Chriss Ashdown

1
Surgical Radiology

• Chriss Ashdown

2
Contents

• The abdominal X-ray
• IVU
• Barium enema
• Orthopaedic X-rays

3
Abdominal X-Ray Projections

• Supine 99
• Erect
• Lateral decubitus.

4
Anatomy on the Abdominal X-Ray
5
Film Specifics and Technical Factors

• The initial assessment of an AXR is the same as
  for a CXR
• Name of Patient
• Age Date of Birth
• Date Taken
• Film Number (if applicable)
• Film Technical factors
• Type of projection (Supine is standard)
• Markings of any special techniques used

6
Assess the Film in Detail

• BLACK BITS
• Intra-luminal gas can be normal.
• Extra-luminal gas is abnormal.
• However, intra-luminal gas can be abnormal if it
  is in the wrong place or if too much is seen.
• Maximum normal diameter large bowel 55mm, small
  bowel 35mm
• The caecum is not dilated unless wider than 80mm.
• Large and small bowel may be distinguished by
  looking at bowel wall markings, as shown in the
  box below.

7
Assess the Film in Detail

• Haustra of large bowel extend 1/3rd across the
  bowel from each side,
• Valvulae conniventes of small bowel tranverse
  complete distance.
• Intra-luminal gas
• It is usual to see small volumes of gas
  throughout the GI tract

8
Assess the Film in Detail

• Intra-luminal Gas
• Low Small Bowel Obstruction

Small Bowel obstruction.
9
Assess the Film in Detail

• If bowel obstruction is observed try to look for
  the cause. For example a hernia as the cause of
  obstruction.

Hernia.
10
Assess the Film in Detail

• Extra-luminal Gas
• When bowel is obstructed, or any other gas
  containing structure perforates, its contained
  gas becomes extra-luminal. Extra-luminal gas is
  never normal, but may be seen following
  intra-abdominal surgery or endoscopic retrograde
  cholangio-pancreatography (ERCP).

11
Assess the Film in Detail

• Causes of Extra-luminal gas
• Post Abdominal Surgery/ERCP
• Perforation of viscus (eg. bowel, stomach)
• Gallstone ileus
• Cholangitis (infection with gas forming
  organisms)
• Abscess
• An erect CXR (not AXR) is the best projection to
  diagnose a pneumoperitoneum (gas in the
  peritoneal cavity).

12
Assess the Film in Detail

• WHITE BITS Calcification
• Calcified structures (WHITE BITS)
• Calcification can be broadly divided into 3
  types
• (1) Calcium that is an abnormal structure - eg.
  gallstones and renal calculi
• (2) Calcium that is within a normal structure,
  but represents pathology - eg. nephrocalcinosis,
  
• (3) Calcium that is within a normal structure,
  but is harmless - eg. lymph node calcification.
• Bones are normal white structures. On the AXR
  they comprise mainly those of the thoraco-lumbar
  spine and pelvis. Findings are largely
  incidental as direct bone pathology would be
  investigated with specific views.

13
Assess the Film in Detail
Gallstones
14
Assess the Film in Detail

• GREY BITS Soft Tissues
• Soft tissues represent most of the contents of
  the abdomen and feature heavily in the AXR.
  However, these tissues are poorly seen when
  compared to other imaging techniques such as
  ultrasound or CT.
• The kidneys, spleen, liver and bladder (if
  filled) can be seen in addition to psoas muscle
  shadows and abdominal fat. Rarely would action
  be taken on the basis of this imaging alone.

15
Assess the Film in Detail

• Splenomegaly

16
Assess the Film in Detail

• BRIGHT WHITE BITS Foreign Bodies
• Foreign Bodies represent an interesting final
  observation. Objects that may be seen include
  ingested and rectal foreign bodies, items in the
  path of the x-ray beam such as belt buckles,
  dress buttons and jewelry. Other objects may
  have been deliberately placed for example an
  aortic stent, an inferior vena cava filter or a
  suprapubic urinary catheter. Sterilization clips
  and an intra-uterine device are common findings
  in women.

17
Assess the Film in Detail

• Sterilisation and Surgical Clips

Foreign body per rectum
18
SBO

• The 3 commonest causes are
• Surgical adhesions
• Herniae
• Intraluminal mass eg, small bowel lymphoma or
  gallstone (in gallstone ileus)

19
SBO

• Plain abdominal radiograph.
• Multiple dilated loops of small bowel within the
  central abdomen. Gas is not seen in the large
  bowel. No evidence of hernia or gallstone to
  suggest potential cause of the dilated loops.
• These findings are in keep with a low small bowel
  obstruction.
• I would like to know if the patient has a history
  of abdominal surgery as the commonest cause is
  surgical adhesions.

20
Bladder calculi

• This 71 year-old gentleman visits his GP
  complaining of blood in his urine. He has had a
  number of UTIs in recent years.
• Bladder calculi are more common in those with a
  history of
• UTIs
• A neurogenic bladder
• Bladder diverticulum

21
Bladder calculi

• Plain abdominal radiograph.
• Two rounded radio-opacities measuring 4cm within
  the pelvis. Both opacities are smooth in
  outline, laminated in nature, have the same
  density as bone and project over the bladder. No
  other renal tract calcification.
• Does the patient have a history of neurogenic
  bladder?
• Given the size of these stones and history of
  UTIs these are bladder calculi.

22
Nephrocalcinosis

• This patient was admitted with poor renal
  function.
• Causes of Nephrocalcinosis include
• Hyperparathyroidism
• Medullary sponge kidney

23
Nephrocalcinosis

• Plain abdominal radiograph
• Multiple areas of punctuate calcification project
  over the renal outlines bilaterally.
• The calcification is within the medulla of the
  renal parenchyma. The bones are normal in
  appearance.
• These findings are consistent with
  nephrocalcinosis

24
The IVU

• Initial control X-ray to exclude calcification
• 5 minute film to determine if secretion is
  symmetrical
• 15 minute film demonstrates pelvicalyceal systems
  ureters
• Post micturition demonstrates bladder emptying
  success
• Delayed films may be taken over 24hrs to
  demonstrate location of ureteric obstruction

25
Large bowel obstruction

• Haustra visible do not cross lumen
• Localised around outside of film
• Small bowel may also be dilated depending on
  competence of ileocaecal valve

26
Gallstones

• Only around 10 are visible on X-ray
• More likely to be renal stones 90 visible

27
Barium enema

• To locate
• Polyps
• Diverticular disease Cnnot have active
  inflammation at the time
• Tumours
• In a double-contrast study the colon is filled
  with barium which is then drained out, leaving
  only a thin layer of barium on the wall of the
  colon. The colon is then filled with air. This
  makes it easier to see colon polyps, colorectal
  cancer, or inflammation.

28
Orthopaedic X-rays

• Wrist s

29
Colles

• Typically dorsally displaced and angulated -
  mechanism     - Forced dorsiflexion of the
  wrist     - occurs in pts gt 50 years of age,
  FOOSH     - dorsal surface undergoes
  compression while volar surface undergoes
  tension

30
Colles

• X-ray appearance is that of a dorsally angulated
  fracture of distal radial metaphysis (2-3 cm
  proximal to wrist joint), w/ or w/o associated
  of ulnar styloid
• Initial line is almost always on volar side
  is a single line

31
Smiths

• Extra - articular palmarly displaced distal
  radius       - volar angulation of is
  referred to as "Garden Spade" deformity         
    (reversed Colles Fracture)      - hand
  wrist are displaced forward or volarly w/ respect
  to forearm      - may be extra articular,
  intra articular, or be part of dislocation of
  wrist- Mechanism      - backward fall on the
  palm of an outstreched hand causing pronation
  of            upper extremity while the hand is
  fixed to the ground- Classification      -
  Type I   extra articular      - Type II  
  crosses into the dorsal articlar surface      -
  Type III enters radiocarpal joint            -
  Volar Barton's Fracture Smith's type III     
        - both involve volar dislocation of carpus
  assoc
• w/ intra articular distal radius component

32
Bartons

• Distal radius fracture w/ dislocation of
  radiocarpal joint    - most common
  dislocation of the wrist joint    - comminuted
  of distal radius may involve either anterior or
  posterior cortex and may extend into the wrist
  joint    - dislocation or subluxation in
  which the rim of distal radius, dorsally or
  volarly is displaced with the hand and carpus 
    - it often occurs along with a radial styloid
  frx    - it differs from Colles' or Smith's
  Fracture in that the dislocation is the most
  striking radiographic finding

33
Orthopaedic X-rays

• Ankle s

34
Ankle - Weber Class A

•   - usually involves a supination-adduction
  injury  - frequently does well w/ closed
  reduction  - if in fibula is transverse, it
  is type I avulsion fibular   - since
  syndesmotic ligaments are intact, ankle mortise
  is also stable    - type A   fibula fracture
  below syndesmosisA1   IsolatedA2   w/ of
  medial malleolusA3   w/ a posteromedial fracture

35
Ankle - Weber class B

• caused by supination and external rotation,
  resulting in oblique at the level of sydesmosis
• - Weber C Subtypes- B1 Isolated- B2 w/ medial
  lesion (malleolus or ligament)- B3 w/ a medial
  lesion of posterolateral tibia

36
Ankle - Weber class C

• Occur above the the syndesmosis
• classificationC     fibula fracture above
  syndesmosisC1   diaphyseal fracture of the
  fibula, simpleC2   diaphyseal fracture of the
  fibula, complexC3   proximal of the fibula
• Result from external rotation or abduction
• forces that also disrupt the syndesmosis and
• are usually associated with an injury to
• medial side

37
Orthopaeidc X-rays

• Hip s

38
NOF

• Normal radiographic anatomy of the femoral head
  and neck reveal a convex outline of femoral head
  joining the concave outline of femoral neck on
  all radiographic projections
• This outline produces the image of an S or a
  reversed S curve
• Hence, the outline of the femoral neck is never
  tangent to the outline of the femoral head in a
  reduced femoral neck

39
Hip - types

• Femoral head usually the result of high energy
  trauma and a dislocation of the hip joint often
  accompanies this fracture.
• Femoral neck subcapital, or intracapsular denotes
  a adjacent to the femoral head in the neck
  between the head and the greater trochanter -
  have a propensity to damage the blood supply to
  the femoral head, may cause avascular necrosis
• Intertrochanteric a break in which the line is
  between the greater and lesser trochanter on the
  intertrochanteric line - the most common type
  prognosis for bony healing is generally good if
  the patient is otherwise healthy.
• Subtrochanteric actually involves the shaft of
  the femur immediately below the lesser
  trochanter, may extend down the shaft of the
  femur.

40
Garden classification of NOF

• Type 1 is non-displaced.
• Type 2 has impaction of the fracture but no
  displacement.
• Type 3 is displaced (often rotated and angulated)
  but still has some contact between the two
  fragments.
• Type 4 is completely displaced and there is no
  contact between the fracture fragments.

41
NOF

• Garden Type 2 Fractured Neck of Femur
• Garden Type 3 Fractured Neck of Femur
• The blood supply of the femoral head is more
  likely to be disrupted in Garden types 3 or 4

42
Thankyou for listening!

• Any questions?