RO ee a eee etn ae radiographic anatomyThe National Medical Series for Independent Study radiographic anatomy Frank Slaby, Ph.D. Associate Professor Department of Anatomy George Washington University Medical Center Washington, D.C. Eugene R. Jacobs, M.D. Associate Professor General Diagnostic Radiology Section Musculoskeletal Radiology George Washington University Medical Center Washington, D.C. Harwal Publishing Philadelphia « Baltimore « Hong Kong « London * Munich « Sydney * Tokyo A Waverly CompanyHarwal Managing Editor: Debra Dreger Project Editor: Gloria Hamilton Art Direction and Illustrations: Wieslawa B. Langenfeld Editorial Assistant: Judy Johnson Compositors: June Sangiorgio Mash, Richard Doyle Layout: Steflany Verna Trueman Figures 1-1C, 1-7C, 1-9C, 1-10C, 1-11C, 1-20C, 2-1C, 2-5C, 2-6C, 2-7C, 2-21C, 2-24C, 2-25C, 5-7C, 5-8C, and 5-12C were modified from Bontrager KL, Anthony BT: Textbook of cadiographic Positioning and Related Anatomy, 2nd ed. St. Louis, CV Mosby, 1987. Library of Congress Cataloging-in-Publication Data Slaby, Frank. Radiographic anatomy/Frank Slaby, Eugene R. Jacobs. p. cm.—{The National medical series for independent study) ISBN 0-683-06266-2 1. Diagnosis, Radioscopic—Outlines, syllabi, etc. 2. Diagnosis, Radioscopic—Examinations, ques- tions, etc. 3. Human anatomy—Outlines, syllabi, etc. 4. Human anatomy—Examinations, questions, etc. |. Jacobs, Eugene R. Il. Title. Ill. Series. IV. Series: A Harwal medical publication. |DNLM: 1. Radiography—examination questions. 2. Radiography—outlines. WN 18 S631r] RC78.15.553 1990 616,07'572'076—dc20 DNLM/DLC for Library of Congress 90-4321 CIP © 1990 by Harwal Publishing Printed in the United States of America. All rights reserved. Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means or stored in a data base or retrieval system, without the prior written permission of the publisher. 10987654a kb WN = Preface Acknowledgments To the Reader Upper Limb Lower Limb Thorax Abdomen Head and Neck Challenge Exam Index Contents xi xill 41 93 137 165 197 303Preface This radiographic anatomy text introduces the reader to the examination of the most common radiographs of the body. The discussion of the radiograph or set of radiographs of each body region begins with a review of the anatomy of the region. This is followed by a comprehensive description of the normal anatomy that is imaged in the radiographs. The presentation concludes with a discussion of frequently encountered abnormal findings. Thus, the intent of each presentation is not only to account for the normal anatomy ap- parent in the radiographs but also to show the anatomic basis of common abnormal find- ings. Specifically, the material covered is as follows. Chapter 1 on the upper limb addresses the AP radiograph of the shoulder; the lateral, AP, internal oblique, and external oblique radio- graphs of the elbow; the PA radiograph of the hand; and the lateral radiograph of the wrist. Chapter 2 on the lower limb discusses the AP radiograph of the pelvis; the AP, tunnel, later- al, and axial radiographs of the knee; the mortise radiograph of the ankle; and the lateral, oblique, and AP radiographs of the foot; two additional sections describe T1-weighted magnetic resonance images (MRIs) of coronal and sagittal sections of the normal knee. Chapter 3 on the thorax outlines the examination of PA and lateral chest films; an additional section describes CT scans of the thorax, with the emphasis on the normal mediastinal rela- tionships at six distinct levels within the superior mediastinum and the upper part of the in- ferior mediastinum. The abdominal plain film of the abdomen is discussed in Chapter 4; an additional section describes CT scans of the abdomen, with an emphasis on the abdominal viscera that are imaged at four broad abdominal levels. Chapter 5 on the head and neck in- troduces the Waters’ view and lateral radiographs of the face and neck, with an additional section on CT scans of the cranium, The text is designed for use by medical personnel and students interested in learning ra- diographic anatomy. In the first year of medical school, the reviews of gross anatomy in each chapter can be used as study aids; the sections that describe CT scans of the thorax and abdomen provide a clinically relevant, cross-sectional perspective to the organization of the trunk. Second-year medical students can quickly review appropriate chapters in preparation for learning pathologic processes. The radiologic sections of each chapter teach the reader to distinguish normal from abnormal findings on plain film radiographs. The questions at the end of each chapter assist in review for the Boards Part | exam and test the reader's mental images of radiographs and CT scans. Prior to each clerkship, third-year medical students can quickly review the relevant radiographs and CT scans presented here. The cases at the end of the book duplicate the format of radiologic presentation in the clini- cal setting, and they test the reader's ability to recognize major abnormal findings. Based on the material in this book, the reader should acquire a good understanding of the anatomic basis of radiographs and CT scans and an ability to recognize major common abnormalities. The reader will then be able to appreciate the more difficult diagnostic features presented in these radiographs. ixFinally, we would like to emphasize that the ability to ‘‘read” a specific radiograph (espe- cially chest and abdominal films) is almost directly proportional to the number of such ra- diographs that are examined. With each chest film or abdominal plain film that is exam- ined, whether pathologic or not, there is an incremental increase in the ability to recognize the spectrum of normal features, especially as they relate to habitus, age, and sex. It is frus- trating and yet exciting to discover that, for example, what is seen in the 100th PA chest film was not recognized in the first 99. The reader will find that experience and repetition are truly the best teachers of the distinction between normal variant and incipient abnormal findings. Frank Slaby Eugene R. JacobsAcknowledgments The first author wishes to acknowledge the support and assistance of his wife, Susan K. McCune, M.D., without whose guidance and perspective this project could not have been initiated. The first author also would like to thank Dr. Frank D. Allan, Acting Chairman of the Anatomy Department at the George Washington University Medical Center, for his sup- port and assistance during the writing of this text. Both authors want to thank James Kendrick and the personnel of the Biomedical Communications division at the George Washington University Medical Center for their professional and superb reproduction of all the radiolog- ic images in this text. Lastly, we would like to thank Jim Harris, Matt Harris, Debra Dreger, and Wiesia Langenfeld of Harwal Publishing Company for their considerations and contri- butions; their cooperation and understanding made the writing of this text exceptionally enjoyable. xiTo the Reader Since 1984, the National Medical Series for Independent Study has been helping medical students meet the challenge of education and clinical training. In this climate of burgeoning knowledge and complex clinical issues, a medical career is more demanding than ever. In- creasingly, medical training must prepare physicians to seek and synthesize necessary infor- mation and to apply that information successfully. The National Medical Series is designed to provide a logical framework for organizing, learning, reviewing, and applying the conceptual and factual information covered in basic and clinical studies. Each book includes a concise but comprehensive outline of the essen- tial content of a discipline, with up to 500 study questions. The combination of distilled, outlined text and tools for self-evaluation allows easy retrieval and enhanced comprehen- sion of salient information. Each question is accompanied by the correct answer, a para- graph-length explanation, and specific reference to the text where the topic is discussed. Study questions that follow each chapter use current National Board formats to reinforce the chapter content. Study questions appearing at the end of the text in the Challenge Exam vary in format depending on the book; the unifying goal of this exam, however, is to chal- lenge the student to synthesize and expand on information presented throughout the book. Wherever possible, Challenge Exam questions are presented in the context of a clinical case or scenario intended to simulate real-life application of medical knowledge. Each book in the National Medical Series is constantly being updated and revised to re- main current with the discipline and with subtle changes in educational philosophy. The authors and editors devote considerable time and effort to ensuring that the information re- quired by all medical school curricula is included and presented in the most logical, com- prehensible manner. Strict editorial attention to accuracy, organization, and consistency also is maintained. Further shaping of the series occurs in response to biannual discussions held with a panel of medical student advisors drawn from schools throughout the United States. At these meetings, the editorial staff considers the complicated needs of medical stu- dents to learn how the National Medical Series can better serve them. In this regard, the staff at Harwal Publishing Company welcomes all comments and suggestions. Let us hear from you. xiii