Xray tf

1. Mentor - Dr Sunita Kale (PROF)
- Sumeet (SR)
- Chandranshu (JRII) / Ajith (JRII)
DEPARTMENT OF
RADIOLOGY

4. Xray views for paranasal sinuses
Differentials of paranasal sinus opacification
Age of pneumatization of the sinuses
Role of radiology in management of JNAF

5.  Orbito-meatal line – 370 to film
 Best – Maxillary sinus
 Modified water – open mouth

6.  Orbito-meatal line – 150 with horizontal
 Best – Frontal sinus

7.  Sagittal plane parallel to the film
 To see anterior and posterior extent of sinuses
 Air fluid levels well appreciated.

8.  Neck is hyperextended until the infraorbitomeatal line (IOML) is parallel with the receptor
 Evaluate fractures and displacement of a fractured zygomatic arch.
 Assessing potential pathology from trauma or disease progression to the basal skull structures ,
including the foramen ovale, foramen spinosum and sphenoid sinuses.

9. Acute / Chronic Sinusitis
Choanal polyp
Sinonasal polyposis
Silent sinus syndrome
Mucocele
Neoplastic
Fungal sinusitis
Dentigerous cyst
Ameloblastoma

10.  The silent sinus syndrome represents maxillary sinus atelectasis that results in
painless enophthalmos, hypoglobus and facial asymmetry
 The sinus is fully formed but fully opacified and reduced in volume with inward bowing of all four
walls

11.  Complete opacification of one or more paranasal sinuses by mucus, often associated with bony
expansion due to obstruction of the nasal sinus drainage.
 Most common – Frontal sinus
 Associations
• cystic fibrosis: particularly if occurring in children
• paranasal sinus fibrous dysplasia: especially in frontal sinus

13.  Benign , locally aggressive tumor
 Origin – Spenopalatine foramen
 C/f – painless progressive unilateral nasal obstruction , epistaxis
 CT – Heterodense mass with avid enhancement , widening of pterygopalatine
fossa, bowing of posterior wall of maxillary sinus (Holman Miller sign), bony
erosion
 Main blood supply – Internal maxillary artery, branch of ECA , others – ascending
pharyngeal , palatine
 Treatment – Preop Embolization – Surgical resection

18. 6 D’s of neuropathic joint
Phases of neuropathic joint
Causes of neuropathic joint

19. DISTINCT LACK OF SUBJECTIVE / OBJECTIVE PAIN
DESPITE JOINT SWELLING / INSTABILITY /
CREPITATIONS
Bone and joint changes that occur
secondary to loss of sensation
AKA CHARCOT JOINT
NEUROPATHIC JOINT

20. DISTENDED JOINT - early due to effusion
DENSITY INCREASE – subchondral sclerosis
DEBRIS PRODUCTION – intra-articular bony fragments
DISLOCATION – malalignment of joint surface
DISORGANISATION – bag of bones (joint components
disrupted)
DESTRUCTION – loss of bone substance

21. Atrophic phase
hypertrophic phase

22. 6 d’s
hypertrophic phase Atrophic phase
LICKED CANDY STICK
APPEARANCE
WEIGHT BEARING JOINTS NON WEIGHT BEARING JOINTS
LUMBAR SPINE
HIP JOINT
KNEES
ANKLE
SHOULDER
HIP JOINT
FOOT

23. TUMBLING BUILDING BLOCK SPINE
JIGSAW VERTEBRA
LICKED CANDY
STICK APP

24. congenital acquired iatrogenic
Congenitalindifferenceto pain
Spinabifidavera
dysautonomia
Diabetes mellitus (mc)
Leprosy
Charcotmarietooth
Neurosyphilis
Trauma
Tumor
alcoholism
Steroids
Indomethacin
phenylbutazone

30. Diagnosis
Differentials
Types

31.  AP and lateral radiographs of the skull show multiple tiny lucent areas with areas of
sclerosis in between, giving rise to salt and pepper skull appearance.
 Radiographs of both the legs, knees and left humerus show diffuse osteoporosis with
few well defined lytic areas.
 Radiograph of the hand shows osteoporosis with coarse trabeculations of the
phalanges with mild erosions along tteh radial aspect.

32. HYPERPARATHYROIDISM
 Primary : Hyperproduction of PTH due to
adenoma/hyperplasia/carcinoma
 Secondary : Feedback response to hypocalcemia (renal osteodystrophy)
 Tertiary : Autonomous parathyroid adenoma

34. FINDINGS
 Osteopenia
 Subperiosteal resorption: classically along radial aspects of phalanges
 Floating tooth
 Subchondral resorption (lateral end of clavicles, pubic symphysis, sacroiliac joints)
 Subligamentous resorption(ischial tuberosity, trochanters)
 Brown tumors(more common in primary)
 Salt and pepper skull
 Rugger jersey spine

35.  Secondary and tertiary hyperparathyroidism may be associated with osteosclerosis of
renal osteodystrophy and osteomalacia of vitamin D deficiency
 Superior and inferior rib notching may be seen

36. SUBPERIOSTEAL RESORPT

37. SUBCHONDRAL
RESORPTION

38. SALT AND PEPPER SKULL

39. Multiple myeloma

40. LCH

45. Benign
•Hemangioma
•AV malformation
•Lipoma
•Fibroma of tendon
sheath
•Tendon sheath GCT
Malignant
•Sarcoma
•Squamous cell Ca

46.  Most common soft tissue tumor
 On USG , it appears as echogenic (isoechoic to fat and echogenic to muscle) well-defined lesion
with echogenic capsule
 On MRI, lipoma shows a similar signal to fat on all sequences

47.  On ultrasound, hemangioma appears moderately well defined and hypoechoic but can be
heteroechoic due to internal adipose and calcium contents. Doppler may depict prominent vascular
channels with the flow.
 On MRI it is intensely hyperintense on T2 and hypointense on T1. It shows homogenous
enhancement. The phleboliths are seen as signal void on both T1- and T2-weighted images and
may show blooming artifact on gradient echo images

48.  Color Doppler is useful to see the internal vascularity including the arterial flow in case of high flow types.
MRI shows T1 hypointense and T2 hyperintense signal, signal voids (reflecting areas of high flow), and
susceptibility artifacts (areas of thrombosis).
 Vascular malformations can be classified as either low-flow or high-flow lesions with dynamic contrast-
enhanced magnetic resonance (MR) angiography.

49.  On the US, it appears homogenously hypoechoic and most commonly seen on flexor surface often
in relation to an annular pulley.[
 MR reveals a focal nodular mass adjacent to a tendon sheath with heterogeneous low to
intermediate signal on all pulse sequences
 Tenosynovial giant cell tumor (TSGCT) both at clinical examination and even at gross pathology
looks similar to FTS. TSGCT, generally, show susceptibility artifacts on GRE images and adjacent
cortical erosion on a plain radiograph; both features are absent in FTS.

50.  presents as a lobulated painless soft tissue mass immediately adjacent to tendon sheath.
 Plain radiograph can show cortical erosions on the underlying bone ~ 20%. Ultrasound shows
homogenous hypoechoic lesion with internal vascularity.
 On MR, it shows T1 low- and T2 low-to-intermediate signal. It shows intense contrast enhancement
as well.

55. PARAVERTEBRAL SOFT TISSUE DIFFERENTIALS
NEOPLASM
NEUROGENI
C
Schwannoma
Neurofibroma
Paraganglioma
Pheochromocytoma
NON
NEUROGENI
C
Lymphoma
Metastasis
Oesophageal Ca
INFECTION
PARASPINA
L ABSCESS
FOREGUT
DUPLICATION
CYST
NEURENTERIC
ESOPHAGEAL
BRONCHOGENIC
INFLAMMATION
MEDIASTINITIS
SARCOIDOSIS
PSEUDOCYST
OTHERS
LYMPHADENOPATHY
ANEURYSM
EXTRAMEDULLARY
HEMATOPOEISIS
HEMATOMA
HIATUS/ BOCHADALEK
HERNIA

56. •CML
•Polycythemia Vera
•Essential thrombocythemia
•Myelofibrosis
•Hodgkin Lymphoma
MYELOPROLIFERATIVE
DISORDERS
•Sickle cell Anemia
•Thalessemia
•Hereditary Spherocytosis
HEMOGLOBINOPATHIES

57.  MC – Diffuse visceromegaly (Hepatosplenomegaly)
 MC intrathoracic – Posterior mediastinal mass
 Rib expansion
 Perirenal soft tissue
 Presacral soft tissue mass
 Epidural soft tissue mass in spinal cord or CNS

58. General
Osteoporosis
Coarsened trabecular pattern
Cortical thinning
Widened medullary cavity
Special
Hair on end appearance
Erlenmeyer flask deformity
Paraspinal extramedullary
haematopoiesis

59. THALASSEMIA SICKLE CELL ANEMIA
Spine less affected Spine more affected
More marrow hyperplasia Less marrow hyperplasia
Skull more affected Skull less affected
Infarctions less common Infarctions more common
Extramedullary hematopoiesis Osteomyelitis

63.  Diagnosis
 Foot radiographic views
 Radiological signs
 Types of periosteal reaction

64.  Dorsoplantar radiograph of the foot shows destruction of the head of the 5th
metatarsal and the base of the proximal phalanx of the 5th toe with apparant
widening of teh joint space.
 There is associated minimal soft tissue swelling

65.  Foot radiograph :
 Dorsoplantar: metatarsals in neutral position
 Medial: DP projection with the foot angled 30-40° medially
 Lateral
 Weight bearing

67.  Arterial supply :
 a. Infant
 b.Child
 c. Adult

68.  Hematogenous spread
 Vascular and cellular response
 Marrow edema
 Marrow necrosis
 Endosteal penetration
 Reaches subperiosteal layer
 Periostitis
 Cortical necrosis

69.  Sequestrum : Dead bone(cortical and medullary necrosis)
 Involucrum : New bone formation
 Cloaca : opening in the involucrum (decompression)
 Marjoulin’s ulcer

71.  Latent period :
 Extremities : 10 days
 Spine : 21 days
 Earliest detection : Bone scan by Tc-MDP, Ga-67
 MRI : T1 hypo, T2 hyper

73.  Soft tissue swelling
 Fat planes : Neoplasm vs infective
 Bone : Moth eateb or permeative destruction
 Periosteal reaction

74.  Pyogenic osteomyelitis : No swelling
 Fungal osteomyelitis : Exuberant soft tissue swelling

75.  Draining sinus
 Debris
 Bone : Destruction of the cortex
 Involucrum
 Cloaca
 Sequestrum
 Sclerosis
 Joint: loss of joint space; healing by ankylosis

77.  physiologic periostitis, most common cause before 6 months old
 Caffey disease
 chronic venous insufficiency
 hypertrophic osteoarthropathy
 congenital syphilis
 fluorosis
 thyroid acropachy
 hypervitaminosis A

78.  Infantile cortical hyperostosis
 Type I collagenopathy
 painful soft tissue swelling, erythema, fever, irritability
 <5 months of age
 Most common : flat bones (mandible)
 Ulna among long bones

79.  Xray foot views
 Types of periosteal reaction
 Radiological signs of osteomyelitis

84.  Differentials
 10% rule in wilms tumor
 Causes of intra and retroperitoneal masses in children

85.  There is fullness in the left side of the abdomen with the displacement of the bowel
loops to the right
 There are no calcifications
 The opacity is crossing the midline
 The lung fields are clear

86.  Neuroblastoma
 Nephroblastoma
 Lymphoma
 Teratoma
 Rhabdomyosarcoma
 Lipoma

87.  Hepatoblastoma
 Hemangioendothelioma
 Mesenchymal hamartoma
 Hepatocellular carcinoma

88. Neuroblastoma Nephroblastoma
Age <2 yrs 3-4 yrs
Presentatio
n
Painful abdominal mass Painless abdominal mass + hematuria
Calcificatio
n
+++ +
Compositio
n
Predominantly solid Predominantly cystic
Margin Poorly circumscribed Well marginated
Vessels Encases Displaces; Invades IVC
Spinal
canal
involvemen
t
+ -
Crosses
midline
+ -
Metastasis Bone Lungs

89.  Most commonly from the adrenal glands
 Along the sympathetic chain
 May present directly with metastasis
 Raccoon eye
 Opsoclonus-myoclonus syndrome
 MIBG scintigraphy

90.  10% rule :
 unfavourable histology
 calcification
 bilateral
 vascular invasion
 pulmonary metastasis

91.  WAGR syndrome
 Danny Drash syndrome
 Beckwith Weidman syndrome

92.  1. Clear cell sarcoma:
 Early skeletal mets
 2. Renal rhabdoid tumor:
 Associated with brain tumors, especially in posterior fossa
 3. Pediatric RCC:
 10-20yrs (RCC > Wilms in second decade)
 Calcifications more common

97.  Differentials
 Lytic lesions of skull in adults and children

98. METASTASI
S
MULTIPL
E
MYELOMA
RAINDROP SKULL

99. HEMANGIOM
A
HONEYCOMB/
SUNBURST PATTERN
EPIDERMOID
CYST
LOBULATED LYTIC –
SCLEROSED MARGINS
LCH

100. LÜCKENSCHÄDEL SKULL
LACUNAR SKULL/ CRANIOLACUNAE
DYSPLASIA OF SKULL VAULTT- INNER TABLE>OUTER
CHIARI II MALFORMATION
abnormal collagen development and ossification
COPPER BEATEN SKULL
CRANIOSYNOSTOSIS/ OBSTRUCTIVE HYDROCEPHALUS/
SOL
Gyral impressions on the inner table of the skull

101. BURR HOLE CRANIOTOMY

102. GEOGRAPHIC
/SHARP
BENIGN
PERMEATIVE / MOTH
EATEN
MALIGNANT

108.  Findings
 Xray views for mandible
 Mandibular lytic lesions

109.  AP and lateral radiographs of the skull show a well defined lytic lesion involving
the left ramus of the mandible causing scalloping of the medial margin with
associated soft tissue swelling.

110. MANDIBLE XRAY
 Axiolateral oblique
 The patient is seated upright
 Give true lateral position
 Slightly extend the neck
 Tilt the head towards the detector
 Central ray 25-30 degree cephalad

112.  The patient is stationary, while the x ray source and the film rotates.
 sitting/standing completely upright
 head immobilized and on a chin rest
 biting down on a radiolucent bite block
 tongue against the hard palate

116. Radioloucent mandibular lesions
Odontogenic Non-odontogenic
Well defined
margins
Ill defined margins Well defined
margins
Ill defined margins
Cysti
c
Solid Cysti
c
Solid
• Odontogenic
keratocyst
• Residual cyst
Ameloblasto
ma
Malignant
Odontogenic
tumors
• Odontogenic
carcinoma
• Stafne cyst/
static bone
cavity
• Simple bone
cyst
• Central
giant cell
granuloma
• Venous
malformation
• Langerhan
cell
histiocytosis
• Brown
tumor
 Osteomyelitis
 Osteonecrosis
 Malignant non-
odontogenic tumors
• SCC of the oral
cavity invading the
jaw
• Metastases
• Hematological
malignancy
• Sarcoma
(osteosarcoma/cho
ndrosarcoma/fibros
arcoma)
• Malignant
transformation of
intraosseous

117.  Infection from carious tooth spreads to the pulp of the tooth
 Formation of granuloma and abscess

118.  Around the crown of the unerupted tooth

119.  After extraction of the tooth

120.  Benign intraosseous tumours arising from the dental lamina.
 Like dentigerous cysts, OKCs are also often associated with unerupted or
impacted teeth. However, unlike dentigerous cysts, these cysts when large envelop
the entire tooth and not just the crown.

121.  Characteristic pattern of growth - expansion along the axis of the mandible with
relatively little expansion along the buccolingual axis.
MRI-
 T1WI -heterogeneous intermediate-to-high signal
 T2WI -low-to-high signal owing to keratinaceous contents within.
 Postcontrast images-Thin or thick rim enhancement .
 DWI- Diffusion restriction due to the proteinaceous contents of the cyst
(characteristically seen in OKC)

124.  Benign but locally aggressive odontogenic tumor
 Typical location-posterior mandible (posterior body and ramus).
 Painless swelling/incidental

125.  Radiolucent, unilocular or multilocular.
 Septations within the lesion -“honeycomb” or “soap bubble” appearance.
 The lesion usually shows marked buccolingual expansion with cortical
thinning/breach . There may be accompanying teeth displacement and resorption.
 Enhancement of solid component on CT and MR.
 Cystic component with low T1W and high T2W signal.
 Diffusion restriction of solid component.

126.  Types :
 Unicystic : No solid component
 Extra-osseous : buccal mucosa, lips, floor of mouth, tongue base
 Metastasizing

128. Ameloblastoma OKC
Enhancement pattern Enhancement of solid
component
Rim enhancement
Pattern of expansion Buccolingual expansion Expansion along
anteroposterior axis
Cystic component T1WI- low signal,
T2WI- High signal
T1WI- intermediate to bright
signal,
T2WI- low to high signal
Solid component- DWI Restricted diffusion
Cystic component- DWI Facilitated diffusion Restricted diffusion

130.  Pseudocyst
 Angle of jaw
 Aberrant submandibular gland or fat causing remodelling

132.  Young women
 Anterior mandible, crosses midline
 Painful swelling

134.  Mandible is 2nd most commonly invovled after skull
 Children
 Floating tooth sign

142.  Indication
 Contrast
 Technique
 Parts of male urethra

143.  Plain film :
 causes of stricture-
 pelvic trauma(pelvic bone fractrues)
 spinal cord injury(lumbar spine fracture)
 prostatic carcinoma mets to bones(stricture at prostatic level)

144.  Contrast
 Trazograf (Ditrazoate sodium 76%)
 Ionic water soluble iodinated contrast
 Dilution :
 1:2 for RGU
 1:10 for MCU

145.  Anterior :
 penile
 bulbar
 Posterior :
 membranous
 prostatic

147.  Verumontanem
 Bulbomembranous junction at the level of the inferior margin of the obturator
foramen

153. Frontal chest radiograph shows few ill defined patchy opacities in both the lung
fields, few of them showing cavitatory changes. TCC seen in situ.
Compared to the previous radiograph there is reduction in the number of opacities
with cavitatory changes.

154.  Malignancy:
 Squamous cell carcinoma of the lung
 Metastasis :
 squamous cell ca
 adenoca from GIT/breast
 sarcoma
 cervical carcinoma
 urothelial carcinoma of the bladder

155.  Infection :
 Septic embolism
 Pulmonary tuberculosis
 Abscess
 Post pneumonic pneumatocele
 Necrotizing pneumonia

156.  Autoimmune :
 Wegeners granulomatosis
 Rheumatoid nodules

157.  Bacteremia
 Fever
 Dyspnea
 Chest pain
 Cough

158.  Source :
 Right sided infective endocarditis
 Infected DVT
 Infected catheters
 Infection anywhere in the body
 Drug abusers
 Immunological deficiencies

159.  Distribution :
 Peripheral
 Lower lobe predominance
 Multiple
 Bilateral
 Varying stages of cavitation

161.  Feeding vessel sign

162.  Complications :
 Empyema
 Pneumothorax

168.  Radiographic views for ankle joint
 Lytic lesions of calcaneum
 Leave alone/ Do not touch lesions

170.  INDICATION
 Ankle farcture/dislocation
 Talus involvement
 Osteoarthritis ankle
•The leg must be rotated internally 15° to 20°, thus aligning the
intermalleolar line parallel to the detector. This usually results in the
5th toe being directly in line with the center of the calcaneum
•To differentiate from AP – the tibia , fibula , talus overlap is gone

171. BIG G
• B: BONE CYST
• I: INTRAOSSEOUS LIPOMA
• G: GANGLION(INTRAOSSEOUS)
• G: GIANT CELL TUMOR

172. GIANT CELL TUMOR
BONE CYST (UNICAMERAL/ ANEURYSMAL)

173. •INTRAOSSEOUS LIPOMA
•COCKADE SIGN – LYTIC LESION WITH CENTRAL CALCIFIC

174.  So characteristic radiographically, that further
diagnostic tests such as a biopsy are
unnecessary and can be frankly misleading
and lead to additional unnecessary surgery.
 Thus a radiologic diagnosis should be made
without a list of differential possibilities.
• non-ossifying fibroma
• bone island (enostoses)
• unicameral bone cysts
• bone infarction
• pseudotumor of the calcaneus
• osteopoikilosis
• fibrous dysplasia
• vertebral hemangioma

175.  Progressive cystic swelling of muscle / bone due to repeated bleeding
 Xray - well-defined, unilocular or multiloculated, lytic, expansile lesions
 MRI- hypointense rim on both T1 and T2-weighted images consists of fibrous tissue that contains
hemosiderin.
 Treatment - low-dose radiotherapy, percutaneous curettage, surgical resection, or filling with bone
graft or other compounds

180.  Radiographic view for
acetabulum
 Zones of transition
 Tumors crossing joint space

181. Rotated 450 anterior

182. Iliac oblique
 ilioischial line of the posterior column
 the posterior column
 the roof of the acetabulum
 Iliac crest.
Obturator oblique
 iliopectineal line of the anterior column
 the anterior column
 the posterior acetabular wall
 obturator foramen

184. NARROW - BENIGN WIDE - MALIGNANT

185.  Plasmacytoma
 Chodrosarcoma
 Metastasis

186.  Osteosarcoma
 Ewings sarcoma
 Chondrosarcoma
 ABC
 Plasmacytoma
 Metastasis

191.  Diagnosis
 Causes of retrocardiac air-fluid levels

192.  Frontal chest radiograph shows an air fluid level in the right paracardiac region.
The nasogastric tube is seen passing through it.
 The fundic bubble is not seen.
 There is obliteration of both the costophrenic angles

193.  Operative history :
 Gastric pull up
 Colonic transposition
 No operative history :
 Achalasia
 Esophageal carcinoma
 Hernia
 Loculated hydropneumothorax
 Lung abscess

197.  Describe the findings
 Differentials
 Neurogenic bladder

198.  Scout film shows enlarged renal shadows
 Full bladder image shows a well distended urinary bladder with multiple broad
based diverticulae and wall irregularities.
 On straining there is no vesicoureteric reflux.

200.  Trauma
 Multiple sclerosis
 Parkinson disease
 Cauda equina syndrome
 Neuritis

201.  Sensory : Inability to sense bladder fullness results in a large rounded and smooth
bladder. Voiding is often preserved.
 Motor : Atonic large bladder with the inability of detrusor contraction during
voiding.
 Reflex/uninhibited : Lesions above S2 level (Christmas tree/pine cone appearance)

203.  Self catheterization
 Prevent complications
 Bladder training
 Cystoplasty
 Neuromodulation

204.  Non-neurogenic neurogenic bladder
 Neuropsychological entity
 Associated with voiding dysfunction, UTI, incontinence.
 The latter can exacerbate the former leading to a vicious cycle

205.  large bladder capacity
 reduced sensation
 increased maximal urethral closure pressure
 detrusor underactivity.
 Several hypotheses:
 hormonal changes (PCOS)
 abnormal stabilization of the muscle membrane
 primary failure of relaxation of the striated muscle of the urethra sphincter
 increased urethral afferent activity, inhibiting the bladder afferent signals from reaching the
brain by potentiating a spinal mechanism of urinary continence.

211.  Complications of osteochondroma
 Signs of malignant transformation
 Role of MRI in osteochondroma

212.  Metaphyseal
 Grows away from joint
 Cortex and marrow is continuous with the parent bone

213. Hereditary multiple exostoses together with enchondromatosis -
METACHONDROMATOSIS.
Dysplasia epiphysealis hemimelica
TREVOR DISEASE
Osteochondromas arising from the epiphyses

214.  Sarcomatous transformation - mnemonic GLAD PAST 1:
• growth after skeletal maturity
• lucency (new)
• additional scintigraphic activity
• destruction (cortical)
• pain after puberty
• and
• soft tissue mass
• thickened cartilage cap greater than 1.5 cm

215.  To assess the cartilage thickness
 Assess for malignant transformation
 The cartilage cap of osteochondromas appears the same as cartilage elsewhere, with intermediate to low
signal on T1 and high signal on T2 weighted images.
 cartilage cap of over 1.5 cm in thickness after skeletal maturity is suspicious for malignant degeneration

216. • impingement upon nearby structures
• nerve compression (up to 25%)
• vascular compression
• reactive myositis
• bursal formation and bursitis
• osteoarthritis from secondary joint deformity
• fracture post-trauma: most commonly through the neck of pedunculated lesions