Lateral View of Hip

This view demonstrates the femoral neck and the relationship of the femoral head to the acetabulum. Fractures of the femoral neck can again be visualized on this film and, in particular, the degree of angulation can be assessed. Dislocations around the hip are not infrequent in road traffic accidents. In most cases, the displacement is posterior due to the impact a patient receives whilst in the sitting position. Dislocations in an anterior direction are much less common. Associated fracture dislocations must be checked for.

Antero-posterior View of Hip

Shenton's line is formed from the continuity of the inferior aspect of the femoral neck through to the inferior aspect of the superior pubic ramus. This gives a good guide to the normal relationship of the head of the femur to the pelvis. Synovial membrane is very extensive around the hip joint and, like the capsule, comes well down the femoral neck, especially anteriorly. Note the normal pattern of the bone trabeculae in the femoral neck, indicating the lines of stress. Fractures of the femoral neck are common, especially in the old, and as they may be impacted they are sometimes difficult to visualize. If severe separation of the femoral head occurs, then the possibility of avascular necrosis exists and it must therefore be checked on follow-up films.

Antero-posterior View of Pelvis

The bones and soft tissues of the pelvis should be studied in this view. Fractures and dislocations occurring in the pelvic bones are particularly important in relation to their effects on the pelvic contents. As with any fixed bony ring, fractures and dislocations must be checked to make sure there is no further breach of the ring, as commonly occurs. Ramus fractures of the obturator ring are often multiple because of this. Look for dislocation of the femoral head in relation to the acetabular fossa and check the relationship of the sacro-iliac joint. If there is suspected instability of the pubic symphysis, as occurs in professional sportsmen, particularly footballers, then films should be taken with the patient standing on one leg and then the other to see if there is any movement of the joint.

Antero-posterior View of Plain Abdomen

This is a supine view to show the general layout of abdominal viscera. Note the slightly lower position of the right kidney compared to the left, due to the liver mass. Note the position of the spleen and liver edge. Note also the normal gas shadow in the antrum of the stomach. When considering abdominal films in patients with abdominal pathology, it is often essential to have an erect film in addition to the one shown. These two films are complementary in showing abnormalities. Look for bowel gas patterns, renal and gall bladder calculi, the psoas outlines, the normality of the bone structure, and check also the hernial orifices.

Left Lateral View of Chest

The projection demonstrates mediastinal divisions into the superior, anterior, middle and posterior. Note the backwards slant of the trachea from the thoracic inlet to the carina. This slant should be borne in mind when tracheal tomograms are performed. Note the position of the outflow tract of the right ventricle and the high position of the left atrium. Note the position of the lung fissures, the left oblique fissure reaching its inferior limit about 5 cm behind the sternum. The right oblique fissure travels more anteriorly at its lower limit. Note also the apparently translucent anterior mediastinum in the normal.

Postero-anterior View of Chest

This is the commonest radiogram taken and thus it is important that the normal anatomy is known thoroughly. As with any x-ray, a system must be devised so that all the film is looked at in turn. However, certain hidden areas on a chest film warrant special attention and these include: behind the first ribs, behind the heart shadow, the posterior costophrenic angles which are obliterated on this view by the diaphragmatic shadows, and the hilar regions. Note the air in the trachea and main extra-pulmonary bronchi. Note that the hilar shadows are composed only of vessels and the normal intra-pulmonary bronchi cannot be visualized. The right heart border is formed from the superior vena cava, right atrium and inferior vena cava. The left heart border is formed from the aortic knuckle, the pulmonary conus, the left atrial appendage and the left ventricle.

Hand and wrist X-ray examination

Fractures and dislocations are particularly important in the wrist, as considerable incapacitation with osteoarthritis can result from delayed treatment. Note that fractures of the scaphoid may not show for 10 days following the injury. If a fracture of the waist of the scaphoid is mistreated, ischaemic necrosis of the distal fragment may result. It is important to learn the normal appearance of the positions of the carpal bones so that dislocations are not overlooked. Common fracture sites include the following: fracture of the distal radius and ulna with backward displacement (Colles' fracture); forward displacement of this fracture may occur which is relatively rare (Smith's fracture); fracture of the base of the first metacarpal (Bennett's fracture). Spiral fractures of the metacarpals and distal shaft fractures of the fourth and fifth metacarpal bones may follow a punch! Note that many systemic diseases have bony and soft tissue abnormalities which can be seen on a hand x-ray, e.g. hyperparathyroidism, scleroderma and rheumatoid arthritis.

Superoinferior View of Shoulder (Axial with Abduction)

This projection shows the position of the head of the humerus in relation to the glenoid cavity. It also shows, on this normal x-ray, that there is no dislocation. In patients with suspected dislocation, this x-ray may not be possible to obtain and a lateral shoot-through is a further method of evaluating displacement. Fractures of the coracoid process and acromion, although uncommon, can be visualized on this film. Fracture of the greater tuberosity, which may be missed on the antero-posterior projection, can again be seen.

Antero-posterior View of Shoulder

The middle and outer parts of the clavicle are well seen and are common fracture sites. Check the acromio-clavicular joint to see if there is any subluxation or dislocation present. This should be confirmed by a weight-bearing view if suspected. 

Look for fractures and dislocations of the humeral head. Both anterior and posterior dislocations can be missed on this view unless another radiogram at a different angle is performed. Look for supraspinatus tendon calcification. Look for deformities of the rotator cuff, evidence of recurrent dislocation or occasional congenital foramina of the scapula.

Lateral Soft Tissue Film of the Face

The soft tissue projection of the face is mainly taken for nasal spine and nasal bone fractures; however, nasal fracture displacement is best visualized on an axial projection. This soft tissue view is also useful for assessment of dental occlusion or bite.

Lateral Soft Tissue Film of the Neck

This film uses the natural air of the pharynx and larynx as contrast medium. The cartilages of the larynx are seen and undergo true ossification rather than calcification. The retropharyngeal space between the posterior wall of the trachea and the anterior border of the cervical spine should not exceed the AP diameter of one vertebral body. Note the following: the articulation of the thyroid and cricoid cartilages; the air in the ventricle of the larynx between the true and false cords; and the position of the larynx extending from C3 to C6. The pharynx can also be seen in its anatomical divisions of nasopharynx, above the soft palate, oropharynx between soft palate and base of tongue, and hypopharynx from base of tongue inferiorly.

Antero-posterior and Lateral Views of Elbow

Effusions into the elbow joint are commonly associated with undisplaced fractures of the radial head due to trauma. These radial head fractures may be difficult to see unless full projections are taken. The anterior and posterior fat pads are a particularly useful guide in assessing an effusion, as both will be elevated from their resting position against the distal end of the humerus. The two views are again needed in trauma cases to show any dislocation with or without associated fractures. A supracondylar fracture in children is particularly important because of the risk of a Volkmann's contracture due to ischaemic fibrosis. 

When the forearm bones are x-rayed for trauma, it is essential to have views of the joints at either end. This applies to any long bone examination. Fractures of the forearm bones are often paired, and if single fractures with displacement occur, then either wrist or elbow dislocation of the other bone must be looked for. Examples of this are fracture of the ulna with forward dislocation of the radial head (Monteggia) and fracture of the radial shaft with distal radio-ulnar dislocation (Galeazzi).

Tomograms of the Internal Ear

These tomograms demonstrate the anatomy more clearly than the plain films, and are essential when looking for small lesions such as fractures and congenital anomalies of the middle ear and temporal bone. High-quality tomography often of polycycloidal type together with 1 or 2 mm cuts are needed to show these minute structures. The crista transversalis separates the facial from the acoustic nerve and is an important landmark, as it disappears in intracanalicular acoustic neuromata.

Occipito-mental and Occipito-frontal Views of Skull

These two projections show the frontal and maxillary sinuses to their best advantage. The maxillary antrum is seen on the occipito-mental view; in particular, the roof of the antrum, the floor of the orbit, is clearly visualized. The frontal sinus is seen on both views. Look for sinus abnormalities such as mucosal thickening and fluid levels. Also check for facial fractures. The infra-orbital foramen and the foramen rotundum can be seen on these projections.

Submento-vertical View of Skull

This projection is of the base of the skull. The sphenoid air sinus is well shown. The numerous exit foramina from the skull are easily identified. Look for enlargement of the foramen spinosum which can occur in vascular vault meningiomas with a large external carotid arterial supply. Check the petrous apex and the region of the jugular foramen. Check the middle ear and its ossicles. Identify the three bony lines which overlap anteriorly: the greater wing of the sphenoid, the posterior wall of the orbit and the posterior wall of the maxillary antrum.

30° Fronto-occipital View of Skull (Towne's Projection)

This view shows the region of the foramen magnum, the occipital bone and the petrous ridges, which should be checked for any abnormality. 

Check for posterior vault fractures. See if the pineal or the choroid plexuses of the lateral ventricles are calcified and, if they are, check there is no midline shift. This view also demonstrates the zygomatic arch clearly.

Lateral View of Skull

This is probably the most important of the skull views. There are several features which must be checked on this projection: the hypophyseal fossa, both for pituitary tumours and for the effects of raised intracranial pressure; the position of the pineal, if calcified; the width of the soft tissue shadow on the posterior aspect of the nasopharynx and oropharynx, and the posterior walls of the maxillary antra.

Do not confuse vault fractures with vascular markings and suture lines. Look for other physiological calcification sites, e.g. habenular calcification (reverse C-shape), petroclinoid and interclinoid ligament calcification. The frontal, sphenoid and maxillary air sinuses are clearly visualized on this projection, as is the pterygopalatine fossa.

Occipito-frontal View of Skull

This projection allows the orbits to be checked for their equality of size, which is important in patients with proptosis. The floor of the hypophyseal fossa can be seen through the nasal cavity and this should be looked at closely if a pituitary tumour is suspected. Check the supraorbital fissure and the greater and lesser wings of sphenoid for any abnormality. Watch for vault fractures in the frontal region and for blowout fractures through the floor of the orbit. The nasal cavity, the medial wall of the maxillary antrum and the ethmoid air cells are well seen in this projection.

Azygos lobe

In human anatomy, an azygos lobe is a rare congenital variation of the upper lobe of the right lung. Embryologically, it arises from an anomalous lateral course of the azygos vein  in a pleural septum within the upper lobe. As it has NO bronchi, veins and arteries of its own, it is not a true, or even accessory, pulmonary lobe, but rather an anatomically separated part of the upper lobe. It is usually an incidental finding on chest x-ray or computed tomography and is as such not associated with any morbidity but can cause technical problems in thoracoscopic procedure.

Azygos lobe on chest x-ray. Arrowheads show the delineation of the lobe. Arrow points to the azygos vein.

Azygos lobe in axial computer tomography. Arrow on azygos vein.

The International Day of Radiology (IDoR)

The International Day of Radiology (IDoR) is an annual event promoting the role of medical imaging in modern healthcare.  It is celebrated on November 8 each year, and coincides with the anniversary of the discovery of x-rays. It was first introduced in 2012, as a joint initiative, by the European Society of Radiology (ESR), the Radiological Society of North America (RSNA), and the American College of Radiology (ACR).

• European Society of Radiology
• Radiological Society of North America
• American College of Radiology
• International Day of Radiology Publications

Wilhelm Conrad Röentgen-Nobel Prize First Winner In Physics

Picture of Wilhelm Conrad Röentgen.

X-Rays were first discovered in 1895 by German scientist,  Wilhelm Conrad Röentgen.

Roentgen won the first Nobel Prize in physics in 1901 for his discovery. While he was experimenting with electric currents passing through a tube, he realized that a nearby fluorescent screen began glowing as the current passed through.

When he switched the current off, the screen ceased to glow. Because the glowing could be attributed to unknown rays, he appropriately named them X-rays, which is the origin of the term we still use to this day.

One of the first x-rays taken was of his wife's hand, where he could see her hand and her wedding ring on the image. 

The first human bones ever to be recorded with X-rays belonged to Bertha, Wilhelm Röntgen’s wife. 

The implications of the technology were huge and the medical community recognized its worth in diagnosis of various broken bones, fractures, and ailments. Within a few months of the discovery, machines were produced to be used in the medical community and it wasn't long before they were a widespread, commonly used technology.

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.

Donation for children’s cancer hospital Egypt

“We can't help everyone, but everyone can help someone.” Ronald Reagan 

57357 family invites you to continue your support 

through this link below:

Thank You 

For making a gift to the Children’s Cancer Hospital Egypt Foundation 57357.

Your support for Hospital 57357 and other projects are helping us to fulfill our vision and mission for children with cancer in Egypt. Your support as our valued donor and partner is curing our children with cancer.

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.

Avascular necrosis (Osteonecrosis)

• Avascular necrosis (AVN) is death of a bony structure secondary to insufficient blood supply.
• Primary pathology is of unknown aetiology, but secondary AVN is linked with a variety of pathologies.
• Idiopathic avascular necrosis occurs in childhood in the proximal femoral epiphysis and it is known as Perthes’ disease.
• Associated with steroid use, alcohol abuse, metabolic disease (e.g.Gaucher’s disease), vasculitis (SLE), sickle cell disease, malaria, occupational causes (e.g. deep-sea divers – caisson disease), venous thromboembolism and bone-marrow transplants.
• Certain bones in adulthood are particularly associated with AVN; e.g. femoral head, distal femur, proximal humerus – idiopathic and post-traumatic, talus, lunate – Kienbock’s disease, metatarsal head – Freiburg’s disease for second metatarsal head, navicular – Kohler’s disease, scaphoid – Preiser’s disease and capitellum – Panner’s disease – associated with osteochondritis.
• Clinically present with pain of insidious onset and the pain often worse at night. Pain is usually severe and often becomes more bearable after several weeks. Joint locking with loose bodies – separated osteochondral fragments. Reduced function of adjacent joints.
• The initial radiograph if taken early may be normal. The affected bone becomes sclerotic with later collapse and remodelling. Degenerative changes within adjacent joints. MRI is 90–100% sensitivity for symptomatic disease.

Freiberg’s osteonecrosis of the second metatarsal head.

The groin and the inguinal region

In both men and women, the groin (inguinal region) is a weak area in the abdominal wall.

During development, the gonads in both sexes descend from their sites of origin on the posterior abdominal wall into the pelvic cavity in women and the developing scrotum in men. Before descent, a cord of tissue (the gubernaculum) passes through the anterior abdominal wall and connects the inferior pole of each gonad with primordia of the scrotum in men and the labia majora in women (labioscrotal swellings).

A tubular extension (the processus vaginalis) of the peritoneal cavity and the accompanying muscular layers of the anterior abdominal wall project along the gubernaculum on each side into the labioscrotal swellings.

In men, the testis, together with its neurovascular structures and its efferent duct (the ductus deferens) descends into the scrotum along a path, initially defined by the gubernaculum, between the processus vaginalis and the accompanying coverings derived from the abdominal wall.

Inguinal region development.

The inguinal canal is the passage through the anterior abdominal wall created by the processus vaginalis. The spermatic cord is the tubular extension of the layers of the abdominal wall into the scrotum that contains all structures passing between the testis and the abdomen. The distal sac-like terminal end of the spermatic cord on each side contains the testis, associated structures, and the now isolated part of the peritoneal cavity (the cavity of the tunica vaginalis).

In women, the gonads descend to a position just inside the pelvic cavity and never pass through the anterior abdominal wall. As a result, the only major structure passing through the inguinal canal is a derivative of the gubernaculum (the round ligament of uterus).

Pancoast’s Syndrome

•Bronchogenic carcinoma in the apex of the lung.

•Horner’s Syndrome: miosis, ptosis, enophthalmos and anhidrosis.

•Lower brachial plexus injury (C8-T1): Klumpke’s palsy.

•Paresthesia of the upper extremity due to compression of subclavian artery & vein.

•Shoulder pain: due to involvement of upper ribs and intercostal nerves.

•Respiratory effects.

•The differential diagnoses of arm and shoulder pain are extensive; however, the primary conditions that must be excluded are thoracic outlet syndrome and cervical disk disease, which are commonly mistaken for Pancoast syndrome in the early clinical course. Careful neurologic examination, electromyographic studies, and ulnar nerve studies are performed to verify the precise diagnosis.

Diagram for Pancoast’s Syndrome.