Fundamentals of Radiology by Altaf Hussain Rathore

FUNDAMENTALS OF RADIOLOGY
FUNDAMENTALS OF RADIOLOGY
Altaf Hussain Rathore

MBBS, DA (LONDON), FRCS, FACS, FICS
Professor (Retired) of Surgery
Punjab Medical College, Faisalabad
Ehsan Rathore
BDS, MCPS (Oral Surgery), FICD
Specialist Oral Surgeon & Implantologist
Associate Professor
Faryal Dental College, Sheikhupura
Iqra Sana
MBBS, FCPS (Radiology)
Consultant Radiologist
DHQ Bahawalnagar
Foreword
Aamer Nadeem Chaudhry
MBBS, DMRD, FCPS
Professor & Chairman
Department of Radiology
Allama Iqbal Medical College, Lahore, Pakistan
Dedicated to
My late parents who themselves lived poor but
brought me up and educated me like a prince
Foreword
Altaf Hussain Rathore is a medical teacher, who is nurturing medical students for the last four decades. He has been heavily
involved in teaching and research for a long period. Much has changed in the last ten years in all fields of medicine. New high
definition radiological investigations are coming up but conventional radiology still has its own place, especially in accident and
emergency department. The kernel of this book is to develop the ability of medical students and residents to pick up radiological
findings with minimal necessary experience of radiology. This is important because even in well-equipped hospitals, there is scarcity
of trained radiologists in accident and emergency department.
I have been privileged to write down the foreword of this book. I am sure that the book will be useful for the residents of not
only radiology but also for the trainees of surgery, medicine and orthopedics as well.
Aamer Nadeem Chaudhry

MBBS (Punjab) DMRD FCPS
Chairman
Department of Radiology
Allama Iqbal Medical College
Jinnah Hospital
Lahore, Pakistan
Preface
Since the discovery by Roentgen, X-ray has been a great help in screening of the human body for the diagnosis of the human
diseases. Initially, it was used for the dense tissues such as bone and radiopaque particles in human bodies. But it was not of much
use for soft tissue except lungs, heart and great blood vessels. Later by introduction of contrast media containing safe barium and
iodine salts, the imaging of soft tissues by X-ray was also possible such as pyelogram, cystogram, urethrogram of urinary tract;
barium-meal, follow-through and barium enema for gastrointestinal tract; cholecystogram and cholangiogram- for biliary tract;
myelogram and encephalogram for central nervous system (CNS); cardiogram, angiogram and venogram for cardiovascular system,
and bronchogram for respiratory system, etc. Its quality and sharpness was not only depended on the individual X-ray machine, but
also on the power of the machine, developing chemicals and most important on the operator. An outdated low voltage, clumsily
operated machine will give X-ray of low quality. More bulky individuals also have some effects on the outcome of machine. The
main disadvantages of the X-ray are the danger of radiation and sensitivity in some cases. Cost and heavy equipment are the other
drawbacks.
Lately, other gadgets and tools have come in the market and become more popular to screen the body tissues. Ultrasound for the
soft tissue, especially biliary tract and urogenital tract CT scan, is a more refined form of radiology but more expensive. Endoscopy
for gastrointestinal tract (GIT), biliary tract and urogenital tract and other cavities are minimal invasive techniques. The greatest
breakthrough has been magnetic resonance imaging (MRI), especially to diagnose the brain, spinal card and vertebral column
diseases. It is 30 times more accurate in imaging of the soft tissue. Radioisotope study of different parts of body, especially of
thyroid, is also a great advancement.
However, the importance of X-ray in the diagnosis of human diseases cannot be ruled out, especially of the bony injuries and
diseases. It is still one of the cheapest, cost effective, safe and easily manageable modality. It is the investigation of the choice for
the third world, and for the smaller unit, and smaller places. In this book, we have tried to highlight the technique of reading the X-
ray of different parts of body in normal conditions, and in diseases by mean of typical X-rays and some text. We tried to make it
simple and easy understandable for quick revision. It will be more useful for the paramedics, medical students and for the young
surgeons and radiologists during training. For further and complicated details, the doctors are advised to go through the bigger
specialized texts.
Altaf Hussain Rathore

Lahore, December 2022
Acknowledgments
The collection of all the typical radiographs of good quality of almost every surgical disease was a herculean job for a general
surgeon like me. More difficult was putting then in form of a text. All this could not have been possible without the help of my sons
and colleagues. Some of them are name below, whom I gratefully acknowledge:
1. Dr Kashif Rathore (PhD), Professor of Administrative Sciences, Punjab University, Lahore, Pakistan, for managing all the
affairs of my book except authoring.
2. Dr Farhan Rathore (MD), Consultant Physician, Tamsworth, Australia, for editing and necessary additions throughout the book.
3. Professor Shuja Tahir (FRCS) Principal and Professor, Independent Medical College, Faisalabad, Pakistan, for his illustrations-
of breast disease.
4. Professor Mahnaz Roohi (FRCOC) Professor of Obstetrics and Gynecology, Independent Medical College, Faisalabad,
Pakistan, for supplying me typical hysterosalpingograms
5. Dr Syed Baqir Hussain (MBBS DMRD), Consultant Radiologist, Foundation Hospital, Rajana, Toba Tek Singh, for supplying
me some rare X-rays
6. Dr Mian Omar Zeeshan (MBBS FCPS), Consultant Physician, Foundation Hospital, Rajana, Toba Tek Singh, Pakistan, for his
illustration of the disease of the chest and heart
My sincere gratitude to all of them:

Contents
1.Bones and Joints 001
2.Chest 111
3.X-ray Abdomen 133
4.Urology 153
5.Head and Neck and Neurosurgery 179
6.Teeth and Jaw 188
7.Special X-rays 200
CHAPTER
1 Bones and Joints
INTRODUCTION  Craniocleido-dysostosis
 Arthrogryposis multiplex
X-rays of the bone is an essential investigation to diagnose local  Fanconi syndrome (rarefaction bone)
bone diseases, fractures and dislocations, and also for focal and  Neurofibromatosis (cause scoliosis)
systemic diseases such as osteoporosis hyperparathyroidism and  Gaucher’s disease (cause cyst in bones)
metastatic cancers.
 Klippel-Feil syndrome (fused deformed vertebrae of
The film should be correctly exposed so that there is bright
neck)
bone shadow and a clear bone texture with a minimum soft
 Cervical rib
tissue shadow. Single radiograph is misleading, so two view in
 Hemivertebra
right angle to each other should be taken; usually
anteroposterior or posteroanterior and lateral views. In  Spina bifida
complicated injuries of ankle and wrist oblique view should also  Amelia and phocomelia
be taken. In suspected fracture of scaphoid or spine or neck  Absent radius
(stress fracture) of metatarsal bones the X-rays should be  Absent thumb
repeated after 2–3 weeks. In suspected subluxation of ankle and  Radioulnar synostosis
for deciding the soundness of union of the fracture long bones  Madelung deformity
one should also take the X-ray in slight stress, i.e. angulation or  Syndactyly
eversion and inversion (in case of ankle joint). For the fracture  Polydactyly
X-ray should be centered on the injured point. Always include  Ectrodactyly
one joint above or and one joint below. In case of fall from  Congenital dislocation hip
height on the feet always take the X-ray of the calcaneum, tibia  Congenital coxa vara
and spine and in case of fall of heavy weight on the head or after  Congenital short femur
head on diving in the shallow water always take X-ray of the  Congenital absence of tibia
cervical spine besides radiograph of scalp. X-ray examination of
bones and joints is not only essential for diagnosis of fracture of B. Inflammatory bone diseases we mostly see the cases of
bone and dislocation of the joints, but is also required to judge acute osteomyelitis, tuberculosis (TB) of bone and joints,
the solid union of the bone. Final consolidation of the solid bone chronic osteomyelitis abscess of bone and Brodie’s abscess.
when the patient is allowed full weight bearing is shown in the
radiographs when: C. Neoplastic bony diseases may be benign or malignant
i. Benign
 No decalcification or sclerosis or undue separation of  Cancellous osteoma (exostosis)—It arises from
the ends or cavitation of the surfaces is present. metaphysis and may contain medullary cavity.
 Uniform calcification of callus is present which may be  Compact osteoma (Ivory exostosis)—Arises from
denser than the normal bone. membranous bone and is usually is sessile.
 Absorption of external callus.  Osteoid osteoma—It is dense on X-rays inside the
 Development of the continuous striae across the medullary cavity of tibia or femur in boys.
fracture.   Fibroma—It shows at puberty in from of an oval gap
in the metaphysis of long bones.
When bone ends are well defined, smooth and sclerotic,  Hemangioma—It involves long bones and spine in
with or without some gap in between then it is a clear case of from of radiolucent trabeculaled expanding cavity.
nonunion. But when there is an accurate internal fixation and  Aneurysmal—Bone cyst.
there is little or no callus, diagnosis of union is very difficult.
 Osteoclastoma (benign giant cells tumor)—It usually
The bone diseases consist of: (A) Congenital deformities;
involves the growing end of long bones, especially
(B) Inflammatory; (C) Neoplastic; (D) Degenerative diseases.
around knee in adults of 20–40 years age. On X-rays it
has bubble soap appearance with expanding thin
A. Congenital deformities
cortex.
 Osteogenesis imperfecta (fragilitas ossium)
ii. Malignant
 Diaphyseal aclasis
 Secondary carcinoma of thyroid, breast, prostate, kidney,
 Olliers disease (multiple chondromatosis) bronchus, uterus, testes and gastrointestinal tract.
 Achondroplasia Frequent site is spine, ribs sternum, pelvis, upper end of
 Osteopetrosis femur and humerus.
 Gargoylism (Hurler syndrome)
2 Fundamentals of Radiology
vi. Osteoarthritis when fracture involves intra-articular

 Multiple myeloma or plasmacytoma. It has multi- surfaces of the bone
centric involvement but common site is skull, bones of vii. False joint, it is the advanced form of nonunion
the trunk. It is diagnosed by Bence Jones protein in the viii. Osteoarthritis following bone injury; the joints lying
urine and electrophoresis of the blood. Usual age is 40– above or below or opposite side can get involved
65 year and on X-rays there are multiple small areas of later on.
rarefaction.
 Osteogenic sarcoma which may be osteosarcoma or Epiphyseal Injuries
chondrosarcoma or fibrosarcoma, involving metaphysis
of long bones, skull, pelvic bones and ribs giving early There are two types of epiphysis:
secondaries in the lungs. Usual age is 10–20 year. X- 1. Traction epiphysis or apophysis. They lie at the insertion of
ray shows rarefaction of medulla with raised some muscles. They are nonarticular and do not contribute to
periosteum with Codman’s triangle or sunray the growth of the bone. They can get avulsed
appearance. by the pull of the attached tendon. Common examples are tibial
 Ewing tumor involves diaphysis of long bones tuberosity (Quadriceps Tendon), calcaneal epiphysis (Tendo
especially tibia. On X-ray it gives onion like achilles) base of fifth metatarsal bone (posterior tibial tendon)
appearances. lessor trochanter (Iliopsoas tendon) etc.
D. Degenerative disease or the so-called osteoarthritis is due to 2. Pressure epiphysis. These are situated at the ends of the long
aging process which can involve any joint after the age of bones between epiphysis and metaphysis, also called
50 years, mostly spine and knee joints are involved. epiphyseal plate. It takes part in articulation and is responsible
for the longitudinal growth of the long bones. Injury to
epiphyseal plate causes the disturbance of the growth of the
FRACTURE OF LONG
bone.
BONES Types The injuries to the epiphyseal plate are divide into five types:
a. Separation of epiphyseal plate from metaphysis.
i. Simple when broken into two pieces and no injury of b. The separated plate carries a triangular bone fragment of
local skin it could be: the shaft.
 Transverse c. Broken and separated plate.
 Oblique d. Broken and separated plate with a piece of metaphyseal
 Spiral bone.
ii. Butterfly when a third small piece is separated at e. Crushing or damage of the whole epiphyseal plate. In the
the site of fracture X-ray of the long bones of young children and
iii. Comminuted when it is broken into so many adolescents epiphyseal plate should not be mistaken for the
pieces fracture of the bony ends.
iv. Greenstick when in children bone is bent or only
one cortex is broken
v. Pathological when bone is broken due to some INDIVIDUAL BONES AND JOINTS:
local pathology like inflammation or some tumors UPPER LIMB
(Secondary’s) or cyst
vi. Compound or open Shoulder Joint
vii. Complicated fracture when important structures
like vein, artery nerve or any viscera is also injured The shoulder joint consist of head of the humerus, shallow glenoid
which cannot be diagnosed by simple radiograph. of the scapula, roofed above by an arch made of acromion process
of scapular and lateral end of clavicle called acromioclavicular
Complications of Fracture joint. In X-rays of the shoulder joint one can see upper end of
humerus, greater tuberosity, surgical neck of humerus, neck and
A few of the complication can be diagnosed by X-ray: body of the scapula, clavicle and its coracoid process. Following
i. Nonunion common in lower end of humerus, tibia, lesions can take place around shoulder joint:
ulnaand scaphoid bones
ii. Mal-union—it may be angular or rotational or i. Shoulder dislocation
overlapping  Anterior (common)
iii. Cross-union in radius and ulnar shaft fracture   Posterior
iv. Myositis ossificans especially around elbow joint ii. Fracture of greater tuberosity
v. Avascular necrosis of bone in femur head, iii. Fracture of surgical neck of humerus
scaphoid,lunate and body of talus iv. Fracture dislocation of shoulder
v. Fracture of neck of scapular
vi. Fracture body of scapula
Bones and Joints 3
Wrist Joint
vii. Dislocation and subluxation of acromioclavicular joint In consists of lower ends of radius and ulna with medial and
viii. Avulsion of coracoid process lateral styloid processes, eight carpal bones and proximal part of
ix. Fracture of clavicle. all metacarpal bones.
Following lesions can take place around wrist joints:
i. Colle’s fracture
Arm ii. Smith fracture (Reverse Colle’s) Fracture of
The bone of the arm is called humerus. Upper end is included in radial styloid
shoulder joint and lower end in elbow joint. Fracture of shaft of iii. Fracture of ulnar styloid
humerus can take place anywhere but at lower part is notorious iv. Fracture dislocation of base of carpal bone of
for nonunion. thumb(Bennett fracture)
v. Fracture of scaphoid bone
vi. Dislocation of lunate bone.
Elbow Joint Hand

Elbow joint is a hinge joint consisting of lower end of humerus; Normally one can see five metacarpal bones with their head
trochlear (for olecranon) and capitulum for radial head, neck, shaft and bases, and fourteen phalanges with
olecranon and coronoid process of ulna and head and neck of carpometacarpal, metacarpophalangeal and interphalangeal
radius. In X-rays of elbow one can also see the lower part of joints.
humerus, lateral and medial epicondyles, upper end of radius Following lesions occur in hand:
and ulna. Following lesions can be seen on radiogram of elbow. 
i. Fracture of metacarpal bones

 Base

i. Dislocation of elbow (In adults) 
 Shaft
 Anterior  Neck
 Posterior (common) ii. Fracture of
ii. Supracondylar fracture of humerus (children) phalanges

 Anterior iii.

Dislocation

 Posterior (common) 
 Metatarsophalangeal joint (MPJ)
iii. Fracture olecranon 
 Interphalangeal (joint)
iv. Radial head (children) subluxation  Fracture dislocation.
v. Fracture radial head (adult)
vi. Fracture neck of radius (children) INDIVIDUAL BONES AND JOINTS:
vii. Fracture of capitulum (adult)
viii. Fracture medial epicondyle LOWER LIMB
ix. Fracture of lateral epicondyle Lower limb skeleton consist of pelvic bone, hip joint, femur,
x. T–fracture of lower end of humerus (adult). knee joint, tibia and fibula, ankle joint, tarsal bones and bone of
the foot.
Forearm Pelvic Bones

It consists of two pelvic bones, one on each side consisting of
It has two bones: ilium, ischium and pubis. Posteriorly, they articulate with the
i. Radius outer side with rotating head above and sacrum and anteriorly with each other called pubic symphysis.
lateral styloid on the lower end. Laterally, it articulates with femoral head to form hip joint.
ii. Inner ulna with olecranon and coronoid processes
above and rotating head with medial styloid
Hip bone can get fractured by violent trauma. Fracture may not
process on the lower end. Following lesions can
be displaced or displaced. It can also get dislocated or have
take place in forearm:
fracture dislocation.
 Fracture of shaft of radius
 Fracture of shaft of ulna
 Fracture of shaft of radius and ulna Hip Joint
 Fracture of shaft ulna with dislocation of radial It consists of head of the femur, acetabulum greater trochanter,
head (Monteggia fracture) lesser trochanter and neck of the femur. Following lesions can
 Fracture of shaft of radius with dislocation of ulnar take place around hip joint:
head (Galeazzi fracture).







4 Fundamentals of Radiology 

xii. Ruptured semilunar cartilage
i. Coxa Vara (decreased joint space)
ii. Slipped epiphysis of head of femur  xiii. Loose body of knee joint
iii. Perthes’ disease xiv. Fracture separation of upper
iv. Congenital dislocation of hip tibial epiphysis.
v. TB hip joint
vi. Osteoarthritis (OA)hip
vii. Fracture acetabulum

viii. Dislocation of hip:

 Anterior Leg
 Posterior (common) It consists of (a) tibia—inner weight bearing bone, and (b)
 Central Fibula—thin deep outer bone of the leg. Upper condyle of the

ix. Fracture of neck of femur: tibia forms the knee join and also articulate with the head of

 Sub capital fibula to form upper tibiofibular joint which is a fixed joint. The

 Cervical lower end of tibia articulates with fibula, talus and calcanium to

 Intertrochanteric—Boyd and Griffin classification: form ankle joint. The lowest end of tibia is called medial
a. Simple malleolus and of fibula is called lateral malleolus. Fibula is a
b. Comminuted thin and cylinder bone which is deep except upper and lower
c. Subtrochanteric ends which are superficial.
d. Subtrochanteric with the continuous longitudinal Following lesions can occur in tibial and fibular shaft:
fractures of upper end of shaft of femur. 1. Fracture of shaft of tibia anywhere, but fracture at
x. Subtrochanteric fracture. the lower end is notorious for delayed union or
nonunion. In tibial shaft, anterior border and
medial surface is subcutaneous so compound
Thigh
fractures are common. Fatigue fracture of tibial
The thigh bone is the longest bone of the body. It has head, shaft is not uncommon.
neck, greater trochanter and lesser trochanter on upper end 2. Fracture of shaft fibula. It may be isolated or
which forms a hip joint. The lower end with two condyles accompanied with the fractures of the tibia on the
articulate with upper end of tibia to form knee joint. The shaft same plane or may be different plane. The
femur can get fractured at any place. fracture of lower shaft may be accompanied by
fracture dislocation of the ankle.
Knee Joints Ankle Joint
The knee joint is formed by the femoral condyles above, tibial It is formed by the lower end of tibia, lateral and medial
condyles below and patella in front. These condyles are mallealus, and body of talus and upper articular surface of
separated by medial and lateral semilunar cartilages. In between calcanium. The joint between talus and calcanium is also called
two femoral condyles there is an intercondylar fossa meant for subtalar joint). The talus head articulates with navicular bone
the attachment of cruciate ligament and in between two tibial which is not a part of ankle joint.
condyles there is tibial spine for cruciate ligament which can Following are the lesion around ankle:
avulse the tibial spine. Anteriorly, tibial tubercle is meant for the i. Fracture dislocation
attachment of ligament patella which can also get avulsed. The of ankle
upper tibiofibular joint does not contribute to the knee joint. ii. Dislocation of
Following lesion can be seen on X-ray: ankle
i. Osteoarthritis of the knee iii. Dislocation of talus
ii. Fracture separation of lower epiphysis iv. Fracture dislocation
iii. Supracondylar fracture of the of talus
femur v. Fracture lateral
iv. T or Y fracture of femoral malleolus
condyle vi. Fracture medial
v. Dislocation of knee joints malleolus
vi. Dislocation of patella vii. Diastasis of
vii. Fracture of patella tibiofibular joint.
viii. Fracture through the tibial
condyle Foot
ix. Fracture neck of fibula Foot consist of:
x. Fracture separation of insertion of i. Tarsal bones—calcaneus talus, navicular, cuboid
tendon patella and three cuneiform bones
xi. Fracture spine of tibia ii. Metatarsal, five in number

iii. Phalanges, fourteen in number
iv. Intertarsal joints
v. Tarsometatarsal joints
vi. Metatarsophalangeal joints

vii. Interphalangeal joints
The fractures and dislocation of the foot are:
i. Fracture of calcaneus
ii. Fracture of neck and body of talus
iii. Fracture navicular and cuboid
bones
iv. Mid metatarsal dislocation
v. Avulsion of base of 5th metatarsal
vi. Fracture of metatarsal bones-neck,
shaft and base
vii. Fracture of phalanges
viii. Dislocation of phalanges.
Bones and Joints 5
GENERAL DISEASES OF BONES
Fig. 1.1: X-ray of tibia and fibula: (1) Epiphysis; (2) Diaphysis; (3) Metaphysis; (4) Epiphyseal cartilage
A B
Figs 1.2.(i)A and B: Normal X-rays of the bones in the children with epiphyseal plate (→) which should not be confused with the
fracture. (A) Shoulder—upper end of humorous; (B) Elbow—lower end of humorous upper end of radius
A B
Figs 1.2.(ii)A and B: Normal X-rays of the bones in the children with epiphyseal plate (→) which should not
be confused with the fracture. (A) Wrist-lower end of radius and ulna; (B) Hip joint-acetabulum and upper end of
the femur
B
Figs 1.2.(iii)A and B: Normal X-rays of the bones in the children with epiphyseal plate (→) which should not be
confused with the fracture. (A) Knee joint-lower end of the femur and upper end of the tibia and fibula; (B) Ankle-
lower end of tibia and fibula
Bones and Joints 7
Fig. 1.3: X-ray of the knee joint showing traction epiphysis

for the attachment patellar tendon
Fig. 1.4: Fracture of apophysis or traction epiphysis of calcanium

which is meant for the attachment of the tendoachilles
Fig. 1.5: X-ray of the conjoint twin joining each other by sacrum (sacrophagus)
Fig. 1.6: A case of osteogenesis imperfecta. Note the fracture of

right femur both tibias with callus formation
Bones and Joints 9
Fig. 1.7: Congenital absence of fibula
Fig. 1.8: Congenital absence of radius. Note radius is rudimentary

and the ray of thumb is absent
Fig. 1.9: X-ray of ectrodactyly or lobster hand Fig. 1.10: Ectrodactyly or lobster foot
Fig. 1.11: X-ray foot—megatoes first and second toes—congenital deformity

Bones and Joints 11
Fig. 1.12: X-ray wrist in a case of rickets. Note splaying,

fraying and cupping at the metaphyseal end
Fig. 1.13: X-ray leg after subacute osteomyelitis fibula. Fig. 1.14: Osteomyelitis of tibia. The whole shaft has become
Note—gross periosteal reaction with decalcification of bone sequestrum. Never remove it until a proper callus is formed. It
may take a long period
Fig. 1.15: Brodie’s abscess upper end of tibia Fig. 1.16: Osteomyelitis fibula. Note a long sequestrum in fibula
Fig. 1.17: X-ray of the pelvis including both hip joints—TB of the right hip joint
Bones and Joints 13
Fig. 1.18: X-ray knee exostosis of upper end of tibia
Fig. 1.19: Diaphyseal aclasis Fig. 1.20: Osteoclastoma or giant cell tumor of upper end tibia
Fig. 1.21: Osteogenic sarcoma lower part of femur Fig. 1.22: Osteogenic sarcoma of fibula
Fig. 1.23: Osteogenic sarcoma lower part of shaft Fig. 1.24: Pathological subtrochanteric fracture of femur
femur (osteolytic lesion)
Bones and Joints 15
Fig. 1.25: Multiple myeloma or plasmacytoma of the humerus Fig. 1.26: X-ray of the hip of seven-year-old-boy showing
aneurysmal cyst of the femoral neck and adjoining shaft
Fig. 1.27: The same case (Fig. 1.26) after operation, i.e. Fig. 1.28: Same case (Fig. 1.27) 14 days after operation when
curettage and bone grafting the patient had a fall and got subtrochanteric fracture
Fig. 1.29: Degenerative disease of bones—osteoarthritis of spine

with marginal osteophytes (arrows) and reduced disc spaces
Fig. 1.30: Osteoarthritis of the knee reduced joint space with osteophytes
Bones and Joints 17
Fig. 1.31: X-ray newborn with multiple fractures—a case of osteogenesis imperfecta
GENERAL FRACTURE OF LONG BONES
Fig. 1.32: Simple fracture of the shaft of humerus Fig. 1.33: Butterfly fracture of shaft of humerus
Fig. 1.34: Fracture tibia oblique type Fig. 1.35: Spiral fracture of femoral shaft
Fig. 1.36: Comminuted fracture of tibia Fig. 1.37: Comminuted fracture of lower end of femur, see also
and simple fracture of fibula pieces of metal—obvious cause is gunshot injury and type of fracture
is compound
Bones and Joints 19
Fig. 1.38: Pathological fracture of femoral shaft fixed with Fig. 1.39: GS fracture of shaft of radius and ulna.
intramedullary K nail Note only one cortex is broken
Fig. 1.40: GS fracture lower part of shaft of tibia and fibula Fig. 1.41: Fracture of tibia and fibular shaft being treated by
continuous traction (Perkin). Position is acceptable but too much gap
between broken ends. What should be done? Reduce the weights on
traction
Fig. 1.42: Fracture of acetabulum with Thomas splint Fig. 1.43: Fracture of medial condyle of femur fixed
by Cramer wire splint
Fig. 1.44: Fracture tibia and fibular shaft treated Fig. 1.45: Comminuted fracture of lower part of shaft of tibia and
by closed reduction and pop fibula of 6 months duration fixed by external fixator with nonunion
Bones and Joints 21
Fig. 1.46: Same fracture (Fig. 1.45) after bone grafting removal Fig. 1.47: Same case (Fig. 1.46) after one year.
of fixator and plaster of Paris (POP) cast. Fracture had a solid Union is satisfactory. Patient is walking well
union after 6 months
Fig. 1.48: X-ray femur with Kuntscher nail for fractured mid shaft with all the signs of union
Fig. 1.49: Spiral fracture of femur fixed by K-nail causing splitting of Fig. 1.50: X-ray of the leg after K-nailing for fracture of tibial
bone and overlapping of fragments resulting shortening of limb. A shaft. Patient had a fall one month after the operation. X-ray
wrong decision it should have been fixed by a long plate shows broken K-nail
Fig. 1.51: X-ray femoral shaft with interlocking nail. Fracture is 3 month old and there is every sign of nonunion.
Patient was treated by removal of upper locking screw and bone grafting
Bones and Joints 23
Fig. 1.52: Fracture of upper 1/4th shaft of radius and fracture of middle part of shaft of ulna fixed by intramedullary K-pins
Fig. 1.53: Fracture of radius and ulna after being fixed by intramedullary nail (Rush nail). Note—The redial nail is lying
outside the bone in the lateral view which shows the importance of taking X-ray in two views
Fig. 1.54: Old fracture of radial shaft fixed improperly by intramedullary nail causing nonunion
Fig. 1.55: Fractured patella fixed by wire loop

Bones and Joints 25
Fig. 1.56: Old fracture of patella fixed by a screw Fig. 1.57: X-ray forearm with fracture of radius and ulnar
shaft fixed by plating. Union satisfactory
Fig. 1.58: Fracture of femur fixed by a plate, Fig. 1.59: Fracture neck of femur with old fashioned pin and plate
plate got broken by metal fatigue
Fig. 1.60: X-ray hip—Austin—Moore’s prosthesis for fracture neck of femur
Fig. 1.61: Fracture of humerus with nonunion

Bones and Joints 27
Fig. 1.62: Old supracondylar fracture of humerus with malunion
Fig. 1.63: A vascular necrosis lateral condyle of femur Fig. 1.64: X-ray forearm with old fracture of radial and ulnar
following fracture of lateral condyle after being fixed by various shaft treated by plating of radius. X-ray shows cross union—a
operations. Note there is osteomyelitis of whole lower end of rare complication after this fracture
femur with disorganized knee. Patient ended up with above knee
amputation. Note also sinogram
SHOULDER
Fig. 1.65: Normal X-ray of shoulder: (1) Head; (2) Greater tuberosity; (3) Coracoid process; (4) Surgical neck;
(5) Glenoid; (6) Clavicle; (7) Acromion process; (8) Scapula; (9) Acromio-clavicular joint
Fig. 1.66: X-ray shoulder with fracture of neck of scapula

Bones and Joints 29
Fig. 1.67: Subluxation of acromio-clavicular joint with a wide gap Fig. 1.68: Dislocation of shoulder
Fig. 1.69: Dislocation of the shoulder with fracture of greater tuberosity

Fig. 1.70: X-ray shoulder with fracture surgical neck of humerus
Fig. 1.71: X-ray shoulder with impacted fracture surgical neck of humerus
Bones and Joints 31
Fig. 1.72: Fracture of the surgical neck of Fig. 1.73: X-ray shoulder with fracture dislocation of
the humerus with displacement surgical neck humerus. She needs open reduction
Fig. 1.74: X-ray shoulder—fracture outer end of clavicle

Fig. 1.75: Fracture clavicle—common—site at the junction

of lateral 1/3 and medial 2/3 of the bone
Fig. 1.76: Fractured clavicle treated by figure of 8 bandages. Position excellent which is unusual; because whatever method of
closed reduction you use position is usually unsatisfactory. But union almost always takes place and molding is so good that after one
year or so one can hardly see any deformity clinically and radiologically
Bones and Joints 33
Fig. 1.77: Fracture of clavicle after one year treated

by figure of 8-union perfect
Fig. 1.78: Fracture clavicle with nonunion, a rare thing

Fig. 1.79: Same case Figure 1.78 open reduction and fixation by K-pin and loop of wire
Fig. 1.80: Fracture upper part of shaft of humerus fixed by

Cramer wire splint position acceptable
Bones and Joints 35
Fig. 1.81: Simple fracture of shaft of humerus
Fig. 1.82: Secondary in upper part of humerus from breast cancer. Spine, pelvis, ribs, upper end humerus and femur are most
common sites, thyroid kidneys, colon, lungs and neuroblastoma which are usually osteolytic
ELBOW
Fig. 1.83: X-ray elbow (AP and LAT) Normal: (1) Lower end of humerus; (2) Radius; (3) Ulna; (4) Medial epicondyle; (5) Lateral
epicondyle; (6) Capitulum; (7) Trochlea; (8) Head of radius; (9) Neck of radius; (10) Olecranon process; (11) Coronoid process
Fig. 1.84: Supracondylar fracture of humerus in AP view

Bones and Joints 37
Fig. 1.85: Another case of supracondylar fracture of Fig. 1.86: Supracondylar fracture of humerus with malunion
humerus with displacement (lateral view)
Fig. 1.87: Supracondylar fracture of humerus after reduction and internal fixation. Position not acceptable
Fig. 1.88: Supracondylar fracture of humerus, fixed by K-pins—position good
Fig. 1.89: X-ray elbow—T—fracture lower end of humerus Fig. 1.90: X-ray lower end of humerus—same T– fracture (Fig. 1.89)
after internal fixation by K-pins and wire loops
Bones and Joints 39
Fig. 1.91: X-ray elbow—with fracture separation and rotation of the capitulum
Fig. 1.92: Old fracture separation of lateral condyle of the humerus, causing gross valgus deformity of the elbow
Fig. 1.93: Dislocation of elbow
Fig. 1.94: X-ray elbow—(lateral) fracture olecranon process

Bones and Joints 41
Fig. 1.95: X-ray elbow with fractured olecranon process fixed by K-pin and wire loops
Fig. 1.96: Fracture of neck of radius, there is also fracture of head of radius
FOREARM
A B
Figs 1.97A and B: Normal X-ray forearm: (A) Radius; (B) Ulna. Fig. 1.98: Congenital absence of radius. Note that radius is
There is an artifact between two bones rudimentary and the ray of thumb is absent
Fig. 1.99: Fracture radial shaft in a baby without much displacement. Both cortex are broken and cannot qualify for greenstick
Bones and Joints 43
Fig. 1.100: GS fracture lower end of radius and ulna (lateral view)
Fig. 1.101: GS fracture lower end of radius and ulna (AP view)
Fig. 1.102: Fracture lower end ulna, usually caused by direct blow and notorious for delayed union
Fig. 1.103: Fracture of upper 1/4th shaft of radius and fracture of middle part of shaft of ulna
Bones and Joints 45
Fig. 1.104: Above fracture (Fig. 1.103) fixed by intramedullary K-pins
Fig. 1.105: X-ray forearm—fracture of shaft of radius and ulna

Fig. 1.106: X-ray shaft of radius and ulna with Fig. 1.107: Fractured ulnar shaft with dislocation
fracture fixed by old styled Rush nail of radial head—Monteggia fracture
Fig. 1.108: Galeazzi fracture, i.e. fracture of shaft Fig. 1.109: GS fracture of shaft of radius and ulna
of radius with dislocation of ulnar head
Bones and Joints 47
Fig. 1.110: X-ray forearm with old fracture of radial and ulnar shaft treated by plating of radius.
X-ray shows cross-union—a rare complication after this fracture
WRIST AND HAND
Fig. 1.111: Normal X-ray of wrist and hand: (1) Lower end of radius; (2) Lower end of ulna; (3) Radial styloid process; (4) Ulnar styloid process:
Note radial styloid process is lower than ulnar; (5) Scaphoid; (6) Lunate; (7) Triquetral; (8) Pisiform (Not yet appeared); (9) Trapezium; (10)
Trapezoid; (11) Capitate; (12) Hamate; (13) Metacarpal bone; (14) Proximal phalanx; (15) Middle phalanx; (16) Terminal phalanx
Note: As this is an X-ray of a young boy so (3) Radial styloid process (4) Ulnar styloid process and (8) Pisiform are not yet clear
Fig. 1.112: X-ray wrist—a case of rickets
Fig. 1.113: X-ray of the wrist with the lesion of the lower end of the radius. Biopsy report was tuberculosis of the bone
Bones and Joints 49
Fig. 1.114: X-ray wrists—fracture of ulna styloid process
Fig. 1.115: X-ray wrist—fracture lower end radius without displacement

Fig. 1.116: X-ray wrist with Colle’s fracture—radial and posterior displacement
Fig. 1.117: X-ray wrist: Taken 2 months after trauma with the fracture of scaphoid
Bones and Joints 51
Fig. 1.118: Old malunited Colle’s fracture Fig. 1.119: Same case (Fig. 1.118) after operation, i.e. reduction of
with clinically Madelung deformity radius and excision of the ulnar head
Fig. 1.120: X-ray wrist—Colle’s fracture reduced and fixed by two K-pins
Fig. 1.121: Smith fracture (reverse Colle’s) usually

needs internal fixation
Fig. 1.122: Smith fracture, distal fragment displaced anterior and proximally carrying whole wrist joint with it
Bones and Joints 53
Fig. 1.123: Slipped epiphysis lower end radius
Fig. 1.124: Bennett’s fracture dislocation of MP joint of the thumb

Fig. 1.125: X-ray of hand with fractured shaft third and fourth metacarpal
bones fixed by K-pin. There is also fracture of base of fifth metacarpal (MC)
bone
Fig. 1.126: X-ray of hand—oblique fractures base of 4th metacarpal bone

Bones and Joints 55
Fig. 1.127: X-ray of hand with fracture proximal phalanx of middle finger and fracture
dislocation of the proximal interphalangeal joint of the index finger
Fig. 1.128: Same case (Fig. 1.127) fixed by K-wires

Fig. 1.129: X-ray hand with fracture of second phalanx of index finger
Fig. 1.130: X-ray of hand comminuted fracture of proximal phalanx

of little finger without much displacement
Bones and Joints 57
Fig. 1.131: X-ray hand—dislocation of proximal IP joints of little and ring fingers
Fig. 1.132: X-ray of hand after being crushed by a machine

Fig. 1.133: Rheumatoid hand with deformities of the fingers
PELVIS
Fig. 1.134: X-ray Pelvis—Normal (anteroposterior view): (1) Sacrum; (2) Ilium; (3) Pubis body; (4) Superior ramus pubis; (5) Inferior ramus pubis; (6)
Pubic symphysis; (7) Ischial tuberosity; (8) Head of femur; (9) Neck of femur; (10) Fifth lumbar vertebra; (11) Sacroiliac joint; (12) Coccyx
Bones and Joints 59
Fig. 1.135: X-ray pelvis—fractured both of pubic rami on right side
Fig. 1.136: X-ray pelvis dislocation pubic symphysis with dislocation of right sacroiliac joint upwards. Note prominence of obturator
foramen. In fracture dislocation pelvis dislocation pelvis there is always disruption of the ring of pelvis or puboischial ring
Fig. 1.137: X-ray pelvis—upward dislocation of right hemi pelvis. It was

treated by continuous heavy skeletal traction of lower limb
Fig. 1.138: X-ray of the pelvis with the fracture and dislocation of the right sacroiliac joint
Bones and Joints 61
HIP
Fig. 1.139: X-ray normal hip joint: (1) Head of femur; (2) Neck; (3) Greater trochanter;
(4) Lesser trochanter; (5) Ischial tuberosity; (6) Acetabulum; (7) Superior ramus of pubis
Fig. 1.140: Perthes’ disease of the left hip

Fig. 1.141: X-ray of the pelvis with the hip joints with the Shenton’s line. Shenton’s line is a line drawn on the lower border of the
neck of the femur and lower part of the superior pubic ramus which form a smoth curve in normel hip joints (left side) but this curve
is disturbed in cases of dislocation of the hip joint (right side) as well as in fracture of the neck of the femur
Fig. 1.142: Unreduced congenital dislocation of hip Fig. 1.143: Same congenital dislocation hip joint (as in Fig. 1.142)
treated by shelf operation. Other alternate is iliac osteotomy or
replacement of the hip joint
Bones and Joints 63
Fig. 1.144: Dislocation of hip, there is also fractures Fig. 1.145: Old dislocation of hip calcified ruptured ligaments
of inferior ramus of pubis
Fig. 1.146: Anterior dislocation of the hip joint (uncommon) Fig. 1.147: X-ray hip—fracture of acetabulum
Fig. 1.148: Central dislocation of left hip joint
Fig. 1.149: Transcervical fracture of neck of femur

Bones and Joints 65
Fig. 1.150: Old transcervical fracture neck of femur immobilized by Fig. 1.151: X-ray of hip—Impacted fracture of neck of femur
Thomas splint. There is necrosis and absorption of the neck
Fig. 1.152: Transcervical fracture treated by conservative treatment, i.e. continuous skin traction
Fig. 1.153: Intertrochanteric fracture of femoral

neck (B and G Type II)
Fig. 1.154: Intertrochanteric fracture of neck of femur (type -1)

Bones and Joints 67
Fig. 1.155: Transcervical fracture neck of femur fixed by cancellous screws
Fig. 1.156: Subcapital fracture of neck of femur Fig. 1.157: Subcapital fracture of neck of femur,
with old fashioned SP nail position good
Fig. 1.158: Subcapital fracture of femoral neck fixed by SP nail. Note that the nail is Fig. 1.159: X-ray hip—Austin—Moore’s
prosthesis
too long and there is gap at the fracture line, so position is not acceptable for subcapital fracture neck of femur
Fig. 1.160: Old bilateral slipped epiphysis of femoral head causing bilateral coxa vara
Bones and Joints 69
Fig. 1.161: X-ray hip—with a nail and interlocking long screw Fig. 1.162: X-ray of the hip showing subtrochanteric fracture
to fix the fractured neck of femur. Note avascular necrosis and fixed with the two interlocking long screws along with the nail.
complete absorption of head and neck of the femur Position is not satisfactory
Fig. 1.163: Intertrochanteric fracture of femoral neck treated Fig. 1.164: Fracture neck of femur with old fashioned pin and plate
conservatively. Union is good but patient had coxa vara with the
effected limb 3 inches shorter than normal side
Fig. 1.165: Intertrochanteric fracture of neck of femur

fixed by dynamic hip screw (DHS) plate
Fig. 1.166: Intertrochanteric fracture fixed by a reconstruction nail

Bones and Joints 71
Fig. 1.167: Subtrochanteric fracture (B and G type III) Fig. 1.168: X-ray hip—dynamic hip screw (DHS) and long plate for
intertrochanteric fracture (G and B type IV)
Fig. 1.169: Tuberculosis hip joint Fig. 1.170: X-ray hip with osteoarthritis of hip joint
Fig. 1.171: X-ray of hip after complete hip replacement for osteoarthritis of hip joint
THIGH
A B
Fig. 1.172: X-ray femur with fracture in lower third of shaft Figs 1.173A and B: Two X-rays with fractures of shaft of femur: (A) At
lower ¼ of femur—K-nail is of no use as lower part is not long enough to
hold the nail from rotational movement. So ideal is either interlocking nail
or plating; (B) In the middle of shaft so K-nail can fix this fracture
Bones and Joints 73
Fig. 1.174: Fractures (in a boy) of lower end of femur fixed improperly by a plate. At least two screws
above and two screws below fracture should be employed to fix the plate
Fig. 1.175: Comminuted fractures of lower fourth of femur fixed improperly by two rush nails
Fig. 1.176: Fracture lower 1/3rd of femur shaft

fixed improperly by K-Nail
Fig. 1.177: X-ray femur with Kuntscher nail for fractured

mid shaft with all the signs of union
Bones and Joints 75
Fig. 1.178: X-ray femur with fracture of shaft of femur fixed by intramedullary K-nail.
Note the nail has slipped out by itself and broken by metal fatigue
Fig. 1.179: Fracture of the femoral shaft

fixed by interlocking nail
Fig. 1.180: Oblique fracture of the shaft of the femur fixed by Fig. 1.181: X-ray femoral shaft with interlocking nail. Fracture
interlocking nail. The broken ends have a gap which should have is 3 month old and there is every sign of nonunion. Patient was
been failed with the cancellous bone graft treated by removal of upper locking screw and bone grafting
Fig. 1.182: X-ray femur with old fracture fixed by K-nail and wire loops. Union satisfactory
Bones and Joints 77
Fig. 1.183: Fracture of shaft of femur in a young girl, plating done three weeks back.
Note upper three screws slipped out with angular deformity
Fig. 1.184: The above case (Fig. 1.183) after one year. Fracture is united with some molding, limb is 1.5 cm short
KNEE
Fig. 1.185: X-ray knee (AP and Lat) Normal: (1) Femur; (2) Patella; (3) Tibia; (4) Fibula; (5) Medial condyle of femur;
(6) Lateral condyle femur; (7) Medial condyle of tibia; (8) Lateral condyle tibia; (9) Tibial spine; (10) Head of fibula
Fig. 1.186: X-ray knee—with a loose body in the joint black arrow— Fig. 1.187: X-ray knee joint with a loose body
Note osteochondritis dissecans of the medial condyle of the femur
Bones and Joints 79
Fig. 1.188: X-ray knee—Gross osteoarthritis especially patellar compartment
Fig. 1.189: X-ray knee with gross osteoarthritis Fig. 1.190: X-ray knee—Charcot joint
Fig. 1.191: X-ray knee—replacement of knee

joint for gross osteoarthritis of knee
Fig. 1.192: Fracture of patella

Bones and Joints 81
Fig. 1.193: Fractures patella fixed by a screw
Fig. 1.194: Fractured patella fixed by two K-pins and wire loop
Fig. 1.195: Fractured patella fixed by wire loop
Fig. 1.196: X-ray knee—fracture of medial condyle

of femur fixed by Cramer wire splint
Bones and Joints 83
Fig. 1.197: Condylar fracture of the femur fixed

by a dynamic condylar screw and plate
Fig. 1.198: X-ray knee T fractures of condyles of femur fixed by Fig. 1.199: Fracture of femur condyle fixed by L plate
dynamic condylar screw and plate and cancellous screws and cancellous screw
Fig. 1.200: Slipped epiphysis upper end of tibia with

chip of bone from metaphysis (Salter II)
Fig. 1.201: Slipped epiphysis lower end of femur with gross displacement patient had ischemia of the leg and
foot no bone chip with it (Salter I). It usually occurs due to the hyperextension injuries of the knee
Bones and Joints 85
Fig. 1.202: Old slipped epiphysis lower end of femur Fig. 1.203: X-ray knee—same patient (Fig. 1.202) in AP view
with callus formation
Fig. 1.204: Dislocation of the knee joint Fig. 1.205: Condylar fracture of tibia with dislocation of knee
Fig. 1.206: Fracture of tibial spine Fig. 1.207: X-ray knee with old fracture of upper part of tibia
including condyle with nonunion
Fig. 1.208: X-ray upper end of tibia and fibula with comminuted Fig. 1.209: X-ray knee—fracture of medial condyle of
fracture of upper end of tibia fixed by T-plate. Note the nonunited tibia fixed by cancellous screws
fracture of shaft of fibula
Bones and Joints 87
Fig. 1.210: T-fracture of tibial condyle with fracture upper part

fibular shaft, treated by pop cast position acceptable. Other
option was dynamic screw with plate
Fig. 1.211: Arthrodesis of knee joint by Ilizwe vertical fixator

LEG
Please check
Fig. 1.212: X-ray of tibia and fibula (normal) (See Fig. 1.1) Fig. 1.213: Fracture of tibia and fibular shaft
Fig. 1.214: Fracture lower part tibia and fibular shaft Fig. 1.215: Comminuted fracture tibia. Lower 1/4th shaft of tibia is
fixed by intramedullary nail—wrong decision—It should have been
fixed by plating
Bones and Joints 89
A B
Figs 1.216A and B: Two old fractures of mid-shaft tibia, one fix by K-nail other by plating. In both cases union is satisfactory
Fig. 1.217: Old fractures of tibia and fibular shafts. Tibia fixed by a Fig. 1.218: Fracture of shaft of tibia and fibula
K-nail and fibula by plating. The union is satisfactory
Fig. 1.219: Same case after K-nail of the tibia. Note there is a gap Fig. 1.220: Same case (Fig. 1.219) after one month after
between two broken ends which can cause delayed or nonunion a fall causing fracture of the nail
Fig. 1.221: Same case (Fig. 1.220) after removal of the nail, plating and bone grafting of the tibia
Bones and Joints 91
Fig. 1.222: X-ray leg after subacute osteomyelitis fibula. Fig. 1.223: Osteomyelitis of tibia. The whole shaft has become
Note gross periosteal reaction with decalcification of bone sequestrum. Never remove it until a proper callus is formed. It
may take a long period
Fig. 1.224: Brodie’s abscess upper end of tibia Fig. 1.225: Osteomyelitis fibula. Note a long sequestrum in fibula
Fig. 1.226: Osteogenic sarcoma of fibula
ANKLE
Fig. 1.227: X-ray ankle—(AP and LAT) Normal: (1) Tibia; (2) Fibula; (3) Medial malleolus; (4) Lateral malleolus;
(5) Talus body; (6) Talus head; (7) Calcaneum; (8) Subtalar joint; (9) Ankle joint; (10) Cuboid; (11) Navicular bone
Bones and Joints 93
Fig. 1.228: Fracture calcaneum
Fig. 1.229: Fracture of apophysis of calcaneum (Apophysis—where by

tendon is inserted) actually it is posterior epiphysis of calcaneum
Fig. 1.230: X-ray ankle fracture medial and lateral malleolus
Fig. 1.231: Dislocation of ankle: Talus and subtalar joint are intact
Bones and Joints 95
Fig. 1.232: Fractured medial malleolus fixed by a screw Fig. 1.233: Fracture dislocation ankle. Note fractured medial
malleolus, transverse fracture fibula above tibiofibular joint (TFJ) and
subluxation of ankle
Fig. 1.234: Neuropathic joint of a diabetic patient—completely disorganised joint

Fig. 1.235: X-ray ankle lateral—note calcaneal spur
FOOT
Fig. 1.236: X-ray foot (Normal): (1) Calcaneum; (2) Talus; (3) Fig. 1.237: Normal midtarsal joint: (1) Calcaneum; (2) Talus;
Navicular bone; (4) Cuneiform bones; (5) Cuboid; (6) Metatarsal (3) Navicular bone; (4) Cuboid; (5) Cuneiform; (6) Metatarsal bones;
bones; (7) Phalanx; (8) Tarsometatarsal joint; (9) Midtarsal joint; (7) Sesamoid bone (arrow)
(10) Metatarsophalangeal joints; (11) Interphalangeal joints
Bones and Joints 97
Fig. 1.238: Two X-rays of the foot with fracture of base of fifth metatarsal bone.
It is usually caused by twisting of the foot so called belly dancer’s fracture
Fig. 1.239: Comminuted fracture of base of second MT with small radio-opaque

particles, most probably caused by firearm injury
Fig. 1.240: X-ray of the foot with fractured shaft of second and third metatarsal bone
Bones and Joints 99
Fig. 1.241: X-ray of the foot—fractured second and third metatarsal shafts, fixed by K-pin
Fig. 1.242: X-ray of foot with fracture of base of first metatarsal bone
Fig. 1.243: X-ray foot with fracture of neck (arrow) of second

metatarsal. Patient had a pain in his left forefoot after a long walk.
No history of injury. Diagnosis: fatigue or March fracture
Fig. 1.244: X-ray foot with the tuberculosis of first metatarsal and cuneiform bone. Note the normal right foot
Bones and Joints 101
Fig. 1.245: Badly disorganised foot bones after crush injury. Usually such foot gets gangrenous
Fig. 1.246: X-ray foot with extra 6th toe. Note duplication of head of fifth metatarsal bone
SPINE
Fig. 1.247: X-ray Lumbosacral spine (Lateral/Normal): (1) Bodies of Fig. 1.248: X-ray thoracolumber spine with hemi
lumbar vertebra; (2) Intervertebral disc space; (3) Sacrum; (4)Coccyx; vertebra left side. Note one left rib is missing
(5) Lumbosacral joint; (6) Intervertebral foramen
Fig. 1.249: X-ray of lumbosacral spine. Note spina bifida of L5 (↑)

Fig. 1.250: X-ray thoracolumbar spine—Note accessory Fig. 1.251: X-ray thoracic spine AP—(Normal)
rib of first lumber vertebra on right side
Fig. 1.252: X-ray lumbosacral spine with osteosclerotic secondaries in spine and pelvis from carcinoma prostate
Fig. 1.253: X-ray lumbosacral spine—classical bamboo Fig. 1.254: X-ray spine—Note a radio-opaque foreign body in
spine—ankylosing spondylitis the neural canal at the level of T12—Bullet. Patient had complete
paraplegia
Fig. 1.255: Same case (i.e. Fig. 1.254) in lateral view Fig. 1.256: Scoliosis—most probable cause is
old tuberculosis of spine
Fig. 1.257: X-ray spine (LAT) TB spine—Body Fig. 1.258: X-ray TB lumber spine—Note that intervertebral
of the T10 is wedged anteriorly disc is also damaged with the body of vertebral
Fig. 1.259: TB spine after complete healing. Note that adjacent Fig. 1.260: Another case of healed tubercular lesion of spine
bodies of the vertebrae are united, causing kyphosis
Fig. 1.261: X-ray spine (LAT) osteoporosis of spine with Fig. 1.262: X-ray spine—osteoporosis with osteoarthritis
compressed vertebral and osteoarthritis of spine
Fig. 1.263: X-ray spine (AP) gross OA spine L 1-2-3. Fig. 1.264: X-ray thoracic spine (AP) paravertebral
With osteophytes abscess D6-7-8 due to TB spine
Fig. 1.265: X-ray spine with secondaries in the body of vertebra
Fig. 1.266: X-ray lumber spine after trauma.

Note compressed fracture of the body
Fig. 1.267: Compressed body of L1 due to secondaries. Note discs are intact
Fig. 1.268: X-ray spine fracture spinal at base of L5 Fig. 1.269: Unstable fracture of thoracic spine
fixed by a frame. Patient has paraplegia
Fig. 1.270: X-ray lumbosacral spine lateral view, Diminished disc space between L 4-5,
due to prolapsed disc. There is also spondylolisthesis (grade1) L5 (see MRI next)
Fig. 1.271: Magnetic resonance imaging (MRI) of the spine (Fig. 1.270) of with
prolapsed L3-4-5 S1 and spondylolisthesis
Fig. 1.272: Magnetic resonance imaging (MRI) Fig. 1.273: X-ray spine—spondylolisthesis L5 Grade II
of lumbosacral spine—normal
Fig. 1.274: Magnetic resonance imaging (MRI) spine showing clear cut spondylolisthesis of L5 (arrow).
It also shows calcification of abdominal aorta
2
CHAPTER Chest
INTRODUCTION Lungs
The X-ray of the lungs mostly comes in the domain of the
X-ray chest is the most common investigation done in the past
physician. The surgeon comes into picture, whenever there is a:
and it is mostly advised by the physician. It is usually taken in
standing position unless patient is too sick to stand up.
i. Cavity of the lung
Posteroanterior view is mostly asked for but lateral, oblique and ii. Lung abscess
even anteroposterior is essential some times in special iii. Carcinoma of the
circumstances. The film is exposed in full inspiration. It is lung—primary or
preferable that the chest should be fully naked or at least no secondary
radiopaque object should be present around it, the arm should be iv.Hydatid cyst or
abducted. The film should include the last two cervical spines, other

cyst
partially both shoulder joints and upper part of abdomen v.Pleural effusion and empyema thoracic
especially whole diaphragm, and first lumbar vertebra. vi. Hemothorax

vii.Pneumothorax

In radiograph of the chest, we examine: viii.Hemopneumothorax

ix.Lung contusion
i.Bones
x.Stomach in the chest cavity, i.e. hiatus hernia.
ii.Lungs 

iii.Mediastinum in midline The diaphragm looks like a dome at the base of the lungs
iv.Diaphragm at the lowest border. on each side of thorax, right side is slightly higher due to liver.
The lateral corner is called costophrenic angle and inner is called
cardiophrenic angle which are normally sharp but are obliterated
Bones in case of pleural effusion. The diaphragm may be raised due to
liver enlargement, but a local rise or the so-called tenting of
The bones are 12 ribs on each side, one sternum, last two diaphragm is due to subphrenic or liver abscess, especially if it
cervical 12th thoracic and first lumbar vertebrae, clavicles and contains air fluid level. A crescent of gas under diaphragm
scapulae on each side. Surgeons request the X-ray chest for especially under right dome indicates perforation of
following bone lesions: gastrointestinal tract.
i. Congenital anomalies such as cervical rib and
hemi-vertebra
ii. Fracture of ribs which may be broken at one or Mediastinum
more places, one rib or more than one. It may be The mediastinum lies in the midline. It contains so many
accompanied by fracture of sternum, clavicle, important structures including heart, trachea, main bronchi,
scapula and thoracic spine. There may be esophagus, big arteries and veins, thoracic duct, thymus, lymph
hemothorax, pneumothorax, hemopneumothorax glands and sometimes retrosternal goiter.
or surgical emphysema or lung contusion. For It is shifted to other side in case of tension pneumothorax
fracture ribs. additional lateral even oblique view and becomes broader in cases of ruptured big vessels,
may be required. pericardial effusion, enlarged lymph glands, tumors or cyst of
iii. Tuberculosis of spine or ribs mediastinal contents, cardiac diseases and aneurysm. Air in the
iv. Tumor of the ribs (usually secondary). mediastinum may be due to ruptured air passage or esophagus.
Bronchiogram, aortogram and pleurogram are rarely done
and barium swallow is given in abdomen section.
Fig. 2.1: Normal X-ray chest. Note lungs on each side. Also note: (1) Head of humerus; (2) Clavicle; (3) Ribs; (4)
Mediastinum; (5) Right dome of diaphragm; (6) Left dome of diaphragm; (7) Costophrenic angle; (8) Cardiophrenic
angle
Fig. 2.2: X-ray neck and thoracic inlet—normal (AP view): (1) Inner Fig. 2.3: Bronchogram done by accident during
end of clavicle; (2) First rib; (3) Second rib; (4) Cervical vertebrae C5, C6, Ba–swallow for carcinoma esophagus
C7; (5) Thoracic vertebrae T1, T2
Chest 113
Fig. 2.4: X-ray chest with pleural effusion on right side
Fig. 2.5: X-ray chest—cardiomegaly

Fig. 2.6: X-ray chest—enlarged heart shadow more on right side—a case of mitral stenosis
Fig. 2.7: X-ray chest (AP) after open heart surgery. (1) central venous pressure (CVP) line;
(2) electrocardiography electrodes; (3) Steel wire sutures sternum
Chest 115
Fig. 2.8: X-ray chest—retrosternal goiter
Fig. 2.9: X-ray chest—note shadow stomach in the left side Fig. 2.10: X-ray chest shadow of stomach with gases and NG tube
of chest cavity: a case of diaphragmatic hernia in the right chest cavity. A case of diaphragmatic hernia
Fig. 2.11: Case in Figure 2.9 with barium meal. Shadow

of stomach in the chest cavity is confirmed
Fig. 2.12: X-ray neck with cervical rib on right side

Chest 117
Fig. 2.13: X-ray chest—tenting of right dome of diaphragm

with an air-fluid level. A case of subphrenic abscess
Fig. 2.14: X-ray chest fibrosis of left lung with tracheal shift most probably
due to healed tuberculosis lung. There is also crowding of ribs on left side
Fig. 2.15: X-ray chest aneurysm left ventricle which was confirmed by echocardiogram
Fig. 2.16: X-ray of the chest there is widening of the upper Fig. 2.17: X-ray chest—raised right dome of diaphragm:
mediastinum due to enlarged paratracheal and peribronchial A case of liver abscess
lymph nodes may be due to Hodgkin’s lymphoma
Chest 119
Fig. 2.18: X-ray chest—miliary tuberculosis of both lungs
Fig. 2.19: X-ray chest cor pulmonale with right ventricular hypertrophy
Fig. 2.20: X-ray chest—calcified hilar lymph glands with bilateral basal calcification
Fig. 2.21: X-ray chest—unfolding of aorta due to hypertension

Chest 121
Fig. 2.22: X-ray chest (Lateral view)—multiple lung

abscesses with air-fluid levels
Fig. 2.23: X-ray chest—multiple abscesses of lungs

Fig. 2.24: X-ray chest—lung abscess (Right)

Note: Air-fluid level in a cavity
Fig. 2.25: X-ray chest—a big abscess almost occupying whole left lung.
Note gas-fluid level in the cavity
Chest 123
Fig. 2.26: X-ray chest cor pulmonale showing: (1) Chronic inflammatory changes on both lungs
fields (lower half of lungs); (2) Right ventricular hypertrophy; (3) Double shadow on right side; (4)
Prominent pulmonary vessels (pulmonary arteries); (5) Idiopathic pulmonary fibrosis (IPF)
Fig. 2.27: X-ray chest—TB lung: Upper left lung is fibrotic with
multiple cavities
Fig. 2.28: X-ray consolidation of (R) basal lobe
Fig. 2.29: X-ray chest—a big secondary in the base of right lung
Chest 125
Fig. 2.30: X-ray chest—hydatid cyst left lung. Note: The diagnosis is confirmed by CT scan which will show daughter cysts in it
Fig. 2.31: X-ray chest with a rounded opacity (secondary) in right lung. Patient has already a big osteogenic sarcoma of femur
Fig. 2.32: CT scan with carcinoma left lung most probably large cell
carcinoma or adenocarcinoma lung
Fig. 2.33: CT scan chest: Irregular mass on right side which could be a carcinoma of lung.
As it is a central lesion, so it could be small cell or squamous cell carcinoma
Chest 127
Fig. 2.34: X-ray chest—multiple rounded (Cannon ball) secondaries in the lung from carcinoma of kidney
(same appearance can be from carcinoma of uterus, prostate breast, colon head and neck)
Fig. 2.35: X-ray chest—lungs riddled with secondaries. The patient had huge teratoma testis
Fig. 2.36: X-ray chest—acute respiratory distress syndrome (ARDS)—fluffy shadows

in both lung bases due to non-cardiogenic pulmonary edema
Fig. 2.37: X-ray chest—another case of ARDS: Fluffy shadows in both lungs
bases due to noncardiogenic pulmonary edema
Chest 129
Fig. 2.38: X-ray—chest single rib fracture
Fig. 2.39: X-ray chest—multiple fracture ribs at their posterior angles with fractured right clavicle
Fig. 2.40: X-ray chest with pneumothorax on left side.

Note: Surgical emphysema (→)
Fig. 2.41: X-ray chest hydropneumothorax on

right side with collapsed lung
Chest 131
Fig. 2.42: X-ray chest—consolidation of whole right lung
Fig. 2.43: X-ray chest—consolidation of upper lobe of right lung

Fig. 2.44: MRI chest—tension pneumothorax (left) pushing mediastinum toward right side
X-ray Abdomen
3
CHAPTER
INTRODUCTION The X-ray is taken mostly in anteroposterior (AP) and

sometimes in lateral view. For intestinal obstruction and
There are four types of X-ray abdomen. perforation, X-rays are taken in erect position and in complete
i. Plain X-ray abdomen expiration state. Lateral view is taken in suspected GIT
ii. X-ray abdomen with contrast media for biliary perforation when patient cannot stand erect and when one wants
tract, including: to differentiate between the kidney stones (Lying behind or side
a. Cholecystogram of spine) and stone in the gallbladder (GB), i.e. lying anteriorly.
b. T tube cholangiogram
c. Operative cholangiogram In plain X-ray abdomen one likes to see:
d. Percutaneous transhepatic cholangiogram i. Bony skeleton
(PTC) ii. Soft tissue
e. Endoscopic retrograde iii. Fluid
cholangiopancreatogram (ERCP) iv. Gas
iii. X-ray abdomen for contrast media for v. Radiopaque shadows
gastrointestinal tract (barium studies), including:
a. Barium swallow i. Bony skeleton: We can see the:
b. Barium meal and follow through a. Lower ribs
c. Barium enema b. Lower thoracic, lumbar (and their transverse
iv. X-ray for urology (Will be discussed in separate processes) sacral and coccygeal vertebrae
Chapters on urology and special X-rays of c. Pelvic bones
hysterosalpingogram) ii. Soft tissue:
a. Intravenous urogram/pyelogram (IVU or IVP) a. Psoas (muscle) shadow
b. Urethrogram b. Two kidneys
c. Retrograde cystogram c. Liver
d. Antegrade pyelogram d. Spleen
e. Retrograde pyelogram e. Urinary bladder
f. Hysterosalpingogram f. Sometimes bulky uterus in female
iii. Fluid: Normally, there is no free fluid in peritoneal
cavity. In cases of ascites or less thick fluid, it has
PLAIN X-RAYS OF ABDOMEN
ground-glass appearance.
A big film should be used to expose the abdomen in adults which iv. Gas: The pattern of gas in the stomach, small
should include the pubic symphysis and lower part of chest intestine and large bowel is classical. Normally,
(diaphragm). For routine X-rays especially for kidney, ureter and there is no free gas in the peritoneal cavity. Free
bladder (KUB) special preparations are required to get rid of gas in peritoneal cavity is present due to perforation
gases and radiopaque foreign body (FB) from the gastrointestinal of GIT or after opening of peritoneal cavity by
tract and preferably should be done on empty stomach. A penetrating injuries or operation. The gas ascends
laxative like Bisacodyl four tablet are given the night before X- on the top of the abdomen and one can see gas
rays. If still the patient has not cleared himself then an enema shadow under the diaphragm. One can also see gas
may be given or the X-ray may be postponed. Gas in the bowel under diaphragm in liver or subphrenic abscess due
obscures the soft tissues and even less radiopaque stones and to gas-producing bacteria. In case of intestinal
foreign body (FB) in the gastrointestinal tract (GIT) may look obstruction when intestinal loops are distended with
like a stone in the urinary tract or in the biliary tract. Some gas and fluid one can see gas fluid levels on X-ray.
patients have already emptied their bowels so one can take the Normally, this gas fluid level is present in the
chance straight away or take the control film. Bowel preparations fundus of stomach and some time in terminal
are contraindicated, if X-rays are indicated for the ileum. The gas in the jejunum is central in steps
gastrointestinal emergencies such as an acute appendicitis, ladder pattern, in ileum shapeless and in large
abdominal trauma, bowel perforation and diverticulitis. Be bowel, it is in the periphery in haustration form. In
careful in pregnant women especially in first three months. case of volvulus, the gas looks like an air-filled
tyre, or inverted U (Omega sign-Ω).
v. Radiopaque bodies: Normally, there is no radiopaque body b. Calcified cyst (especially hydatid and dermoid
in abdomen except bones, most common radiopaque cyst) fibroid uterus and calcified tubercular lesion
particles, we see are radiopaque food particles, of kidney, psoas abscess or neuroblastoma, adrenal
enterolith, phlebolith, calcified lymph glands, and and pancreas, nephrocalcinosis, healed abscess of
adrenals and the nephrocalcinosis and intrauterine liver, hepatoblastoma and colonic metastasis in the
contraceptive device (in female). We ask for the X-ray liver and calcified blood vessels.
abdomen to see: c. FB in GIT and abdomen.
d. Scattered omental calcification after acute
a. The radiopaque stone in urinary tract, biliary tract and pancreatitis.
pancreas.
Fig. 3.1: Plain X-ray abdomen: (Normal)—(1) Vertebra;

(2) 12th rib; (3) Psoas muscle; (4) Kidney; (5) Liver
Fig. 3.2: Plain X-ray abdomen with ground

glass appearance. Patient has gross ascites
X-ray Abdomen 135
Fig. 3.3: X-ray chest in standing position. Gas under Fig. 3.4: Plain X-ray abdomen in standing position multiple
diaphragm due to gastrointestinal perforation air-fluid levels—a case of acute intestinal obstruction
Fig. 3.5: Plain X-ray abdomen in standing position, notice a big Fig. 3.6: Plain X-ray is newborn with gas in the stomach
inverted U-shaped air-fluid level (Omega sign)—volvulus of (single bubble)—a case of congenital pyloric stenosis
sigmoid colon
Fig. 3.7: Plain X-ray abdomen in a newborn with two gas Fig. 3.8: Infantogram showing foreign body (Coin) in abdomen
shadows (two bubbles) a case of duodenal atresia which patient swallowed one day earlier
Fig. 3.9: Foreign bodies abdomen—a bullet in the abdomen Fig. 3.10: X-ray abdomen after laparotomy. Note a
left over artery forceps in the peritoneal cavity
X-ray Abdomen 137
Fig. 3.11: X-ray abdomen—two calcified hydatid cyst of liver Fig. 3.12: X-ray abdomen—a single calcified hydatid cyst of liver
Fig. 3.13: X-ray lower abdomen containing a FB a contraceptive device in the uterus
Abbreviation: KUB; kidney, ureter and bladder
BILIARY TRACT after 3–10 days to see free flow of dye from CBD into the
duodenum, and to see if any residual stone in the biliary
Oral cholecystogram when dye is given by mouth 12 hours tract is present.
before or 2 hours before by intravenous injection and X-ray of
biliary tract is taken. This dye is excreted by liver, concentrated iii.Percutaneous transhepatic cholangiogram (PTC): A
in the GB. After X-rays of right upper ¼ of abdomen is taken GB special needle (Chiba) is introduced in the tributaries of the
is visualized, if normal. Then some fatty food is given by which biliary tree through the skin across the liver under
GB contracts, if healthy. There will be a filling defection, if there fluoroscope and dye is injected through this needle which
are stones or growth in it. This investigation is obsolete and will show of the whole patent biliary tree. It is done for
given up and is replaced by US. obstructive jaundice, especially in malignancy of the biliary
However, other contrast studies when dye is injected tract or head of pancreas or ampulla. It is not popular
directly in the biliary tract are still in use. anymore and replaced by ultrasound and CT scan.
i. Operative cholangiogram: A tube is inserted in common
bile duct (CBD) through cystic duct during operation for GB iv.Endoscopic retrograde cholangiopancreatogram
and dye is injected through this tube and X-rays are taken at (ERCP): It is a special test when a tube is passed through
the operation table. It is done when one suspects a stone or a the papilla in the second part of duodenum into CBD and
growth in the biliary tract. dye is injected through this tube. It is done to see residual
ii. T-tube cholangiogram: Most of the surgeons retain a T-tube stone, stricture and malignancy in biliary ducts. It is done
in CBD after its exploration. A dye is injected in it after passing a gastroduodenoscope to visualize the
duodenum and its papilla under topical local anesthesia.
Fig. 3.14: Plain X-ray abdomen showing stone in GB Fig. 3.15: Oral cholecystogram—normal, no filling defect. Have
to be seen after fatty meal, if it contracts when no inflammation
X-ray Abdomen 139
Fig. 3.16: Oral cholecystogram after fatty meal. Normal Fig. 3.17: Oral cholecystogram—filling defects in
GB because it contracts and there is no filling defect gallbladder—a case of cholelithiasis
Fig. 3.18: Oral cholecystogram—a solitary stones in gallbladder Fig. 3.19: Oral cholecystogram—multiple stones in gallbladder
Fig. 3.20: Oral cholecystogram with multiple gallstone Fig. 3.21: T-tube cholangiogram 7 days after operation. Note: Arrow
pointing to a filling defect in the lower end of CBD—may be a gas
bubble or a residual stone
Fig. 3.22: Same T-tube cholangiogram (Fig. 3.21) after injection of

papaverine. No filling defect. Dye is passing freely into duodenums. Means:
T-tube can be removed safely. If this defect would have persisted and it
proved to be left over stone in CBD then ERCP papillotomy and stone
extraction is advised. Old washing away of stone with different chemical
solutions through T-tube is not recommended any more
X-ray Abdomen 141
A B
Figs 3.23A and B: Endoscopic retrograde cholangiopancreatogram (ERCP).
Note: (A) Pancreatic duct visualized, and in (B) Biliary tree is visualized
Fig. 3.24: T-tube cholangiogram, dilated biliary tract with a Fig. 3.25: Percutaneous transheptic cholangiogram (PTC).
stone in lower part of CBD. No dye is present in duodenum Dilated CBD with obstruction lower end of CBD—may be
carcinoma head of pancreas
Fig. 3.26: Percutaneous transheptic cholangiogram (PTC). Dilated

CBD with obstruction at its lower and due to a stone
BARIUM STUDIES when empty as well as to visualize the duodenum and small
intestine. Later exposure is done for large intestine, but it is
An emulsion of barium sulfate is used for this examination better to do Ba-enema to visualize the whole large bowel and
which is radiopaque. Remember barium chloride and sulphides terminal ileum. We also do contrast studies after evacuation of
are deadly poisons which should not be used. This contrast emulsion and pumping in some air in the bowel. Its
radiography is done to visualize the gastrointestinal tract. It is contraindications are perforation of intestine, intestinal
better to take the X-rays under fluoroscopy, but it is not obstruction and acute inflammatory disease of intestine.
essential. Iodine containing salts such as gastrograffin can also Ba-swallow is done for:
be used in very young patients or where some gastrointestinal a. Esophageal atresia
perforation is suspected. b. Pharyngeal pouch
The chest is exposed for anteroposterior and oblique views c. Esophageal varices
while patient is swallowing the emulsion and it is called Ba- d. Foreign body
swallow, which is done to delineate the esophagus. Immediately e. Carcinoma
and ½ hour after swallowing exposure is called Ba-meal to esophagus
show stomach. X-ray is taken in head tilted done position when f. Achalasia cardia
one wants to see the lower part of esophagus especially in reflux g. Hiatus hernia
and sliding hernia. h. Any other
Subsequent X-ray 2–6 hours after barium intake is called Ba swallowing
follow-through which is done to see the stomach 
disorder
Ba meal and follow through is indicated to see:
a. Congenital duodenal or jejunal atresia and pyloric

stenosis
b. Pyloric stenosis (acquired)
X-ray Abdomen 143
 c. Gastric ulcer evacuation of barium from the large intestine. It is called

 d. Duodenal ulcer double-contrast studies.
 e. Hour-glass contraction of stomach Ba-enema is indicated to diagnose:
 f. Carcinoma of stomach  Hirschsprung’s disease
 g. Hiatus hernia —Rectovesical fistula
 h. Pseudopancreatic cyst —Rectovaginal fistula
 i. Carcinoma head of pancreas  Sigmoid diverticulosis:
 j. Any other filling defect of stomach —Intussusception
 k. Intestinal diverticulosis —Ulcerative colitis
 l. Intestinal tuberculosis especially ileocecal region —Crohn’s disease
 m. Crohn disease —Polyposis coli
 n. Meckel’s diverticulum  Carcinoma large intestine
 o. Tumor of small intestine. —Ileocecal tuberculosis
Barium enema is done to visualize large intestine, —Rectal injuries
ileocecal region and terminal part of ileum. The colon and —Before closure of colostomy.
rectum is cleared by soap water enema before and preferably Before closure of colostomy which is done for any reason
after the X-rays. For more accurate studies additional X-ray the dye is injected in the distal loop through the distal
is also taken after insufflations of air in the rectum after colostomy opening and it is called cologram.
Fig. 3.27: Barium swallow: Pharyngeal pouch Fig. 3.28: Barium swallow: Carcinoma of cervical part of esophagus
Fig. 3.29: Barium swallow: A regular stricture lower Fig. 3.30: Barium swallow a very much dilated esophagus with
end of esophagus—a benign stricture smooth tapering stricture—Achalasia cardia
Fig. 3.31: Barium swallow another case of Achalasia cardia Fig. 3.32: Barium swallow—esophagogastric varices
X-ray Abdomen 145
Fig. 3.33: Barium swallow gastric varices Fig. 3.34: Barium swallow irregular stricture:
Carcinoma lower end of esophagus
Fig. 3.35: Barium swallow—long irregular stricture: Fig. 3.36: Barium study—after esophagectomy for carcinoma middle
Carcinoma middle part of esophagus part of esophagus and replacement a by pulling up of the
stomach. Arrow marks the esophagogastric anastomosis at the
entrance of nasogastric (NG) tube in the stomach
Fig. 3.37: Barium study after one month of the Fig. 3.38: Barium study—after esophagectomy and retrosternal
operation (See Fig. 3.36) replacement by ascending and transverse colon
Fig. 3.39: Barium study after esophagectomy and replacing it Fig. 3.40: Gastrograffin in newborn—a case of duodenal atresia
retrosternally by transverse colon. Note: Haustration of colon. Arrow
pointing at esophageal colonic anastomosis
X-ray Abdomen 147
Fig. 3.41: Gastrograffin in a newborn a case of jejunal atresia Fig. 3.42: Gastrograffin in newborn a case of pyloric stenosis
Fig. 3.43: Barium meal normal stomach J-shaped: (1) Cardiac; Fig. 3.44: Barium meal after 12 hours—huge stomach with
(2) Fundus; (3) Body; (4) Lesser curvature; (5) Greater curvature; (6) residual food—a case of pyloric stenosis
Pylorus; (7) Duodenal bulb
Fig. 3.45: Barium meal—a huge gastric ulcer Fig. 3.46: Barium meal—a big prepyloric ulcer
Fig. 3.47: Barium meal—deformed bulb Fig. 3.48: Barium meal—after subtotal
of duodenum: Duodenal ulcer gastrectomy Billroth I operation
X-ray Abdomen 149
Fig. 3.49: Barium meal—after gastrojejunostomy Fig. 3.50: Barium meal—filling defect in
pylorus—carcinoma stomach
Fig. 3.51: Barium meal—whole stomach is deformed—a case of linitis plastica (Carcinoma stomach).
Note: X-ray lying in reverse direction
Fig. 3.52: Barium meal follow-through—note a big C of Fig. 3.53: Barium meal follow-through—filling defect in terminal
duodenum. A case of carcinoma of head of pancreas ileum, cecum higher up—string sign—case of ileocecal tuberculosis
Fig. 3.54: Barium enema—normal, no diverticulum, no filling Fig. 3.55: Barium enema in a case of
defect in the colon and cecum. Cecum is at normal site, appendix intussusception with a first sign or a claw sign
not visualized; no barium in the terminal ileum. Final result can
only be given after evacuation of enema and insufflation of air in
the colon (Double contrast)
X-ray Abdomen 151
Fig. 3.56: Barium enema—filling defect in cecum and Fig. 3.57: Barium enema. Note: Pseudopolyposis of
ascending colon may be due to carcinoma the colon—a case of ulcerative colitis
Fig. 3.58: Barium enema. Note: Descending and sigmoid colon—a case of ulcerative colitis
Fig. 3.59: Cologram. It is done by injection of the barium emulsion in the distal opening of the colostomy
(sigmoid in this case or transverse) already done for imperforate anus or injury of the rectum
4
CHAPTER Urology
INTRODUCTION a. To judge the function of the kidney. When kidney does not
excrete dye up to ½ hour after injection its function is
There are two types of urinary tract contrast studies. compromised or there is some obstruction in the
A. Intravenous (IV) we inject dye in the vein which is urinary passage
excreted by kidneys and gives shadow of the urinary b. In emergency in cases of:

tract. It is called intravenous urogram (IVU) or  Renal injury and

intravenous pyelogram (IVP). Mostly the dyes being
 To differentiate renal stone from cholelithiasis.
used contain iodine, so if a person is allergic to iodine,
c. To diagnose the congenital renal malformations such as
he should not be given this salt. It delineates the calyces,
crossed dystopia, duplex kidney, horseshoe kidney,
pelvis of the kidney, ureters and urinary bladder.
ectopic kidney, hypoplastic, absent kidney and
Normally, a proper preparation of the bowel should be
vascular malformation
done and plain X-ray should be taken to confirm the
preparation. Then 20–40 mL of the dye is be injected d. See the size and location of the stones in the urinary tract.
intravenously and film is exposed immediately, after 5, Uric acid stones cannot be seen on plain X-rays but
15 and 30–45 minutes. After 5 minutes one should see can bepinpointed by filling defect
calyces, pelvis of the kidney ureter and urinary bladder e. Cyst of the kidney
in the subsequent films. If one does not see the shadows f. Scaring and tuberculosis of the kidney
of conducting system after 5–30 mm and can see only g. Tumor of the kidney
h. Stricture of ureter
the shadow of the kidney (so called nephrogram or
i. Injury or ligation of ureter
renogram), it is pathological, i.e. may be due to some
j. Dilatation of pelvic and ureter of kidney
kidney pathology or obstructive uropathy. In such cases,
(hydronephrosisand hydroureter)
the films should be exposed after 2, 4, 8, 12 even 24
k. Diverticulum of ureter
hours till one can visualize the urinary tract. After
l. Reflux ureter (in micturition cystogram)
seeing the dye in urinary bladder (cystogram) ask the
m. Diverticulum of bladder
patient to evacuate his bladder then take another film to
n. Bladder malformation
see if the bladder is empty completely. In some cases
o. Stone bladder
film is exposed during act of micturition called
p. Carcinoma bladder
micturition cystogram.
q. Ruptured bladder
r. Neurogenic bladder
B. After injection of dye directly in the urinary tract. Dye
s. Thimble bladder
is the same but technique is different:
t. Enlarge prostate
— Urethrogram: When dye is instilled directly into the
u. Rectovesical fistula
external meatus by a syringe and X-ray are taken.
v. Vesicovaginal fistula
— Cystogram: Dye is injected in the urinary bladder
w. Stricture urethra
through a urethral catheter followed by the X-rays.
x. Rupture urethra
— Retrograde pyelogram: The dye is injected in the ureter
y. Stone urethra
and pelvis of the kidney through a ureteric catheter z. Prostatic calculi
retained by a urologist by a cystoscope. aa. Diverticulum urethra
— Antegrade pyelogram: A tube is passed in the pelvis of
bb. Posturethral valves
the kidney directly by operation or percutaneously cc. Stress incontinence.
under US, then dye is injected in the tube.
Indications of Contrast Studies

The contrast study of the urinary tract is indicated to see the anatomy of this system before any urological operation
Fig. 4.1: Plain X-ray abdomen: (Normal): (1) Vertebra; Fig. 4.2: Plain X-ray abdomen in a baby. A big space-occupying
(2) 12th rib; (3) Psoas muscle; (4) Kidney; (5) Liver soft tissue lesion in right side of abdomen displacing intestinal gas
shadows to opposite side—probable diagnosis is nephroblastoma
Fig. 4.3: Plain X-ray abdomen—calcified para-aortic Fig. 4.4: Plain X-ray abdomen—nephrocalcinosis
and mesenteric lymph glands
Urology 155
Fig. 4.5: Plain X-ray kidney ureter bladder (KUB)—multiple radiopaque shadows
both side of base bladder due to calcified lymphatic glands
Fig. 4.6: Plain X-ray kidney ureter bladder (KUB)—Multiple stones Fig. 4.7: Plain X-ray abdomen—a radiopaque shadow in right
in both kidneys. Note the long axis of both kidneys is reverse to lumbar region which may be stone in (R) kidney or gallbladder
normal, i.e. the distance between lower poles is less than upper
poles—a case of bilateral nephrolithiasis in a horseshoe kidney
Fig. 4.8: The (Fig. 4.7) patient X-ray in lateral position—

note radiopaque body is lateral to vertebral body so it is a stone kidney
Fig. 4.9: Plain X-ray KUB—staghorn stone left kidney

and multiple stones in right kidney
Urology 157
Fig. 4.10: Plain X-ray KUB—multiple stones in both Fig. 4.11: Plain X-ray KUB 6 months after extracorporeal
kidneys; how patient is alive in any body’s guess shock-wave lithotripsy (ESWL). Arrow pointing to a stone in left
kidney (see IVP Fig. 4.44)
Fig. 4.12: X-ray KUB—stone in right kidney of a shape Fig. 4.13: X-ray KUB—stone in the bladder and
of pelvis (See IVP Fig. 4.42) staghorn stone in right kidney
Fig. 4.14: Plain X-ray KUB—three stones in right kidney Fig. 4.15: Plain X-ray abdomen. See DJ right ureteric stent retained
before ESWL. Note multiple small stones in right kidney
Fig. 4.16: Plain X-ray abdomen showing Fig. 4.17: X-ray pelvis—two pieces of broken stick in the bladder
classical calcified fibroid uterus
Urology 159
Fig. 4.18: X-ray pelvis—A big stone in the urinary bladder
Fig. 4.19: X-ray pelvis—two stones in the bladder usually such

stones are formed in chronic urinary obstruction
Fig. 4.20: X-ray pelvis—multiple stones in urinary bladder—a usual scene in neurogenic bladder
Fig. 4.21: Plain X-ray KUB—single stone in urinary bladder, a Fig. 4.22: Plain X-ray KUB—A huge stone in the lower
rosary of multiple stones in the lower end of left ureter and three end of left ureter, which was confirmed by IVP
stones in left kidney
Urology 161
Fig. 4.23: X-ray pelvis—stone lower end of ureter
Fig. 4.24: X-ray pelvis in a boy with retention urine.

Note stone in urethra (arrows)
Fig. 4.25: X-ray pelvis in a young man with difficulty and frequency of micturition. One stone in
bladder and lower stone lying in prostatic urethra which is the main cause of his symptoms
Fig. 4.26: X-ray of the bladder of a man who had open prostatectomy two years before. He developed difficulty of
micturition. Photograph shows a stone in the urinary bladder and in prostatic and membranous urethra
Urology 163
Fig. 4.27: X-ray pelvis-pubic bones are wide apart—a case of ectopia vesicae
Fig. 4.28: Normal IVP right kidney is lower than left. (1) Calyx minor; Fig. 4.29: Normal IVP. Note arrow at anatomical narrowing of ureter
(2) Calyx major; (3) Pelvis of the kidney; (4) Ureter; (5) Urinary bladder where stones get stuck, i.e. pelvic–ureteric junction, where
ureter
crosses pelvic brim and iliac vessels and ureteric–vesicle junction
Fig. 4.30: IVP Ectopic (pelvic) right kidney Fig. 4.31: Intravenous pyelogram (IVP)—Bilateral
pelvic (ectopic) kidneys
Fig. 4.32: IVP—left kidney is pushed upwards due Fig. 4.33: Plain X-ray abdomen—note four radiopaque particles
to some soft tissue lesion or abscess lying outside (R) kidney which may be in the gallstones. It can be
confirmed by IVP
Urology 165
Fig. 4.34: IVP-stone in the upper part of the right Fig. 4.35: IVP—horse—shoe kidneys long axis of the kidneys are in
ureter with the hydronephrosis downward medially and calyx minor are pointing medially and pelvic-
ureteric junction (PUJ) is lateral to the lower calyces. PUJ is higher and
both ureters have flower—vase appearance
Fig. 4.36: IVP—A horse shoe kidney with left component Fig. 4.37: IVP—crossed dystopia kidneys. Single arrow pointing to
nonfunctioning full of stones normal kidney. Remember ureteric opening is always on the normal
side. When lower pole of the normal kidney is joined with the upper
pole of crossed kidney, it is called sigmoid kidney
Fig. 4.38: IVP—Bifid pelvis of both kidneys
Fig. 4.39: IVP—Duplex kidney left side the, both components are Fig. 4.40: IVP—Hydronephrosis (bilateral) left kidney hypoplastic
joining at lowest end. They can open independently in bladder,
urethra, vagina and seminal vesicles, upper component opens lower
than upper. If opening is ectopic, i.e. other than bladder, then main
symptom is incontinence of urine. Usually upper component get
diseased
Urology 167
Fig. 4.41: IVP hydronephrosis of the left kidney Fig. 4.42: IVP—stone in pelvis of (R) kidney with hydronephrosis,
left kidney is normal (See also Fig. 4.12)
Fig. 4.43: IVP—note a filling defect in the pelvis of left kidney due to Fig. 4.44: IVP 6 months after ESWL. Note hydrocalyx (middle)
nonradiopaque stone in left kidney pelvis. (Plain X-ray does not show with small stones. Patient never passed a single stone after
any stone though there was a big stone in left kidney on US) ESWL and continued suffering from left kidney pain. Treatment
suggested percutaneous nephrolithotomy—we did open
nephrolithotomy (See plane X-rays abdomen, Fig. 4.11)
Fig. 4.45: IVP in a Wilms’s tumor right kidney, lower calyx

major is pushed downwards
Fig. 4.46: IVP in a carcinoma of left kidneys (upper pole)—lower calyx is displaced downward
Urology 169
Fig. 4.47: CT scan of abdomen for carcinoma left kidney.

Note the clear-cut extension of left kidney cancer
Fig. 4.48: IVP—cyst of upper part of right kidney deforming upper and middle calyx major
Fig. 4.49: IVP—right kidney is displaced downwards by some

extra renal growth
Fig. 4.50: IVP—note stricture of upper end of ureter,

most probably malignant (shouldering)
Urology 171
Fig. 4.51: IVP stone intramural part of right ureter with hydroureter
Fig. 4.52: IVP stone middle part of ureter causing no hydronephrosis which is quite rare
Fig. 4.53: IVP in a case of prune belly syndrome: Fig. 4.54: IVP of patient with ectopia vesicae, re-implantation of
bilateral megaureter and enlarged bladder ureters in sigmoid colon done 18 years before. Note the bilateral
hydronephrosis and dye in the rectum
Fig. 4.55: Cystogram—normal

Urology 173
Fig. 4.56: Cystogram—irregular filling defect in the bladder—

carcinoma of urinary bladder
Fig. 4.57: Cystogram following IVP. Note bilateral traction Fig. 4.58: Cystogram. Note the enlarged prostate bulging at the
diverticuli of the bladder due to bilateral inguinal hernias base and an irregular filling defect in the bladder above it—
carcinoma of bladder
Fig. 4.59: Cystogram—a neurogenic bladder Fig. 4.60: Cystogram—a neurogenic bladder
with a reflux right ureter
Fig. 4.61: IVP with cystogram—note the shadow of enlarged pros- Fig. 4.62: Cystogram with a diverticulum of the bladder
tate with two rounded shadows of bladder stones. The stone was
not visualized on plain X-ray
Urology 175
Fig. 4.63: Cystogram with diverticulum bladder, left ureter is opening in the diverticulum
Fig. 4.64: Cystogram with grossly enlarged prostate pushing at the Fig. 4.65: Urethrogram with stricture membranous urethra
base and multiple diverticuli of the bladder
Fig. 4.66: Urethrogram—stricture bulbar urethra
Fig. 4.67: Urethrogram in a case of ruptured membranous urethra Fig. 4.68: Urethrogram with stricture urethra. Note the old fracture
of right pubis which was the cause of rupture causing stricture
Urology 177
Fig. 4.69: CT scan urethrogram, note the long stricture Fig. 4.70: Urethrogram with diverticulum of bulbar urethra.
with fracture pelvis X-ray also shows big diverticulum of bladder
Fig. 4.71: Urethrogram with stricture bulbar urethra Fig. 4.72: Antegrade pyelogram after introduction of a tube in the
left kidney under US. Note a filling defect in the pelvis of the kidney—
carcinoma of the pelvis of the kidney
Fig. 4.73: Retrograde pyelogram—a case of Fig. 4.74: Retrograde pyelogram (left), note whole kidney is dilated.
bifid pelvis of the kidney There are three stones in right kidney perhaps the only functioning
kidney. Patient had already nephrolithotomy 3 years back. Treatment
suggested ESWL after retaining ureteric stent
Fig. 4.75: Retrograde pyelogram in a nonfunctioning Fig. 4.76: Retrograde pyelogram in left
left kidney with a staghorn stone nonfunctioning hypoplastic kidney
Head and Neck
5
CHAPTER
and Neurosurgery
INTRODUCTION encephalogram and cerebral angiography are the things of the
past: However, X-rays of the skull are useful for injury, bone
Once X-ray of skull was essential for neurosurgical diagnosis inflammations and tumors in smaller units. X-rays of face, orbit
but lately computed tomography (CT) scan, magnetic resonance and jaw comes in the domain of maxillofacial surgery. X-ray
imaging (MRI), positron emission tomography (PET) scan have neck is still useful to see neoplastic and the degenerative
almost replaced it. Other investigations for neurosurgery such lesions, disc prolapse, tuberculosis, injuries and cervical rib.
as myodil encephalogram, air
Fig. 5.1: Normal X-ray skull (lateral view): (1) Sutures; (2) Marking of anterior branch of middle meningeal artery;
(3) Pituitary fossa O—sella turcica No 3; (4) Sphenoidal air sinus; (5) Frontal sinus; (6) Mastoid sinus
1 1
2
2
Fig. 5.2: Normal X-ray skull (AP): (1) Frontal sinus; and (2) Maxillary sinus
Fig. 5.3: X-ray skull after craniotomy—note part of parietal bone is missing
Head and Neck and Neurosurgery 181
Fig. 5.4: X-ray skull lateral view after craniotomy. Note four burr holes craniotomy flap has been replaced
Fig. 5.5: X-ray with nasal bones fracture

Fig. 5.6: X-ray skull (lateral view) hair line fracture of the occipital bone
Fig. 5.7: X-ray skull (lateral)—fracture of the frontal bone

Fig. 5.8: X-ray skull after head injury. Note air inside skull and ventricles
Fig. 5.9: X-ray skull: Meningioma parietal region

Fig. 5.10: Myodil—air encephalogram
Fig. 5.11: Cerebral angiography (lateral view)

Fig. 5.12: Cerebral scintiscan with space-occupying lesion in parietal lobe
Fig. 5.13: CT scan of skull. Extradural hematoma in occipital region

Fig. 5.14: X-ray neck—a big stone in the right submandibular duct (arrow)
Fig. 5.15: X-ray mandible—a big stone in Fig. 5.16: X-ray neck (lateral) normal. Cervical spine 1-7.
right submandibular duct
Fig. 5.17: X-ray neck—see a soft tissue shadow of goiter Fig. 5.18: X-ray neck (lateral view) gross cervical spondylosis
C 4-5, 6-7 with the diminished disc spaces
Fig. 5.19: X-ray neck (lateral view) dislocation cervical spine C3 Fig. 5.20: X-ray cervical spine (LAT) decrease space C4-5,
may be due to tuberculosis spine
6
CHAPTER Teeth and Jaw
INTRODUCTION palatal aspect and beam comes parallel from the cone placed
outside the month. It is indicated for:
Diagnosis in dentistry and maxillofacial surgery depends very 1. Assessment of fracture after trauma to teeth and
much on accurate radiology. One can utilize the routine X-ray surrounding structures (dentoalveolar fractures).
technique of the skull with some modification. But for accurate 2. Detection of apical cysts and other lesion within
diagnosis one uses other specific techniques which require the alveolar bone
special machines built especially for dentistry and maxillofacial 3. Assessing periapical granuloma.
surgery. For more accurate diagnosis in complicated cases CT 4. Pre- and postoperative assessment of apical
scan is advised. The popular techniques are (besides standard X- surgeries.
ray): 5. Preoperative assessment of impacted 3rd
1. Periapical molar teeth.
2. Panoramic tomography, dental panoramic tomography 6. Detection of oroantral fistula in maxillary
(DPT) or orthopantomogram (OPG). molars.
3. Occlusal view.
DENTAL PANORAMIC TOMOGRAM
ROUTINE X-RAY OF JAW
It is also called orthopantomogram (OPG) or just panoramic
They are just like ordinary X-ray skull taken in posteroanterior view and is popular X-ray technique. It shows all the teeth with
(PA) in such position that dense bones of the base of the skull their supporting structures in one film. It omits low radiation and
may not come in the way. For the mandible, it is taken in the simple to operate though it is more expensive. In this technique,
forehead nose position and its indications are: X-ray tube rotates horizontally from behind the skull and X-ray
1. Fractures of the mandible involving the posterior third of film rotates horizontally in the opposite direction in front of face.
the body, angles and low condylar necks. So final X-ray view in approximately is horse-shoe shaped. It
2. Lesions such as cysts or tumors in the posterior third of takes about 18 seconds when head has to be kept still so it is not
the body or rami to note any mediolateral expansion. suitable for the children under 5 years. It gives information about
3. Mandibular hypoplasia or hyperplasia and maxillofacial all the teeth erupted or nonerupted, deciduous or permanent,
deformities. especially fractures, lesions of temporomandibular joint (TMJ)
Occipitomental view in nose chin position is done for maxillary and diseases of antrum especially floor, posterior and medial
antrum and facial skeleton. In maxillofacial surgery, it is wall. It is not indicated in midline structures as its accuracy for
indicated for: this part is doubtful.
1. Detecting the middle third facial and coronoid process
fractures. OCCLUSAL RADIOGRAPHY
2. Investigation of the frontal and ethmoidal, sphenoid and
maxillary sinuses. This technique is used in special cases to visualize the anterior
part maxilla and mandible with their teeth. Cassette is 5.7 × 7.6
2
cm and placed inside the mouth between upper and lower jaw.
PERIAPICAL X-RAY
The source beam is placed below the mandible for lower jaw
It is most common X-ray used by the dentists. This machine is a and above midline aiming downward through the bridge of the
standard gadget attached with almost every dental unit. It is nose for maxilla. It is more suitable for the children after
cheap, reliable, and easy to operate and emits very little trauma. The main indications are:
radiation. 1. For evaluation of fractures of anterior teeth and
It describes individual teeth and tissues surrounding the alveolar bone
teeth. The film is placed inside the oral cavity on the lingual or 2. For assessment of cysts and tumors, their size and
extent in anterior of maxilla.
3. For detecting unerupted canines and their position and
relation to the mandible or maxilla.
Teeth and Jaw 189
Fig. 6.1: Normal X-ray of the face occipitomental view
Fig. 6.2: Normal X-ray of the mandible

Fig. 6.3: X-ray of the skull with fracture of the mandible
Fig. 6.4: X-ray of the skull with fracture of the right maxilla
Teeth and Jaw 191
Fig. 6.5: X-ray of the mandible (PA) showing fracture in the midline and neck of left condyle
Fig. 6.6: X-ray jaw—fracture left mandible

Fig. 6.7: X-ray mandible—fracture (oblique) ramus of mandible
Fig. 6.8: Periapical X-ray with impacted mandibular third molar

Teeth and Jaw 193
Fig. 6.9: Periapical view impacted permanent molar tooth along with retained deciduous molar
Fig. 6.10: Periapical X-ray with periapical abscess

Fig. 6.11: Periapical X-ray with the radiotranslucent shadow at the dental roots
Fig. 6.12: Orthopantomogram. Normal though it is difficult to find any normal orthopantomogram.
Note: All the four third unerupted molar teeth
Teeth and Jaw 195
Fig. 6.13: Orthopantomogram with fracture of the mandible
Fig. 6.14: Orthopantomogram. Cyst involving body and ramus of the mandible
Fig. 6.15: Orthopantomogram. A closer view of the above Orthopantomogram clearly showing cyst boundary
Fig. 6.16: Orthopantomogram. Arrows showing pathology in maxilla. The roots are involved in this case
Teeth and Jaw 197
Fig. 6.17: Orthopantomogram. Arrows showing a cyst in midline of mandible. The cyst is involving the roots of lower anterior teeth
Fig. 6.18: Plating of the mandible after left hemimandibulectomy

Fig. 6.19: Normal occlusal view Fig. 6.20: Occlusal view impacted canine
Fig. 6.21: Occlusal view of radiolucency in palate involving teeth

Teeth and Jaw 199
Fig. 6.22: X-ray of the jaw-giant cell tumor or ameloblastoma right mandible.
Note the displacement of third molar tooth
Fig. 6.23: Orthopantomogram confirms the finding of X-ray (Fig. 6.20). It was removed and biopsy reported giant cell tumor
7
CHAPTER
Special X-rays
RELATIVE CONTRAINDICATIONS
MAMMOGRAPHY
1. Inflammatory breast
INTRODUCTION lesions
X-ray of the breast visualizes the soft tissue structures. It is also 2. Lactating breast
3. Pregnancy.
called radiomammography. Normally, a female adult breast
consists of connective tissue, mammary glandular tissue and
fats. The ratio varies in different stages of life. Both connective INDICATIONS
tissue and glands give same homogeneous dense shadows on X-
ray, whereas fats give less dense shadow. Any abnormal growth 1. For screening for carcinoma of the breast in women
or lesion will show clear shadows on X-rays. 40–70 years age especially of high-risk women.
It is done by special machine emitting less radiation. The 2. For the diagnosis of any breast lesion:
front of chest must be naked and breast is compressed by the  Fibroadenoma breast will appear as well-defined oval
plates during radiography. X-ray of each breast is taken or rounded shadows, may be with course peripheral
separately. Other normal side X-rays should also be taken for calcification.
contrast purpose. Normally, two views craniocaudal and  Carcinoma breast will appear as irregular lesion with the
mediolateral are taken, but in special circumstances oblique and irregular or spiculated margins. Tiny or
cone views are also taken: microcalcification will be seen in breast cancer
whereas gross or macrocalcification is present in
benign lesion. This X-ray can visualize a lesion up to 1
DRAWBACKS cm which cannot be palpated normally.
1. Compression of the breast which may be uncomfortable,  Breast abscess or cysts are diagnosed more accurately
even painful in inflammatory lesion. by US or magnetic resonance imaging (MRI).
2. Nakedness of front of the chest which some ladies do not 3. Lately, it is also indicated before starting hormonal
like. replacement therapy (HRT) in menopausal women. Before
3. The breast implants and scar tissue may give misleading this X-ray, a clinician should also conduct the clinical
results. examination of the breast for any lesion, i.e. swelling ulcer,
eczema, induration, scar and retracted nipple.
Fig. 7.1: Mammogram—normal breast of a 20-year-old woman

Special X-rays 201
Fig. 7.2: Mammogram of normal lactating breast
Fig. 7.3: Mammogram—duct ectasia

Fig. 7.4: Mammogram—of carcinoma breast—irregular soft tissue spiculated mass
Fig. 7.5: Mammogram—carcinoma breast

Special X-rays 203
Fig. 7.6: Mammogram—mammogram fibroadenoma breast with regular margins
Fig. 7.7: Mammogram—fibroadenoma breast

Fig. 7.8: Mammogram—invasive ductal carcinoma
Its main indication is infertility but it is also done to

HYSTEROSALPINGOGRAPHY diagnose congenital malformation of uterus, incompetent cervix
and submucous fibroid.
INTRODUCTION It may cause pain, anaphylactic shock, false passage,
spillage into blood vessels and air embolism. It should be done
It is the radiological study of the female genital tract, i.e. uterus under the cover of some antibiotics.
and tubes. The radiopaque dye is injected into the cervix uteri Normally, the dye will pass easily through the uterus, to
through a cannula introduced by a gynecologist. It is ovarian tubes and will spill into the peritoneal cavity on both
contraindicated during menstrual periods, pregnancy and pelvic sides (peritoneal spill). There will not be blockage anywhere
inflammatory disease. and any filling defect.
Special X-rays 205
Fig. 7.9: Hysterosalpingogram—uterine cavity is well outlined. Fig. 7.10: Hysterosalpingogram—uterine cavity deviated to left
Right tube not outlined left tube is tortuous and dilated. There is side; only one tube has been filled but no spill due to some mass,
extravasation of dye in the pelvic vessel which is considered normal possibly ovarian cyst
Fig. 7.11: Hysterosalpingogram—bicornuate uterus or Fig. 7.12: Hysterosalpingoram right tube is normal with the
might be double uterus. But tubes are not outlined spill of the dye and on the left side the tube is dilated
organs such as cerebral (carotid) coronary, renal, femoral (lower

ANGIOGRAPHY limb) and axillary (upper limb).
Its main principle is to introduce a catheter into the femoral
INTRODUCTION artery under strict aseptic conditions and advance its tip to the
desired level under fluoroscopy and inject the radiopaque dye
It is the contrast radiography of the blood vessels—venogram for take the series of the X-ray films. Lately, for coronary
the veins and arteriogram for the arteries. It is done to see any angiography, angiocatheter is introduced through the right radial
malformation obstruction or dilatation, narrowing and artery. Venogram is mostly being replaced by Doppler
displacement of blood vessels. It is specific for different ultrasound studies.
Fig. 7.13: Femoral angiography with obstruction at popliteal artery Fig. 7.14: Coronary angiography: Right anterior oblique view (↑
Left circumflex—blocked, ↓ Left anterior descending—mild
narrowing)
Special X-rays 207
Fig. 7.15: Coronary angiography: AP cranial view. Fig. 7.16: Coronary angiography: Right anterior oblique view
Almost normal LAD (↓ Right coronary artery mild diffused narrowing, → Posterior
descending artery partially occluded, ↑ Posterior left ventricular
completely blocked
Fig. 7.17: Cerebral angiography (AP) normal Fig. 7.18: Venogram—arrows pointing to
two incompetent perforators
in the external opening and radiopaque dye is injected through

SINOGRAPHY the cannula and X-rays are taken. It will verify the size, depth,
origin and cause of the tract so that surgeon can be planned for
INTRODUCTION excision of the tract and removal of the pathology.
It is done to visualize an abnormal tract opening anywhere on The main disadvantages are that the dye may overflow and
the body surface discharging liquid material. The skin is cleaned may give false results. It may also cause pain and can also
by an antiseptic solution and a cannula is introduced spread infection in the neighboring tissues.
Fig. 7.19: Sinogram—a case of branchial sinus Fig. 7.20: Sinogram—subtrochanteric bursa

Fundamentals of Radiology by Altaf Hussain Rathore

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Fundamentals of Radiology by Altaf Hussain Rathore

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FUNDAMENTALS OF RADIOLOGY

Altaf Hussain Rathore

Aamer Nadeem Chaudhry

Altaf Hussain Rathore

My sincere gratitude to all of them:

1.Bones and Joints 001

3.X-ray Abdomen 133

5.Head and Neck and Neurosurgery 179

6.Teeth and Jaw 188

7.Special X-rays 200

vi. Osteoarthritis when fracture involves intra-articular

Elbow Joint Hand

Forearm Pelvic Bones

The fractures and dislocation of the foot are:

GENERAL DISEASES OF BONES

Fig. 1.3: X-ray of the knee joint showing traction epiphysis

Fig. 1.4: Fracture of apophysis or traction epiphysis of calcanium

Fig. 1.6: A case of osteogenesis imperfecta. Note the fracture of

Fig. 1.7: Congenital absence of fibula

Fig. 1.8: Congenital absence of radius. Note radius is rudimentary

Fig. 1.11: X-ray foot—megatoes first and second toes—congenital deformity

Fig. 1.12: X-ray wrist in a case of rickets. Note splaying,

Fig. 1.18: X-ray knee exostosis of upper end of tibia

Fig. 1.29: Degenerative disease of bones—osteoarthritis of spine

GENERAL FRACTURE OF LONG BONES

Fig. 1.55: Fractured patella fixed by wire loop

Fig. 1.60: X-ray hip—Austin—Moore’s prosthesis for fracture neck of femur

Fig. 1.61: Fracture of humerus with nonunion

Fig. 1.62: Old supracondylar fracture of humerus with malunion

Fig. 1.66: X-ray shoulder with fracture of neck of scapula

Fig. 1.69: Dislocation of the shoulder with fracture of greater tuberosity

Fig. 1.70: X-ray shoulder with fracture surgical neck of humerus

Fig. 1.74: X-ray shoulder—fracture outer end of clavicle

Fig. 1.75: Fracture clavicle—common—site at the junction

Fig. 1.77: Fracture of clavicle after one year treated

Fig. 1.78: Fracture clavicle with nonunion, a rare thing

Fig. 1.80: Fracture upper part of shaft of humerus fixed by

Fig. 1.81: Simple fracture of shaft of humerus

Fig. 1.84: Supracondylar fracture of humerus in AP view

Fig. 1.88: Supracondylar fracture of humerus, fixed by K-pins—position good

Fig. 1.93: Dislocation of elbow

Fig. 1.94: X-ray elbow—(lateral) fracture olecranon process

Fig. 1.104: Above fracture (Fig. 1.103) fixed by intramedullary K-pins

Fig. 1.105: X-ray forearm—fracture of shaft of radius and ulna

WRIST AND HAND

Fig. 1.112: X-ray wrist—a case of rickets

Fig. 1.114: X-ray wrists—fracture of ulna styloid process

Fig. 1.115: X-ray wrist—fracture lower end radius without displacement

Fig. 1.121: Smith fracture (reverse Colle’s) usually

Fig. 1.123: Slipped epiphysis lower end radius

Fig. 1.124: Bennett’s fracture dislocation of MP joint of the thumb

Fig. 1.126: X-ray of hand—oblique fractures base of 4th metacarpal bone

Fig. 1.128: Same case (Fig. 1.127) fixed by K-wires

Fig. 1.130: X-ray of hand comminuted fracture of proximal phalanx

Fig. 1.132: X-ray of hand after being crushed by a machine

Fig. 1.133: Rheumatoid hand with deformities of the fingers

Fig. 1.135: X-ray pelvis—fractured both of pubic rami on right side

Fig. 1.137: X-ray pelvis—upward dislocation of right hemi pelvis. It was

Fig. 1.140: Perthes’ disease of the left hip

Fig. 1.148: Central dislocation of left hip joint

Fig. 1.149: Transcervical fracture of neck of femur

Fig. 1.153: Intertrochanteric fracture of femoral

Fig. 1.154: Intertrochanteric fracture of neck of femur (type -1)

Fig. 1.155: Transcervical fracture neck of femur fixed by cancellous screws