Radiology final

What will air look like on an x-ray?

Black

What will subcutaneous fat look like on an x-ray?

Dark grey

What will soft tissue look like on an x-ray?

Light grey

What will bone look like on an x-ray?

Off white

What will metal look like on an x-ray?

Bright white

In a PA chest x-ray where is the cassette positioned?

On the chest

In an AP chest x-ray where is the cassette positioned?

On the back

What is the disadvantage of an AP chest x-ray?

Makes it look larger, especially the heart (cardiomegaly) & also can’t get a lateral

This infiltrate over the the hemi-diaphragm indicates what?

Right lower lobe pneumonia

When would you ask a patient to exhale on a chest x-ray?

1. Pneumothorax - air between lung wall & parenchyma

2. Atelectasis - collapsed lung

3. Air trapping

In pneumonia, what would you expect to see on the chest x-ray?

Trachea deviated away from itself & the affected lung

In atelectasis, what would you expect to see on the chest x-ray?

Trachea deviated toward/into the affected lung

In tension pneumothorax (filled with air), what would you expect to see on the chest x-ray?

Trachea deviates away from affected lung

When looking at the caridac silhouette what is considered normal?

Width of the heart being half the width of the thoracic cage

What is skiing down Mt. APAV?

1. Aorta

2. Pulmonary artery (trunk)

3. Left atrium

4. Left ventricle

If the delineation is disrupted on the right what is the expected diagnosis?

Right middle lobe pneumonia

If the delineation is disrupted on the left what is the expected diagnosis?

Lingula pneumonia

When would the Costophrenic angle go from sharp to blunted?

In a right/left lower lobe pneumonia (filled with fluid)

What do the lucencies in the diaphragm represent?

Free air meaning there’s a perforation somewhere

What is the diagnosis based off of this chest x-ray?

Atelectasis

What is the diagnosis based off of this chest x-ray?

Complete atelectasis of the right side

What is the diagnosis based off of this chest x-ray?

Left lower lobe pneumonia

42 year old comes in with acute SOB. What is the diagnosis based off of this chest x-ray?

Tension pneumothorax

What does this “C” sign indicate?

Talocalcaneal coalitions (TCC)

Other than the “C” sign, what is seen radiographically on TCCs?

Talar beaking

What does this “anteater” sign indicate?

Calcaneonavicular coalitions (CNC)

What is the image & view?

Sagittal CT of the foot

What is the image & view?

Coronal CT of the hind foot

What is the image & view?

T1 & T2 Sagittal MRI of the ankle

What is this image & view?

Coronal CT of a TC coalition

What is Stage 1 of Paget’s disease?

Starts in subchondral & spreads to whole long bone. Will also see “blades of grass” sign

What is Stage 2 of Paget’s disease?

Osteolysis & osteonecrosis - diaphysis is lucent while rest of bone is sclerotic

What is Stage 3 of Paget’s disease?

All sclerotic & thickening

What is Stage 4 of Paget’s disease?

Malignant degeneration

What is this?

Blades of grass in stage 1 of Paget’s disease

What is this?

Banana/chalk transverse fracture - insufficiency fractures bc bone is weak seen in Pagets

What are clinical signs of Hyperparathyroidism?

• HTN

• Weakness

• Bone pain

• Anxiety/confusion

• Polyuria/nocturia

What are radiographic signs of Hyperparathyroidism?

• Subperiosteal resorption

• Brown’s tumors (lucent oval lesions)

• Soft tissue calcification

What is this a sign of?

Sub-periosteal bone resorption distal tufts in Hyperparathyroidism

What are these signs of?

Rheumatoid arthritis

What is usually affected 1st in RA?

5th MTPJ

What is usually spared in RA?

IPJs except for the Hallux

Where do the erosions in RA usually occur?

• MTPJs & IPJ of hallux

• Medial aspects of met heads & the head of the proximal phalanx of hallux

What comes first in Psoriatic arthritis?

Skin changes (then articular changes)

What clinical signs would be seen in Psoriatic arthritis?

• Nail changes - subungual keratosis, lateral onycholysis, thickening, & irregularly

• Affects hands & feet

What are radiographic signs seen in Psoriatic arthritis?

• No osteoporosis

• DIPJ involvement

• Widening/narrowing of joint space

• Distal phalangeal tuft erosion

• Pencil-in-cup deformity

What are clinical signs of Gout?

• 1st MTPJ most common

• Soft tissue swelling

• Tophi

• Cortical erosions w/ overhanging margins (Martel sign

What does this x-ray indicate?

Martel sign in Gout

What is Ankylosing spondylitis?

Chronic inflamm disorder of unknown origin that’s a widespread systemic disorder affecting the MTPJ, Lis Franc’s joint, & IPJ. Also causes subluxations & tarsal tunnel syndrome

What are radiographic signs seen in Ankylosing spondylitis?

• Bilateral symmetrical sacroilitis

• Bamboo spine

• Oligoarticular asymmetrical joint changes in foot

• Calcaneal changes (retrocalcaneal bursitis leading to erosion + enthesophytes)

Where are Angiosarcomas mainly found?

Bone - tibia

What does this x-ray indicate?

Lysis of the bone in Angiosarcoma

What would be seen on a CT for angiosarcomas?

• Similar to muscle

• Bright contrast

• Large feeding vessels

What would be seen on a MRI for angiosarcomas?

• Soft tissue mass

• Hyperintense on T2

• Prominent flow voids

What is the T score of the Dexa scan?

Based on normal mineralized bone of a 30 year old female

What is the Z score of the Dexa scan?

Based on normal density of the age of patient as compared to same age & gender normal value

What does a T score of -1 - -2.5 SD indicate?

Osteopenia

What does a T score at or below -2.5 SD indicate?

Osteoporosis

What does a Z score at or below -2.5 SD indicate?

It’s lower than it should be for age & gender

What are the 3 categories of Juvenile RA?

• Pauciarticular

• Polyarticular

• Systemic-onset

What is Type I Pauciarticular Juvenile RA?

Involvement of 4 or less joints in young females

What is Type II Pauciarticular Juvenile RA?

Involvement of 4 or less joints in older boys, associated with spondyloarthropathies

What is Polyarticular Juvenile RA?

Involvement of 5 or more joints either seronegative or seropositive

What is Systemic-onset Juvenile RA?

Fever, skin rash, lymphadenopathy, organomegaly, &/or pericarditis

What are characteristics of a periosteal reaction in benign tumors?

Slow growing with time to remodel

• Solid

• Uniform

• Wavy

What are characteristics of a periosteal reaction in malignant tumors?

Quick growing with no time to remodel

• Multilayer or lamellated

• Perpendicular to long axis of bone

• Spiculated or interrupted

What type of Periosteal interaction is Codman’s triangle?

Periosteum lifts away from the bone, seen in osteogenic sarcomas &/or osteomyelitis

What type of Periosteal interaction is “Hair on end?”

Perpendicular rays of periosteal new bone, seen in osteogenic sarcomas &/or ewings sarcomas

What type of Periosteal interaction is “Sun burst?”

Filiform radiating pattern seen in osteogenic sarcoma

What type of Periosteal interaction is “Onion skin?”

Multiple layers of concentric layers of periosteal new bone formation seen in ewings sarcoma

What type of Periosteal interaction is “Buttressing?”

Formation of many layers of thick periosteum seen in Paget’s disease

What is concerning for malignancy?

Wide zone of transition (border)

What are aggressive, destructive, & have a wide zone of transition but are not malignant tumors?

• Infection

• Eosinophilic granuloma

What does a lucent - narrow zone of transition indicate?

• Well-defined

• Good sign

What does a lucent - wide zone of transition indicate?

• Ill-defined

• Concerning

What type of Zone of transition do sclerotic lesions have?

Wide

What are the most common tumors over 40?

MM (primary)

• Multiple myeloma

• Metastatic

What are the over-under/transitional tumors?

GE

• Giant cell

• Endochondroma

Which tumors under 30 are malignant?

• Osteosarcoma

• Ewing sarcoma

What are the other significant over 30 tumors?

Old Folk Population in the Country

• Osteoma

• Fibrosarcoma

• Pareosteal sarcoma

• Chondrosarcoma

What will not produce a Periosteal reaction unless the bone fractures from them?

• Simple bone cyst

• Non-osseous fibroma

• Enchondroma

• Fibrous dysplasia

What is the most common area for bone tumors & what kind occur there?

Knee - all, especially osteosarcoma, ewings

What is the most common area for non-osseous fibromas, fibrous dysplasia, & osteoid osteomas?

Tibial shaft

What is the most common area for simple bone cyst, ewing sarcoma, osteoblastoma, & chondroblastomas?

Calcaneus

What is the most common area for enchondroma (most occurrence), chondromyxoid fibrous, & osteoid osteomas?

Phalanges

Where in the bone are Chondroblastomas & giant cell tumors (giant joint) found?

Epiphysis

Where in the bone are osteosarcomas, chondrosarcomas, & _ fibromas found?

Metaphysis

Where are CEMENTs found?

• C - bone cysts

• E - enchondroma/ewing

• M - metastatic

• E - eosinophilic granuloma

• N - non-ossifying fibroma

• T - tuberculosis

Where do tumors primarily metasticize?

PBKTL/Lead Kettle

• P - prostate

• B - breast

• K - kidney

• T - thyroid

• L - lung

What is multiple lesions (enchondromatosis)?

Ollier’s disease

What is multiple lesions + hemangiomatosis (enchondromas)?

Mafucci’s disease

What is associated with Albright’s disease as well as Von recklinghausen’s disease?

Fibrous dysplasia

What is the most common benign bone tumor in children?

Osteochondroma

Where would you see a fallen fragment or fallen leaf sign?

Solitary bone cysts (simple or unicameral)

Where are Chondroblastomas of the foot most commonly found?

Subchondral areas of the talus, calcaneus, & calcaneal apophysis

What is the most common soft tissue tumor in children?

Rhabdomyosarcoma

What are the most common Podiatry masses?

• Ganglion cysts

• Synovial cysts

• Lipomas

What is the preferred imaging for soft tissue masses?

MRI with T1 & T2 STIR

What is the best combination for anterior/posterior soft tissue lesions?

Sagittal & axial

What is the best combination for medial/lateral soft tissue lesions?

Coronal & axial