Lectures by Ibnlatef

1. Radiology
For 5th stage
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2. Content
Topics: Page:
Radiology of GIT system 6
 Normal esophagus film 6
 Tertiary contraction 7
 Diffuse esophageal spasm 7
 Congenital anomalies 7
 Benign strictures of esophagus 7
 Malignant structures of esophagus 8
 Candida esophagitis 8
 Esophageal web 8
 Esophageal varieces 8
 Achalasia cardia 9
 Esophageal diverticulum 9
 Hiatus hernia 9
 Normal stomach film 10
 Peptic ulcer 10
 Gastric cancer 11
 Hypertrophic pyloric stenosis 12
 Gastric outlet obstruction 12
 Normal duodenum film 12
 Duodenal ulcer 13
 Duodenal diverticulum 13
 Atresia or stenosis 13
 Pneumo-peritoneum 13
 Sub-phrenic abscess 14
 Congenital diaphragmatic hernia 14
 Normal small intestine film 15
 Crohn's disease 15
 Ulcerative colitis 16
 Toxic megacolon 16
 Lymphoma of small bowel 16
 Malabsorption syndrome 17
 Bowel obstruction 17
 Normal large intestine film 18
 Colorectal carcinoma (CRC) 18

3.  Irritable bowel syndrome (IBS) 18
 Intussusception 19
 Colonic diverticulosis 19
 Familial adenomatous polyposis syndrome (FAPS) 19
 Hirschprung disease 19
 Anal atresia (imperforated anus) 20
Radiology of Renal system 21
 Stone diseases 28
 Urinary tract neoplasm 30
 Urinary tract infections 31
 Congenital anomalies 32
 Other conditions 34
Radiology of musculoskeletal system 35
 Solitary Bone Lesion 38
 Malignant bone tumors 39
 Benign bone tumors and tumor like conditions 40
 Multiple focal bone lesions 44
 Bone infections 45
 Generalized decrease in the bone density 47
 Generalized increase in the bone density 49
 Arthritis 50
 Other conditions 54
Radiology of chest 58
 Cardiothoracic ratio (CTR) 62
 Mitral valve disease 62
 Congestive cardiac failure 63
 Pulmonary edema 63
 Pericardial effusion 64
 Tetralogy of Fallot 65
 Transposition of the great arteries 65
 Ventricular septal defects 65
 Pulmonary arterial hypertension 66
 Pulmonary venous hypertension 66
 The mediastinum 67
 Normal thymus gland 67
 Retro sternal goiter 67
 Lymphadenopathy 68

4.  The lung 69
 Consolidation 69
 Collapse 72
 Bronchiectasis 74
 Pulmonary emphysema 74
 Subcutaneous emphysema 75
 Pneumomediastinum 75
 Bronchogenic carcinoma 76
 Pancoast tumor 76
 Secondary lung tumor 77
 TB of the lung 77
 Lung abscess 78
 Hydatid cysts 79
 Pleural effusion 79
 Empyema 80
 Pneumothorax 81
 Tension pneumothorax 81
 Hydropneumothorax 82
 CXR signs 83
Radiology in women 84
 Obstetric Ultrasound 84
 Age of the pregnancy 85
 Placenta 86
 Liquor 86
 Fetal sex 87
 Doppler ultrasonography 87
 Blighted ovum 87
 Molar pregnancy 87
 Ectopic pregnancy 88
 Anencephaly 88
 Hydropis fetalis 88
 Polyhydramnios 89
 Gynecological Ultrasound 90
 Fibroid 90
 Ovarian cyst 90
 Polycystic ovarian syndrome 91
 Ovarian tumors 91

5.  Mammography 92
 Breast cancer 94
 Invasive ductal carcinoma 95
 Infiltrating or invasive lobular carcinoma 95
 Microcalcifications 95
 Vascular calcifications 95
 Popcorn calcifications 96
 Cyst 96
 Fibroadenoma 96
Computerized tomography (CT scan) 97
 Encephalitis 98
 Brain abscess 99
 Infarction 99
 Hemorrhage 100
 Meningioma 101
 Glioma 102
 Posterior fosse tumor 102
 Supra seller tumor (cranio-phyrengioma) 103
 Hydrocephalous 104
 Hydatid cyst of the brain 104
 Hydatid cyst of the abdomen 105
 Secondary metastasis in the liver 105
 Pancreatitis 105
Magnetic resonance imaging (MRI) 106
 Congenital hydrocephalus 107
 Arnold Chiari malformation 107
 Arachnoid cyst 107
 White matter disease 108
 Neuroradiology of the spine 109
 Spondylosis 110
 Disc prolapse 110
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6. Part1: Radiology of GIT system
Esophagus
Type of study:
 Single contrast (SC): use barium swallow or gastrograffin.
 Double contrast (DC): use sodium bicarbonate.
Indications of study:
 Odynophagia.
 Dysphagia.
 Hematemesis.
 Abdominal pain.
 Unexpected weight loss.
1- Normal esophagus film:
 Start at C5 and end in the cardia of stomach.
 25 cm length.
 Mucosa  thin, regular, longitudinal, parallel.
 Number of lines of mucosa = 4-5 lines.
 Indentations  at aortic arch, left atrium, diaphragmatic
hiatus, body of cervical vertebra, right bronchus.
On the Hypo pharyngeal part common structures that we
can visualize are:
 Epiglottis (red arrow in the left)
 Post cricoid impression (yellow arrow in the left)
 lateral pharyngeal pouches (white arrow in the left)
 Crico pharyngeal muscle impression (white arrow in the right)
This is lateral oblique view

7. 2- Tertiary contraction:
 The film show that the esophagus is
contracted and dilated as the peristaltic wave
move.
 Occur in:
o Diffuse esophageal spasm.
o Nutcracker esophagus (crock screw
esophagus).
o Decreased peristalsis (resulting from achalasia, scleroderma, dermatomyositis,
polymyositis, esophagitis, and secondary to many other diseases)
3- Diffuse esophageal spasm:
 Intermittent contractions of the mid and distal esophageal smooth
muscle.
 Tertiary peristalsis (crock screw appearance)
4- Congenital anomalies:
 Atresia with TEF  most common one is esophageal atresia with
distal TEF).
 Congenital short esophagus.
 Congenital duplication.
5- Benign strictures of esophagus:
 Due to  peptic esophagitis,
corrosive, traumatic.
 Ba swallow show:
o Funnel (tapering shape).
o No shouldering sign.
o Smooth and regular.
o Long length (lower third).
o Constant narrowing.
o Mid proximal dilatation.
Note:
 If the stricture is due to GERD  short part of esophagus is narrow.
 If the stricture is due to corrosive  long part of esophagus is narrow.

8. 6- Malignant strictures of esophagus:
 Due to  SCC and adenocarcinoma.
 Types  infiltrative, as filing defect, ulcerative.
 Ba swallow show:
o Shouldering sign = apple core sign = minscus sign.
o Constant narrowing.
o Irregular and variable length.
o Soft tissue shadow of the mass.
o Fistula (double tract).
7- Candida esophagitis:
 Type of study: Ba. swallow.
 Showing: numerous fine erosions and plaques causing shaggy outline
of the esophagus.
8- Esophageal web:
 Occur in the cervical part of esophagus.
 Ba swallow show:
o Thin mucosal fold arise from the anterior wall of esophagus and
extend posteriorly.
o Shelf like filling defect with proximal dilatation.
o Single or multiple.
9- Esophageal varieces:
 Dilated veins of the wall of esophagus.
 Due to portal hypertension, lead to hematemesis.
 Ba swallow (DC) show:
o Early changes  loss of parallelism with thick tortious
folds.
o Later  multiple filling defects (fine cobble stone).
o Advanced  larger filling defects (coarse cobble stone).
o More advanced  elongated (worm like filling defect).
 These changes could be seen at the lower third of
esophagus and at the cardia.

9. 10- Achalasia cardia:
Ba swallow show:
 Tapering (Rat tail, Tip of pencil, cigar shape)
under left dome of diaphragm.
 Proximal part dilitation (sac like).
 Regular and smooth.
 No shouldering sign.
 The narrowing is constant short length (confined to cardia).
 Sluggish peristalsis (undulating or spiky out line).
 Food particles (non-homogeneity of Barium).
 Air Barium level.
 Absence of fundal gas shadow.
 CXR shows  widening of mediastinum, basal fibrosis (due to repeated aspiration
pneumonia).
11- Esophageal diverticulum:
 Pulsion diverticulum:
o In the upper third of esophagus.
o Causes: chocking after meal, increased
intraluminal pressure.
o Ba show: abnormal dilatation and
pouching due to increased pre-vertebral
space, A/F level (killence dehiscent) posteriorly.
 Traction diverticulum:
o In the middle third of esophagus.
o Causes: post-TB.
o Ba show: upward direction of diverticulum and irregular base.
 Epi-phrenic diverticulum:
o In the lower third of esophagus.
o Ba show: arise from the esophagus, above the diaphragm.
12- Hiatus hernia:
 Sliding (95%)  gastro-esophageal junction above the
hiatus, stomach protrude through the hiatus.
 Para-esophageal (5%)  gastro-esophageal junction below
the diaphragm, gastric fundus protrude through hiatus.
 Mixed  gastro-esophageal junction above diaphragm,
gastric fundus herniate beside distal esophagus.

10. Stomach
Type of study:
 Barium meal (use barium sulphate).
 Two views  AP or PA view (enface), lateral view (profile).
Indications of study:
 Gastric or duodenal obstruction.
 GIT hemorrhage.
 Malignancy.
 Upper abdominal mass.
 Motility disorders.
 Systemic diseases (T.B).
1- Normal stomach film:
 Anatomy:
o Note the shape of the stomach.
o Not the size of the stomach.
o Anatomical parts  cardia, fundus, body, pylorus.
o Mucosal pattern  regular, longitudinal lines, more than 5 lines.
 Supine position of the patient lead to  white color (SC) of the body, pyloric antrum
and black color (DC) of the fundus.
 Prone position of the patient lead to  black color (DC) of the body, pyloric antrum
and white color (SC) of the fundus.
2- Peptic ulcer:
Ba meal findings:
 Direct signs:
o Ulcer crater (nitch)  in enface or profile views.
o Associated signs  spasm, radiated mucosal folds, edema (Hampton's line).
 Indirect signs:
o Hyper-peristaltic waves.
o Companion B sign.
o Thick mucosal folds and hyper-peristaltic stomach (angry mucosa).
Benign ulcer:
 Profile view:

11. o Ulcer crater (collection of Ba projects from stomach
wall).
o Hampton's line (1mm thin straight line at the neck of
ulcer).
o Ulcer mound (smooth sharply delineated soft tissue mass
surrounding a benign ulcer).
 Enface view:
o Ulcer crater.
o Zone of edema with mucosal lines.
Malignant ulcer:
 Profile view  large circle with large zone of edema.
 No enface view  no projection.
Complicated benign ulcer:
 Filling defect with central ulcer crater.
 No mucosal radiation  due to destruction.
 Meniscus sign  the ulcer crater is not projected outside the
lumen.
 Hour glass deformity (X) of stomach.
3- Gastric cancer:
 95% of benign ulcer arising form the lesser curvature, but
malignant ulcer arise from the greater curvature.
 Site of predilection of gastric cancer is pylorus.
 Presentation  polypoidal, ulcerative, infiltrative (localized
or generalized).
 Ba meal show:
o Single or multiple irregular filling defect.
o Alternation of nearby mucosal pattern.
o Localized or generalized narrowing of the stomach.
o Stomach rigid in appearance.
o Shouldering sign: in either sided aspect of the narrowing.
 Ulcerative cancer:
o Polypoidal tumor with ulceration.
o Complicated benign gastric ulcer.

12. 4- Hypertrophic pyloric stenosis:
 Causes  congenital type, adult type.
 Information  M:F = 4:1 / Caucasian / 4-8 weeks
of life / +ve family history.
 Normally:
o Pyloric muscle thickness = less than 3 mm.
o Pyloric length = less than 15 mm.
 Ba meal show:
o Thickening of pyloric muscle (better by US).
o Narrowing of pyloric region.
o Dilatation of other regions.
o Contraction not go to the duodenum.
5- Gastric outlet obstruction:
 Information:
o Lead to recurrent vomiting of food.
o Stomach dilate to accommodate food intake and
secretions.
o Causes  peptic ulcer (benign), gastric carcinoma
(malignant).
o Other benign causes of narrowing is corrosive obstruction (like the photo )
 Ba meal findings in pyloric stenosis:
o Marked dilatation of the stomach.
o Failure of passage of content in to the duodenum.
o Multiple filling defect within the stomach  due to retained food materials.
Duodenum Study by barium meal
1- Normal duodenum film:
 C shape, start at pylorus, end at jejunum.
 Consist from 4 parts.
 Normal Anatomy of Duodenum:
o Duodenal cap.
o Duodenal loop.

13. 2- Duodenal ulcer:
 Information:
o 95% of DU occur in the duodenal bulb (2 cm above the ampulla of vator).
o 5% of DU occur in the post bulbar duodenum.
o Half of DU occur in the anterior wall of the bulb.
o Most of DU  round or ovoid pools of barium.
o 5% of DU  may be linear.
o Most DU  smaller than 1 cm in diameter.
o Giant DU  above 2 cm in diameter.
o Multiple DU (15% of patient) lead to Zollinger
Ellison syndrome.
 Complicated chronic DU:
o Trifolate duodenum (tri foil tree shape).
o Pseudo diverticulum (Akerland diverticulum).
o Gastric outlet obstruction (Pyloric obstruction).
3- Duodenal diverticulum:
 95% in the second part of the duodenum.
 Well defined oval or round shape smooth wall out
pouching from the 2nd part of the duodenum with or
without A/F level.
4- Atresia or stenosis:
 Pyloric stenosis  single bubble sign.
 Duodenal stenosis  double bubble sign.
 Jejunal atresia  triple bubble sign.
Abdominal problems in the chest
1- Pneumo-peritoneum:
 Use erect CXR.
 Free intra-peritoneal gas.
 Due to critical illness  perforated viscus or ulcer.

14.  Finding: Crescent shape of lucency below the right diaphragm
described as sub-diaphragmatic free gas.
 Could lead to huge collection of gas below both sides of
diaphragm.
2- Sub-phrenic abscess:
 Lesion like abscess (not free air).
 Use erect CXR.
 Findings  air below the diaphragm, A/F level, thick wall.
3- Congenital diaphragmatic hernia:
 Mostly is Bockdolik type.
 Use plain x-ray of chest and abdomen.
 Findings:
o Multiple air filled loops of bowel in hemithorax (mostly left
side).
o Indistinct left dome of the diaphragm.
o Shifting of mediastinum (cardiac shadow) to the right side.
Small intestine
Type of study:
 Barium follow through (SBFT).
Indications of study:
 Inflammatory bowel disease.
 Malabsorption syndrome.
 Tumors.
 Ulcer.
 Swelling or inflammation of small intestine walls.
Contraindications of study:
 Suspected bowel perforation.
 Bowel obstruction.
 Conditions when aspiration of barium is likely (cough, choking).

15. 1- Normal small intestine film:
 Information:
o Jejunum in the upper left abdomen, ileum in the lower
right abdomen.
o Valvule conniventis  give normal feathery appearance
in Ba. study.
o Small bowel diameter = 3-3.5 cm (above 4 is abnormal).
o Ileum loop diameter = 2-2.5 cm (above 3 is abnormal).
o Distance between loop and loop should be less than 1-2
mm.
 Normal SBFT:
o Complete filling of the lumen of small intestine.
o Normal distance between small bowel loops.
o No any flocculation or segmentation of Ba.
o No loss of feathery appearance.
2- Crohn's disease:
 Information:
o Transmural lesion.
o Skip area.
o Rectal sparing.
o Any region of GIT.
o Terminal ileitis.
o Stricture in chronic Crohn's.
o No gender preference.
o Small bowel involvement 70-80%, colonic
involvement 15-20%.
 SBFT findings:
o Multiple mucosal ulcers (aphthous ulcers).
o Multiple skip lesions.
o Longitudinal fissures.
o Widely separated loops of bowel (due to fibro-fatty proliferation).
o Thickened folds (due to edema).
o May lead to sinus tracts and fistulae.
o Severe CD lead to cobblestone appearance: apthae enlarge and merge with
edematous mucosa and deep ulcers.
o Pseudo diverticula formation: due to contraction at the site of ulcer with
ballooning of the opposite site.
o Stricturing:

16.  Active disease (string sign, edema, spasm).
 Fibrotic diseases (irreversible stricture, lead to obstruction and fistula).
o Pseudo polyps:
 Inflammatory  cobble stoning, nodular filling defects, edematous mucosa
surrounded by ulcerations.
 Post-inflammatory  filiform, mucosal overgrowth during healing process.
3- Ulcerative colitis:
 Information:
o Affect the mucosa.
o Continuous lesion.
o Involves the rectum.
o Usually limited to the colon.
o Back-wash ileitis.
o Lead pipe appearance.
o Thumb-printing = lead pipe + granulation in acute UC.
o Male predilection.
o Rectal involvement 95%, terminal ileum only involved in
pan colitis (back wash ileitis).
 Palin film: mural thickening + Thumb printing.
 Ba enema:
o Bowel wall and hastura thicken.
o Button shaped ulcers.
o Pseudo polyp appearance  mucosa lost + mucosa
remain.
o Lead pipe sign  featureless bowel + loss of hastura +
luminal narrowing + bowel shortening.
 Note: colorectal carcinoma in UC  sessile or simple stricture.
4- Toxic megacolon:
 Seen in UC more than in CD.
 The colon (transverse colon) is dilated more than 6 cm.
 Additional loss of hastural markings.
 Risk of perforation.
 Splenic and hepatic flexure are high.
 It is dangerous condition  so do plain x-ray before Ba study.

17. 5- Lymphoma of small bowel:
 Splaying ‫تفلطح‬ and separation (>1-2 mm) of the bowel loops
 due to enlarged L.N.
 Saw tooth appearance  thickening of mucosa (lead to
nodular appearance), irregular outline.
 Loss of normal feathery appearance.
 Later stage  signs of malabsorption syndrome
(flocculation and segmentation of Ba.).
6- Malabsorption syndrome:
 Loss of feathery appearance.
 Dilated small bowel loops > 3.5 cm.
 Flocculation and segmentation of Ba. (Mosaic appearance).
 Splaying and increase distance between small bowel loops.
7- Bowel obstruction:
Small bowel obstruction 80% Large bowel obstruction 20%
Central location (cross transversely). Peripheral location.
Maximum diameter is 5 cm. Maximum diameter is 8 cm.
Valvule connictivae are visible. Hasturation is present.
In erect position A/F level small and many. In erect position A/F level large and few.
Colon is filled with feces which has bubbly
appearance.
Type of study  plain x-ray, KUB, Ba (more than 3 cm is small bowel obstruction).

18. Large intestine
Type of study:
 Barium enema.
 Before examination empty the colon by  restricted diet, laxative, enema.
 After examination get rid of any barium still in the body by  laxative.
1- Normal large intestine film:
 Diameter of large bowel normally 5-6 cm.
 Above 8 cm means large bowel obstruction.
 Normally we see hastura.
2- Colorectal carcinoma (CRC):
 Most common cancer in GIT.
 Most commonly occur in the recto-sigmoid region.
 Ba enema:
o Infiltrative  apple core sign (the lesion infiltrate the
bowel wall from outside).
o Ill-defined filling defect  within the lumen of bowel.
o Could be ulcerative nodule or ulcerative lesion.
 Area of stoppage, narrowing, missing, filling defect,
shouldering  means that there is problem here.
3- Irritable bowel syndrome (IBS): see a lot of hastura in the
descending colon.
4- Intussusception:
 Information:
o Causes  inflammation of L.N (90% child), CA colon (90% adult).
o In pediatric  most common cause of intestinal obstruction is intussusception
and lead to acute abdomen.
o 90% of intussusception occur in the ileo-colic region.
 Abdominal plain film:
o Elongated soft tissue mass (typically in the right upper quadrant in children).

19. o With a bowel obstruction proximal to it.
 Ultrasound sigs:
o Target or doughnut sign (ileum is hypo-echoic, Colon is hyper-echoic).
o Pseudo kidney shape sign.
o Area of devoid of gases shadow called spring sign.
o If there is no vascularity it means  ischemic segment (in the ileum).
 Contrast enema "gold standard":
o Coiled spring appearance  demonstrating the intussusception as occluding
mass prolapsing into the lumen.
o Contraindicated in perforation.
o Diagnostic and therapeutic.
5- Colonic diverticulosis:
 SC or DC Ba enema.
 Diverticula  few mm to few cm.
 Description  barium filling out pouching.
 Here the pouching of mucosa from outline of the bowel
(outside).
6- Familial adenomatous polyposis syndrome (FAPS):
 Innumerable adenomatous polyps.
 Size < 5 mm.
 Pouching mucosa inside the lumen of colon.
 Predisposition to CRC.

20. 7- Hirschprung disease:
 Most common cause of neonatal colonic obstruction.
 More in boys.
 The affected segment is of small caliber with proximal
dilatation.
 Fasculation / saw teeth irregularity of a ganglionic segment.
 Most common area is recto-sigmoid.
 Transition zone (could be seen with x-ray).
8- Anal atresia (imperforated anus):
 Abdominal radiograph:
o Show  multiple dilated bowel loops + absence of
rectal gas.
o Can be variable depending on:
1- Site of atresia (high or low).
2- Level of impaction with meconium.
3- Physiological effects such as straining.
 Invertogram:
o Baby is turned upside down for 3 min.
o Distance of gas bubble in the rectum from the the metal piece  less than 3 cm is
low type, more than 3 cm is high type.
For more photos about GIT:
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21. Part2: Radiology of Renal system
Basic information
Types of study:
 Palin kidney, ureter and bladder (KUB).
 Intravenous urography (IVU), intravenous pyelography, excretory urography (EU).
 Ultrasonography (US).
 Magnatic resonance imaging (MRI).
 Radionuclide imaging.
 More invasive tests.
Benefits:
 US - MRI  anatomical information.
 IVU - CT  functional & anatomical information.
 Radionuclide scanning  functional information.
1- KUB:
 Simple procedure.
 Requires adequate patient preparation.
 Diagnostic vale:
o Radiopaque calculi.
o Calcifications (schistosomiasis of bladder).
o Gas pattern (in intestinal obstruction)
o Organomegaly (liver, spleen).
o Bony abnormality.
2- Intravenous urography (IVU):
 Information:
o It means the visualization of kidney parenchyma, calyces and pelvis after
intravenous injection of iodinated contrast medium to the patient, followed by a
series of x-ray films.
o Replaced by US and CT.
o Remains the primary modality for visualization of the pelvicalyceal system and
ureters.
o Providing both functional and anatomical information.

22.  Requirements:
o Fasting 4-6 hours, good hydration is essential.
o Adequate bowel preparation.
o Renal function test beforehand (serum creatinine level below 3).
o Nonionic contrast media are used to guard against contrast nephropathy.
 Indications:
o For detailed demonstration of the pelvicalyceal system and ureters.
o Show renal function.
o Suspected acute ureteric colic, hematuria, UTI.
o Renal calculi (stones).
o UT obstruction (hydronephrosis).
o Renal and bladder masses.
o Congenital anomalies.
 Contraindication:
o Renal impairment.
o Hypersensitivity to contrast media.
 Contrast medium:
o Urographic contrast media are highly concentrated solutions containing iodine,
also known as iodinated.
o Large volume of contrast media (50-100ml) is injected intravenously passes to
glomerular filtrate concentrated in renal tubules passes to  pelvicaticeal
systems  ureters  bladder.
o Contrast media is iodinated solution that make the renal tract white in color so
radiolucent stone appear black (as filling defect).
 The procedure of performing IVU:
o KUB taken before injection of contrast media to see  calcification, radiopaque
stones.
o Inject the contrast media.
o Nephrogram phase (Immediately after injection of contrast)  see parenchyma.
o Pyelogram phase (l-5 minutes after injection of contrast)  see pelvis.
o Compress on the abdomen by billow.
o After 10 min with compression take the film  get better distention of pelvis and
calyces and see the upper ureter till the site of compression.
o Full length film after the release of compression  see the full ureter.
o After 10 min take full bladder film  the bladder is fully distended with contrast.
o Post voiding full length film  for reflux, retention, neurogenic bladder.
 Interpretation of IVU films:
o Kidney  position (left kidney higher), renal parenchymal width (uniform 2-2.5
cm), length of adult kidney (10-16 cm) at IVU but longer in US due to
magnification.
o Calyces  symmetrical, cup shape (normal), club shape (dilated).

23. o Renal pelvis and ureter  funnel shaped, ureter not seen by single film due to
peristalsis, filling defect (stone, tumor, blood clot), ectopic ureter.
o Bladder  centrally located, smooth outline, smooth indentation, abnormality
(filling defect, wall irregularity, diverticula, trabiculae).
3- Cystourethrography (CUG):
 Information:
o Contrast is inserted into the bladder and images are
obtained.
o The patient is then asked to void and images are also
taken.
 Benefits:
o Urethral lesions.
o Vesicouretheral reflux.
o Stress incontinence.
4- Ultrasonography (US):
 Information about US in general:
o US waves in the 2-10 MHz frequency range.
o The higher the frequency the lees the penetration.
o Air or gas reflect the US waves so put gel.
o US radiation is nonionizing so there is no adverse biological effect.

24. o US used in  obstetrics, gynecology, abdominal US, superficial structure,
pediatrics, pediatric neurology, vascular US (Doppler), cardiology (Echo),
interventional radiology (biopsy, intrathecal injection, aspiration of cyst or
abscess).
 Gray scale:
o Echofree or unechoic (black) fluid, edema, cyst, plural effusion, ascities,
bladder, gall bladder, stomach and intestine (if contain fluids).
o Echogenic (white)  Bone, calcification, F.B (metallic), stone, gas, pneumothorax.
o Hypoechoic – hyperechoic  liver, kidney, pancreas, soft tissue.
 Probe (transducer):
o Convex probe (3.5 Hz)  for abdomen.
o Linear probe (7.5 Hz)  for superficial tissue (thyroid, breast, scrotum, muscle,
soft tissue).
o Endovesiral probe  transrectal, transvaginal.
o Biopsy US probe.
o 3D probe  used in pregnancy.
 Advantages:
o Safe, less expensive, small, available, portable.
o Images in the real time.
o High resolution.
o No adverse effects.
o Noninvasive nature.
o Ultrasound is the tool of choice in obstetrics primarily.
 Disadvantages:
o Organs containing gases and bony structures need specialized procedure.
o Only limited window is available.
o It depend on operator skill.
o It is sometimes impossible to obtain good images (in obese patient for example).
o Not detect all diseases.
Renal US:
 Requirements:
o Fasting 4-6 hours.
o Not need bowel preparation.
o Not use contrast media.
o No radiation hazards.
 Normal kidney:
o Central of the kidney is echogenic (white)  because pelvicalyceal system contain
fat and vessels.

25. o Peripheral of the kidney is hyperechoic (gray)  the parenchyma contain cortex
and medulla.
 Abnormalities:
o Echogenic  stone, calcifications.
o Echofree  cyst, hydronephrosis.
o Hypoechoic  tumor, mass.
o Hyperechoic  in the parenchyma (RCC), in the pelvicalyceal system (TCC).
 Notes:
o Hydronephrosis  central (echofree), peripheral (hypoechoic).
o Cyst  peripheral (echofree).
o Stone  hyperechoic + acoustic shadow.
o Ureter  the only abnormality is dilatation.
 Renal mass:
o Tumor  has blood vessels, fixed, arise from the wall.
o Hematoma  not contain blood vessels, mobile.
o Differentiate between them by using Doppler.
 Bladder (echofree):
o Stone  echogenic + acoustic shadow.
o Mass  hypoechoic, use Doppler to see vessels inside the tumor.
o Calcification of wall  echogenic plaque.
o Cyst (uretrocele or diverticulum)  echofree.

26. 5- Computed tomography (CT):
 Information:
o More sensitive.
o Considered with care.
o Plans or views  axial, coronal, sagittal.
o Black (hypodense), white (hyperdense).
o Opaque and lucent stones appear hyperdense in CT.
o Types  plane CT (without contrast) and contrast CT.
o Oral contrast  use gastrographine and the stomach appears white.
o IV contrast  the vessels appear white.
o According to the density we can differentiate between fluid, soft tissue, mass.
 Requirements:
o Fasting 4-6 hours.
o May need bowel preparation.
o May use contrast media.
o Consider radiation hazards.
 Diagnostic value:
o Detection of small radiopaque or radiolucent stone.
o UT obstruction.
o Renal and bladder masses.
o Differentiate cystic form solid masses.
o Congenital anomalies.
o CT angiography.
 CT urinary tract (CTUT):
o Test for detection of stones.
o No preparations required.
o The patient should stop his breath.
o The patient drink large amount of water to distend the ureter and bladder.
o Take films from the start of the kidney to the end of the bladder every 3 mm.
o Any white dot is stone (sometimes it is phlebolith if this white dot not seen
in the ureter after reconstruction of coronal image of the ureter).
o The two ureters no appear in one reconstructed image (should be 2 images)
 CT urography (CTU):
o Show the kidney, ureter, bladder only and remove other structures from
the image.
o There is contrast and multi-detector CT.
o Can give color image (not has any diagnostic value).
 CT angiography (CTA):
o Image the renal vessels with the kidney.
o See congenital anomalies, and vascular abnormalities.

27. 6- Magnetic resonance imaging (MRI):
 Information:
o Functional imagining.
o Morphological imagining.
o Used when the patient has hypersensitivity to
contrast or has bad renal function.
o T1 weighted image  black color of moving fluid
(blood vessels).
o T2 weighted image  white color of stable fluid (gall bladder).
 Requirements:
o Fasting 4-6 hours.
o No bowel preparation.
o May use contrast media.
o No radiation hazards.
 MR urography (MRU):
o No contrast is needed.
o See the flow in the urinary system.
 MR angiography (MRA):
o No contrast is needed.
o See the vascularity of urinary system.
7- Renal scintigraphy (nuclear medicine):
 Information:
o Use radiopharmaceuticals (isotopes) IV or orally
and gamma camerass.
o Types of isotopes  Tc DMSA or Tc DTPA
o Safe, minimally invasive, expose the patients to
radiation is less.
 Uses:
o Evaluating renal function  blood flow, GFR,
effective renal plasma flow (ERPF), nephron
uptake and clearance, renovascular hypertension.
o Renal artery stenosis (RAS).
o Acute and chronic renal failure.
o Ischemic nephropathy.
o Pyelonephritis.
o Trauma or surgical complications.
o Renal transplant function, obstruction, and acute or chronic rejection.
o Ureteral obstruction and vesicoureteral reflux.

28.  Risks:
o Diagnostic nuclear medicine procedures result in relatively low radiation
exposure.
o Allergic reactions to radiopharmaceuticals.
o Injection of the radiotracer may cause slight pain and redness which should
rapidly resolve.
 Limitations:
o Cannot reliably differentiate between cysts and tumors.
o Time-consuming.
o Low resolution compared with CT or MRI but more sensitive, and giving functional
information.
Renal pathology
Types renal pathology:
 Stone diseases.
 UT neoplasms.
 UT infection.
 UT trauma (hematoma, laceration, avulsion) use CT scan.
 Congenital anomalies.
 Vesico-ureteric reflux.
 Urethral lesions.
 Reno-vascular hypertension.
1- Stone diseases:
 Causes of urinary tract obstruction:
o Within the lumen  Calculi, Blood clot, Sloughed papilla (papillary necrosis).
o Within the wall of the collecting system  Tumor (transitional cell carcinoma),
Infective stricture (TB or Schistosomiasis), Intrinsic PUJ obstruction.
o Extrinsic pathology  Tumors (CA cervix or recto-sigmoid junction),
Retroperitoneal fibrosis, Aberrant renal artery, retrocaval ureter.
 Information:
o Calcium oxalate and phosphate stones (90% of urinary stones) are radiopaque 
use KUB, CT.

29. o Pure uric acid and xanthine stones (10% of urinary stones) are radiolucent  use
IVU, CT, US.
o Principal feature is dilatation of pelvicalyceal system and ureter, the degree of
dilatation depends on chronicity, and the dilatation is down to the level of
pathology.
o In the renal region  renal stone.
o Outside the renal region  ureteric stone.
o Pelvic rejoin  bladder stone or phlebolith.
 Methods:
o KUB  radiopaque (white).
o IVU  Radiolucent (filling defect).
o US  hyperechoic (white) + acoustic shadow.
o CT  hyperdense (white). Note: use non-contrast CT.
 US findings:
o Dilatation of P.C.S.
o Stones larger than 5 mm are easily to seen but
smaller are missed  so stones should be large
and no gases.
o Hyperechoic + cast acoustic shadow.
o Stones may lodged in the VUJ or PUJ are easily to
seen.
o Stones in the middle of ureter are hard to seen.
 IVU findings:
o Acutely obstructed kidney show dense
nephrogram.
o Dilated P.C.S and ureter down to the point of
obstruction (point of hold up).
o Pyeloxinus reflux may result from rapture of fornix
 urine and contrast extravasate into the renal
sinus and perirenal space.
o Filling defect in IVU could be stone (regular, well
defined) or tumor (irregular, ill defined).
 KUB findings:
o Stone  oval shape, homogenously radiopaque (white).
o Phlebolith  round shape, radiopaque with radiolucent
center.
o DDx of stone in KUB 
 Phlebolith.
 Gallstone.
 Metallic F.B.
 Calcification, calcified LN or cartilage or fibroid.

30. Stage horn calculus  appears radio opaque in KUB.
2- Urinary tract neoplasm:
 Benign tumors of the kidney:
o IVU: stretching and spraying of P.C.S.
 RCC:
o It account for 85% of malignant tumors of the kidney.
o Arise from the parenchyma, attached to the wall.
o KUB: soft tissue masses.
o IVU: irregular filling defect with destruction of calyces.
o Also we can use US (hypoechoic), CT (mass).
 Wilm's tumor:
o Most common renal malignancy in children.
o Abdominal x-ray typically reveals a large soft tissue opacity
displacing bowel shadow.
 Urothelial tumors:
o 85-90% of tumors in the collecting systems of kidney are TCC.
o Occur in multiple sites  P.C.S, ureter, bladder.
o IVU  radiolucent filling defect, projecting into the lumen,
within the collecting system.
o US  soft tissue mass lesion irregular in
outline.
o Differentiated from blood clots
and radiolucent stones.
o Use tomography to differentiate
the overlying gas shadow.
Benign
Malignant

31. 3- Urinary tract infections:
 Acute renal conditions:
o Use CT scan.
o Most common infection is acute pyelonephritis
(striated nephrogram).
o Findings  Swollen kidney, Poor renal function,
Dirty perinephric fat.
 Renal abscess:
o Use CT scan.
o Like the renal cyst but it take the
contrast and has thick wall.
o Sometimes see air in the abscess.
 Emphysematous pyelonephritis:
o Gas shadow within and around the kidney.
o Surgical emergency that is lethal if treated medically.
 Renal TB:
o KUB  large globular amorphous calcifications with
destruction of P.C.S.
o IVU  cortical scarring, smudged papillae (moth
eaten), infundibular strictures, hydrocalyces,
hydroneprhrosis, autonephrectomy.
o Could be in the kidney and upper or lower third of
ureter and bladder.
o In the late stage it lead to  calcification of whole kidney, loss of function.
 Schistosomiasis:
o Infestation by S.henatobium.
o Calcification (bladder, lower ureter).
o Cobble stone appearance (in early stage).
o Bladder capacity not affected.

32. 4- Congenital anomalies:
 Renal agenesis:
o Incidental finding.
o The opposite kidney shows compensatory
hypertrophy.
o Can be diagnosed as absent kidney on ultrasound or CT.
o IVU will show a single kidney with active contrast excretion.
 Ectopic kidney:
o Incidental findings during routine ultrasound.
o Findings: located in the lower abdomen (pelvis), rotated, short
ureter.
o Problems: chronic pyelonephritis, calculi, hydronephrosis.
 Crossed ectopia:
o Right kidney in the left side.
o The right ureter is inserted in the right side of bladder.
 Horseshoe kidney:
o Incidental finding.
o Caused by fail of separation (usually lower poles fused).
o Use KUB, US, CT, MRI.
o Problems: PUJ obstruction, stone formation.
o IVU shows:
 The kidneys at low position.
 Close to the spine with long axis parallel to the spine.
 Malrotation manifested by medially directed calyces.
 The renal pelvis and ureters are anterior and lateral in
position.
 Adult polycystic disease:
o Bilateral numerous cysts of variable size contain fluid.
o Present after the third decade of life, familial.
o Clinically  renal colic, loin mass, hematuria,
hypertension, ended with renal failure.
o IVU findings:
 Large kidney with lobulated outline.
 Distortion of P.C.S.
 In advanced cases there is elongation and
stretching of minor and major calyces (spider leg) + non-functioning kidney.
 Infantile polycystic disease:
o Usually affect liver, spleen, pancreas  Incompatible with life.
o Bilateral large kidney due to numerous small cysts (1-2 mm size).
o The outline is not lobulated as in adult.

33. o I.V.U, may be normal.
o Nephrogram shows minute filling defects.
 PUJ obstruction (infantile hydronephrosis): by IVU
o Marked dilatation of pelvis and may be extra-renal.
o Calyceal dilatation is late and in advanced cases form foot
shape P.C.S.
o The ureter is normal or not seen.
o Delayed film with I.V. diuretic produce gross dilatation.
Q: why not hydronephrosis? Infant patient, no cause of hydronephrosis like mass or stone,
there is PUJ obstruction.
 Bifid collecting system and ureter:
o Unilateral or bilateral.
o Partial  only P.C.S is bifid, 10 %of population.
o Complete  two ureters may be separate down to their
insertion into the bladder, 1-2 % of population.
o Upper moiety ureter  inserts inferior and medial to its
normal site, or ectopically to vagina or urethra leading to
urine incontinence, if beyond urethral sphincter, may
associate with obstruction or uretrocele.
o Lower moiety ureter  inserts into normal anatomical
position, usually associated with reflux.
 Retrocaval ureter :
o In the right ureter only.
o Behind inferior vena cava.
o Lead to obstruction of upper third of ureter and
hydronephrosis.
 Mega ureter:
o Cause is unknown.
o Unilateral or bilateral dilatation of the ureter.
o No evidence of organic obstruction (stone, mass).
o Should exclude stone, then say mega ureter.
 Ureterocele:
o Congenital cystic dilatation of lower end of ureter (intra-mural
part) due to pin-hole meatus.
o Simple  the orifice is in proper position of bladder.
o Ectopic  in bladder neck, urethra, uterus, vagina.
o IVU findings :
 Cobra head appearance  rounded or elliptical dilatation
of lower end of ureter with thin lineal filling defect around it.

34.  Proximal dilatation of rest of ureter.
 In advanced cases  hydronephrosis.
 In obstructed ureterocele  filling defect in the bladder.
 Ectopia vesicae:
o Bladder located at low position.
o Plain x-ray shows separation of symphysis pubis.
o Bladder exstrophy (also known as ectopia vesicae) refers to
a herniation of the urinary bladder through an anterior
abdominal wall defect.
5- Other conditions:
 Neurogenic bladder:
o Irregular shape of the bladder called christmas tree sign.
 Benign prostatic hyperplasia:
o IVU show filling defect in the bladder which could be stone,
tumor or BPH and we can differentiate between them by
clinical picture.
o In male  BPH lead to filling defect in the base on bladder.
o In female  uterus compress the bladder from above.
 Multicystic dysplastic kidney:
o Hypoechoic cysts of variable sizes and shapes.
o Interfaces between cysts.
o Absence of an identifiable renal sinus.
o Lack of communication between cysts on sonograms.
o Minimal surrounding parenchyma.
 Vesical diverticulum:
o Filled with contrast.
o Connected to the bladder posteriorly.
 Vesicoureteric reflux:
o Detected by voiding cystourethrogram.
o The contrast ascending to the lower ureter (unilateral or bilateral).
 Urethral stricture:
o Use ascending cystourethrogram.
o Area of narrowing in the urethra.
For more photos about renal system:
www.muhadharaty.com/lecture/4213
www.muhadharaty.com/lecture/3340

35. Part3: Radiology of musculoskeletal system
Basic information
Types of study:
 Plain bone radiographs.
 Radionuclide bone scan.
 CT scan.
 MRI.
1- Plain bone radiographs:
 Radiological signs of bone diseases need longer time to develop in adults than in
children.
 Normal X-ray of the bone does not exclude the presence of pathology for example
osteomyelitis in children and scaphoid fracture in the first week.
Conventional radiological signs of bone diseases:
 Decreased bone density:
o Focal (lytic area or area of bone destruction).
o Generalized (osteopenia  either osteoporosis or
osteomalacia).
 Increase bone density: sclerosis (focal or generalized).
 Periosteal reaction:
o Definition: new bone formation by the periosteum.
o Normal periosteum is not visible.
o Types:
 Solid periosteal reaction  e.g. osteoid osteoma (A).
 Single laminated periosteal reaction  e.g. Brodie's abscess (B).
 Multi-laminated periosteal reaction  e.g. Ewing's sarcoma (C).
 Hair-on-end periosteal reaction  e.g. Ewing's sarcoma (D).
o Causes:
 Trauma, Tumors, Infection, Inflammation.
 Metabolic: thyroid achropachy, hypertrophic osteoarthropathy,
hypervitaminosis A.
 Vascular: venous stasis.
 Physiological: in 35% of infants between 1-6 months.
 Congenital: syphilis, osteogenesis imperfecta.

36.  Cortical thickening:
o Caused by lying down of new bone by the periosteum for long duration of time.
o It indicates slow process.
o The thickened cortex appears irregular and dense.
o Causes: chronic osteomyelitis, stress fracture, healed trauma, bone tumors as
osteoid osteoma.
 Alteration of trabecular pattern:
o Definition: reduction in the number of trabeculae with alteration in the remaining
trabeculae.
o In osteoporosis  there is cortical thinning and trabeculae that remain become
more prominent than usual.
o In Paget's disease  the trabeculae are thickened and extend into the compact
cortex that normally devoid of trabeculae.
 Alteration in the shape of the bone:
o As in osteogenesis imperfecta, acromegaly & expanding bone tumors.
 Alteration of bone age:
o The best site of assessment of bone age is at the wrist, hands, and in newborn the
knee joint.
o In cretinism there is delayed appearance of the epiphyseal bone centers.
2- Radionuclide bone scan:
 Tc99m- labelled with phosphate complex is a bone seeking agent.
 Given IV and excreted in urine.
 Advantages  any lesion in the bone will take it and appear as hotspot
area in the bone.
 Disadvantages  it is not specific and cannot differentiate between
different bone diseases because it is taken up by soft tissue
calcifications, areas of tissue damage, soft tissue tumors.
 Positive scan shown as increased uptake (hot areas) seen in  trauma,
tumor, infection, infarction, Paget's disease.
 Indications:
o Detection of metastases.
o Detection of osteomyelitis.
o Determination if the lesion is solitary or multiple.
o Determination (in equivocal cases) of whether an abnormality seen on radiograph
is significant or not.
o Investigation of clinically suspected bone lesion despite normal radiographs.
o Investigation of painful hip prosthesis.

37. 3- CT scan:
 CT scan in bone imaging is similar to x-ray but with high level of
radiation emitted.
 Bone window setting is required  (Window width window
level 3000450 ) for optimum results.
 Indications:
o Abnormality in complex bones (spine, pelvis, face, skull).
o In orthopedic (compound fractures, gunshot injury, knee joint injury, shoulder
dislocation).
o Determination of the local extent of bone tumor (within, outside the bone, soft
tissue invasion).
o Planning for surgery (3D CT in planning corrective surgery for fracture & bone
deformity).
o Guide for bone biopsy.
 Bone:
o Cortex  need time for H+ molecule to enter and give signal.
o Medulla  bone marrow / fat (not need time to give signal because H+ molecule
enter through it easily).
 Use US for:
o Abscess.
o Cellulitis.
o Sub-periosteal reaction.
4- Magnetic resonance imaging (MRI):
 Calcified structures produce signal void areas on MRI.
 Indications:
o Showing the intra and extra-osseous extent of bone pathology.
o Investigation of disc (bulging, herniation, prolapse) and spinal stenosis.
o Grading of disc lesions.
o Assessment of soft tissue masses, cartilage, ligaments, meniscal injury, avascular
necrosis.
o Used when nerve being compressed.

38. Solitary Bone Lesion:
Causes:
 Bone tumors (benign, malignant).
 Tumor like conditions (fibrous cortical defect, fibrous dysplasia, bone cyst).
 Osteomyelitis.
 Conditions of uncertain origin (Langerhans histiocytosis, osteoid osteoma).
Assessment of radiological findings in bone lesion:
 Check the age and sex of the patient:
o Osteosarcoma (10-35 years).
o Ewing's sarcoma (3-5 years).
 Site:
o Metaphyseal lesion (osteomyelitis).
o Sub articular (giant cell tumor).
o Appendicular skeleton (primary bone tumor).
o Axial skeleton (multiple myeloma, metastases).
 Edge (zone of transition):
o Well defined clear cut with narrow zone of transition  benign or slowly growing
lesion.
o Ill-defined wide zone of transition  aggressive rapidly growing lesion
(osteomyelitis, malignant tumors).
o Well defined lytic lesion with no sclerotic margin metastases, myeloma.
 Adjacent cortex:
o Cortical destruction (osteomyelitis, malignant tumors).
o Cortical expansion with no destruction (fibrous dysplasia, enchondroma).
 Periosteal reaction:
o Osteomyelitis.
o Malignant tumors (osteosarcoma, Ewing's sarcoma).
o Metastasis (Neuroblastoma).
 Calcification:
o Well defined, patchy popcorn (cartilaginous origin).
o Ill-defined speckles (osteoid forming tumors as in osteosarcoma).
 Soft tissue swelling:
o Ill-defined swelling with blurring of the tissue fat planes due to edema 
inflammation as osteomyelitis.
o Well defined swelling with displacement of clear cut fat planes  tumors.

39. Malignant bone tumors:
Information:
 Secondary bone tumors (metastases) are the commonest malignant tumors affecting
the bone.
 Osteosarcoma is the commonest primary malignant bone tumor in young adults.
 Use  conventional X-ray, CT, MRI (show the extent within the bone marrow, soft
tissue involvement).
General features on X-ray are:
 Area of bone destruction or sclerosis
 With ill-defined margins.
 Wide zone of transition.
 Periosteal reaction.
 With or without cortical destruction.
 Soft tissue swelling.
1- Osteosarcoma:
 Age: 5-20-years or in elderly with Paget's disease.
 Site: metaphyseal around the knee joint.
 Presentation: history of trauma, pallor, fever, anorexia.
 Types:
o Lytic  destruction of cortex, multiple lesions.
o Blastic  new bone formation in dense form along with excessive area of
sclerosis.
o Mixed  there is destructive lesion in the center surrounded by area of sclerosis.
 Plain x-ray findings:
o Poorly defined bony destruction.
o Sun ray speculation  periosteal reaction.
o Codman's triangle  elevation of the periosteum at the margin.
o Cortical destruction.
o Soft tissue swelling.
2- Chondrosarcoma:
 Age: 30-50 years.
 Site: pelvic bones, scapula, humerus, femur.

40.  Findings:
o Ill-defined expanding lytic lesion.
o Flecks of calcification.
o Periosteal reaction.
o Large extra osseous component.
3- Ewing's sarcoma:
 Highly malignant with tendency to metastasize.
 Age: children.
 Site: shaft of long bone.
 Findings: ill-defined destruction with onion peal
periosteal reaction.
 Note: sometimes we find sunray speculation in
Ewing's sarcoma.
4- Giant cell tumor:
 Slowly growing, locally invasive, rarely metastasize.
 Age: after closure of epiphysis (20-40 years).
 Site: around knee & wrist joints.
 Findings:
o Lytic expansile lesion (soap bubble appearance).
o Sub articular in location.
o Not clearly defined margin.
o Thinning of the cortex (sometimes with destruction of cortex).
o No soft tissue affection.
o It is centric or peri-centric.
o Not pass through the diaphyseal plate.
Benign bone tumors and tumor like conditions:
Features of benign tumors in X-ray film:
 Well demarcated.
 Cortical expansion but no destruction (unless pathological fracture occurred).
 No periosteal reaction (unless pathological fracture developed).
Sunray speculation onion peal

41.  No soft tissue mass.
 No or little increase in uptake on bone scan (unless pathological fracture developed).
1- Osteochondroma (exostosis):
 Exostosis  is cartilage-covered bony projection on the external surface of a bone.
 Most common benign bone lesion.
 Age: < 20 years.
 Location: tibia, femur, humerus.
 Malignant transformation (in < 1%) if:
o Pain in the absence of fracture, bursitis, nerve compression.
o Growth of lesion after skeletal maturation
o Dispersed calcifications in the cap.
o Enlargement of lesion.
o Increased uptake on bone scan.
 Types:
o Pedunculated: slender pedicle directed away from growth plate.
o Sessile: broad base.
 Characteristic findings:
o Metaphyseal location (cartilaginous origin).
o Continuous with parent bone.
o Cauliflower-like calcification in the chondrous portion of cap.
o Lesion grows away from joint.
 Multiple osteochondromas called Diaphyseal aclasia.
 If the thickness > 1 cm of cartilaginous cap by CT, > 2 cm by MRI give
high possibility of malignant transformation.
2- Enchondroma:
 Site: small bones of the hands & feet.
 Clinical features: painless asymptomatic swelling.
 Findings:
o Lytic lesion.
o Expansion &thinning of the cortex.
o No periosteal reaction (unless pathological fracture develops).
 1 % risk of malignant transformation in solitary type
 Multiple enchondromatosis (Ollier's disease) affect long bones &
carry 10% risk of malignant transformation.

42. 3- Osteoma:
 It is excess lying down of normal bone (not tumor).
 Localized masses of mature bone on the endosteal or
periosteal surface of cortex.
 Commonly in the skull or paranasal sinuses.
 Could be single or multiple.
 Multiple osteoma associated with Gardner's syndrome
(familial colorectal polyposis).
4- Fibrous cortical Defect & Non ossifing Fibroma (NOF):
 Common incidental findings in children.
 Site: affect diaphysis of long bone.
 Findings: well defined lucent areas in cortex with sclerosed margin.
5- Fibrous Dysplasia:
 Defect in the osteoblastic development and maturation as a result of mutation.
 Monostotic:
o Age: 10~30yrs.
o Site: ribs, proximal femur, craniofacial bones.
o Usually asymptomatic.
 Polystotic:
o Age: at first decade.
o Site: femur, tibia, pelvis, cranial bones, spine, feet.
o Usually unilateral, asymptomatic.
 It causes leg length discrepancy,
 Findings:
o Shepherd crook deformity (coxa varus angulation of the proximal femur).
o Facial asymmetry, rib deformity, tibial bowing associated with
hyperparathyroidism, acromegaly, DM.
o Lytic expansile lesion.
o Ground-glass matrix mineralization.
o Sclerosed margin.
6- Solitary bone cyst:
 Age: young adults & children.
 Site: long bones.

43.  Findings:
o Well-defined expanding lytic lesion.
o Fallen fragment sign  a piece of cortical bone has broken off and descended
through the serous fluid contained within the lesion and can be seen in the
dependent portion of the lesion.
o A fallen fragment sign is said to be pathognomonic for a unicameral bone cyst.
7- Aneurysmal bone cyst:
 Benign but may be aggressive in appearance.
 Age: children, young adults.
 Site: spine, long bones, pelvis.
 Occur in the metaphyseal area.
 DDx: giant cell tumor.
 Findings:
o Purely lytic lesion (soap bubble appearance).
o Massive cortical expansion (can expand upward with expansion).
o CT and MRI show blood pools (fluid -fluid levels within the cyst).
8- Osteoid osteoma:
 Age: young adults.
 Site: tibia, femur.
 Presentation: benign, fever, sweating, painful escpically at night.
 It is excessive lay down of bone inside the cortex + sclerosis.
 Managed by aspiration to relieve the pain.
 Findings:
o Lucent area surrounded by calcification.
o Nidus surrounded by sclerotic rim with or without periosteal reaction.
o Radionuclide bone scan: area of increased uptake.
9- Hemangioma:
 Occur in the vertebra.
 It is asymptomatic condition.
 No change in the size of vertebral disc.
 Fat tissue in the vertebra.
 Incidental finding.
 MRI show vertebral bodies high lightened.

44. Multiple focal bone lesions:
1- Metastases:
 Seen in bone with active haemopoiesis (spine, skull, ribs, pelvis, humeri, femora).
 Metastases site of predilections:
o Vertebral metastases (94%) causing primarily affection of the pedicle.
o Intradural extramedullary metastases (5%)
o Intramedually metastases (1%)
 Types of metastasis:
o Osteolytic (most common causes)  neuroblastoma (in children), breast (adult
female), bronchus (adult male), thyroid, kidney, colon, vertebral pedicles.
o Osteoblastic  prostate, breast, carcinoid, TCC of bladder, neuroblastoma.
o Mixed  breast, prostate, lymphoma.
o Solitary expansile bubbly metastases with soft tissue involvement  thyroid,
kidney.
o Bone metastases with sun burst periosteal reactions  prostate, retinoblastoma,
neuroblastoma.
2- Multiple Myeloma:
 Site: axial skeleton.
 Findings:
o Well demarcated lytic lesion occasionally with expansion of the
bone.
o Rain drop appearance  in the skull.
o In the spine Generalized form can resemble osteoporosis.
 Solitary type (plasmacytoma):
o Represent early stage of MM; precede it by 1-20 years.
o Negative IgG spike in the serum.
o It affects the thoracic, lumbar spine, pelvis, ribs, femora.
o It is seen as expansile lytic ill-defined lesion with soft tissue mass.
 Differences:
o Secondary metastasis  multifocal lesion, expansile or not, bence jones protein
not present.
o Multiple myeloma  multiple, expansile, lytic lesion, bence jones protein is
present.
o Myeloma resembles metastases in everything except  it's more well defined,
cause bone expansion and spares vertebral pedicle.

45. Bone infections:
1- Osteomyelitis:
 Information:
o Osteomyelitis refers to inflammation of bone that is almost always due to
infection (staphylococcus aureus 80-90%).
o Osteomyelitis can occur at any age (commonly 2-12 years of age).
o More common in males (M:F of 3:1).
o Osteomyelitis results from hematogenous spread, direct extension from trauma
or ulcers.
o Metaphysis is the most common site of bone infection because this area is highly
vascularized so there is hematogenous spread of the infection.
 Location:
o Neonates  metaphysis, epiphysis.
o Children  metaphysis.
o Adults  epiphyses, subchondral regions.
 The earliest changes:
o Are seen in adjacent soft tissues +/- muscle outlines.
o Swelling and loss or blurring of normal fat planes.
o Changes may not be obvious until 5 to 7 days in children and 10 to 14 days in
adults.
 Acute osteomyelitis:
o Regional osteopaenia at site of infection.
o Periosteal irritation and reaction  Moth eaten appearance.
o Formation of a Codman's triangle.
o Focal bony lysis or cortical loss.
o Endosteal scalloping.
o Loss of bony trabecular architecture.
o New bone apposition.
 Chronic or untreated osteomyelitis:
o Sequestrum  dead bone represents devascularization
of a portion of bone.
o Involucrum  new bone formation represents a thick
sheath of periosteal new bone surrounding sequestrum.
o Cloaca  an opening in an involucrum which allows
drainage of purulent and necrotic material out of the
dead bone.
o Sinus tract  it is portion of tract extending beyond the
involucrum to the skin surface.

46.  Special types of chronic osteomyelitis (depend on type of organism and immunity):
o Brodie’s abscess  a localized osteolytic lesion at the end of the long
bone surrounded by sclerosis.
o Gary’s osteomyelitis (Sclerosing osteomyelitis)  Characterized by
localized sclerosis in the shaft of long bone, and it typically affect the
mandible. DDx ostiod osteoma.
2- Tuberculosis of the bone:
 Spread from infected joint.
 Most common site  dorsolumber part of spine.
 More than 90% of adult (40 years)  T.B infection located in vertebra.
 Osteomyelitis in adult is less than in children because in adult there is complete
sclerosis but in children this area still vascularized / but TB in adult is more common
and can still in area of low vascularity (low O2) so T.B in adult is subarticular or
subchondral in long bones.
 TB of long bones (early findings):
o Osteopenia in proximal area.
o Soft tissue swelling.
o Destruction of articular surface.
o Moth eaten not occur / sclerosis only slightly.
 Pott’s Disease (findings in the spine):
o Affect two adjacent vertebrae.
o Erosion of the superior and inferior end plates.
o Irregular narrowing of the joint space.
o Para-spinal cold abscess (seen as a fusiform para spinal soft tissue on AP or PA
view of the chest).
o End with wedging of the vertebra (anterior loss of vertebral height) lead to
angular kyphosis.
o Gebus deformity (wedging of the vertebra, sign of old T.B, occur after treatment
and healing).
 T.B Dactylitis or spina ventosa:
o T.B of peripheral bone is not common and usually affect the
small bones (phalanx).
o There will be destruction of the phalanx.
o Expansion of middle metacarpal bone + dense sclerosis.
o Expansion with soft tissue shadow around it.

47. Generalized decrease in the bone density:
1- Osteoporosis:
 Reduction in the bone matrix that subsequently results in reduced calcium contents.
 Causes:
o Idiopathic: juvenile, senile and postmenopausal.
o Cushing syndrome & steroid therapy.
o Disuse (immobilization for fracture treatment or local pain).
o Sudeck's atrophy (disorder of the sympathetic nervous system where sever
osteoporosis and soft tissue edema occur disproportionate to the trauma or the
degree of disuse).
 Findings:
o The changes are best seen in the spine.
o Wedged vertebra with widening of the disc space.
o Overall reduction in bone density.
o Clear penciled in cortex.
o Long bones (thin cortex, resorption of many trabeculae
but those that remain stands out clearly).
 Other causes of reduced bone density:
o Metastatic carcinoma.
o Multiple myeloma.
o Hyperparathyroidism.
o Osteomalacia.
 Bone mass assessed by quantitative CT or by dual energy X-ray (DEXA scan).
2- Rickets and Osteomalacia:
 Poor mineralization of osteoid (decrease in number of osteoid tissue in the matrix).
 If occur before epiphyseal closure then it is rickets, after that called osteomalacia.
 Causes:
o Dietary deficiency of Vit.D.
o Lack of exposure to sun light.
o Malabsorption.
o Renal disorders.
 Findings in rickets:
o The findings are best seen at the knee, wrist, ankles.
o Frayed, cupped, splaying of the metaphysis.
o Increased distance between the growing epiphysis &
metaphysis.

48. o Generalized decrease in bone density.
o Bossing and bowing deformity (due to softening).
o Greenstick fractures.
o Rackety rosary of the ribs.
 Findings in osteomalacia:
o Decrease bone density (osteopenia).
o Thin cortex and trabeculae.
o Looser's zones:
 These are thin short lucent lines with sclerotic margins running
across the cortex at right angle.
 Best seen in the scapula, medial aspect of the femoral neck,
pubic rami.
o Codfish appearance  vertebral collapse resulting in biconcave
vertebra with widened disc.
o Bowing of the femur.
o Triradiate pelvis  in severe cases the pelvic side walls bend
inwards, lead to waddling gait.
 After treatment with Vit.D = appearance of dense line of calcification
(dense sclerosis).
3- Hyperparathyroidism:
 Primary hyperparathyroidism (tumors of the parathyroid glands).
 Secondary hyperparathyroidism (with chronic renal failure).
 Findings in hand:
o Subperiosteal bone resorption (in the radial aspect
of the middle phalanges).
o Resorption of the terminal tuft of terminal phalanges
and outer end of the clavicle.
o Decrease bone density with loss of corticomedullary
differentiation.
o Vascular calcification, soft tissue calcification, multiple callus
formation (chondrocalcinosis).
o Brown tumor (lytic expansile lesion particularly in mandible &
pelvis).
 Findings in skull:
o Salt and pepper sign (multiple tiny hyperlucent areas in the
skull vault caused by resorption of trabecular bone).
o Loss of definition between the inner and outer tables of the skull.
o Ground-glass appearance.
o In multiple myeloma (dots = 3-4 mm), in hyperparathyroidism (dots = 1-2 mm).

49. 4- Renal Osteodystrophy:
 Occurs in patients with chronic renal failure.
 Findings:
o Features of osteomalacia in adults & rickets in children.
o Features of hyperparathyroidism.
o Sclerosis: bands of increased density in the spine named as
rugger jersey spine & across the metaphysis of long bones.
5- Osteogenisis imperficta:
 Imperfect bone formation with multiple callus formation and
multiple bone fractures.
 Die within 2-3 years or still birth due to associated CHD.
 Findings:
o Generalized decrease in bone density
o The medulla is very thin.
o Multiple bone deformity (large, small, flat bones) due to multiple
fractures and bizarre healing.
o Widening of the sutures and wormmian bone formation.
Generalized increase in the bone density:
1- Sclerotic metastases.
2- Osteopetrosis (Marble bone disease): Congenital condition, the
bone is brittle & easily fracture but heals normally.
3- Myelosclerosis: Replacement of the bone marrow by fibrous tissue
& progress to lay down new bone, splenomegaly is invariably present.
4- Fluorosis.
Wormmian bone  Are a subset of the small intra sutural
bones that lie between the cranial sutures mainly seen
around the lambdiod sutures.
Causes:
 Osteogenesis imperfecta.
 Rickets.
 Cleidocranial dysostosis.
 Hypothyroidism.
 Down syndrume.

50. Arthritis:
1- Osteoarthritis (OA):
 It is type of degenerative joint disease (DJD).
 80% of population > 50 years have radiological evidence of OA.
 Types:
o Primary OA  no underlying local etiological factors, abnormally high mechanical
forces on normal joint, age related.
o Secondary OA  trauma, inflammatory arthritis,
hemochromatosis, acromegaly, congenital hip dysplasia,
osteonecrosis, loose bodies, normal forces on abnormal joint.
 Radiographic features (OA changes):
o Narrowing of joint space (usually asymmetrical).
o Subchondral sclerosis.
o Subchondral cysts (true cysts or pseudocysts).
o Osteophytes.
o Lack of osteoporosis.
 In the Spine:
o Lower cervical and lower lumbar spine are most commonly affected.
o Osteophytes may encroach on neural foramina (best seen on oblique views).
o Vacuum phenomenon: gas (N2) is pathognomonic of the degenerative process.
o OA of the spine occurs in the apophyseal joints.
o Degenerative spondylolisthesis (pseudospondylolithesis).
o No wedging in vertebra like that occur in T.B.
 In the knee  OA changes + elongation and spike formation
of tibial space (tibial sper).
2- Rheumatoid arthritis (RA):
 It is type of inflammatory arthritis.
 F:M = 3:1.
 Start at peri-articular area at site of attachment of ligaments.
 Early changes:
o Peri articular soft tissue swelling (edema, synovial
congestion)
o Peri articular osteoporosis in symmetrical distribution
(hallmark)
o Preferred sites of early involvement:
 Hands: 2nd
and 3rd
MCP joint.
 Feet: 4th
and 5th
MTP joint.

51.  Late changes
o Erosions (pannus formation, granulation tissue).
o Erosions of the ulnar styloid and triquetrum are characteristic.
o Subchondral cysts formation (results from synovial fluid).
o Subluxations.
o Carpal instability.
o Ulnar deviation.
o Fibrous ankylosis (late finding).
o Narrowing or loss of joint space between metacarpal bones.
o Boutonniere deformities.
o Swan-neck deformity.
3- Ankylosing spondylitis (AS):
 Information:
o Seronegative spondyloarthropathy of the axial
skeleton and proximal large joints.
o Clinical: males >> females.
o HLA-B27 in 95%.
o Insidious onset of back pain and stiffness.
o Onset: 20 years.
 Radiographic features:
o Sacro-iliac joint  start as inflammation then destruction then sclerosis then
ankylosing.
o Thoracolumbar spine  bridging osteophyte or called syndesmophytes (lateral
view: squaring) (PA view: Bamboo spine).
o Vertebra filled with osteoid tissue lead to sclerosis.
o Ligamentous ossification  calcification of anterior spinal ligament.
o Ankylosed spine (fracture).
o Enthesopathy (whiskering of tuberosities).
o Arthritis of proximal joints (hip > shoulder).
o Widening of joint space, erosions, osteophytes.
4- Diffuse idiopathic skeletal hyperostosis (DISH):
 Radiographic features:
o Flowing osteophytes (at least four contiguous vertebral
bodies).
o Preserved disk height.
o No sacroiliitis or facet ankylosis.

52. o Calcification of ligaments and tendons.
o Associated with hypertrophic DJD.
 It is one of the DDx of ankylosing spondylitis:
o Differentiate between them by the changes in sacro-iliac joint.
o Spinal changes are similar in both.
5- Erosive osteoarthritis:
 Characteristically affects middle-aged women.
 Radiographic features:
o Erosive and productive changes of DIP and PIP.
o Gull-wing pattern: secondary to central erosions,
occur in distal and proximal phalanges.
o Marginal proliferation osteophytes.
o Interphalangeal fusion may occur.
 Typical involvement of first CMC may help distinguish
erosive OA from RA, psoriatic arthritis, and adult Still's disease.
 No affection to metacarpal joints (RA affect them).
6- Gout:
 Information:
o Site of predilection is big toe (First MTP).
o Lower extremity > upper extremity.
o Small joints > large joints.
o Presence of tophi (excessive amount of uric acid).
o Erosions and tophi only seen in longstanding disease.
 Radiographic features:
o Soft tissue and bursa deposition:
 Tophi: juxtaarticular, helix of ear.
 Bursitis: olecranon, prepatellar.
o Tophi lead to punched-out lytic lesion + overhanging edge
(seen in lateral view as sclerosis at the base of punched out
lesion).
o Tophi calcification
o Marginal, peri articular erosions: overhanging edge
o Erosions may have sclerotic borders.
o Joint space is preserved.
o Chondrocalcinosis.
o Snow-night appearance.

53. 7- Septic arthritis:
 Cause:
o Organism  Staphylococcus aureus (most common), B-Streptococcus in infants,
Salmonella in sickle cell patients.
o Hematogenous spread to synovium and subsequent
spread into the joint.
o The diagnosis is made by joint aspiration.
 Radiographic features:
o Joint effusion.
o Juxtaarticular osteoporosis.
o Destruction of subchondral bone on both sides of the joint.
 Same as TB arthritis but joint space is preserved and it healed by sclerosis.
8- Neuropathic arthritis (Charcot's joint):
 Causes:
o Diabetes neuropathy: usually foot.
o Tertiary syphilis: usually knee.
o Syringomyelia: usually shoulder.
o TB, immobility, long standing polio.
 Radiographic features:
o Joint instability: subluxation or dislocation.
o Prominent joint effusion.
o Hypertrophic type (20%)  marked fragmentation of articular bone, much
reactive bone.
o Atrophic type (40%)  bone resorption of articular portion.
o Combined type (40%).
 Other changes:
o Reduction of joint space.
o Osteophytes.
o Osteopenia.
o OA changes.
o Joint deformity.

54. Other conditions:
1- Alteration in the Trabecular Pattern  in Hemolytic anemia:
 Thalassemia and sickle cell anemia result in bone hyperplasia.
 Sickle cell anemia in addition causes infection & infarction.
 Bone marrow hyperplasia:
o Thinning of cortex.
o Increase thickness of bone with resorption of some trabeculae
and increase thickness of the remaining.
o Increase diploic space thickness with vertical striation resulting
in hair on end appearance.
o Enlargement of ribs.
o Widening of the phalanges (cylindrical shape appearance of
the hand).
 Infarction:
o Infarction of the bone ends results in sclerosis and flattening of
the femoral & humeral heads
o Medullary infarction appears as lytic areas with or without
periosteal reaction.
o Healing appears later as areas of irregular medullary calcification.
2- Changes in Bone Shape:
Diaphyseal achalasia (in page 41).
Achondroplasia:
 Defective ossifications of bones formed in cartilages.
 Shortening of the shaft of the long bones with distal metaphyseal flaring.
 Deformity of the pelvis (contracted pelvis).
 Bullets like vertebrae due to anterior beaking.
Acromegaly:
 The bone changes are maximum at the hands, feet & face.
 Increase joint space due to overgrowth of cartilage.
 Enlargement of the tufts of the terminal phalanges.
 Enlargement of the pituitary fossa double floor sign.
 Thickening of occipital tubercle.
 Widening of the skull vault and frontal bone posing.
 Enlargement of the sinuses & mastoid air cells.
 Prognathisim: widening of angle between the body and ramus of the mandible.

55. 3- Osteonecrosis:
 Other names: avascular necrosis, ischemic necrosis,
aseptic necrosis.
 Causes: Interruption of arterial supply,
Intra/extraosseous venous insufficiency.
 MRI  Most sensitive imaging modality: 95%-100%
sensitivity.
 Plain film findings:
o Areas of radiolucency, fissuring, fragmentation, bone collapse and condensation.
o End with dense and flat bone with loss of bone contour and secondary
osteoarthritis.
4- Osteochondrosis:
 Legg-Calve-Perthes disease  osteochondrosis of the femur head, lead to mushroom
deformity, for early OA changes.
 Scheuermann's disease (adolescent Kyphosis)  osteochondrosis of the vertebral end
plates, lead to vertebral wedging ending with kyphosis.
 Osgood-Schlatter  osteochondrosis of the tibial tubercle.
 Blount's disease  tibial epiphysis.
 Kohler's  osteochondrosis of the Navicular bone (flat disk like shape).
 Kienbock's  osteochondrosis of the lunate bone.
 Osteochondritis dissecans  medial femoral condyle, talus, trochlea, resulting in
intra-articular loose body.
5- Developmental dysplasia of Hip (congenital dislocation of the hip):
 Information:
o An abnormally lax joint capsule allows the femoral head to fall out of the
acetabulum, leading to deformation.
o Predisposing factors for the development of CDH  Abnormal ligamentous laxity,
Acetabular dysplasia.
o CDH occurs most commonly (70%) in the left hip, bilateral involvement is seen in
5%.

56.  Radiographic features:
o 1-3 months:
 Best diagnosed by US (safe).
 In CDH < 50% of femoral head is covered by acetabulum (normally = 50%).
o At 3-6 months :
 Plain x-ray with Von Rosen view (abduction of the thigh 45 degree and internal
rotation).
 In DDH the lines that drown through the femura will meet in higher level than
the normally should at lumbosacral joint.
 Never crossed at lumbo-sacral joint.
o 6 months and later:
 Use AP view to visualize femoral epiphysis.
 Superolateral displacement of proximal femur (disturbed shenton’s line)
 Femoral head is located lateral to Perkin's line.
 Increase in acetabular angle.
 Small capital femoral epiphysis.
 Retardation of epiphyseal plate (tubercle).
o Other features that are sometimes present:
 Abnormal sclerosis of the acetabulum.
 Shallow acetabulum.
 Formation of a false acetabulum.
 Delayed ossification of femoral head.
 Old neglected CDH  pseudoathrosis of femoral head with iliac bone.
 Shenton line  is drawn along the inferior border of the superior pubic ramus and
should continue laterally along the infero medial aspect of the proximal femur as a
smooth line. If there is supero lateral migration of the proximal femur due to DDH
then this line will be discontinuous.
 Perkin line  is drawn intersecting the lateral most aspect of the acetabuler roof &
iliac crest.

57. 6- Spondylolysis and spondylolisthesis:
 Spondylolisthesis:
o Is a term denoting forward or backward movement of a
vertebra relative to the vertebral segment below.
o Typically due to spondylolysis (pars interarticularis defects).
 Spondylolysis:
o Is a defect in the pars interarticularis of the neural arch.
o The portion of the neural arch that connects the superior and
inferior articular facet in which cause defect in the neck of
scotty dog.
 Scotty dog sign:
o Refers to the normal appearance of the lumbar spine when
seen on oblique radiographic projection.
o On oblique views, the posterior elements of vertebra form
the figure of a Scotty dog with:
 The transverse process being the nose.
 The pedicle forming the eye.
 The inferior articular facet being the front leg.
 The superior articular facet representing the ear.
 The pars interarticularis (the portion of the lamina that lies between the
facets) equivalent to the neck of the dog.
For more photos about musculoskeletal system:
www.muhadharaty.com/lecture/4214
www.muhadharaty.com/lecture/4400
www.muhadharaty.com/lecture/4215

58. Part4: Radiology of the chest
Basic information
Type of imaging modalities:
 Plain chest x-ray.
 Fluoroscopy.
 Computerized tomography CT.
 MRI.
 Radionuclide lung scan.
 Ultrasound.
 Pulmonary angiography.
 Positron emission tomography (PET).
 ECHO.
 Doppler.
 Magnetic resonance angiography (MRA).
Plan chest radiograph:
1- Standard views:
 Postero-anterior (P/A) view:
o The x-ray tube is 72 inches away from
the patient.
o The patient is in the standing
position.
o Most common used view.
 Anterio-posterior (A/P) view:
o The x-ray tube is 40 inches away from the
patient.
o The patient is in the supine position.
o It shows magnification of the heart and widening of the
mediastinum.
o AP view is less useful so used in very ill patient who
cannot stand erect.
 Lateral (Right or left) view:
o Used to see the site of the mass.
o Sometimes used in pleural effusion.

59. 2- Additional views:
 Oblique view (ribs).
 Apical lordotic view:
o Used to get clear view due to presence of clavicle.
 Expiration view.
 Decubitus view:
o Used to detect small amount of pleural effusion.
Notes:
 Correct film: distance from vertebra to clavicle is same at both sides, if not called rotated film so the
patient should repeat the film.
 Posterior ribs appear horizontal, and anterior ribs appear oblique.
 The film should be taken in inspiratory phase, If the image is acquired in the expiratory phase, the
lungs are relatively airless and their density is increased. Also, the raised position of the diaphragm
leads to exaggeration of heart size, and obscuration of the lung bases.
 Diaphragm level  anteriorly (till 6th
rib), posteriorly (till 10th
rib).
Systemic approach in chest radiograph:
 Bone and soft tissue:
o Look at the soft tissues, especially around the neck, the thoracic wall, and the
breasts.
o Fat is less dense than muscle and so appears blacker.
o Note that the edge of fat is smooth.
o Irregular areas of black within the soft tissues may represent air tracking in the
subcutaneous layer "surgical emphysema".
 Heart:
o The heart has a conical form and is enclosed
by pericardium.
o It is positioned posteriorly to the body of the
sternum.
o With one-third of it is situated on the right and two-thirds
on the left of the midline.
o Right border: IVC, right atrium, SVC.
o Left border: left ventricle, left atrium, pulmonary trunk and
arch of aorta.
o Inferior border: right ventricle.
o Superior border: right and left atria, SVC, ascending aorta
and pulmonary trunk.
 Mediastinum:
o It lies in the midline of the chest between the pleural
surfaces of each lung and extends from the sternum to the vertebral column.

60. o The mediastinum contains  heart, great vessels, esophagus, trachea, phrenic
nerve, cardiac nerve, thoracic duct, thymus, mediastinal lymph nodes.
o Anatomical division:
– Superior mediastinum: located between the thoracic
plane inferiorly and the thoracic inlet superiorly.
– Anterior mediastinum: anterior to the pericardium.
– Middle mediastinum: within the pericardium.
– Posterior mediastinum: posterior to the pericardium.
o Relations:
– Superiorly: continuous with the loose connective tissue of the neck.
– Anteriorly: chest wall.
– Laterally: lungs and pleura.
– Posteriorly: thoracic spine.
– Inferiorly: diaphragm.
 Hila:
o The hila (lung roots) consisting of the major bronchi and
the pulmonary veins and arteries.
o There are also lymph nodes on each side (not visible
unless abnormal).
o The left hilum is often higher than the right.
o The hila are not symmetrical but contain the same basic
structures on each side.
o Both hila should be of similar size and density.
o If either hilum is bigger and denser, this is a good indication that
there is an abnormality.
o Lateral surface of the hilum is concave "if convex it means early
problem".
 Pulmonary vasculature:
o Lung markings reflects pulmonary vasculature.
o When this normal markings disappear it means pneumothorax.
 Pleura.
 Lungs:
o The left lung  upper lobe, oblique fissure, lower lobe.
o The right lung  upper lobe, horizontal fissure, middle lobe, oblique fissure,
lower lobe.
o Upper zone in the right lung = upper and middle lobe / in the left lung = upper
lobe.
o Lower zone in the right lung = lower lobe / in the left lung = lower lobe.
o Each lobe has its own pleural covering.
o The horizontal fissure (right) is often seen on a normal frontal view.
o The oblique fissures are often seen on a normal lateral view.

61. In summary - look to the structures in the CXR by the following order:
1- Trachea (position).
2- Heart (position, size, shape, contour).
3- Diaphragm (normal, elevated, gas under it).
4- Costo-phrenic angle (acute, meniscus sign).
5- Lung field (pulmonary markings, patch,
nodule, mass, cavity).
6- Ribs and bones.
7- Soft tissues (surgical emphysema).

62. The heart
1- Cardiothoracic ratio (CTR) = Cardiac Width = Thoracic Width:
 For correct measuring of CTR  the film should be PA view, no
rotation of the patient, should be complete inspiration.
 CTR greater than 1:2 (50%) considered abnormal.
 Enlargement of the cardiac silhouette on chest x-ray can be due to:
o Cardiomegaly (most common):
 Mitral valve disease.
 Congestive heart failure.
 Congenital heart disease:
– Tetralogy of Fallot (boot shape).
– Ebstein anomaly (box shape).
o Pericardial effusion.
o Anterior mediastinal mass.
o Prominent epicardial fat pad.
2- Mitral valve disease:
Typical radiographic features of mitral regurgitation include:
 Left atrial enlargement: convexity or straightening of the left atrial appendage just
below the main pulmonary artery (along left heart border).
 Straight left cardiac border (mitralization).
 Left ventricular enlargement (volume overload).
 Double density sign: the right side of the enlarged left atrium pushes into the
adjacent lung and creates an addition contour superimposed over the right heart.
 Elevation of the left main bronchus.
 Splaying and widening of the carina (above 90 degree).
 Upper zone venous enlargement (pulmonary venous hypertension).
 Features of pulmonary edema.
 Cardiomegaly.
Cardiomegaly Normal CTR

63. 3- Congestive cardiac failure (CCF):
 It can affect the left (common) or right cardiac
chambers or both.
 Left sided congestive cardiac failure = give the
features of pulmonary edema which includes:
o Prominent hilum  due to central
pulmonary venous congestion.
o Cephalization of pulmonary veins  upper
lobe pulmonary venous diversion.
o Pulmonary interstitial edema.
o Pulmonary alveolar edema.
o Cardiomegaly (CTR = 18/30).
o Pleural effusion.
 Clinical features:
o Worsening exercise tolerance.
o Chronic uncontrolled hypertension.
o Rapid onset of dyspnea.
o Atrial fibrillation.
4- Pulmonary edema:
 Defined as an abnormal accumulation of fluid in the extra-vascular compartments of
the lung.
 Radiographic features when pulmonary capillary wedge pressures = 20-25 mmHg:
Septal lines (Kerley lines):
o Are seen when the interlobular septa in the pulmonary interstitium become
prominent.
o This may be because of lymphatic engorgement or edema of the connective
tissues of the interlobular septa.
Kerley A lines Kerley B lines
2-6 cm long 1-2 cm long
<1 mm thick Thin
Oblique Perpendicular
Course towards the hila In the peripheries of the lung (seen at lung bases)
Represent thickening of the interlobular septa Represent thickened sub pleural interlobular septa
 Radiographic features when pulmonary capillary wedge pressures > 25 mmHg:
o Cardio-thoracic ratio (If increased it indicate cardiogenic cause).
o Bat wing pulmonary opacities.
o Peri-bronchial cuffing.
o Kerley lines become more prominent.
1- Pulmonary venous hypertension.
2- Pulmonary edema.
3- Kerley B lines.
4- Pleural effusion.

64. o Pleural effusions.
o Upper lobe pulmonary venous diversion.
Note:
 Interstitial pulmonary edema (Kerley line).
 Alveolar pulmonary edema (Bat wing sign).
5- Pericardial effusion:
 Normal pericardial sac contains approximately 30-50 mL of
fluid.
 Pericardial effusion occur when fluid collects in
the pericardial space.
 Plain radiograph:
o Very small pericardial effusion can be occult on plain film.
o Globe shape heart or pumpkin shape heart  it is
globular enlargement of the cardiac shadow giving
a water bottle configuration.
Causes of congenital heart disease:
Cyanotic CHD Acyanotic CHD
increased pulmonary
vascularity
decreased pulmonary
vascularity
increased pulmonary
vascularity
normal pulmonary
vascularity
 TAPVR
 TGA
 truncus arteriosus
 large AVSD
 single
ventricle without
pulmonary stenosis
 TOF
 pentalogy of
Cantrell
 Ebstein
anomaly with atrial
septal defect
 VSD
 ASD
 AVSD
 PDA
 small shunts
 aortic valve stenosis
 aortic coarctation
 pulmonary stenosis
Interstitial pulmonary edema Alveolar pulmonary edema

65. 6- Tetralogy of Fallot (TOF):
 It is one of the most common cyanotic CHD.
 Has four features  VSD, overriding aorta, right ventricular hypertrophy, pulmonary
artery stenosis.
 Plain films show:
o Boot shaped heart (apex is rounded-tenting from
the head).
o Upturned cardiac apex (due to right ventricular
hypertrophy).
o Concave pulmonary arterial segment.
o Pulmonary oligaemia (due to decreased
pulmonary arterial flow).
o Right sided aortic arch (seen in 25%).
7- Transposition of the great arteries (TGA):
 It is the most common cyanotic CHD (7% of all CHD).
 Cyanosis in first 24 hours of life.
 Frontal chest radiograph classically shows:
o Cardiomegaly.
o Cardiac contours appearing like an Egg on a string sign.
o Apparent narrowing of the superior mediastinum (result
of the aortic and pulmonary arterial configuration).
8- Ventricular septal defects (VSD):
 It is the most common CHD in children.
 It is the second most common CHD in adults
 It typically results in a left to right shunt.
 The chest radiograph can be normal with a small VSD.
 Larger VSDs may show:
o Cardiomegaly (particularly left atrial
enlargement although the right and left ventricle can
also be enlarged).
o Features of pulmonary arterial hypertension.
o Pulmonary edema.
o Pleural effusion.
o And/or increased pulmonary vascular markings.

66. 9- Pulmonary arterial hypertension:
 Results from elevation of the resistance in the pulmonary
arterial bed, usually at the arteriolar level.
 Plain radiograph:
o Elevated cardiac apex (due to right ventricular hypertrophy).
o Enlarged right atrium.
o Enlarged right and left main pulmonary arteries.
o Prominent pulmonary outflow tract.
o Pruning of peripheral pulmonary vessels.
10- Pulmonary venous hypertension (PVH):
 Results from an increase in pressure in the pulmonary
veins, usually as a result of left atrial hypertension.
 This is measured clinically as an increase in the pulmonary
capillary wedge pressure (PCWP) over the normal 12 to 14
mmHg.
 As the pressure approaches 20 mmHg, interstitial edema
develops.
 Common causes of PVH  obstruction to LV inflow, LV systolic dysfunction, severe
mitral regurgitation, acute pulmonary and systemic volume overload.
Eisenmenger syndrome:
 It is a complication of an uncorrected high-flow, high-pressure CHD like VSD.
 Leading chronic pulmonary arterial hypertension and shunt reversal (L to R becomes R
to L).
Important signs:
 Figure of 3 sign  contour abnormality of the aorta with
inferior rib notching.
 Roesler sign  coarctation of the aorta.
 Box shape heart  Ebstein anomaly.
 Boot shaped heart  TOF.
 Egg-on-a-string sign  TGA.
 Figure of 8 heart or cottage loaf heart  TAPVR. Box shape heart

67. The mediastinum
Differential diagnosis of mass in the mediastinum
Anterior mediastinum
 Thymoma.
 Thymic cyst.
 Thyroid neoplasms.
 Thyroid goitre.
 Parathyroid neoplasms.
 Lymphoma (HL, NHL).
 Germ cell tumors.
 Mediastinal teratoma.
 Teratocarcinoma.
Middle mediastinum
 Malignancy.
 Lymphadenopathy.
 Hiatus hernia.
 Thoracic aortic
aneurysm.
 Thyroid mass.
 Bronchogenic cysts.
Posterior mediastinum
 Nerve sheath tumors.
 Neurofibroma.
 Schwannoma.
 Esophageal neoplasm.
 Lymphoma.
 Metastasis.
 Paraspinal abscess.
 Mediastinitis.
 Sarcoidosis.
Note:
 Thymoma is most common primary
neoplasm of the antero-superior
mediastinum.
 Sarcoidosis cause bilateral hilar
lymphadenopathy.
1- Normal thymus gland:
2- Retro sternal goiter:
Chest radiograph:
 Inverted cone shape of homogenous opacity in the
superior mediastinum.
 Narrowing and deviation of trachea to opposite site.
 Cervicothoracic sign: opacity present in upper chest and
lower neck.
 The superior margin of the radio-opacity/mass is
untraceable.

68. 3- Lymphadenopathy:
 Conditions than can result in mediastinal lymphadenopathy:
o Primary lung lung cancer.
o Metastatic malignancies (esophageal, breast, thyroid
cancers).
o Mediastinal lymphoma (large B-cell lymphoma).
o Sarcoidosis.
o Infective (acute suppurative).
o Reactive (follicular hyperplasia, granulomatous TB,
fungal infection, neoplastic, drugs like cyclosporine-
phenytoin-methotrexate).
 Lymphoma is a malignancy arising from lymphocytes or lymphoblasts.
 Lymphoma can be restricted to the lymphatic system or can arise as extra nodal
disease.
 Nodal disease  Hodgkin's disease is almost entirely confined to the lymph nodes.
 Extra nodal disease  Extra nodal HD although uncommon may be found in any
organ system, either as a primary manifestation or as dissemination of systemic
disease.
 Non-Hodgkin lymphoma located inside L.N and extra-nodal.
Bilateral hailer lymphadenopathy:
Well defined mass, lobulated, opaque.
Causes: sarcoidosis, TB, lymphoma, metastasis.
Hodgkin lymphoma:
Widening of mediastinum.
Soft tissue opacity.

69. The lung
Types of pathology that can be detected by CXR:
 Patch or opacity:
o Consolidation (pneumonia/TB)  contain air bronchogram.
o Collapse  loss of volume, deviation of the trachea and mediastinum.
 Mass:
o Single  cancer, hydatid cyst.
o Multiple  metastasis (solid content by CT), multiple hydatid cyst (fluid content
by CT), miliary TB.
o Note  Less than 3 cm = nodule / more than 3 cm = mass.
 Cavity:
o Abscess  A/F level.
o Raptured hydatid cyst  water lilly sign.
o TB cavity  in upper lobe, no A/F level, clinical picture of TB.
 Lesions in the pleura:
o Pneumothorax.
o Pleural effusion.
o Hydropneumothorax.
o Empyema.
1- Consolidation:
 It is a radiological sign that refers to non-specific air-space opacification on a chest
radiograph or chest CT  appear radio-opaque on chest radiograph and chest CT.
 Many things can fill the alveolar spaces:
o Fluid (heart failure).
o Pus (pneumonia).
o Blood (pulmonary hemorrhage).
o Cells (lung cancer).
 Loss of volume:
o Pull the fissure.
o Pull the bronchus.
o Pull the mediastinum.
 Lobar consolidation:
o Increased density/opacity is seen in individual lung lobes.
o Not cross the fissure.
o Air bronchograms can be seen.
o Volume loss not seen.
1- Cavity = wall + air.
2- Without wall = emphysematous ballue.
3- Cavity only air = TB.
4- Cavity + horizontal A/F level = abscess.
5- Cavity + water lilly sign = hydatid cyst.

70.  Multi-focal consolidation:
o Multiple areas of opacity seen throughout the lung.
o Usually ill-defined with peripheral distribution (Starting from bronchi and
spreading outwards).
o Causes  bronchopneumonia, primary malignancy, metastasis.
- Right upper lobe consolidation:
 Increased opacity within the right upper lobe.
 Some loss of outline of the upper right heart
border may be apparent.
 Dense opacity seen above the horizontal
fissure.
 Air-bronchogram line.
 The lower border of the consolidation is
sharply delinated by the horizontal fissure
suggesting it lies in the anterior segment of the RUL.
- Right middle lobe consolidation:
 Opacification of the RML bordered superiorly by
the horizontal fissure, and medially by the right
heart border.
 Indistinct right heart border.
 Loss of the medial aspect of the right
hemidiaphragm.
 Air bronchograms.
- Right lower lobe consolidation:
 Airspace shadowing that abuts the right hemidiaphragm.
 Obliterating the crisp margin of the hemidiaphragm and normal
aerated lung.
- Silhouette sign:
In PA view of right lung:
 Middle lobe pneumonia  heart border not appear but diaphragm border appear.
 Lower lobe pneumonia heart border appear but diaphragm not appear.

71. - Bulging fissure sign:
 Refers to lobar consolidation where the affected portion of the
lung is expanded.
 It is now rarely seen due to the widespread use of antibiotics.
 Most commonly seen in Klebsiella (Friedlander's) pneumonia.
- Left upper lobe consolidation:
- Left lower lobe consolidation:
- Left total lung consolidation:
- Bronchopneumonia (lobular pneumonia):
 Associated with suppurative peribronchiolar inflammation.
 Subsequent patchy consolidation of one or more secondary
lobules of a lung.
 In response to a bacterial pneumonia (child, fever, cough).
 CXR description:
o Multiple ill-defined non homogenous patchy opacification.
o In upper zone only  TB bronchopneumonia.
o In middle or lower zone  Bronchophrenic shadow.
o In middle or lower zone + cardiomegaly  pulmonary edema.

72. 2- Collapse:
 Lobar collapse refers to the collapse of an entire lobe of the lung.
 Atelectasis more generic term for 'incomplete expansion'.
 Individual lobes collapse due to obstruction of the supplying bronchus that caused by:
o Luminal  aspirated foreign material, mucous plugging.
o Mural  bronchogenic carcinoma.
o Extrinsic  compression by adjacent mass.
 Radiological features for all types of collapse = generic markers of volume loss:
o Elevation of the ipsilateral hemidiaphragm.
o Shift of the mediastinum towards the side of atelectasis.
o Crowding of the ipsilateral ribs.
o Crowding of pulmonary vessels or air bronchograms.
- Right upper lobe collapse:
 Use frontal radiographs.
 Increased density in the lobe.
 Elevation of the horizontal fissure.
 Elevation of the right hilum.
 Loss of the normal right medial cardiomediastinal contour.
 Hyperinflation of the right middle & lower lobe (Lead to
increased translucency).
 Right juxtaphrenic peak.
 Generic markers of volume loss.
 Golden S sign  common cause of lobar collapse is a hilar mass.
When a right hilar mass is combined with collapse of the right
upper lobe, the result is an S shape to elevated horizontal fissure.
- Right middle lobe collapse:
 Frontal CXR  opacity cause obscuration of the right cardiac
border.
 Lateral CXR  opacity is tongue like shape and diaphragm is
elevated (triangular in shape in right middle lobe consolidation
and diaphragm not elevated).
- RT lower lobe collapse:
 The medial aspect of the dome of right hemidiaphragm is lost.
 The right hilum is depressed.
 The right heart border which is contacted by the right middle lobe
remains well seen.
 Generic markers of volume loss.

73. - Left upper lobe collapse:
 Note: The left upper lobe collapses anteriorly becoming
a thin sheet of tissue apposed to the anterior chest wall,
and appears as a hazy or veiling opacity extending out
from the hilum and fading out inferiorly. It thus reverses
the normal slight increase in radiographic density seen as
you move down the lung (due to increased thickness of
the chest soft tissues).
 Parts of left cardiomediastinal contour may be
obliterated by the the lingual.
 The anterior parts of the aortic arch are also often obliterated from view.
 Luftsichel sign  the hyper-expanded superior segment of the left lower lobe
insinuates itself between the left upper lobe and the superior mediastinum, sharply
silhouetting the aortic arch and resulting in a lucency medially.
 The left hilum is also drawn upwards  resulting in an almost horizontal course of
the left main bronchus and vertical course of the left lower lobe bronchus.
 Juxtaphrenic peak sign  'peaked' or 'tented' hemidiaphragm.
 Generic markers of volume loss.
 On lateral projections  the left lower lobe is hyperexpanded, the oblique fissure
displaced anteriorly, increase in the retrosternal opacity.
- Left lower lobe collapse:
 It is readily identified in a well penetrated film of a patient with
normal sized heart.
 Can be challenging in the typical patient (unwell patients, with
portable (AP), under-penetrated films, cardiomegaly).
 Triangular opacity in the posteromedial aspect of the left lung.
 Edge of collapsed lung may create a Double cardiac contour.
 Left hilum will be depressed.
 Loss of the normal left hemidaphgragmatic outline.
 Loss of the outline of the descending aorta.
 Generic markers of volume loss.
 On lateral projection  the left hemidiaphragmatic outline is
lost posteriorly, the lower thoracic vertebrae appear denser
than normal (they are usually more radiolucent than the upper
vertebrae).
- Total left lung collapse:

74. 3- Bronchiectasis:
 Refers to abnormal dilatation of the bronchial tree.
 CT is the most accurate modality for diagnosis (so every
bronchiectasis should go CT to determine the affected segment),
also can use bronchogram in the diagnosis.
 It is largely considered irreversible
 Causes:
o Post-infective (most common)  necrotising bacterial
pneumonia (Staph. Aureus), granulomatous disease (TB),
bronchopulmonary aspergillosis (ABPA).
o Congenital  congenital cystic bronchiectasis, cystic fibrosis
(CF), ciliary dysfunction syndromes (Kartagener syndrome).
o Bronchial obstruction  bronchogenic carcinoma, inhaled
foreign bodies, chronic aspiration lung changes.
 Plain radiograph:
o Tram-track opacities  seen in cylindrical bronchiectasis.
o Multiple Air-fluid levels  seen in cystic bronchiectasis.
o Honey comb shadow.
o Bronchi seen end on may appear as ring shadows.
o Increase in bronchovascular markings.
o Pulmonary vasculature appears ill-defined (represent peri-
bronchovascular fibrosis).
4- Pulmonary emphysema:
 Defined as the abnormal permanent enlargement of the airspaces distal to the
terminal bronchioles accompanied by destruction of the alveolar wall and without
obvious fibrosis.
 Types of emphysema  septal, bullous, generalized.
 CXR not image emphysema directly, but rather infers the diagnosis due to associated
features (Except in the case of very advanced disease with bulla formation).
 Radiological features:
o Flattened hemidiaphragm (s): most reliable sign.
o Tenting of the diaphragm.
o Increased and irregular radiolucency of the lungs.
o Increased retrosternal airspace.
o Increased antero-posterior diameter of chest (hyperinflation).
o Widely spaced ribs.
o Sternal bowing.

75. o Saber-sheath trachea.
o Absent pulmonary markings in outer 1/3 of the lung fields.
o Pulmonary arterial hypertension (pruning of peripheral vessels, increased calibre
of central arteries, right ventricular enlargement).
 Unilateral obstructive emphysema:
o Causes  elderly (tumor), child (TB).
o Radio-opaque foreign body be demonstrated.
o Aspirated foreign bodies have a predominance for the right
tracheo-bronchial tree.
 Pulmonary bullae:
o Are focal regions of emphysema with no discenible wall.
o Measure more than 1cm in diameter.
5- Subcutaneous emphysema:
 Refers to air in the subcutaneous tissues.
 But the term is generally used to describe any soft tissue
emphysema of the body wall or limbs, since the air often
dissects into the deeper soft tissue and musculature along
fascial planes.
 Radiological features if affecting the anterior chest wall:
o Subcutaneous emphysema can outline the pectoralis
major muscle, giving rise to the ginkgo leaf sign.
o Dissecting air along tissue fat planes appears as multiple lines of lucency.
6- Pneumomediastinum:
 It is the presence of extra-luminal gas within the mediastinum.
 Gas may originate from the lungs, trachea, central bronchi, oesophagus, and track
from the mediastinum to the neck or abdomen.
 Radiographic features:
o Small amounts of air appear as linear or curvilinear
lucencies outlining mediastinal contours such as
subcutaneous emphysema.
o Pneumopericardium  air anterior to pericardium.
o Ring around artery sign  air around pulmonary artery
and main branches.
o Tubular artery sign  air outlining major aortic branches.
o Double bronchial wall sign  air outlining bronchial wall.
o Continuous diaphragm sign  due to air trapped posterior to pericardium.
o Extrapleural sign  air between parietal pleura and diaphragm.