Imaging Modalities

X-RAY
● X-rays are directed in a focused beam towards the patient. They will either pass through the patient to the film, be
absorbed by the patient’s tissue, or scatter. As X rays reach the cassette and interact with the radiographic film,
their energy is converted into visible light which exposes film and creates the radiograph.
● Areas of the film that are more exposed appear black (lungs); less exposed appear white (bone)cxΩ
● Indications:
○ A preliminary inexpensive fast way to image the patient
○ Pneumonia, pneumothorax
○ Fractures, trauma
○ Foreign bodies
○ Evaluate position of lines and tubes
● Ionizing Radiation
○ Can induce detrimental biological effects by depositing energy that may damage important molecules
such as DNA causing cell function to be modified. At very high doses, radiation can cause cell death.
○ As dose ↑ so does the risk of complications: skin erythema (reddening), cataract
formation, decreased sperm count and sterility, cancers (bone marrow, colon, lung,
stomach, thyroid are most susceptible)
● Radiation Protection
○ Minimize patient dose
○ Gonadal shielding if of reproductive age.
○ Wear protective lead – lead has an atomic number of 82 and acts as a barrier to x rays
○ Lead apron, lead glasses, lead barrier
○ Neck shields to protect the thyroid
COMPUTED TOMOGRAPHY (CT)
● A method of using x-rays in multiple projections to produce axial cross sectional images of the body.
● X-rays pass through the body to many detectors → send the info to a computer that
reconstructs the images
● More sensitive than plain films in distinguishing differences in tissue density
● Indications:
○ Any part of body where fine anatomic detail or subtle distinction between tissue types is necessary for
diagnosis.
○ Head CT to look for bleeding or skull fractures in head trauma
○ Chest CT to look for nodules or masses in smokers
○ Abdominal CT to look for bowel obstruction
○ Skeletal CT to look for fractures not clearly seen on plain films
● Noncontrast
○ Acute stroke (suspected) - preferred initial study if performed within 3 hours of acute symptom onset
○ Closed head injury - spinal CT if spinal injury is suspected
○ Chronic pancreatitis - sensitive for calcifications
○ Diffuse lung disease/chronic dyspnea - thin section high-resolution CT without contrast
○ Extremity soft tissue swelling, infection, or trauma (contrast is necessary if vascular involvement or injury
is suspected)
○ Kidney stone (suspected) - specify renal stone protocol
○ Spinal trauma (suspected) - scan suspected area of trauma in cervical, thoracic, or lumbar spine
● Contract-enhanced
○ Acute appendicitis - abdominal/pelvic CT; oral or rectal contrast agent based on institutional preference
○ Cancer staging - protocols vary depending on cancer type and stage
○ Diverticulitis; suspected complications of inflammatory bowel disease
○ Pancreatitis - best for evolving pancreatitis or pancreatic pseudocyst
○ Pulmonary embolism (suspected) - many centers now include venous phase CT of the pelvis and lower
extremities in combination with CT angiography of the lung
○ Stroke - contrast-enhanced CT should be obtained for patients with symptoms lasting longer than three
hours; contrast-enhanced CT combined with CT angiography of the neck may be needed for follow-up

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 ○ Vascular imaging
MAGNETIC RESONANCE IMAGING (MRI)
● Uses the principle that hydrogen protons will align when placed in a strong magnetic field.
● Protons in patients tissues align with the vector of the magnetic field. The MRI machine shoots radiofrequency
pulses to deflect the protons perpendicular to their original vector.
● When the RF pulse stops the protons relax back to original position and release energy which is detected by
receiver coils of the scanner. Different tissues relax back at different times depending on relative proton
composition.
● Signals processed by a computer to produce final image.
● Versus CT (MRI left, CT right → )
○ MRI does not use ionizing radiation and
therefore avoids harmful effects of radiation.
○ MRI generally provides better anatomic detail
of soft tissues than CT
○ MRI takes much longer
○ MRI more expensive
○ MRI more contraindications eg. Pacemakers,
metallic foreign bodies.
● Indications:
○ Brain – indications include stroke, temporal
lobe epilepsy, infection, inflammation, tumour,
multiple sclerosis (MS), dementia, post-trauma,
metabolic disorders, congenital malformations,
internal auditory canal pathology, vascular pathology, pituitary fossa pathology, nerve palsies and
metabolic disorders.
○ Spinal cord – indications include radiculopathy, myelopathy, MS, inflammation, infection, tumour,
congenital malformation, postoperative investigation and post-trauma.
○ Musculoskeletal (MSK) – indications include all MSK system: joints for derangement, infection,
inflammation, post-trauma, tumour and vascular pathologies. Plain films are still very useful.
○ Abdomen and pelvis – investigates pathology of the various organs including tumours, vascular
pathologies, infection, inflammation, congenital abnormalities and metabolic disorders. Used for
detection of local invasion of rectal, prostatic and cervical carcinomas, and assessing the anatomy in
peri-anal fistulae.
○ Cardiac – ischaemia, tumour, infiltrative diseases, congenital malformation and cardiomyopathy
○ Vascular studies – increasingly being carried out without contrast medium
○ Pregnancy – indications for the placental position and invasion, as well as reviewing fetal anomalies,
particularly cerebral.
● Contraindications: metal-containing implants (e.g. pacemaker, defibrillator) might heat up or move
ULTRASOUND
● A probe is applied to the skin and a high frequency beam of sound waves is focused on the area of interest.
● Sound waves propagate through different tissues at different velocities, with denser tissues allowing the sound
waves to move faster.
● A detector measures the time it takes for the wave to reflect and return to the probe.
● Tissue density determined by the reflection time and image produced on the screen
● Echogenicity of the tissue refers to the ability to reflect or transmit US waves in the context of surrounding
tissues. Whenever there is an interface of structures with different echogenicities, a visible difference in contrast
will be apparent on the screen.
○ Anechoic (black on the screen) - bone is anechoic on US, with a bright hyperechoic rim. Because the US
beam cannot penetrate bone, it casts an acoustic shadow beyond it. Blood vessels are also anechoic.
○ Hypoechoic (gray on the screen) - cartilage (more penetrable by US than bone)
○ Hyperechoic (white on the screen)- dense tissue
● Indications:
○ Ovaries and uterus; pregnancy
○ Evaluate for testicular torsion

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 ○ Can show blood flow with Doppler. Better than CT for torsion
○ Gallstones and cholecystitis
Acute Glomerulonephritis (AGN)
● Immunologic inflammation of the glomeruli causing protein AND RBC leakage into the urine.
● HTN. HEMATURIA (RBC CASTS). DEPENDENT EDEMA (PROTEINURIA) & AZOTEMIA HALLMARK!!!*
Etiologies:
● IgA nephropathy (berger's disease) → MC in adults worldwide
○ Often affects young males within days (24-48h) after URI or GI infection* (due to IgA immune
complexes). lgA is 1st line of defense in resp/GI secretions so infections may cause lgA overproduction.
○ Henoch-Schonlein purpura is a similar disease (but associated with generalized IgA vasculitis).
○ Dx: (+) IgA mesangial deposits on immunostaining
○ Management: ACE Inhibitors ± Corticosteroids.
● Post infectious→ MC after GABHS (group A strep)
○ Classically: 2-14y boy with facial edema up to 3 weeks after Strep with scanty, cola-colored/dark urine*
(hematuria & oliguria).
○ Dx: ↑ antistreptolysin (ASO) titers, Low serum complement (C3). Biopsy:
hypercellularity, ↑monocytes/lymphocytes, immune humps of IgG, IgM & C3 (seldom
done as disease usually resolves without complications).
○ Mgmt: Supportive. ±Antibiotics.
● Membranoproliferative/Mesangiocapillary: due to SLE, viral hepatitis (ex. HCV, HBV), hypocomplementemia,
cryoglobulinemia. Usually present with a mixed nephritic-nephrotic picture.
Imaging: bedside renal US may be appropriate to evaluate kidney size (usually enlarged), as well as to assess the
echogenicity of the renal cortex, exclude obstruction, and determine the extent of fibrosis. A kidney size of less than 9 cm
is suggestive of extensive scarring and a low likelihood of reversibility.

Rapidly progressive Glomerulonephritis (RPGN)

● Crescent formation on biopsy
○ Two main etiologies:
1. Goodpasture's disease: + ANTI-GBM ANTIBODIES. Ab vs. type IV collagen of the
glomerular basement membrane in kidney & lung alveoli→ KIDNEY FAILURE &
HEMOPTYSIS.* (not due to immune complex deposition). Often occurs post URI.
● DX: LINEAR lgG DEPOSITS* on staining of tissue specimen
● TX: high dose Corticosteroids + Cyclophosphamide + Plasmapheresis (removes antibodies).
2. Vasculitis: characterized by lack of immune deposits, ANCA antibodies.
● Microscopic Polyangiitis (vasculitis of small renal vessels):+ P-ANCA.
● Granulomatosis with Polyangiitis (Wegener's): necrotizing vasculitis → + C-
ANCA.
● Management: Corticosteroids + Cyclophosphamide
General Clinical Manifestations (AGN & RPGN):
● HEMATURIA: hallmark.* Microscopic or macroscopic/gross ("cola-colored"/dark urine). The presence of gross
hematuria in nephritic distinguishes nephritic from nephrotic.
● EDEMA (85%): peripheral, periorbital (esp in children) due to ↓oncotic pressure & ↑Na
retention.
● HYPERTENSION* (80%): secondary to Na+ & H20 retention.
● Fever, abdominal pain, flank pain (due to renal capsule expansion), malaise
● Acute Kidney Injury: OLIGURIA* !urine output <200ml (not always present).
DIAGNOSIS
● Urinalysis (UA): hematuria (RBC casts},* dysmorphic RBCs, proteinuria (usually <3g/d but may be in the nephrotic
range), high specific gravity> 1.020osm. ± WBCs
● ↑BUN,↑ Cr: varying degrees. Renal biopsy gold standard* (not needed if post strep
suspected).
IMAGING: CXR in any pt with cough - may be Goodpasture’s or Wegener’s
MANAGEMENT

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Glomerulonephritis is usually self-limited with a good prognosis (except in cases of RPGN).
● Berger's disease or proteinuria: ACE inhibitors ± Corticosteroids.
● Edema, hypervolemia or hypertension: Loop diuretics (edema); beta-blockers, CCBs (for HTN).
● Post streptococcal AGN: Supportive ,± Abx. Lupus nephritis: Steroids or Cyclophosphamide
● Rapidly progressive AGN or severe disease: Corticosteroids plus Cyclophosphamide
Pyelonephritis
● Clinical manifestations: fever & tachycardia, back/flank pain. (+) CVA tenderness. nausea/vomiting.
● Imaging: CT of the abdomen and pelvis with and without contrast.
○ unenhanced followed by contrast-enhanced images taken 50 to 90 seconds after contrast injection to
image the kidney in the nephrographic phase.
○ Usually diagnosed on clinical basis without imaging
○ Indication for CT: there is no response to treatment within the first 72 hours; the patient is at high risk of
developing serious complications, such as with diabetic and immunocompromised patients; when the
patient has congenital or anatomic genitourinary anomalies; or to assess the severity of complications.

○ Findings:
■ Unenhanced images may reveal mild renal enlargement, stranding of the perirenal fat planes, and
thickened Gerota's fascia
■ When focal, wedge-shaped areas of low attenuation or hypoenhancement that extend from the
renal papilla to the cortical surface. The diffuse form may demonstrate a striated nephrogram

● Ultrasound: focal area of increased echogenicity (brightness) in the right upper pole cortex

Xanthogranulomatous Pyelonephritis
● Clinical scenario: A 40-year-old diabetic woman with a history of recurrent urinary tract infection presents with
right flank pain, hematuria, a low-grade fever, and malaise.
● Imaging: CT of the abdomen and pelvis with IV contrast
● Findings: renal enlargement, staghorn stone, and partial or complete renal function compromise. There is
destruction and replacement of the renal parenchyma, with multiple low-attenuating areas that represent
xanthomatous tissue and dilated calyces filled with debris

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Polycystic kidney disease / Renal Cyst****
● Clinical manifestations:
○ Abdominal/flank pain: may be due to infection, nephrolithiasis or bleeding into the cyst
○ Palpable flank mass: large palpable kidneys on physical examination.
○ HTN. hepatomegaly, hematuria (may also bleed into the cyst), decreased urine concentrating ability,
microalbuminuria.
○ Extrarenal: cerebral "berry" aneurysms.* hepatic cysts, mitral valve prolapse.* colonic diverticula.
● DIAGNOSIS
○ Renal ultrasound: most widely used 1st line diagnostic test.* Genetic testing also done.
■ distinguish a simple benign cyst that needs no further workup from a complicated cyst that
requires further evaluation by CT
● simple cysts appear as well-defined, thin-walled anechoic lesions with posterior acoustic
enhancement and no internal echoes, septations, or solid nodules.
○ CT scan/MRI: more sensitive than renal ultrasound.
■ assessing indeterminate renal lesions
■ On CT, simple cysts appear as fluid density lesions with no wall enhancement after intravenous
contrast.
■ CT shows multiples cyst with variable densities

Renal Cell Carcinoma:

● Clinical Manifestations:
○ Classic triad: hematuria (90%), flank/abdominal pain, palpable mass
○ Malaise, weight loss. - L-sided varicocele* (blocks left testicular vein drainage).
○ HTN & hypercalcemia common (↑PTH-related proteins leads to hypercalcemia).
● DIAGNOSIS:
○ CT scan w/o & w/ contrast first choice
○ Ultrasound

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Kidney stones
● Clinical Manifestation:
○ RENAL COLIC: sudden, CONSTANT upper/lateral back/flank pain over the costovertebral angle radiating
to the groin/anteriorly,* nausea/vomiting. ± Unable to find a comfortable position.
○ + Costovertebral angle tenderness (CVAT). Usually afebrile. ± Hematuria. frequency, urgency.
○ Proximal ureter → flank, CVAT. Midureter → midabdominal; Distal ureter → groin
pain.
● Imaging: Noncontrast computed tomography (CT)
○ shows hyper dense renal stone with mild dilation of the renal pelvis. There is also surrounding perinephric
stranding.

Ultrasound

Hydronephrosis
● swelling of a kidney due to a build-up of urine. It happens when urine
cannot drain out from the kidney to the bladder from a blockage or
obstruction.
● dilation of the renal collecting system due to some obstruction distally,
usually renal stones, but also tumor, or blood clots.
● Diagnosis: Ultrasound
○ If reason to believe stone CT scan without contrast

Bladder Cancer
● RISK FACTORS: SMOKING MC* >60%, occupational exposure:
dyes, rubber, leather (beauticians, auto workers), age >40y,
white males 3x MC, schistosomiasis, chronic bladder
infection; Cyclophosphamide* (Cyclophosphamide also
causes hemorrhagic cystitis), Pioglitazone.
● CLINICAL MANIFESTATIONS: PAINLESS GROSS or
microscopic HEMATURIA* (80-90%), pain or burning during
urination w/o evidence of UTI, change in bladder habits.
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 ● DIAGNOSIS:
○ Cystoscopy with biopsy* (can be diagnostic or curative - ± be able to do excision).
■ gold standard for the initial diagnosis and staging of bladder cancer.
○ CT or IVP
■ Contrast pools in the bladder as you excrete it, so it’ll show any masses
Bladder Diverticula
● Urinary tract structural abnormality leading to stasis and repeated infection (such as bladder diverticulum)
● Bladder diverticula are acquired abnormalities in most instances, usually forming as a result of bladder outlet
obstruction or a neurogenic bladder.
● Imaging: Ultrasound or CT of the abdomen and pelvis, without and with intravenous contrast

Bladder fistula
● Vesicovaginal fistulas are approximately three times more
common than ureterovaginal fistulas, with uretero-
vesicovaginal fistulas being very infrequent.
● Clinical manifestations:
○ Painless urinary leakage from the vagina. Intermittent
leakage, particularly when positional, can be a sign of
ureterovaginal fistula, whereas continuous urine loss
is more characteristic of vesicovaginal fistulas
● Diagnosis:
○ Dye test or IVP
○ Cystoscopy, voiding cystourethrography (VCUG)

Bladder Trauma
Imaging:
● CT pelvis with bladder contrast (CT cystography) is sensitive and accurate
● Conventional cystogram may be performed in the acute setting.

Male Pelvis

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The male reproductive system encompasses several organs: the testes, ejaculatory ducts, seminal vesicles, prostate, and
penis.
● Prostate - most commonly performed for suspected masses or obstruction. Imaged on MRI & CT
○ Prostate on CT is an ovular soft-tissue density, often difficult to separate from the surrounding fascia and
musculature
○ MRI provides exquisite anatomic detail of the prostate.
● Testes - ultrasound most sensitive and specific test for torsion, infection, or
mass.
● Penis/urethra - trauma patients: fluoroscopy performed for stricture,
obstruction, bleeding

Prostate Cancer
● Slow growing tumor usually (most patients die with
prostate cancer rather than from it).
● Risk Factors: Genetics; Diet: high fat intake,* obesity,
African-American. Adenocarcinoma (>95%).
● CLINICAL MANIFESTATIONS: Often asymptomatic until
invasion of bladder, urethral obstruction or bone
involvement.
○ Urethral obstruction: ↑urinary frequency,
urgency, urinary retention, ↓urinary
stream. Back pain/bone pain: ↑ incidence
of METS to bone,* weight loss.
● DIAGNOSIS
○ ↑Prostate Specific Antigen (PSA): PSA
>10ng/mL ↑likelihood for prostate cancer
& METS.
○ Digital rectal exam (DRE): hard. nodular. enlarged
asymmetrical prostate.•
○ Transrectal ultrasound (TRUS) with needle biopsy:
if PSA >4ng/mL. If>10 → bone scan to r/o
METS.
■ Seen as a hypoechoic lesion (60%-70%) in
the peripheral zone of the gland, but can
be hyperechoic or isoechoic (30%-40% of
lesions).
○ MRI with endorectal coil→ when TRUS is
inconclusive

Testicular Torsion:
● Spermatic cord twists & cuts off testicular blood supply due to congenital malformation ("bell clapper" deformity
of the processus vaginalis), which allows the testicle to be free floating in the tunica vaginalis (90%) causing it to
twist on itself. True urologic emergency
● Clinical manifestations:
○ ABRUPT onset of scrotal, inguinal or lower abdominal pain (usually <6 hours), 士 nausea &
vomiting.* If nausea/vomiting presents, suspect torsion (usually absent in epididymitis).
● Physical Examination:
○ Swollen, tender, retracted (high-riding) testicle :t horizontal lie.
○ NEGATIVE PREHN's SIGN: no pain relief with scrotal elevation.*
○ NEGATIVE (ABSENT) CREMASTERIC REFLEX:*no elevation of the testicle after stroking the inner thigh
○ Blue dot sign "at the upper pole=torsion of appendix of testis.*
● DIAGNOSIS
○ Testicular color Doppler Ultrasound: best initial test* - avascular testicle (↓blood flow).

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 ■ The normal testis has a homogeneous, moderately grainy, echotexture.
■ The torsed testis has decreased echogenicity due to swelling
○ Emergency surgical exploration is required if ultrasound is unable to exclude torsion

Hydrocele
● Cystic testicular fluid collection → testicular mass. MC cause of painless scrotal swelling.
● Communicating: peritoneal/abdominal fluid enters scrotum via a patent processus vaginalis that failed to close.
● Noncommunicating: derived from fluid from the mesothelial lining of the tunica vaginalis (no connection to the
peritoneum).
● Infants: congenital (due to incomplete obliteration of the processus vaginalis).
Congenital defects usually close within the 1st year of life and may not require
treatment
● Adults: usually acquired, i.e. injury, infection or inflammatory etiologies.
● CLINICAL MANIFESTATIONS
○ Painless scrotal swelling (may increase throughout the day). ±dull ache or
heavy sensation.
■ Communicating: swelling worse with Valsalva (blow out against
closed mouth and nose).
○ ⨁ transillumination on physical examination. Must rule out testicular tumor (also
painless).
● Can perform ultrasound to confirm diagnosis (image above)
● MANAGEMENT
○ Usually no treatment needed (most resolve by the child's first birthday).
○ Surgical repair may be needed if it persists beyond 1 year of age, older patients with communicating
hydroceles (elective) or hydroceles associated with complications.

Cryptorchidism
● Undescended testicle. ↑risk: premature infants (30% of premature vs. 5% in full term
infants), low birth weight.
● CLINICAL MANIFESTATIONS
○ Empty, small scrotum, ±inguinal fullness (MC located in inguinal canal). MC right-sided. 10% bilateral.
● COMPLICATIONS
○ Testicular cancer (both affected & unaffected testicle)
○ Subfertility (body temperature ↓ sperm formation, scrotum ~9 degrees cooler than
core body temp)
○ Testicular torsion, inguinal hernia
○ Early diagnosis & treatment prevents some of the complications.
● MANAGEMENT
○ Most descend spontaneously (~70%).
○ Orchiopexy: testicle fixation in scrotum. Rec’d as early as 6 months (ideally performed before age 1)
○ Observation can be done only if <6 months of age. Most descend by 3 months of age (rarely
spontaneously descend after 6 months of age).
○ hCG or gonadotropin releasing hormone: human chorionic gonadotropin stimulates testosterone &
hormonal testicular descension. May be used prior to orchiopexy (not used often).
○ Orchiectomy recommended if detected at puberty to reduce testicular cancer risk.

Testicular Cancer
● MC solid tumor in young men 15-40y (average 32y).
● 5 year survival 90% with treatment (associated with good prognosis - very curable)
● RISK FACTORS:
○ Cryptorchidism: in both the undescended & normal testicle. Associated with a 40x
↑risk.
○ MC in Caucasians. Klinefelter's (XXY) syndrome.
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 ● GERMINAL CELL TUMORS (97%) - usually malignant
○ Seminoma (SGCT): see below
○ Nonseminomatous (NSGCT):
■ Embryonal cell carcinoma, teratoma, yolk sac (MC in young boys ≤10y),
choriocarcinoma (worst prognosis).
■ Mixed tumors (seminomatous + nonseminomatous components) - treated like nonseminomas.
■ Nonseminomas associated with ↑serum α-fetoprotein, ↑beta-hCG & radioresistance*
(irradiation is unable to reduce its volume or recurrence after a possible regression)
● NONGERMINAL CELL TUMORS (3%)
○ Can spread hematogenously and cause pulmonary symptoms.
○ Leydig cell tumors: may be benign. May secrete hormones (ex. androgens or estrogens), which may lead
to precocious puberty in children or gynecomastia/loss of libido in adults.
○ Sertoli cell tumors: often benign. May secrete hormones.
○ Gonadoblastoma, testicular lymphoma.
● CLINICAL MANIFESTATIONS
○ Painless testicular nodule, solid mass or enlargement* unable to be separated from testicle.
○ May have dull pain or testicular heaviness. Any hematoma or hydrocele 2ry to minor scrotal trauma
should raise suspicion for testicular cancer. Hydrocele present in 10%.
○ Gynecomastia in <10% (seen especially with Leydig or Sertoli tumors that secrete estrogen).
○ Rarely, tumors present with signs of METS: hemoptysis (pulmonary), supraclavicular lymph node neck
mass, abdominal mass (retroperitoneal). Seminomas may spread to the bone.
● DIAGNOSIS
○ Scrotal ultrasound: seminomas (hypoechoic mass); nonseminomatous = cystic, inhomogenous masses.
○ Alpha-fetoprotein, beta-hCG, LDH
■ beta-hCG often elevated in nonseminomatous (NSGCT), especially choriocarcinoma.
■ a-fetoprotein elevated in many NSCGT. Not usually elevated in seminoma & choriocarcinoma.
● MANAGEMENT: Low-grade (Stage I) Nonseminoma (limited to testes): orchiectomy with retroperitoneal lymph
node dissection.*

Seminoma
● Most common type in men 30s-40s, presents with painless scrotal mass.
● 4 S’s: seminomas are Simple (lack tumor markers= normal serum a-
fetoprotein & B-hCG), Sensitive (sensitive to radiation), Slower
growing & associated with Stepwise spread
● Manifestation: painless testicular nodule, solid mass or enlargement*
unable to be separated from testicle.
○ May have dull pain or testicular heaviness. Any hematoma or
hydrocele 2nd to minor scrotal trauma should raise suspicion
for testicular cancer. + Hydrocele present in 10%.
○ May spread to bone
● Diagnosis: Ultrasonography
○ Demonstrates areas of uniformly decreased echogenicity,
usually focal but may be diffuse and may cause bulging of
the tunica albuginea.
● Management:
○ Low-grade Seminoma: orchiectomy + radiation.
○ High-grade Seminoma: debulking chemotherapy orchiectomy & radiation

Female Pelvis
● Ultrasound is the first test usually performed for imaging of the female pelvis.
○ Normally, the Fallopian tubes are never seen - indicates pathology of
some sort if they are visualized on ultrasound. (i.e. hydrosalpinx)

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 ● CT/MRI usually performed if there is insufficient evidence from the ultrasound or if there is clinical concern and
further workup is needed for further intervention

Endometrial Masses
UTERINE/ENDOMETRIAL POLYPS - most are benign, but sometimes hyperplasia or cancer can first manifest as polyps.
Visualized on transvaginal ultrasound, possibly with hysterosonography (injection of saline into uterus) for better view.
ENDOMETRIAL HYPERPLASIA
● Endometrial gland proliferation; cytologic atypia (precursor to endometrial carcinoma).*
● Hyperplasia due to continuous ↑UNOPPOSED ESTROGEN* (unopposed by progesterone). Ex.
chronic anovulation, PCOS, perimenopause, obesity (conversion of androgen → estrogen in
adipose tissue).
● Often occurs within 3 years of estrogen-only therapy. MC postmenopausal.
● Clinical manifestation - bleeding: menorrhagia, metrorrhagia, postmenopausal bleeding. ±vaginal discharge.
● DIAGNOSIS
○ Transvaginal Ultrasound (TVUS): ENDOMETRIAL STRIPE >4 mm* (screening test).
○ Endometrial Bx: definitive diagnosis.* Indications: >35y, endometrial stripe seen on TVUS, unopposed
estrogen therapy, Tamoxifen, AGS on Pap smear or persistent bleeding w/ endometrial stripe <4mm.
● MANAGEMENT
○ Endometrial hyperplasia without atypia: Progestin* (PO or IUD-Mirena). Repeat endometrial biopsy in 3-6
months. MOA: stops estrogen from being unopposed, limiting endometrial growth:
○ Endometrial hyperplasia with atypia: hysterectomy* (TAH ±BSO).
Progestin treatment if not a surgical candidate or if patient wishes to
preserve fertility.
ENDOMETRIAL CANCER
● MC gynecologic malignancy in the US.* (2x more than cervical cancer).
● 4th MC malignancy incidence in women overall (after breast, lung, colorectal).
● Postmenopausal 75%; 50-60y. Perimenopausal 25%, premenstrual 5-10%
● Estrogen-dependent cancer. Associated with antecedent endometrial
hyperplasia.
● Risk Factors: ↑estrogen exposure* nulliparity, chronic
anovulation, PCOS, obesity, estrogen replacement therapy, late
menopause, Tamoxifen (estrogen stimulates endometrial growth);
HTN, Diabetes mellitus.
● Combination OCPs are protective against both ovarian & endometrial
cancers.*
● Clinical manifestations: ABNORMAL UTERINE BLEEDING: postmenopausal
bleeding* ( causes of 10% postmenopausal bleeding). Pre or
perimenopausal → menorrhagia or metrorrhagia.
● DIAGNOSIS
○ Endometrial biopsy: Adenocarcinoma MC (>80%), Sarcoma 5%.
○ Ultrasound: Usually endometrial stripe >4mm. May rule out other causes of bleeding.
● MANAGEMENT: stage I-III surgery + radiation, stage IV systemic chemo

Ovarian Torsion
● The ovary, and often the fallopian tube as well (adnexal torsion) become twisted
around their vascular pedicle
● Clinical manifestations: acute onset of moderate to severe pelvic pain, often with
nausea and possibly vomiting, in a girl or woman with an adnexal mass
● Diagnosis is made on transabdominal pelvic Doppler ultrasound
○ ovarian enlargement due to edema, with lack of blood flow within the ovary.
○ There may be multiple peripherally based follicles.
● Treatment: ovarian torsion is swift operative evaluation to preserve ovarian function
and prevent other adverse effects

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Pregnancy normal vs abnormal
Normal
● Transvaginal image of yolk sac (red arrowhead) and amniotic sac (red arrow). The embryo (E) is seen within the
amniotic cavity. The chorion (blue arrowhead) is defined by the outer aspect.
● We can confirm an intrauterine pregnancy (IUP) with ultrasound by documenting a yolk sac or a live embryo with
a heartbeat.
○ Seen about 5 weeks
Abnormal
● ectopic pregnancy is implantation of a fertilized ovum outside the uterine cavity.
○ Usually bleeding or pain in a patient with a positive BHCG is the common presentation. Ectopic pregnancy
can never be excluded.
● Serial BHCG measurements are very useful to distinguish between early IUP,
spontaneous abortion and ectopic pregnancy.
● A follow up ultrasound can be obtained if the serial B-HCG values are confusing.
● Diagnosis:
○ SERIAL quantitative beta-hCG: should double q24-48h. In ectopic, serial B-hCG
fails to double (rises <66% expected, decreases or plateaus). If initial value
<1,500-=> repeat q2-3 days.
○ Transvaginal Ultrasound: presence (or absence) of pregnancy within or outside
the uterus.
○ Absence of gestational sac with beta ·hCG levels >2,000 strongly suggest ectopic
OR nonviable intrauterine pregnancy (IUP)
● MANAGEMENT
○ UNRUPTURED/STABLE:
■ Methotrexate:* MOA: destroys trophoblastic tissue (disrupts cell
multiplication).
● Indications: hemodynamically stable, early gestation <4cm, beta-hCG <5,000, no fetal
tones.*
○ Multiple dose: Methotrexate + Leucovorin x 4 doses. beta-hCG monitoring day 0
then odd- numbered days. Successful if beta-hCG drops 15% between 2
successive draws.
○ Single dose or Double Dose! monitor beta-hCG on days 0,4, 7. Should drop ~15%
by day 4-7. Contraindications: ruptured ectopic, h/o TB, P-hCG >5,000,@fetal
heart tones, noncompliant.
■ Laparoscopic salpingostomy or salpingectomy if the patient prefers a surgical procedure.
■ RhoGAM administration if mother is Rh negative.* Use contraception for at least 2 months.
○ RUPTURED/UNSTABLE:
■ Laparoscopic salpingostomy: 1st choice* to remove ectopic gestation (may need reparative
procedure to save reproductive organs). Salpingectomy. Laparotomy in severe cases. b. RhoGAM
administration if mother is Rh negative & unsensitized.

12
Gestational age
● Gestational age is calculated from the first day of a woman’s last menstrual period.
● By measuring the fetal crown rump length and a number of other parameters, the gestational age of the fetus can
be determined
○ Crown-rump length (CRL) is the measurement of the length of human embryos and fetuses from the top
of the head (crown) to the bottom of the buttocks (rump).
● The yolk sac is the earliest intra gestational sac structure to be visualized at US that can absolutely confirm an
IUP
○ It is the primary maternal-fetal transport system before the establishment of a fully developed placental
circulation and can be visualized at approximately 5.5 weeks of gestational age as a round 3-5mm
structure, usually eccentrically located within the gestational sac.
○ In gestational sacs at 5.0–5.5 weeks, the yolk sac may sometimes appear as two parallel lines,
representing the leading edge and the posterior wall, rather than as a discrete circle
● First trimester
○ The embryo is first visible at approximately 6 weeks of gestational age as a 1–2-mm structure at the
periphery of the yolk sac. The length of the embryo is measured from the head (crown) to the buttocks
(rump)
● Second trimester
○ After 13-14 weeks measurements used for dating are:
■ Biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur
length (FL)

13
Hirschsprung Disease
● Congenital absence of ganglion cells → functional obstruction. MC in distal colon & rectum (75%).
● May occur in other parts of the GI tract. Increased incidence in males & children with Down syndrome.
● PATHOPHYSIOLOGY
○ Failure of complete neural crest migration during fetal development → absence of
enteric ganglion cells (Auerbach & Meissner plexuses).
○ Functional obstruction due to failure of relaxation of the aganglionic segment. MC affects the distal colon
(often with a transitional zone in the rectosigmoid colon).
● CLINICAL MANIFESTATIONS
○ Neonatal intestinal obstruction: meconium ileus - failure of
meconium passage >48 hours in a full term infant (most full term
infants usually pass meconium within 24 hours, may be delayed in
preterm infants normally). Bilious vomiting, abdominal distention.
Failure to thrive.
○ Enterocolitis: vomiting, diarrhea, signs of toxic megacolon (looks
similar to sepsis).
○ Chronic constipation.
● DIAGNOSIS
○ Anorectal manometry: lack of relaxation of the internal sphincter with balloon rectal distention.
■ Often used as an initial screening test. ↑pressure of the anal sphincter.
○ Contrast enema: transition zone (caliber change) at the area between normal & affected bowel.
○ Abdominal radiographs: signs of obstruction - decreased or absence of air in the rectum & dilated bowel
loops. Not specific.
○ Rectal biopsy: definitive diagnosis. Shows the absence of
ganglion cells. Rectal suction biopsy is less invasive (done
without anesthesia). Full thickness biopsy done if suction is
nondiagnostic.
● MANAGEMENT: Surgical resection of the affected bowel.

Identification of air in the bowel

● Normal abdominal x-ray (right)
○ Pockets of gas appear as darker areas in the bowels
○ Can see haustra in the large bowel

Aortic Dissection

14
Clinical definition
● Tear in the innermost layer of aorta (intima) d/t cystic medial necrosis
● If the blood bursts through the outer wall of your aorta, it’s life-threatening
● 65% ascending (MC site is ascending near the aortic arch or left subclavian, has the highest mortality), 20%
descending, 10% aortic arch
● Debakey classification
○ Type I/type A - originates in the ascending aorta, propagates at least to the aortic arch and often beyond it
distally
○ Type II - originates in and is confined to the ascending aorta
○ Type III/ Type B - originates in descending aorta, rarely extends proximally but will extend distally
● Painless aortic Dissection: presented more frequently with a persistent disturbance of consciousness, syncope or
a focal neurologic deficit.
Pathophysiology
● Intimal wall tear → propagation of tear
○ Blood under high systemic pressure flows
into the media at the point of the tear →
causing a false lumen (channel) → blood
may propagate proximal or distal to the
tear (sometimes both)
● Intramural hematoma - bleeding into the media
Risk factors
● HTN (most important predisposing factor)
● Age (MC 60-80), vasculitis, trauma, family history of aortic
dissection, turner’s syndrome, collagen disorders (marfan
syndrome→ arachnodactyly, pectus excavatum, lanky
limbs), cocaine use, men 2x greater than women,
atherosclerosis, pre-existing aneurysm, bicuspid aortic valve, aortic coarctation, smoking, Connective tissue
disorders (Ehlers-Danlos syndrome & Loeys-Dietz syndrome), giant cell arteritis, syphilis, pregnancy, high intensity
weight lifting
Causes:
● your aortic wall is weak. Over time, high blood pressure can weaken your aortic tissue.
● Sometimes the weakness is from a condition you’re born with that affects the strength or
size of your aorta→ Marfan syndrome
● In rare cases it’s caused by a traumatic injury to the chest, as can happen in a car accident
Clinical manifestations
● Chest pain - sudden onset of severe, tearing (ripping, knife like), chest/upper back pain accompanied by nausea,
vomiting, diaphoresis. Symptoms depend on the location
○ Ascending aorta → anterior chest pain (especially Type A)
○ Aortic arch → neck/jaw
○ Descending aorta → interscapular pain (especially Type B)
● Decreased peripheral pulses: radial, carotid or femoral
○ Variation in pulse (>20 mmHg difference between the
right and left arm)
● HTN: MC in distal/type B, (may be hypotensive)
● Ascending dissections: acute new onset aortic regurgitation
(diastolic decrescendo murmur if the dissection involves the
aorta and aortic valve), acute MI, cardiac tamponade
● Descending dissections: back pain, HTN, hypotension/shock
(3%), spine ischemia
● Neurological deficits including stroke, hemiplegia, and syncope
● Loss of vision, fever
Diagnosis
● CT, MRI, and TEE are most common first line imaging modalities

15
 ○ CT scan with contrast test of choice
○ MRI angiography (gold standard)
○ TEE (transesophageal echocardiography) initially evaluate if hemodynamically unstable
● CXR - see widening of the mediastinum classic sign
○ Loss of the aortic knob/aortic-pulmonary window and calcium sign.
■ A distance >0.5cm is considered a positive calcium sign and a distance >1.0cm is considered
highly suspicious for aortic dissection
● Ultrasound: retinal detachment of the aorta
Management
● Surgical management (open surgery treatment) done in acute proximal (Stanford A/ DeBakey type I and II) or
acute distal (type III) with complications (vital organ involvement, impending rupture)
○ involves removing the dissection and “rebuilding” your aorta with a graft
● Medical management done in descending if no complication (Stanford B/ Debakey type III) or endovascular repair
○ Labetalol #1, esmolol
○ Sodium nitroprusside added if needed, ± Nicardipine

Pneumothorax
● Presence of air in the pleural space
● There is no standard definition of pneumothorax size; “large” pneumothorax → distance of
3 cm or more from the apex of the lung to the scapula of the
chest wall
Categorized as:
1. Primary (no underlying lung disease)
○ blebs (little air collections), bullae
○ small collection of air between the lung and the outer surface of the
lung (visceral pleura) usually found in the upper lobe of the lung
2. Secondary (underlying lung disease present)
○ emphysema (destruction of lung tissue), defects in visceral pleura
3. Traumatic
○ penetrating chest trauma (most common)
4. Iatrogenic
○ insertion of devices into the chest wall (second most common)
Signs & symptoms:
● Chest pain ranging from minimal to severe on affected side and dyspnea
○ Usually begin during rest and usually resolve within 24hrs
● Pneumothorax is small (less than 15% of a hemithorax) - physical findings, other than mild tachycardia, are
normal
● Pneumothorax is large - diminished breath sounds, decreased tactile fremitus, decreased movement of the chest
are often noted, hyperresonance.
● S&S: steady chest ache, SOB, cold sweats, chest tightness, cyanosis, severe tachycardia
Diagnostic test:
● X-ray shows absence of lung markings and demarcation of lung tissue
● Demonstration of a visceral pleural line on CXR is diagnostic and may be seen only on expiratory film
Tension pneumothorax (medical emergency)
● Increased positive pleural pressure throughout the respiratory cycle which
is life-threatening as:
○ Ventilation is severely compromised
○ The positive pressure is transmitted to the mediastinum, resulting
in decreased venous return to the heart and reduced cardiac
output
● Causes:
○ Usually occurs during medical procedures that can damage the
lungs, such as a central line placement, ventilator use, lung
biopsies, or CPR

16
 ○ trauma to the chest from a motor vehicle accident, broken ribs, hard hit to the chest from a contact sport
(such as from a football tackle), stab wound or bullet wound to the chest
● Hyperresonance to percussion, shift of the mediastinum to the contralateral side
● If not treated timely, the patient is likely to die from
inadequate cardiac output or marked hypoxemia.
○ They may also go into cardiac arrest,
respiratory failure, or shock
● Physical examination: Enlarged hemithorax with no
breath sounds, tachycardia, hypotension, and
mediastinal or tracheal shift

Identification of the Cervical Spine

Plain films
● Lateral view (include C1-C7 and C7-T1 junction)
● AP view → middle image
● Open mouth odontoid view → right image
● Plain films provide the quickest way to survey the cervical spine. An adequate spine series includes all 3 above
views, which do not require the patient to move his neck, and should be obtained without the removal of the
cervical collar.
● Indications
○ Mental status less than alert or intoxicated
○ Reports neck pain
○ Midline neck tenderness
○ Neurologic signs and symptoms
○ Distracting injury (i.e. painful injuries elsewhere, e.g. extremity
fractures)
CT
● Up to 20% of fractures are missed on radiographs (fracture
of C2, image right → )
● Advantages
○ Excellent for characterizing fractures and identifying osseous
compromise of the vertebral canal
○ Provides patient comfort by being able to reconstruct images in the
axial, sagittal, coronal, and oblique planes from one patient positioning
● Limitations
○ Difficult to identify fractures in axial plane (e.g. dens fracture, which is
seen on below MRI - top arrow)
○ Unable to show ligamentous injuries
○ Relatively high costs
MRI
● Provides the best visualization of the soft tissues, including ligaments,
intervertebral disks, spinal cord (bottom arrow), and epidural hematomas
● Indications
○ spinal canal involvement
○ clinical neurologic deficits
○ ligamentous injuries (image right, middle arrow)
● Advantages
○ Excellent soft tissue contrast
○ Provides good general overview because of its ability to show information in different planes (e.g.
sagittal, coronal, etc.)
○ Ability to demonstrate vertebral arteries
○ No ionizing radiation
● Disadvantages
○ Loss of bony details

17
 ○ Relatively high cost
Interpretation (AABCDS)
● Adequacy: Can you see all 7 vertebral bodies and C7-T1 (a lot of injuries occur there)? Is the patient positioned
properly?
● Alignment: 4 parallel lines
○ Anterior vertebral line
○ Posterior vertebral line
○ Spinolaminar line
○ Posterior spinous line
○ Lines should follow a slightly lordotic curve, smooth
and without step-offs. Any malalignment should be
considered evidence of ligamentous injury or occult
fracture, and cervical spine immobilization should
be maintained until a definitive diagnosis is made.
● Bone, cartilage, disk, soft tissue

Jefferson fracture (atlas C1)***

● Bilateral fractures of the anterior & posterior arches of C1 (disruption of the transverse ligament may lead to
instability if it occurs with the fracture). ± C1/C2 dislocation.
● MOI: vertical compression force through the occipital condyles to the lateral masses
of the atlas.
● DIAGNOSIS:
○ Lateral radiographs: increase in the predental space between C1 & the
odontoid (dens). >3mm in adults & >5mm in children.
○ Open-mouth (odontoid) view: may also show step-off of the lateral masses of
the atlas.
● MANAGEMENT
○ Nonoperative: hard cervical orthosis vs. halo immobilization for 6-12 weeks
○ Operative: posterior C1-C2 fusion vs. occipitocervical fusion if unstable (controversial).

Odontoid fractures
● Type I: Avulsion of the tip of the dens where it is attached to C1. RARE.
It is stable, since the fracture line is above the transverse ligament
● Type II: Through the base of the dens. Most common fracture. Always
unstable and poor healing. Tx : Surgical fusion.
● Type III: Fracture through the body of the axis and sometimes facets.

Hangman fracture ***

● most common cervical spine fracture. traumatic
spondylolisthesis of the axis C2, is a result of
hyperextension and distraction.
● Traumatic bilateral fractures (spondylolysis) of the pedicles
or pars interarticularis of the AXIS vertebra(C2). May lead to
spondylolisthesis between C2&C3.
● Unstable fracture. 30% are associated with cervical spinal
fractures. Usually no cord injury.
● MECHANISM OF INJURY
○ Extreme hyperextension injuries of the skull, atlas &
axis (especially in an already extended neck) &
secondary flexion with subsequent subluxation (due
to tearing of the posterior longitudinal ligament).
● CLINICAL MANIFESTATIONS
○ Neck pain. Neurologic exam is usually intact because the cervical canal is widest at C2 area.
● Diagnosis:

18
 ○ Cervical xray: subluxation
○ CT exam of choice
○ MRI if vertebral artery injury is suspected
● MANAGEMENT
○ Nonoperative: Type I (<3mm horizontal displacement) rigid cervical collar 4-6 weeks. Type II (3-5 mm
displacement) closed reduction followed by halo immobilization 8-12 weeks.
○ Operative: Type II (>5mm displacement with severe angulation), Type III facet dislocations
Flexion Teardrop fracture
● Anterior displacement of a wedge-shaped fracture fragment (the so-called teardrop shape
of the anterior-inferior portion of the superior vertebra). Often associated with loss of
vertebral height
● MOI: severe flexion & compression causes the vertebral body to collide with an inferior
vertebral body.
● Most commonly occurs in the lower cervical spine.
● Highly unstable (because of disruption of the posterior longitudinal ligament).
● May cause anterior cervical cord syndrome.
● Radiographic features: (best seen on lateral view)
○ Prevertebral swelling associated with anterior longitudinal ligament tear.
○ Teardrop fragment from anterior vertebral body avulsion fracture.
○ Posterior vertebral body subluxation into the spinal canal.
○ Spinal cord compression from vertebral body displacement.
○ Fracture of the spinous process.

Assessment of Stroke

19
20
Ischemic stroke (above)
Hemorrhagic stroke (right)

Assessment of Cranial Hemorrhages

21
Hemangioblastoma
● Arises from the blood vessel lining. Benign, slow growing, well-defined tumors. Often >40y.
● MC found in the posterior fossa (brainstem & cerebellum). May occur in the cerebral hemispheres or spinal cord.
● Retinal hemangiomas associated with von Hippel-Lindau syndrome.
● CLINICAL MANIFESTATIONS
○ Headache, nausea, vomiting, gait abnormalities, poor coordination of the limbs.
○ May produce erythropoietin (secondary polycythemia).
● DIAGNOSIS: CT scan or MRI w/ contrast
○ Biopsy: well-defined borders, usually does not invade
surrounding healthy tissue. Foam cells (macrophage that
localize to fatty deposits on blood vessel walls →
ingest LDLs → foamy appearance) with high vascularity.
● MANAGEMENT: Surgical resection. Radiation may be used in tumors
attached to the brainstem.

Osteosarcoma
● MC bone malignancy. * MC adolescents (80% occur <20y). Produces osteoid
(immature bone).
● 2nd peak 50-60y (especially if history of Paget disease of the bone or
radiation therapy).
● 90% occur in the metaphysis of long bones (MC in femur > tibia, humerus).
● MC METS to the lungs* (usually the cause of death).
● CLINICAL MANIFESTATIONS: bone pain/joint swelling. Palpable soft tissue mass.
● DIAGNOSIS
○ Radiographs: "HAIR ON END" or "SUN RAY/BURST"* (left→ )
appearance of the soft tissue mass. Mixed sclerotic/lytic
lesions. Periosteal bone reactions.
○ Codman's triangle: ossification of raised periosteum.
(right image → )
● MANAGEMENT: limb-sparing resection (if not neovascular); radical amputation (if
neovascular).
○ Chemotherapy as adjuvant treatment.

Ewing Sarcoma
● Giant cell tumor MC in children. MC in males 5-25y. Femur (MC) & pelvis are
common sites.
● CLINICAL MANIFESTATION
○ Bone pain, ±palpable mass, may have joint swelling. ± fever.
○ Bone MC site of metastasis.

22
 ● DIAGNOSIS: lytic lesion, layered periosteal reaction "ONION SKIN"* appearance on radiographs. ± Codman's
triangle.
● MANAGEMENT: Options include chemotherapy, surgery & radiation therapy.

Chondrosarcoma
● Cancer of the cartilage. MC seen in adults (40-75y).
● 3rd MC primary malignancy of the bone after myeloma & osteosarcoma.
● DIAGNOSIS: CT, xray = mineralized chondroid matrix with PUNCTATE OR
RING & ARC APPEARANCE pattern of calcification.
● MANAGEMENT
○ Surgical resection: all grades and subtypes of nonmetastatic
chondrosarcoma.
○ Chemotherapy may be used in select cases of advanced disease.

Musculoskeletal system and imaging

● X-ray: excellent depiction of fracture, low cost, poor depiction of soft tissue,
often take multiple views
● CT scan: cross sectional, excellent depiction of bones and soft tissue
○ Pelvic CT: trauma with high suspicion, negative x-ray, complex
fracture
● MRI: cross sectional imaging, excellent soft tissue contrast, sensitive to
motion
○ T1 weighted imaging: Tissues with high fat content appear bright
and compartments filled with water appears dark, good for demonstrating anatomy
○ T2 weighted imaging: Compartments filled with water appear bright and tissue with high fat content
appear dark, good for demonstrating pathology because most lesions are associated with an increase in
water content
● Ultrasound: soft tissues and fluid, doppler can show blood
flow
○ Ex. ultrasound guided knee aspiration, identification
of cysts
● Nuclear medicine: ex. Assessing metastatic cancer to the
bones
● Types of fractures
○ Transverse - The break is in a straight line across
the bone.
○ Spiral - The break spirals around the bone; common
in a twisting injury.
○ Oblique - Diagonal break across the bone.
○ Compression - The bone is crushed, causing the broken bone to be wider or flatter in appearance.
○ Comminuted - The break is in three or more pieces and fragments are present at the fracture site.
○ Segmental - The same bone is fractured in two places, so there is a "floating" segment of bone.
○ Stable fracture. The broken ends of the bone line up and are barely out of place.
Stress fracture
● Common in athletes & military personnel due to overuse. 3RD METATARSAL MC.•
● CLINICAL MANIFESTATIONS
○ Early findings: Insidious onset of localized aching pain, swelling &
tenderness at the end of activities. As It progresses, the patient may have
tenderness throughout weight bearing.
● DIAGNOSIS: 50% of X-rays will be negative (EB with healing), Bone scan/MRI may
be needed.
● MANAGEMENT: rest (avoidance of high-Impact activities), splint or post-op shoe.
Colles fracture

23
 ● Distal radius fracture with DORSAL/POSTERIOR ANGULATION. * 60% also have ulnar styloid fracture. MC FOOSH
with wrist extension.* ↑ postmenopausal (60-70%), Asian, osteoporotic women.
● DIAGNOSIS: "dinner fork deformity”* On AP, Colles & Smith look alike (need lateral view).
○ Unstable fractures: if >20° angulation, intraarticular, >lcm shortening or comminuted.
● COMPLICATIONS: EPL (extensor pollicis longus) tendon rupture MC,* malunion, joint stiffness, median nerve
compression, residual radius shortening, complex regional pain syndrome.
● MANAGEMENT: Sugar tong* splint/cast. If stable ( <20° angulation → closed reduction).
○ ORIF if unstable or comminuted.
Smith fracture
"Reverse Colles Fracture" (ventral"anterior) angulation.• MC FOOSH with wrist flexion. ------>

Compression fracture
● "Burst" fractures occur in children from jumping/fall from height. Lumbar
compression fractures in the elderly (osteoporosis), tumor or systemic illness.
Pathologic fractures in malignancy.
● CLINICAL MANIFESTATIONS: pain & POINT
TENDERNESS* at the level of compression.
● MANAGEMENT: orthopedic & neurosurgery consult
Analgesics; ± kyphoplasty /vertebroplasty.

Compound/Open fracture
● broken bone is exposed through the skin. ------------->
● This may mean that the bone is actually sticking out of the skin, or it may
mean that the skin and soft-tissue are disrupted and exposes a path to the
site of the fracture

Greenstick fracture
● Incomplete fracture with cortical disruption & periosteal tearing on the
convex side of the fracture (intact periosteum on the concave side)
"bowing".*

Buckle (torus) fracture

● Incomplete fracture with "wrinkling or bump" of the metaphyseal-diaphyseal junction where the dense bone meets
the more porous bone due to axial loading

24
Hip fracture
● MOI: minor or indirect trauma in the elderly. High-
impact injuries in younger patients.
● MC in osteoporotic women. Common in the elderly
& patients with decreased bone mass.
● Femoral Head/Neck Fractures: high incidence of
avascular necrosis with femoral neck fractures.*
High incidence of DVT & pulmonary embolism.
● Intertrochanteric/Subtrochanteric are
extracapsular. Femoral head/neck fractures are
intracapsular.
● CLINICAL MANIFESTATIONS: hip pain with leg
SHORTENED, EXTERNALLY ROTATED,* ABDUCTED.
● MANAGEMENT: ORIF. ± Observation if high surgical risk, minimal pain or non-
ambulatory
Pelvic fracture
● MOI: high impact injuries (ex. MVA). acetabular fractures MC occur with associated lower extremity, abdominal or
neurologic injuries. May have perineal ecchymosis
● MANAGEMENT: ORIF. Weight bearing as tolerated for some pubic rami fractures.
● COMPLICATIONS: infection, DVT, sciatic nerve damage, vascular injury (bleeding).

Boxer’s fracture
● Fracture at the neck of 5th metacarpal (±4th).
● ± rotational deformity. ± Loss of the knuckle on exam.
● Mechanism: punching with a clenched fist.
○ If at the base → look for associated carpal Injuries.
● MANAGEMENT
○ 1. Ulnar gutter splint with joints in @ least 60° flexion.
■ any fracture> 25-30° angulation should be reduced.
■ ORIF If it remains >40° angulated.
○ 2. Always check for bite wounds, If present treat with the appropriate
antibiotics (ex. Amoxicillin/ clavulanic acid).

25
Bennett fracture
● BENNETT'S FRACTURE: intra-articular fracture through the base of the 1st metacarpal (MCP) bone with a large
distal fragment dislocated radially & dorsally by the abductor pollicis longus muscle.
● ROLANDO'S FRACTURE: comminuted Bennett's fracture.
● Management: Unstable/ Requires ORIF. Thumb spica for temporary stabilization

Weber ankle fracture

● Whole body MRI is not widely used, but is highly sensitive to replacement of normal bone marrow
Clavicular fracture
● Midclavicular MC site
● Plain radiograph- AP & Axial views; usually clinically obvious

Skeletal deformities and effusions

● Osteomalacia & rickets
○ Due to vitamin D deficiency* → ↓ calcium AND phosphate →
demineralization → "soft bones."
○ In contrast to osteoporosis (where mineral & matrix loss
is proportional), osteomalacia is characterized by
decreased mineralization of bone osteoid only - cortical
thinning, layers of demineralized bone.
○ CLINICAL MANIFESTATIONS

26
 ■ 1. RICKETS (CHILDREN): delayed fontanel closure, growth retardation, delayed dentition costal
cartilage enlargement (rachitic rosary), long bones: bowing "fuzzy" cortex.
■ 2. OSTEOMALACIA (ADULTS): Asymptomatic at 1st• Diffuse bone pain, muscular weakness
(proximal). Hip pain may cause antalgic gait Bowing of long bones. Hypocalcemia symptoms.
○ DIAGNOSIS
■ ↓vitamin D, ↓ calcium AND ↓ phosphate, ↑ alkaline phosphatase.
■ Radiographs: LOOSER LINES (ZONES}:* transverse "pseudo-fracture" lines (visible osteoids).
○ MANAGEMENT: Vitamin D (Ergocalciferol) first line.* Calcium
supplementation in some patients.
Pagets disease of the bone ------->
bone interferes with your body's normal recycling process, in which new bone
tissue gradually replaces old bone tissue. Over time, the disease can cause
affected bones to become fragile and misshapen.

Salter Harris fractures

Hernias
● Upper GI series (UGI)
○ Single vs double contrast
■ Barium, gastrograph, air contrast (granules)
■ Barium plus air --> double
○ With small bowel follow through
● UGI - indications (helpful in the diagnosis and evaluation of)
○ Suspected or known gastritis or duodenitis
○ Peptic ulcer disease
○ Hiatal hernia
○ Pediatric patients*
○ Varices
○ Suspected perforation
○ Neoplasms
○ Gastric bowel obstruction
● Ultrasound, CT, and MRI

27
Assessing Metastasis

↑ nuclear medicine bone scan

● bone is the third most common
organ affected by metastasis,
surpassed only by the lungs and
liver
● benign osseous lesions and bone metastases often times have similar imaging features, so the location of a
lesion in the skeleton can sometimes be used to help distinguish between the two in equivocal cases.
● The vertebrae, pelvis, ribs and the ends of long bones are preferred destinations of metastases because of their
high red marrow content
● Diagnosis: cause “lytic lesions” (holes) in bone or may cause dense white (sclerotic lesions), or mixed lesions
○ Most neoplasms, including lung, renal, breast cancer, and multiple myeloma → lytic
lesions
○ Prostate cancer, breast cancer → sclerotic lesions
● Spine → MRI is best (but can only focus on limited portions of the body at one time)
● nuclear medicine bone scan is most cost-effective routine imaging study to try and identify both sclerotic and
lytic lesions
○ (usually used for initial staging, bone pain by history, 6 wks after chemotherapy completion, or non-small
cell cancer of the lung, breast, or prostate, etc)
● CT does not have a role in primary assessment for the presence of metastases (except for difficult areas to
image such as the spine) but is excellent at defining the extent of bony involvement and in helping assess the risk
of pathological fracture.
● As is the case with other bone lesions, skeletal metastases can be difficult to identify on plain x-ray films since
extensive (30-50%) bone mineral loss is required before the density loss is radiographically-visible

know the various views that are best for specific body regions, parts/areas
● AP and lateral – on all patients
● Odontoid view – on all trauma (standard though on most “C-spine series”)
○ examine atlantoaxial joint/dens

28
 ● Flex/exten views – looking for instability → give info on loss of motion and spasm
○ concern for spondy or increase atlantodens interval (atlantoaxial instability) in RA or Downs
● Oblique: examine foramina for narrowing (stenosis)
● Chest x-rays best done PA upright view to show air and fluid levels and less magnification of the heart
● extremities: AP, lateral, oblique (opens joint space)

Know that landmark boundaries when attempting to identify prominent body structures

Child abuse
● when clinical or imaging findings are suspicious for potential abuse, a
radiographic skeletal survey is obtained.
○ Frontal views of all long bones, rib views with obliques, skull,
pelvis, hands/feet, and spine.
○ X-ray bone survey, CT head without contrast, CT abdomen if
abdominal trauma
● Multiple fractures of various ages as well as multiple fractures of
various body parts are highly suspicious for abuse.
● Highly specific fractures for child abuse include bucket handle
fracture(Corner), posterior rib fracture, scapula fracture, sternum
fracture, spinous process fracture
● The fact that the fractures are of different stages can be ascertained
by periosteal reaction or callus around some, but not around other,
fracture sites.
● If child abuse is suspected, additional views of the skull, ribs, pelvis,
and both upper and lower extremities should be obtained

compare the use radiological methods in pediatrics vs adult population

children
● Children are much more sensitive to the potential harmful effects of radiation than are adults, and they also have
a longer expected life span during which to develop potential complications of radiation such as cancer.
○ Radiation dose reduction techniques: avoiding CT when unnecessary, using alternative diagnostic
methods that do not utilize radiation such as ultrasound, adjusting CT parameters to minimize dose when
CT is performed, using in-plane shielding for areas such as the eye, thyroid, and breast, collimation

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 Ultrasound, conventional radiography, and fluoroscopy are heavily utilized modalities in pediatric
○
population
● Comparison views:
○ comparison views are recommended only if the observer is confused by the appearance of an epiphysis
or other ossification center on a certain projection; comparison views should never be obtained on a
routine basis.

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1. know the various views that are best for specific body regions, parts/areas
2. Know that landmark boundaries when attempting to identify prominent body structures
3. Identification of the cervical spine
4. Identify various fractures on X-ray
5. Hernias
6. Know the characteristic finds on imagery the various conditions/structural defects discussed
7. The identification of air in the bowel (???)

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8. Hirschsprung disease
9. Hemangioblastoma, seminoma, sarcoma
10. Make clinical diagnosis based on imagery
11. Pyelonepthitis
12. Polycystic kidney disease
13. Renal cell carcinoma,
14. glomerulonephritis
15. Kidney stones, renal cyst
16. Testicular tumor, hydrocele, cyrptochidism
17. Testicular torsion
18. Pregnancy (normal vs abnormal)
19. Endometrial masses
20. Urinary bladder abnormalities
21. The use go HCG during imagery when assessing pregnancy
22. View of the normal and healthy male & female reproductive structures
23. Determining gestation age????
24. The characteristic radiology findings as gestation progresses
25. Prostate cancer imagery
26. The technologies of the various radiological technics/methods/imagery
27. The imagery test of choice of various medical conditions
28. compare the use radiological methods in pediatrics vs adult population
29. Assessing child abuse
30. Assessment of stroke
31. Assessment of hemorrhages
32. Assessment of cranial hemorrhages
33. Clavicular fracture
34. Skeletal deformities and effusions
35. Ovarian and testicular torsion
36. Aortic dissection
37. Assessing metastasis
38. Assessment of pneumothorax

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