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MusculoskeletalRadiology

1. Cervicalspinefracture
a. Clinicalfindings
1. Trauma
2. Painintheneck
3. Neurologicsigns
*aboveareunreliableifthepatientisintoxicated
orhasadecreasedlevelofconsciousness.

b. Imagingapproach
1. APandlateralfilmsandopenmouthofodontoid
2. IfaportionofthecspineisnotvisualizeddoaCT
3. Ifsuspiciousareas,raisingthequestionoffracture,do
aCT
4. IfcordissuesdoMRI

2. Fracturespossiblyinvolvingajoint
a. Clinicalfindings
1.
2.
3.
4.

Trauma
Jointeffusion
Lossofjointfunction
Swellingandtenderness

b. TheImagingApproach
1. Plainradiographwithatleasttwoviews
2. CTveryusefulbutespeciallyfordisplacedtibial
plateaufracturesandcomminutedcalcaneal
fractures.
3. Techniciam 99BoneScancanbeusedtoexclude
fractureinweightbearingareassuchasthehip

3. Hipfracture
a. Clinicalfindings
1.
2.
3.
4.

Historyoffall
Difficultyweightbearing
Paininthehip
Externalrotationoftheupperthigh

b. Theimagingapproach
1. Plainradiographs;APandlateralprojections
2. OccasionallyCTmaybenecessary
3. Ifplainfilmisnegativebutthereisahighclinical
suspicionMRIshouldbeobtained.
Patientshouldbenonweightbearinguntilthe
questionoffractureisruledout.

4. Stressfracture
a. Clinicalfindings
1. Historyofrepetitiveactivityoractivityinthepatient
withosteoporosis
2. Localizedpain
3. Specificlocations(tibia,metatarsals,lowback,groin)

b. Imagingapproach
1. Plainradiographs
2. IfradiographsarenegativeeitherdoaTCbonescan;
orrestpatientandrexrayin1014days.

5. Shoulderpain
a. Clinicalfindings
1. Painandlimitationofmotion

b. Imaging
1. Plainfilms,internalandexternalrotationwithaxillary
view
2. MRwithorwithoutarthrography

6. Painfulprosthesis
a. Clinicalfindings
1. Paininthearea
2. Elevatedwhitecountwithtemperature

b. Imaging
1. Plainradiography;InthehipuseAPpelvisand
frogleg lateral
2. Bonescan

7. Knee
a.

Clinicalfindings
1.
2.
3.
4.
5.

b.

Pain
Locking
Instability
Swelling,questionablejointeffusion
Previousinjury

Imaging
1.
2.
3.
4.
5.
6.

Posttrauma;APandlateral;inpatientswithacutetraumacross
tablelateral
Obliqueviewsincasessuspiciousfortibial plateaufracture
Sunriseviewinsuspectedpatellafracture
CTormultiplanarreconstructiontodetectocculttibial plateau
fractureortoevaluatecomplexplateaufracture.
ForarthritisobtainstandingAP,lateralandsunriseviewofthe
patella
Meniscalorcruciateligamenttear,obtainMRI.ForBakerscystor
thrombophlebitis ultrasound

8. BoneMetastases
a. ClinicalFindings
1. Bonepain

b. Imaging
1. Radionucleibonescan(exceptinpatientswith
multiplemyelomaforwhichradiographicskeletal
surveyshouldbedone).Bonescanshouldonlybe
performedifitwillaltermanagement
2. Xraypositivelesions,seenonscaninpatientsthat
onewouldsuspectarthritisorpossibleoldfractures
thataccountsforpositivesignsonthebonescan
3. Inscansthatarepositivebuttheradiographsare
negative,obtainMR

9. Osteomyelitis
a. Clinicalfindings
1. Fever
2. ElevatedWBC
3. Ulcerationorcellulitisoverboneinthediabeticfoot
orinpatientswithdecubitusulcer

b. ImagingApproach
1.
2.
3.
4.

Plainxraysintwoplanes
CTinspecificlocationsi.e.SIorsternoclavicular joints
Bonescan
Inthespine,forsuspecteddiscitis ofosteomyelitisdo
MR

10. Osteoporosis
a. Clinicalfindings
1.Fractureswithminimaltraumainsuchlocationsasvertebral
body,upperextremityorintertrochantericregion
2.Predisposingfactors
3.Lossofheightandincreasingkyphosis

b.Imagingapproach
1.Plainradiographs
2.Bonedensityscan
3.Rememberserialstudiesaregenerallynecessaryto
determinerateofboneloss
4.Resultofmedication

GI

A. PreparationforGIstudy
1. Clinicianshoulddescribetheexaminationtothepatientbeforethe
patientgoesfortheradiologicexamination.
2. Clinicianshouldgivetoeachpatientaspecificsetofinstructionsthat
theradiologisthasprovidedforeachspecificGIstudy.Theclinician
shouldexplaintherationaleandneedforproperpreparation.

A. Theclinicianshouldfilloutarequestwhichincludespertinent1.)
Clinicalhistory2.)Physicalexaminationfindings3.)Laboratorydata
4.)Medicationsthatmaycausecomplicationsoralterthestudyfor
example,opiates5.)Surgicalhistory.Thisisimportantsothe
radiologistcanunderstandwhattypeofsurgicalanatomyhewill
encountersothathecanappropriatelyperformthecorrectstudy.

1.Dysphasia
a.Clinicalfindings
1.Difficultyinitiatingswallow
2.Nasalregurgitation
3.Substernal dysphasia,chestpain,heartburn

b. ImagingStudies
1.Videopharyngoesophagram
2.Doublecontrastesophagus
3.Singlecontrastesophagus
4.Checkforreflux

2. Dyspepsia(chestpainrelatedtotheGItract)
a.Chestpainandupperabdominalpainwith
symptomsofnausea,upperabdominalbloating
b.Recommendedimaging
1.Questionofendoscopyvs.doublecontrastesophogram

3. Upperabdominalpain
a. ClinicalFindings
1.Pancreatic
2.Cholecystitis
3.Bowelobstructionorinfarction
4.Renalcolic
5.Appendicitis
6.Rupturedviscus
7.Abdominalaorticaneurysm

b.Imagingmodalities
1.Plainfilmincludesupine,erect,orperhapsdecubitusfilms
2.UpperGIseries
3.Ultrasound
4.CT
5.ERCP

4. Acuterightlowerquadrantpain
a.Clinicalfindings
1.Periumbilical
2.Rightlowerquadrantpain,nauseavomiting

b.Imagingapproach
1.Inchildrenstartwithultrasound
2.Inpregnantorovulatingwomen,ultrasound
3.CTusingoralandIVcontrast

Plainfilmstosearchforappendolith

5. Leftlowerquadrantpain
a.Persistentleftlowerquadrantpainwithsome
guardingandtenderness,fever

Imaging
a.CTwithandwithoutoralcontrastwithdelay(long
drink)andIVcontrast

1.UltrasoundandifnecessaryHida examination

b.Imaging

1.RightupperquadrantpainandpositiveMurphyssign
2.Palpablegallbladder

a.Clinicalfindings

6. Rightupperquadrantpain

2.Patientswithspecificprimariesbreast,lungtumors,
pheochrocytoma,renalcellcarcinoma,thyroidcarcinoma,
choriocarcinoma,carcinoid;unenhancedCTfollowedby
biphasicCT
3.Cirrhoticpatient MRI
4.Questionableangioma:uselabeledredbloodcellstudyor
MR;iflesionissmallerthan2cmandunabletobeseenon
nuclearmedicinestudydoMRI.

1. DoaCTwithandwithoutcontrast

1.Ifthequestionisafocalhepaticmass

b.Imagingapproach

1.Tenderness,ascitis,jaundice
2.Abnormalliverfunctiontests
3.Cirrhotics

a. Clinicalfindings

7. Masslesionsintheliver

GU

Therearesomemedicationswhichareassociatedwithanincreasedriskofadversereactionsto
thepatientsaftercontrastagents.Theseincludemetformin(glucophage).Thisdrugshouldbe
discontinuedfortyeighthourspriortocontrastinjectionandnotreinstateduntilfortyeight
hoursaftercontrastinjectionanduntilthepatientsrenalfunctionhasbeenrestudied.Thisis
alsotrueforinterleukin2.Theremaybeadelayedreactiontothesedrugsuptotwoweekpost
contrastinjections.Also,nephrotoxicmedicationssuchasaminoglycosideantibiotics,steroidial
drugsandantiinflammatoryagents.Theuseofthesemedicationsmayincreasethepossibility
ofthepatientdevelopingcontrastinducedrenalfailure.Alsobetaadrenergicblockershavean
increasedincidenceofadversereaction.

Allionated contrastmaterialissimilar.ThisincludesallcontrastagentsusedforIVPs,angiography
computertomography,retrogradeurethrography,cystography,retrogradepyelography,sinusorfistula
injections,orhysterosalpingography.UsewatersolublecontrastaswellforGItractstudieswhena
questionofperforationhasbeenraised.

B. ContrastMaterial

Riskfactorsincludeprevioussignificantcontrastreaction,asthma,andsevereallergichistory.
Alsopatientswithcardiacdysfunction,angina,andpatientswithsicklecelldiseaseormultiple
myelomashouldhavetheirexaminationsaltered.Patientsusingtheoralhyperglycemicagent
metforminshouldstoptakingthedrugfortyeighthourspriortotheuseofIVcontrast.Most
importantistorememberthatanypatientwithimpairmentofrenalfunctionitiscontra
indicatedtogivecontrast.

1. Theclinicianshouldalerttheradiologistiftherehavebeenanypriorproblemswithintravenous
contrastagents.Theclinicianshouldknowifthereareriskfactorsthatmayprecludetheuseof
IVcontrastagents.Apartiallistofpriorcontrastreactionsincludeurticaria,shortnessofbreath,
chestpain,laryngospasm,bronchospasm,hypotension,shock.

A. Intravenouscontrastagents

1. Manycausesofhematuriainadultsaredueto
lowertractbleedingeitherinfectionorother
abnormalities.Atrialofantibioticspriortowork
upisoftenhelpful.Significantpersistent
hematuriashouldbereferredtoaurologist.The
initialstudyisaCTstudytolookforpossibilityof
abnormalitiesintheuppertractsandinthe
bladder.Alsoacystoscopyshouldbeperformed.

b. Imaging

1. Hematuriamaybegrossormicroscopic

1. PainlessHematuria
a. Clinicalfindings

1. UnenhancedCTfromxyphoid topubisisthestateof
theartrecommendationtolookforstonesinthe
kidney,ureter,orbladder.Inpregnantpatientsorin
children,ultrasonographytolookforstonesor
hydronephrosis ishelpful.Plainabdominalfilmcan
occasionallybehelpful.

b. Imaging

1. Acuteflankpainisoftensevereandpatientsmayhave
nauseaandvomiting.Symptomsmaybeperiodicand
painmayproceeddowntheflankintothescrotum.

a. Clinicalfindings

2. Acuteflankpain

Ifnonoduleisfelt,thenultrasonographyoftheprostateisperformed.
Anyhypoechoic lesion,orglandasymmetryshouldbebiopsiedunder
ultrasoundguidance.MRImaybeanextremelyusefulandahelpful
toolinevaluatingforprostaticcarcinoma.Inpatientswithamarkedly
elevatedPSA,wellover10mg/mlthenbonescanandplainfilmsare
recommended.

1. Digitalrectalexaminationshouldinitiallybeperformed.Ifanoduleis
felttransrectal biopsycanbeperformed.

b. Imaging

1. PSAlevelsareobtainedtoscreenforprostatecancerinmenoverfifty
yearsofage.Under4mgpermlisconsiderednormal.PSAlevels
betweenfourandtenareworrisomeforprostatecancerbutcanbe
seeninbenignprostatichypertrophyespeciallyinelderlypatients.
Over10mg/ml,manypatientsarereferredforprostatebiopsy.

a. Clinicalfindings

3. ElevatedPSA

1.Sonography withcolordoppler scanisthemethodof


choice.
2.Occasionallynuclearmedicinescanmaybehelpful

b.Imagingapproach

1.Acutetesticularpainmayoccurintheabsenceorasa
resultoftrauma.Somecausesrequireimmediate
surgery

a.Clinicalpresentation

4. AcuteTesticularPain

a.Oftenthepossibleetiologyofacuterenalfailurecanbe
obtainedviaeitherahistoryofaspecificmedicationora
medicalhistory.Ultrasoundisagoodfirsttesttolookfor
size,shape,andconfigurationofthekidneyandforthe
possibilityofobstruction.Pleaselookforthepossibilityof
renalveinorrenalarteryocclusion.Otherpossibilitiescould
beangiography,orvenographybutMRisnowaviable
alternative.

b.Imaging

a.Acuterenalfailureistheprecipitousdecreaseinglomerular
filtrationforashortperiod.Therearemanyetiologies.

a. Clinicalfindings

5. AcuteRenalFailure

1. Inchildren,voidingcystourethrography isperformedandthis
techniqueisalsohelpfulinwomen.Thiscanbedoneviaradionuclide
scanning.Ultrasoundisthefirstimagingmodalitytousetoruleout
obstruction,orstoneformation,andcangiveoneagood
understandingofkidneysizeandrenalcorticalsize.Incomplicated
patients,CTurographycanbeusedtodeterminethecompleteextent
oftheinflammatoryprocess,andtodirectsubsequenttherapy,which
couldincludepercutaneousprocedures.

b. Imaging

1. Mostpatientswhohaveurinarytractinfections,theinfectionisdueto
cystitisthatcanberapidlycuredbyantibiotics.Recurrentepisodesof
cystitismayoccurinwomenandonlyafterseveralepisodesshould
theybeworkedup.Inmen,evenoneboutshouldbeviewedwith
somedegreeofsuspension.Possiblecausesincludereflux,urolithiasis
orcongenitaltractabnormalitiessuchas,neurogetic bladderor
variousformsofobstruction

a. Clinicalfindings

6. UrinaryTractInfections

a)

Inpatientswithmicroscopichematuriaduetoblunttraumaitis
extremelyunlikelythesepatientshaveanysignificantabnormality
whichrequiressurgeryandoftenimagingisnotneeded.When
imagingisneeded,duetosignificanthematuria,CTbothwithand
withoutcontrastisthemostsensitiveinevaluatingmajorinjuries.
Thisisalsotrueforpatientspostrenalbiopsywhoarebleeding.

b. Imaging

a. Traumacanbebluntorpenetrating,andtraumaiscommon.Most
injuriesaretheresultofblunttrauma.Theseproducerenal
contusions.Renallaceration,isatearoftherenalcortexextending
throughthecapsule.Renalfracturesextendscompletelythroughthe
kidney.Renalvascularpedicleinjuriesareduetosevereandoften
penetratingtrauma.Mostinjuresdonotrequiresurgerybut
rememberthatinakidneythathasnovascularity,surgeryand
revasculization mustbeperformedinapproximatelyasixhour
window.Donotwastetimewithimaging.

a. Clinical

7. RenalTrauma

Insignificantpelvictrauma,aplainfilmtodeterminethedegreeof
pelvicinjuryshouldbeobtained.Ifinjurytothebladderis
suspected,cystographybeforeaCTishelpful.Onemust
determineifthebladderruptureisintraorextraperitoneal.
Treatmentiscompletelydifferent.

1. Inpatientsposttraumaticinsertionofaurethralcatheter,a
retrogradeurethrogram shouldbeperformed.Significanttrauma
inthesepatientsisoftentreatedwithasuprapubic bladder
catheter.

b. Imaging

1. TraumatothelowerGUtractissuspectedwhenthereisblunt
traumatothepelvisafteramotorvehicleaccidentorpenetrating
gunshotwounds.Also,remembertheseinjuriescanoccur
secondarytoatraumaticcatheterization.

a. Clinicalapproach

8. LowerGUTrauma

1. Inahemodynamically stablepatient,ifoneworriesaboutabdominal
aorticaneurysmrupture,CTisthestudyofchoice.Ifthepatientis
unstable,noimagingshouldbedonebuttakethepatientimmediately
tosurgery.Inapatientwithsuspectedretroperitonealhematoma
aftercardiaccatheterization,unlessthepatientisuncomfortableand
thehematocritdrops,nodefiniteimagingisneeded.Ifbleedingis
protracted,andrecurrent,anunenhancedCTshouldbeperformed.
Occasionally,especiallyintrauma,angiographymaybehelpfulsince
onecanembolize thevesselthatisbleeding.

b. Imagingapproach

1. Patientswithretroperitonealhemorrhagepresentwithabdominalor
backpain.Theymaybehypotensiveandtheirhematocrithasusually
dropped.
2. Causesmaybeduetoruptureoftheabnormalaortaoriatrogenic.
Traumamayalsobeacause

a. Clinicalpresentation

9. RetroperitonealHemorrhage

Chest

a. Mostpatientswithproblemsinthechest,present
witheithercough,dyspnea,hemoptysisorchestpain.
Thexrayisthefirstradiologicexaminationperformed
inthesepatients.Inaddition,manyasymptomatic
patientsmayhaveascreeningchestxray
performed.Occasionallyanunsuspectedabnormality
suchasatumororanodulemaybefoundinthese
patients.Onemustapproachthefindingina
systematicandappropriatemannerinordertoavoid
wastefulandinappropriateuseofthemoreexpensive
hightechimagingmodalitiessuchasCT,
angiography,andnuclearscans.

1. ChestDiseases

1. Themostimportantthingistoseewhethertherearepriorchestx
raysavailableforcomparison.Anodulewhichhasbeenstablein
sizefortwoormoreyearsisconsideredtobebenign.Do
remember,howeverthatsomemalignanttumorssuchas
carcinoid,orhamartomas maygrowveryslowly.
2. CTisthemodalityofchoicetoinvestigatethecharacteristicsofa
nodule.Lookforsize,shape,aswellascalciuminternally.See
whetherthereareareasofnecrosisorwhethertumorgrowthhas
beenalongthealveolarwalls.

b. Imaging

1. Initiallyasolitarypulmonarynodulemustbeworkedupasifit
wasamalignancyuntilprovenotherwise.Thisappliestopatients
whoaresymptomaticorasymptomatic.Mostoftenthesenodules
turnouttobebenignbuttheymustbeinvestigated.

a. ClinicalFindings

2. Solitarypulmonarynodule

1.Inapatientwithoutcompleteresolution,thepossibilityofan
obstructingbronchiallesionmustbeconsidered.Repeatxray
infourtoeightweeks.Thisisespeciallytrueifthereis
associatedlossofvolumeasdemonstratedbyshiftofthe
diaphragm,fissures,ormediastinum.
2. IfthisispresentthendoCTwiththinsections.

b.Imaging

1.Pneumoniaswhichreoccursinthesamelungsegmentorlobe
mustbeviewedwithsuspicion.Ifthepneumoniafailsto
resolveorwhenthereisvolumeloss,thenanendobronchial
obstructinglesion,possiblyacarcinoma,mustbesuspected.

a. Clinicalfindings

3. Persistentpneumoniawithorwithoutvolumeloss

1. Chestxrayistheinitiallymodality
2. CTisrecommendedwhenbronchogeniccarcinomaor
bronchiectasisissuspected.IftheCTisunrevealingthen
bronchoscopyshouldbeperformed.
3. Bronchoarteriography withthepotentialforembolizationcanbe
usedinthediagnosisandtreatmentofpersistenthemoptysisin
patientswithchronicpulmonarydiseasesuchascysticfibrosis,or
othergranulomatos disease.

b. Imaging

1. Becertainthatthebloodarisesfromthelung,andnotfromthe
nose,throat,orGItract.
2. Rememberthatthemostcommoncauseofhemoptysisisacute
chronicbronchitisorpneumonia.Historyandphysical
examinationwillhelpinthisdetermination.
3. Inapatientwithrecentlydevelopedhemoptysis,pleasebewary
ofpatientsovertheageoffortyandobtainasmokinghistory.

a. Clinicalfindings

4. Hemoptysis

1. Chestxrayistheinitialimagingmodality.Ifinterstitiallungdiseaseis
suspectedthemhighresolutionCTshouldbethenextprocedure.CT
willalsoclearlydefineanalveolarprocess.
Oftenlungbiopsyisnecessarytodifferentiatebetweentheseentities.

b. Imaging

1. Alargedifferentialispossibleforpatientswithdyspneasecondaryto
pulmonarydisease.Thechestxrayhelpstodifferentiatebetweenthe
manycauses.Oneshouldattempttodifferentiatebetweenwhether
theprocessiseitherintheinterstitium orinthealveolarcompartment
ofthelung.Interstitialdiseaseislinearwhereas,alveolardiseaseisill
definedorfluffy.Theentitiesmaybeacuteorchronic.

a. Clinicalfindings

5. Dyspneasecondarytointerstitialorvascularlungdisease

1.Chestradiograph.Thisisusefulandwillattimesruleout
otheretiologiessuchaspneumoniaorpulmonaryedema.
2.ThenextstepisgenerallyCTA.OccasionallyTEEorMRIis
useful.
3.Aortographyremainsasaviabletechnique.

b.Imaging

1.Aorticdissectionpresentswithsevereacuteneckorchest
paininapatientwhoishypertensive.Ifnottreated,the
initialmortalityisapproximatelytwentyfivepercentinthe
firsttwentyfoursandninetypercentatoneyear.
2.Certainentitieshaveanincreasedincidenceofdissection
suchasMarfans syndrome,bicuspidaorticvalve,aortic
coarctation,andrarelyinpregnancy.

a. Clinicalfindings

6. Aorticdissection

1. Chestradiographisthefirststudydonetoruleoutother
possibilitiessuchaspneumonia,pneumothorax,etc.
2. ThenexttestisCTA
3. RememberthatonecanusetheVQscantodiagnosepulmonary
emboliespeciallyinapatientwhohasanormalchestxray.The
profusionscancanbeusedaloneinpatientsinwhichradiation
becomesanissuesuchpregnancyorinyoungadults.
4. Pulmonaryangiographyisalsopotentiallyuseful.

b. Imaging

1. Chestpain,tachypnea,hemoptysisarecommonsigns.
Occasionallysomepatientsareasymptomatic.Alwaysthinkofthis
diagnosisinpatientsonoralcontraceptives,andthosewithdeep
veneous lowerlegthrombosis.Also,patientsonprolongedbed
rest,ahistoryofrecentMIorcongestiveheartfailure.

a. Clinicalfindings

7. PulmonaryEmbolis

1.Chestradiographisusefultolookforotheretiologies.
2.Otherimagingmodalitiessuchasechocardiographyor
nuclearimagingmustbeconsidered.IfacuteMIis
suspectedcoronaryangiographywithpotentialangioplasty
isanoption

b.Imaging

a. Crushingretrosternalchestpainradiatingtotheleftshoulder
suggestsacuteMI.
b. Paininthelowerportionofthechestassociatedwithdeep
inspirationorcoughing suggestspleuraeffusionor
inflammatoryprocess.
c. Painwithcoughingintheupperchest suggestscentral
tracheobronical issues.
d. ChestpainaftereatingalargemealmaybeassociatedwithGI
reflux.

1.Anypatientwithchestpain,thefirstissueistodetermine
whetheritisduetocardiac,pleura,chestwall,lung,or
possibleGIetiologies

a. Clinicalfindings

8. Chestpainsecondarytocardiacissues

1.Chestxray.Seeifonecandeterminewhich
mediastinal componentthemassisinandwhether
thereiscalcification
2.CThelpsgreatly.CTisthemethodofchoiceforfurther
evaluation.

b.Imaging

1.Oftenasymptomatic,andoncediscoveredthe
importanceoflocalizingthemasstoeithertheanterior,
middle,orposteriormediastinumisimportant.
Rememberthatafairnumberofmediastinal masses
canbemissedonplainradiographs.

a.Clinicalfindings

9. Mediastinal mass

1.Anoldfilmisoftenhelpfultodetermineenlargementsofthe
hilastructures.
2.ContrastCTisthemostusefulindeterminingmassfrom
pulmonaryvesselsorotherthoracicabnormalities.In
patientswithacontrastallergy,MRImaybehelpful

b.Imaging

1.Onceagaintherearenodefinitiveclinicalsymptoms
associatedwithmosthilar masses.Achestxrayto
determineifthereisahilar massisthefirststepand
remembertheimportanceofvisualizingthecentralhilaon
thelateralfilm.Itisimportanttodistinguishbetweenahilar
massandlargepulmonaryarteries.

a. Clinicalfindings

10.Hilar masses

1. Plainchestfilmtakenintheerectposition,bothininspirationand
expiration.
2. Occasionallyalateraldecubitusfilmbehelpful
3. CTisverysensitiveindetectingunsuspectedpneuomothorasis
althoughrememberlateraldecubitusfilmindifficultpatinest can
bealmostaseffectiveandismuchcheaperwithmuchless
radiationexposure.

b. Imaging

1. Patientpresentwithacutechestpain.Rememberthatthechestx
raytakeninexpirationisthebestwayoffindingapneumothorax.
Lookforthethinpleuralinedisplacedawayfromthethoracicwall.
Insupinefilmsrememberairwillcollectinthenondependent
portionofthethorax.Becarefulofpatientswithbullous
emphysemaandremembersignssuchasthedeepsulcussign.A
smallpneumothoraxcanbeverydifficulttodetect

a. Clinicalfindings

11. Pneumothorax

1.Chestxraywithpossiblelateraldecubitusfilms.
2.Thoracentesis todeterminethecompositionofthepleura
fluidisimportant.Patientpositionisimportantand
remembertousebothlateraldecubitusfilms.Supinefilms
makethedeterminationofeffusiondifficult.

b.Imaging

1.Manypatientspresentwithpleuritic chestpain,whichis
sometimesreferredtotheshoulder.Cough,fever,anda
historyofpreviouspneumoniaorcongestiveheartfailure
aresignificant.

a. Clinicalfindings

12.Pleuraleffusion

1.Mostoftenportablechestxrayistheinitialscreeningstudy.
2.Ifthepatientisstable,aCTwithandwithoutcontrastis
extremelyimportanttoevaluateallthepotentialinjuriesto
thechest.
3.Rememberinpatientswithpossibleesophagealrupture,to
doabariumswallowusingwatersolublecontrast.
4. Echocardiographycanbeperformedtolookforcardiac
contusionorpericardialdiffusion

b.Imaging

1.Traumaisaleadingcauseofdeathinpeopleundertheage
offorty.Chestinjuryisamajorconsiderationinthese
patients.Remembertoconsiderthingssuchas
pneumothorax,aorticrupture,multipleribfractures,
trachobronchial tear,anddiaphramatic rupture.

a. Clinicalfinding

13.Lungtrauma

1.Chestxray
2.CT

b.Imaging

1.Patientsclassicallyhavechroniccoughproducing
producing copus amountsofpurulentsecretions.Many
havehadseveralepisodes.Thisisalsoassociatedwith
adrycough,occasionalhemoptysis,andpleuritic chest
pain.Manyofthepatientshavesinusitis.

a.Clinicalfindings

14.Bronchiectasis