X-ray beam The collimated vertical beam is centred to the middle of the superior border of the medial tibial condyle, with the central ray at 90° to the long axis of the tibia. Essential image characteristics (Fig. above) The patella should be projected clear of the femur. The femoral condyles should be superimposed. The proximal tibio-fibular joint is not clearly visible.(Approximately 1/3 of the fibula head should be superimposed behind the tibia.) Femur – shaft Two projections are taken routinely, preferably with both the knee and hip joints included on the image. Antero-posterior Lateral Antero-posterior (Basic) Position of patient and image receptor The patient lies supine on the X-ray table, with both legs extended and the affected limb positioned to the centre line of the table. The affected limb is rotated to centralise the patella over the femur. Sandbags are placed below the knee to help maintain the position. The image receptor/Bucky mechanism is located directly under the posterior aspect of the thigh to include both the hip and the knee joints. Alternatively, a CR cassette or mobile DDR detector is positioned directly under the limb, against the posterior aspect of the thigh to include the knee and hip joints. Direction and location of the X-ray beam The collimated vertical beam is centred to the mid-shaft of the femur, with the central ray at 90° to an imaginary line joining both femoral condyles. Essential image characteristics Ideally, the length of the femur should be visualised, including the hip and knee joints. This may be difficult to obtain and an additional projection of the knee or hip joint may be required if coverage is not initially achieved; however, this will depend on the clinical information required. The patella should be centralised to indicate rotation has been minimised. Direction and location of the X-ray beam The collimated vertical beam is centred to the middle of the femoral shaft, with the central ray parallel to the imaginary line joining the femoral condyles. Lateral (Basic) Position of patient and image receptor From the antero-posterior position, the patient rotates on to the affected side with the knee is slightly flexed and the patient adjusted so that the thigh is positioned to the centre line of the table. The pelvis is rotated backwards to separate the thighs. The position of the limb