The Unofficial Guide To Radiology

Introduction
Rodrigues
Introduction
The Unofficial Guide to Radiology QuresHi

‘The Unofficial Guide to Radiology’ follows on from the ‘The Unofficial Guide to Passing OSCEs’. This book
teaches systematic analysis of the three main types of X-rays: chest, abdominal and orthopaedic, with
X-Rays
X-Rays
additional chapters looking at all the other main radiology tests such as CT and MRI. The layout is designed
Chest
Chest
Orthopaedic X-Rays, plus CTs, MRIs and Other Important Modalities
to make the book as relevant to clinical practice as possible; the X-rays are presented in the context of a real
life scenario. The reader is asked to interpret the X-ray before turning over the page to reveal a model report
accompanied by a fully annotated version of the X-ray. To further enhance the clinical relevance, each case has
The Unofficial Guide to Radiology: Chest, Abdominal and

5 clinical and radiology-related multiple-choice questions with detailed answers. These test core knowledge
Abdominal
Abdominal
X-Rays
X-Rays
for exams and working life, and illustrate how the X-ray findings will influence patient management.
This book is suitable for:

• Medical Students • Physicians Associates
Orthopaedic
Orthopaedic
X-Rays
X-Rays
• Radiographers • Nurses
• Nursing Students • Advanced Nurse Practitioners
• Junior Doctors
Scans
Scans
“Radiology is a constant challenge for students and doctors in busy clinical units: having
CT
CT
a good command of the essentials is a real advantage. This book is well-presented and
very accessible. The annotated examples provide realistic challenges with immediate
feedback. It didn’t take long before I felt better prepared for my next ward round!”
Scans
Scans
Simon Maxwell, Professor of Student Learning, University of Edinburgh
MRI
MRI
“Perhaps one of the biggest strengths of this book is the cases section, allowing you to
practice not only interpreting high quality images but also to link them to a case history.
Scans
Scans
USS
USS
The questions that follow not only test your radiology, but also your understanding of signs,
symptoms, underlying pathophysiology and management of the condition. As well as detailed
answers in each section, the book also shows you the best way to present each case, whether
Medicine
Medicine
Nuclear
Nuclear
in an OSCE situation or on a ward round. The ease of use, detailed pictures and emphasis on
Scans
Scans
key points of this one should cement it as the number one undergraduate book for radiology.”
James Brookes, Medical Student
Fluoroscopy
Fluoroscopy
“Which radiographs from each system are most likely to be presented in exams?
This excellent book presents the classics, and at one level this makes it a high-yield
textbook that will be extremely valuable to medical students and junior doctors. What is
especially striking is the definition and clarity of the illustrations, with on-image The Unofficial Guide to
X-Rays
X-Rays
Bonus
Bonus
labelling enabling one to be absolutely certain of which is the endotracheal tube, the
Chest
Radiology: Chest, Abdominal and
Chest
nasogastric tube and the central line, for example.”
Bob Clarke, Associate Dean, Professional Development, London.
Director, Ask Doctor Clarke Ltd. Orthopaedic X-Rays, plus CTs, MRIs
Abdominal
Abdominal
X-Rays
and Other Important Modalities
Bonus
Bonus
X-Rays
ISBN: 978 0 9571499 4 6

Core Radiology Curriculum Covered: 100 Annotated X-Rays (including how to present them),
300 Multiple Choice Questions (with detailed explanations)
Orthopaedic
Orthopaedic
X-Rays
X-Rays
Bonus
Bonus
RRP £39.99 Mark Rodrigues and Zeshan Qureshi

FIRST EDITION
Join Our Medical Book Writing Project (details inside) Join Our Medical Book Writing Project (details inside)
The Unofficial Guide
to Radiology
FIRST EDITION
Mark Rodrigues BSc (Hons) MBChB (Hons)

Radiology Registrar, Royal Infirmary of Edinburgh;
Honorary Clinical Tutor, University of Edinburgh, UK
Zeshan Qureshi BM BSc (Hons)

Academic Clinical Fellow (International Child Health) Great Ormond Street
and Institute for Global Health, London;
Honorary Clinical Tutor, University of Edinburgh, UK
INTRODUCTION
‘The Unofficial Guide to Radiology’ is the fifth book in the Unofficial Guide to Medicine series. Almost every
patient has some form of medical imaging performed during his or her investigations and management.
The commonest form of imaging, and the modality which all doctors should be able to interpret, remains the
X-ray. This important aspect of radiology is therefore the main focus of the book. Other imaging modalities
are specialised investigations interpreted by radiologists. However, medical students, doctors, nurses,
physician’s associates, and surgeons need to understand what these tests involve, when they are indicated
and contraindicated, and how to best request them. Therefore, these aspects are also covered in the book.
Despite its universal importance, X-ray interpretation is often an overlooked subject in the medical school
curriculum, which many medical students and junior doctors find difficult and daunting. I was no different
when I started work as a junior doctor. However, since starting radiology training, I have realised X-ray
interpretation should not be that way.
The keys to interpreting X-rays are having a systematic method for assessing the X-ray and getting lots of
practice at looking at and presenting X-rays. Occasionally, there may be a complex X-ray you find difficult, or
a subtle finding you overlook, but that’s what keeps people like me in a job, so do not worry about it.
The “4 Ds” are a useful framework for X-ray interpretation which underpins the approach used in this book.
First, you need to Detect and Describe the abnormalities on the X-ray. You then need to form a Differential
diagnosis based on clinical and X-ray findings before Deciding what further imaging and management is
required.
There are lots of radiology textbooks available, but I do not think there is one which is ideally suited for
teaching medical students and junior doctors. Many have small, often poor quality images. Radiology is
a visual subject and therefore such images are difficult to use to demonstrate key clinical findings. This is
confounded by the fact that the findings are usually only described in a figure below the image, and it is
often difficult to know exactly what part of the image corresponds to which finding! Another fundamental
problem with many radiology textbooks is that they deal with X-rays in isolation. In reality, X-rays are part of
the clinical assessment and management of patients, and thus they should be taught in a clinical context.
The content, layout and approach used in this book are designed to make it as useful and clinically relevant
as possible:
• Over 200 large, high quality radiological images are used throughout the book and important findings
are annotated on the images to highlight the key points and findings to the reader.
• The chest, abdominal and orthopaedic X-ray chapters contain step-by-step approaches to interpreting
and presenting X-rays.
• Each of these chapters also covers 20 common and important X-ray cases/diagnoses. They are
labelled as ‘Case X’ to not give away the diagnosis, but at the end of the book there is a list of all the
diagnoses.
• The X-rays are presented in the context of a clinical scenario. The reader is asked to “present their
findings” before turning over the page to reveal a model X-ray report accompanied by a fully
annotated version of the X-ray. This encourages the reader to look at the X-ray thoroughly, as if
working on a ward, and come to their own conclusions about the X-ray findings and any further
management required before seeing the answers.
• To further enhance the clinical relevance, each case has 5 clinical and radiology-related multiple-
choice questions with detailed answers. These are aimed to test core knowledge needed for exams
and working life, and illustrate how the X-ray findings will influence patient management.
• 3
• The bonus X-ray chapter provides over 50 further X-ray cases to help consolidate the reader’s
knowledge and provide an opportunity to practice the skills they have learnt.
• Five chapters are devoted to other important imaging investigations: computed tomography (CT),
magnetic resonance imaging (MRI), ultrasound (USS), nuclear medicine, and fluoroscopy. These cover
the details of what the examinations entail, their common indications, contraindications and key
imaging findings.
• The content is in line with the Royal College of Radiologists’ Undergraduate Radiology Curriculum 2012,
making it up to date and relevant to today’s students and junior doctors.
With this textbook, we hope you will become more confident and competent in these radiology competencies,
both in exams and in clinical practice, and we also hope that this is just the beginning. We want you to get
involved, this textbook has been a collaboration with junior doctors and students just like you. You have the
power to contribute something valuable to medicine; we welcome your suggestions and would love for you to
get in touch. A good starting point is our Facebook page, which is growing into a forum for medical education:
Search for “The Unofficial Guide to Medicine” or enter the hyperlink below into your web browser.
Please get in touch and be part of the medical education project.
Mark Rodrigues, Zeshan Qureshi,

mark.a.rodrigues@gmail.com zeshanqureshi@doctors.org.uk,
@DrZeshanQureshi
Facebook: http://www.facebook.com/TheUnofficialGuideToMedicine
4 •
FOREWORD
Radiology is encountered every day by medical students. From the wards to OSCEs,
from theatre to outpatient clinics, radiology is everywhere at the undergraduate level
and beyond. The importance of understanding the principles of imaging, radiation
doses and the clinical interpretation of results is paramount. Radiology is a key
diagnostic and monitoring tool in modern medicine, so the ability to assess an X-ray
in a systematic order is a vital skill. The vast range of techniques, and the complexity
of the human body, means this is not a subject that can be learnt overnight, and this
book aims to provide you with a grounding in this mammoth specialty.
The authors have ensured they have included the basic scientific principles underlying
James Brookes,
radiology. The book covers many imaging modalities and presents them in a systematic
Medical Student, order to give you a clear approach to interpreting what you see. Detailed pictures along
University of Southampton the way point out normal anatomical features as well as deformities and anomalies.
Perhaps one of the biggest strengths of this book is the cases section, which allows
you to practice not only interpreting high quality images but also to link them to a case history. The questions
that follow not only test your radiology knowledge, but also your understanding of signs, symptoms, underlying
pathophysiology and management of the condition. As well as providing detailed answers in each section, the
book also shows you the best way to present each case, whether in an OSCE situation or on a ward round.
“ The Unofficial Guide to OSCEs has quickly become established as one of the most useful undergraduate books.
The ease of use, detailed pictures and emphasis on key points of this title should cement it as the number one
undergraduate book for radiology. I hope you find it invaluable throughout your studies and it brings you success
in all of your exams!
”
James Brookes
Which radiographs from each system are most likely to be presented in exams?
textbook that will be extremely valuable to medical students and junior doctors.
But it is much more than that. Not only does it teach pattern recognition, it also
clearly and simply explains the underlying concepts which make such images easier
to interpret and answers all those tricky questions that return to haunt clinicians on a
regular basis. For example, when should I use CT and when would magnetic resonance
imaging be more appropriate?
This book also teaches a systematic approach to reporting, with the bonus cases
Bob Clarke, particularly useful in enabling readers to check that they have learnt from the core
Associate Dean,
Professional Development,
cases that have gone before. This interactivity is essential to its success and the skills
London. acquired will transfer to life beyond the exams.
Director, Ask Doctor
Clarke Ltd. What is especially striking is the definition and clarity of the illustrations, with on-
image labelling enabling one to be absolutely certain of which is the endotracheal
tube, the nasogastric tube and the central line, for example.
“ Mark Rodrigues and Zeshan Qureshi are to be congratulated on producing this excellent volume. As with
the other books in this series, the multi-author collaborative approach works exceptionally well and the
democratisation of the reviewing process ensures that this will meet the needs of medical students and junior
doctors, both in their exams and in their day to day work. In summary, this is another classic in the “Unofficial
Guide” series.
” Bob Clarke
• 5
Abbreviations
A&E accident and emergency ENT ear, nose and throat
AAA abdominal aortic aneurysm ERCP endoscopic retrograde cholangiopancreatogram
ACE angiotensin converting enzyme ESR erythrocyte sedimentation rate
ACJ acromio-clavicular joint ESWL extracorporeal shock wave lithotripsy
ADEM acute disseminated encephalomyelitis ET endo-tracheal
ADH anti-diuretic hormone EVAR endovascular aneurysm repair
AIN anterior interosseous nerve FAST focused assessment with sonography in trauma
AMT abbreviated mental test FDL flexor pollicis longus
ANCA anti-neutrophil cytoplasmic antibodies FDP flexor digitorum profundus
AP anterior to posterior FDS flexor digitorum superficialis
ATLS Advanced Trauma Life Support FLAIR fluid attenuation inversion recovery
AV arteriovenous FOOSH falls onto an outstretched hand
AVN avascular necrosis G gauge
AXR abdominal X-ray g/L grams per litre
BTS British Thoracic Society G&S group and save
CABG coronary artery bypass graft GCS Glasgow coma scale
CBD common bile duct GI gastrointestinal
CCAM congenital cystic adenoid malformation GTN glyceryl trinitrate
cm centimetre HAS human serum albumin
COPD chronic obstructive pulmonary disease HIDA hepatobiliary iminodiacetic acid
CPAP continuous positive airway pressure ventilation HIP heparin-induced thrombocytopaenia
CRP C-reactive protein HLA human leukocyte antigen
CSF cerebrospinal fluid HPOA hypertrophic pulmonary osteoarthropathy
CT computer tomography HRCT high resolution CT
CTPA computer tomography pulmonary angiogram
HRT hormone replacement therapy
DDH developmental dysplasia of the hip
HU Hounsfield unit
DEXA dual energy X-ray absorptiometry
IRMER ionising radiation [medical exposure]
DHS dynamic hip screw regulations
DIPJ distal interphalangeal joint ITP idiopathic thrombocytopenic purpura
DMSA dimercaptosuccinic acid ITU intensive treatment unit
DTPA diethylenetriaminepentaacetic acid IU international unit
DVT deep venous thrombosis IUCD intrauterine contraceptive device
DWI diffusion weighted image IV intra-venous
ECG electrocardiogram IVC inferior vena cava
6 •
Abbreviations
IVU intravenous urogram PET positron emission tomography
JVP jugular venous pressure PFO patent foramen ovale
kg kilogram PICC peripherally inserted central catheter
KUB kidneys, urethra, bladder PIN posterior interosseous nerve
LDH lactate dehydrogenase PIPJ proximal interphalangeal joint
LIF left iliac fossa PR per rectum
LLL left lower lobe RLL right lower lobe
LUL left upper lobe RML right middle lobe
m metre RUL right upper lobe
MAG3 methyl-acetyl-gly-gly-gly RUQ right upper quadrant
MCPJ metacarpophalangeal joint SCIWORA spinal cord injury without radiological
MDP methylene disphosphonate abnormality
MDT multi-disciplinary team SHO senior house officer
MIRP minimally invasive retroperitoneal pancreatic SI sacroiliac

necrosectomy SiADH syndrome of inappropriate anti-diuretic
mm millimetre hormone
mmHg millimetres of mercury SLE systemic lupus erythematosus
mmol/L millimoles per litre SMA superior mesenteric artery
MRA magnetic resonance angiography SMV superior mesenteric vein
MRCP magnetic resonance cholangiopancreatogram SP spinous process
MRI magnetic resonance imaging STIR short tau inversion recovery

MRSA methicillin resistant Staphylococcus aureus SUFE slipped upper femoral epiphysis
mSv milliSieverts TB tuberculosis
MTPJ metatarsophalangeal joint THR total hip replacement
NAI non-accidental injury TNF tumour necrosis factor
NG naso-gastric TNM tumour, nodes, metastases
NSAID non-steroidal anti-inflammatory drug U&Es urea and electrolytes
OA osteoarthritis USS ultrasound scan
PA posterior to anterior VQ ventilation/perfusion
PaCO2 partial pressure of carbon dioxide VTE venous thromboembolism
PaO2 partial pressure of oxygen β-HCG beta human chorionic gonadotrophin
PE pulmonary embolus
PEA pulseless electrical activity
PEG percuntaneous endoscopic gastrostomy
• 7
Contributors
Editors
Mark Rodrigues Radiology Registrar,
Edinburgh Royal Infirmary,
Edinburgh, UK
M.Rodrigues
Z.Qureshi
Zeshan Qureshi Academic Clinical Fellow,
Great Ormond Street and Institute of Global Health,
London, UK
Authors
Jonathan Rodrigues Radiology Registrar
Chest X-rays (Bristol Royal Infirmary, Bristol)
Abdominal X-rays
J.Rodrigues
Mark Rodrigues Radiology Registrar
Introduction (Edinburgh Royal Infirmary, Edinburgh)
Chest X-rays
Abdominal X-rays
CT
MRI
Ultrasound
Nuclear Medicine Scans
Fluroscopy
Bijan Hedayati Radiology Consultant

Chest X-rays (Lewisham Hospital, London)
B.Hedayati
Chris Gee Orthopaedic Registrar, Trauma and Orthopaedics
Orthopaedic X-rays (Western Sussex Hospitals, Sussex)
C.Gee
Amanda Cheng Radiology Registrar (Western General Hospital
Bonus X-rays and Edinburgh Royal Infirmary, Edinburgh)
Kabir Varghese Radiology Registrar

Bonus X-rays (Chelsea and Westminster, London)
K.Varghese
A.Cheng
Reviewers
Brendan Kelly University College Dublin
Chloe Thomson University of Leicester
Marianna Christodoulou University of Manchester
Madelaine Gimzewska University of Edinburgh
Katherine Lattey Brighton and Sussex Medical School
Jessica Spiteri Paris University of Malta
8 •
ConTENTS
Introduction........................................................... 11 MRI Scans......................................................... 543
What are X-rays?........................................................................ 11 MRI Head....................................................................................544
How are X-rays used to produce images?......................... 12 MRI Spine....................................................................................549
The main densities on X-ray................................................... 12 MRCP............................................................................................553
Magnification.............................................................................. 12 MRI Small Bowel......................................................................554
The hazards of using X-rays................................................... 13 MRI Knee & Other Joints.......................................................555
Relevant legislation................................................................... 13
Pregnancy and X-rays............................................................... 14 Ultrasound Scan.............................................. 557
How to request radiology examinations........................... 14 Neck USS.....................................................................................558
When and how to discuss a patient with radiology...... 15 Chest USS...................................................................................558
Abdominal USS.........................................................................560
Chest X-Rays* .....................................................17
Pelvic USS...................................................................................562
Introduction................................................................................. 17
FAST Scanning...........................................................................563
20 Clinical Cases......................................................................... 29
Vascular USS..............................................................................563
Musculoskeletal USS..............................................................564
Abdominal X-Rays*......................................... 181
Ultrasound Guided Procedures...........................................564
Introduction...............................................................................181
20 Clinical Cases.......................................................................189
Nuclear Medicine Scans................................. 565
VQ scan........................................................................................566
Orthopaedic X-Rays*....................................... 335
Myocardial perfusion scan...................................................567
Introduction...............................................................................335
Genitourinary scan..................................................................567
Spine X-Ray Cases ...................................................................367
Bone imaging............................................................................568
Shoulder X-Ray Cases ............................................................391
PET/CT..........................................................................................569
Elbow X-Ray Cases...................................................................399
Wrist X-Ray Cases ...................................................................407
Fluoroscopy...................................................... 571
Hip X-Ray Cases .......................................................................429
Contrast Swallow.....................................................................572
Knee X-Ray Cases ....................................................................473
Barium Follow Through.........................................................576
Tibia/Fibular X-Ray Cases . ...................................................497
Contrast Enema........................................................................576
Ankle X-Ray Cases . .................................................................513
Tubogram...................................................................................576
CT Scans............................................................ 521
Bonus Cases*.................................................... 579
CT Head.......................................................................................525
Bonus Chest X-Rays.................................................................579
CT Cervical Spine......................................................................530
Advanced Chest X-Rays.........................................................603
CT in Orthopaedics..................................................................530
Bonus Abdominal X-Rays......................................................613
CT Chest......................................................................................531
Advanced Abdominal X-Rays...............................................625
CT Abdomen and Pelvis.........................................................535
Bonus Orthopaedic X-Rays...................................................637
Advanced Orthopaedic X-Rays............................................671
* For Chest X-Rays, Abdominal X-Rays, Orthopaedic X-Rays and the Bonus Cases, all cases have been labelled ‘Case X’ to mimic
real life clinical situations/assessment. For reference, the X-rays are also all listed by diagnosis and clinical signs on p695.
• 9
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Chest X-Rays - Introduction • 17

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18 • Chest X-Rays - Introduction

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• More ribs, particularly with flattened is in the lung, compare it to the normal lung; if in the
diaphragms, indicate hyperinflation due to bone, compare ithiwith the other bones.
u r e shi ures ures
hi
airway obstruction, n Q
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n Q n Q Qu
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n Q ures n Q ures
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KEY POINT in lung shadowing/obvious masses. Previously,
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n Q ures Q ures on manmade abnormalities, n Qures
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ha
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use upper, middle, or lower e
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such as a large pleural effusion or mediastinal aortic dissection), masses (mediastinal tumours
mass)? or lymph node enlargement) or haemorrhage
i shi eshi
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look for differences. • The right paratracheal stripe can be useful
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n Qand costophrenic angles. Q u
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right measure <5mm in
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C o p
and y should
right. If this is the case, you must look for volume diameter. If it is thickened, it is commonly due to
loss either pulling the right hilum up or pulling lymph node enlargement.
the left hilum down. i
ures
h • The shi
ureaortopulmonary window is another area ures
hi
a n Q a n Q a n Q
hshould be the same density and have esh h The
f Zes or convex margins. f Zes between
• Both hila to assess for lymph node enlargement.
h t o h t o fZ h t o
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for pneumothoraces. These can be particularly
in this region, thus giving the impression of
subtle at the lung apex.i i
s h resh If this is not the case, you must hi
n Qure n
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• You should assess p y
Cothe mediastinum for the
presence of gas within it (pneumomediastinum).
the maximal transverse cardiac diameter being
This appears as linear lucencies projected over
greater than 50% of the maximal transverse
the mediastinum. These often extend into
internal thoracic diameter
u r e shi (cardiothoracic ratio). u r e s hi
ures
hi
a n Qaccurately assessed on a well- a n Q
the neck and may be associated withansurgical Q
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r i g h t of Z PA X-ray due the effects of magnification
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on an AP X-ray – if it’s normal on the AP, then it the left lower lobe is behind the heart). The
i i i
will be normal on the
Q u resh PA; conversely, if it is grossly
Q u reshshadow should be of uniform density.
cardiac
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n PA, it is likely to be enlarged on shan this is not the case, you must consider
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difficult to assess due to the overlying cardiac
clearly visible. If this is not the case, you must
shadow. Inverting the image often makes any
consider whether there is pathology in the
i shi shi
adjacent lung. Quresh
abnormality more obvious (figure 5).
n n Qure n Qure
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patient is not rotated. Then you must assess upwardly convex. Flattening of a hemidiaphragm
for volume change inshthe i lungs (either volume hi raised intrathoracic pressure either hi
suggests
n Q ure towards the abnormal n Q ureslung hyperexpansion, as seen innairQures
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• The right hemidiaphragm is normally slightly
and heart. Marginal mediastinal shift can be
higher than the left due to the mass effect of
observed if the margins of the thoracic vertebral
the adjacent liver. If this is not the case, you must
bodies can be clearlysh i beyond the cardiac
seen hi hi
n Q r e
ucontours on a well-centred n Q ures whether one of the hemidiaphragms
consider
n Q ures is
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or bone destruction. Assess the rib spaces, which
X Rays
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inverting the image can make such pathology
more obvious. should be roughly equal. Narrowing can be seen
hi
resdiaphragm.
with volume i in the underlying lung. Review eshi
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• Look at the soft tissues for evidence of surgical
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there is likely to be pleural fluid present. and previous surgery (surgical clips, mastectomy).
i i i
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hi hi hi
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pneumomediastinum. There may also be evidence
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ureshi hi
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u
n Q n Q an Q
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very subtle retrocardiac mass, will be located in the medial
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Figure 6: These three X-rays show how difficult it can be to diagnose free subdiaphragmatic gas.
Image A: Is a normal chest X-ray with gas in the stomach. We know the gas is within the stomach, as it is under the left
hemidiaphragm, and the soft tissue rim overlying the gas is a few millimetres thick, as it consists of the stomach wall and
i adjacent diaphragm. hi
eshi
Q u resh s
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h a n
Image B: Contrast that appearance to the centre X-ray, a
which
h nshows h a n the
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h t o f Zeiss very thin, as it solely represents thehdiaphragm.
t o f Zes
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reveals bowel markings. These appearances are due to interposition of a loop of bowel between the liver and right
hemidiaphragm, and is known as Chilaiditi’s sign.
hi hi hi
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rig rig ht of rig ht of
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• An endotracheal (ET) tube should have its tip
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Problems to look out for include misplacement
proximal to the carina. Problems can arise if it into the lungs, and the tip being within the distal
is inserted too far and the tip enters one of the oesophagus.
bronchi. This willu r e shi in collapse of the non-
result hi
ures lines are most commonly inserted resh
uinto
i
a n Q a•n Q
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the internal jugular veins.hTheir
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mid or lower superior
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an Q an Q an Q
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shan shan shan
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satisfactorily positioned endotracheal tube,
right and left internal jugular central lines,
i and nasogastric tube. Note that the right i
resh e shiinternal jugular line descends straightudown sh
Qu Q u r Q re
f Ze shan f Ze shan es h a n
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r ight o r ight o r i g hright
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travels through the brachiocephalic
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i i hi
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f Ze shan f Ze shan Zesh
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hi hi review areas. ureshi
nQ ures nQ ures Q
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Double-check the following areas, since pathology
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res hi i
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as well as the X-ray findings • Dense or patchy consolidation,
making your differential diagnosis.
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eshi help. hi
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imaging if you think n Q urwould
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an sign is useful for locating in which an usually sharp border between theelung an
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f t o f Zesh t o f Z sh and these
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yrig (figure h
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the lobe abuttingCthese soft tissues.
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the aerated lung and the soft tissues of the

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heart and diaphragm. This is due to the large
heart and diaphragmatic borders in order to behi
e shi of X-rays attenuated e shi s
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differences in theurnumber u r
a n Q (a relatively high proportion of an Q able to use the silhouette sign: a n
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yrigh
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o Diaphragms: left and
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f Ze shan f Ze shan f Ze shan
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hi hi hi
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an Q an Q an Q
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shan shan shan
hi hi hi
n Q uresFigure 9: X-rays demonstrating consolidation
n Q uresand the silhouette sign. n Q ures
sha
f ZA:eShows esha
f Zhemidiaphragm sha
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rigImage loss of the medial aspect rig
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middle lobe consolidation.
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hheart hi consistent with left lower lobe consolidation.
hi
ures ures ures
Image C: Shows a clear left
n Q
a bottom right X-ray shows loss of the left n Q
a border but a clear left hemidiaphragm, a n Q
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Technical Aspects
X-Rays
Chest
Check patient details (name, date of birth, hospital number)

hi hi 4 hi
res res res
n Qu
sha of the X-ray an Qu an Qu
Zedate
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to t of Zesh t of Zesh 4
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shi shi resh
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Qure Qure Qu
shan
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Ze Ze shan eshan
r i g ht of r i g ht of righ t of Z
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nQ u nQ ures nQ ures
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shi shi
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sh an Q sh an Q sh an Q
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hi hi shi
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t of Zes t of Zes t of Zesh
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sh i i i
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r i g h t oatf Zreview areas (apices, hila, behind rthe
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PRESENTshi CASE 1 i i
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YOUR
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an Q an Q an Q
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Chest X Rays - Case 1 • 29

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30 • Chest X Rays - Case 1

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t of Zesh QUESTIONSt o f Zes
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1. Which of the following are risk factors for a primary
X Rays
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hi hi resh
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•• There are no identifying
s h a n Qumarkings 2. Which of the s n Qu
hafollowing clinical findings would beshan Qur
Zeto ensure that this is Z e Ze
ht of f ht of
– I would like
y r i g
p correct patient, and to check ight o
yrsupportive of a large simple right sided
yrigpneumothorax?
Cothe Cop A) Central trachea. Dull percussion and p
Coreduced air entry on the right
when the X-ray was taken.
side of the chest
•• The patient is slightly rotated;
B) Central trachea. Dull percussion with bronchial breathing and
this is otherwise a technicallyshi shiof the chest shi
adequate X-rayswith a n Qure
adequate
crackles on the Q
a n ureside
right
a n Qure
o e h
f Zand o
C) Central sh
f Zetrachea. Hyperresonant percussion and o
reduced
h
f Zes air entry on
h t
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g good inspiratory g h t g h t
pyri No important areas are cut
Coeffort.
ri
Copy the right side of the chest Copy
ri
off at the edges of the film. D) Central trachea. Hyperresonant percussion and reduced air entry on
the left side of the chest
•• There is an obvious abnormality
shi u es
E) Trachea deviated torthe i Hyperresonant percussion and reduced
hleft. shi
in the right hemithorax:
a n Quraeline a n Q a n Qure
sh esh
air entry on the right side of the chest. Hypotensive, esh
tachycardic
i g h t o Zeseen with absence
can clearlyfbe
ight o
fZ
ight o
fZ
r markings beyond it, in r r
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of lung p p
Co 3. Which of the following are appropriate
Co differential diagnoses
keeping with a lung edge.
for a patient who presents with sudden breathlessness?
•• The aerated right lung is
A) Pulmonary embolus
shi
otherwise normal in appearance.
ure B) Pneumothorax Quresh
i
ures
hi
•• The tracheaZande s an Q
hmediastinum esh a n
esha
nQ
are rnot of
ightdeviated, and the right r i t of Z
C) hPneumonia
g rig ht of
Z
Co p y Copy D) Heart failure Copy
hemidiaphragm is not flattened.
E) Anaphylaxis
•• Reviewing the rest of the film, the
left lung is normal. i 4. Which of the following i the most appropriate initial
is i
sh resh resh
n Qureheart Q u Q u
•• The heart is not es h a
enlarged, han
imagingZeinvestigation in a patient suspected Z han a
of having
h of Z
tare h t o f s h t o f es
i
borders
r g clear, and there is no ig ig
py
Coabnormality visible behind the C opyrsimple pneumothorax? opyrC
A) Erect PA chest X-ray
heart.
B) PA and lateral chest X-rays
•• There is minor blunting of the
hi C) Expiratory chest X-ray hi resh
i
n Q uresmay
costophrenic angles which
n Q ures Qu
ha
f Zesvolumes of
D) Supine
f Zes
ha X-ray
chest shan
representosmall
h t h t o ight of Ze
pyrig effusion.
Copleural C
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opyrE) CT C opyr
•• The hemidiaphragms are clear. 5. Which of the following is the most appropriate
•• There is no free air under the
diaphragm.
anQure
shi A management option for a previously healthy patient
n Qu
resh
i
with a small, asymptomatic
sha
primary pneumothorax?n Qu
resh
i
sha
Zesh
f soft tissue
ono t of Z
e of Ze
rig t
•• There hare A) hConservative management and discharge the htpatient
p y y r i g y r i g
C oabnormalities or fractures; in Cop B) Conservative management with outpatient
Cop follow up
particular, no rib fractures are
C) Admit for conservative management, high flow oxygen, and
visible.
monitoring
i i hi
Qu resh D) Aspirate as much Q
shpneumothorax
uofrethe as possible Q ures
e shan esha
n
esha
n
righ t of Z t of Zdrain insertion
E) Chest
righ right of Z
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h an Q h an Q an Q
Answers
t o f Zes to Questions t o f Zes t of Zesh
rig h rig h yrigh
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1. Which of the following are risk factors for a primary spontaneous pneumothorax?
X-Rays
Chest
i i i
shan
e The correct answers are A) Male shan
Ze gender and B) Smoking. e shan
righ t of Z r i g ht of r i g h t of Z
Copy Cop y Copy
A pneumothorax is the presence of air or gas within the pleural space. The gas separates the visceral and
parietal pleura, and can
hilead to the compression of the adjacent hlung.
i Pneumothoraces can be considered has:i
Q ures Q ures Qure
s
shan spontaneous (no cause is identified)
• Primary
Ze shan
f Ze f Zes
han
y r i g ht o•f Secondary spontaneous (occuryrinigthe
ht osetting r ight o
Copy
of lung disease)
Cop Cop
• Traumatic (either blunt or penetrating)
• Iatrogenic (such as after lung biopsy or central line or pacemaker insertion)
hi hi hi
n Q ures n Q ures n Q ures
a
h – Correct. As mentioned above, primary a
h D) Trauma – Incorrect. Trauma is a well h a
f Zes pneumothoraces occur in patients f Zes Zesnot
A) Male gender established cause
h t o h t o h t o fdoes
ri g spontaneous i g of a pneumothorax. g
However,
ri it cause a
opyr The
Copy without underlying lung disease orCtrauma. Copy
spontaneous pneumothorax. Blunt trauma can result
precise cause of these pneumothoraces is uncertain. in rib fractures which tear the lung surface, whereas
There is some evidence that they are due to the penetrating trauma can injure the lung surface
rupture of small sub-pleural blebs (small, air-filled directly. In
eshi pleura). Patients are hi addition to air, there may be blood inrthe shi
cysts just under Q u
the rvisceral Q ures space, resulting in a haemopneumothorax.
pleural Qu e A
han
Zestall, slim young men. Other risk factors f Zesh
an a n
eshto the presence
t o f
typically
t o t of Zclue
horizontal air fluid level is a useful
righfor primary spontaneous pneumothoraces h
riginclude i g h
yr pleural space (remember
Copy smoking and family history. Copy
of both air and fluid inpthe
Co will
that a pleural effusion usually have a curving
meniscus rather than a completely horizontal upper
B) Smoking – Correct. Smoking is a recognised risk factor
margin).
for primary spontaneous pneumothoraces.
hi hi shi
n ures is a risk factor for a
QCOPD E) ures syndrome – Incorrect. Marfan’s syndrome
Marfan’s
Q Qure
C) COPD – Incorrect.
e s h a e s h an a n
shwhich is
t of Z fZ of Ze
is a systemic connective tissue disorder
ight o tpneumothoraces.
pneumothorax. However, it results in secondary not
y r ighprimary y r r i g h
Copyfor secondary, not primary
p p known to increase the risk of It is
Co spontaneous Co
pneumothoraces. Patients
considered a risk factor
who have extensive emphysema and large bullae are
spontaneous pneumothoraces.
most at risk, as these are thin-walled, air-containing
structures which are prone to rupture. Most
i shi shi
pneumothoraces (>70%)
Q u reshare secondary. In addition to Qure ure
n many other lung pathologies which shan
haare an Q
t o f es the risk of a secondary pneumothorax,
COPD,Zthere
t of Z
e
t of Zesh
r i g h
can increase r i g h yrigh
Copy including airway disorders (such asC opy
asthma/interstitial Cop
lung disease), infections (such as tuberculosis (TB)/
necrotising pneumonia/pneumocystis jiroveci),
systemic connective tissue i disorders (such as Marfan’s
shsyndrome/rheumatoid shi i
Q
syndrome/Ehlers-Danlosu r e Qure Qu resh
shan shan shan
ight of Ze and lung cancer.
arthritis),
ight of Ze ight of Ze
Qu resh
i KEY POINT
n Qu
resh
i
Qu resh
i
Ze shan f Zes
ha shan
t of t o of Ze disorders
htsystemic
Cop yrigh Most pneumothoraces
y r i g hare secondary, and a variety
Cop Spontaneous primary pneumothoraces
of lung
y r i
and g
Cop typically occur in young,
can be implicated.
slim, tall male smokers.
i i i
e shan e shan eshan
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an Q an Q an Q
2. Which of the following clinical findings would be supportive of a large simple right sided
X-Rays
Chest
pneumothorax?
i i i
righ t of Z r i g ht of r i g h t of Z
Copy op y
The correct answer is C)CCentral Copy
trachea. Hyperresonant percussion and
reduced air entry on the right side of the chest.
i i i
u resh resh resh
an Q
Accurate clinicalhassessment
s of the patient is a key part of
s n Qu practice, and is commonly assessed
haclinical s
Qu
han in
Z e
of It is important to know the different Z e
of combinations of clinical findings associated Z e
of with a
right right right
examinations.
o p y
C pneumothorax, a pleural effusion, lobar o p y
C collapse, and pneumonia. Briefly, the chest o p y
C examination should
follow the pattern of inspection, palpation, percussion, and auscultation. Look for symmetrical shape
and chest expansion. Assess the position of the mediastinum (trachea and apex beat) and assess for
chest expansion. Percuss and hiauscultate both lungs. Assessing routine shiobservations, such as oxygen shi
ures Qure Qure
an Qpressure, is also important.
saturations and hblood h a n h a n
A)
pyrig
CoCentral trachea. Dull percussion and reduced pyrig
Coair pyrig
Co percussion and reduced
D) Central trachea. Hyperresonant
entry on the right side of the chest – Incorrect. This air entry on the left side of the chest – Incorrect. These
combination of findings is suggestive of a right sided findings would be in keeping with a simple left sided
s i hi hi
pleural effusion. With a pleural h effusion you would pneumothorax.
expect to find reduced n Q u
chestreexpansion, a very dull/ n ures
Qdeviated n Q ures
h a h a h a
f Zes note, absent or reduced breathht of Zespercussion and reduced air entry onhthe f Zesside of
E) Trachea to the left. Hyperresonant
stony dull o percussion oright
i g h t i g i g t
pyr reduced vocal resonance, and no added
sounds,
Coon Copy
r
sounds r
Copy – Incorrect. This
the chest. Hypotensive, tachycardic
the side of the effusion. With large effusions there
combination of clinical findings is worrying and should
may be a shift of the mediastinum to the contralateral
raise your suspicions of a tension pneumothorax.
side.
i In addition to the usual findings associated with a
u r e shand u r e shi there is mediastinal shift to Qures
hi
a n Q
B) Central trachea. Dull percussion bronchial breathing simple
a n Qpneumothorax,
a n
sh right side of the chest – Incorrect. f Zesthe
ethe h contralateral side and evidence of significantlyesh
t o Z of clinical findings is in keeping with t of Z cyanosis,
and cracklesf on
r i g h r i g h to r i g h
y
This
Coapright
combination
opy impaired ventilation and
opy
circulation (hypoxia,
sided pneumonia. Typically, there is Creduced hypotension, tachycardia,C reduced consciousness level).
chest expansion, dull percussion, bronchial breathing Tension pneumothoraces are a medical emergency and
with added crackles, and increased vocal resonance in need urgent treatment (there is a case covering tension
pneumonia. sh i pneumothorax i more detail later in the chapter).
shin shi
Qure Qure n Qu
re
han han sha
f ZesHyperresonant percussion and ht of Zes
C) Central trachea.
t o of Ze
h
pyrig air entry on the right side of the chest
reduced
py–rig right
CoCorrect. These findings are consistent withCaosimple Copy
right pneumothorax. You would expect to find
reduced chest expansion, hyperresonant percussion,
and absent breath sounds, with hino added sounds on hi resh
i
n Q ures There should be no n Q ures Qu
shan
the side of the pneumothorax.
a
Zesh esha of Ze
ight of shift.
mediastinal t of Z
igh ight
KEY POINTs
hi shi if any findings on clinical hi
n Q ureswith a small pneumothorax may
1. Patients
n Q urefew
have
n Q ures
ha sha ha
h t o f Zes examination. Chest X-ray is hatmore
o f Zesensitive h t o f Zes
test for identifying a pneumothorax,
ig ig ig
C opyr opyr
particularly a small pneumothorax.
C opyr C
2. Not all patients have classic findings on history and examination. It is important
to use your clinical findings to request appropriate investigations, such as blood
i i i
Qu resha chest X-ray, to help narrow your differential
tests and resh
Qu
diagnosis.
Qu resh
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h an Q esh an Q h an Q
3. Which
h t o f Zesof the following are appropriate
h t o f Zdifferential diagnoses for a patient
h t o f Zeswho
rig rig rig
Copy presents with sudden breathlessness?
Copy Copy
X-Rays
Chest
The correct answers are A) Pulmonary embolus, B) Pneumothorax, and

hi hi resh
i
Q ures
E) Anaphylaxis. ures Q Qu
eshan e shan e shan
r i g t of Z
hThere r i g h t of Z r i g h t of Z
Cop y y
Copwhich can cause breathlessness. These
is a wide range of pathologies py
Coinclude respiratory conditions,
cardiac diseases, and systemic problems. It is important to be able to formulate an appropriate differential
diagnosis from the history and examination to guide suitable investigations and initial management.
Establishing the time frame of the onset of breathlessness is very helpful in formulating your differential
diagnosis. Sudden
Q eshi refers to breathlessness that develops
uronset Q
hi
uresover seconds and includes pulmonary Q ures
hi
ha n ha n a n
t o f Zespneumothorax, anaphylaxis, and
embolus,
t o f Zesforeign bodies. Dyspnoea associated
inhaled
t o Zeshpneumonia,
f with
rig h rig h rig h
Copy heart failure, metabolic acidosis,Cand opyexacerbations C pydevelop more slowly, over
of asthma or COPD tendoto
minutes to hours. Other conditions, such as interstitial lung disease and anaemia, have a much more
chronic onset.
hi Pulmonary embolus can i
ofhbreathlessness is usually more subacute, eshi
u s ures over hours rather than seconds. Other
A) Pulmonary embolus r–eCorrect. onset
r
cause verysh a n Qbreathlessness.
sudden Other symptoms s h a n Qoccurring
s h a n Qufeatures
e Ze f Ze sputum, a raised
r i g t of Zpleuritic chest pain and dizziness. Clinical
hinclude r i g ht of include a productive cough with
r i g ht ogreen
Cop y Cono
examination of the chest often reveals y
p abnormal Cop y
temperature, and appropriate clinical findings.
signs. There may be a swollen limb, suggesting an
D) Heart failure – Incorrect. Heart failure is a common
underlying deep venous thrombosis. The patient may
cause of breathlessness, but usually its onset is more
have had recent surgery or have other risk factors
s h i shi Patients may also complain of orthopnoea
insidious. hi
n Qurepost-partum, or having an
present, such as being
n ureparoxysmal
Qand n Q ubereas
a
shmalignancy or a genetic prothromboticf Zesh a nocturnal dyspnoea. Therea may
t of Ze
underlying
t o previous history of cardiac disease.t Zesh examination
of Clinical
r i g h r i g h i g h
Copy
tendency.
Copy may demonstrate an pyr jugular venous pulse and
Coelevated
B) Pneumothorax – Correct. A pneumothorax often results evidence of pleural effusions.
in a sudden onset of breathlessness and pleuritic chest
E) Anaphylaxis – Correct. Anaphylaxis is a systemic and life
pain. There may be a history of an underlying lung
i shi allergic reaction. It usually occurs shortly
threatening hi
Q u res1hfor examples of conditions
condition (see question
Q u recontact Q ures
a n a n after n
with the allergen (previous sensitisation
a
esh
which predispose to secondary pneumothoraces) or esh esh
r i g h t of Z The constellation of clinical findings
trauma. r i g h t of Z
associated r i g h t of Z develop rapidly
to the allergen is required). Symptoms
Copy with a pneumothorax is discussed inCquestion opy 2. Copy facial swelling, wheezing,
over minutes and include
breathlessness, urticaria, and, potentially, shock.
C) Pneumonia – Incorrect. Pneumonia and other infections Urgent management using the ABCDE approach and
are common causes of breathlessness; however, the administration of intramuscular adrenaline is required.
an Q an Q an Q
t of Zesh KEY h
ZesPOINT
t of t of Zesh
Use the history and examination findings to help formulate a differential diagnosis
to guide appropriate investigations and management. But remember that some
patients, such as those presenting with anaphylaxis, may need urgent treatment
hi i
resh and examination. In these patients, hi
n Q ures you will be able to complete anfull
before Q uhistory n Q ures
sha use the ABCDE approach to assessment
sha and management. sha
of Ze of Ze of Ze
right right right
Copy Copy Copy
4. Which of the following is the most appropriate initial imaging investigation in a patient
hi hi hi
ures a simple pneumothorax?
suspectedanofQhaving n Q ures n Q ures
a a
Cop yrigh C op yrigh Cop yrigh
The correct answer is A) Erect PA chest X-ray.
i line imaging modality for suspected

hfirst i
hsimple pneumothoraces. Imaging reshi
u es ures
The chest X-ray is rthe
n Q n Q Qu
has a keysh
Z e a
role in confirming the diagnosis of a ha
pneumothorax,
Z e s assessing its size, and excluding
Z e s hanother
t of
righdifferential t of
righdifferent
diagnoses. There are various t of
righdiscussed
types of chest X-ray, which are below.
Copy Copy Copy

i i i
a–nCorrect. The standard method han chest X-ray – Incorrect. Pneumothoraces a n
Zesh f Zesbe very subtle and difficult to identify Zesh chest
A) Erect PA chest X-ray D) Supine can
h t o f pneumothoraces h t o h t o f supine
pyrigperformed during inspiration. This provides rig rig
for imaging is an erect PA chest on
CoX-ray Copy an Copy and there may not
X-rays, as the air collects anteriorly,
accurate and reliable assessment for a pneumothorax. be a clearly discernible lung edge as seen in an erect
X-Rays
Chest
A well inspired PA X-ray allows a better assessment of X-ray. Supine chest X-rays are thus not performed
the lungs and cardiac contours compared to an AP or routinely. Instead they are reserved for trauma patients
expiratory X-ray. The key u r e shi on a chest X-ray is
finding who cannoturebe
i
shsafely moved. Features suggestive ofQ a uresh
i
n Q n Q n
ha ha a
Zesha sharply
f Zofesthe lung edge (visceral pleura) awayht of Zesoutlined dome of the hemidiaphragm,
displacement pneumothorax on a supine chest X-ray include
h t o h t o fdeep
pyrigthe chest wall, with no lung markingsCvisible opyr
ig
opyr
ig
from a lateral
Coperipheral to this. costophrenic sulcus, and aChyperlucent upper quadrant
of the abdomen (due to the lucent gas within the
B) PA and lateral chest X-rays – Incorrect. The lateral chest pleural space overlying the upper abdomen).
X-ray can provide helpful information if a pneumothorax
is not visible on the PA X-ray.ure shi
However, it is not part of urefor
i
shWhilst
E) CT – Incorrect. CT is the most sensitive and
ures
hi
n Q n Q n Q
ha ha
specific test a pneumothorax, its high ha
radiation dose
f Zes f Zes(approximately equivalent to 400 chest f Zes and the
routine practice.
h t o h t o h t oX-rays!)
pyrig chest X-ray – Incorrect. Expiratory
C) oExpiratory
C may Copy
rig
X-rays rig
Copy PA chest X-rays mean
satisfactory accuracy of standard
make a subtle pneumothorax more readily visible. CT is not the first line imaging modality for suspected
However, there are not performed in the first instance. pneumothoraces; instead, it is reserved for patients in
Additionally, they can limit the assessment of the lungs whom there is continued suspicion of a pneumothorax
s hi hi hi
ures on a chest X-ray, or for assessing n Qures
and cardiac shadow. e
Qu r but no evidence
Q
h a n h a n h a
f Zes f Zesassessment of pneumothorax size. ht of Zes
trauma patients. CT also provides the most reliable
i g h t o i g h t o i g
r r r
Copy Copy Copy
KEY POINTS
hi
res that your environment can affect res hi res hi
s h n Qu
1. Remember
a s h a n Quhow easy or difficult it is to interpret
s h a n Qu
f Ze X-rays. For example, a brightly e
f Zroom, Ze
fward
ight o ght o ght o
lit with glare and a low resolution
p y r p y r i p y r i
Co monitor, may makeCitodifficult or impossible to identify a small Co pneumothorax.
Always try to optimise your chance of picking up pathology by using diagnostic
quality workstations in a dark room if you are making diagnostic decisions.
shi shi shi
a n Qure
2. Pneumothoraces
a n QureX-rays. Inverting the image can an Qure
can be difficult to see on chest
esh make the lung edge more obvious. esh your eyes tend to see horizontaloflines
Also, esh
r i g h t of Z r i g h t of Z r i g h t Z
Copy Copy C py
better than vertical ones; it is thus sometimes useful to rotateothe chest X-ray by
90 degrees so that the lateral chest wall (and therefore the lung edge) is horizontal.
3. Always check the apices on an erect chest X-ray and around the lung bases on a
shi X-ray for evidence of a pneumothorax.
supinerechest
u resh
i
u ure shi
an Q an Q an Q
5. Which of the following is the most appropriate management option for a previously
healthy patient with a small, asymptomatic primary pneumothorax?
i i i
shan shan shan
i g h of Zecorrect answer is B) Conservative
t The i g h
e
t of Zmanagement with outpatient
i g h of Ze up.
t follow
r r r
Copy Copy Copy
The management of pneumothoraces depends on whether the patient is symptomatic, the size of the
hi hicase with all potentially unwell hi
u es u s ures
pneumothorax, and the rpresence of underlying lung disease. As isrethe
n Q n Q n Q
ha initially to approach the assessment
patients, it is useful ha management of the patient using
and ha
the
h t o f Zes h t o f Zes h t o f Zes
Cop yrig
ABCDE approach. yrigCop
rig
Copy
A) Conservative management and discharge the patient – This is to ensure that the patient has not deteriorated
Incorrect. Whilst asymptomatic (not breathless) and the pneumothorax has not increased in size.
patients with a small (<2cm) spontaneous primary Patients should be followed up with the respiratory
s hi hi resolution of their pneumothorax reshi
pneumothorax can be safely r emanaged conservatively
n Qu to arrange for the patient Q u es
team untilrcomplete
u
with analgesia, itsisha
important s ha
has n
occurred. Patients s
should also be instructed ton Q
ha
Z e Z e Z e
r ht of in the outpatient clinic in 2-4 weeks.ight of
to beigreviewed
r ght o
f
return to hospital if they develop isymptoms.
r
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i i i
n
shamanagement n Aspirate as much of the pneumothorax
- haD) haasnpossible –
f Zes f Zes symptomatic
B) Conservative with outpatient follow up
h t o f ZeSee h t o h t o
rig Correct. above. The patient should berig Incorrect. Patients with
yrig
a large and/or
Copy instructed to return immediately ifCtheyopyexperience Coppneumothorax
primary or secondary need active
symptoms, to identify those patients with enlarging management. Needle aspiration, using a 14-16G
X-Rays
Chest
pneumothoraces. All patients with a pneumothorax needle, is as effective as chest drain insertion, but
should avoid air travel until
hi complete resolution. reduces length of hospital stay and morbidity. These i
shi should be performed in the safe triangle sh
ures
Diving shouldnbeQpermanently avoided in most Q u r e
procedures Qure in
s h a have had a pneumothorax. han h a n
of Z
patientsewho f Zes the mid-axillary region. If, following s
of Zeneedle aspiration,
y
t
rC)ighAdmit y r ight o r i g h timproved
C o p o p
C high flow
the patient’s symptoms
opy have and the
pneumothorax is C
for conservative management,
<2cm in size, then no further
oxygen, and monitoring – Incorrect. If the patient is
intervention is required at that stage. If, however, this
not breathless and has a small primary spontaneous
is not the case, the patient may require a chest drain
pneumothorax, he or she can usually be managed
hi i
eshneedle eshi
ures admission to hospital
(repeat aspiration should not be performed).
safely as an outpatient;
n Q n Qur n Qu
r
ha oxygen is not required. In contrast, ZeshaE)
esflow ha
t o Z
and fhigh
ht o f t o f Zes bore (<14F)
Chest drain insertion – Incorrect. Small
righsymptomatic pyrigsecondary opyr
h
igin patients who do not
Copy pneumothorax should be admitted,
patients with a small (<2cm) chest drains are indicated
Cotreated with improve followingCneedle aspiration and those with
high flow oxygen (if necessary), and monitored for bilateral or tension pneumothoraces.
24 hours. Supplementary oxygen not only improves
shi
hypoxaemia, but also increases the speed at which a shi ures
hi
pneumothorax Qure
an resolves. an Qure nQ
f Zes
h
f Zes
h esha
ht o ht o righ t of Z
Co pyrig Co pyrig Copy
KEY POINTS
1. The size of the pneumothorax is one of the parameters used in deciding
eshi
Qurappropriate Qure
treatment. A large pneumothorax shi is defined by a rim of >2cm ureshi
e sh a n
e h a n
schest e sh an Q
o f Z between the lung margino f Z
and wall, measured at the level of
o f Z
the hilum.
right right right
Copy Copythe patient has a small pneumothorax.
If this rim is <2cm Copy
2. Patients admitted with a pneumothorax should be reviewed by a respiratory
physician within 24 hours.
eshi es hi s hi
nQ 3.urPleurodesis is a procedure in whichn Qurpleural
the space is obliterated n Qure
Z esha (either chemically or t of Zes
h a esh a
rig ht of r i g h r i g h t of Z
Copy py be used
Cocan
surgically) and Copy
in patients who suffer
recurrent pneumothoraces.
ure shi u
Im
resphortant Learning Points
i
u resh
i
an Q han :
Q Q
Zesh han • A pneumothorax
t of t o f Zes is a colle ct
t oiofnZofesair in th
Cop yrigh Copy
rig h pleural space. opyrig
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• It can be primary, se
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i med ica
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ur Typical
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shan f Zes
ha n clinical features of a
f Zplees
ha n
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i i ed iastinal shift or hi
Qu resh Q uca sh
rerd iovascular compromise Q ures
e shan f Zes
n
ha • The er .
ect PA chest X-ray is tht of Zes
ha n
righ t of Z rig h t o h e
pyrig
first line
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• Treatment depend
s on whether the patie
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Qu resh Q u resto pn eu mo th orax Q ures
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an Q an Q an Q
Cop yrigh
t of Zesh Abdominal X-Rays
Cop yrigh
t of Zesh
Cop yrigh
t of Zesh
Case 1...................189 Case 6...................225 Case 11.................263 Case 16.................299

Case 2...................195 Case
hi 7...................233 Case 12.................269
hi Case 17.................305 hi
res res Qure
s
ha n Qu n Qu
sha 13.................277 han
f Zes
Case 3...................203
o
Case 8...................241 f ZeCase
o f Zes
Case 18.
o
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y right y right y right
Abdominal
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Casep 4...................211 C o p
Case 9...................247 o p
Case 14.................285C Case 19.................321
X-Rays
Case 5................... 217 Case 10.................255 Case 15.................293 Case 20.................327
i i i
shan
Zeto the chapter is aimed at providing e shan e shan
This introduction
i g ht of details and examples of the specific
i g ofaZsystematic
ht X-rays
framework for approaching
i g
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ht of more
y r y r y r
Cop Cop Cop
X-rays. Further findings discussed below are covered
extensively in the example cases later in the chapter and in the bonus X-ray chapter.
KEYa n
POINT
Q ures
hi
nQ
eshi
2. Patient Details
ur nQ ures
hi
h
f Zes esha esha
t of Z ht of
Z at the
• It is important to check you are looking
ht o righ
Co pyrig Coptoy
Systematic approach correct X-ray from the C op y
correct r i g
patient.
abdominal X-rays
• The patient details should be listed on the film.
1. Projection
ure shi eshi
• State the name, age (or date of birth), and the
shi
an Q
h 2. Patient details date
a n Q
on u r
which the film was taken. a n Qure
h h
Co pyrig Co
3. Technical adequacy pyrig Co pyrig
3. Technical Adequacy
4. Obvious abnormalities
• The entire abdomen should be included in the
shi review of X-ray. Quresh
i shi
a n Qure
5. Systematic
an anQure
h the X-ray Zesh Zesh
o f Zes o f o f
right righ t • Check the X-ray includes the igh t
hemidiaphragms
opyr and hernial orifices.
Copy 6. Summary Copy down to the symphysisCpubis
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you need to decide whether a repeat/additional
ure shi u resh
i
u resh
i
an Q han
X-ray Q
is required. han
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t of Zesh of Ze
s
of Ze
s
yrigh ight ight
p
CoProjection
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4. Obvious Abnormalities
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X-ray with the patient in the supine position. • If there is an hobvious abnormality, such as
hi unless told
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small Q u r
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your systematic review
p yrigh Cop is yrig Cop yrig
•CoSometimes, a lateral decubitus (the patient
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an AP direction) or a lateral shoot through (the 5. Systematic Review of the Film
patient is supine but a lateralh i
X-ray is taken) eshi (see figure 1) hi
n Q ures Such X-rays should Assessn the
Q urBowel n Q ures
abdominal X-ray ha
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an Q n Q Qu
f Zes
h
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Abdominal X-Rays - Introduction • 181

PRESENTshi CASE 11 i i
ure u resh u resh
YOUR
fZ e s h an Q e ha
A 38 year old manspresentsQ
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f Zhaematuria.
n Q
haurinary
f Zes X-ray is
r ight o FINDINGS... frequency
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and As part of his work up, an
rig h t o
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e shan e shan shan
righ righ opyr
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Abdominal
C
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hi hi hi
esha esha esha
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hi hi hi
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an Q an Q an Q
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Abdominal X-Rays - Case 11 • 263

ureshi ure shi ure shi
an Q an Q an Q
Cop yrigh Annotated CX-ray
op yrigh Cop yrigh
i shi hi
Qu resh T11 han Qure Q ures
f Ze shan Rounded f Zes f Zes
ha n
h t o h t o Left renal h t o
rig calcifications rig rig
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Abdominal
X-Rays
in keeping with
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hi hi hi
ha Zesh
a ha
h t o f Zes h t o f L1 h t o f Zes
rig rig rig
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L2
sh i hi hi
n Qure nQ ures nQ ures
esha esha esha
righ t of Z righ t of Z r i g ht of
Z
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L3 Expected course
of the left ureter
hi hi (over the transverse hi
nQ ures Q ures ures
esha e shan processes of the eshan Q
Z L4
Z fZ
rig ht of righ to f lumbar spine)
r ight o
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L5
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hi
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hi
shan Q esha
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u resh
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projected over
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i hi i
Qu resh joint Q ures Qu resh
shan f Zes
ha n shan
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Copy IN Summary – This abdominal X-ray shows
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multiple small left sided renal calculi.
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264 • Abdominal X-Rays - Case 11

an Q an Q an Q
t of Zesh Zesh
QUESTIONS
t of t of Zesh
1. Which of the following is/are risk factors for
developing renal calculi?
PRESENT Qureshi ures
A) Hypercalcaemia
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hi
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hi
n n n
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rig h t o f Zes
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hi
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Q ur s 2. Which ur following are symptoms n Qur
n Qthe
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associated with renal calculi? h t o f Zes
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timing of the examination is not
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the name and date of birth, as C) Dysuria
hi
esthe shi hi
well as the time and date
n Qurof n Qure nQ ures
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examination. f Zes f ZAll t of Z
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hemidiaphragm have not been 3. Which type of renal stone is least likely to be
included on the image; therefore,
hiX-ray.
this is a technically inadequate
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•• The most pertinent an Q
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B) ZCalcium
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quadrant at the level of T12/L1. D) Struvite
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shi resh
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left renal outline) and appearance,
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Z
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•• There is no evidence of urinary calculi A) Abdominal X-ray/KUB (Kidney, Ureter, Bladder)
in the expected distribution of the B) Intravenous urogram
left ureter, nor are there any visible
i C) Ultrasound hi i
Q
right sided urinary tract u resh
calculi. Q u res Q u resh
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D) Non-contrast CT KUB
f f Zes f Zes
ght o gas pattern is normal.
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t o and pelvis
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obstruction, perforation or mucosal 5. What is the most appropriate initial management
oedema. of a well patient with renal colic and a small
sh i shi calculus at the left hi
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n
(<5 mm) left
n Q ure
sided
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the left sacro-iliac
h f Zes
t ovesicoureteric junction identified f ZCT
t oon
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an abnormal area of bone on the
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left side of the L5 vertebral body
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which is in keeping with partial
sacralisation of the L5 vertebra C) Urgent percutaneous nephrostomy
hi hi hi
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no significant abnormality of the
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Answers
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to Questions
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h
yrigh
t of Zesh
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1. Which of the following is/are risk factors for developing renal calculi?
hi answers are A) Hypercalcaemia,

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a Inflammatory bowel diseaseesand
hD) ha E) Recurrent urinary tract infections.
ha
f Zes fZ f Zes
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Abdominal
X-Rays
Renal calculi are common, occurring in 5-10% of the population. They typically occur in middle age (30-60 years)
and affect men more commonly than women. There are several risk factors for developing renal calculi.
A) Hypercalcaemia – Correct. Calcium is a component of Normally,i calcium within the lumen of the GI tract binds i
hi of calcium
esform resh and the resultant calcium oxalate is Q h
most renal calculi,Qinurthe oxalate or touoxalate
Q ures
poorly
s han There is increased risk of developing esha
n n
ha occurs in
calcium
t o f Z e
phosphate.
o f Z
t cause t o f Zes
absorbed from the GI tract. Fat malabsorption
righcalcium righthat o yr
h
igbowel resections or Crohn’s
Copy hypercalcaemia, such as primary hyperparathyroidism,
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containing renal calculi with conditions patients who have hadpsmall
disease (due to the Cdisruption of the enterohepatic
malignancy, sarcoidosis, Addison’s disease and circulation of bile acids). Unabsorbed fats preferentially
medications (thiazides, vitamin D analogues, lithium). bind with luminal calcium. This results in oxalate binding
hi
B) Renal tubular acidosise–sCorrect. There is an increased risk hi in the GI tract. Sodium oxalate is absorbed
with sodium
rescolon shi
of developing a n Qur renal stones in type 1 renal tubular an
calcium inuthe
Q a Qure
and results in high serum oxalatenlevels,
sh is due to alkaline urine, hypercalciuria and
f ZeThis f Zes
h increasing the risk of calcium oxalate esh formation.
f Zstone
g t o
acidosis.
h g h t o g h t o
ri yri yri
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Recurrent urinary tract – Correct. Struvite stones
C) Over hydration – Incorrect. Renal calculi are more common (magnesium ammonium phosphate) form in alkaline
in hot climates due to dehydration. Dehydration results urine which contains ammonia. These conditions can
in concentrated urine, which can become supersaturated occur in the presence of urease producing bacteria, such as
eshi in stone formation.
Qurresult
with substances that ures
Proteus,
Q
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urea into ammonia and carbon dioxide).sStruvite
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D) Inflammatory
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righstones are more common in patients with t typically occur in patients who t
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pCrohn’s
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resection.
neurogenic bladder and obstructive uropathies.
2. Which of the following are symptoms associated with renal calculi?

shi shi ures
hi
a n Qure a n Qure nQ
eshThe correct answer is E) All of eshabove.
the esha
r i g h t of Z r i g h t of Z rig ht of
Z
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Many patients with renal calculi are asymptomatic; however, renal calculi can cause a variety of symptoms.
A) Pain – Incorrect. Renal colic is the classic symptom C) Dysuria – Incorrect. Dysuria can occur with urinary tract
associated with urinary
u r e shi calculi. It is caused by a
tract calculi.
u
i
reshIt is also commonly seen in cystitis (bladder u resh
i
Q Q Q
han lodged in a ureter, with resultant hyper- han inflammation, which is often secondary htoaninfection).
f Z sof the ureter in an attempt to overcome f Zes f Zes
calculus ebecoming
h t o h t o h t o
rig peristalsis
yrig typically
the rig
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D) Haematuria – Incorrect.yHaematuria is another classic
Copcalculi Cop with renal calculi. It is often
clinical finding in patients
become obstructed are a) the pelvi-ureteric junction, b) microscopic and is related to inflammation and trauma
where the ureter crosses over the iliac vessels, and c) at caused by the calculus. However, the absence of
the vesico-ureteric junction. Additionally, any pathological
shi can cause stone impaction. shi
haematuria on urinalysis does not exclude renal calculi.i
e e sh
narrowing, such as
h a n Q u
a r
stricture,
a n
E) Q u r
All of the above – Correct. As the previousaanswersn Qure
Zes s h h
of Ze f Zes of symptoms.
The pain usually starts acutely, spreads from the loin to
r i g h t of and
groin r i g
comes in waves. In contrast to peritonitis, h t patients suggest, renal calculi can causet aovariety
r i g h
Copy with renal colic usually writhe around the Cobed py in agony. Copy and rigors if there is super-
They can also cause fever
added infection, acute kidney injury secondary to
B) Nausea and vomiting – Incorrect. Nausea and vomiting ureteral obstruction, as well as being asymptomatic.
is common. It is mediated via an autonomic response to
the pain. The ganglion which i receives pain signals from
shthe i i
u r e resh resh
the kidneys alsonQ
a supplies stomach.
a n Qu a n Qu
Zesh Zesh Zesh
Cop yrigh
t of
op yrighKEY POINT
t of
op yrigh
t of
Dissecting or C leaking abdominal aortic aneurysms can C cause loin pain similar in
nature to renal colic. In addition, if the aneurysm is adjacent to a ureter, there
may be haematuria. Therefore, it is important to consider this serious differential
i i hi
Q resh
udiagnosis resh65 years presenting with renal colic
particularly in patients ageduover
Q Q ures
a n a n a n
f Zesh for the first time. Zesh f Zesh f
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an Q
shrenal stone is least likely to be esh on an X-ray? an Q an Q
3. Which type
f Zeof
to f Zvisible to t of Zesh
The correct answer is A) Uric acid.
i shi 75-90% of renal calculi ureshi

Q resh have varying X-ray density. Overall,
Different types of renalucalculi
Q ureapproximately Q
n n shan
are radio-opaque
o f Z esha(i.e. visible) on plain X-rays, and almost
o f Z hastones are radio-opaque on CT. The
esall o f Z eexception
ispy right that form in HIV patients beingotreated
calculi ht
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opyr
ght stones are
ithese
Abdominal
Coclassically C C
X-Rays
radiolucent even on CT.
A) Uric acid – Correct. Uric acid stones are the least radio- C) Calcium phosphate – Incorrect. See ‘B’.
opaque stones out of the listed options. They are typically
hi shi bacteria (see Question 1) and accountureshi
D) Struvite – Incorrect. Struvite calculi form in the presence
radiolucent on X-ray butQ ures visible on CT. They form
usually
nQ u r e
an Q
n of urease producing
in patients with
f whosha levels of uric acid, such as those f
Zeincreased haapproximately
Zesfor 15% of renal stones. They f Z eshgenerally
are
t o o o
o
with
p y rig h
gout or right
are being treated for myeloproliferative
o p y radio-opaque, and are the second ight
opyr densest type of renal
C disorders. They account for approximately 10% C of renal C
calculi. Most staghorn calculi are composed of struvite.
calculi. Xanthine stones are also typically radiolucent but
E) Cysteine – Incorrect. Cysteine stones are rare. They
are a rare cause of renal calculi.
occur in patients with cystinuria, an uncommon
shi containing renal
B) Calcium oxalate – Incorrect. Calcium
u es
hi condition. Cysteine stones are shi
Quretype of stone, accounting Qure
autosomalrrecessive
n
calculi are the mostacommon a n Qradio-opaque a n
h h
usually on plain X-ray but less h
dense than
o f Zes 75%. They are the most radio-opaque f Zescalcium f Zes
ight o ght o
for approximately
t
g h containing or struvite stones.
C pyri calculi.
orenal opyr C Copy
ri
KEY POINT
Not all renal i
calculi are radio-opaque on X-ray. Therefore, i a normal abdominal/ hi
Q u resh Q u resh Q ures
sh a
KUB n X-ray does not exclude renal calculi.
sh a
CTnis much more sensitive for identifying
sh a n
i g h t of Ze renal calculi. i g h t of Ze i g h t of Ze
r r r
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4. What is the diagnostic modality of choice for identifying renal calculi?

shi shi ures
hi
a n Qure a n Qure nQ
The h
escorrect answer is D) Non-contrast h KUB.
esCT esha
r i g h t of Z r i g h t of Z rig ht of
Z
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Imaging is used to confirm the diagnosis of renal/urinary tract calculi, exclude differential diagnoses, such
as appendicitis and diverticulitis, and identify any complications, such as hydronephrosis. All the options
hi tract calculi.
listed can help diagnose urinary hi hi
uresnQ ures Q ures
ha han an Q
shurinary
f Zes – Incorrect. Whilst 75-90% of renal
A) Abdominal X-ray/KUB
o f Zesobstruction Z
(hydronephrosis) secondaryf toethe
y r h t
igare radio-opaque, they can be difficult topidentify y r ight o right
o
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calculi
p tract calculus can be diagnosed.
Coon abdominal X-ray if they are small. Additionally, Co it can
C) Ultrasound – Incorrect. Ultrasound can occasionally
be difficult to differentiate urinary tract calculi from identify renal calculi. However, this modality is not as
other causes of renal, abdominal or pelvic calcification sensitive as CT. Additionally, it is usually impossible
such as nephrocalcinosis and calcified i phleboliths. An
shperformed hi ureter due to overlying bowel hi
ures ultrasound has a low sensitivity forn Qures
to image the entire
abdominal/KUB X-raynshould Q urebe if a calculus n Q
s h a can be used to monitor ha
gas. Therefore,
sha
is identified of Z
t to
on e
CT; X-rays its of Zesdetecting o f Zisegood
right t
h urinary tract calculi. Ultrasound
h at
p y r i
response g treatment if the calculus is p y
radio-opaque p y rig which may be
o
C and visible on the X-ray. Additionally, if a patient o
C is C o
identifying urinary tract obstruction
caused by calculi. Furthermore, it can identify other
known to have radio-opaque calculi, plain X-rays can be causes of loin pain and haematuria such as renal
used if they re-present with acute pain to assess any
tumours, as well as gynaecological pathology, such as
change in position of the knownhcalculi. i hi hi
n Q ures In the past, IVUs ureswhich can present in a similar manner. ures
ovarian cysts,
Q nQ
B) Intravenous urogram ha – Incorrect. han haKUB
were the h t o f Zes test of choice for urinary tract ht of
diagnostic ZD)esNon-contrast
ht o f Z
CT KUB – Correct. Non contrast esCT
pyrig However, they have now been superseded
Cocalculi. Copy
rig is the imaging modality of o
C pyrigIt is a low dose non-
choice.
by CT. IVUs involve intravenous administration of contrast CT which has a sensitivity of 95-100% and a
contrast followed by plain X-rays of the kidneys, higher specificity than IVU. It is readily available and
ureters and bladder (KUB) once the contrast is within quick to perform. As it is a non-contrast examination,
hi i
shperformed hi
uresasUrinary ures
it can be safely in patients with renal
the urinary collecting system.
n Q
calculi, including
n Q ure(which n Q
radiolucent calculi, ha will show filling defects ha
impairment may be secondary to ha
urinary tract
f Zes tract. Additionally, urinary tract ht of
t ourinary Zescalculi). Zescan
of KUB
As well as identifying calculi,t CT
within
righthe ri g righ
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i i i
han
scomplications haE)n Contrast enhanced CT of the abdomen hanpelvis –
f Zes f ZesCT can identify
assess for (e.g. urinary tract obstruction and
h t o f Zehydronephrosis). h t o h t o
rig causing Additionally, it rig
permits an Incorrect. Standard ig
contrast enhanced
opyitruses a higher dose of radiation
Copy assessment of the other abdominalCand opypelvic organs, Cbut
urinary tract calculi,
helping to identify or exclude other differential than CT KUB and requires intravenous contrast.
diagnoses, such as appendicitis and diverticulitis Therefore, non contrast scans are preferred. It does,
(although the accuracy for this is limited by the low however, provide a better assessment of the abdominal
i shi organs. Additionally, a delayed phase u i
dose nature of the Q resh
uexamination and the lack of urepelvic
and
Q Q resh
scan,
s h n
acontrast). As discussed in Question 3, eshan ha n
of Z e
intravenous
t of Z
where the patient is imaged when the
o Zescontrast
f urogram)
is being
y righatsmall proportion of urinary tract calculi y ighnot
rare rig
excreted into the urinaryytract h t(CT , would help
Abdominal
C o p o p
C be secondary Cop calculi as these would appear
X-Rays
visible on CT; however, there may still identify non-radio-opaque

signs of urinary tract calculi, such as perinephric and as filling defects in the urinary tracts.
peri-ureteral stranding.
i i i
e shan shan shan
i g t of Z is the most appropriate initial
5. hWhat
i g of Ze
ht management of a well patient with
i g
Ze
ht ofrenal colic and a
y r y r y r
Cop Cop at the left vesicoureteric junction
small (<5 mm) left sided calculus Cop identified on CT KUB?
The correct answer is D) Conservative approach (supportive treatment with

shi shi X-ray KUBs [if the stone is ureshi
n Qure and anti-emetics and follow
analgesia n urewith
Qup Q
Z e s h a
Z e s h a
Z e s han
rig ht of t of has passed).
visible on X-ray] until the hstone
rig ht of rig
Copy Copy Copy
The management of urinary tract calculi depends on the size and site of the stone and whether there is
evidence of associated infection.
shi hi i
A) Urgent ureteroscopy Qureand stone retrieval – Incorrect. ures
spontaneously,
Q particularly if they are located resh
Qudistally.
a n an a n
t o f Zesh is an invasive procedure reservedt for
Ureteroscopy
o f Zesh t
sh
of Ze obstructed
Patients can therefore be treated conservatively
righpatients with larger stones, persistentoppain rigorh yr
if there is no evidence of i
an g h
infected,
Copy those who fail to respond to conservative C y therapy. Copabove).
collecting system (see The mainstay of
A ureteroscope is inserted via the urethra, through the treatment is analgesia (NSAIDs such as diclofenac
bladder and into the appropriate ureter. Most ureteric are used as 1st line), anti-emetics and IV fluids if
calculi are accessible. However, results are best for dehydrated.
i Medications such as tamsulosin (an ealpha
r e hi distal ureters.
sthe r e shor shi
those calculi locatedQ u in Q u
blocker) nifedipine (a calcium channel blocker) Qur
f Z e shan f Z-esh
an can be used to facilitate the passage Zeof
a n
shthe stone. If
B) Urgent
t o extracorporeal shock wave lithotripsy (ESWL)
t o ofsuch
t of
righ igh
opyr reserved r i g h
Copy Incorrect. py
ESWL is another treatment modality visible on X-rays, the progress stones can be
C
for patients who fail conservative management or have monitored by serial CoX-ray KUBs. If the stone fails to
large stones. An external energy source causes shock pass after 4-6 weeks, the pain becomes intolerable,
waves which are targeted towards the stone. The aim is or if the patient develops an infected, obstructed
hi them to pass through the
r scan hi system, an alternative treatment option
collecting
resh
is i
ures (see above).
to fragment stones toeallow
n Q u cause renal colic and ESWL han Q
required Q u
ureters. Theha fragments an
to
may f Z
faile s large
in and hard stones. t of Z
es E) Percutaneous nephrolithotomy t o Zesh
–f Incorrect.
r i g h r i g h h
rig is used to fragment
Copy C) Urgent percutaneous nephrostomyC–oIncorrect. py Copy
Percutaneous nephrolithotomy
Urgent percutaneous nephrostomy is needed in large renal calculi. It is usually reserved for large
patients with an obstructed kidney and super-added or complex stones or patients in which ESWL and
infection. It is usually performed under sedation ureteroscopy have failed.
hi shi resh
i
ures to reduce the risk of
with antibiotic coverage
n Q n Qure Qu
eshaOnce the collecting system has of Zesha shan
of Ze
septicaemia.
o f Z
t suitably drained and the infection treated, t
righbeen yrigh ight
Copy the access gained via the nephrostomy Copcan be C opyr
used for nephrolithotomy (procedure to remove
Important Learning
the stone) if required. An alternative approach
to draining an infected, obstructed collecting • Renal ca
Points:
ure(inshai retrograde fashion) i lculi ar
sh e common and can caus
ures
hi
system is from below
n Q n Qurvaeriety of sympto ea
n Q
withfan Z sha
eendoscopically placed ureteric stent f Z esha ms, however, mostZsto ha
f esnes are
t o ight o t o
righextending rand asymptomatic. rig h
Copy into the renal pelvis.
from the bladder, up the ureter
Copy • 75-90% of stones ar Copy
e visible on X-rays, whils
D) Conservative approach (supportive treatment almost all are visible on t
with analgesia and anti-emetics and follow CT.
• Non-contrast low do
up with X-ray KUBs (ifsthe hi stone is visible on hi se CT KUB is the imaging hi
Q urehas passed) - Correct. Qumo redaslit y of choice, with X-ray KU Q ures
a n n n
esha ersvehdafor
X-ray) untilhthe stone
Mosto f Z es (<5
small mm) stones in the ureter pass o f Z follow-up of radio-opa
Bs res
o f Ze
righ t righ t qu g h t
eristones.
Copy Copy • Treatment dependsCopy
on the size and site of th
stone and the presence e
of infection or urinary
tract obstruction.
ureshi ure shi ure shi
an Q an Q an Q
Cop yrigh
t of Zesh Orthopaedic X-Rays
Cop yrigh
t of Zesh
Cop yrigh
t of Zesh
Spine Case 1.................367 Wrist Case 1.................407 Hip Case 3.....................443 Knee Case 2..................481
Spine Case 2.................375 Wrist Case 2.................415 Hip Case 4.....................451 Knee Case 3..................489 i
e shi e shi sh
h a n u r
Q Wrist Case 3.................423 a n u r
Q5.....................457 a n Qure
Spine Case 3.................383
Zes
Hip
Zes h Case Tibia/Fibular es h
Case 1....497
r i g ht of r i g ht of r i g h t of Z
Cop y
Shoulder Case 1...........391 Cop y
Hip Case 1.....................429 Hip Case 6.....................465CopyTibia/Fibular Case 2....505
Elbow Case 1................399 Hip Case 2.....................435 Knee Case 1.................. 473 Ankle Case 1.................513
hi hi hi
a chapter is aimed at providing a systematic
shthe ha framework for approaching orthopaedicha X-rays.
f Zes f Zes
Orthopaedic
This introduction
h t o f Zeto h t o h t o
X-Rays
g
ridetails igfindings discussed below are coveredpmore
rig extensively in the
opyr
Further and examples of the specific X-rays
Copy cases later in the chapter and theCbonus
example X-ray chapter. Co y
shi
KEY POINT shi hi
n Qure n Qure n Q ures
h a h a h a
h t o f Zes Systematic approach to orthopaedic
h t o f Zes X-rays h t o f Zes
ri g ri g ri g
Copy 1. Projection Copy Copy
4. Obvious abnormalities
2. Patient details 5. Systematic review of the X-ray
3. Technical
hi adequacy 6. Summary
hi hi
ure s ure s ures
han Q h an Q esha
nQ
ht o f Zes ht o f Zes ht of
Z
rig
1. Projection • For some patients in whom the clinical suspicion
of a fracture is high but is not evident on the usual
• Assessment of any bone or joint in general requires two views, additional views may be requested,
at least two views– ‘one eshiis one too few!’ These
Qurview Q
i
resh rotation views of the hip.
such asuinternal
Q ures
hi
a n
shof AP and lateral X-rays (figure 1). f Zeshan shan
normally consist
f Z e f Z e
ight o right
o • If the shaft of a long bone isigfractured
ht o it is
pyrsome
•CoFor Copy
sites, such as the scaphoid, where imperative to X-ray the pyr above and below
Cojoint
fractures are difficult to detect, it is routine to because of the potential for additional injuries
obtain more than two views. (fracture or dislocation) at these sites.
ure shi • Comment u shiwhether the patient is skeletally mature

reon u resh
i
an Q Q
an epiphyses/growth plates). This iseuseful
han
Q
t of Zesh t o
h(fused
f Zes because the types of injury andhpathology
t o f Z s vary
CoAp yrigh Copy
rig h rig
Copy and mature patients.
B between skeletally immature
res hi res hi KEY POINT s hi

a n Qu a n Qu a n Qure
t of Zesh t of Zesh Zes
Remember: children develop
t ofrates
h and
Cop yrigh Cop yrigh Copy
mature at r i g h
different and
therefore the age of a patient
does not tell you whether they
are skeletally mature or not.
i i i
righ t of Z righ t of Z Figure 1. righ t of Z
Copy Copy Copy
Image A: AP view of this finger shows apparently normal
alignment of the interphalangeal joints
Image B: The lateral view shows posterior dislocations at
i shi hi
Qu resh urejoints!
both of these
Q Q ures
e shan f ZeThese
n
sha X-rays dramatically show why one view n
shatoo few!
f Ziseone
righ t of Z ri g h t o i grh t o
Copy Copy Copy
Orthopaedic X-Rays - Introduction • 335

esh an Q an Q an Q
Z ZeBsh Zesh
ht of
rigA yrigh
t of
yrigh
t of
Copy Cop Medial epicondyle Cop
ossification centre
Lateral epicondyle
eshi eshi i
ossification centre
Qur Qu r Qu resh
shan appearance of the shan shan
Normal
e e of Ze
righ t of Z anterior pad
righ t of Z ight
Copy Copy C opyr
i i i
resh resh resh
Radial head
Qu
ossification
Qu Qu
shan shan shan
Orthopaedic
centre
e e e
X-Rays
Trochlear
Copy Copy ossification
centre Copy
Capitellar
Radial head
ossification
i i ossification
hi
resh resh ures
Olecranon centre
nQ u nQ u centre
nQ
esha esha esha
ossification
t of Z t of Z t of Z
centre
righ righ righ

Copy Copy Copy
hi hi hi
fZ esha fZ esha fZ esha
p y r ight o20. Lateral (Image A) and AP (ImagepyB)rielbow
Figure ght o X-rays demonstrating the various possification
y r i ght o centres
Co (Capitellar, Radial head, Medial/Internal epicondyle,
Co Co epicondyle = CRITOE).
Trochlear, Olecranon, External/Lateral
The Gartland classification system is useful for categorising the severity of supracondylar fractures, and
the X-ray features are summarised in Table 1. It relates to ‘extension type’ supracondylar injury, where the
s hi s hi hi
n u r e
Q posteriorly. Flexion type injuries comprise
distal fragment is displaced n Q u r e 5% of supracondylar fractures, andn Q ures
a a a
Zesh
are classifiedofseparately. of Ze
sh
of Ze
sh
right right right
Copy Gartland 1
Copy Gartland 2
CopyGartland 3
ure shi ure shi ureshi

an Q an Q an Q
i i i
shan shan shan
C opyr C opyr Copyr
i i i
Qu fracture.resh Qu resh Qu resh
Z e han
An undisplaced supracondylar
s Z e s han
This is a displaced supracondylar This is a completely displaced
Z e s han
f of posterior cortex ht of and the
ight o (anterior humeral line) righthumerus is intact.
A line drawn along the anterior edge fracture but the supracondylar fracture,
o p y rhumerus opydistal o p y rigof
C
of the ofCthe C
posterior cortex the distal
transects the capitellum. However, the anterior humeral humerus is not intact. These are
line now does not transect the the injuries most often associated
capitellum. with neurovascular compromise
i hi and compartment syndrome. shi
Qu resh Qu r e s
Qure
f Ze shan esha
n
f Z for supracondylar fractures. f Ze shan
right o ight o
Table 1: The Gartland Classification
r right o
Copy Copy Copy
Orthopaedic X-Rays - Introduction • 353

PRESENTshi HIP CASE s5hi i
ure u re u resh
YOUR
fZ e s h an Q A 75 year old manshas Q
hanfallen over at home. He was unable to
f Ze to A&E by ambulance where it washnoted
anand
eshleft
get up
f Zhis
Q
r ight o FINDINGS... has been
ig h t o
brought
ig t o leg was
Co p y opyr
Cshortened opyr
and externally rotated. This is hisCX-ray.
i i i
e shan e shan shan
righ righ opyr
Copy Copy C
i i i
shan shan shan
Orthopaedic
e e e
X-Rays
Copy Copy Copy
hi hi hi
esha esha esha
Copy Copy Copy
hi hi hi
Copy Copy Copy
hi hi hi
Copy Copy Copy

an Q an Q an Q
i i i
shan shan shan
Copyr C opyr C opyr
i i i
Copy Copy Copy
i i i
Copy Copy Copy
Orthopaedic X-Rays - Hip Case 5 • 457

an Q an Q an Q
Cop yrigh Annotated CX-ray
op yrigh Cop yrigh
i i i
e shan e shan shan
righ righ opyr
Copy Copy C
i i i
shan shan shan
Orthopaedic
e e e
X-Rays
Copy Copy Copy
hi hi hi
esha esha esha
Copy Copy Copy
hi hi hi
Copy Copy Copy
hi hi hi
Copy Copy Copy

an Q an Q an Q
i i i
shan shan shan
ight of Ze IN Summary – This X-ray i g h of Ze a displaced left intracapsular
tshows i g h t of Z
e
Copyr Copy
r opy r
fracture of the neck of femur. I would want to seeC a lateral X-ray
of the hip to complete my radiological assessment of the fracture.
hi hi hi
n Q ures changes of the hips and
Degenerative n Q ures are evident and theren Qures
spine
ha ha ha
t o f Zes t o f Zes t o f Zes
Copy
rig h is Cmarked
opyr
ig vascular calcification.
h
Copy
rig h
i i i
Copy Copy Copy
458 • Orthopaedic X-Rays - Hip Case 5

ureshi ure shi ureshi
an Q an Q an Q
t of Zesh Zesh
QUESTIONS
t of t of Zesh
1. The initial management of this fracture
PRESENT involves which of the following?
hi i
eshpatient hi
ures A) Stabilise
urthe ures
YOUR h t o f Zes
ha n Q
h t o f ZB)
ha n Q
esIdentify any medical issues
h t o f Zes
ha n Q
rig rig rig
Copy
FINDINGS... Copy Copya history of the
C) Take a full history including
mechanism of injury
•• This is an AP X-ray of the pelvis of D) Take a full social history
hi hiof the hip to allow accurate hi
ures u s ures
a skeletally mature patient. E) Request raeCT
Q Q Q
Zes han ha n
espreoperative planning esha
n
Orthopaedic
f anonymised Z Z
•• It has been
h t o and the
ht of ht of
X-Rays
p y rig of the examination is not y r i g y r i g
C otiming Cop Cop using the Garden
2. What grade is this fracture
available. I would like to confirm
the patient’s details and timing
of the examination before I make
A Classification?
A) 1
hi shi hi
ures B) 2 Qure ures
an Q
any further assessment.
h es3h a n
esha
nQ
f Zes f ZC) t of Z
•• They ght ois adequately
riX-ray ri g h t o
righ
o p
C penetrated, with no important Copy D) 4 Copy
areas cut off. E) A
•• There is a displaced fracturehof
s i 3. What is the
ures
hi surgical management for this
best shi
the left hip. It is ana Qure
intracapsular
n 75 a n
year Qold patient if they are a
independent n Qure
subcapital t Zesh of the femoral
offracture t
esh
of Zand t of Ze
sh
i g h i g h medically fit prior to i
the g hinjury?
pyr
Coneck. C opyr opyr
C
A) Hemiarthroplasty
•• There is shortening and external
B) Total hip replacement
rotation of the femur.
Qur eshi eshi
C) Surgical fixation
Qurand Qure
shi
haisnvisible.
•• No other fracture
s esh
D) a n
Traction bed rest esh a n
ht of Ze h t of ZE) Early mobilisation h t of Z
pyrig are no areas of lucency
•• There
Coor Copy
r i g
Copy
r i g
cystic changes to suggest a
pathological fracture. 4. If this fracture occurred in a fit and well
20 year old, which would be the best surgical
•• There is a loss of joint space ini i i
Q u resh option? Q u resh Q u resh
n
both hips with osteophytes, n n
esha and
f Zsclerosis
ha
esHemiarthroplasty
f ZA) Zesh
a
t
subchondral
h o h t o t of
pyrig
Cosubchondral cysts consistent with Cop yrig B) Total hip replacement Cop
yrigh
osteoarthritis. C) Surgical fixation
•• Degenerative changes are also D) Traction and bed rest
hi hi resh
i
n uresand the
visible in the lumbar spine
Q E) nQ
Early ures
mobilisation Qu
lumbosacral esha
f Zjunction. f Zes
ha e shan
to t o t of Z
yrigh
p
•C• oThere is calcification of the Copy
r i g h 5. Which of these is r
absolutely
Copy
i g h
necessary prior
femoral vessels bilaterally, in to the patient having surgery?
keeping with diabetes or renal A) Consent from the patient
failure. shi B) Nil by mouth
ures
hifor 6 hours
ures
hi
a n Qure n Q n Q
h
Zes surgical clips ha cross-matched ha
f Zes f Zes
•• There areoaf few C) Blood
g ht over the left thigh h t o h t o
y r i rig g
riincluding
Cop Copy Copy
projected D) Results of a full set of bloods urea and
suggesting previous surgery. electrolytes
E) None of the above
i i i
eshan e shan e shan
Copy Copy Copy

h an Q h an Q an Q
Answers
t o f Zes to Questions t o f Zes t of Zesh
rig h rig h yrigh
Copy Copy Cop
1. The initial management of this fracture involves which of the following?
i i i
shan
e The correct answers are A) Stabilise Ze shan Ze shan
righ t of Z r i g ht of
the patient, B) Identify any
r i g h t ofmedical issues,
Copy y
Copincluding a history of the mechanism
C) Take a full history Copy of injury and
D) Take a full social history.
shi
re shi
urea full history including a history of the shi
re
A) Stabilise the patient
s h a n Qu – Correct. Stabilising all trauma shaC) nQTake
s h a n Qu
Orthopaedic
eis important however there are other of Ze e history of the

t of Z points to consider. Patients should t Z
patients mechanism of injury – Correct.oAf full
himportant htbe himportant.
X-Rays
y r i g y r i g y r i g
Cop Cop Cop
mechanism of injury is very Did they trip
assessed using the ATLS ABCDE algorithm if there or did they collapse?
is any concern about major trauma. Stabilisation
includes fluid resuscitation and early pain relief. D) Take a full social history – Correct. It is important
Analgesia should be e
u shi
rprescribed using the WHO pain to takehai full social history from all patients who hi
ures fractures to the femoral neck. This ures
a
ladder assahguide, Q
n starting at the most appropriate shan sustained Q a n Qincludes
e s h
t of AZnerve block is a very effective method
hstep. f Ze
htofopain
where the patient lives, the requirement
t of Z
hliving,
e of assistance
Cop relief but should only be performedCby opa trained with their
Cop
activities of daily the use of walking
member of staff. aids both in the house and outside and an abbreviated
mental test (AMT). The degree of independence will
B) Identify any medical issues – Correct. Patients with impact on surgical decision-making.
h i hi hi
femoral neck fractures
n ures are
Qmedical
typically elderly and
n
E) Q ures a CT of the hip to allow accurate n Qures
Request
often have h a
other co-morbidities which must sh a a
eshis not
h bet f Zes
oconsidered. These include chronic co-morbid h t of Ze preoperative planning – Incorrect.
h t of ZThis
r i g yr i g i g
Copy conditions such as renal failure, COPD, Copischaemic heart opyr
required. The mainCquestions which needs to be
disease and dementia as well as acute problems which answered for preoperative planning are whether the
may have contributed to the fall (e.g. infection) or fracture is intra or extracapsular and the degree of
resulted from the fall (e.g. intracranial haemorrhage). displacement. AP and lateral X-rays can almost always
s h i s h i hi
Qure and treated early to
These must be identified
n n Q ure
answer these questions. CT of the hip can
n uresif
be used
Q
a
h patient for surgery. Patients may alsoZesh a a
esthe Zesh imaging
there is high clinical suspicion of a hip fracture but no
t oonf Zwarfarin. This will need to be reversed
optimise
r i g h r i g h t of to evidence on the X-rays. MRI r i g h of alternate
ist an
Copy surgery. However, the indication for py Copy
be prior
Cowarfarin must be strategy in such cases.
considered before reversing it, as the risks of stopping
it may be high. In these cases, or if you are in doubt,
i with a haematologist i i
re h resh resh
you should discuss thescase
for advice.han Qu han
Q u
han
Q u
s s s
KEY POINT
Q eshi
ur tests should also be performedn to Q uassess
i
resh for: Q ures
hi
ha n Blood
ha ha n
h t o f Zes h t o f Zes h t o f Zes
rig A) Pre-operative rig
anaemia rig transfusion
– patients may need a pre-operative
Copy Copy Copy
B) Pre-operative renal failure or electrolyte derangement which may affect
anaesthesia and fluid management
i i hi
Qu reC)shBlood group and save – surgery can Q esh
urbe associated with significant blood loss
Q ures
e shan and should be prepared esha
f Zfor
n
f Zes
ha n
righ t of Z rig h t o
rig h t o
Copy Copymarkers – patients may have sepsisCopy
D) Inflammatory
E) Clotting – drugs or liver dysfunction may affect clotting and may need to be
corrected pre-operatively
i i i
Copy Copy Copy

an Q an Q an Q
2. What grade is this fracture using the Garden Classification?
i i i
shan
e correct answer is C) 3. e shan shan
The
righ righ opyr
Copy Copy C
Intracapsular fractures often need surgery to have the femoral head replaced, but in certain cases
this is not necessary, and in some cases conservative management might
shi hi be considered. The Garden
sintracapsular hi
Classification is used
n Q
tou r e
categorise the degree of displacement
n Q u
of r
ane femoral neck Q
fracture,
n ures
esha sha Zesh
a
Orthopaedic
and as such,
h igh of Zesupply to the femoral head has been
t of Zalso defines how likely it is that the tblood igh t ofdisrupted.
X-Rays
pyrig
CoThe C opyr C opyr
classification system goes from 1 to 4, where 1 and 2 are undisplaced and 3 and 4 are displaced.
The subtle differences between 1/2 (undisplaced) and 3/4 (displaced) are best appreciated by looking
at the trabeculation (lines seen within bone) in the different fractures. In Garden 1 fractures, the
shi shi shi
trabeculation lines in the
a n Qurehead point vertically in comparison a n Q re normal. In Garden 2 fractures, an Qure
to uthe
sh In Garden 3 fractures, the trabeculation
f Zeline.
they are all in h
f Zes lines in the head are more horizontal
h
f Zesthan
g h t o g h t o g h t o
pyri In Garden 4 fractures, the head
normal.
Cotrabeculations
i
has rdisplaced
Copy Copy
ri
but returned to its normal alignment and so the
are all in line.
A) 1 – Incorrect. In Garden 1 fractures, there is an B) 2 – Incorrect. In Garden 2 fractures, the fracture is

i at the fracture i hi
Q resh
incomplete fracture withuimpaction reshundisplaced and again surgical fixation
completeuand
Q Q ures
a n
sh head tilted into a valgus (more a n
sishpossible as the risk of AVN is low. Thisf fracturea n
site with the femoral
of Ze Therefore, the capsule is likely toight of Ze often grouped with Garden 1 fractures esh is
o asZundisplaced
i g
upright) h tposition. i g h t
pyr intact and the risk of AVN (avascular
Coremain pyr
Conecrosis) and treatment is essentially pyrsame although
Cothe
is reduced. Surgical fixation using screws prevents as the fracture is complete there is a higher risk of
displacement of the fracture and is the best option displacement if the fracture is treated non-operatively.
for most patients. Keeping the patient’s own femoral
hi shi is a Garden 3 fracture. In Garden shi
ures
head reduces the risknofQdislocation or need for n Qurethere is displacement and there is aan Qure
C) 3 – Correct. This
a a
f
revision surgery.
t o ZesIfhthe patient has little pain, this t sh
3 fractures,
of Ze high chance of AVN. In the majority Zesh
tofofpatients,
h yrigh h
pyrig could potentially be treated without i g
r a
fracture
Coand C opsurgery py
hemiarthroplasty or THRCisonecessary.
with full weight bearing but follow-up X-rays are
needed to ensure the fracture does not displace. D) 4 – Incorrect. In Garden 4, the fracture is fully
displaced. For the vast majority of patients, THR or
ure shi hemiarthroplasty
u
i
resh is required. ure shi
an Q an Q an Q
t of Zesh t of ZE)esAh– Incorrect. The classification is fromt o1ftoZ4enot
sh A to D.
Cop yrigh Cop yrigh Copy
rig h
Qu resh
i KEY POINTSQureshi Qu resh
i
shan shan shan
ight of Ze 1. Undisplaced fractures have i g h f Ze
t olower i g h t of Z
e
opyr r r
a risk of AVN in comparison to displaced
C opy Copyof displacement
fractures. Use the C
Garden Classification to consider the degree
and then this will help guide your surgical decision making.
hiit a screw, 3, 4, Austin Moore” is anreaid

2. “1, 2 give himemoire for the treatment of hi
n Q ures
intracapsular fractures. Cannulated n
screwsQ ucansbe used in undisplaced fractures n Q ures
ha ha ha
h t o f Zes (Garden 1 or 2), whereas anhtarthroplasty
o f Zes is usually required for h t o
displaced f Zes
rig rig rig
Copy fracture (Garden 3Candopy4). Austin Moore is an outdated type Copofy arthroplasty.
i i i
eshan eshan e shan
Copy Copy Copy

an Q an Q an Q
3. What is the best surgical management for this 75 year old patient if they are
independent and medically fit prior to the injury?
i i i
shan
e The correct answer is B) Total Ze shan shan
t of Z ht of hip replacement. ight of Ze
righ r i g
opyr
Copy Cop y C
The aim of surgery in fractures of the neck of femur should be to allow early mobilisation with limited
hi In the elderly, most surgeons willreopt
hifor either a THR or a hemiarthroplasty hi
ures u s ures
chance of further surgery. for
n Q n Q n Q
esha fractures.
intracapsular esha sha
Orthopaedic
e
X-Rays
Copy Copy
A) Hemiarthroplasty – Incorrect. A hemiarthroplasty Copy
C) Surgical fixation – Incorrect. In this age group, it is
is a half hip replacement. The ball of the ball and not advisable to attempt fixation for a displaced
socket joint is replaced but the socket is left alone. intracapsular fracture as the risks of further surgery
This option has some advantages
hi such as a low risk are too high
resh
i if AVN develops. However, if the fracture hi
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of dislocation.nHowever, n Q
isuundisplaced or minimally displaced, then n Q
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normal
h t o f Zeanatomy and patients will often not beoable
h t f Zetos may be a good option. The riskooff Z
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g
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ri may be much lower in
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fractures is above 30%, but
In undisplaced fractures.
addition, if a patient had arthritis in the joint prior to
the fracture, then there is the chance of ongoing pain D) Traction and bed rest – Incorrect. Intracapsular
hi present in the acetabulum.
because the arthritisreissstill fractures i do not respond well to traction and bedesrest.
resh some extracapsular fractures will Q hi
n Q u n Q u
Although n ur with
heal
h a sh a h a
B) Total
t Zesreplacement
of hip – Correct. In a THR, the ball
t of Ze time, as this fracture is displaced
t Zesintracapsular,
of and
r i g h yr i g h i g h
Copy and socket are replaced, allowing for Coapbetter the likelihood is the o pyr will not heal (non-union)
C fracture
correction of the prior anatomy and a better return and the patient will be left immobile with all the
to function. NICE guidelines state that THR should associated/related complications. This treatment
be considered for independent patients with a option may be considered in very frail patients who
s h i hi to die from an underlying or acutereshi
ure
displaced intracapsular
Qno
fracture of the neck of the
u es
arerexpected
Q u
femur who
e s h a n
need more than one stick to mobilise.
e s h a n medical problem (in these patients, surgery
e s h an Q is not
Z
t ofoperation fZ fZ
p y r ighThis p y r ght o
takes slightly longer and is itherefore appropriate).
p y r i ght o
Co associated with slightly more blood o compared
Closs Co
with a hemiarthroplasty. There is also a higher chance E) Early mobilisation – Incorrect. Very occasionally,
of dislocation. However, by replacing both the ball patients will present with an undisplaced
and socket, it is possible to get a more anatomical intracapsular fracture where the fracture is old and
h i i i
implant which allowsQ u s
rebetter return to function. Q u reshor the patient is able to mobilise. In such
healed
Q u resh
han han circumstances, it is possible to avoid an
anhoperation.
h t f Zes there are further benefits for patients
In addition,
o h t o f Zes h t o f Zes X-rays are
rig with a fracture and pre-existing hip joint ig
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opyrhas been no displacement
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acetabulum will help alleviate the symptoms of that would warrant surgical intervention.
arthritis.
i i i
r i g h t of Z r i g h t of Z r i g h t of Z
Copy 4. If this fracture occurred in C pyand well 20 year old, which would
a ofit Copy be the best surgical
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hi hi resh
i
n Q ures n Q ures Qu
f Zes
a correct answer is C) Surgicalesfixation.
hThe
fZ
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rig h t o
rig h t o
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There is a significant difference between femoral neck fractures in the elderly (> 65 years) and the young.
Young patients are usually fit and the fracture is often associated with high-energy trauma. They are
hi hi of the native femoral hip is crucial hi
n Q ures and be more active. Therefore,npreservation
expected to live longer
Q ures n Q uresin
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youngZpatients
f f Zesh
a
f
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an Q an Q an Q
A) Hemiarthroplasty – Incorrect. This surgical option D) Traction and bed rest – Incorrect. This is not appropriate
would provide a poor outcome for a 20 year old, for patients in this age group with this fracture.
resulting in limited mobility and future problems
hi shi – Incorrect. Young patients with ureshi
E) Early mobilisation
n u es tear from the metal
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anaintracapsular nQ
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femoral head against
e f Z h
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ht o o even if the fracture is o
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CoTotal
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very unlikely for a young person
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then this is the best surgical option. However, a THR injury which will be picked up on initial presentation.
does not last forever and it is likely a 20 year old with a
hi hi hi
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go straight to theatre. The fracture can be accurately of their intracapsular neck of
s i
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reduced and fixed with either
n Qu r e3 or a short
n Qu r e
n Q ures
a
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dynamic hip screw
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significant risk AVN of the femoral head, which g
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Corequire Copatient AVN
young and fit, the risks of further surgery are relatively the femoral head, improving
low. It is therefore desirable to keep the patient’s the long-term functional
shi shi outcome. shi
femoral head and accept the possibility of further
re Qure Qure
ha n Qu it in the first instance.
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i i In an emergency situation, ureshi

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None of these are absolutely
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you may notZbee an to wait for the patient to be adequately
shable e shan fasted or to consent the patient shanare
ifethey
f f Z f Z
ht o Similarly, blood results may not o
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hi
n
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f Zes consenting should either be the ht of Zeshours prior to the operation. This reduces Z srisk
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Ideally, the person
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of aspiration of gastric contents
operation. If not, then the person consenting should induction. Although this applies for all surgical patients,
have a full understanding of all the risks and benefits this is especially relevant in trauma, which itself delays
of a surgery together with the technical steps of the gastric emptying. Again, in some circumstances, this
u r e sbehiallowed sufficient u r e shi and emergency surgery should ureshi
an Q In some circumstances, such nQ nQ
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an Q an Q an Q
yrigh
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Cop yrigh op yrigh
E) None of the aboveC– Correct. Although not absolutely
undergoing surgery for femoral neck fractures are necessary, these should all be done for the standard
at risk of significant intra-operative blood loss and patient with a neck of femur fracture.
hiand save (G&S). If there is hi resh
i
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n Q n Q Qu
concern that hathe
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rig pyrig opyr
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blood is not necessary as O negative or type specific
blood is readily available. Important Learning
• Thh
e Ga
Points:
shi including urea and
D) Results of a full set of bloods s i rden classification helps classify intracap ureshi
n Qure Elderly patients with neck Qurefractures based sulQar
electrolytes a
h - Incorrect.
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f Z e
cem
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o
oft femur
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X-Rays
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o p (Ga rden 1 and 2) are at lower
These can adversely affect their renal function risk of AVN, as thCe capsular blood vessels are
to be damaged. These patie less likely
and electrolyte balance, which needs to be nts can be considered for
recognised and addressed prior to surgery. It is surgical fixation using, for
hi shi example, cannulated screw
esdiscuss e s, shi
urto Qu thus preserving the patient ’s native femo an Qure
r
therefore important such patients
a n Q n
f Z s h
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f Z esha • Displaced fractures (Ga shhead.
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uire some form of
medical registrar. In emergency situations, the arthroplasty. Hemiarthrop
lasty is a good option
full blood result may not be available at the time for minimally mobile elderl
of surgery. In such cases, the y patients who are frail.
i anaesthetic team
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an
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nQ ures n Qseuco tion. n Qure
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an Q anQure
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an Q
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shan shan shan
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Copy Copy Copy

sh an Q
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sh an Q
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of Ze of Ze Ze
t of Pelvis.......535
right
CT Head......................... 525 right
CT in Orthopaedics...... 530 CT Abdomen
righand
Copy Copy Copy
CT Cervical Spine.......... 530 CT Chest......................... 531
hi hi hi
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they Looking through a CT scan
axial, coronal and sagittal planes of the body
A CT scanner essentially consists of an X-ray tube (figure 2). The standard CT image is the axial
which spins around the CT table (figure 1). The
ure shi ures
hi and on this the left side of thereshi
(transverse) image
u
X-ray tube is housedain n Q
the gantry, which is the n Q an Q
Z e s h Z e s ha
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f part of the scanner. The patient lies of (for example in, figure 16, the iheart, ofwhich is a left
ght o
donut shaped
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couch o p y r ght
C C sided structure, is on theC right side of the image).
travels through the centre of the gantry as the X-ray At first glance, this may appear counterintuitive.
tube spins around the patient, taking hundreds of However, considering how we look at a frontal chest
X-rays from different angles. The i data are processed X-ray helps us i why the CT images are shi
resh shunderstand
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by a computer to produce n Quimages. n Quin Qure
h a a
displayed
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f Zes f Zes f Zes
CT
ht o ht o h t o
g
ri X-ray, it is as if the
When we look at a frontal chest
patient is standing directly opposite and looking
towards us (i.e. we are face to face). Therefore,
their left hand side is in the right side of our field of
hi shi shi
nQ ures n Q rethe cardiac shadow and other left
view, anduso
n Qure
sided
Zesha sh a
of Zevice versa. A coronal CT imageiis
structures h a
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rig ht of r i g h t r g h t
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exactly
it’s as if the patient is standing
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i patient lies back onto a bed (or eshi
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e s h an Q e
the aCT
s h n Q
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fZ f Z head is furthest away. As we look Z
atfthem,
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their left
p y r p y r p y r i
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and vice versa. So, if we take an image in the axial
(transverse) plane with the patient lying on their
back and viewhiti from their feet end, then we will
Figure 1. Diagram of a CTuscanner r e shi u resleft sided structures, such as the Q u resh
i
n Q see n Q
that their heart,
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on the right side of the image. When f Zes we look
rig pyrig ig
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Copyvery quick (lasting seconds), making
scan CoCT at axial CT images on a C monitor,
suitable for, and well tolerated by, most patients, standing at the feet end of the patient and looking
including those who are unwell. Patients need to up towards their head.
i i i
Q u reshand remain still,
be able to lie flat on their back
Q u resh
The same principles apply to MRI images.
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n n n
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albeit for a short speriod of time. Depending on
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breath t o f Zes Sagittal h t o f Zes
rig pyrig rig
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momentarily. Contrast Corectal)
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the scan (this will be decided by the radiologist). Coronal
Indications for contrast willebe h i

considered within hi hi
n Q ur s a hot flushing n Q ures n Q ures
the text. IV contrast shacan cause
f Zeadministered f Zes
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f Zes
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yrig
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rig
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shi
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Figure 2. Axial,ncoronal
f Zes
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Co Copy Copy
CT Scans • 521
esh an Q
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of Z t of Z Z
ht of Joints.....555
right ......................544
MRI yHead. MRCP..............................
yrigh 553 MRI Knee y&rigOther
Cop Cop Cop
MRI Spine....................... 549 MRI Small Bowel.......... 554
i i i
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t ofitZ and how is it
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r i g righ t of Z ight
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performed?
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hi how MR images hi resh
i
n Q ures
not necessary to fully understand
n Q ures Qu
hasame way you can drive a car Zesha
f Z sexactly how the engine works!);
are produced (inethe e shan
without rig h t o
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however, a basic understanding is helpful.
In simple terms, MRI uses a magnetic field and

radiowaves to produce images. iThe patient lies shi shi
resh
Qucauses Qure Qure
inside the magnet,hwhich
s a n hydrogen ions h a n h a n
(protons) h t o f Zethe
within body to align (either with orh t o f Zes h t o f Zes
ri g ri g yri g
Copy the magnetic field). A radiofrequency
against Copy pulse Figure 1. Diagram of a MRICopscanner.
of a specific magnitude and duration is then sent
through the patient. This transfers energy to the
protons (excitation) and changes
eshi
their direction Use of ionising radiation
shi shi
Scans
u r Qure Qure
MRI
of alignment. Overhtime, a n Q the energy from these a n a n
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excited gprotons
i h t of Zeis lost (decays) and the protonsight of ZeOne of the benefits of MRI over i g CT
h t oisf Z
that
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realign CopyThis ionising radiation used.CInstead,
process emits radiofrequencies which are detected above, MRI uses a magnetic field and radiowaves
by the MRI scanner and result in the image. The to produce the images. However, MRI scanning has
speed of the relaxation process idepends on the other hazards i
associated with it. hi
Q u reshradiofrequency Q u resh Q ures
size and duration of
sh a n
the initial a n a n
of Ze of the substance in whichithe esh esh
pulse, the
i g h tstructure g h t of Z i g h t of Z
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hydrogen
r
ions/protons are in and the influence Copy
r Magnetic fields Copy
r
of surrounding hydrogen ions/protons. Thus, the
• The strong magnetic field of the MRI scanner
different tissues and substances result in different
can turn ferromagnetic objects, such as scissors
signals which are detected byshthe i MRI scanner and i i
Q u re andQ u resh compatible oxygen cylinders, into
non-MRI Q u resh
influence the image hanproduced. han han
h t o f Zes h t o f Zes projectiles, with the potentialhto t o f Zesserious
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pyrig to CT, the hole in the MRI scanner
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injury or death to patients
C
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long time to be acquired and the scanner is noisy. MRI compatible metallic objects should be taken
Patients who are claustrophobici or unable to lie still into the MRI scanner room.
s h hi hi
for prolonged periodsnmay Q e
urnot be able to tolerate • n
The Q ures fields can interfere with some
magnetic n Q ures
ha ha Zesh
a
a MRI.
h t o f Zes h t o f Zes electronic devices, such as certain h t o fpacemakers and
o p y rig o p y rig o p y rig must be checked
C
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C cochlear implants. C
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which provide different types of information. The
or staff member with one of them can enter the
science behind the different types of sequence is
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complex and does not need u r e
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a n Q n Q n Q
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T2 sequences are useful for showing
and therefore areas of oedema. • These can result in heating of tissues and
structures. Usually, the body can dissipate the heat
h i hi hi
ures ures ures
Images can be acquired in various planes. However, with vasodilation. However, the potential for burns
n Q
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unlike CT, the images
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ri ri g
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MRI Scans • 543

shi shi shi
t of Zesh
an Q Ultrasound SCANS
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t of Zesh
an Q
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t of Zesh
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yrigh
Cop Ultrasound.............................558 Pelvic p yrigh
CoUltrasound............................562 Cop yrigh
Neck Musculoskeletal Ultrasound.........564
Chest Ultrasound............................558 FAST Scanning..................................563 Ultrasound Guided Procedures.....564
s hi hi resh
i
Qure ures Qu
Abdominal Ultrasound.
an..................560 an Q
Vascular Ultrasound.......................563
shan
t of Zesh t of Zesh of Ze
yrigh yrigh ight
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What is it and how is it allows the velocity to be calculated (the angle
between the ultrasound beam and the direction
performed? n Qureshi of flow also
n Q
hi
ures needs to be measured). The velocity n Q ures
hi
sha
f Zevery
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f Zes a stenosis. Doppler also provides sha of
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rig pyrig rig a of
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(which Coimages. Copy and direction
the flow in terms of amplitude
The ultrasound waves are produced by the ultrasound (waveform) and the appearance of the waveform
transducer and travel as a beam through the body. can be a useful indicator of pathology.
When they come across a boundary es h i between two hi
esusually hi
n Qurcan Ultrasound
n Quris a quick and well-tolerated n Q ures
different tissues, the
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h t f Zthe radiology
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back Copused department using the Cop
departmental ultrasound
machines. The patient can be scanned on the
to make the images. The amplitude of the reflected
ultrasound couch or in a trolley/bed depending on
waves, combined with the time they take to return to
their clinical condition. Portable ultrasounds can
the transducer, are used to generate
r e s hi the image. eshi who are unable to travel to Qureshi
n Qu be usedQ
n urpatients
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liquid waves ultrasound machines produce Copyinferior images
are scattered by gases. Therefore, gel is used as an compared with the departmental machines, meaning
interface between the transducer and the patient the examination is usually less comprehensive.
Scans
USS
to improve the transmission of ultrasound waves
u shibody.
rethe resh
The patient may
u
i have to move into different positions
resh
i
between the transducer
a n Q
and Q
duringn the examination; therefore, patient mobility n Qu
o f Zesh o f esha
Zand o f
ha
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t
righthree main types of ultrasound imaging:
righ t cooperation are igh t
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opyr through, the fewer
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Copy Copy ultrasound waves have toCtravel
•• B-mode (brightness mode) produces real-time 2
that are returned and detected. Therefore, it is easier
dimensional images (figure 6A). The amplitude
to image superficial rather than deep structures.
of the echo for each pixel is represented using a
i i image quality in overweight and eshi
resh ultrasound image. resh
Additionally, the
u
grey-scale. This is theQstandard Q u ur
e s h n
ademonstrated obese
e s h anpatients is often reduced and occasionally
e s h an Qa
o Z
Pathology fmay
ightor
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ighint of Zdiagnostic scan is not possible rifigthe f Z is too
ht opatient
p
they rsize shape of a structure, or an p y r
alteration p y
Co Co large. Co
its brightness (echogenicity).
•• Colour flow imaging is used to show the direction Use of ionising radiation
of flow and provides an estimationhi of velocity
eshi no ionising radiation, it has no Qureshi
(figure 6B). The h flown Q ures is usually blood
assessed n Q
Ultrasound uruses n
a
es any esha sha
euse
o f Z o f Zsignificant adverse effects and is safeo f Z
to in all
ri ht right right
flowgbut can be flowing or moving substance,
o p y
C such as a jet of urine entering the bladder C o p y patients. C o p y
from the ureter. The colour flow information is
superimposed on the B-mode image. In general, Main indications
red indicates flow towardssthe hi ultrasound h i hi
ures ures
As mentioned above, ultrasound travels well through
transducer, bluehaway, n Q ure yellow/green turbulent
and n Q n Q
a eshaand liquid. It is therefore most ouseful a
Zesh and
solid for
h t o f Zes in velocity and/or the direction
flow. Alterations h t o
off Zimaging solid organs, such as the h t f kidneys
liver,
pyrigcan indicate pathology.
Coflow Copy
rig rig
Copy such as the bladder.
spleen, and fluid filled structures,
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Nuclear Medicine Scans • 565

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Fluoroscopy • 571
CASE INDEX
Orthopaedic X-Rays Chest X-Rays Abdominal X-Rays
Lumbar degenerative changes Primary spontaneous pneumothorax.............. 29 Normal AXR.............................................................189
(case about cauda equina syndrome)............367 Tension pneumothorax......................................... 37 Small bowel obstruction.....................................195
Anterior wedge compression fracture............375 Normal CXR................................................................ 45 Large bowel obstruction.....................................203
Cervical spine fracture.........................................383 Collapsed right upper lobe................................... 53 Sigmoid volvulus....................................................211
Anterior shoulder dislocation............................391 Pleural effusion........................................................ 61 Pneumoperitoneum.............................................217
Supracondylar fracture........................................399 Hilar mass.................................................................. 69 Thumbprinting.......................................................225
Salter Harris fracture............................................407 Apical lung mass with rib destruction............. 77 Pneumatosis intestinalis and
Scaphoid fracture..................................................415 Multiple pulmonary metastases........................ 85 pneumoperitoneum.............................................233
Colles’ fracture........................................................423 Sarcoidosis................................................................. 91 Constipation............................................................241
Hip joint osteoarthritis........................................429 Ingested foreign body............................................ 97 Splenomegaly.........................................................247
Perthes’ disease......................................................435 Left lower lobe consolidation............................105 Gallstones................................................................255
Pelvic fracture.........................................................443 Possible pulmonary embolism..........................113 Renal calculi.............................................................263
Slipped upper femoral epiphysis......................451 Congestive cardiac failure...................................121 Chronic pancreatitis..............................................269
Intracapsular fracture of the neck Free subdiaphragmatic gas................................129 Uterine fibroid........................................................277
of femur....................................................................457 Mediastinal mass..................................................137 Splenic artery aneurysm.....................................285
Extracapsular fracture of the neck Lung abscess and pneumonia...........................145 Abdominal aortic aneurysm..............................293
of femur....................................................................465 Sclerotic bone metastases..................................299
Left lower lobe collapse and humeral
Paediatric aggressive bone lesion....................473 fracture......................................................................153 Ankylosing spondylitis.........................................305
Lipohaemarthrosis/Tibial plateau Incorrectly placed NG tube.................................161 Ingested foreign bodies.......................................313
fracture/Fibular fracture.....................................481
Pericardial effusion...............................................169 Duodenal atresia/Double-bubble sign...........321
Knee joint osteoarthritis.....................................489
Calcified pleural plaques.....................................175 Pneumatosis intestinalis.....................................327
Tibial and fibular shaft fractures......................497
Osteomyelitis/Periosteal reaction...................505
Bonus Chest X-Rays Bonus Abdominal X-Rays
Bimalleolar fracture/Dislocation of
Apical pneumothorax..........................................579 Gallstones................................................................613
the ankle joint.........................................................513
Normal CXR..............................................................581 Migrated IUCD........................................................615
Free subdiaphragmatic gas................................583 Large bowel obstruction.....................................617
Bonus Orthopaedic X-Rays
Pleural effusion......................................................585 Normal AXR.............................................................619
5th metacarpal fracture......................................637
Misplaced NG tube...............................................587 Small bowel obstruction/
Normal foot X-ray..................................................639
Left lower lobe collapse.......................................589 Pneumoperitoneum.............................................621
Healed fractures (rib/clavicle/coracoid)/
Pericardial effusion...............................................591 Thumbprinting/Toxic dilatation of
Pneumothorax........................................................641
Misplaced NG tube and dilated small bowel the transverse colon.............................................623
Normal elbow X-ray..............................................643
loops under Bilateral nephrostomies......................................625
Slipped upper femoral epiphysis......................645
the diaphragm........................................................593 Thumbprinting.......................................................627
Lisfranc injury..........................................................647
Left lower lobe consolidation............................595 Necrotising enterocolitis.....................................629
Distal radial (with dorsal angulation)
Right middle lobe consolidation.......................597 Paget’s disease........................................................631
fracture......................................................................649
Right upper lobe collapse...................................599 Splenomegaly.........................................................633
Weber C ankle fracture........................................651
Right upper lobe consolidation/Basal Intra-abdominal surgical swab/
5th metatarsal fracture.......................................653
atelectasis................................................................601 Small bowel obstruction.....................................635
Lipohaemarthosis..................................................655
Right lower lobe consolidation.........................603
Anterior shoulder dislocation............................657
Free subdiaphragmatic gas................................605
Comminuted mid shaft femoral fracture......659
Lingula consolidation...........................................607
Comminuted humeral surgical neck
Left upper lobe collapse.......................................609
fracture......................................................................661
Pneumomediastinum..........................................611
Monteggia fracture...............................................663
Posterior shoulder dislocation..........................665
Rheumatoid arthritis............................................667
Distal radial (minimally displaced)
fracture......................................................................669
Pathological shaft of femur fracture...............671
Acromio-clavicular joint disruption................673
5th metatarsal fracture.......................................675
Enchondroma (lytic bone lesion)......................677
Distal radial (buckle) fracture............................679
Intracapsular fracture of the femoral neck.... 681
Triquetral fracture.................................................683
Weber A ankle fracture........................................685
Radial head fracture.............................................687
Trimalleolar fracture.............................................689
Extracapsular (subtrochanteric) fracture
of the femoral neck...............................................691
Supracondylar fracture........................................693
Case Index • 695

INDEX
Page numbers followed by f indicate large bowel obstruction, 203f, Ottawa Ankle Rules, 516
figures. 204f, 205–210, 617f, 618f Weber classification of lateral
necrotising enterocolitis, 327f, malleolus fractures, 363, 517
AAA, see Abdominal aortic aneurysm 328f, 331–332, 629f, 630f talar shift, 518–519
ABCDD mnemonic, chest X-ray nephrostomy complications, 625f, triplane fracture, 414
assessment 626f Ankle jerk, spinal injury assessment, 380
airway, 19–20 Paget’s disease, 631f, 632f Ankylosing spondylitis
breathing, 20 pancreatitis, 269f, 270f, 271–276 abdominal X-ray, 305f, 306f, 309
cardiac and mediastinum, 20, 21f pneumoperitoneum, 217f, 218f, clinical presentation, 308
delicates, 21 219–224, 234f, 621f, 622f extra-spinal joint involvement, 310
diaphragm, 20–21, 22f renal calculi, 263f, 264f, 265–268 hepatic fibrosis, 311
ABCDE assessment, pelvic fracture, 446 sigmoid colon volvulus, 211f, 212f, treatment, 311–312
ABCDEF mnemonic, pulmonary oedema 213–216 Anterior interosseous nerve (AIN)
small bowel obstruction, 195f, injury following supracondylar
chest X-ray assessment, 25
196f, 197–202, 635f, 636f fracture, 404
Abdominal aorta, abdominal X-ray
splenic artery aneurysm, 285f, testing, 427
assessment, 185f
286f, 287–292 Aortic dissection, chest computed
Abdominal aortic aneurysm (AAA)
splenomegaly, 247f, 248f, 249–254, tomography, 534f
abdominal X-ray, 293f, 294f
633f, 634f Appendicitis, foreign body ingestion, 430
causes, 296
uterine fibroid, 277f, 278f, 279–284 Asbestos exposure, case example with
clinical findings, 296
checklist, 186 chest X-ray of pleural plaques, 175f, 176f,
computed tomography angiography, . 177–180
542f dose, 192–193, 523
indications, 192 Ascites, portal hypertension, 290
diameter, 297 Aspirin, pericardial effusion
management, 297 normal findings, 189f, 190f, 191–194,
619f, 620f management, 174
rupture imaging, 298 Atherosclerosis, abdominal aortic
Abdominal computed tomography projection, 181
small/large bowel differences, 193 aneurysm, 296
colonoscopy, 539f ATLS, see Advance Trauma Life Support
haematuria, 541f systematic review, 181–185
Abscess, see Lung abscess; Pancreatic Avascular necrosis
haemorrhage, 537f hip, see Perthes’ disease
indications, 535 abscess
Achilles tendon, rupture, 517 scaphoid, 419
renal tract calculi, 540f Axillary nerve, injury in shoulder
sepsis, 536f Acute pancreatitis
causes, 273 dislocation, 396
trauma, 535f
complications, 276
tumour staging, 538f Babinski sign, 304
management, 275
Abdominal ultrasound, 559f, 560f Back pain
pleural effusion induction, 66
Abdominal X-ray management, 374
ultrasound for gallstones, 274
adequacy, 181 red flags, 308
Adhesions, small bowel obstruction, 200
case examples Bamboo spine, ankylosing spondylitis, 309
Advance Trauma Life Support (ATLS),
abdominal aortic aneurysm, 293f, . Barium follow-through, 576
446–447, 478
294f, 295–298 AIN, see Anterior interosseous nerve Barium swallow
ankylosing spondylitis, 305f, 306f, Alcoholism constipation induction, 246
307–312 acute pancreatitis, 273 principles, 572
bone metastasis, 299f, 300f, chronic pancreatitis, 272 small bowel obstruction diagnosis, 202
301–304 lung abscess risk factor, 149 views, 573f, 574f, 575f
bowel ischaemia, 233f, 234f, Allergy, contrast agents, 523 Bat’s wing consolidation, 122f
235–240, 627f, 628f AMPLE assessment, 447 Bell classification, necrotising
colitis, 225f, 226f, 227–232 Anal fissure, constipation, 245 enterocolitis, 332
constipation, 241f, 242f, 243–246 Anaphylaxis, breathlessness, 34 Bennett’s fracture, 364
duodenal atresia, 321f, 322f, Anatomical snuff box, pain and scaphoid Biliary colic, gallstone presentation, 259
323–326 fracture, 418 Blood culture, necrotising enterocolitis,
foreign body ingestion, 313f, 314f, Ankle 331
315–320 medial clear space, 518 Blood gas, venous central line, 167–168
gallstones, 255f, 256f, 257–262, orthopaedic X-ray Bone metastasis
613f, 614f assessment, 362f, 363f abdominal X-ray, 299f, 300f
inflammatory bowel disease, 623f, fracture with talar shift, 651f, 652f causes, 302
624f malleolar fracture case examples, clinical findings, 302
intrauterine contraceptive device 513f, 514f, 515–520, 685f, 686f, spinal cord compression
migration, 615f, 616f 689f, 690f management, 304
696 • Index
INDEX
Bone scan placement verification, 167–168 pulmonary oedema, 121f, 122f,
principles, 565, 568f, 569 Chance fracture, 364, 379 123–128
prostate cancer staging, 302–303 Chest computed tomography, see also sarcoidosis of lung, 91f, 92f, 93–96
radiation dose, 566 Computed tomography pulmonary tube and line displacement, 161f,
Bony Bankart lesion, 397 angiography 162f, 163–168, 587f, 588f, 593f, 594f
Bowel ischaemia aortic dissection, 534f checklist, 28
abdominal X-ray, 233f, 234f, 235–240 indications, 531 consolidation causes, 108, 117, 122f,
acute versus chronic, 240 lobar lung collapse, 532 162f
case examples with abdominal X-ray, lung parenchyma assessment, 532f dose, 48–49
233f, 234f, 235–240, 627f, 628f pulmonary nodule, 531f indications, 48
computed tomography, 237, 239 trauma, 533f inspiration during, 18–19
management of acute disease, 237 Chest drain lines and tubes, 22f
pneumatosis intestinalis, 236, 238 Seldinger technique, 68 lung collapse, see Lobar lung collapse
Bowel obstruction tension pneumothorax, 44 lymphadenopathy, 94
abdominal X-ray assessment, 182, 183f Chest ultrasound, 558, 559f patient details, 18
case examples with abdominal X-rays Chest X-ray penetration assessment, 19
large bowel obstruction, 203f, 204f, abnormality assessment, 19 pleural effusion, 25f
205–210, 617f, 618f calcification causes, 180 pneumonia, 23, 24f, 25
small bowel obstruction, 195f, case examples pneumothorax, 25f
196f, 197–202, 621f, 622f, 635f, asbestos exposure and pleural projection, 17f, 18
636f plaques, 175f, 176f, 177–180 pulmonary oedema, 25f
central loops in small bowel foreign body ingestion, 97f, 98f, review
obstruction, 198 99–104 ABCDD mnemonic
foreign body ingestion, 320 lobar collapse airway, 19–20
pseudo-obstruction versus right upper lobe collapse, 53, breathing, 20
mechanical large bowel obstruction, 206 54f, 55–60, 599f, 600f cardiac and mediastinum, 20, 21f
small/large bowel differences on left lower lobe collapse, 153f, delicates, 21
X-ray, 193 154f, 155–160, 589f, 590f diaphragm, 20–21, 22f
stenting of large bowel lung abscess, 145f, 146f, 147–152 summarisation, 23
Breast cancer lung cancer rotation, 18f
lobar lung collapse, 156 hilar mass, 69f, 70f, 71–76 Cholecystitis, gallstone presentation, 259
sclerotic bone metastasis, 302 metastasis sites, 74–75 Chronic myeloid leukaemia,
Breathlessness, differential diagnosis, 34 Pancoast tumour, 77f, 78f, 79–84 splenomegaly, 252
Bronchiectasis, pneumonia complication, pulmonary metastases, 85f, 86f, Chronic obstructive pulmonary disease
111–112
87–90 (COPD), 20, 603f, 604f
Bronchoscopy, foreign body retrieval, 104
mediastinal mass, 137f, 138f, Chronic pancreatitis, abdominal X-ray,
Burst fracture, 364
139–141 269f, 270f
normal findings, 46f, 47–52 Clavicle, see Shoulder
Caecum, volvulus, 213–214, 216
pericardial effusion, 169f, 170f, Clips, see Sterilisation clips
CAP, see Community acquired pneumonia
591f, 592f Cocksackie virus, pericardial effusion
Cardiothoracic ratio
pleural effusion, 61f, 62f, 63–68, induction, 172
congestive cardiac failure, 125
585f, 586f Coffee bean sign, sigmoid colon volvulus,
measurement, 50–51
pneumomediastinum, 611f, 612f 215
Carotid artery, Doppler ultrasound, 558,
pneumonia, 105f, 106f, 107–112, Colchicine, pericardial effusion
559f
595f, 596f, 597f, 598f, 601f, 602f, management, 174
Carpal tunnel, anatomy, 422
603f, 604f, 607f, 608f Colitis
Cauda equina syndrome
clinical features, 370 pneumoperitoneum, 129f, 130f, case example with abdominal X-ray,
decompression surgery, 373 131–136, 583f, 584f 225f, 226f, 227–232
lumbar spine X-ray, 367f, 368f pneumothorax causes, 228
magnetic resonance imaging, 372, primary spontaneous, 29f, 30f, ulcerative colitis, see Inflammatory
550f 31–36 bowel disease
physical examination, 371 small left apical pneumothorax, Colles’ fracture, 364, 423f, 424f, 425–428
Cavitating tumour, lung, 148 579f, 580f Colon cancer
Central cord syndrome, 382 tension pneumothorax, 37f, 38f, colonoscopy, 209
Central line 39–44 large bowel obstruction, 207
chest X-ray, 22f pulmonary embolism, 113f, 114f, lobar lung collapse, 156
insertion, 166–167 115–120, 581f, 582f Colon, see Large bowel
Index • 697
INDEX
Colonoscopy, 209, 539f Continuous positive airway Duodenum, volvulus, 213
Community acquired pneumonia (CAP) pressure (CPAP), pulmonary oedema DVT, see Deep vein thrombosis
case examples, 595f, 596f, 601f, 602f management, 128 Dysmenorrhoea, uterine fibroids, 281
pathogens, 110 Contrast agents
scoring, 111 computed tomography ECG, see Electrocardiogram
Compartment syndrome, 402, 486, 503 allergy, 523 Elbow
Computed tomography (CT) metformin patient precautions, 524 anatomy, 405
abdominal aortic aneurysm rupture nephropathy induction, 523–524 anterior interosseous nerve injury, 404
imaging, 298 types, 523 effusion X-ray, 337f, 687f, 688f, 693f,
abdominal CT, 535f, 536f, 537f, 538f, gadolinium for magnetic resonance 694f
539f, 540f, 541f imaging, 544 orthopaedic X-ray
angiography, 542f Contrast enema, 576f assessment, 350, 351f, 352f, 353f, 403
bone tumour, 479 Contrast swallow, see Barium swallow normal findings, 643f, 644f
bowel ischaemia, 237, 239 COPD, see Chronic obstructive pulmonary radial head fracture, 687f, 688f
cancer staging, 159 disease supracondylar fracture
cervical spine, 344f, 388–389, 530f Costophrenic angle, blunting, 30f, 62f case examples, 399f, 400f,
chest CT, 531f, 532f, 533f, 534f CPAP, see Continuous positive airway 401–406, 693f, 694f
contraindications, 524 pressure deformities following, 405–406
contrast agents Cremasteric reflex, spinal injury Gartland classification, 353, 403
allergy, 523 assessment, 380 ossification centres, 351, 353f
metformin patient precautions, 524 CRITOE acronym, ossification centres, Electrocardiogram (ECG), congestive
nephropathy induction, 523–524 351, 353f cardiac failure, 127
types, 523 Crohn’s disease, see Inflammatory bowel Emergency surgery, prerequisites,
dose, 523 disease 463–464
foreign body ingestion, 101 CTPA, see Computed tomography Emphysema, lung abscess risk factor, 149
head CT, 525, 526f, 527f, 528f, 529f pulmonary angiography Empyema
indications, 524 Cubitus varus, supracondylar fracture, 406 pleural calcification, 178
lung abscess, 150–151 CURB 65, pneumonia scoring, 111 pneumonia complication, 111–112
lung cancer, 75 Enchondroma, location and age, 480
orthopaedic CT, 530f, 531 Danozol, uterine fibroid management, 283 Endoscopic retrograde
pancreatic abscess, 276 Deep vein thrombosis (DVT) cholangiopancreatography (ERCP), acute
pelvis fracture, 446 complications, 119–120 pancreatitis, 273
PET/CT, see Positron emission pneumonia complication, 111–112 Endoscopy
tomography prophylaxis in ulcerative colitis flare battery stuck in mid-oesophagus, 319
pleural calcification, 179 management, 232 complications, 320
pneumoperitoneum, 132–133, ultrasound, 118 Endotracheal tube (ET)
223–224 Demyelination, magnetic resonance chest X-ray, 22f
principles, 521f imaging, 547f positioning, 166
pulmonary metastases, 90 Dermatome, spinal injury assessment, Enema, sigmoid colon volvulus
scanner, 521f 380, 389–390 management, 216
sigmoid colon volvulus, 216 Diarrhoea, bloody diarrhoea assessment, Enterocolic fistulae, necrotising
tibial plateau fracture, 488 229 enterocolitis, 334
windowing, 522f, 523 Dislocation, 339, 340f Epilepsy, magnetic resonance imaging, 548
Computed tomography pulmonary Disseminated intravascular coagulation, ERCP, see Endoscopic retrograde
angiography (CTPA) necrotising enterocolitis, 334 cholangiopancreatography
pleural effusion, 67 Diverticulitis, stricture formation, 208 ET, see Endotracheal tube
pulmonary embolism, 531f Docusate sodium, constipation Ewing’s sarcoma
Congestive cardiac failure management, 245 differential diagnosis, 477
assessment, 117 Double bubble sign, 322f location and age, 480
chest X-ray findings, 114–115 Down’s syndrome, duodenal atresia, 325
clinical features, 114 Duodenal atresia Faecal loading, see Constipation
Constipation abdominal X-ray, 321f, 322f, 325
FAST, see Focused assessment with
ankylosing spondylitis, 306f associated conditions, 325
sonography in trauma
bone metastasis, 302 case example with abdominal X-ray,
Femoral vein, ultrasound, 563f
causes, 244–245 321f, 322f, 323–326
Femur
complications, 246 double bubble sign, 322f
neck fracture, see Hip
imaging, 241f, 242f, 245–246 management, 326
management, 245 signs and symptoms, 324 shaft fracture X-rays, 339f, 659f, 660f,
tenesmus, 244 stenosis similarity, 324 671f, 672f
698 • Index
INDEX
Fibula, see also Knee cholecystitis management, 262 haemorrhage, 525, 526f, 527
shaft fracture case example, 497f, 498f, clinical presentation, 259 hydrocephalus, 526f, 528
499–504 risk factors, 258 indications, 525, 527
Finger, X-ray ultrasound, 274, 560f, 561f mass effect, 527
bone lesion in proximal phalanx, 677f, Garden classification, hip fractures, 359, 461
space-occupying lesions, 527f
678f Garland’s triad (1, 2, 3 sign), 96 Head magnetic resonance imaging
lucent lesion, 338f Gartland classification, supracondylar congenital abnormalities, 549
subluxation versus dislocation, 339, 340f fracture, 353, 403 demyelination, 547f
views, 335f Gas, see also Pneumoperitoneum; epilepsy, 548
Fish bone, X-ray findings of ingestion, 103 Pneumothorax indications, 544
Fistula, Crohn’s disease, 230 pneumatosis intestinalis, 236, 238 pituitary, 548
FLAIR, see Fluid attenuation recovery subdiaphragmatic, 22f, 129f, 130f, space occupying lesions, 548f
Fluid attenuation recovery (FLAIR), 547f 131–136, 605f, 606f stroke, 546f
Fluid resuscitation, ulcerative colitis flare Gastric tube, duodenal atresia, 326 vascular abnormalities, 549
management, 232 Genitourinary scan weighted images, 545f
Fluid therapy principles, 565 Heparin-induced thrombocytopaenia (HIP),
duodenal atresia, 26 radiation dose, 566 119
necrotising enterocolitis, 332–333 renal cortex assessment, 567–568 Hepatic fibrosis, ankylosing spondylitis, 311
Fluoroscopy Glenohumeral joint, see Shoulder Hereditary spherocytosis, splenectomy, 253
barium follow-through, 576 Globular heart, pericardial effusion chestHilar mass, case example, 69f, 70f, 71–76
barium swallow, see also Barium X-ray, 174 Hill Sachs lesion, 365, 397
swallow Glycerol suppository, constipation Hilum overlay sign, mediastinal mass, 142
principles, 572 management, 245 HIP, see Heparin-induced thrombocytopaenia
views, 573f, 574f, 575f Glyceryl trinitrate (GTN), pulmonary Hip
contraindications, 572 oedema management, 128 ankylosing spondylitis, 310–311
contrast enema, 576f Goitre avascular necrosis case example, 435f,
indications, 572 mediastinal mass differential 436f, 437–442
principles, 571 diagnosis, 142 femur neck fracture
radiation dose, 572 ultrasound, 558f case examples
tubogram, 576, 577f Golden S sign, 26f, 54f, 59 extracapsular fracture, 465f,
Focused assessment with sonography in Growth plate 466f, 691f, 692f
trauma (FAST), 448, 563 fracture intracapsular fracture, 457f,
Foot, metatarsal fracture, 639f, 640f, growth disturbances, 412 458f, 459–464, 681f, 682f
647f, 648f, 653f, 654f, 675f, 676f management, 413 Garden classification, 359, 461
Foreign body ingestion Salter Harris classification, 364, management, 462–463, 470–471
abdominal X-ray, 313f, 314f 408f, 411–412 mechanism of injury, 468
age groups, 316 physis components, 410 mortality, 471–472
battery stuck in mid-oesophagus, 319 GTN, see Glyceryl trinitrate overview, 462
case examples Gunstock deformity, supracondylar 2 to 4 parts classification, 360, 470
abdominal X-ray, 313f, 314f, fracture, 406 indications, 433–434
315–320 Gustilo classification, open fractures, 504 orthopaedic X-ray assessment, 357f,
chest X-ray, 97f, 98f, 99–104 358f, 359f, 360
oropharynx trapping, 317 Haematuria, abdominal computed osteoarthritis
physical examination, 318 tomography, 541f case example, 336f, 429f, 430f,
pneumoperitoneum induction, 135 Haemolytic anaemia, gallstone risks, 258 431–434
Foreign body inhalation, lobar lung Haemoptysis, differential diagnosis, 72 X-ray, 336f
collapse, 157 Haemorrhoids, constipation association, parts classification of neck of femur
Functional ileus, small bowel obstruction 246 fractures, 360
differentiation, 199 Haemothorax, pleural calcification, 18 Perthes’ disease, 442
Hampton’s hump, 117 septic arthritis distinguishing from
Gadolinium, precautions, 544 Hand, see also Finger irritable hip, 512
Galeazzi fracture, 364 erosive arthropathy, 667f, 668f slipped upper femoral epiphysis case
Gallbladder, abdominal X-ray metacarpal fracture, 637f, 638f examples, 451f, 452f, 453–456, 645f,
assessment, 185 Hangman’s fracture, 364 646f
Gallstones Hartmann’s procedure, 210 surgical approaches, 434
acute pancreatitis, 273 Head computed tomography Trendelenburg sign, 432–433
case examples with abdominal X-ray, contrast enhanced imaging, 528, 529f Hippocratic method, shoulder dislocation
255f, 256f, 257–262, 613f, 614f grey-white matter differentiation, 528f reduction, 395
Index • 699
INDEX
Holstein Lewis fracture, 365 failure, see Renal failure right upper lobe, 26, 53, 54f, 55–60,
Hormone replacement therapy (HRT), stones, see Renal calculi 599f, 600f
pulmonary embolism risks, 116 ultrasound, 560, 561f clinical presentation, 56
Horner’s syndrome, lung cancer, 80–81 Klein’s line, 366 computed tomography, 532
Hounsfeld unit (HU), 522 Knee foreign body induction, 102
HPOA, see Hypertrophic pulmonary aspiration, 487 Low-molecular-weight heparin,
osteoarthropathy bone tumour case study, 473f, 474f, pulmonary embolism management, 119
HRT, see Hormone replacement therapy 475–480 Luftsichel sign, 26f
HU, see Hounsfeld unit magnetic resonance imaging, 555f Lumbar spine, see Cauda equina
Hydronephrosis, abdominal aortic orthopaedic X-ray assessment, 360, syndrome; Spine
aneurysm, 296 361f Lung
Hypercalcaemia osteoarthritis case example, 489f, parenchyma assessment with chest
constipation, 244 490f, 491–496 computed tomography, 532f
renal calculi, 266 tibial plateau fracture case studies, X-ray, see Chest X-ray
Hypertension, splenic artery aneurysm 481f, 482f, 483–488, 655f, 656f Lung abscess
risks, 290 X-ray features, 494–495 aetiology, 150–151
Hypertrophic pulmonary osteoarthropathy Knee replacement, 496 chest X-ray findings, 145f, 146f
(HPOA), lung cancer, 74 Kocher’s method, shoulder dislocation differential diagnosis, 148
Hypotension reduction, 395 risk factors, 149
pericardial effusion, 173 treatment, 151–152
tension pneumothorax, 41 Lactulose, constipation management, 245 Lung cancer
Hypoxia, tension pneumothorax, 41 Large bowel case examples with chest X-rays
Hysterectomy, uterine fibroid abdominal X-ray assessment, 182f hilar mass, 69f, 70f, 71–76
management, 284 abscess, 334 metastasis sites, 74–75
constipation and perforation, 246 Pancoast tumour, 77f, 78f, 79–84
Idiopathic thrombocytopaenic purpura, obstruction, 182, 183f, 617f, 618f pulmonary metastases, 85f, 86f,
Splenectomy, 253 obstruction, see Bowel obstruction 87–90
Inflammatory bowel disease sigmoid colon volvulus, 211f, 212f, consolidation on chest X-ray, 108
abdominal X-ray findings, 623f, 624f 213–216 lobar lung collapse, 156
Crohn’s disease versus ulcerative small bowel differences on X-ray, 193 Lung collapse, see Lobar lung collapse
colitis, 230 thumbprinting, 185f, 185 Lung ventilation/perfusion scan
flares Laryngeal cancer, asbestos exposure, 179 principles, 565
toxic megacolon assessment, 231 Left lower lobe collapse, 26f, 153f, 154f, pulmonary embolism, 566, 567f
ulcerative colitis management, 232 155–160 radiation dose, 566
gallstone risks with Crohn’s disease, 258 Left upper lobe collapse, 26, 58, 609f, 610f Lymphadenopathy
pneumoperitoneum induction, 135 Levonorgestrel intrauterine device, chest X-ray findings, 94
renal calculi, 266 uterine fibroid management, 283 sarcoidosis of lung, 91f, 92f, 94
stricture formation, 208 Lipohaemarthrosis Lymph node, calcification in upper left
Infliximab, ankylosing spondylitis fracture association, 484 quadrant of abdominal X-ray, 288
management, 312 tibial plateau fracture case studies, Lymphoma
Interosseus nerve, testing, 427 481f, 482f, 483–488, 655f, 656f hilar mass, 73
Interventional radiology, bowel Lisfranc injury, 365 mediastinal mass differential
ischaemia, 237 Liver diagnosis, 142–143
Intra-aortic balloon pump, pulmonary abdominal X-ray assessment, 185 splenomegaly, 252–253
oedema management, 128 ultrasound, 560f, 561f
Intrauterine contraceptive device (IUCD), Liver transplantation, splenic artery Magnetic resonance
X-ray of migration, 615f, 616f aneurysm risks, 290 cholangiopancreatography (MRCP), 261,
IUCD, see Intrauterine contraceptive Lobar lung collapse 553f
device cancer association, 156 Magnetic resonance imaging (MRI)
causes, 57 bone tumour of knee, 479
Jaundice, gallstone presentation, 259 chest physiotherapy, 60 cauda equina syndrome, 372
Jefferson fracture, 365, 388 chest X-ray cervical spine, 388–389
Jones fracture, 365 left lower lobe, 26f, 153f, 154f, contraindications, 544
155–160, 589f, 590f gadolinium contrast agent, 544
Kerley B lines, 25f left upper lobe, 26, 58, 609f, 610f head MRI
Kidney right lower lobe, 27f congenital abnormalities, 549
abdominal X-ray assessment, 185 right middle lobe, 27f demyelination, 547f
700 • Index
INDEX
epilepsy, 548 Myelofibrosis, splenomegaly, 252 fracture
indications, 544 Myocardial infarction, pericardial appearance, 336f
pituitary, 548 effusion induction, 172 descriptors, 338–339
space occupying lesions, 548f Myocardial perfusion scan names, 364–366
stroke, 546f principles, 565, 567 hip assessment, 357f, 358f, 359f, 360
vascular abnormalities, 549 radiation dose, 566 knee assessment, 360, 361f
weighted images, 545f Myomectomy, uterine fibroid pelvis assessment, 357f, 358f, 359f, 360
indications, 544 management, 284 projection, 335f
knee, 555f Myotome, spinal injury assessment, 380, shoulder assessment, 348, 349f, 350f
osteomyelitis, 510 390 spine
Pancoast tumour, 83 cervical spine assessment, 340–341,
principles, 543 Nasendoscopy, foreign body retrieval, 104 342f, 343f, 344f, 345f
safety, 543 Nasogastric (NG) tube thoracolumbar spine assessment,
scanner, 543f acute pancreatitis, 275 345, 346f, 347f
small bowel, 554f chest X-rays, 22f, 161f, 162f, 165, 587f, subluxation versus dislocation, 339, 340f
spinal cord compression, 303 588f, 593f, 594f systematic review, 336f, 337f, 338f
spine MRI placement, 164 technical adequacy, 336
cauda equina syndrome, 550f small bowel obstruction wrist assessment, 354f, 355f, 356f
indications, 549 management, 201 Ossification centres, elbow, 351, 353f
normal findings, 549f Necrotising enterocolitis Osteoarthritis
spinal canal stenosis, 552f abdominal X-ray, 327f, 328f, 331–332, hip case example, 336f, 429f, 430f,
spinal cord compression, 550, 551f 629f, 630f 431–434
spinal cord trauma, 553f Bell classification system, 332 knee case example, 489f, 490f, 491–496
uterine fibroids, 282 complications, 333–334 severity assessment, 433
weighted sequences, 544 management, 332–333 X-ray features, 432
risk factors, 330
Maissonneuve injury, 365 Osteomyelitis
stricture formation, 208
Malaria, splenomegaly, 252 clinical findings, 508
Needle decompression, tension
Malleolus, see Ankle differential diagnosis, 477
pneumothorax, 38, 42, 44
Malrotation, duodenal atresia, 325 magnetic resonance imaging, 510
Nephrostomy, complications, 625f, 626f
Medial clear space, 518 management, 511
NG tube, see Nasogastric tube
Median nerve, injury in Colles’ fracture, pathogens, 509
Nuclear medicine, see Bone scan;
426–427 tibia case example, 505f, 506f,
Genitourinary scan; Lung ventilation/
Mediastinum 507–512
perfusion scan; Myocardial perfusion
chest X-ray assessment, 20, 21f, 140 Osteophyte, knee arthritis, 494–496
scan; Positron emission tomography
gas, see Pneumomediastinum Osteosarcoma
mass, case example with chest X-ray, Obesity, gallstone risks, 258 location and age, 480
137f, 138f, 139–141 Oesophageal varices, portal hypertension pathological fracture, 158
mediastinitis and oesophagus foreign as cause, 291 Ottawa Ankle Rules, 516
body induction, 100 Oesophagus Ovarian cyst, ultrasound, 562f
Menorrhagia, uterine fibroids, 281 battery stuck in mid-oesophagus, 319
Mesothelioma, asbestos exposure, 179 fistula from foreign body ingestion, 320 Paget’s disease, X-ray findings, 631f, 632f
Metacarpal, fracture, 637f, 638f perforation from foreign body Pancoast tumour, see Lung cancer
Metal detector, ingested coin detection, 100 ingestion, 320 Pancreas
Metastasis, lung cancer, 74–75 Open fracture abdominal X-ray assessment, 185
Metatarsal, fracture, 639f, 640f, 647f, Gustilo classification, 504 annular pancreas, 324–325
648f, 653f, 654f, 675f, 676f management, 501–502 ultrasound, 560
Mitral regurgitation Opioids, constipation, 244 Pancreatic abscess, acute pancreatitis
calcification on X-ray, 180 Orthopaedic computed tomography, association, 276
pulmonary oedema, 126 530–531 Pancreatitis, see Acute pancreatitis;
Metformin, contrast agent precautions, 524 Orthopaedic X-rays, see also specific Chronic pancreatitis
Monteggia fracture, 365 bones and joints Patella reflex, spinal injury assessment, 380
MRCP, see Magnetic resonance ankle assessment, 362f, 363f Pelvic ultrasound, 562f
cholangiopancreatography checklist, 366 Pelvis
MRI, see Magnetic resonance imaging elbow fracture
Mucus plug, lobar lung collapse, 157 assessment, 350, 351f, 352f, 353f bladder and urethral injuries, 449
Multiple myeloma, 158, 480 Gartland classification of case example, 443f, 444f, 445–450
Myasthenia, lung cancer, 74 supracondylar fracture, 353 computed tomography, 446
Index • 701
INDEX
management, 450 case examples with abdominal X-ray, chest X-ray findings, 25f, 108
mortality, 449 217f, 218f, 219–224, 234f, 583f, 584f, treatment, 128
types, 448–449 621f, 622f Pulmory infarction
orthopaedic X-ray assessment, 357f, causes, 134–135, 220 haemoptysis, 72
358f, 359f, 360 chest X-ray findings, 129f, 130f, lung abscess differential diagnosis, 148
tumour staging with computed 131–136 pleural effusion induction, 66
tomography, 538f post-operative, 136
Pericardial effusion, case examples with Pneumothorax Radial inclination, 355
chest X-ray, 169f, 170f, 591f, 592f breathlessness, 34 Radial nerve, testing, 427
Periosteal reaction case examples with chest X-rays Radius, see Elbow; Wrist
aggressive bone lesion, 476 primary spontaneous, 29f, 30f, Renal artery stenosis, pulmonary
osteomyelitis, 505f, 506f 31–36 oedema, 126
Peritonitis, pneumoperitoneum small left apical pneumothorax, Renal calculi
induction, 136 579f, 580f abdominal X-ray, 263f, 264f
Perthes’ disease tension pneumothorax, 37f, 38f, calcification in upper left quadrant of
differential diagnosis, 440 39–44 abdominal X-ray, 288
severity assessment, 441 chest X-ray findings, 25f computed tomography, 267–268, 540f
treatment, 441–442 evolution from simple pneumothorax, 40 management, 268
X-ray case example, 435f, 436f, pneumonia complication, 111–112 risk factors, 266
437–442 shoulder X-ray, 641f, 642f symptoms, 266
PET, see Positron emission tomography tension pneumothorax, 20 uric acid stones, 267
Phlebolith, 278f Portal hypertension, 290–291, 560 Renal failure
Physis, see Growth plate Positron emission tomography (PET) contrast agent nephropathy
Pituitary, magnetic resonance imaging, 548 indications, 420 induction, 523–524
Pleural calcification PET/CT pericardial effusion induction, 172
pulmonary oedema, 126
causes, 178 principles, 565
Renal tubular acidosis, renal calculi, 266
imaging, 177f, 179 radiation dose, 566
Retroperitoneal fibrosis, abdominal
Pleural effusion tumours, 569f
aortic aneurysm, 296
case examples with chest X-ray, 61f, Posterior interosseus nerve, testing, 427
Rheumatoid arthritis, hand X-ray, 667f, 668f
62f, 63–68, 585f, 586f Pregnancy
Right lower lobe collapse, 27f
chest X-ray findings, 25f pulmonary embolism evaluation, 118
Right middle lobe collapse, 27f
clinical signs and symptoms, 64 splenic artery aneurysm risks, 290
Right upper lobe collapse, 26, 53, 54f,
congestive cardiac failure, 125 X-ray safety, 14
55–60, 599f, 600f
draining, 68 Premature infants, necrotising
Rigler’s sign, 234f
exudate analysis, 64–65 enterocolitis, 330 Rolando’s fracture, 365
exudative effusion aetiology, 65–66 Prostate cancer Round atelectasis, asbestos exposure, 179
pneumonia complication, 111–112 bone metastasis, 299f, 300f, 301–304
transudate versus exudate effusions, 66 staging, 302–303 Sacroiliac joint, abdominal X-ray, 194
ultrasound, 559f Pulmonary artery hypertension Saddle anaesthesia, cauda equina
Pneumatosis intestinalis, differential hilar mass, 73 syndrome, 371
diagnosis, 236, 238 pulmonary embolism complication, Sail sign, 26, 27f, 154f
Pneumomediastinum, case example, 119–120 Salter Harris classification, growth plate
611f, 612f Pulmonary embolism fractures, 364, 408f, 411–412
Pneumonia breathlessness, 34 Sarcoidosis
case examples with chest X-rays, 105f, case examples with chest X-ray, 113f, . clinical presentation, 95–96
106f, 107–112, 595f, 596f, 597, 598f, 114f, 115–120, 581f, 582f differential diagnosis in lung, 78
601f, 602f, 603f, 604f, 607f, 608f complications, 119–120 hilar mass, 73
chest X-ray findings, 23, 24f, 25 lung ventilation/perfusion scan, 566, lung, 91f, 92f, 93–96
community acquired pneumonia 567f risk factors, 94–95
case examples, 595f, 596f, 601f, 602f pregnant patient evaluation, 118 Scaphoid, see Wrist
pathogens, 110 risk factors, 116 SCIWORA, see Spinal cord injury without
scoring, 111 treatment, 119 radiological abnormality
complications, 111–112 Pulmonary fibrosis, 96, 179 Segond fracture, 365
consolidation on chest X-ray, 108–109 Pulmonary oedema Seldinger technique, 68
pleural effusion induction, 65 case example with chest X-ray, 121f, Senna, constipation management, 245
Pneumoperitoneum 122f, 123–128 Septic arthritis, distinguishing from
abdominal X-ray assessment, 184f, 185f causes, 126 irritable hip, 512
702 • Index
INDEX
Shenton’s line, 366 magnetic resonance imaging, 550, 551f risk factors, 290
Short bowel syndrome, necrotising Spinal cord injury without radiological treatment, 292
enterocolitis, 334 abnormality (SCIWORA), 384 Splenomegaly
Shoulder Spinal cord trauma, magnetic resonance case examples with abdominal X-ray,
ankylosing spondylitis, 310 imaging, 553f 247f, 248f, 249–254, 633f, 634f
dislocation Spinal shock, 381 causes, 252
axillary nerve injury, 396 Spine, see also Cauda equina syndrome physical examination, 250
bony abnormalities with anterior back pain management, 374 portal hypertension, 290
dislocations, 397 cauda equina syndrome splenic artery aneurysm, 286f
instability following injury, 397–398 decompression surgery, 373 ultrasound, 560
reduction, 395 cervical spine computed tomography, Staphylococcus aureus, osteomyelitis
types, 394 530f association, 509
orthopaedic X-ray computed tomography of cervical Sterilisation clips
acromio-clavicular joint disruption, spine, 388–389 abdominal X-ray assessment, 186
673f, 674f magnetic resonance imaging of displacement, 248f
assessment, 348, 349f, 350f cervical spine, 388–389 Stomach, volvulus, 213
glenohumeral joint dislocation, orthopaedic X-ray Streptococcus pneumoniae, community
391f, 392f, 393–398, 657f, 658f central cord syndrome, 382 acquired pneumonia, 110
humeral neck fracture, 661f, 662f cervical spine Stroke
posterior dislocation, 665f, 666f assessment, 340–341, 342f, computed tomography of
SiADH, see Syndrome of inappropriate 343f, 344f, 345f haemorrhage, 525, 526f, 527
antidiuretic hormone secretion case example of fracture magnetic resonance imaging, 546f
Sickle cell anaemia, calcification in upper without trauma, 382f, 383f, Subluxation, 339, 340f
left quadrant of abdominal X-ray, 288 384–390 SUFE, see Slipped upper femoral epiphysis
Sigmoid colon volvulus lines for lateral X-ray Superior vena cava, stenting in Pancoast
tumour, 84
abdominal X-ray, 211f, 212f, 213–216 assessment, 387
Supracondylar fracture, see Elbow
contrast enema, 576f Chance fracture-associated
Syndrome of inappropriate antidiuretic
Sigmoidoscopy, sigmoid colon volvulus injuries, 379
hormone secretion (SiADH), lung cancer, 74
management, 216 Jefferson fracture, 388
Silhouette sign L1 fracture, 375f, 376f
Tachycardia, tension pneumothorax, 41
mediastinal mass, 142 level of sensation and fracture
Talus, shift, 518–519
pneumonia chest X-ray, 24f, 109 location, 380, 389–390
TB, see Tuberculosis
Silicosis, calcification on X-ray, 180 stable fracture, 376
Tenesmus, constipation, 244
Slipped upper femoral epiphysis (SUFE) thoracolumbar spine assessment,
Teratoma, mediastinal mass differential
case examples, 451f, 452f, 453–456, 345, 346f, 347f diagnosis, 142–143
645f, 646f Spine magnetic resonance imaging Thrombolysis, pulmonary embolism
clinical presentation, 454 cauda equina syndrome, 550f management, 119
contralateral slippage incidence, 455 indications, 549 Thumbprinting, colitis, 218
management, 456 normal findings, 549f Thurstand Holland fragment, 365
pathology, 454 spinal canal stenosis, 552f Thymoma, mediastinal mass differential
Trethowan’s sign, 455 spinal cord compression, 550, 551f diagnosis, 142–143
Small bowel spinal cord trauma, 553f Thyroid cancer, lobar lung collapse, 156
abdominal X-ray assessment, 182f Spleen Tibia, see also Knee
barium follow-through, 576 abdominal X-ray assessment, 185f osteomyelitis case example, 505f,
dilation in necrotising enterocolitis, congenital asplenia, 251 506f, 507–512
331–332 erythrocytes, 251 shaft fracture case example, 497f,
large bowel differences on X-ray, 193 lymphocyte production, 251 498f, 499–504
magnetic resonance imaging, 554f size, 251 Toxic megacolon, 231
obstruction, see Bowel obstruction Splenectomy Tranexamic acid, uterine fibroid
ultrasound, 561f indications, 253 management, 283
Smith’s fracture, 365, 427–428 management in post-operative Trauma, initial series X-rays, 447
Spinal canal stenosis, magnetic period, 254 Trendelenburg sign, 432–433
resonance imaging, 552f splenic artery aneurysm, 292 Trethowan’s sign, 366, 455
Spinal cord compression Splenic artery aneurysm Triplane fracture, 414
bone metastasis, 302–304 abdominal X-ray of calcification, 285f, Triquetral bone, see Wrist
cauda equina syndrome 286f, 288 Tuberculosis (TB)
decompression surgery, 373 pseudoaneurysm differentiation, 289 differential diagnosis, 89
Index • 703
INDEX
hilar mass, 73 Volar angulation, 355
pleural effusion induction, 66 Volar Barton’s fracture, 365
Tubogram, 576, 577f Volvulus
sigmoid colon volvulus, 211f, 212f,
Ulcerative colitis, see Inflammatory 213–216
bowel disease sites, 213
Ulna
distal fracture, see Wrist Wackenheim’s line, 366
shaft fracture, 663f, 664f Wall test, 308
Ulna variance, 355 Warfarin
Ultrasound scans initial prothrombotic effects, 119
abdominal aortic aneurysm, 297 pulmonary embolism management, 119
abdominal ultrasound, 559f, 560f Water skiing, pneumoperitoneum
B-mode, 557 induction, 135
chest ultrasound, 558, 559f Weber classification, malleolus fractures,
colour flow imaging, 557, 563f 363, 517, 686f
congestive cardiac failure Wegener’s granulomatosis, 148
echocardiogram, 127 Westermark’s sign, 114f
contraindications, 558 Wilm’s tumour, 89
deep vein thrombosis, 118 Wrist
Doppler imaging, 557–558, 559f carpal tunnel anatomy, 422
focused assessment with sonography orthopaedic X-ray
in trauma, 448, 563 assessment, 354f, 355f, 356f
gallstones, 260, 274 case examples
guided procedures, 564 Colles’ fracture, 423f, 424f,
indications, 557 425–428
musculoskeletal ultrasound, 564 distal radius fracture, 407f, 408f,
neck, 558f, 559f 409–414, 649f, 650f, 669f, 670f,
pelvic ultrasound, 562f 679f, 680f
pleural effusion, 67–68 scaphoid fracture, 415f, 416f
principles, 557 triquetral fracture, 356f, 683f,
reflection of waves, 558 684f
safety, 557 distal radius radiological
vascular ultrasound, 563f measurements, 428
Ultrasound therapy, uterine fibroid radial inclination, 355
management, 284 radius fracture, 356f
Urinary incontinence, cauda equina Smith’s fracture, 365, 427–428
syndrome, 370 ulna variance, 355
Urinary tract infection, renal calculi, 266 volar angulation, 355
Uterine fibroid
abdominal X-ray of calcification, 277f, X-ray, see also specific areas and
278f structures
case example with abdominal X-ray, densities, 12f
277f, 278f, 279–284 dose, 192–193, 523
magnetic resonance imaging, 282 generation, 11f
management, 283–284 hazards, 13
sites, 281 image production, 12
symptoms, 280 magnification of anteroposterior view,
12, 13f
VACTERL, duodenal atresia, 325 pregnancy, 14
Varicella pneumonia, calcification on regulatory legislation, 13–14
X-ray, 180 requesting
Veil sign, 26f form, 14–15
Ventilation/perfusion scan, see Lung radiology team interactions, 15–16
ventilation/perfusion scan
Vertebral body osteitis, ankylosing
spondylitis, 309
704 • Index
Introduction
Rodrigues
Introduction
The Unofficial Guide to Radiology QuresHi

‘The Unofficial Guide to Radiology’ follows on from the ‘The Unofficial Guide to Passing OSCEs’. This book
teaches systematic analysis of the three main types of X-rays: chest, abdominal and orthopaedic, with
X-Rays
X-Rays
additional chapters looking at all the other main radiology tests such as CT and MRI. The layout is designed
Chest
Chest
Orthopaedic X-Rays, plus CTs, MRIs and Other Important Modalities
to make the book as relevant to clinical practice as possible; the X-rays are presented in the context of a real
life scenario. The reader is asked to interpret the X-ray before turning over the page to reveal a model report
accompanied by a fully annotated version of the X-ray. To further enhance the clinical relevance, each case has
The Unofficial Guide to Radiology: Chest, Abdominal and

5 clinical and radiology-related multiple-choice questions with detailed answers. These test core knowledge
Abdominal
Abdominal
X-Rays
X-Rays
for exams and working life, and illustrate how the X-ray findings will influence patient management.
This book is suitable for:

• Medical Students • Physicians Associates
Orthopaedic
Orthopaedic
X-Rays
X-Rays
• Radiographers • Nurses
• Nursing Students • Advanced Nurse Practitioners
• Junior Doctors
Scans
Scans
“Radiology is a constant challenge for students and doctors in busy clinical units: having
CT
CT
a good command of the essentials is a real advantage. This book is well-presented and
very accessible. The annotated examples provide realistic challenges with immediate
feedback. It didn’t take long before I felt better prepared for my next ward round!”
Scans
Scans
Simon Maxwell, Professor of Student Learning, University of Edinburgh
MRI
MRI
“Perhaps one of the biggest strengths of this book is the cases section, allowing you to
practice not only interpreting high quality images but also to link them to a case history.
Scans
Scans
USS
USS
The questions that follow not only test your radiology, but also your understanding of signs,
symptoms, underlying pathophysiology and management of the condition. As well as detailed
answers in each section, the book also shows you the best way to present each case, whether
Medicine
Medicine
Nuclear
Nuclear
in an OSCE situation or on a ward round. The ease of use, detailed pictures and emphasis on
Scans
Scans
key points of this one should cement it as the number one undergraduate book for radiology.”
James Brookes, Medical Student
Fluoroscopy
Fluoroscopy
“Which radiographs from each system are most likely to be presented in exams?
textbook that will be extremely valuable to medical students and junior doctors. What is
especially striking is the definition and clarity of the illustrations, with on-image The Unofficial Guide to
X-Rays
X-Rays
Bonus
Bonus
labelling enabling one to be absolutely certain of which is the endotracheal tube, the
Chest
Radiology: Chest, Abdominal and
Chest
nasogastric tube and the central line, for example.”
Bob Clarke, Associate Dean, Professional Development, London.
Director, Ask Doctor Clarke Ltd. Orthopaedic X-Rays, plus CTs, MRIs
Abdominal
Abdominal
X-Rays
and Other Important Modalities
Bonus
Bonus
X-Rays
ISBN: 978 0 9571499 4 6

Core Radiology Curriculum Covered: 100 Annotated X-Rays (including how to present them),
300 Multiple Choice Questions (with detailed explanations)
Orthopaedic
Orthopaedic
X-Rays
X-Rays
Bonus
Bonus
RRP £39.99 Mark Rodrigues and Zeshan Qureshi

FIRST EDITION
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Introduction

The Unofficial Guide to Radiology QuresHi

The Unofficial Guide to Radiology: Chest, Abdominal and

This book is suitable for:

Radiology: Chest, Abdominal and

ISBN: 978 0 9571499 4 6

RRP £39.99 Mark Rodrigues and Zeshan Qureshi

Mark Rodrigues BSc (Hons) MBChB (Hons)

Zeshan Qureshi BM BSc (Hons)

Please get in touch and be part of the medical education project.

Mark Rodrigues, Zeshan Qureshi,

MDT multi-disciplinary team SHO senior house officer

MIRP minimally invasive retroperitoneal pancreatic SI sacroiliac

mmHg millimetres of mercury SLE systemic lupus erythematosus

mmol/L millimoles per litre SMA superior mesenteric artery

MRA magnetic resonance angiography SMV superior mesenteric vein

MRCP magnetic resonance cholangiopancreatogram SP spinous process

MRI magnetic resonance imaging STIR short tau inversion recovery

Bijan Hedayati Radiology Consultant

Kabir Varghese Radiology Registrar

ure shi shitwo chest X-rays from the same patient.

Chest X-Rays - Introduction • 17

(figure 1). They are usually only performed for

18 • Chest X-Rays - Introduction

Chest X-Rays - Introduction • 19

20 • Chest X-Rays - Introduction

Chest X-Rays - Introduction • 21

ure shi ure shi ure shi

22 • Chest X-Rays - Introduction

7. Summary Specific findings on chest X-ray

Chest X-Rays - Introduction • 23

the aerated lung and the soft tissues of the

ure shi ure shi ure shi

24 • Chest X-Rays - Introduction

Check patient details (name, date of birth, hospital number)

28 • Chest X-Rays - Introduction

ure shi ure shi ure shi

Chest X Rays - Case 1 • 29

ure shi ure shi ure shi

There is no evidence of associated tension.

30 • Chest X Rays - Case 1

•• This is a PA chest X-ray of an adult. E) Marfan’s syndrome

Chest X Rays - Case 1 • 31

32 • Chest X Rays - Case 1

Chest X Rays - Case 1 • 33

The correct answers are A) Pulmonary embolus, B) Pneumothorax, and

i line imaging modality for suspected

34 • Chest X Rays - Case 1

Chest X Rays - Case 1 • 35

36 • Chest X Rays - Case 1

Case 1...................189 Case 6...................225 Case 11.................263 Case 16.................299

Abdominal X-Rays - Introduction • 181

ure shi ure shi ure shi

Abdominal X-Rays - Case 11 • 263

264 • Abdominal X-Rays - Case 11

Abdominal X-Rays - Case 11 • 265

hi answers are A) Hypercalcaemia,

2. Which of the following are symptoms associated with renal calculi?

266 • Abdominal X-Rays - Case 11

i shi 75-90% of renal calculi ureshi

4. What is the diagnostic modality of choice for identifying renal calculi?

Abdominal X-Rays - Case 11 • 267