Documentos de Académico
Documentos de Profesional
Documentos de Cultura
1. Dorsoplantar Projection: X-ray tube angled 15° from vertical and aimed
at the lateral aspect of the navicular.
9. Ankle Mortise Projection: The ankle is internally rotated 15° with the x-
ray tube at 90° from vertical. Good for evaluating the joint space. The view
for measuring the angles of the ankle (see Anatomic Angles below).
10. Lateral & Oblique Projections of the Ankle: Used in looking for the
effects from trauma.
16. Anthansen Projections: To view the medial and posterior facet of the
STJ.
NOTE* Bone
Osteomyelitis
scans arehas
a good
intense
indicator
and focal
if the uptake
Reflex Sympathetic
in all 3 phases
Dystrophy
patient will be responsive to treatment
3. 111 Indium White Cell Scanning (Indium is just the label): This scan
is much more specific for infection (especially acute infections) and involves
predomininantly granulocytes. With this scan, the patient's white blood cells
are labeled with the tracer and injected intravenously. This technique was
developed to detect leukocyte accumulation at sites of inflammation and
abscess formation. Scans are performed 24 hours after injection. A positive
scan is defined as a focal accumulation of leukocytes that is higher than the
surrounding bone activity. This technique is reserved for complicated post-
traumatic or post-surgical patients with equivocal conventional bone scans, in
cases where 99mTc MDP scanning reveals false positive results because of
rapid turnover. Therefore, it may be more accurate in detecting acute
infections. VIII. Limitations of Scans: Some patients show multiple hot spots
at an early stage of S. aureus septicemia but do not progress to OM. You can
have a negative scan with a confirmed OM due to impaired blood supply
(false-negative). You can have difficulty in differentiating OM from cellulitis.
You can have difficulty in differentiating normal bone repair from bone
infection (false-positive).
6. MRI: MRI gathers information (imaging the nucleus of the atom) in the
form of low energy radiowaves and transduces this energy into images
with the use of computers. Four components are necessary for the
production of such images:
Magnetic nuclei (the sample)
The strong magnetic field
Coils to transmit and receive radio frequency waves
Magnetic gradiance (small magnetic fields with known, carefully
controlled spatial variation)
NOTE* Protons spin on their long axis, making a magnetic field. In the human
body, these protons spin randomly. When the body is placed in the MRI
machine, most (or more) of the protons line up parallel to the magnetic field
of the machine. Feeding radiowaves into the body (RF), the protons are
excited and energy is released producing an image.
By varying both TR and TE, images that primarily reflect TI-relaxation, T2-
relaxation, or proton density may be obtained.
a. A signal that reflects primarily T1 images is produced by using a spin-echo
sequence of a short TE (20-30 msec) and short TR (300-800 msec)
b. T2 images are produced with a long TE (60-120 msec) and long TR
(15003000 msec)
c. A proton image (or balanced image containing properties of both T1 and
T2) is produced with a short TE and long TR
With all other factors being equal, imaging time is directly proportional to TR,
with T2 images taking the longest time to obtain (prone to degradation due
to motion by the patient)
f. NOTE* When ordering an MRI you must specify what you are trying to look
for, and if you want a certain view, you must specify this too
Precautions:
i. MRI not to be done in the first trimester of pregnancy (no studies showing
fetal abnormalities with MRI to date)
ii. MRI should be avoided with cerebral aneurysm clips (may become
dislodged), cardiac pacemaker (interfere with function), and implanted
metallic objects near the orbit of the eye)
iii. Patients with claustrophobia may require sedation
7. CT
Scanning:
Can
establish
the
presence,
nature,
size,
margination, and exact location of tumors. Muscle and soft tissue
involvement can be determined. If a tumor is located next to blood
vessels, a contrast medium is needed to enhance its identification. Is
excellent to evaluate metabolic bones diseases (osteoporosis, aseptic
necrosis, osteomalacia). It is excellent in evaluating trauma especially the
calcaneus and STJ. The CT can dictate
whether open reduction would be beneficial and whether one or a twosided
approach is indicated to effect the reduction. CT is excellent in the diagnosis
of tarsal coalition and degenerative changes of the tarsus or lesser tarsus
where superimposition has always been a problem.
10. Tenography: Is most often used on the ankle tendons. It can also
document calcaneofibular ligament tears, because this ligament is
contiguous with a part of the peroneal tendon sheath. It has been used to
identify irregularities of the peroneal tendons themselves. Has generally be
replaced with MRI (non-invasive).
a. Tenogram shows narrowing and irregularity of the involved tendon
b. Is only useful in tendons that go around a bone (like the malleoli)
c. Tenography of the posterior tibial tendon reveals 3 types of pathology:
central swelling, thinning of the tendon, and rupture
d. The results of tenography can be:
i. Normal
ii. Mild marginal irregularity
iii. Moderate marginal irregularity
iv. Marked marginal irregularity
v. Occlusion of the tendon sheath
e. Contrast is injected into the proximal portion of the tendon sheath (Conray
43®) mixed 50/50 with Xylocaine®. Upon completion of the
tenogram, a steroid is injected
Anatomic Angles
1. Angles of the Ankle: Are helpful when evaluating ankle trauma. on the
D-P projection.
2. Angular Relationships on the D-P Projection:
a. Talocalcaneal Angle or Angle of Kite (normal for ages 0-5 years=
35-50° & ages 5-adult= 15-35°): Has long been used as an index of
relative foot pronation and supination. It is a measure of the transverse plane
angular relationship between the longitudinal bisectors of the talus and
calcaneus. It becomes increased with STJ pronation and reduced with
supination.
NOTE* The intermetatarsal angle between the 4th and 5th metatarsals can
also be drawn using a line parallel to the proximal medial portion of the
5th metatarsal as the lateral arm and bisected the 4th metatarsal as the
medial arm of the angle
NOTE* When examining for lateral bowing of the 5th metatarsal an angle
calledthe lateral deviation angle of the 5th metatarsal is
examined. This angle isformed by a line bisecting the head and neck of
the 5th metatarsal and the line previous described to simulate the
proximal 5th metatarsal shaft. Normal= 2.640 With pathology of the 5th
metatarsal this number usually = 8°. When this is present the structural
deviation should be considered as a significant contributing factor in the
tailor's bunion deformity, and addressed surgically.
m. Metatarsal Parabola (normal= 142.5°): The angle formed by the
intersection of lines touching the 1 st and 2nd metatarsal heads intersecting
with 2nd-5th metatarsal heads.
Note* The Talar Declination Angle and the Calcaneal Inclination Angle are
inversely proportional
c. Cyma Line: A lazy S curve formed by the T-N and C-C joints (Chopart's
joint). Pronation causes the T-N joint to be anteriorly displaced, and
supination causes the T-N joint to be posteriorly displaced.
d. Sinus Tarsi: In the normal foot it is seen on lateral view as an oval area of
decreased bone density, separating the posterior from middle subtalar
facets. When pronation occurs, as the talus rides anteriorly on the calcaneus
and plantarflexes, the sinus tarsi is obliterated.
Pediatric Radiology
1. Roentgenographic Development of the Foot:
a. Important ossification points to remember:
i. 1st bone to ossify before birth: calcaneus
ii. Last bone to ossify before birth: cuboid
iii. 1st bone to ossify after birth: lateral cuneiform
iv. Last tarsal bone to ossify after birth: navicular at 3.5 years
v. Calcaneal apophysis appears at age 7 years
vi. Sesamoids appear at age 12 years
b. Ossification at birth:
i. Talus
ii. Calcaneus
iii. Cuboid (can be absent in the premature baby)
iv. Metatarsals
v. Proximal phalanges
vi. Middle and distal phalanges 2-4
vii. Distal phalanx 1
c. Age 3 months: lateral cuneiform
d. Age 4 months: tibial epiphysis
e. Age 6 months: cuboid and lateral cuneiform articulate
f. Age 7 months: talar neck appears, base of metatarsals widen
g. Age 11 months: fibular epiphysis appears
h. Age 18 months: phalangeal epiphyses appear
i. Age 24 months: medial cuneiform and ossification of epiphysis of
metatarsal 1
j. Age 30 months: intermediate cuneiform ossifies
k. Age 36 months: ossification of epiphysis of metatarsals 2,3, and 4
l. Age 3.7 years: ossification of navicular
m. Age 4.2 years: ossification of epiphysis metatarsal 5
n. Age 4.9 years: alignment of tarsal and metatarsal bones
The Osteochondritities
1. These are a group of related disorders which effect the primary or
secondary centers of ossification. Its etiology probably relates to some type
of vascular disturbance to the ossification center, during the time of their
greatest developmental activity.