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Atlas On X-Ray and Angiographic Anatomy
Atlas On X-Ray and Angiographic Anatomy
Angiographic Anatomy
Consultant Radiology
Shrimati Kashibai Navale Medical College
Pune, Maharashtra, India
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Atlas on X-ray and Angiographic Anatomy
First Edition: 2013
ISBN978-93-5090-432-9
Printed at
Dedicated to
Our dear consorts
Arvind Hariqbal
and
Naasiya Musthafa
Saying
Anatomy is a nursery
offers framework to enter the infirmary,
clasp it firmly
it will help analyze the pathology rightly
with foundation in place
all is well
the value of radiology cannot be measured
it can only be treasured.
Hariqbal Singh
Preface
Human anatomy has not transformed over the years but the advance in imaging has changed the perception
of structural details. Thorough understanding of the normal anatomy is an essential prerequisite to precise
diagnosis of pathology.
Atlas on X-ray and Angiographic Anatomy is loaded with meticulously labeled illustrations. This book is
steal a look into the anatomy in an easy and understandable manner.
This atlas is meant for undergraduates, residents in orthopedics and radiology, orthopedic surgeons,
radiologists, general practitioners and other specialists. It is meant for medical colleges, institutional and
departmental libraries and for stand-alone X-ray and orthopedic establishments. They will find the book
useful.
Hariqbal Singh
Parvez Sheik
Acknowledgments
We thank Professor MN Navale, Founder President, Sinhgad Technical Educational Society and Dr Arvind V
Bhore, Dean, Shrimati Kashibai Navale Medical College, Pune, Maharashtra, India, for their kind acquiescence
in this endeavor.
Our special thanks to the consultants Dr Sasane Amol, Roshan Lodha, Santosh Konde, Shishir Zargad,
Yasmeen Khan, Shivrudra Shette, Anand Kamat, Varsha Rangankar, Prashant Naik, Abhijit Pawar, Aditi
Dongre, Rajlaxmi Sharma, Manisha Hadgaonkar, Subodh Laul, Sumeet Patrikar, Ronaklaxmi, Shrikant Nagare
and Vikash Ojha, who have helped in congregation of this imagery and for their indisputable help in assembly
of this educational entity.
Our special appreciation to the technicians Mritunjoy Srivastava, Premswarup, Sudhir Mane, Sonawane
Adinath, Deepak Shinde, Vinod Shinde, Yogesh Kulkarni, Pravin Adlinge, Parameshwar and Amit Nalawade,
for their untiring help in retrieving the data.
Our gratitude to Sachin Babar, Anna Bansode, Sunanda Jangalagi and Shankar Gopale, for their clerical
help.
We are grateful to God and mankind who have allowed us to have this wonderful experience.
Last but not least, we would like to thank M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi,
India, who took keen interest in publishing the book.
Contents
1. Skull
2. Spine
13
3. X- ray Chest
28
4. Abdominal Radiograph
34
5. Upper Limb
37
6. Lower Limb
49
7. Angiograms
67
8. Radiological Procedures
103
9. Ossification Centers
127
133
135
137
140
142
Index
145
1
CHAPTER
INTRODUCTION
The term Skull includes the mandible, likewise
the term Cranium is the Skull without the
mandible (Figs 1.1 and 1.2). The cranial cavity has
a roof (cranial vault) and floor (base of the skull).
The frontal bone occupies the upper third of
the anterior view of the skull; the rest is formed
by the maxillae and mandible. The frontal bone
extends downwards to form the upper margins
of the orbits. Medially the frontal bone articulates
with the frontal process of each maxilla. Laterally
the frontal bone projects as the zygomatic process
to make the frontozygomatic suture with the
zygomatic bone at the lateral margin of orbit (Figs
1.3 to 1.6). The frontal bone articulates with the
parietal bones at the coronal sutures (which run
transversely).
The temporal bone consists of five parts
Squamous, mastoid, petrous, tympanic and
styloid process. The squamous portion forms
part of wall of temporal fossa and gives rise to
zygomatic process. The mastoid portion contains
the mastoid antrum, in adults it elongates
into mastoid process. The mastoid antrum
communicates with the remainder of mastoid air
cells and with the epitympanum via the aditus ad
antrum. The petrous portion is wedge-shaped and
lies between the sphenoid bone anteriorly and
occipital bone posteriorly. The tympanic portion
lies below the squamous part and in front of the
Skull
Figs 1.1A to D: CT scan multiplanar reconstruction images of skull: (A) Frontal view; (B) View from back;
(C) Lateral view; (D) View from below
Skull
B
Figs 1.2A and B: X-ray skullAP view
B
Figs 1.3A and B: X-ray skullLateral view
Skull
Fig. 1.5: X-ray skullLateral view (close-up view to show the pituitary fossa)
Fig. 1.6: X-ray skullPA view (Caldwell view for paranasal sinuses)
Skull
Skull
in midline and the apex of occipital bone reaches
out to join it in midline. The mastoid region of the
temporal bone articulates with the parietal and
occipital bones posteriorly, the mastoid process
projects down at the sides. Inferiorly the parietal
bones articulate with the squamous portion of
temporal bone on either side.
The occipital bone on its lower surface has
a ridge which is pointing towards the base of
the mastoid process; this is called the external
occipital protuberance. The basiocciput extends
forward from the foramen magnum and fuses
with the basis
phenoid. The foramen magnum
is located in the basilar part of the occipital
bone (basiocciput). The pharyngeal tubercle is a
slight bony prominence in front of the foramen
magnum. One-third of the foramen magnum lies
in front and two-thirds behind an imaginary line
joining the tips of the mastoid processes. This is
contrary to the occipital condyles, where twothirds of the condyles lie in front of this imaginary
line.
The internal surface of the base of skull is
divided into the anterior, middle and posterior
cranial fossa. The orbital part of the frontal bone
forms a large part of anterior cranial fossa. The
anterior cranial fossa extends up to the posterior
edge of the lesser wing of sphenoid. The anterior
cranial fossa articulates with the cribriform plate
medially. The crista galli is a sharp projection of
the cribriform plate.
The sphenoid bone contributes to the
middle cranial fossa. The small midline body of
sphenoid bone contains the sella turcica (means
Turkish saddle), a small elevation in front of
sella turcica is called tuberculum sellae (Fig. 1.5).
The tuberculum sellae has three small spikes,
the middle spike is called the middle clinoid
process, the two lateral spikes are called anterior
clinoid process. At the posterior edge of the sella
turcica is an elevation called the dorsum sellae,
which has two lateral spikes called the posterior
clinoid process. A fibrous portion of the dura
forms the roof of the sella turcica extending from
9
the tuberculum sellae to the dorsum sellae and is
called the diaphragm sellae. The diaphragm sellae
has a central opening to allow the pituitary stalk
and vessels to pass through it.
The posterior cranial fossa extends from the
petrous temporal bone anteriorly to the internal
occipital protuberance in the midline. The floor
is formed by the foramen magnum, basiocciput
and posterior part of sphenoid bone. The dorsum
sellae slopes downwards in front of foramen
magnum, this slope is called the clivus.
The mandible or the jaw bone is a Ushaped, a
horizontal central part with two lateral ramus on
each side. The posterior border of each ramus has
a condyle with a neck which articulates with the
temporal bone forming the temporomandibular
joint, while the anterior border of each ramus is
sharp and is called the coronoid process (Figs 1.1
to 1.4).
The temporormandibular joint is a synovial
joint between the head (condyle) of the mandible
and mandibular fossa on the undersurface of the
squamous part of the temporal bone. The joint
is separated into the upper and lower cavities
by a fibrocartilaginous disc within it. There
is no hyaline cartilage within the joint which
makes it an atypical synovial joint. The synovial
membrane lines the inside of the capsule and
the intracapsular posterior aspect of the neck
of the mandible. The articular disc is attached
around its periphery to the inside of the capsule
and to the medial and lateral poles of the head
of the mandible. The joint is more stable with the
teeth in occlusion than when the jaw is open. The
movements at the temporomandibular joint are
depression and elevation (opening and closing
of the jaws), side to side grinding movements,
retraction and protaction movements (retrusion
and protrusion).
THE NASAL CAVITY AND NASAL SEPTUM
The nasal cavity is pear-shaped, broader below
and narrower at the top. From its lateral walls the
10
Skull
11
12
2
CHAPTER
Spine
14
Figs 2.1A to D: (A) Cervical spine MRI sagittal section T2WI; (B) Multiplanar reconstructed CT scan images of cervical spine
posterior view; (C) View from above; (D) Lateral view
Spine
B
Figs 2.2A and B: X-ray cervical spineLateral view
15
16
Spine
B
Figs 2.4A and B: X-ray cervical spineAP view
17
18
Fig. 2.6: X-ray cervical spine swimmers view for cervicothoracic junction
Spine
Fig. 2.7: X-ray cervical spine right posterior oblique for intervertebral foramina
19
20
Fig. 2.10: X-ray cervical spine open mouth view for atlantoaxial junction
Spine
21
Figs 2.11A to C: Multiplanar reconstructed CT scan images of dorsolumbar spine: (A) Posterior view;
(B) Anterior view; (C) Lateral view
22
B
Figs 2.12A and B: X-ray dorsolumbar spineLateral view
Spine
23
B
Figs 2.13A and B: X-ray dorsolumbar spineAP view
24
Figs 2.14A to D: Multiplanar reconstruction CT scan images of lumbosacral spine: (A) Posterior view; (B) Lateral view; (C)
Lateral view showing the intervertebral neural foramina; (D) Oblique view
Spine
B
Figs 2.15A and B: Lumbosacral spine X-rayAP view
25
26
B
Figs 2.16A and B: Lumbosacral spine X-rayLateral view
Spine
27
3
CHAPTER
X-rayChest
X-rayChest
29
E
Figs 3.1A to E: CT scan multiplanar reconstructed (MPR) images of thorax: (A) View from front; (B) Lateral view;
(C) View from back; (D) CT scan coronal section of thorax; (E) CT scan axial section of thorax
30
X-rayChest
Check patient name and date
Identify the diaphragms (gastric air bubble
lies under the left hemidiaphragm
Compare the lung fields in retrosternal space,
retrocardiac space and supracardiac space,
they should all have the same density on the
X-ray film
Look carefully at the retrosternal space, a mass
in this space will obliterate this space turning
it white on the X-ray film
Check the position of horizontal fissure and
oblique fissures
Check the density of the hila
Do not forget to carefully examine the vertebral
bodies on the chest X-ray lateral view.
Lung Fissures
They are thickening of the septae in the lung
parenchyma. For a fissure to be seen on a
radiograph, the X-ray beam has to be tangential
to it. The right lung has horizontal and oblique
31
32
X-rayChest
Lesion in right lung field
If the lesion lies posterior to the oblique
fissure it must lie within the lower lobe,
does not matter how high it appears on the
PA view.
If the lesion lies anterior to the oblique
fissure it may be in the upper or middle
lobe.
If the lesion is below the horizontal fissure
it is in the middle lobe
If the lesion lies above the horizontal
fissure it is in the upper lobe.
Lesion in left lung field
If the lesion is behind the oblique fissure it
must be in the lower lobe.
If the lesion is anterior to the oblique
fissure then it must be in upper lobe (there
is no middle lobe in left lung).
IMPORTANT POINTS TO OBSERVE
ON CHEST X-RAYS
In a well-centered chest X-ray, medial ends
of clavicles are equidistant from vertebral
spinous process. Both lung fields are of equal
radiolucency.
Both hila are concave outwards. The
pulmonary arteries, upper lobe veins and
bronchi contribute to the making of hilar
shadows (Fig. 3.7).
The normal length of trachea is 10 cm, it
is central in position and bifurcates at T4T5 vertebral level. Left atrial enlargement
increases the tracheal bifurcation angle
(normal is 60 to 75). An inhaled foreign body
is likely to lodge in the right lung due to the
fact that the right main bronchus is shorter,
straighter and wider than left.
Mediastinum is the space between the lungs. It
is divided into a superior and an inferior com
partment. Superior compartment consists
of the thoracic inlet. Inferior compartment
33
4
C H A PT E R
Abdominal Radiograph
Abdominal Radiograph
cases of perforated viscus. Also remember not
to waste any time if the patients condition is
critical, stabilize the patient and shift the patient
to operating theater if needed.
Radiation exposure in early pregnancy can be
disastrous. It is always safer in female patients of
reproductive age group to check the date of their
last menstrual period. Written consent form is
needed confirming that the patient is not pregnant/
unlikely to be pregnant at the time of examination.
Additional points to note while examining
abdominal radiographs:
Maximum diameter of small bowel should not
exceed 3 cm and that of large bowel by more
than 5 cm in diameter.
35
Figs 4.1A to E: CT scan (A to C) multiplanar reconstructed images of abdomen: (A) Coronal view; (B) Sagittal view; (C) Axial
view; (D) MRI-T2WI coronal section of abdomen; (E) MRI-T2WI axial section of abdomen
36
5
CHAPTER
Upper Limb
SHOULDER JOINT
It is a ball and socket joint and can produce
a range of movement such as adduction,
abduction, extension and flexion. The head of
humerus articulates with the shallow glenoid
cavity of scapula thus connecting the upper
limb to the chest (Figs 5.1A and B). The joint
is made more stable by the articular capsule,
ligaments, glenoid labrum and the rotator cuff.
The labrum is a fibrocartilaginous rim attached
B
Figs 5.1A and B: (A) Multiplanar reconstructed CT scan image of shoulder joint;
(B) MRI-T1WI coronal section of shoulder joint
38
Upper Limb
39
40
Figs 5.5A and B: (A) Multiplanar reconstructed CT scan image of upper arm; (B) MRI-T1WI sagittal section of upper arm
Upper Limb
41
42
Figs 5.8A and B: (A) Multiplanar reconstructed CT scan image of elbow joint; (B) MRI-T1WI coronal section of elbow joint
Upper Limb
43
44
Upper Limb
45
46
Figs 5.15A and B: (A) Multiplanar reconstructed CT scan image of hand and wrist joint,
(B) MRI-T1WI coronal section of wrist joint
Upper Limb
47
48
6
CHAPTER
Lower Limb
HIP JOINT
On plain X-rays, the hip joint is appreciated on AP,
lateral and postero-oblique views (Figs 6.1 to 6.5).
The hip joint is a multiaxial synovial joint (ball
and socket joint). It comprises of the head of femur
articulating with the acetabular cavity of the hip
bone. The hip joint is supported by muscle and
ligaments which not only provide stability, but
also produce a range of movements at the joint.
The three parts of the hip bone are ilium, ischium
and pubis, they join together at the acetabulum to
form the triradiate synchondrosis. The acetabular
labrum is attached to the acetabular rim and
the transverse acetabular ligament. It forms a
complete ring encircling the head of femur which
fits into the acetabular cavity (Figs 6.2 and 6.3).
Movements at the hip joint include flexion
(normal range 120o), extension (normal range
20o), adduction (normal range 30o), abduction
(normal range 60o), medial and lateral rotation
(normal range along a vertical axis 40o). The fibers
of the capsule become stiffer during movements
like extension and medial rotation of the femur.
The ligament of head of femur connects the head
of femur to the acetabular cavity. The ligament
of the head of femur becomes stiffer during
adduction movement of the hip joint, when the
legs are crossed in front.
Major anastomosis occurs around the femoral
neck involving branches from the femoral
50
Figs 6.1A to D: CT scan multiplanar reconstructed (MPR) images of pelvis with hip joints: (A) Anterior view; (B) As seen from
below; (C) Oblique view; (D) MRI-T1WI hip joint coronal section
Lower Limb
51
52
Lower Limb
two condyles that articulate with the upper end
of tibia. The head of femur has the fovea on
its medial surface where the ligament of head
attaches to it. The neck of femur has an angle of
around 125 with the shaft of femur and slightly
tilted forwards. The greater trochanter projects
upwards and backwards from the junction of the
neck and shaft of femur, it is slightly pyramidal
in shape with its apex pointed outwards. The
lesser trochanter arises from the lowermost part
of the neck of femur on the posterior aspect of
femur. Between the greater trochanter and lesser
trochanter anteriorly lies the intertrochanteric
line, posteriorly lies the intertrochanteric crest.
The shaft of femur is long and gives attachment
53
Figs 6.6A to E: (A) CT scan topogram of thigh with both hip joints; (B to D) CT scan multiplanar reconstructed (MPR) images of
femur with hip joint; (B) Anterior view; (C) Lateral view; (D) Posterior view; (E) MRI-T1WI coronal section of femur with hip joint
54
Lower Limb
55
56
Figs 6.10A to D: CT scan (A and B) multiplanar reconstructed images of knee joint: (A) Anterior view; (B) Lateral view, MRIT1WI images; (C) Coronal section; (D) Sagittal section
Lower Limb
57
58
Lower Limb
The tibia is a long bone on the medial aspect
of leg; it has a larger upper end at the knee joint
and a rather smaller lower end at the ankle joint.
At the knee joint the upper end of tibia has a
superior articular surface (plateau-like surface),
and divided by the intercondylar eminence
into two unequal surfaces (medial and lateral
surfaces). The medial surface is larger than the
lateral surface, they articulate with the medial and
lateral condyles of femur. The shaft of tibia is more
triangular in shape and provides attachment
to the muscle of knee joint and leg. The lower
end of tibia has a prominence called the medial
malleolus on its medial side at the ankle joint. The
tibia articulates with the talus at the ankle joint
(talocrural joint).
The fibula is a slender long bone on the lateral
aspect of leg. The head of fibula has a facet to
articulate with the upper end of tibia. The shaft has
surfaces for muscle attachments. The common
peroneal nerve run close to the neck of fibula and
in case of fracture to the neck of fibula the nerve
59
Figs 6.14A to E: CT scan multiplanar reconstructed images of lower leg with ankle: (A) Anterior view; (B) Medial view;
(C) Lateral view; (D) Posterior view; (E) MRI-T1WI coronal section of lower leg
60
Lower Limb
61
Figs 6.17A to C: CT scan multiplanar reconstructed images of ankle joint: (A) Anterior view; (B) Posterior view; (C) MRI-T1WI
coronal section of ankle joint
62
Lower Limb
63
Figs 6.20A to F: CT scan multiplanar reconstructed images of foot with ankle: (A) Medial view; (B) Anterior
view; (C)Posterior view; (D) Lateral view; (E) View from below; (F) MRI-T1WI sagittal section of foot with ankle
64
Lower Limb
The medial collateral ligament or deltoid
ligament includes the tibionavicular ligament,
calcaneotibial ligament, anterior talotibial
ligament and the posterior talotibial ligament.
They prevent abduction and limit plantar flexion
and dorsiflexion of the ankle joint.
Tarsal joints at ankle: comprises of the talocal
caneonavicular joint, talocalcaneal joint and the
calcaneocuboid joint. The main action at these
joints is inversion and eversion at ankle joint.
The talocalcaneonavicular joint is a synovial
joint of the ball and socket type. The ball is formed
by the head of talus; the socket is formed by
the navicular, calcaneus and spring ligament.
The posterior surface of navicular is concave
and articulates with the head of talus which is
convex-shaped. The inferior convexity of head
65
66
7
CHAPTER
Angiograms
CEREBRAL CIRCULATION
Normal Intracranial Arterial System
Branches of the aortic arch: Brachiocephalic
artery, the left common carotid artery, and left
subclavian artery (Flow chart 7.1).
The extracranial carotid arteries: The right
common carotid artery usually arises from the
bifurcation of the brachiocephalic artery. The
left common carotid artery arises from the aortic
arch distal to the origin of brachiocephalic artery.
Both the right and left common carotid arteries
bifurcate into the external and internal carotid
arteries on either side at C4- C5 level.
Branches of the external carotid artery: Superior
thyroidal artery, ascending pharyngeal artery,
lingual artery, occipital artery, facial artery,
posterior auricular artery, internal maxillary
artery and superficial temporal artery.
The internal maxillary artery branches are
superficial temporal artery, middle meningeal
artery, accessory meningeal artery and anterior
deep temporal artery.
The superior thyroid artery supplies the thyroid
and larynx. The ascending pharyngeal artery
supplies the nasopharynx and tympanic cavity. The
lingual artery supplies the tongue, floor of the mouth
and submandibular gland. The occipital artery
supplies the scalp and upper cervical musculature.
68
Angiograms
segments, paired distal ICAs, paired posterior
communicating arteries (PCOM), paired
proximal A1 segments of ACAs and the anterior
communicating artery (ACOM). This vascular ring
is complete only in about 25 percent of cases (Fig.
7.1). Perforating vessels arising from the circle of
Willis include branches to the thalamus, limbic
system, reticular activating system, cerebral
peduncles, posterior limb of internal capsule
and oculomotor nerve nucleus. The recurrent
artery of Heubner originates from the A1 segment
to supply the anterior limb of internal capsule,
portion of the globus pallidus and head of the
caudate nucleus.
The anterior cerebral artery: The most proximal
segment is the A1 segment, its origin at the
terminal ICA to the anterior communicating
artery (ACOM). A2 segment is the portion distal
69
70
Fig. 7.2: Angiogram of right anterior cerebral circulation arterial phaseAP view
Fig. 7.3: Angiogram of right anterior cerebral circulation arterial phaseLateral view
Angiograms
Fig. 7.4: Angiogram of right anterior cerebral circulation arterial phaseLateral view
Fig. 7.5: Angiogram right anterior cerebral circulation capillary phaseAP view
71
72
Fig. 7.6: Angiogram of right anterior cerebral circulation capillary phaseLateral view
Fig. 7.7: Angiogram of right anterior cerebral circulation venous phaseAP view
Angiograms
73
Fig. 7.8: Angiogram of right anterior cerebral circulation venous phaseLateral view
74
Angiograms
75
76
Angiograms
77
78
Angiograms
79
80
Fig. 7.15: Outline of the thoracic aorta on chest X-rayPA view. (A) Ascending thoracic aorta curves upwards and at the level
of sternal angle continues as arch of aorta; (B) Arch of aorta curves above the left main bronchus and descends into posterior
mediastinum. It gives off the: 1. Brachiocephalic trunk; 2. Left common carotid artery; 3. Left subclavian artery; (C) At the level
of 4th thoracic vertebra, the arch of aorta becomes the descending thoracic aorta; (D) Descending thoracic aorta in posterior
mediastinum enters the abdominal cavity through the aortic hiatus (12th dorsal vertebra level)
Angiograms
81
ABDOMINAL ANGIOGRAPHY
ABDOMINAL AORTA
The abdominal aorta is the continuation of the
thoracic aorta below the diaphragm at T12 vertebral
level. In the abdomen aorta is retroperitoneal in its
course and travels downwards to its bifurcation
at the level of L4 vertebral body. The abdominal
aorta supplies the viscera, peritoneum, gonads
and spine during its course. Its anterior branches
are the celiac arterial trunk, superior mesenteric
artery, inferior mesenteric artery (Fig. 7.17).
Its lateral branches are inferior phrenic artery,
suprarenal arteries, gonadal arteries, lumbar
arteries. Its terminal branches at L4 vertebral level
are the common iliac arteries and the median
sacral artery (Flow chart 7.7).
CELIAC TRUNK
The celiac trunk is the main vascular supply
of the foregut supplying the lower part of the
esophagus to the duodenum; it also supplies the
liver, pancreas and spleen. The celiac trunk arises
at the level of T12 vertebra from the abdominal
82
Angiograms
83
84
Angiograms
sigmoidal arteries and superior rectal artery. These
branches supply the descending colon, sigmoid
colon and upper rectum. The marginal artery
85
86
Angiograms
87
88
Angiograms
89
90
Fig. 7.27: Angiogram showing ulnar artery and anterior interosseous artery
Angiograms
in the hand. A deep branch of the ulnar artery in
hand anastomoses with the deep palmar arch to
maintain collateral circulation.
The common interosseous artery is a branch
of the ulnar artery close to cubital fossa. It divides
into the anterior and posterior interosseous
branches distal to the radial tubercle and supplies
the muscles of the forearm (Figs 7.27 and 7.28).
The superficial palmar arch is a direct continuation of the ulnar artery in the hand, it is joined
on its lateral side by the superficial branch of
radial artery to complete the superficial palmar
arch.
The deep palmar arch is a direct continuation
of the radial artery, it is joined on its medial side
by the deep branch of ulnar artery to complete the
deep palmar arch (Fig. 7.29).
The dorsal carpal arch is formed by both the
radial and ulnar arteries within the fascia on
dorsum of hand.
91
Venous System
The veins of the upper extremity can be classified
into the superficial veins and the deep veins. The
superficial veins are digital veins, metacarpal
veins, cephalic veins, basilic vein and median
vein. The deep veins are the venae comitantes of
radial and ulnar arteries, volar arches of hand,
brachial vein, axillary vein and subclavian vein.
Superficial Veins
The digital veins are subclassified into dorsal and
volar digital veins. The dorsal digital veins pass
along the sides of the fingers and are joined to one
another by oblique communicating branches.
They have an ulnar and radial network of veins on
either side. A communicating branch frequently
connects the dorsal venous network with the
cephalic vein about the middle of the forearm. The
volar digital veins on each finger are connected to
92
Angiograms
93
94
Angiograms
95
96
Flow chart 7.16: Superficial femoral artery and profunda femoris artery
Angiograms
Fig. 7.31: Angiography of lower limb (external iliac and common iliac artery)
97
98
Fig. 7.32: Angiography of lower limb (external iliac and common iliac artery)
Angiograms
99
100
Angiograms
101
102
8
C H A PT E R
Radiological
Procedures
BARIUM SWALLOW
104
A
Fig. 8.2A
Radiological Procedures
B
Fig. 8.4B
Figs 8.2A and B: Barium swallow study (upper gastrointestinal tract posteroanterior view)
Fig. 8.3: Barium swallow study (upper gastrointestinal tractright antero-oblique view)
105
106
Fig. 8.4: BMFT study erect posteroanterior (PA) view of stomach with duodenal cap
Radiological Procedures
Fig. 8.5: BMFT study erect right antero-oblique (RAO) view of stomach with duodenal cap
Fig. 8.6: BMFT study erect left antero-oblique (LAO) view of stomach with duodenum
107
108
Fig. 8.7: BMFT studySupine posteroanterior (PA) view of stomach with ileal loops
Radiological Procedures
Fig. 8.8: BMFT studySupine posteroanterior (PA) view of ileal loops with cecum
Fig. 8.9: BMFT studySupine right antero-oblique (RAO) view of terminal ileum with ascending colon
109
110
Fig. 8.10: BMFT studySupine right antero-oblique (RAO) view of ileocecal junction
Radiological Procedures
111
Barium enema
The anal canal is around 4 cm in length; it is the
terminal end of gastrointestinal tract. At its distal
end is the anal opening in the perineum. The
proximal end of anal canal is the anorectal junction,
here the puborectalis muscle fibers on either side
of the perineum act as a sling around this junction
and provide support. The tone of the anal canal is
maintained by the internal and external sphincters.
The rectum is around 10 to 12 cm in length
(Fig. 8.11). It begins at the level of the 3rd sacral
vertebra; the proximal end of rectum is continuous
with the sigmoid colon above, while the distal end
of rectum terminates at the anorectal junction
below. The presacral space lies behind the rectum.
In males the rectovesical space is anterior to
rectum, while in females the rectouterine pouch
is anterior to the rectum (Fig. 8.12).
Fig. 8.11: Barium enema studyLeft lateral view (rectum and sigmoid colon)
112
Fig. 8.12: Barium enema studySupine view (ascending, transverse, descending colon)
Radiological Procedures
reaches the hepatic flexure. Barium is inert
substance and reactions to it hardly ever occur,
but certain conditions are contraindicated for
barium enema. Barium enema is contraindicated
in toxic megacolon, pseudomembranous colitis,
postrectal biopsy, bowel perforation. Nonionic
contrast media is used in cases of perforation.
113
INTRAVENOUS UROGRAM
It is a radiological procedure to investigate the
kidneys, ureter and bladder by injecting a nonionic
water-soluble contrast media intravenously.
Patient preparation includes nil per orally for at
least 8 hours but patient should not be dehydrated,
oral laxatives are usually prescribed to take the
night before the procedure. Serum creatinine and
blood urea nitrogen tests are done to evaluate if
contrast can be safely administered. Patient may
have allergic reaction to the contrast media and
all emergency drugs and equipment should be
ready before contrast is injected. In infants and
children the radiation dose should be minimized.
Pregnancy is a contraindication for this procedure.
Plain X-ray KUB control film AP taken in
supine position (Fig. 8.13), check for good bowel
preparation, outline of both renal kidneys, psoas
muscle outlines, bony pelvis, also look for any
abnormal calcific densities for example in the
renal areas and bladder. It is important to ask the
patient to void before taking the plain X-ray KUB
film and make sure the plain KUB film covers the
diaphragms above to the pubis below. Normally,
a portion of each upper renal pole usually extends
above the 12th rib, with the right kidney normally
slightly lower than the left due to the position of the
liver. Each kidney normally measures around 12
cm 6 cm 3 cm, kidneys lies in the retroperitoneal
region, the hilum of each kidney lies over the psoas
muscle, the outer convexity of each kidney lies on
the aponeurosis of transversus abdominis muscle.
The vertical axis of the kidney lies parallel the upper
one-third of the psoas muscle, due to this slight
114
Radiological Procedures
115
116
Radiological Procedures
should be examined closely because intravenous
urography is the most accurate imaging modality
for visualizing the urothelium-lined surfaces and
evaluating potential abnormalities. The ureter
usually begins as a smooth extension from the
renal pelvis adjacent to the lateral margin of the
psoas muscle. At about the L3 level, the ureter
passes to anterior to the psoas muscle, crossing it
from lateral to medial side. The proximal ureteric
117
MICTURATING CYSTOURETHROGRAM
The bladder is a hollow muscular organ in the
pelvic cavity. It has a rounded appearance with
smooth margins when distended with contrast.
The ureters insert into the bladder base on the
posterior surface. The area between the opening
of the two ureters on either side and the internal
urethral opening inferiorly at bladder neck is
called the trigone of bladder. The bladder neck is
surrounded by smooth muscle fibers, also called
as the internal urethral sphincter. The urethra
begins inferiorly at the bladder neck and courses
downwards to open into the external urethral
meatus. In males the urethra is around 18 cm
in length, and for descriptive purposes divided
into anterior urethra and posterior urethra. The
posterior urethra has two segments the more
proximal segment is called the prostatic segment,
while the distal segment which lies close to the
perineal membrane is called the membranous
segment. The prostatic segment (3-4 cm in
length), it runs through the prostate downwards,
the proximal part of prostatic urethra is also
known as preprostatic part and it is surrounded
by smooth muscles of the bladder neck. This
smooth muscle encasing the preprostatic part
contracts during ejaculation to prevent seminal
reflux into the urinary bladder. The membranous
urethra is the segment of posterior urethra is
around 1.5 cm in length and it traverses the
perineal membrane. The membranous urethra
118
Fig. 8.19: Micturating cystourethrogramAnteroposterior view (standing) with urinary catheter in the bladder
Radiological Procedures
119
120
RETROGRADE URETHROGRAM
The anterior urethra is 15 cm in length, it has
two segments, the proximal segment is called
the bulbar segment; the distal segment is called
the penile segment. Fossa navicularis is a small
dilated part of penile urethra near the external
urethral meatus. When passing the cannula
into the external urethral meatus the tip of the
cannula should be directed downwards towards
the floor of fossa navicularis, otherwise injury to
Radiological Procedures
The patient does not need any special prior
preparation before procedure, but the patient
should empty his bladder before the procedure
is started. The urethra is opacified and any
narrowing or obstruction to the flow of contrast
is identified. The patient is asked to lie down
supine on the X-ray table (Bucky table) and
30o left anterior oblique view is taken when
the contrast is injected. The position of the
patient in supine position is important, the hip
121
122
A
Fig. 8.25A
Radiological Procedures
B
Fig. 8.25B
Figs 8.25A and B: Hysterosalpingogram (uterus with both fallopian tubes)
Fig. 8.26: Hysterosalpingogram (fallopian tubes with spillage into peritoneal cavity)
123
124
Fig. 8.27: Hysterosalpingogram (fallopian tubes with spillage into peritoneal cavity)
Radiological Procedures
125
DACROCYSTOGRAM
The lacrimal apparatus consists of the lacrimal
gland, lacrimal canaliculi, lacrimal sac and the
nasolacrimal duct. The lacrimal gland lies in the
lacrimal fossa, located on the lateral part of the
roof of the orbit. The lacrimal gland secretes clear
fluid known as tears which helps to lubricate and
protect the cornea and the sclera of the eye. At the
medial end of each eyelid on its inner surface is
a small punctum which opens directly into the
lacrimal canaliculus. The lacrimal canaliculus is
a small tubular canal that leads into the lacrimal
sac. Excess tears produced by the lacrimal gland
are conveyed into the lacrimal sac through the
lacrimal canaliculus. The lacrimal sac is a small
structure located in the lacrimal groove (Figs
8.28 and 8.29). The lacrimal groove is lies at the
126
9
C H A PT E R
Ossification Centers
128
Ossification Centers
129
130
Bones
Body of scapula
Body of clavicle (two centers)
Shaft of humerus
Epiphysis
Head of humerus
Greater tuberosity
Lesser tuberosity
Acromion process
Middle of coracoid process
Root of coracoid process
Inferior angle of scapula
Medial border of scapula
Medial end of clavicle
Ossification
8th week of fetal life
5th and 6th week of fetal life
8th week of fetal life
Appearance
1 year
3 years
5 years
1518 years
1 year
17th years
1420 years
1420 years
1820 years
Bones
Radial shaft
Ulnar shaft
Epiphysis
Lateral epicondyle
Medial epicondyle
Capitellum
Head of radius
Trochlea
Olecranon process
Ossification
8th week of fetal life
8th week of fetal life
Appearance
1012 years
0508 years
0103 years
0506 years
11th year
1013 years
Fusion
25th year
15th year
25th year
2225 years
2225 years
25th year
Fusion
1718 years
1718 years
1718 years
1619 years
18th year
1620 years
Ossification Centers
131
Bones
Ossification
Capitate
4 months
Hamate
4 months
Triquetral
3 years
Lunate
45 years
Trapezium
6 years
Trapezoid
6 years
Scaphoid
6 years
Pisiform
11 years
Metacarpals
Proximal phalanges
Middle phalanges
Distal phalanges
Epiphysis
Appearance
Fusion
12 years
20th year
58 years
20th year
Metacarpal heads
2.5 years
20th year
2.5 years
20th year
3 years
1820 years
3 years
1820 years
2.5 years
20th year
Bones
Ossification
Epiphysis
Appearance
Fusion
Femoral head
1 year
1820 years
Greater trochanter
35 years
1820 years
Lesser trochanter
814 years
1820 years
132
Bones
Ossification
Tibial shaft
Fibular shaft
Patella
5 years
Epiphysis
Appearance
Fusion
Proximal tibia
At birth
20th year
Tibial tubercle
510 years
20th year
Proximal fibular
4th year
25th year
Distal femur
At birth
20th year
Bones
Ossification
Calcaneus
Talus
Navicular
34 years
Cuboid
At birth
Lateral cuneiform
1 year
Middle cuneiform
3 years
Medial cuneiform
3 years
Metatarsal shafts
Phalangeal shafts
Epiphysis
Appearance
Fusion
Metatarsals
3 years
1720 years
3 years
1720 years
3 years
1720 years
5 years
1720 years
Posterior calcaneal
5 years
At puberty
10
C H A PT E R
Production of X-rays
134
11
C H A PT E R
Digital Subtraction
Angiography
136
12
C H A PT E R
Computed Radiography
Computed radiography (CR) uses similar
equipment as conventional radiography except
that in place of a film to create the image, an
imaging plate (IP) made of photostimulable
phosphor is used. The imaging plate housed in a
special cassette is placed under the body part or
object to be examined and the X-ray exposure is
made. Thereafter, instead of taking an exposed film
into a darkroom for developing in chemical tanks
or an automatic film processor, the imaging plate is
run through a special laser scanner, or CR reader,
that reads and digitizes the image. The digital
image can then be viewed and enhanced using
software that has functions very similar to other
con
ventional digital image-processing software,
such as contrast, brightness, filtration and zoom.
The CR imaging plate (IP) contains photo
stimulable storage phosphors, which store the
radiation level received at each point in local
electron energies. When the plate is put through
the scanner, the scanning laser beam causes the
electrons to relax to lower energy levels, emitting
light that is detected by a photomultiplier
tube (Fig. 12.1), which is then converted to an
electronic signal. The electronic signal is then
converted to discrete (digital) values and placed
into the image processor pixel map. The signals
generated by the photodetector as the plate is
being scanned are amplified and digitized by an
138
139
Fig. 12.2: Schematic diagram showing types of DR flat panel detectors (FPD): (i) Direct conversion flat panel detectors: X-rays are
converted to electronic signal by amorphous selenium photoconductor; (ii) Indirect conversion flat panel detector: X-rays are
converted to visible light by scintillator, which is further converted to electronic signal by silicon photodiode. Electronic signal is
converted to digital image by TFT arrays
13
C H A PT E R
141
14
C H A PT E R
Computed Tomography
Contrast Media
143
143
ORAL CONTRAST
Iodinated Agents
Barium Sulfate
Barium sulfate preparations are used for
evaluating gastrointestinal tract. Barium (atomic
weight 137) is an ideal choice element for X-ray
absorption because the K shell binding energy
AIR
Air is used as a negative per rectal contrast
medium in large bowel during CT abdomen and
during CT colonography.
CARBON DIOXIDE
Rarely,
carbon
dioxide
is
used
for
infradiaphragmatic CT angiography in patients
who are sensitive to iodinated contrast.
Index
Page numbers followed by f refer to figure and t refer to table
A
Abdominal
angiography 81
aorta 81, 95f
branches 82
radiograph 34
Acromion process 130
Advantages over conventional
radiography 137
Amorphous selenium flat panel
detectors 138
Analog-to-digital converter 137
Anatomical segmental division of
lungs 28
Angiogram of
abdominal aorta 82f
celiac arterial trunk 83f
posterior cerebral circulation
arterial phase 74f, 75f
capillary phase 75f, 76f
venous phase 77f
renal arteries in
pyeloureterogram phase 87f
right anterior cerebral
circulation
arterial phase 70f, 71f
capillary phase 71f, 72f
venous phase 72f, 73f
right renal artery
early arterial phase 85f
late arterial phase 86f
nephrogram phase 86f
superior mesenteric artery 84f
Angiography of lower limb 95f,
97f-101f
Angle of Louis 79
Ankle joint 60
Anterior
cerebral artery 69
communicating artery 69
interosseous artery 90f
spinal arteries 73
B
Barium
enema 111
study 111f
sulfate 143
swallow 103
study 104f, 105f
Base of
distal phalanges 131
middle phalanges 131
proximal phalanges 131
Basilar artery 73
Body of
clavicle 130
scapula 130
Brachial artery 89f, 93f
Branches of
aortic arch 67
external carotid artery 67
Bucky table 121
Cervical spine 13
Cervicothoracic junction 18f
Circle of Willis 68
Clivus canal angle 27
Coccyx 16
Computed radiography
137, 139, 140
contrast media 142
Coupled charged couple devices 138
Craniovertebral angle 27
D
Dacrocystogram 125, 125f, 126f
Deep
cerebral veins 74
palmar arch 92f
vein 92
Digital
radiography 138
subtraction angiography 135
veins 91
Direct digital radiography 140
Distal
femur 132
phalanges 131
Dorsolumbar spine 14
Dural sinuses 76, 79
Calcaneus 132
Capitellum 130
Carbon dioxide 143
Cavernous portion of internal
carotid artery 67
Celiac
arterial trunk 83
trunk 81
Cephalic veins 91
Cerebral
circulation 67, 68
cortical veins 74
F
Fallopian tubes 123, 123f, 124
Femoral head 131
Fibular shaft 132
Forearm 44
146
G
Greater
trochanter 131
tuberosity 130
H
Head of
humerus 130
radius 130
Hilgenreiners line 49
Hip joint 49, 129f, 131t
Hysterosalpingogram 121,
122f-124f
I
Inferior
angle of scapula 130
mesenteric artery 84
Internal carotid artery 67-69
J
Jugular bulb 78
K
Knee joint 55, 129f, 132
L
Lateral
cuneiform 132
decubitus 34
epicondyle 130
Leech-Wilkinson cannula 124
Lesser
trochanter 131
tuberosity 130
Locating lesions of lungs 31
Location of arches of foot 64f
Low osmolar contrast media 142
Lower
end of
radius 131
ulna 131
limb 49
angiography 95
arterial system 96
venous system 102
Lumbosacral spine 14, 24f
X-ray 25f, 26f
Lung fissures 31
M
Medial
border of scapula 130
cuneiform 132
end of clavicle 130
epicondyle 130
Metacarpal
heads 131
veins 91
Metatarsal shafts 132
Micturating cystourethrogram
117, 118f, 119f
Middle
cerebral artery 69
cuneiform 132
of coracoid process 130
phalangeal base 132
phalanges 131
Multiplanar
reconstructed CT scan image of
elbow joint 42f
forearm 44f
hand and wrist joint 46f
shoulder joint 37f
upper arm 40f
reconstructed images of
abdomen 35f
joint 61f
foot with ankle 63f
knee joint 56f
lower leg with ankle 59f
thorax 29f
N
Nasal
cavity 9
septum 9
Normal
intracranial
arterial system 67
venous system 74
venous anatomy of brain 78
O
Olecranon process 130
Orbit 10
Ossification centers 127
P
Paranasal sinuses 6f, 10
Patella 132
Pelvic phleboliths 34
Perkins line 49
Petrous portion of internal carotid
artery 67
Phalangeal shafts 132
Pituitary fossa 5f
Popliteal artery 97, 100, 100f
Posterior
cerebral arteries 69, 73
communicating arteries 67, 69
fossa veins 74, 78
inferior cerebellar artery 69
Production of X-rays 133
Profunda femoris artery 96
Proximal
femoral shaft 131
phalanges 131
tibia 132
R
Radial arteries 90f, 94
Radiological
anatomy of female reproductive
organs 121
importance of
craniovertebral junction 27
vertebral column in spinal
injuries 24
Renal artery 88
angiogram 87
Index
Retrograde urethrogram 120
Root of coracoid process 130
S
Sacrum and coccyx X-ray 27f
Shaft of humerus 130
Shoulder joint 37, 127f, 130t
Sims speculum 124
Spinal
canal 21
cord 21
Subclavian artery 89f
Superficial
femoral artery 96, 99f
palmar arch 91f
veins 91
Superior
internal carotid artery 69
mesenteric
arteriogram 85
artery 83
Systemic lupus
erythematosus 142
T
Teres minor 37
Thoracic aorta 79, 80f
Tibial
shaft 132
tubercle 132
Trochlea 130
Turkish saddle 9
U
Ulnar
artery 90f, 94
shaft 130
Upper
arm 38
gastrointestinal tract 104f, 105f
limb 37
angiography 88
venous system 94
V
Vein of
Galen 74
Trolard and Labbe 74
Venous system 91
Vertebral arteries 69
Vertebrobasilar circulation 69
W
Wrist joint and hand 44
147
X
X-ray 28
abdomen 36f
ankle
and foot 63f
joint 62f
cervical spine 15f-20f
open mouth 20
right posterior oblique for
intervertebral foramina
19f
cervicothoracic junction 18f
chest 29f-32f
dorsolumbar spine 22f, 23f
elbow joint 42f, 43f
foot 64f, 65f
forearm 45f
hand and wrist joint 47f
hip joint with pelvis 52f
knee joint 57f
skyline 58f
KUB region 114f
leg 60f, 61f
pelvis with both hip joints 51f
right hip joint 51f, 52f
shoulder joint 38f, 39f
skull 3f, 4f, 5, 5f, 6, 6f-8f, 11f, 12f
thigh 54f, 55f
upper arm 40f, 41f