Benign cardiac masses

• Myxoma: most common benign adult cardiac tumor, left > right atrium, often originates from interatrial septum with stalk, may be mobile with prolapse through mitral valve (obstruction); T1- and T2-heterogeneous signal,heterogeneous or homogeneous enhancement.

• Rhabdomyoma: most common benign tumor in children, associated with tuberous sclerosis, T1-isointense, T2-hyperintense with hypoenhancement.

• Lipoma: Second most common benign adult cardiac tumor, fat signal with no enhancement.

• Fibroma: second most common benign cardiac tumor in children, right ventricular free wall, T1- and T2-hypointense, may or may not enhance.

• Papillary fibroelastoma: most common tumor of valves, usually <1.5 cm, atrial surface of AV valves and aortic surface of aortic valve.

• Hemangioma: capillary, cavernous, or AV malformation, may involve any chamber, T1-hypointense, T2-hyperintense with heterogeneous enhancement.

Oreo cookie sign

Oreo cookie. 

The classic sign of pericardial effusion on the lateral chest radiograph is the "Oreo cookie sign". The most anterior radiolucent line is the epicardial fat, the radiopaque line is the pericardial effusion, and the posterior radiolucent line is the pericardial fat.

Oreo cookie sign:

Epicardial fat and retrosternal fat stripes are the outer DARK cookie layers while the opaque fluid is the WHITE fluff of the cookie.

Congenital absence of the pericardium

May be total or partial. Partial absence is MORE common, occurs mainly on the LEFT, and is usually ASYMPTOMATIC. Large defects may cause cardiac strangulation. Small defects are usually asymptomatic.

Radiographic Features:

Total absence of the pericardium: Mimics the appearance of the large silhouette seen in pericardial effusions.

Partial absence of the pericardium: Heart is shifted and rotated into left pleural cavity. PA view looks like an RAO view. Heart is separated from the sternum on crosstable lateral view. Left hilar mass: herniated left atrial appendage and pulmonary trunk.

Patella fracture

• The patella is largest sesamoid bone in the body.
• It forms part of the extensor mechanism of the knee and is held in place by the patellar tendon, quadriceps tendon and the adjacent retinaculae.
• Patella fracture is classified according to site and appearance – longitudinal, transverse, stellate, marginal, polar or osteochondral fractures. All except small rim avulsions are thought of as intracapsular.
• The commonest fracture is the transverse type resulting from a powerful muscular contraction transmitted to the patella. This type is commonly displaced.
• AP and lateral views are essential. In some cases a skyline view is helpful but often difficult to obtain in the acute stage as knee flexion is required.
• The fracture is usually obvious. Look for associated lipohaemarthrosis on the horizontal beam lateral.
• The congenital bi-partite and multi-partite patella; usually occur at the superolateral aspect of the patella. In these the fragments tend to be rounded and corticated as compared to the sharp non-sclerotic margins in a fracture. MRI is useful in subtle cases.

Displaced horizontal patella fracture.

Fifth metatarsal base fractures

• Commonest fracture of the lower limb.
• Tuberosity fractures:The commonest form. Secondary to an inversion injury in the plantar flexed foot. Originally thought to be an avulsion fracture at the site of insertion of peroneus brevis, although more recently the lateral band of the plantar aponeurosis has been implicated. The types of injury ranges from a small avulsion to fracture of the entire tuberosity.
• Jones’ fracture: Diaphyseal fracture occurs approximately 1.5cm from the base (metaphyseal–diaphyseal junction). More serious than tuberosity fractures. Usually caused by combination of forces produced during running or jumping.
• Always look at the base of 5th metatarsal in an ankle view.
• The fracture line appears transverse at right angles to the axis of the metatarsal.
• If the fragment is small, the fracture will often involve the joint with the cuboid.
• Fragment separation may be evident.
• A Jones’ fracture classically extends into the inter-metatarsal joint.
• Never be confused with the epiphyseal plate in children. This is aligned parallel to the shaft.With this in mind a fracture through the epiphysis can occur.

Fifth metatarsal base fractures.(A) Base of 5th metatarsal fracture.

(B) Partial avulsion of the apophysis at the base of 5th metatarsal.

(C) Always remember to examine the base of the 5th metatarsal on an ankle X-ray.

(D) Spiral fracture of the fifth metatarsal bone.

Shoulder dislocation

• The gleno-humeral joint is the commonest joint in the body to dislocate.
• Related to lack of bony stability.
• Bimodal age distribution – men aged 20–30 and women aged 60–80.
• Anterior, posterior and inferior seen in decreasing order of frequency.
• Anterior dislocations usually secondary to a fall. The labrum detaches allowing the humeral head to dislocate anteriorly.
• With posterior dislocations, the head is displaced directly backwards and is usually secondary to a direct blow or fall onto an internally rotated hand. It can be missed following a difficult obstetric delivery.
• Anterior shoulder dislocation : Majority seen well on the standard AP view.An axial or apical view may be obtained if in doubt.The greater tuberosity may be fractured. Hill–Sachs lesion: A depression of the postero-lateral aspect of humeral head; common with recurrent dislocations, as the humeral head hits the glenoid. Bankart lesion: Anterior glenoid labrum defect best seen on MRI. Bulbous distortion of the scapulo-humeral arch.
• Posterior shoulder dislocation : Best seen on the axillary view. Light-bulb sign on AP view and widened gleno-humeral space ( 6 mm). The scapulo-humeral arch may have an abnormally sharp angle. Trough sign, an associated compression fracture of the antero-medial humeral surface, seen as a sclerotic line parallel to the articular surface.

Anterior and posterior shoulder dislocation.

Acromio-clavicular joint injury

• Recommended views include AP, 15 degree cephalic tilt and axial views.
• Specific acromio-clavicular (AC) joint views should be specified as the exposure is different from shoulder views.
• In the normal patient, the inferior surfaces of the acromion and clavicle are aligned.
• Grade I injury is radiographically normal. Grade II injury shows widening of the joint with upward displacement of the clavicle. Grade III injury has a widened coraco-clavicular space ( 13 mm or a difference of 5 mm between the two sides) and complete disruption of the AC joint (should be 8 mm).
• Stress views were commonly requested but cannot be recommended due to the discomfort caused and the high rate of false negatives seen from muscular spasm.

Acromio-clavicular joint dislocation.

How to report an intracranial aneurysm

• A well defined rounded ------x----- cm [mention the measurement of the lesion] lesion is seen in the ------- [mention the site] common sites include:
•  Suprasellar region to the left or right of the midline plane.   
•  Within the sylvian fissure.
•  In the pre-pontain cistern.

NB:

 If the lesion is more than 2 cm (giant aneurysm), it may show internal thrombosis, then you can say that the lesion has a homogeneously enhancing component which represents the patent lumen and a non enhancing component which represents the thrombosed part.

• The lesion showed homogenous post contrast enhancement with no perifocal brain edema around ± marginal curvilinear calcification.
• Normal size and configuration of the ventricular system with no midline shift.
• Normal posterior fossa (if no lesions are present in the posterior fossa).
• Scanned para-nasal sinuses are clear.                                                                                       OR  Scanned para-nasal sinuses showed mucosal thickening in the ------,------ (mention the name of the affected sinuses ) denoting sinusitis.

Soft-tissue rim sign

• The CT evaluation of stone disease has given rise to new signs as Soft-tissue rim sign. This sign is caused by edema of the ureteral wall surrounding a stone at its site of impaction.

• The importance of the sign lies in the fact that it may help to distinguish a stone in the ureter from a phlebolith in an adjacent vein, because the occurrence of a soft-tissue rim around a phlebolith is uncommon.

Soft-tissue rim sign 

Normal brain MRI report

MRI of the brain using different pulse sequences (T1, T2 & flair) and in different planes (axial, coronal & sagittal) revealed:

•  Normal size and configuration of the ventricles with no midline shift.
•  Normal gray white matter interface with no signal abnormality.
•  No mass lesions.
•  Normal cerebellum, brain stem and cervico-medullary junction.
•  Normal sellar region. 

Normal CT scan of the para-nasal sinuses report

CT scan of the para-nasal sinuses coronal cuts revealed:

•  Clear all paranasal sinuses.
•  Intact bony boundaries.
•  No significant deviation of the nasal septum.
•  Patent osteomeatal complexes.

Normal CT chest report

CT scan examination of the chest with IV contrast revealed:-

•  Clear both lung parenchyma with no pulmonary masses or calcification or  cavitation.
•  No pleural collection.
•  No abnormal hilar or mediastinal masses.
•  No gross cardiac anomaly.
• The upper section of the abdomen shows no abnormality.

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Plain chest x-ray report

Item to be evaluated:

§Lung parenchyma.
§Costophernic sinuses.
§Cardiac size and shape.
§Chest wall including ribs, scapulae, clavicles & spine.
§Extra-thoracic soft tissues specially:    

*  Shoulder joint.

*   Lower neck.

*   Breast shadows [females].

Normal Findings:

• Clear both lung fields and costophrenic angles.
• Normal Cardiac size and shape.

Lumbarization & sacralization

• Transitional vertebrae: 25% of normal cases.
• Sacralization of lumbar body: Spectrum from expanded transverse processes of L5 vertebra articulating with top of sacrum to incorporation of L5 vertebra into sacrum.
• Lumbarization of sacrum: Elevation of S1 vertebra above sacral fusion mass assuming lumbar body shape.
• Sacrum lies at 40° incline from horizontal at lumbosacral junction.
• Lumbarization & sacralization may appear similar that requires counting from C2 caudally to precisely define anatomy.

Lateral radiograph of sacrum & lumbosacral junction.