Dr Kamar’S Radiology

Posterior dislocation
ANTERIOR SHOULDER DISLOCATION

The key to deciding whether a dislocation is anterior or posterior is to identify the coracoid process,
which is pointed anteriorly. If the humeral head is displaced towards this it is an anterior dislocation and
if it is displaced away from it then it is a posterior dislocation.
 Predisposing factors
 flattened: shallow anterior/antero-inferior glenoid bony contour: may predispose to recurrent dislocations 5
Radiographic features
Anterior dislocations can be further divided according to where the humeral head comes to lie:

 subcoracoid: most common
 subglenoid
 subclavicular
 intrathoracic: very rare
In anterior dislocations the humeral head comes to lie anterior, medial and somewhat inferior to its normal location
and glenoid fossa

PHYSICAL EXAMINATION

If the shoulder is anteriorly dislocated, the arm is in slight abduction and external rotation.

Performing a detailed neurovascular examination before and after the shoulder has been reduced is imperative. Injury to the
axillary nerve during shoulder dislocation has been reported to be as high as 40%

 An anteriorly dislocated shoulder causes the arm to be slightly abducted and externally rotated. The
patient resists all movement. The acromion appears prominent in thin individuals and there is loss of
the normal rounded appearance of the shoulder ( picture 1 ). Clinicians perform a neurovascular
examination paying particular attention to distal pulses and the function of the axillary nerve, which is
most commonly injured in anterior shoulder dislocations. Axillary nerve dysfunction manifests as loss
of sensation in a "shoulder badge" distribution, although this finding is not reliably present [ 8,9 ].
Deltoid muscle weakness may also be present, 

TREATMENT: close reduction

Normal half moon sign

Examination – Examination reveals prominence of the posterior shoulder with flattening anteriorly.
The coracoid process appears prominent. The patient holds the arm in adduction and internal rotation
and is unable to externally rotate
The light bulb sign manifests because the humeral head is internally rotated and the tuberosities no
longer project laterally, resulting in a circular appearance of the humeral head ( image 7 ) [ 26 ]. 

The rim sign refers to the distance from the medial aspect of the humeral head to the anterior glenoid
rim. Although this distance may be normal with a posterior dislocation, if there is superimposition of
these two structures or conversely a widened joint space (>6 mm), posterior dislocation should be
suspected ( image 3 and image 7 ). 
treatment:  We suggest obtaining consultation with an orthopedic surgeon for all cases of posterior
shoulder dislocation. Closed reduction is only attempted if the anterior articular surface defect
The trough line sign is present when two parallel lines of cortical bone are seen on the medial cortex
of the humeral head. One line represents the medial cortex of the humeral head, while the other line
represents the "trough" of an impaction fracture
Inferior dislocation

Examination – Patients with this injury hold the involved arm above their head and are unable to
adduct the arm [ 31 ]. The forearm is pronated and in most cases rests on the top of the head

axillary nerve most commonly involved 

Closed reduction is successful.  We suggest immobilizing the shoulder in the traditional position of
adduction and internal rotation. A collar and cuff, sling and swathe, or a commercially available
shoulder immobilizer are equally effective.

Sternoclavicular joint displacement:

Patients commonly complain of chest and shoulder pain exacerbated by arm movement or by assuming a supine position
wn medial head is abv normal joint it is posteriosly displaced

wn medial headis below than niormal joint dn it is anteriorly displaced

Whn medial joint is prominent then blow is on shoulde

t/m

Options include conservative treatment, especially for anterior dislocation. Posterior dislocations are normally treated
with closed reduction. Surgical fixation (ORIF) is usually reserved for unreduced posterior dislocations

ACROMIOCLAVICULAR JOINT DISLOCATION

 In addition to commenting on whether or not a subluxation/dislocation is present a number of features should be
examined and commented upon:

 presence of soft tissue swelling

 degree of subluxation of the clavicle 
o grade II: inferior border of clavicle not elevated beyond the superior border of the acromion
o grade III: inferior border of clavicle is elevated beyond the superior border of the acromion, but
coracoclavicular distance is not greatly increased (less than twice normal)
o grade V: marked superior elevation of the clavicle with coracoclavicular distance more than twice
normal
Treatment largely depends on the age and lifestyle of the patient as well as the grade of the injury. In general grades
I and II are treated conservatively, grades IV, V and VI are treated surgically, and grade III injuries are variably
treated
STEP UP DEFORMITY OF ACJ

CLAVICULAR FRACTURE:
The focus of treatment of middle third fractures remains nonoperative, although evidence is mounting, in support of
operative treatment for displaced midshaft clavicle fractures. Management of medial clavicle fractures also has remained
nonoperative

The incidence of nonunion of displaced distal third fractures is high, and current recommendations are to fix these injuries
surgically.
 HIP JOINT:

 posterior hip dislocation (most common ~85%)

 anterior hip dislocation (~10%)
o inferior (obturator) hip dislocation (rare)
o superior (pubic/iliac) hip dislocation
Posterior hip dislocation
  Discussion: 
    - diagnosis: limb is shortened, internally rotated, and adducted; 

Acutely after successful reduction, resting and icing the hip and taking anti-inflammatory and/or narcotic medications to
reduce pain are helpful.

 For type 1 posterior dislocations, athletes may return to weight bearing as pain allows.
Th Closed reduction should be attempted under conscious sedation, general anesthesia, or spinal anesthesia immediately
after the injury. The inability to perform closed reduction provides evidence for bony fragment involvement in the joint space
and/or soft-tissue damage. CT scanning is warranted, followed by excision of loose bodies and open reductione sciatic
nerve sits just inferoposterior to the hip joint and is injured in approximately 20% of all hip dislocations.

ANTERIOR HIP DISLOCATION:

 lesser trochanter more visible in anterior dislocation due to external rotation
 femoral head will appear larger than the contralateral hip on account of geometric magnification
Diagnosis:
    - may see slight shortening;
    - superior dislocations: (iliac or pubic):
         - hip is extended and externally rotated
         - femoral head is palpable in the vicinity of ASIS;
         - w/ superior dislocations note injury to femoral artery, vein, or nerve;
    - inferior dislocations (obturator, thyroid, or perineal)
         - hip is abducted, externally rotated, and varying deg of flexion;
         - fullness may be palpable in region of obturator foreamen;

- Associated Injuries:
    - femoral head is displaced anteriorly & may compress femoral NV bundle;
    - femoral head frx
         - may occur as often as 75% of cases
         - these will be difficult to diagnos w/o tomograms or CT scans;

 Radiographic Findings:
    - on AP find that femoral head is out of the acetabulum in either superior or inferior position;
   
    - femoral head appears to be slightly larger than on the contralateral side, and the lesser trochanter is in full profile;
    - look for frx of acetabular rim or floor, femoral head, & femoral neck;
    - if of other fracture: get CT;
Techniques of Closed Reduction
    - Closed Reduction is achieved by traction, followed by extension and internal rotation;
    - Gravity Method of Stimson
    - Allis's maneuver

- Complications:
    - AVN: occurs in approx 10% of anterior dislocations;
    - DJD:
    - Transchondral and Indentation Fractures
CHEST:
See:

A, airway

B, bones, kerley b lines

C, cardiac shadow

D, diaphragm

E, exposure

F, fluid

G, gas under diaphragm

Trachea shifted towards opaque side will b

1.collapse

2.cancer
Trachea shifted away from lesion

1.pnemothorax

2.hydrothorax

3.massive empyma

ATELECTASIS:
Ryt middle lobe:
Pneumothorax:

Bleb on right upper side

Pneumothorax.

 diagnosis:
             - dx should be made clinically rather than radiographically;
             - listen for decreased breath sounds, and hyperresonance;
             - tracheal deviation is often difficult to feel unless it is pronounced;
             - dx by CXR implies that treatment was needlessly delayed;
    - treatment:
             - needle rx for tension pneumothorax
             - identify the 2nd ICS in the MCL on the hyperresonant side;                 
             - mark the point with a pen;                                                 
             - insert 14 gauge IV needle, listen for rushing air w/o suction;                  
             - insert the chest tube, (placement of a needle alwasys mandates a chest tube)

Subcutaneous emphysema:
Pnemomediastinum
Hb 2.116
Pnemopericardium
Pneumonia
Bronchopneumonia:
Interstitial pneumonia:
Interstitial lung disease:
 numerous poorly defined small (<5 mm) opacities throughout both lungs, sometimes with sparing of the
apices and bases
 airspace disease: usually seen as ground-glass opacities (can be patchy or diffuse, resembling pulmonary
oedema) or, more rarely, as consolidation
 a pattern of fine reticulation may also occur
Sarcoidosis:
Pnmohemothorx:
CA lung:
Abdomen:
 Abdominal radiograph
Abdominal radiographs are only 50-60% sensitive for small bowel obstruction 3. In most cases, the abdominal
radiograph will have the following features:

 dilated loops of small bowel proximal to the obstruction

 predominantly central dilated loops
 three instances of dilatation over 3 cm
 valvulae conniventes are visible
 fluid levels if the study is erect (non-standard technique)
However, obstruction (which may be high grade mechanical obstruction) may also present with the following features:

 a gasless abdomen: gas within the small bowel is a function of vomiting, NG tube placement and level of
obstruction
 the string-of-beads sign: small pockets of gas within a fluid-filled small bowel
String of pearls sign, abdominal xray

The linear arrangement of air bubbles on the image (string of pearls) is considered diagnostic of small bowel obstruction. The large
bowel can also have its own string of pearls sign, however the air bubbles are larger and flatter. The patient will typically present
with nausea and crampy abdominal pain, vomiting, distension and decreased bowel sounds without rebound or localized
tenderness. Management with nasogastric tube drainage and IV fluids in often adequate
cecal voluvlus, AXR

Classic test question is a young marathon runner with prior abdominal surgeries who presents with acute abdominal pain.
Abdominal imaging shows several distended loops of small bowel and coffee bean shaped hypodensity. Contrast this with the
sigmoid volvulus, classically occurring in elderly individuals with chronic constipation and abdominal distension. The treatment for
both is NGT decompression and surgery. 

 High-grade SBO. Plain abdominal radiograph shows multiple air-fluid levels (arrows), some with a width
of more than 2.5 cm. In addition, thereis a differential vertical height of more than 2 cm between
corresponding air-fluid levels in the same bowel loop (circled area). There is also distention of the

small bowel diameter to more than 2.5 cm and a small bowel–colon diameter ratio of greater than 0.5.
CT criteria for SBO. Axial CT scan shows a disparity in caliber between distended proximal small bowel
and collapsed distal small bowel loops (arrows). loops (diameter &gt;3 cm) (dotted line

LBO:
The most common causes of large bowel obstruction are colo-rectal carcinoma and diverticular
strictures. Less common causes are hernias or volvulus (twisting of the bowel on its mesentery).
Adhesions do not commonly cause large bowel obstruction.

Radiological appearances of large bowel obstruction differ from those of small bowel
obstruction, however, with large bowel obstruction there is often co-existing small bowel
dilatation proximally.

Dilatation of the caecum >9cm, and >6cm for the rest of the colon is considered abnormal.
Anteroposterior supine abdominal radiograph in a 67-year-old man with LBO shows dilated ascending,
transverse, and descending colon. A
transition point is identified in the region of splenic flexure from an obstructing colon carcinoma (arrow).</p>
Ct liver abcess:

As a general rule, bacterial and fungal abscesses are often multiple, whereas amoebic abscesses are more
frequently single. Amoebic abscesses are more common in a sub-diaphragmatic location and are more likely to
spread through the diaphragm and into the chest

 In general they appear as peripherally enhancing, centrally hypoattenuating lesions

Pyogenic liver abcess

Amebc abcess:
Hemangioma:
Hydrated cyst:
 The differential for the skeletal manifestations of RA includes:

The radiographic hallmarks of rheumatoid arthritis are:

 soft tissue swelling:

o fusiform and periarticular; it represents a combination of joint effusion, oedema and tenosynovitis 5
o this can be an early/only radiographic finding

 osteoporosis: initially juxta-articular, and later generalised; compounded by corticosteroid therapy and

disuse
 joint space narrowing: symmetrical or concentric
 marginal erosions: due to erosion by pannus of the bony “bare areas”
 osteoarthritis
o involves the: DIPs, PIPs, 1st CMC joints
o nonuniform joint space loss, subchondral sclerosis and osteophyte. soft tissue swelling: Heberdon’s
node (DIPs) and Bouchard node (PIPs). no Erosions and no anklylosis.
 erosive osteoarthritis:
 o clinically an acute inflammatory attacks (swelling, erythema, pain) in postmenopausal woman
o typically includes the DIPs, PIPs 1st CMC joint 6, but not The metacarpophalangeal (MCP) joints and
large joints. 
o classic central erosions. possible ankylosis.

 psoriatic arthritis (PsA):

o commonly involves the hands and there is an interphalangeal predominant distribution in PsA vs.
MCP joint predominance in rheumatoid arthritis (RA)
o starts with erosions in the margins and eventually involves the
whole joint. classic: “pencil in cup” and bone proliferation (unlike RA). osteoporosis not a feature in PsA.
 reactive arthritis (Reiter syndrome):
o predilection for the lower limb
o osteopenia and then osteoporosis, uniform joint space loss, subchondral cyst
formation, subluxations, marginal erosions but no bone formation. 
o symmetrical involvement of the: PIPs, MCPs, and carpal bones.

 systemic lupus erythematosus (SLE)/Jaccoud arthropathy:


o joint space loss, subchondral sclerosis, osteophyte, and ulnar deviation of the phalanges without
erosions
 calcium pyrophosphate dehydrate (CPPD) arthropathy
o usually only in the MCPs: symmetric joint space narrowing, subchondral cysts, and
osteophytes. unlike RA: chondrocalcinosis and no erosions 
 gout
o usually in older men
o punched out erosions usually with a sclerotic border and overhanging edges, tophi, most commonly
involves the 1st MTP known as podagra

BRAIN PATHOLOGIES:
MRI BRAIN
New born baby WD bilious vomiting
Patients present in early life with duodenal obstruction and associated symptoms of abdominal
distension, vomiting and absent bowel movements. In complete atresia duodenum ends blindly with no
communication with the distal bowel (and therefore no aeration distally). The atretic segment is usually
just distal to the ampulla of Vater 1 and the child has bilious vomiting. If the atresia is proximal to the
ampulla, the vomiting is non-bilious.

Down syndrome : 30% of duodenal atresia cases may have Down syndrome while 3% of Down
syndrome cases may have duodenal atresia

May classically show a double bubble sign with gas filled distended stomach and duodenum with an
absence of distal gas
NEC=necrotizing enterocolitis
This is typical presentation of osteosarcoma. The codman triangle, confirmation of uncontrolled
osteoblastic activity raising the periostium.

Ct liver abcess:

As a general rule, bacterial and fungal abscesses are often multiple, whereas amoebic abscesses are
more frequently single. Amoebic abscesses are more common in a sub-diaphragmatic location and are
more likely to spread through the diaphragm and into the chest

In general they appear as peripherally enhancing, centrally hypoattenuating lesions

Pyogenic liver abcess

Scaphoid fracture
33 yr male present with ho progressive numbness nd weakness in his ryt leg
young girle with hx of4 days blurring of vision then sudden loss of vision on mri there is white
calcification in ventricles (weired scenario ! ) ms
FRACTURES:
COLES Fracture: Lateral radiograph of the wrist showing a

distal radial fracture (white arrow head). The distal fragment is posteriorly
displaced (black arrow).
Ankle fracture
Osteoarthritis
Hip osteoarthritis

Magnified radiograph of the right hip showing periarticular sclerosis (black arrow
heads) and osteophytes (white arrow).

Notice also the joint space narrowing especially superiorly

Subcapital fracture of Femur
Intertrochenteric fracture of femur

Dr Kamruddin Khan

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