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Milton
Milton R.
R. Wolf,
Wolf, M.D.
M.D. film radiology cases provided in a self-tutorial format that have been specifically selected for the
Interested in Radiology? medical student and non-radiology resident. This is a compilation primarily of “horses” with just
Contributors enough “zebras” to keep it interesting. With hundreds of patients and images, this program will
References
References provide you with the basics of chest, abdominal and orthopedic radiology. While the emphasis
Copyright is clearly on plain film studies, other modalities such as computed tomography (CT), magnetic
Quit resonance imaging (MRI), nuclear studies, angiography, and positron emission tomography
(PET) are included when they clarify the basic findings.
IMPORTANT: For optimal viewing, set the screen resolution to 1024x768 and the color quality to
24-bit (Control Panel : Display Properties: Settings).
Navigation through the images is largely random which will allow you to study the cases and attempt
your own interpretation before the answer is given. An explanation of each case can then be toggled on
and off with the unique Interpretation Button™. When multiple images exist in a single case, it is
suggested that you return to the first image before toggling the Interpretation Button™.
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Milton R. Wolf, M.D.
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Milton R.
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M.D. Milton R. Wolf, M.D.
Interested in Radiology? milton@planetkc.com
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Quit Milton Wolf is a graduate of The University of Kansas and
The University of Kansas School of Medicine. He
completed his intern year at Baptist Medical Center and is
currently a radiology resident at the University of Missouri-
Kansas City School of Medicine at the historic Saint Luke’s
Hospital, Truman Medical Center and Children’s Mercy
Hospital.
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Rotating through the three highest volume hospitals in Kansas City in addition to an active outpatient imaging
center prepares our graduates for the breadth and volume of today’s busy radiology practice. Still, at Saint Luke’s
on the Country Club Plaza, academics reign supreme. Numerous didactic lectures, case conferences, symposia,
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Milton R.
R. Wolf,
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Nationally recognized, board-certified and fellowship- Residents’ conferences sharpen analytical skills
trained faculty provide daily morning lectures. while simulating oral boards.
And interacting with the technology students But remember, radiology is more than just a 9-to-5
QUIT provides numerous teaching opportunities. job. Be prepared for evening and weekend work.
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Milton
Milton R.
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M.D. of Medicine, contact the Radiology Resident Coordinator at (816) 932-2047 or write:
Contributors UMKC Diagnostic Radiology Residency
References
References Saint Luke’s Hospital of Kansas City
Copyright 4401 Wornall Road
Quit Kansas City, Missouri 64111
Clinical externships or rotations in diagnostic radiology can be requested by contacting:
Saint Luke's Hospital Truman Medical Center

(816) 932-2047 (816) 404-0760
Visit the website:

http://research.med.umkc.edu/residency/radiology/default.html
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Milton R.
R. Wolf,
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M.D.
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Douglas L. Nelson, M.D. Gerald E. Staab, M.D.
Alliance Radiology / Saint Luke’s Midwest Radiology
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Mark S. Reinsel, M.D. Larry F. Frevert, M.D.
Alliance Radiology / Shawnee Mission Rockhill Orthopedics
I would also like to thank the following for their help:
Pablo N. Delgado, M.D. Troy Avendanio, M.D.

Greg I. Gordon, M.D. Niska Blevins, D.O.
Thomas H. Waddell, M.D. Jorge Vidal, M.D.
Naveed Akhtar, M.D. Jason Skiles, D.O.
Andy Jett Lawrence A. Rues, M.D.
Kathy Graham Kimberly Backes
Steve Bolin Janet Miller
Christina Carlson Karrie Wolf
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Here The following sources were used extensively in the creation of The Wolf Files™ and
Milton
Milton R.
R. Wolf,
Wolf, M.D.
M.D. are highly recommended:
Contributors Brant William E., Helms Clyde A. Fundamentals of Diagnostic Radiology, 2nd Edition. New York: Lippincott, Williams &
Wilkins, 1999. Z
References
References
Copyright Felson Benjamin. Chest Roentgenology, Philadelphia: W. B. Saunders Company, 1973.
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Juhl John H. et al. Paul & Juhl’s Essentials of Radiologic Imaging, New York: Lippincott Williams & Wilkins, 1998.
Kahn Charles. CHORUS Website, Medical College of Wisconsin, 2001.
Mettler Fred. Essentials of Radiology, Philadelphia: W. B Saunders Company, 1996. Y
Netter Frank H. Atlas of Human Anatomy, New Jersey: Ciba-Geigy Corporation, 1989.
Robbins Stanley et al. Pathologic Basis of Disease, Philadelphia: W. B. Saunders Company, 1999.
Webb, W. Richard et al. Fundamentals of Body CT, Philadelphia: W. B. Saunders Company, 1998.
Weist Philip, Roth Paul. Fundamentals of Emergency Radiology, Philadelphia: W. B. Saunders Company, 1996. X
Where you should start:

X Weist is the best “first read” for every medical student. You can finish it in a few evenings.
Y Future radiology residents should then read Mettler (it may take a couple weeks). Interested non-
radiologists may also want to read it.
Z Brant & Helms is the “gold standard” first book to read during radiology residency.
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Milton
Milton R.
R. Wolf,
Wolf, M.D.
M.D.
Interested in Radiology? The images and information contained in The Wolf Files™ are the exclusive property of American Wolf. All
Contributors rights reserved. No part of the this publication may be reproduced or transmitted in any form or by any means,
References electronic or mechanical, including photocopy, recording, or any information storage retrieval system, without
References
permission in writing from the author.
Copyright
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The Wolf Files™ is provided for educational purposes only. It is intended as a resource for healthcare
professionals. The author has used resources believed to be reliable at the time of this publishing. However, in
light of the possibility of human error and the rapidly changing body of medical knowledge, this resource should not
be used for the basis of diagnosis or treatment of patients and the author is not responsible for the results obtained.
The user is encouraged to confirm all information contained herein with other sources. The author also strongly
recommends that all radiological studies be interpreted by a radiologist. So there.
ISBN 0-9726882-1-8 The Wolf Files: An Interactive Radiology Atlas of Fundamental Cases, Clinician’s Edition 1.0.
American Wolf
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Chest Home
CHEST
Home
Atelectasis Miscellaneous
Lobar [Case 64] Aortic Aneurysm [Case 45]
Segmental [Case 15] Asthma Exacerbation [Case 62]
Subsegmental [Case 17] Broken Pacemaker Wire [Case 34]
Option A Bronchogenic Carcinoma[Case 55]
Congestive Heart Failure Chronic Obstructive Pulmonary Disease [Case 17 | Case 63]
Emphysema [Case 43]
Mixed Pattern [Case 2 | Case 37]
ET Tube [Case 33 | Case 40 | Case 66]
Click Here To Interstitial Pattern [Case 4 | Case 7 | Case 30 | Case 49]
Foreign Body [Case 66]
Alveolar Pattern [Case 8 | Case 17 | Case 21 | Case 33]
Start
Hair Artifact [Case 46]
In Azygos Lobe [Case 13]
Hiatal Hernia [Case 54]
Kerley’s A Lines [Finding | Case 7 | Case 30]
Mediastinal Mass [Case 60]
Kerley’s B Lines [Finding | Case 2 | Case 4 | Case 7 | Case 17 |
Metastases [Case 29]
The Chest Tour Case 29 | Case 36 | Case 48]
NG Tube [Case 14 | Case 24 | Case 40 | Case 48 | Case 66]
Bat Wings [Case 8 | Case 33]
Pectus Excavatum [Case 56]
Pseudotumor [Case 12]
Pneumonectomy [Case 58]
Pulmonary Hypertension [Case 9]
Congenital Anomalies Scoliosis [Case 51]
Azygos Lobe [Case 13 | Case 31 | Case 32] Tuberculosis [Case 19 | Case 35]
Option B Cleidocranial Dysostosis [Case 50] Viral Myocarditis [Case 65]
Left Horizontal Fissure [Case 61]
Use the index to the right to Right-sided Aortic Arch [Case 25]
review individual cases. Situs Inversus [Case 44]
Pneumo
Pneumomediastinum [Case 20 | Case 32]
Pneumoperitoneum [Case 52]
Pneumothorax [Case 5]
Tension Pneumothorax [Case 27 | Case 38 | Case 59]
Pneumonia
Aspiration [Case 22]
Azygos [Case 31]
Lobar [Case 3 | Case 6 | Case 10 | Case 11 | Case 16 | Case 28 |
Case 36 | Case 53]
Lingular [Case 18]
PCP [Case 47]
Pneumatocoele [Case 57]
Round [Case 41]
Pulmonary Embolus
Amniotic Fluid [Case 26]
Hampton’s Hump [Case 42]
Westermark’s Sign [Case 23]
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Orthopedics Home
ORTHO
Home
General Principles
[ Case 1 | Case 2 | Case 3 | Case 4 | Case 5 ]
Option A Neck
[ Case 6 | Case 7 | Case 8 | Case 9 | Case 10 | Case 11 | Case 12 | Case 13 | Case 14 ]
Click Here To
Shoulder
Start
The Orthopedic Tour
Elbow
[ Case 20 ]
Wrist & Hand

[Case 21 | Case 22 | Case 23 | Case 24 | Case 25 | Case 26 | Case 27 | Case 28 | Case 29 | Case 30 | Case 31 ]
Option B
Use the index to the right to Back
[ Case 32 ]
review individual cases.
Pelvis & Hip

[ Case 33 | Case 34 | Case 35 | Case 36 | Case 37 | Case 38 | Case 39 ]
Knee
Distal Leg, Ankle & Foot

[ Case 45 | Case 46 | Case 47 | Case 48 | Case 49 | Case 50 ]
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Abdomen Home
ABDOMEN
Home
Bowel Gas Pattern
[ Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | Case 6 | Case 7 | Case 8 | Case 9 | Case 10 | Case 11 | Case 12 | Case 13 ]
Option A
Calcifications
[ Case 14 | Case 15 | Case 16 | Case 17 | Case 18 | Case 1 | Case 4 ]
Click Here To
Start
The Abdomen Tour
Miscellaneous
[ Case 19 ]
Option B
Use the index to the right to
review individual cases.
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Copyright © 2002 Milton R. Wolf, M.D.
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Clinical
30-year-old radiology resident.
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Clinical
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Trachea
Clinical
30-year-old radiology resident. Posterior
Junction Line
Normal Chest (Almost)
The heart size and pulmonary
Aortic
vasculature are within normal
Knob
limits. No infiltrates or effusions
are seen. The heart, Right Mainstem
hemidiaphragms and pulmonary Bronchus
arteries have sharp borders. Left
The left hilum is normally Right Hilum
slightly higher than the right. Hilum Carina
The carina is important to
locate. The so called
Left Pulmonary
cardiothoracic ratio compares
Right Pulmonary Artery
the heart width to the chest.
Artery
Normal on a PA chest is 0.5 or Left Mainstem
less (normal on a portable AP is Bronchus
0.6 or less). Here it is 0.4.
Incidental calcified granulomas

are likely Histoplasma, endemic
in the Midwest. The right
hemidiaphragm is usually higher Gastric Bubble
than the left, however, with
gastric distention -- large gastric Right Left
bubble consistent with a post- Hemidiaphragm Hemidiaphragm
call Mountain Dew -- the left
may be higher.
The right heart border has an

unusual lie, but is within normal
limits with CT confirmation.
Image 1 of 2
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Clinical Trachea
Scapular
Normal Chest Blades
The lateral view reveals a
normal cardiac size, sharp
costophrenic and cardiophrenic
angles bilaterally, well-domed
hemidiaphragms and a normal Aorta Retrosternal
pattern of decreasing Airspace
opacification over the vertebral
bodies moving in the
craniocaudal direction. The Pulmonary
small calcified granulomas are Trunk
again seen.
The left hemidiaphragm

contains the gastric bubble and
its anterior third cannot be seen
as it silhouettes the heart.
Notice the right hemidiaphragm
can be seen overlying the heart.
Gastric Bubble
Left
&
Right
Hemidiaphragms
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Clinical
Middle-aged man short of
breath.
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Clinical
breath.
Congestive Heart Failure

A mixed pattern of interstitial
and alveolar edema is seen. In
the presence of cardiomegaly,
this is consistent with
congestive heart failure.
Cephalization (blue) is often the
first sign. Interstitial edema
follows, seen here as Kerley’s B
Lines (red) and peribronchial
cuffing (green). The perihilar
congestion (yellow) represents
early alveolar edema. Notice
also the right pulmonary artery
has become obscured.
The pulmonary effects of heart

failure occur in a predictable
pattern. While the numbers
below can vary, the sequence of
their presentation usually does
not.
CVP* Finding
8-12 Normal
12-18 Cephalization
18-25 Interstitial edema
25-30 Alveolar edema
*Central Venous Pressure
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54-year-old woman short of
breath.
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Clinical
breath.
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Clinical
breath.
LUL Pneumonia
A left-sided consolidative
process has silhouetted the left
heart border. The left
hemidiaphragm, however, has
been spared. This pattern is
consistent with a left upper lobe
infiltrate considering only the
lower lobe makes contact with
the diaphragm. The lateral view
should confirm this finding.
Blunting of the left costophrenic
angle (blue) is caused by a
parapneumonic effusion.
Elevation of the left
hemidiaphragm suggests that
some atelectasis is present on
the left. Alternatively, a
loculated subpulmonic effusion
could give a similar appearance.
Air bronchograms (green) are

seen suggesting an alveolar
process. Compare this to the
normal pulmonary vasculature
of the right lung (red).
“Branching white things are
good; branching black things
are bad.”
Image 1 of 2
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Clinical
breath.
LUL Pneumonia
The infiltrate has consolidated
along the anterior aspect of the
left major fissure (yellow) in the
upper lobe.
The left hemidiaphragm (blue)

contains the gastric bubble
(purple) and silhouettes the
heart border. The right
hemidiaphragm (green) projects
over the heart. A small
parapneumonic pleural effusion
(red) is present on the left.
Image 2 of 2
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Clinical
67-year-old man short of breath.
Image 1 of 1
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Clinical

This is an excellent example of
Kerley’s B Lines (yellow). This
finding, especially in the
presence of marked
cardiomegaly is consistent with
CHF. An artificial aortic valve
(blue) and sternotomy wires
(red) are seen. A pericardial
effusion may be present; notice
the left heart border has lost its
usual concave appearance and
the heart has begun to take on a
symmetrical shape with sharp
borders.
Notice also the splaying of the
carina (green) as the bronchi
are displaced to accommodate
the large left atrium. “Atrial
escape” occurs when the left
atrium enlarges enough to
create it’s own border in the
right chest (red dotted line)
within the shadow of the right
atrium. This is a subtle sign and
probably beyond the scope of
this review. Toggle the
Interpretation button on and off
to see it.
Image 1 of 1
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Kerley’s B Lines
Kerley’s B Lines represent
interstitial edema of peripheral
interlobular septa. They
typically are 1 to 3 cm linear
opacities projecting horizontally
from the periphery of the lungs
and are usually found in the
bases.
Click to see:
Kerley’s B Lines on CT
Compare to:
Kerley’s A Lines
Image 1 of 1
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Kerley’s B Lines
Kerley’s B Lines represent
interstitial edema of peripheral
interlobular septa. They
opacities projecting horizontally
from the periphery of the lungs
and are usually found in the
bases.
Click to see:
Kerley’s B Lines on Plain Film
Compare to:
Kerley’s A Lines
Image 1 of 1
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Clinical
breath
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Clinical
breath
Hydropneumothorax
The pleural line (red) can be
seen collapsed from the chest
wall. The heart and media-
stinum are midline suggesting
that this pneumothorax is not
under tension. An air-fluid level
(green) is seen in the right base
that may represent effusion or
possibly blood.
Image 1 of 1
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Clinical
Middle-aged man with
shortness of breath.
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Clinical
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Clinical
LLL Pneumonia
OK, the “positive wax sign”
gives away this impressive air
bronchogram (blue). Still, two
important observations are
noteworthy. First, notice that
the descending aorta is no
longer visible as it has been
silhouetted by a posterior
infiltrate.
Image 1 of 2
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Clinical
LLL Pneumonia
In the lateral view, there should
normally be a decreasing
pattern of opacification over the
thoracic vertebrae in the
craniocaudal direction. An
increasing pattern of opacity
over the vertebrae is known as
“The Spine Sign” and suggests
an infiltrate or other lower lobe
process. In this case, air
bronchograms within an
infiltrate (blue) represents a left
lower lobe pneumonia. The
confluent opacity (red) is likely
fluid in the major fissure vs.
atelectasis.
Image 2 of 2
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Clinical
Image 1 of 1
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Clinical

Cardiomegaly is seen in the
presence of interstitial markings:
Kerley’s A Lines (red) and
Kerley’s B Lines (yellow).
Perihilar congestion suggests
an early alveolar process.
Margins of the right pulmonary
artery and right hemidiaphragm
are becoming obscured.
Image 1 of 1
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Kerley’s A Lines
Kerley’s A Lines (red) represent
interstitial edema of central
connective tissue septa. They
opacities radiating from the hila.
Peribronchial cuffing (yellow) is
also seen. The linear opacity in
the mid lung (blue) is a left
minor fissure (a normal variant)
vs. another Kerley’s A line.
Compare to:
Kerley’s B Lines
Image 1 of 1
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Clinical
Image 1 of 1
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Clinical
Pulmonary Edema
The classic “bat wings”
distribution of alveolar edema is
seen here (green). It is unclear
why the periphery is spared.
Pulmonary edema is most
commonly the result of CHF
(especially in the presence of
cardiomegaly) . Bilateral pleural
effusions are present with the
classic “meniscus sign” on the
right (blue).
Causes of Pulmonary Edema

Congestive heart failure
Chronic renal failure
Hypoalbuminemia
Head trauma
Drug overdose
Toxin inhalation
Sepsis
Burn
Shock
Near-drowning
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Clinical
breath.
Image 1 of 1
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Clinical
breath.
Pulmonary Hypertension
The large bilateral hilar masses
are indeed worrisome. Hilar
lymphadenopathy might be
considered, but notice the
contiguity of these masses with
the pulmonary arteries and their
rapidly tapering nature which is
typical of pulmonary artery
dilatation as they move to the
periphery. The cardiomegaly
likely represents cor pulmonale
which is right heart failure
secondary to pulmonary
causes. The most common
cause of right heart failure is, of
course, left heart failure,
however no radiographic
evidence of left heart failure is
seen (cephalization, interstitial
or alveolar edema) and thus,
this likely represents primary
pulmonary hypertension.
This case is beyond the scope

of this review, but is included
primarily to help the user
identify the pulmonary arteries.
Image 1 of 1
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Clinical
44-year-old woman with cough.
Image 1 of 2
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Clinical
Image 2 of 2
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Clinical
RML Pneumonia
Breasts shadows should
normally be symmetrical,
however in this case there is a
marked asymmetry. A right
mid-lung infiltrate (green) with
air bronchograms (red) is seen
silhouetting the right heart
border. The solitary round
opacity (blue) is problematic. It
is important to find it on the
lateral view before further
characterizing it. Differential
includes parenchymal mass,
calcified granuloma, nipple
shadow, or chest wall mass.
Image 1 of 2
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Clinical
RML Pneumonia
The consolidation is seen along
the major fissure in the right
middle lobe (green). An air
bronchogram is barely visible
(red). The round opacity is not
visible within the lung which
effectively excludes a
parenchymal mass or
granuloma. A density
consistent with a nipple shadow
in the anterior chest wall is seen
(yellow). Repeating the study
with radiopaque nipple rings
might be helpful if uncertainty
persists.
Image 2 of 2
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Clinical
6-year-old boy with cough.
Image 1 of 2
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Clinical
Image 2 of 2
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Clinical
RUL Pneumonia
An opacity is seen within the
right upper lobe with air
bronchograms (blue). Notice
the superior aspect of the
infiltrate is somewhat ill-defined
but the minor fissure brings the
infiltrate to an abrupt halt
inferiorly.
Image 1 of 2
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Clinical
RUL Pneumonia
The three lobes of the right lung
are nicely demonstrated in this Upper
lateral view. The right upper
Upper Lobe
Lobe
lobe infiltrate is consolidating
along the major (green) and
minor (blue) fissures.
Toggle the overlay on and off to

better appreciate the fissures.
Lower
Lower Middle
Middle
Lobe
Lobe Lobe
Lobe
Image 2 of 2
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Clinical
66-year-old smoker with
shortness of breath and cough.
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Clinical
Image 2 of 2
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Clinical
Pseudotumor of CHF
This dramatic finding (yellow) is
often misdiagnosed as a lung
tumor, however it actually
represents fluid trapped in the
minor fissure as a result of heart
failure. Supporting evidence
includes cardiomegaly,
cephalization (blue), and
prominent interstitial markings.
A right-sided pleural effusion
(green) is also present.
Follow up films to document

resolution is critical. If a
confident diagnosis cannot be
established, a pleuracentesis
could differentiate an exudative
from a transudative process, the
former suggesting cancer and
the the latter CHF.
Image 1 of 2
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Clinical
Pseudotumor of CHF
Pseudotumors, like other signs
of failure, characteristically
resolve rapidly with appropriate
treatment.
Notice this study was performed

one week later.
Image 2 of 2
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Clinical
74-year-old man with shortness
of breath.
Image 1 of 3
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Clinical
of breath.
Azygos Lobe in CHF

Azygos
Azygos
Supine portable chest films
Lobe
Lobe
pose challenges in
interpretation. Bilateral pleural
effusions layer superiorly
creating the opacity pattern A
seen here in the lung bases.
The striking finding is an azygos
lobe with an entrapped
engorged azygos vein (A).
An azygos lobe is a 1-2%

normal variant caused by
delayed migration of the azygos
vein to midline during fetal
development entrapping a
portion of the developing lung.
The visible demarcation (yellow)
represents a reflection of four
layers of pleura; two layers of
parietal sandwiched between
two layers of visceral, all
dragged inferiorly by the
migrating azygos vein.
Click to see progression of this

patient’s engorged azygos vein.
Image 1 of 3
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Clinical
of breath.
Azygos Lobe in CHF

The progressive engorgement
of this azygos vein nicely
demonstrates the increasing
central venous pressure seen in
congestive heart failure.
Click to see another patient’s

azygos lobe on CT.
Image 2 of 3
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Clinical
Unknown.
Azygos Lobe on CT
In the axial projection, an
azygos lobe gives a distinctive
appearance. Normal lung
tissue --the azygos lobe-- can Right Upper Left Upper
be seen medial to the pleural Lobe SVC Lobe
reflection (yellow) that contains
the azygos. Felson calls this Aortic
pleural reflection the Arch
mesoazygos. The large pleural
effusion (red) is unrelated to the Azygos
presence of the azygos lobe. Lobe
Trachea
Image 3 of 3
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Clinical
Unknown.
Image 1 of 1
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Clinical
Unknown.
NGT in Right Mainstem

Despite this technically
compromised film, the
nasogastric tube is clearly seen
in the right mainstem bronchus
(red). It is critical to follow each
line and tube in a study.
Image 1 of 1
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Clinical
Shortness of breath, cough.
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Clinical
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Clinical
LUL Atelectasis
This study presents many
classic findings of segmental
atelectasis: confluent
opacification (yellow) with
evidence of volume loss. As
alveoli collapse, adjacent
structures move toward the
affected area: tracheal deviation
(red) from the midline (blue),
and an elevated hemidiaphragm
(green). Notice also the
vascular crowding within the
collapsed lung and diminished
size of the entire left
hemithorax.
Hilar elevation (not seen here)

in upper lobe atelectasis and
hilar depression in lower lobe
atelectasis are other classic
findings.
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Clinical
LUL Atelectasis
The atelectatic left upper lobe
(yellow) is again visible as well
as yet another sign of volume
loss: a dramatic anterior shift of
the left major fissure (blue).
Collapse of a portion of the

lung, such as this, may simply
be the result of mucus plugging.
Consideration should be given
to bronchogenic carcinoma,
however, as it can compress a
bronchus and cause atelectasis
as well.
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Clinical
10-year-old known asthmatic
with cough.
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Clinical
with cough.
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Clinical
with cough.
LLL Pneumonia
There is a slight asymmetry of
opacification in the left base.
This is a subtle finding that
might easily be overlooked in
the absence of the lateral view.
Notice that the heart and
hemidiaphragm borders are
both well maintained.
Recall the saying, “One view is

no view.” Hopefully, this will
impress upon you the need to
order two views unless your
patient is absolutely too
unstable to be moved. I see
patients who have walked in to
the ER, for example, and then
receive only a 1-view study.
Consider this. With only one

view, would you have correctly
diagnosed this or would you
have sent this boy home on
nebulizers and steroids?
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Clinical
with cough.
LLL Pneumonia
An infiltrate with air
bronchograms is seen in the
base (blue). Recall that the
vertebral bodies should
normally appear progressively
less opacified in the
craniocaudal direction. This
infiltrate is located posteriorly
enough to not silhouette the
hemidiaphragm and therefore it
was maintained in the PA
projection.
This lateral film should have

prompted you to reexamine the
PA view for the (likely) missed
infiltrate. On occasion, it cannot
be found on the PA at all and
the radiologist will diagnose a
lower lobe pneumonia with
uncertainty of its side.
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Clinical
Shortness of breath.
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Clinical
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Clinical

Cardiomegaly, cephalization
(green), Kerley’s B Lines
(yellow), and an obscured right
pulmonary artery are all
consistent with CHF. The linear
opacity in the bases (red) is
likely subsegmental (or plate-
like) atelectasis.
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Clinical

Hyperinflation or “air trapping” is
evidenced by flattened
hemidiaphragms, increased
antero-posterior diameter and
an increased retrosternal
airspace is consistent with
COPD.
Take note of this normal

progressively decreasing
opacification over the thoracic
vertebrae in the craniocaudal
direction as previously
discussed.
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Clinical
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Clinical
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Clinical
Lingular Pneumonia
A consolidative process that
silhouettes the left heart border
(green) is a lingular pneumonia.
Slight blunting of the left
costophrenic angle (blue) is
likely a tiny parapneumonic
effusion. The remainder of the
exam is normal.
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Clinical
Lingular Pneumonia
The consolidation (red) is visible
along the anterior aspect of the
left major fissure which is
consistent with a lingular
infiltrate.
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Clinical
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Clinical
Tuberculosis
A large thick-walled cavitary
lesion (yellow) is present in the
right apex. A solitary calcified
granuloma in the parenchyma
(green) is visible as well as
multiple tiny granulomas in the
right hilum (red). Blunting of
the costophrenic angles may
represent pleural thickening or
tiny pleural effusions.
Click to see a tomogram of

this patient.
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Clinical
Tuberculosis
Rarely used today in the age of
computed tomography, the
tomogragm is a plain film x-ray
technique that brings only one
plane of tissue into focus at a
time. The x-ray beam source
and the film cassette rotate
about a fixed point to isolate the
desired area as seen here. The
cavitary nature of this lesion is
easily seen.
Click to see an interesting

historic treatment of TB.
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Clinical
Tuberculosis patient.
Plastic Ball Plombage

In an effort to eradicate the
mycobacteria, large excisions
were made of both lung tissue
and chest wall including ribs if
necessary. The resulting defect
was then packed with antibiotic-
coated plastic balls. The
plombage seen here is only
moderate in size; they were
often much larger and could be
quite disfiguring.
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Clinical
43-year-old man with chest pain
following an EGD.
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Clinical
43-year-old man with chest pain
following an EGD.
Pneumomediastinum
Free air is evident along the left
heart and bilateral mediastinal
borders (yellow). Subcutaneous
emphysema (red) has resulted
from air tracking into the neck.
A search for upper rib fractures

should ensue, but this
pneumomediastinum is likely a
result of perforation during the
EGD.
Pneumothoraces commonly
accompany pneumomedia-
stinum and there appears to be
a small one in the right apex
(green).
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Clinical
63-year-old man with COPD,
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Clinical
Same patient, three days later.
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Clinical
63-year-old man with COPD,
Pulmonary Edema
A large infiltrate is seen in the
right lung base. It appears to be
mostly in the lower lobe as
evidenced by silhouetting of the
right hemidiaphragm. However,
the right heart border is also
slightly obscured possibly owing
to middle lobe involvement.
A pacemaker is seen in the left

anterior chest. Its wires are
radiographically intact and the
atrial lead (blue) terminates in
the appropriate place while the
ventricular lead (green)
terminates beyond the borders
of this study. Post-surgical
changes are seen in the right
clavicle (red). A small calcified
granuloma (yellow) is present
in the left mid lung.
It is important to realize that

alveolar infiltrative causes (eg.
pus, blood, fluid, etc.) cannot be
distinguished radiographically
so clinical correlation is
imperative.
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Clinical
Same patient, three days later.
Pulmonary Edema
Three days later, the infiltrate is
now resolved confirming the
diagnosis of pulmonary edema
rather than pneumonia. The
atypical pattern (seen in image
1) resulted from “sparing” of the
right upper lobe and left lung
presumptively by a vascular
restrictive disease.
The prominent pulmonary artery

(blue) plus cephalization
(yellow) suggest a cardiogenic
etiology. The ventricular lead
(green) is now visible and
terminates appropriately.
Two important points:

1. Alveolar infiltrates -- with the
exception of pneumonia --
characteristically resolve rapidly
with appropriate therapy.
2. COPD patients often present

with atypical findings.
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Clinical
71-year-old febrile woman with
previous CVA.
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Clinical
previous CVA.
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Clinical
previous CVA.
Aspiration Pneumonia
A large patchy infiltrate is seen
in the right mid lung and base.
A few air bronchograms (yellow)
are visible. The scattered small
lucent areas within the infiltrate
likely represent air
alveolograms and bronchiolo-
grams. Slight blunting of the
right costophrenic angle
suggests a tiny pleural effusion.
Notice the right heart border
and hemidiaphragm are spared.
Incidental finding of rotary

scoliosis with right convexity
(green) is noted.
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Clinical
previous CVA.
Aspiration Pneumonia
The lateral view shows an
infiltrate in the lung base with air
bronchograms (yellow).
These findings are consistent

with an aspiration pneumonia in
the right lower lobe, specifically
the superior, posterior basal and
possibly the lateral basal
bronchopulmonary segments.
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Clinical
tachypnea and new oxygen
requirement.
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Clinical
tachypnea and new oxygen
requirement.
Pulmonary Embolus
The majority of patients with
pulmonary emboli have normal
chest radiographs. The
usefulness of the study is
primarily to rule out other
diagnoses. Still, occasionally a
suggestive finding is present.
Notice the asymmetrical

vascular pattern in the apices.
Normal apical vasculature
(green) is seen in the right but
a hyperlucency is seen on the
left (yellow) in this patient with a
proven LUL PE.
Radiographic evidence of
oligemia distal to pulmonary
emboli is known as
Westermark’s Sign.
Click to see the CT of another

PE patient.
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Clinical
Unknown.
Pulmonary Embolus
An axial CT image shows filling
defects (blue) in both right and
left main pulmonary arteries
confirming the diagnosis of
bilateral pulmonary emboli. A
pleural effusion is seen on the
right.
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Clinical
Dobhoff placement.
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Clinical
Dobhoff placement.
Dobhoff in Left Mainstem

While the tip of the Dobhoff tube
does terminate in the vicinity of
the stomach, it clearly is seen
following the left mainstem
bronchus. It appears to
terminate in the left
subpulmonic space. This
should serve as a reminder to
attain radiographic confirmation
of tube placement before using
them.
A correctly placed Dobhoff or

NG tube should split the carina.
This story does not stop here,

however. Click to see the same
patient 45 minutes later.
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Clinical
Same patient, 45 minutes later.
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Clinical
Same patient, 45 minutes later.
Dobhoff in Rt. Mainstem

The patient is now intubated
(yellow) with the ET tube
terminating appropriately above
the carina (green). An apical
pneumothorax (red) has
developed on the left. By
definition, a pneumothorax in an
intubated patient is a tension
pneumothorax. The Dobhoff
tube (blue) is now in the right
mainstem bronchus.
As we have run out of bronchi to

intubate, one might suggest to
this clinician that nutrition is no
longer the highest priority for
this tension pneumo patient.
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Clinical
30-year-old female with chest
tightness.
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Clinical
30-year-old female with chest
tightness.
Right-sided Aortic Arch

A right-sided aortic arch (red) is
a normal variant and usually
occurs in isolation though
truncus arteriosis and Tetralogy
of Fallot may accompany.
Notice the trachea is deviated to
the left (blue). In this patient,
the aorta descends through the
right side of the thorax (green),
though this can vary.
This is likely an incidental

finding in this patient. It is
included here as a reminder to
always evaluate the contours of
the mediastinum.
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Clinical
24-year-old woman with
shortness of breath 24 hours
post-partum.
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Clinical
shortness of breath 24 hours
post-partum.
Amniotic Fluid Embolism

Bilateral confluent airspace
opacification in this clinical
setting is consistent with
amniotic fluid embolism.
Differential diagnosis includes
large bilateral pleural effusions
which could take on a similar
appearance in a supine AP
study as the fluid layers
superiorly. Lateral decubiti
studies could easily distinguish
the two.
As the mortality rate of amniotic

fluid embolism exceeds 80%,
this is a very worrisome finding.
Women who survive the initial
crisis often fall victim to the
ensuing pulmonary edema or
DIC. Post-partum shortness of
breath should raise an
immediate red flag to the
clinician.
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Clinical
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Clinical
Tension Pneumothorax
Survival of this life-threatening
condition depends upon your
rapid and accurate diagnosis.
The large pneumothorax
(green) is easily visible, but
don’t miss that the entire
mediastinum has shifted to the
contralateral side (compare to
the blue midline) under the
pressure. Subcutaneous
emphysema is noted (red) in the
neck and along the pectoralis
major muscles bilaterally.
Notice also that the left
hemidiaphragm has maintained
it’s normal dome appearance.
A finding of pneumothorax
should always prompt the
examiner to seek signs of life-
threatening tension.
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Clinical
Woman with shortness of
breath.
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Clinical
breath.
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Clinical
breath.
RML Pneumonia
An infiltrate (green) with air
bronchograms (blue) is present
in the right mid lung. The right
heart border is slightly
silhouetted, but the right
hemidiaphragm is intact.
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Clinical
breath.
RML Pneumonia
The lateral view localizes the
consolidation (green) in the right
middle lobe. The barrel-shaped
chest associated with flattened
hemidiaphragms and an
enlarged retrosternal airspace is
suggestive of COPD.
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Clinical
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Clinical
Lung Metastases
Numerous “cannonball” lesions
of various sizes (green) are
seen throughout both lungs.
There are bilateral pleural
effusions (yellow), left greater
than right. Surgical clips in the
left axilla indicate a previous
lymph node dissection making
metastases from a previous
breast cancer the likely
diagnosis.
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Clinical
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Clinical
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Clinical

Cardiomegaly with interstitial
markings is consistent with
failure. Kerley’s A (red) and B
(green) lines are noted. The
hemidiaphragms appear
flattened and pleural effusions
are present. A large aortic knob
(blue) suggests aortic ectasia.
Two incidental small calcified
granulomas (yellow) are seen in
the left lung base.
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Clinical

Marked cardiomegaly is again
seen in a pattern consistent with
left ventricular hypertrophy
(click below for details). The
ectatic aorta is again seen.
Click to see:
Hoffman-Rigler Sign
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Hoffman-Rigler Sign
The Hoffman-Rigler sign for left
ventricular hypertrophy is HEART
HEART
positive when the posterior
heart border (yellow) extends
greater than 1.8 cm (red dotted
line) posterior to the inferior
vena cava (blue) at a position
(green dotted line) 2 cm
superior to where the IVC
crosses the diaphragm (green
line).
A simplified method to assess

LVH -- that I call The Staab
Rule -- is to determine where
the heart and IVC cross the
diaphragm in relation to each
other. If the heart crosses the
diaphragm posterior to the IVC,
then LVH is likely.
Toggle the Interpretation

Button to see an overlay of
Hoffman-Rigler’s Sign.
DIAPHRAGM
DIAPHRAGM
VERTEBRAE
VERTEBRAE
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Hoffman-Rigler Sign
The Hoffman-Rigler sign for left
ventricular hypertrophy is HEART
HEART
positive when the posterior
heart border (yellow) extends
greater than 1.8 cm (red dotted
line) posterior to the inferior
vena cava (blue) at a position
(green dotted line) 2 cm
superior to where the IVC
crosses the diaphragm (green
line).
A simplified method to assess

LVH -- that I call The Staab
Rule -- is to determine where
the heart and IVC cross the
diaphragm in relation to each
other. If the heart crosses the
diaphragm posterior to the IVC,
then LVH is likely.
Toggle the Interpretation

Button to see an overlay of
Hoffman-Rigler’s Sign.
DIAPHRAGM
DIAPHRAGM
VERTEBRAE
VERTEBRAE
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Clinical
Shortness of breath & cough.
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Clinical
Azygos Lobe Pneumonia

A patchy infiltrate in an azygos
lobe creates an interesting
appearance.
Click to see a close up.
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Clinical
Azygos Lobe Pneumonia

The pleural reflection (yellow) of
an azygos lobe can be seen
surrounding the patchy infiltrate.
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Clinical
MVA and chest pain.
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Clinical
MVA and chest pain.
Pneumomediastinum
Free air is visible tracking along
the left heart and mediastinal
border (yellow). Subcutaneous
emphysema (red) is seen in the
neck bilaterally. Interestingly, a
small azygos lobe (green) is
present.
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Clinical
MVA and chest pain.
Pneumomediastinum
On closer inspection, a fracture
of the right first rib is seen
(blue). This is a common cause
of pneumomediastinum.
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Clinical
Tachypnea, post-op day two
partial colectomy.
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Clinical
Tachypnea, post-op day two
partial colectomy.
Flash Pulmonary Edema

This impressive bat wings
configuration of alveolar edema
resulted from a “fluid challenge”
to a patient who had
unknowingly suffered an
intraoperative MI. Twelve hours
before this study, a resident
suspected heart failure by exam
and initiated diuresis. The
surgeon then intervened.
Despite a previous film (not
shown) read as “congestive
heart failure”, the surgeon
explained third-spacing to the
resident, cancelled the Lasix
and gave a 1 liter bolus “fluid
challenge” to this “dry” patient.
Hours later, the patient was in
respiratory distress, transferred
to the ICU with pink, frothy
sputum, required intubation
(yellow) and this film was taken.
The lateral displacement of the
right IJ catheter (blue)
demonstrates the greatly
distended venous system. An
NG Tube (purple) appropriately
splits the carina (green).
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study, two days later.
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Clinical
Same patient, 2 days later.
Flash Pulmonary Edema

After appropriate therapy
(aggressive diuresis and fluid
restriction), the alveolar edema
resolved nicely, a characteristic
of pulmonary edema. The ET
tube (yellow) is over the carina
(green). The right IJ (blue)
terminates in the SVC and
shows that the venous system
is now less distended. The NG
tube courses the esophagus.
This high-risk patient with pre-

existing cardiac risk factors had
a pre-operative ejection fraction
of 65%. After the intraoperative
MI, it collapsed to only 10%.
The patient died one day after
this study.
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Clinical
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Clinical
Broken Pacemaker Wire

A small fracture in one of the
pacemaker wires (red) is
radiographically evident.
This is admittedly difficult to see

due to the reduced size of these
images. It is included here as a
reminder to always inspect
pacemakers wires in your
evaluation.
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Clinical
Broken Pacemaker Wire

A small fracture in one of the
pacemaker wires (red) is
radiographically evident.
This is admittedly difficult to see

due to the reduced size of these
images. It is included here as a
reminder to always inspect
pacemakers wires in your
evaluation.
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Clinical
Young woman with a cough.
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Clinical
Young woman with a cough.
Tuberculosis
Bilateral cavitary lesions (green)
are visible in the apices.
Cavitation indicates an active
and transmissable disease
state. Immediately lateral to
the left lesion is a small
infiltrative process (blue) that
likely represents a spread of
organisms.
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Clinical
3-year-old girl with fever.
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Clinical
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Clinical
LUL Pneumonia
While the borders of the heart
and the hemidiaphragms are
maintained, an asymmetry of
opacity is seen in the mid lung
fields. Notice how subtle
asymmetries such as this are
easier to appreciate as you
move back further from the
screen. A normal open humeral
head epiphysis (red).
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Clinical
LUL Pneumonia
The lateral view shows a
consolidation along the anterior
aspect of the left major fissure
(blue) which confirms a left
upper lobe infiltrate.
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Clinical
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Clinical
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Clinical

Cardiomegaly with cephalization
(yellow), Kerley’s B Lines (blue),
fluid in the right minor fissure
(purple) and obscuration of the
right pulmonary artery is
consistent with heart failure.
There is an alveolar infiltrative
process in the right lower lung
with air bronchograms (red) that
silhouettes the right heart
border. A blunted left
costophrenic angle (teal)
suggests an effusion. While this
infiltrate looks very much like a
RML pneumonia, one diagnosis
is better than two (and it would
be difficult to explain why
pneumonia would have a
contralateral pleural effusion).
Additional history revealed that
this patient was afebrile, had a
normal white count and no
cough, and thus, this likely
represents alveolar edema
rather than pneumonia.
Incidental finding: aortic ecastia
(green) that displaces the
trachea to the right.
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Clinical

The right posterior costophrenic
sulcus is filled with a pleural
effusion (yellow). The confluent
opacity seen anteriorly (red) is
likely pleural fluid within the left
major fissure.
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Clinical
Tachypnea in a newborn.
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Clinical
Tachypnea in a newborn.
At first glance there is a marked
asymmetry in the opacities of
the two lungs. A pneumothorax
is present on the left with the
collapsed lung clearly visible.
The entire mediastinum has
shifted to the contralateral side
indicating increased pressure.
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Clinical
Unknown.
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Clinical
Unknown.
Pleural Effusion
A meniscus (red) is seen in the
left base indicating a left pleural
effusion. The right base
appears opacified but
characterizing it with only this
portable semi-upright study is
difficult. Calcified hilar lymph
nodes are seen (blue).
Since this patient is immobile,

decubitus studies may be
helpful for further evaluation.
Click to see the lateral

decubitus study.
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Clinical
Unknown.
Pleural Effusion
As the patient is placed in the
decubitus position, the
dependent side can be
evaluated for an effusion, seen
here as the meniscus (blue).
Notice the left effusion seen in
the AP is not visible here.
Decubiti films are only able to
evaluate the dependent side.
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Clinical
Unknown.
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Clinical
Unknown.
Low ET Tube
The appropriately placed
endotracheal tube should
terminate somewhere between
the clavicles and 2 cm above
the carina. Positioning the tip to
rest within the height of the
aortic arch can be used as a
simple landmark. A right
mainstem intubation has
occurred here and the ET tube
should be withdrawn 3 cm. The
left lung is diffusely opacified
which likely represents
resorptive atelectasis. Also
notice that the cuff has been
over inflated (red). This can
cause long-term sequelae, such
as tracheal stenosis. The NG
Tube (yellow) appropriately
splits the carina.
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Clinical
6-year-old boy with cough
Round Pneumonia
The most common lung “mass”
in children is a pseudomass that
is actually a round pneumonia.
A consolidation (yellow) with an

air bronchogram (blue) is
readily apparent. The well-
defined superior margin
represents consolidation along
the minor fissure indicating a
middle lobe process.
A pseudotumor of CHF might

give a similar appearance, but
in the absence of other signs of
failure, and especially in a 6-
year-old, this is unlikely. Still,
this should be considered in the
appropriate patient.
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Clinical
6-year-old boy with cough
Round Pneumonia
The lateral view clearly shows
this to be a right middle lobe
process.
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Clinical
Middle-aged man with recent
pulmonary embolus.
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Clinical
pulmonary embolus.
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Clinical
pulmonary embolus.
Pulmonary Infarct
A rounded opacification (yellow)
is seen in the right lung base
with an absence of air
bronchograms. The right heart
and hemidiaphragm shadows
are well maintained.
Characterizing this mass is
problematic with only this view.
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Clinical
pulmonary embolus.
Pulmonary Infarct
This posterior wall mass
(yellow) is a localized
pulmonary infarction known as a
Hampton’s Hump. It is the
sequela of a pulmonary
embolus where the lung
parenchyma supplied by the
occluded vessel becomes
ischemic and infarcts.
A small pleural effusion (blue) is

also seen.
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Clinical
Unknown.
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Clinical
Unknown.
Emphysema
An impressively large bullous
lesion is present on the left and
at least two more bullae are
seen on the right (red). Pleural
adhesions hold the remaining
portions of lung to the chest wall
and fibrotic changes are seen
throughout the remainder of the
lungs.
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Clinical
11-year-old boy, history
unknown.
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Clinical
11-year-old boy, history
unknown.
Kartagener’s Syndrome
Situs inversus or film hung
backwards? The importance of
markers (yellow) is evident.
Dextrocardia may occur in

isolation or as part of situs
inversus, where the entire
anatomy is reversed (notice the
right-sided gastric bubble).
Kartagener’s Syndrome is a
disease of defective mucosal
cilia that results in a
combination of dextrocardia,
situs inversus, sinusitis and
bronchiectasis. Changes in the
left lower bronchi -- namely
distal bronchi that branch but do
not taper -- are consistent with
early bronchiectasis.
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Clinical
79-year-old woman.
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Clinical
79-year-old woman.
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Clinical
79-year-old woman.
Aortic Aneurysm
A large left mediastinal mass is
seen here in the region of the
left hilum. Notice the left heart
border -- which is in the middle
mediastinum -- is preserved
which suggests that the mass is
in the posterior mediastinum.
More importantly, notice that the
margins of the mass are
contiguous with the descending
aorta.
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Clinical
79-year-old woman.
Aortic Aneurysm
The lateral view confirms a
thoracic aortic aneurysm. This
hopefully illustrates the
necessity of carefully surveying
the contours of the
mediastinum.
Vertebral bodies are

approximately 3 cm in both the
AP and lateral diameters and
can be used to estimate this
aneurysm to be about 4 cm in
size. Risk of rupture increases
significantly at 5 cm.
Click to see this patient three

years later.
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Clinical
Same woman, 3 years later.
Aortic Aneurysm
The aneurysm has greatly
increased in size.
Keep going.
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Clinical
Aortic Aneurysm
This impressive aneurysm is
now in the 6 cm range and has
resulted in tortuosity of the distal
thoracic aorta (red).
Click to see this patient’s

chest CT.
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Clinical
Aortic Aneurysm
The lumen (highly attenuated by
IV contrast) is approximately 4
cm. The outside-to-outside
diameter is about 6 cm. The
hypodense crescentic mass
(yellow ¹) within the wall (blue)
is thrombus formation. The
normal heart is seen here in the
middle of the chest.
Risk of rupture is based on the

outside-to-outside diameter:
<5 cm → 5%
6 cm → 16%
LUMEN
7 cm → 76%
¹
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Clinical
Unknown.
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Clinical
Unknown.
Hair Artifact
These curious bilateral
crescent-shaped opacities
(yellow) occurring in couplets do
not conform to any known
pathologic process. Markings in
the neck (red) resemble
subcutaneous emphysema.
Click to see the repeat study.
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Clinical
Unknown.
Hair Artifact
The study was repeated after
the artifact was realized. The
hair was pulled up out of the
way but is still seen over the
neck. The lucent areas
between strands of hair create
the appearance of subcutan-
eous emphysema. A small left
pleural effusion (versus pleural
thickening) is present (green).
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Clinical
of breath.
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Clinical
of breath.
Pneumocystis carinii
A bilaterally symmetric dis-
seminated miliary (or micro-
nodular) pattern without
adenopathy or effusions is
suggestive of Pneumocystis
carinii pneumonia. Subsequent
broncho-alveolar lavage con-
firmed the diagnosis and HIV
was ultimately diagnosed as
well.
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Clinical
Unknown.
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Clinical
Unknown.
NGT in Both Bronchi

It is indeed a rare achievement
to simultaneously intubate both
mainstem bronchi with a single
NG tube. There should be an
award for this sort of thing.
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Clinical
Middle-aged woman with
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Clinical
Middle-aged woman with

Cardiomegaly in the presence
of cephalization, Kerley’s B
Lines (blue) and loss of
pulmonary artery definition are
consistent with CHF. Evidence
of a prior CABG (green) adds
confidence to this diagnosis and
suggests ischemic cardio-
myopathy is the cause.
When you start to see miniature

skulls (red) hiding in the lung
markings -- (is this an ominous
sign?) -- you know you’ve spent
too much time in the reading
room. Go home.
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Clinical
Unknown.
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Clinical
Unknown.
Here’s a clue...
Something is missing.
Click again to get the answer.
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Clinical
Unknown.
Cleidocranial Dysostosis
Cleidocranial dysostosis is a
congenital malformation of the
clavicles and cranium. In this
case, there is a complete
agenesis of the clavicles, but
this can be variable. Other
bony structures can be affected
as well; note the spina bifida
occulta (blue).
Affected patients have the

interesting ability to approximate
their shoulders anteriorly.
This disorder is obviously

beyond the scope of this review.
It is included simply as an
interesting reminder to always
inspect the bony thorax in your
chest films.
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Clinical
Elderly woman with shortness of
breath.
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Clinical
Elderly woman with shortness of
breath.
Severe rotary scoliosis

This patient’s severe rotary
scoliosis and resultant chest
deformity makes interpretation
difficult. Marked volume loss is
noted bilaterally. Opacification
in the bases bilaterally (yellow)
represents layered pleural
effusions in this semi-upright
portable study. An infiltrate in
the right apex (red) cannot be
excluded.
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Clinical
Unknown.
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Clinical
Unknown.
Pneumoperitoneum
Free air under the diaphragm
(blue) is best appreciated on an
upright chest study.
Causes
Perforated ulcer
Bowel obstruction
Toxic megacolon
Trauma
Surgery
Dialysis
Pneumotosis intestinalis
Female genital tract
(intercourse, douching,
insufflation)
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1-month-old with tachypnea.
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Clinical
RLL Pneumonia
There is a patchy infiltrate in the
right lung base that includes a
focal area that silhouettes the
right hemidiaphragm (green).
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Clinical
RLL Pneumonia
Consolidation along the major
fissure in the right lower lobe is
seen (blue).
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Clinical
Unknown.
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Clinical
Unknown.
Hiatal Hernia
A large mass (red) is seen
behind the heart with an air-fluid
level (blue) which represents a
large hiatal hernia. Sternotomy
wires are seen. The splenic
flexure can be seen under the
left hemidiaphragm. Notice the
semilunar fold (green). This
colonic interposition simulates
free air and can occur under
either hemidiaphragm.

hiatal hernia on an upper GI.
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Clinical
Unknown.
Hiatal Hernia
This upper GI contrast study
nicely demonstrates a hiatal
hernia. A portion of the
stomach (red) protrudes past
the left hemidiaphragm (blue).

hiatal hernia on CT.
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Clinical
Unknown.
Hiatal Hernia
Serial axial images show a
hiatal hernia (yellow) as a
dilated mass in the lung bases
that is continuous with the
esophagus. Oral contrast is
seen within its lumen. This
hiatal hernia was an incidental
finding on this study to evaluate
rectosigmoidal dilatation (red).
A small right pleural effusion
(green) is also seen.
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Clinical
hemoptysis.
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Clinical
hemoptysis.
Bronchogenic Carcinoma
A well-circumscribed mass
measuring approximately 3 cm
x 2 cm is seen in the left mid-
lung in this scout view (plain
films not available). It appears
to be homogeneous and without
calcifications.
Click to see the axial view.
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Clinical
hemoptysis.
The axial view clearly reveals
the well circumscribed mass
mass (red). Solitary pulmonary
nodules present a common --
and often difficult-- diagnostic
challenge for the radiologist. It
is often difficult to exclude
malignancy from a CT scan.
Click to see a PET scan of this

patient.
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Clinical
hemoptysis.
Positron Emission Tomography
(PET) is a promising new
frontier of radiology that helps to
identify malignancy. Positrons
(positive electrons) are labeled
into compounds that have
selective affinities, in this case
oncologic. As the desired
biochemical process occurs,
positrons are released from the
nucleus and travel only a few
millimeters before combining
with an electron which emits
annihilation radiation which can
be seen here (red). Notice that
there is indeed a second
smaller carcinogenic focus.
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Clinical
36-year-old woman, history
unknown.
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Clinical
unknown.
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Clinical
unknown.
Pectus Excavatum
The heart has assumed a
curious shape and the entire
right heart border become
obscured. This is the result of
the heart having been shifted to
the left to accommodate the
malpositioned sternum in a
patient with pectus excavatum
or funnel chest. Commonly, as
is seen here, the right heart
border becomes indistinct which
simulates the silhouette sign.
This condition is occasionally
misdiagnosed as a RML
pneumonia.
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Clinical
unknown.
Pectus Excavatum
The lateral view clarifies the
matter. The sternum is seen to
lie in an inwardly depressed
location and the anterior ribs lie
anterior to it in a manner
consistent with pectus
excavatum. The condition is
usually asymptomatic but has
been associated with
connective tissue disorders
such as Marfan’s syndrome.
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15-year-old with fever & cough.
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Clinical
Pneumatocoele
There is an obvious opacity in
the left mid-lung that silhouettes
the left heart border suggesting
a LUL infiltrate (red). Within the
infiltrate is a thin-walled air-filled
cavity (yellow) known as a
pneumatocoele. They are
classically associated with
staphylococcal pneumonia, as
is the case here. The clinician
should be aware that this
patient is at an increased risk of
pneumothorax.
Interestingly, blunt trauma to the

pediatric chest can create a
pneumatocoele and the
surrounding contused lung
tissue creates an identical
appearance to that seen here.
Click to see a tomogram of

this patient.
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Clinical
Pneumatocoele
Tomography, such as this, is
becoming a dying art in the age
of computed tomography (CT)
and other imaging modalities.
Tomogragms are created by
simultaneously moving both the
x-ray source and the film
cassette in opposite directions
about a fixed point that serves
as an imaginary fulcrum. The
result is an x-ray that focuses
on only one depth of tissue at a
time; in this case, the thin-
walled pneumatocoele.
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Clinical
78-year-old ICU patient.
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Clinical
Pneumonectomy
The right lung field is almost
completely whited out except a
small portion in the paratracheal
region. The mediastinum
appears to have shifted
ipsilaterally; notice the NG tube
in the esophagus (green).
Surgical clips at the hilum
(yellow) and surgical partial rib
excision (blue) are consistent
with a pneumonectomy. A
tracheostomy tube is seen (red).
Notice the layered opacification
in the left base which represents
a large pleural effusion.
Click to see this patient’s CT.
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Clinical
Pneumonectomy
The right chest cavity has been
filled with a loculated fluid
collection. The small amount of
air anteriorly may represent a
persistent pneumothorax versus
a bronchopleural fistula. The
large left pleural effusion is
confirmed.
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Clinical
Acutely dyspneic 37-year-old
man with end-stage HIV, PCP
and possible TB.
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Clinical
and possible TB.
A large left-sided pneumothorax
(green) is seen with pleural
adhesions. A ruptured bulla is
likely the cause. The
mediastinum has shifted
contralaterally. Severe under-
lying parenchymal infiltrates are
seen. A right IJ catheter and
spinal fixation rods are also
seen.
I was called emergently to see
this acutely dyspneic patient
one night while alone as an
intern. Tachypneic (60 bpm)
and hypoxic (60% sats) with
absent breath sounds on the
left, contralateral tracheal shift
and JVD; the diagnosis was
made. A needle thoracotomy
was performed and the patient’s
sats climbed to the mid 80’s.
This film was then attained (as I
quickly read how to place a
chest tube).
Click to see the next study.
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Clinical
and possible TB.
A chest tube was successfully
placed and the pneumothorax
resolved. Notice the media-
stinum has returned to its
normal position. The large left
apical rounded lucency is again
seen and thought to represent a
large bulla. The severe under-
lying parenchymal infiltrates are
again seen and both heart
borders are sillhouetted.
The patient was stabilized and

his sats improved to the mid
90’s. My tachycardia resolved.
The patient’s underlying

infections proved overwhelming,
however, and he died the next
day. A repeat film taken one
hour before death documented
continued resolution of the
pneumothorax.
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Clinical
Unknown.
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Clinical
Unknown.
Mediastinal Mass
Mediastinal masses (red) pose
a challenge that goes well
beyond the scope of this review.
The differential diagnoses are
numerous and include such
entities as lymphoma, germ cell
and mesenchymal tumors,
masses of the thymus, thyroid
and even ectopic parathyroid
and finally tortuous vascular
patterns. Curiously the trachea
has shifted ipsilaterally which is
obviously not consistent with a
mass.
In light of this, a tortuous blood

vessel was suspected and an
angiogram was performed.
Click to see this patient’s digital

subtraction angiogram.
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Clinical
Unknown.
Tortuous Innominate
The tortuosity of the innominate
artery (red) is easily identified
with this digital subtraction
angiogram. Notice also the
common takeoff of the
innominate and left common
carotid (blue) arteries, a normal
variant. Right subclavian
(purple), right common carotid
(green), left subclavian (yellow).
This case was included to

remind the user to evaluate the
mediastinum in every chest film.
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Clinical
Unknown.
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Clinical
Unknown.
Left Horizontal Fissure

A left-sided horizontal fissure
(red) is seen in addition to the
normal right-sided horizontal
fissure (blue) signifying that
each lung as three lobes. This
is considered a normal variant
in the absence of other
anomalies. Rarely, a patient
may also be asplenic and have
a liver that spans both sides of
the upper abdomen; a condition
known as “bilateral right-
sidedness”. The reciprocal is
also possible: bilateral two-
lobed lungs and bilateral
polysplenia which is known as
“bilateral left-sidedness”.
If you made this finding, you

should consider becoming a
radiologist.
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Clinical
19-year-old male asthmatic,
short of breath, cough.
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Clinical
19-year-old male asthmatic,
short of breath, cough.
Asthma
The plain chest film is typically a
poor predictor of the severity of
an asthma exacerbation.
Classic findings include signs of
hyperinflation, such as flattened
diaphragms, narrowed media-
stinum and an enlarged
retrosternal airspace, though
without the classic barrel-
shaped chest seen in COPD.
Also characteristic are
prominent hila, peribronchial
cuffing (green) and tram-
tracking (red). The latter two
represent thickened bronchial
walls seen on end or
longitudinally, respectively.
The usefulness of the study is

primarily to rule out other
disease processes.
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Clinical
COPD Exacerbation
The heart is of normal size and
there are no signs of failure.
Even in the PA projection, there
is evidence of hyperinflation.
Notice the flattened diaphragms
and narrowed mediastinum.
Blunting of the left costo-
vertebral angle may represent a
partially inverted left hemi-
diaphragm or a pleural effusion.
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Clinical
COPD Exacerbation
The lateral projection reveals a
markedly flattened diaphragm
(blue), an enlarged retrosternal
airspace (yellow) and the
classic barrel-shaped chest.
Incidentally, an ectatic and

calcified aorta is seen. Notice
also the small, focal
calcifications over the heart
(red) which likely represent
calcified coronary arteries.
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Clinical
breath.
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Clinical
breath.
RLL Atelectasis
The triangular opacity in the
right lung base represents a
total collapse of the right lower
lobe. Notice the diaphragm is
mostly, though not entirely,
silhouetted (blue) while the right
heart border is maintained. The
smooth upper margin of the RLL
represents a markedly
depressed horizontal fissure
(green), which is characteristic
of RLL atelectasis. The entire
right hemithorax has become
smaller than the left which is an
example of volume loss. And
finally, notice the hyperlucency
of the remaining right lung
(compared to the left). As the
RUL and RML expand to fill the
space left by the atelectatic
RLL, their bronchovascular
components become more
widely spaced and create a
hyperlucent appearance.
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Clinical
29-year-old previously healthy
man, 1 week severe dyspnea,
recent URI.
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Clinical
29-year-old previously healthy
man, 1 week severe dyspnea,
recent URI.
Viral Myocarditis
Prominent interstitial markings
are seen in the presence of
cardiomegaly. In one week’s
time, this young man
decompensated from an active,
healthy man to one who
became dyspneic just tying his
shoes. This immediately
followed an upper respiratory
infection and he returned to his
normal state of health within a
month of this film.
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Clinical
Post-thoracotomy patient with
incorrect instrument count.
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Clinical
Oh, Crap.
Foreign Body
Yes, this is real. The surgeon
left a foot-long instrument in this
patient’s chest.
Aside from the forceps,

however, there are several
other findings. Remember, the
most difficult finding in any
study is the second one.
Click again for the additional

findings.
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Clinical
Additional Findings
The diffuse opacification of the
right lung likely represents a
hemothorax versus effusion.
The ET Tube (yellow)
terminates in the proximal to
mid trachea. An NG Tube (red)
appropriately splits the carina
(green). A right IJ swan
catheter (purple) terminates in
the right pulmonary artery. A
chest tube (blue), inserted
through the incision,
appropriately has its side port
(blue arrowhead) within the
chest cavity. A ball-and-valve
artificial mitral valve (green
arrowheads) is seen [compare
its shape to the metal
sternotomy wires]. A
mediastinal drain is present
(purple arrowheads). The
identity of the linear wire- or
needle-like structures whose
shadows are projected over the
hemidiaphragms bilaterally is
undetermined. Are these inside
or outside the chest? Clinical
correlation is needed.
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Complete!
Congratulations, you’ve completed the chest section. Hopefully you are starting to feel
comfortable recognizing the common patterns seen in heart failure, pneumonia and, of course,
the normal chest. Don’t be fooled by the name “plain film” because there is nothing plain about
them. In fact, most radiologists consider reading plain films of the chest to be one of the most
difficult imaging tasks. Findings can be extremely subtle and missing a cancer, for example,
can be devastating. Your goal as a clinician should be to (1) not miss anything that will kill the
patient in the next few hours (e.g.- pneumothorax) and to (2) recognize common diagnoses
that need prompt treatment (e.g.- failure or pneumonia).
You should also know a common mistake made by -- quite frankly -- lazy clinicians so you can
avoid it. All too commonly, the only clinical information the radiologist is given for a chest film
is “SOB” (shortness of breath). It is much better for your patient if you will take a few seconds
to specify, for example, “tachypnea, productive cough, fever” when, in fact, true shortness of
breath is usually not present. You must also insist that clerks enter the information you give.
Failure to do so constitutes insurance or Medicare fraud. More importantly -- and this applies
to all studies -- if you expect the radiologist to give you a diagnosis, then you must give them
the information that will allow them to do so. It’s been my observation that the clinicians who
whine most about radiologists being too vague are the ones who don’t give adequate clinical
information in their orders. Garbage in, garbage out.
Return Home
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Clinical
Left thigh pain.
We’ll start slowly. Look closely.

Can you find the fracture?
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Clinical
Left thigh pain.
We’ll start slowly. Look closely.

Can you find the fracture?
Femoral Fracture
Complete oblique fracture of the
femoral mid-shaft with medial
displacement and slight varus
angulation of the distal
fragment.
(They won’t all be this easy.)
Varus - toward the midline
Valgus - away from the midline
DUH
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Clinical
Hand pain.
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Clinical
Hand pain.
Multiple Fractures
A comminuted fracture of the
second proximal phalanx (red)
is easily visible, but don’t miss
the other fractures, particularly
an intra-articular fracture that
will have severe sequelae if
missed. They are: a
comminuted intra-articular frac-
ture of the first IP joint (yellow),
a medial chip fracture of the
distal first metacarpal that is
likely intra-aticular (purple) and
comminuted fractures of the
second middle phalanx (green)
and third metacarpal (blue).
This case is included to remind

the user that the most difficult
fracture to see is the second
one. Stay vigilant.
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Clinical
Leg pain.
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Clinical
Leg pain.
“One view is no view”

No radiology atlas would be
complete without emphasizing
the importance of multiple
views. This dramatic example
illustrates the concept quite
well.
The oblique view (right) shows

two impressive spiral fractures
of the distal tibia. Surprisingly
however, little evidence exists
on the AP view of these
minimally displaced fractures
except a small periosteal
elevation (green).
In orthopedic trauma, a second

view -- 90 degrees from the first
-- is a minimal requirement.
Often a third oblique view is
helpful.
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Clinical
Wrist pain. Swelling prevented
removal of this woman’s
bracelet initially and she refused
having it cut. One week later
pain had not resolved but
decreased swelling allowed
partial removal of the bracelet.
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Clinical
Wrist pain. Swelling prevented
removal of this woman’s
bracelet initially and she refused
having it cut. One week later
pain had not resolved but
decreased swelling allowed
partial removal of the bracelet.
Distal Radial Fracture

A fracture of the distal radius is
seen (red). It is likely a Colle’s
fracture, but without the lateral
view, a Smith’s fracture could
also give this appearance..
The importance of exposing the

patient should be obvious.
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Clinical
Hand pain.
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Clinical
Hand pain.
No Fracture Seen
No obvious fractures,
dislocations or radiopaque
foreign bodies are seen in this
skeletally immature hand.
However, this patient continued

to experience pain.
Parenthetically, the astute

clinician will take the few extra
seconds to specify where
exactly the patient is tender.
Otherwise small fractures
become a needle in a haystack.
Click to see a follow up study

done three weeks later.
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Clinical
Same patient, 3 weeks later.
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Clinical
Same patient, 3 weeks later.
Metacarpal Fracture
An oblique fracture is seen in
the base of the third metacarpal.
It is not uncommon for occult

fractures to escape radiographic
detection on the initial exam. It
is therefore important to perform
follow up studies when clinical
suspicion is high. A CT can
also be useful.
Go back now and re-examine

the initial study.
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Clearing The C-Spine

Evaluation of the traumatic
cervical spine requires a
systematic approach. The
normal study consists of seven
films: lateral, AP, odontoid, right
oblique, left oblique, flexion and
extension. Dens
Lateral View
Step 1
Confirm that the study includes
all 7 cervical vertebrae including C2
C2
the C7-T1 junction. Lower
cervical fractures & dislocations
are commonly missed because C3
C3
of inadequate studies.
Step 2
Assess the prevertebral tissue.
The retropharyngeal space C4
[anterior to C3] should be 7 mm
or less (blue); the retrotracheal
space [anterior to C6], 22 mm or
C5
C5
less (yellow).
Step 3
Examine the anterior spinal line
(red), posterior spinal line C6
C6
(yellow) and spinolaminal line
(green) for contiguity.
C7
W More
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Step 4
Examine the vertebral bodies
for intact cortical margins and
preserved body height.
Step 5
Ensure the spinous processes
are intact. Dens
Step 6
Examine the disk spaces for
narrowing or widening.
Step 7 C2
C2
Confirm that the predental
space is 3 mm or less (red) and
that the clivus points to the
dens. C3
C3
Step 8
Assess the curvature of the
neck. Here, a loss of normal C4
cervical lordosis is demon-
strated. This could suggest
chronic changes or muscle
spasm, however since this neck C5
C5
is mine, I know neither is
present and this is simply
positional. Confirmation is seen
in the flexion/extension views. C6
C6
C7
V Back
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AP View
Step 1
Re-evaluate the vertebral C2
C2
bodies for cortical contiguity and
maintained height.
Step 2
Ensure the lateral processes
are intact. C3
C3
Step 3
Assess the disk spaces again
for abnormal narrowing or
widening.
C4
C4
Step 4
Confirm smooth margins of the
uncovertebral joints (red).
C5
C5
C6
C6
C7
T1
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Odontoid View
Step 1
Examine the odontoid process
for cortical disruptions.
Step 2
Ensure the lateral masses of C1
and C2 are aligned (red).
Widening of C1 on C2 suggests
a burst fracture of C1.
Dens
C1
C1
C1
C1
C2
C2 C2
C2
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Left Oblique View
Step 1
Re-evaluate the vertebral
bodies for cortical contiguity and
maintained height.
Step 2
Assess the neural foramina
(blue), pedicles and facet joints
(red) for any evidence of
disruption. The contralateral
pedicles (green) and facet joints
(purple) are also seen.
A contralateral oblique
examination is also performed
(not included here).
Pedicle
Pedicle
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Flexion/Extension Views
It should be stressed that flexion
and extension views are only
attained if the patient has
cleared the preceding exams
and is relatively pain free and
able to flex and extend on their
own. Never do it for them and
never flex & extend an altered
mental status or intoxicated
patient. These studies are
helpful, but flexing or extending
a fractured neck would be
considered poor form.
Step 1
Re-evaluate the spinal lines.
Disruption of these would
suggest ligamentous injury.
Step 2
Assess the spinous processes
to rule out spondylolysis.
Notice the loss of cervical

lordosis that was seen on the
lateral view is now resolved and
therefore not worrisome.
Flexion Extension
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Clinical
Neck pain.
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Clinical
Neck pain.
Hangman’s Fracture
Disruption of the C2 neural arch
is known as a Hangman’s
fracture (red). Corresponding
findings: prevertebral soft tissue
swelling (blue), interrupted
anterior and posterior (green)
spinal lines, and wide-spaced
C1-C2 spinous processes
(yellow).
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Clinical
Neck pain.
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Clinical
Neck pain.
Odontoid Fracture
Marked cortical disruption of the
odontoid process is seen (red)
with prevertebral tissue swelling
(blue). The linear lucency
(green) on C4 may be better
characterized with CT. Loss of
normal cervical lordosis is
noted.
Failure to remove this patient’s

earrings was a gross oversight
could have easily hidden a life-
threatening or disabling fracture.
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Clinical
Neck pain.
C2 Fracture
CT shows the extension of the
fracture through the lateral
masses of C2 bilaterally.
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Clinical
Neck pain.
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Clinical
Neck pain.
Locked Facet
The inferior articular facet of C2
(yellow) is locked anterior to the
superior articular facet of C3
(red). No fracture is identified.
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Clinical
Neck pain.
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Clinical
Neck pain.
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Clinical
Neck pain.
C4 Spondylolysis
There is a grade I
anterolisthesis of C4 on C5 that
is suspicious for spondylolysis
based on the marked disruption
in the posterior spinal line
(green) and spinolaminal line
(yellow). There is a loss of
normal cervical lordosis. Disc
space narrowing of C5-6 and
C6-7 (blue) with anterior
spondylophyte formation (red)
appear to be chronic changes.
Anterolisthesis - anterior
dislocation from any cause
Retrolisthesis - posterior
Spondylolysis - pars defect
Spondylolisthesis - anterolis-
thesis secondary to spondylo-
lysis
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Clinical
Neck pain.
C4 Spondylolysis
The flexion view clearly shows
the separation of the C4 inferior
facet process from its body.
This is a pars defect.
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Clinical
Neck pain, odontoid view only.
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Clinical
Neck pain, odontoid view only.
Jefferson Fracture
Axial loading of the c-spine
most commonly occurs by
striking the top of one’s head on
the dashboard or windshield
during an MVA. This can result
in a burst of C1 which is known
as a Jefferson fracture.
The only plain film evidence is

the subtle widening of the lateral
masses of C1 (blue) on C2
(green). Though a fracture
cannot be seen, the step-off
(red) created by the widened C1
is very worrisome. A fracture
must be assumed until a CT can
be attained.
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Clinical
Neck pain.
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Clinical
Neck pain.
Odontoid Fracture
The extension view shows a
compete fracture of the
odontoid.
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Clinical
Neck pain.
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Clinical
Neck pain.
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Clinical
Neck pain.
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Clinical
Neck pain.
Odontoid Fracture
The lateral view shows no
obvious fracture. The pre-
vertebral soft tissues are within
normal limits as are the spinal
lines. C5-6 disc space
narrowing (blue) with anterior
spondylophyte formation
(yellow) is chronic. Loss of
normal cervical lordosis could
be chronic or acutely secondary
to muscle spasm. Although a
subtle finding, the loss of the
normal Harris Ring (green) may
suggest a C1 or C2 fracture.
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Clinical
Neck pain.
Odontoid Fracture
The odontoid view shows no
fracture. The dens (green) is
intact and the lateral masses of
C1 and C2 show no step-off
(blue).
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Clinical
Neck pain.
Odontoid Fracture
The flexion view is highly
suspicious for an odontoid
fracture. Notice the posterior
aspect of the dens has lost its
normal alignment (red). A CT is
needed for further evaluation.
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Clinical
Neck pain.
Odontoid Fracture
CT with sagittal reconstruction
confirms a comminuted fracture
of the odontoid process.
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Clinical
MVA.
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Clinical
MVA.
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Clinical
MVA.
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Clinical
MVA.
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Clinical
MVA.
Perched Facet
The inferior articular facet of C4
(green) is “perched” on the
superior articular facet of C5
(yellow). This has caused
marked disruption of the
posterior spinal line (blue) with a
50% anterolisthesis of C4 on C5
(grade II to III) which makes this
an unstable injury and severe
neurologic sequalae are likely.
This is likely bilateral since a
unilateral perched facet would
cause rotation of the neck (and
less anterolisthesis). An
absence of prevertebral soft
tissue swelling makes a fracture
less likely. Notice also the
grade I anterolisthesis of C3 on
C4.
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Clinical
MVA.
Perched Facet
The lucent line (red) seen in C6
might be mistaken for a fracture.
Notice, however, the well
corticated margins which
excludes an acute process.
This likely represents spina
bifida occulta.
The small, left-sided step-off of

C1 on C2 is a normal finding
with slight rotation of the neck
(blue). If this was a bilateral
finding, a Jefferson fracture
would be suspected.
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Clinical
MVA.
Perched Facet
The left oblique view shows
marked disruption of the neural
foramina.
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Clinical
MVA.
Perched Facet
The right oblique view shows
marked disruption of the neural
foramina which confirms that
this is bilateral.
This clearly is a neurosurgical

emergency as the cord is likely
severely compressed and the
respective nerve roots are at
risk.
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Clinical
Shoulder pain.
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Clinical
Shoulder pain.
Shoulder Dislocation
An anterior shoulder dislocation
is easily appreciated on the Y-
view. The humeral head (red)
should normally be centered
over the glenoid process (blue).
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Clinical
Shoulder pain.
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Clinical
Shoulder pain.
Hill-Sachs Deformity
The Hill-Sachs deformity is a
common complication of an
anterior shoulder dislocation;
notice the humeral head is
dislocated anterior to the
glenoid. The posterosuperior
aspect of the humeral head
impacts on the inferior portion of
the glenoid causing the fracture
deformity (blue).
The presence of Hill-Sachs

fracture implies a greater likeli-
hood for repeated dislocations.
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Clinical
Shoulder pain.
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Clinical
Shoulder pain.
Osteochondroma
The epiphysis (blue) is nearly
closed and might be mistaken
for a fracture. Notice the
posterior aspect of the
epiphyseal line is projected
inferior to the anterior aspect,
but they are contiguous.
The thumb-like projection seen

on the medial aspect of the
humerus (red) represents an
osteochondroma which is a
benign bony outgrowth found
primarily at the shoulder or knee
of young people. The calcified
cartilaginous cap has a 1 to 2
percent per year probability of
converting to a malignant
chondrosarcoma and should
therefore be followed radio-
graphically.
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Clinical
Shoulder pain.
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Clinical
Shoulder pain.
Scapular Fracture
A complete fracture of the
scapula is present (red). This is
usually the result of a direct
impact from a fall or MVA. If the
closing epiphysis (green) is
unclear, a contralateral exam
may help clarify the matter.
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Clinical
Arm pain.
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Clinical
Arm pain.
Osteomyelitis
The periosteal elevation seen
along the humeral shaft (red) is
consistent with osteomyelitis in
this patient with overlying
cellulitis. The open epiphysis
(blue) should not be mistaken
for a fracture.
Periosteal Reaction DDx

Infection
Inflammation
Trauma
Tumor
Subperiosteal hemorrhage
Normal Variant
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Clinical
Elbow pain.
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Clinical
Elbow pain.
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Clinical
Elbow pain.
Elbow Fat Pad Sign

Hemarthrosis in the setting of
trauma -- even in the absence
of definitive findings -- is
worrisome for fracture. The
posterior fat pad (green) is
normally not visible without
being displaced by something
such as hemarthrosis or
effusion. The anterior fat pad Anterior
(red) normally is visible but is Fat Pad
seen here to be displaced by
the distended joint capsule. Posterior
This is known as the Sail Sign. Fat Pad
In adults, a radial head fracture

is most likely; in children, a
supracondylar fracture.
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Clinical
Elbow pain.
Radial Head Fracture

A tiny cortical disruption (blue)
and lucent fracture line (red) is
seen in the radial head.
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Clinical
Wrist pain.
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Clinical
Wrist pain.
Colles’ Fracture
A complete fracture of the distal
radius with dorsal angulation of
the distal fragment is known as
a Colles’ fracture. Notice the
overriding nature of the distal
fragment. There also appears
to be a distal ulnar fracture.
This is a common result of

falling forward on an
outstretched arm.
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Clinical
Wrist pain.
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Clinical
Wrist pain.
Distal Radial Fracture

This fracture is similar to a
Colles’ fracture except the distal
fragment angulation is volar
rather than dorsal. The
mechanism is a backwards fall
on an outstretched hand. This
fracture is complicated by a
coronal component that is intra-
articular, which makes this a
Reverse Barton’s Fracture.
Medicine is replete with dead

doctor eponyms and fractures of
the wrist is no exception.
Knowing these names is far less
important than being able to
describe them and, in particular,
recognizing an intra-articular
component.
Colles’ - dorsal angulation

Smith’s - volar angulation
Barton’s - Colles’ with intra-
articular component
Reverse Barton’s - Smith’s
with intra-articular component
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Clinical
Wrist pain.
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Clinical
Wrist pain.
Salter Fracture
Pediatric fractures commonly
involve the physis, which is
known as a Salter fracture. A
fracture through the metaphysis
(as seen here) is the most
common type. Notice the
convexity opposite the fracture
which may represent a buckling
(or torus) component.
Salter Classification
1 Slipped epiphysis
2 Metaphysis
3 Epiphysis
4 Metaphysis & Epiphysis
5 Crushed physis
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Clinical
Wrist pain.
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Clinical
Wrist pain.
Galeazzi Fracture
A fracture of the distal radius
with a concomitant dislocation
of the distal ulna is termed a
Galeazzi fracture.
The comminuted oblique

fracture of the distal radius with
a dorsally angulated and
partially overriding distal
fragment would otherwise be
consistent with a Colles’ fracture
in the absence of the ulnar
dislocation (blue). This
indicates a complete disruption
of the radioulnar ligaments. The
avulsed bony fragment from the
medial aspect of the distal radial
metaphysis is the result of
extreme tension placed on it by
the interosseous membrane.
An ulnar styloid fracture (yellow)
is also present.
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Clinical
Wrist pain.
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Clinical
Wrist pain.
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Clinical
Wrist pain.
Lunate Dislocation
The lunate has assumed a
triangular shape (green) -- as
opposed to its normal trapezoid
appearance -- which should
raise suspicion of a lunate /
perilunate dislocation. Disrup-
tion of the normal carpal arcs
also indicates a carpal disloca-
tion.
The lateral view should be

diagnostic.
Lunate / perilunate dislocations

are commonly associated with Lunate
scaphoid, capitate, radial
styloid, and triquetral fractures
and an intensive search should
ensue.
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Clinical
Wrist pain.
Lunate Dislocation
Lunate / Perilunate dislocations
are not always clearly
distinguishable as various
degrees of each are often
present. The radiolunocapitate
line (blue) is obviously
disrupted. The lunocapitate
articulation (green) is disrupted
as well.
In this patient, the lunate is

entirely outside the extension of Capitate
the radial line making this a Lunate
lunate dislocation. Still, the
capitate is subluxed dorsally.
Compare to:
Perilunate Dislocation
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Clinical
Wrist pain.
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Clinical
Wrist pain.
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Clinical
Wrist pain.
The lunate has assumed a
triangular shape (red) -- as
opposed to its normal trapezoid
appearance -- which should
raise suspicion of a lunate /
perilunate dislocation.
Disruption of the normal carpal
arcs also indicates some form of
carpal dislocation.
The lateral view should be

diagnostic.
Lunate / perilunate dislocations Lunate

are commonly associated with
scaphoid, capitate, radial
styloid, and triquetral fractures
and an intensive search should
ensue. However, no fractures
are seen.
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Clinical
Wrist pain.
Lunate / Perilunate dislocations
are not always clearly
distinguishable as various
degrees of each are often
present. The radiolunocapitate
line (blue) is obviously
disrupted. The lunocapitate
articulation (green) is disrupted
as well.
Capitate
In this patient, the lunate is
partially within the extension of Lunate
the radial line, this is considered
a perilunate dislocation. Still the
lunate is subluxed volarly.
Compare to:
Lunate Dislocation
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Clinical
Wrist pain.
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Clinical
Wrist pain.
Scapholunate Dislocation
Disruption of the scapholunate
ligament is indicated by a 4mm
or greater separation between
the scaphoid and lunate bones
(blue) which is known as the
David Letterman Sign. This
creates a rotary subluxation of
the scaphoid as evidenced by
its altered shape. A small
fracture is also seen in the
lateral portion of the lunate
(red).
The previous generation of

radiologists called this the
“Terry Thomas Sign” in honor of
some gap-toothed English
actor. But, come on, Terry
Thomas? What has he done for
us lately?
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Clinical
Wrist pain.
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Clinical
Wrist pain.
Scaphoid Fracture
A comminuted fracture is seen
through the waist of the
scaphoid.
Avascular necrosis is an un-

fortunately common sequela of
a missed scaphoid fracture so
the examiner must be ever
vigilant. This is a common frac-
ture from falling on an
outstretched arm. Typically,
radiographic examination of the
wrist includes three views. If a
patient has tenderness in the
anatomic snuffbox, however,
you should order an additional
scaphoid view which is the most
sensitive for scaphoid fractures.
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Clinical
Wrist pain.
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Clinical
Wrist pain.
Avascular Necrosis
Avascular necrosis is the
dreaded sequela of a scaphoid
fracture. Sclerosis of the
proximal scaphoid pole (red) is
indicative of AVN. Recall, the
blood supply to the scaphoid
enters its midsection and a
fracture to the waist disrupts the
vascular supply to the proximal
pole leaving it to die. Notice the
linear opacity (yellow) of the
waist suggesting an old fracture.
Focal sclerosis of the opposing
radius indicates chronic
degeneration. Notice also the
diffuse osteopenia of the entire
wrist.
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Clinical
Hand pain.
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Clinical
Hand pain.
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Clinical
Hand pain.
Boxer’s Fracture
A fracture to the distal 4th or 5th
metacarpal with volar angulation
of the distal fragment results
from striking an object with a
clenched fist.
This tends to be a fracture of

young men.
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Clinical
Hand pain.
Boxer’s Fracture
The oblique view shows an
oblique fracture of the distal 5th
metacarpal metaphasis with
volar angulation of the distal
fragment.
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Clinical
Thumb pain.
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Clinical
Thumb pain.
Torus Fracture
A small cortical buckling is seen
on the lateral aspect of the base
of the proximal phalanx of the
thumb that is consistent with a
torus fracture. Notice the open
epiphyses.
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Clinical
Low back pain.
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Clinical
Low back pain.
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Clinical
Low back pain.
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Clinical
Low back pain.
Spondylolysis
Disruption of the pars
interarticularis (red) is known as
a pars defect or spondylolysis.
Most believe this to be the result
of repeated subacute trauma as
it is most commonly seen in
young athletes. Other explan-
ations include a congenital
malformation or even a fracture
caused by repeated falls (and
axial loading) as a toddler
learns to walk. It is usually only
repaired when symptomatic.
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Clinical
Low back pain.
Spondylolysis
A coned-in view better shows
the L5 spondylolysis (red) as
well as a grade 1
spondylolisthesis of L5 on S1
(blue).
A spondylolisthesis is an
anterior dislocation of a
vertebral body secondary to a
spondylolysis causing an offset
appearance on the lateral view.
It is graded by degree of
subluxation, with one grade for
each 25% of anterolisthesis.
Recall
Anterolisthesis - anterior
Retrolisthesis - posterior
Spondylolysis - pars defect
Spondylolisthesis - anterolis-
thesis secondary to spondylo-
lysis
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Low back pain.
Spondylolysis
The oblique projection shows
the classic “Scottie Dog”
(yellow).
Ear - superior articular facet
Foot - inferior articular facet
Nose - transverse process
Eye - pedicle
Neck - pars interarticularis
A “broken neck” of the Scottie

dog or a collar around the dog’s
neck represents a pars defect
(red).
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Clinical
Hip pain.
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Clinical
Hip pain.
Acetabular Fracture
A burst fracture of the left
acetabulum with a nondisplaced
femoral head.
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Clinical
Left hip pain.
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Clinical
Left hip pain.
Ischium Avulsion
Avulsion injuries of the pelvis
are common, especially in
athletes. Common sites include
the anterior superior iliac spine
(sartorious), the anterior inferior
iliac spine (rectus muscles),
pubis (adductors), and the
ischial tuberosity (hamstrings).
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Clinical
Left hip pain.
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Clinical
Left hip pain.
Pubic Rami Fractures

Fractures of the superior and
inferior pubic rami are seen.
These are common, stable
fractures and usually only need
pain management.
Patients who complain of hip

pain after a fall often have
fractured their pubic rami rather
than their hip. It is important to
palpate the pubis in anyone
complaining of hip pain. If the
clinician were to only order hip
films, these fractures may be
missed.
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Clinical
Left hip pain.
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Clinical
Left hip pain.
Avascular Necrosis
Stage IV avascular necrosis
includes articular collapse; in
this case, flattening of the left
femoral head. Notice the
generalized left-sided osteo-
penia and asymmetry of the
pelvis.
Two common causes of AVN

are trauma and steroid therapy.
A mnemonic of etiologies is
‘PLASTIC RAGS’.
Pancreatitis
Lupus
Alcoholism
Steroids
Trauma
Idiopathic or Infection
Caisson’s Disease
Radiation or Rheumatism
Amyloidosis
Gaucher’s Disease
Sickle Cell
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Clinical
13-year-old, hip & knee pain.
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Clinical
13-year-old, hip & knee pain.
Slipped Capital Epiphysis

A slipped capital femoral
epiphysis (SCFE) is an
occasional cause of hip and/or
knee pain in obese -- notice the
air trapped in the skin fold
(green) -- adolescents.
The next case illustrates why

you don’t want to miss it.
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Clinical
Hip pain.
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Clinical
Hip pain.
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Clinical
Hip pain.
SCFE Sequelae
This skeletally mature
adolescent exhibits the
unfortunate long-term sequelae
of a missed slipped capital
femoral epiphysis earlier in life.
There are marked deformities of
the femoral head and neck and
advanced degenerative arthritis.
Notice the generalized left-sided
osteopenia as well as a
complete asymmetry of the
pelvis. A subchondral cyst (red)
and large osteophyte (blue) is
seen about the superior
acetabulum (red).
Interpretation of this case is

obviously beyond the scope of
the non-radiologist. It is
included here as a reminder of
the importance of diagnosing
SCFE when it first occurs.
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Clinical
Hip pain.
SCFE Sequelae
The frog-leg view shows the full
extent of the femoral head
deformity as well as severe
osteopenia.
A positive Throckmorton sign is

also noted.
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Clinical
Hip pain.
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Clinical
Hip pain.
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Clinical
Hip pain.
Hip Fracture
An oblique fracture through the
lesser trochanter of the right hip
is seen (red). The irregularity of
the left pubic rami is likely due
to rotation. A fracture should be
excluded either by another view
or by physical exam.
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Clinical
Hip pain.
Hip Fracture
The AP view of the right hip
clearly shows the oblique
fracture through the lesser
trochanter. This is a sub-
trochanteric fracture. One
would expect this patient to
have a foreshortened limb prior
to repair. This patient is also at
risk of life-threatening
hemorrhage.
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Clinical
Knee pain.
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Clinical
Knee pain.
NOF Pathologic Fracture

Nonossifying fibromas (NOF)
are common benign cortical-
based lesions in young patients
(note the open epiphyses)
commonly found in the
metaphyses of long bones. The
thin, sclerotic border (blue) is
typical and indicates the long-
standing nature of the defect
which has allowed adjacent
bone to remodel accordingly.
An absence of periosteal
reaction also indicates a benign
process.
NOF’s regress with age and are

usually resolved by the third
decade of life.
While NOF’s are histologically

benign, they can weaken bone
and therefore predispose the
bone to fractures. A spiral-type
fracture line (red) is seen here.
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Clinical
Knee pain in an active
adolescent, no known trauma.
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Clinical
Osteochondritis Dissecans
Osteochondritis dissecans is a
form of avascular necrosis seen
in adolescents. Most believe it
to be secondary to repeated
subacute trauma, though it may
be idiopathic. It is most
commonly seen in the medial
condyle of the knee, but also the
elbow capitellum and the ankle
talus. When found, contra-
lateral studies are indicated
because 25% of cases are
bilateral.
This AP view reveals no

abnormalities.
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Clinical
The lateral view reveals a
comminuted cortical disruption
of one of the femoral condyles,
though this view cannot
distinguish medial from lateral.
A tunnel view might help better

characterize the lesion.
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Clinical
The tunnel view in this patient
confirms the diagnosis. Notice
the sclerotic margins of the
lesion which confirm its chronic
nature.
Occasionally, osteochondritic
fragments, known as “joint
mice” escape into the the joint
space and worsen the
symptoms.
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Clinical
Knee pain in an active teenager,
no known trauma, palpable
mass.
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Clinical
mass.
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Clinical
mass.
Osteosarcoma
Osteosarcoma is the most
common malignant primary
bone tumor. It typically occurs
at the end of long bones in
young people.
A mixed sclerotic and lytic

lesion with ill-defined borders is
seen in the distal femoral
metaphysis (red). A small
periosteal elevation (green) is
present.
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Clinical
mass.
Osteosarcoma
The mixed sclerotic and lytic
lesion with ill-defined borders is
again seen on the lateral
projection.
Click to see the MRI.
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Clinical
mass.
Osteosarcoma
The destructive nature of an
osteosarcoma can better be
appreciated on MR images as
well as the classic mixed high-
and low-signal areas.
This young patient received a

limb-salvaging excision and, at
the time of this writing -- two
years later -- continued to be
active and healthy.
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Clinical
Knee pain.
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Clinical
Knee pain.
Tibial Plateau Fracture

Lipohemarthrosis of the knee is
best identified on the cross-
fat
table lateral as a fat-fluid level.
Marrow fat and blood distend
fluid
the joint capsule.
Hemarthrosis in the setting of

trauma is highly suggestive of
fracture. Indeed, a large bony
fragment is seen fractured from
the proximal tibia (red).
Incidentally, a calcified popliteal

artery (blue) and anterior
(yellow) and posterior (green)
tibial arteries are seen.
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Clinical
Knee pain.
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Clinical
Knee pain.
Nonossifying Fibroma
This skeletally mature individual
has a small NOF of the proximal
tibial metaphysis (red). Notice
the characteristic sclerotic rim.
Some radiologists call an NOF
that is smaller than 2 cm a
“fibrous cortical defect”, though
histologically they are identical.
No fractures or dislocations are

seen. This NOF is an incidental
finding.
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Clinical
Ankle pain.
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Clinical
Ankle pain.
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Clinical
Ankle pain.
Maisonneuve Fracture
Fracture lines are clearly seen
in both the tibia and fibula.
From this projection, the fibular
fracture appears oblique while
the tibial fracture appears to be
spiral-type.
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Clinical
Ankle pain.
Maisonneuve Fracture
The tibial fracture is now clearly
seen to be a complete oblique
fracture with minimal medial
displacement and angulation of
the distal fragment.
A Maisonneuve [/may-sahn’-
new’] fracture is a fibular head
fracture associated with ankle
injury. This illustrates the
important concept of the bony
ring. A fracture at any point on
a bony ring (in this case the
tibia/fibula ring) is likely to be
associated with another fracture
or dislocation on the ring. That
is why ankle injuries are often
associated with fibular head
fractures. Other bony rings
include the pelvis, vertebral
arches, radius/ulna ring, etc.
Clinical Pearl: Palpate the

fibular head with any ankle
injury. These fractures are
missed because the incorrect
study is ordered.
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Clinical
Leg pain after being tackled.
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Clinical
Leg pain after being tackled.
Point of Impact
NOF Pathologic Fracture

A nonossifying fibroma is
present in the distal tibial
metaphysis. Spiral fracture
lines are seen from the point of
the tackle impact to the NOF.
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Clinical
Ankle pain.
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Clinical
Ankle pain.
Trimalleolar Fracture
Fractures can be seen in the
medial malleolus (red), lateral
malleolus (green) and posterior
malleolus or posterior aspect of
the distal tibia (blue).
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Clinical
Foot pain.
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Clinical
Foot pain.
Calcaneal Fracture
A large comminuted calcaneal
fracture is present despite a
normal Böhler’s Angle.
Calcaneal fractures often cause
a collapse or flattening that is
indicated by a Böhler’s Angle of Böhler’s
Böhler’s
less than 20 degrees.
Angle
Angle
Calcaneal fractures are often
associated with contralateral
calcaneal fractures and
vertebral fractures.
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Clinical
Foot pain.
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Clinical
Foot pain.
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Clinical
Foot pain.
Calcaneal Stress Fracture

The small area of increased
density is a subtle finding that is
suspicious for a calcaneal
stress fracture. If there is any
question, an MRI or bone scan
may prove useful.
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Clinical
Foot pain.

The small area of increased
density is a subtle finding that is
suspicious for a calcaneal
stress fracture. If there is any
question, an MRI or bone scan
may prove useful.
Click to see this patient’s

bone scan.
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Clinical
Foot pain.

A radionuclide bone scan shows
a “hot spot” in the region
consistent with the suspicious
plain film finding. The diagnosis
can be confidently made.
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Clinical
Ankle & foot pain.
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Clinical
Ankle & foot pain.
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Clinical
Ankle & foot pain.
Jones Fracture
A transverse fracture at the
base of the fifth metatarsal is
known as a Jones or Dancer’s
fracture. It is the result of
repeated impaction and is most
commonly seen in dancers and
basketball players. Healing is
slow and often requires internal
fixation.
The Jones fracture is not an

avulsion fracture though it is
commonly confused as one. A
true avulsion (from the
peroneus brevis tendon) is more
proximal and is usually the
result of an inversion injury.
Important Clinical Pearl: Both

the Jones and the avulsion
fractures can present with ankle
(rather than foot) pain. The
clinician mistakenly orders only
an ankle study and the fracture
is missed. You need to palpate
the 5th metatarsal in every
ankle pain patient and search
for these fractures.
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Clinical
Ankle & foot pain.
Jones Fracture
A transverse fracture at the
base of the fifth metatarsal is
known as a Jones or Dancer’s
fracture. It is the result of
repeated impaction and is most
commonly seen in dancers and
basketball players. Healing is
slow and often requires internal
fixation.
The Jones fracture is not an

avulsion fracture though it is
commonly confused as one. A
true avulsion (from the
peroneus brevis tendon) is more
proximal and is usually the
result of an inversion injury.
Important Clinical Pearl: Both

the Jones and the avulsion
fractures can present with ankle
(rather than foot) pain. The
clinician mistakenly orders only
an ankle study and the fracture
is missed. You need to palpate
the 5th metatarsal in every
ankle pain patient and search
for these fractures.
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Complete!
Congratulations, you’ve completed the orthopedic section. Hopefully you are starting to feel
comfortable identifying fractures and their suggestive findings. Some simple rules can be
helpful:
1. If you are clinically suspicious of a fracture but cannot see it radiographically, treat it as
though it is fractured: splint it and have the patient follow up. This is true even if the radiologist
does not see the fracture (recall, not all fractures can be seen on the first exam).
2. When ordering an exam, specify the exact location of the patient’s tenderness (i.e. - “base of
the 5th metatarsal” is much better than “foot pain”). In fact, if you cannot specify the exact
location of the pain, you either did not do an adequate physical exam or the patient does not
have a fracture (or both).
3. If you are uncertain, consider a fracture to be unstable, especially if it involves the c-spine or
a joint.
4. Equivocal findings in the c-spine deserve a CT exam.
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ABDOMEN
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Bowel Obstruction
Multiple loops of distended small
bowel have assumed the classic
“stack of coins” configuration. Gas
is seen in the ascending colon but
not the transverse or descending.
This suggests a colonic obstruction
A partial small bowel obstruction
(SBO) in which the colonic gas has
not yet cleared could give a similar
appearance.
A calcified gallstone with central

lucency (blue) is seen in the RUQ.
Surgery revealed an obstructive
ascending colon cancer and an
intact gallbladder. In light of this,
the numerous round opacities in
the RLQ are believed to be calcified
enteroliths (rather than gallstones)
which, along with the gallstone and
injection granulomas (green), are
probably incidental findings.
This case is included to familiarize

the user with distinguishing small
from large bowel and to recognize
signs of an obstruction. Compare
the periodicity and complete
traverse nature of the valvulae
conniventes (red) of the small
bowel compared to the semilunar
folds (yellow) of the colon.
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Small Bowel Obstruction

This upright KUB shows
multiple differential air-fluid
levels (AFL’s) in distended
small bowel with a paucity of
colonic gas. A close inspection
of the left upper quadrant
reveals two distended small
bowel loops with extreme
differential AFL’s. This might be
mistaken for a large gastric
bubble.
Surgical clips indicate previous

abdominal surgery and adds
confidence to the diagnosis.
The contrast material in a loop

of bowel in the LLQ is actually
free mercury. This
anachronistic finding is the
result of a ruptured Bilboa Tube
(no longer in use) that contained
mercury as a radiopaque
leading weight that would be
carried to the obstruction by
peristalsis.
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.

Distended loops of small bowel
seen in the lower abdomen with
a paucity of colonic gas is
consistent with an SBO. A
gastric tube (green) terminates
in the region of the stomach.
Click to see the barium upper GI

study in this patient.
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Clinical
Abdominal pain.

Contrast material given through
the gastric tube cannot pass
beyond the jejunum.
Notice the valvulae conniventes

show their characteristic
periodicity and complete
traverse nature.
The colon is without gas.

Normally, gas in the GI tract is
from swallowed air, not gas-
forming bacteria. This often
means identifying an obstruction
is simply recognizing and
locating the transition zone
between distended and gasless
bowel. Unfortunately however,
fluid-filled loops of bowel can
virtually disappear radio-
graphically and hide a bowel
obstruction.
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Gallstone Ileus
Air in the biliary tree (red) can
be a worrisome finding.
postsurgical changes, biliary-
enteric fistula (for example,
gallstone ileus or perforated
duodenal ulcer) and infection
such as ascending cholangitis.
The absence of signs of surgery
implies a fistula or an infection.
Surgical confirmation of a
gallstone ileus was made.
Incidental findings: postsurgical

changes of the right hip and
benign calcifications of the
costal cartilage (green), spleen
(yellow) and the tortuous splenic
artery (blue).
Click to see a CT of another

gallstone ileus patient.
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Clinical
Different patient, history
unknown.
Gallstone Ileus
A large concentrically calcified
gallstone is seen within the
lumen of small bowel (red) while
other fluid-filled loops of small
bowel (blue) are mildly
distended. Other axial images
through the liver (not shown
here) revealed air in the biliary
tree.
A small, incidental ventral

hernia (yellow) is seen.
Rigler’s Triad
1. Dilated small bowel
2. Air in biliary tree
3. Ectopic gallstone
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Clinical
Abdominal pain in a 52-year-old
woman status post TAH/BSO,
post op day 2.
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Clinical
post op day 2.
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Clinical
post op day 2.
Paralytic Ileus
There is proportional gaseous
distention of both the small (red)
and large (green) bowel, which
is classic for paralytic ileus (also
known as adynamic ileus).
Surgical clips (yellow) are seen
in the region of the gallbladder
consistent with a previous
cholecystectomy and in the
pelvis (blue) consistent with the
total abdominal hysterectomy
and bilateral salpingo-
ophorectomy.

an early small bowel obstruction
where the colonic gas has not
yet cleared [and this patient is at
risk for an SBO considering the
previous surgeries]. Still, on
POD #2 of her recent surgery,
an ileus is the far more likely
diagnosis. An NG Tube was
placed, the symptoms resolved
and a follow up study showed
resolution.
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Clinical
post op day 2.
Paralytic Ileus
In the upright position, multiple
non-differential air-fluid levels.
This again is consistent with
paralytic ileus.
Clinicians commonly and

mistakenly equate air-fluid
levels with obstruction. AFL’s,
however, in the absence of
distention or differential levels,
are not worrisome. They are
common in cases of ileus and
even in asymptomatic patients.
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Atypical Paralytic Ileus

Markedly distended small bowel
with a paucity of colonic gas is
entirely consistent with a small
bowel obstruction. Surprisingly,
surgery found no obstruction,
the diagnosis of paralytic ileus
was made and the patient
recovered with expectant
therapy.
Important points:
1. This gas pattern more
typically represents an SBO
rather than paralytic ileus. The
exploratory laparotomy was
warranted.
2. Paralytic ileus classically is

seen as equally distended small
and large bowel.
3. Paralytic ileus -- as in this

case -- can occasionally closely
mimic an SBO.
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Clinical
Abdominal pain.
Atypical Paralytic Ileus

The left lateral decubitus study
is a substitute for an upright
view when the patient is not
able to rise. Free air (not seen
here) will collect along the right
abdominal wall.
Multiple non-differential air-fluid

levels are seen in this patient.
The linear opacity is an artifact
(notice its absence on the
supine view).
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ABDOMEN
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Case 7 Next
Clinical
Abdominal pain.
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ABDOMEN
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Clinical
Abdominal pain.
Cecal volvulus
A large, distended loop of bowel
doubled over itself in the mid-
abdomen represents a large
volvulus. Three clues suggest a
cecal origin: (1) it’s base
appears to be in the right lower
quadrant, (2) the additional loop
of extended bowel appears to
be small intestine [notice the
valvulae conniventes (red) that
extend across the entire width
of the lumen and occur in close
proximity to each other], (3)
absence of colonic gas.
The small round opacity

(yellow) likely represents a
calcified mesenteric node vs. an
atypically located appendicolith
or possibly even an undigested
pill.
Click to see a CT of this patient.
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Clinical
Abdominal pain.
Cecal volvulus
A large air-fluid level is seen in
the cecum which has moved
into the left upper quadrant.
Cecum
Cecum
Oral contrast is seen in proximal
small bowel loops [left
abdomen] but has not reached
the distended, fluid-filled distal
small bowel loops [right
abdomen]. Rectal contrast is
visible in the colon (red).
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Sigmoid Volvulus
A large, distended loop of bowel
doubled over itself in the mid-
abdomen represents a very
large volvulus; “a football on a
tee” or the “coffee bean” sign..
Clues suggesting sigmoid
origin: (1) the base appears to
be the left lower quadrant, and
(2) the distended bowel along
the periphery appears to be the
transverse and descending
colon based on the periodicity
and partially traverse nature of
its semilunar folds.
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Inguinal Hernia with SBO

Gas pattern reveals a
distended, air-filled small bowel
with absence of colonic gas
which is consistent with a small
bowel obstruction. A loop of
bowel appears to pass below
the inguinal ligament which
suggests an inguinal hernia as
the cause.
Click to see a coned-in close up

of this patient.
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Clinical
Abdominal pain.
Inguinal Hernia with SBO

An inguinal hernia is clearly
seen and is the presumed
cause of the SBO.
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Clinical
Abdominal pain.
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Case 10 Next
Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Pneumatosis Intestinalis
A chest film in the abdomen
section? Recall that the upright
PA chest is the most sensitive
test for free air under the
diaphragm which represents
pneumoperitoneum.
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Clinical
Abdominal pain.
Gas pattern reveals a slightly
distended small and large bowel
consistent with a paralytic ileus.
The thin, lucent line along the
wall of the ascending colon
represents free air tracking
within the wall of the intestine
(pneumatosis intestinalis, or
more specifically in this case,
pneumatosis coli). Small
lucencies seen over the liver
represents portal venous air as
it has tracked from the bowel.
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Clinical
Abdominal pain.
Closer inspection clearly
reveals gas tracking within the
colonic wall. Occasionally
pneumatosis intestinalis is
simply a benign process of gas
collections in intramural cysts.
It usually runs the entire length
of the bowel and it’s cause is
unknown. Here, however, the
gas has assumed a mottled
appearance and is limited to a
localized area. Free air has
also escaped into the
peritoneum. This patient is
severely ill with an ischemic,
necrotic bowel.
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Clinical
Abdominal pain.
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Case 11 Next
Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Sigmoid Volvulus
A greatly dilated loop of bowel
is seen rising out of the left side
of the pelvis. Large bowel
proximal to this is also gas filled
and helps to confirm the
volvulus to be sigmoid rather
than cecal.
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Clinical
Abdominal pain.
Sigmoid Volvulus
A greatly dilated loop of bowel
is seen rising out of the left side
of the pelvis. Large bowel
proximal to this is also gas filled
and helps to confirm the
volvulus to be sigmoid rather
than cecal.
The upright view shows a large

air-fluid level.
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Clinical
Elderly man with abdominal
pain.
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Clinical
pain.
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Clinical
pain.
Rectosigmoid Dilatation
A massively dilated rectum (red)
is occupying the entire right
abdomen while the gas-filled
sigmoid is also distended. This
pattern is consistent with
obstipation in an atonic colon
which is known as Ogilvie’s
Syndrome.
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Clinical
pain.
The upright view reveals a large
air-fluid level in a massively
distended colon that reaches
the diaphragm.
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Clinical
pain.
CT demonstrates the gas-filled
distended rectum that is making
contact with the diaphragm.
Oral contrast can be seen within
an incidental hiatal hernia
(yellow) and a small right
pleural effusion (blue) is seen.
This should serve as a reminder
that intra-abdominal processes
can occasionally cause pleural
effusions.
Keep going.
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Clinical
pain.
The massive colonic dilatation is
again seen. An air-fluid level is
present within the rectum.
Incidentally, a small renal
cortical mass (red) is seen. Sigmoid
Subsequent imaging (not Rectum
shown) confirmed it to be a
simple renal cyst.
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Clinical
Elderly hospitalized woman with
moderate to severe abdominal
pain.
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Clinical
pain.
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Clinical
pain.
Paralytic Ileus
Gas is seen throughout the
large and small bowel with mild
diffuse colonic distention.
Copious amounts of stool are
present.
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Clinical
pain.
Paralytic Ileus
The upright view reveals no
abdominal air-fluid levels or free
air. An impressive hiatal hernia
(red) with its own AFL (blue)
and sternotomy wires are
incidentally seen.
From this study alone, colonic

obstipation (a distal colonic
obstruction) cannot entirely be
excluded, however with the
colon only mildly distended, a
paralytic ileus is more likely in
this bed-ridden patient. An NG
tube was placed and the patient
was treated expectantly. Her
symptoms resolved within hours
and follow-up films were not
needed.
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Clinical
Unknown.
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Clinical
Unknown.
Aortic Aneurysm
The calcified walls of the aorta
are often visible in plain films of
the abdomen. The width and
the AP diameter of the vertebral
bodies is approximately 3 cm
which allows approximation of
the aneurysm’s size.
Abdominal aortic aneurysms

such as this are often incidental
findings. The asymptomatic
patient should be followed and
intervention should be
considered when the aneurysm
reaches 5 cm in width as risk of
rupture greatly increases.
Click to see the lateral view.
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Clinical
Unknown.
Aortic Aneurysm
The lateral view shows this
aneurysm to be about 4 cm in
size.

AAA patient.
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Case 14 Next
Clinical
Different patient, history
unknown.
Ruptured AAA
This large aneurysm (green)
with calcified walls is easily
seen on axial CT. The
crescentic hypodensity within
the lumen is a large thrombus.
A large volume of extravasated
blood is seen within the
abdomen (red). This patient Lumen
died one day after surgery.
Risk of rupture is based on the

outside-to-outside diameter:
<5 cm → 5%
6 cm → 16%
7 cm → 76%
Thrombus
Thrombus
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Clinical
Unknown.
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Case 15 Next
Clinical
Unknown.
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Clinical
Unknown.
Calcified Splenic Cyst

This impressively large and
well-defined calcification likely
represents a post-traumatic
splenic cyst.
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Clinical
Unknown.
Calcified Splenic Cyst

This impressively large and
well-defined calcification likely
represents a post-traumatic
splenic cyst.
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Case 16 Next
Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Appendicolith
Appendicoliths are classically
oval calcifications with a central
lucency. Also known as
fecoliths, they are formed by
calcium deposits on a nidus of
inspissated feces. Although
only a minority of the cases of
acute appendicitis involve an
appendicolith, this finding in the
presence of right lower quadrant
pain is virtually diagnostic.

appendicitis patient.
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Clinical
Another patient with RLQ pain.
Appendicolith on CT
A calcification (red) is seen
within a retrocecal (green)
appendix (yellow). Rectal
contrast fills the colon.
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Clinical
Abdominal pain.
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Clinical
Abdominal pain.
Phlebolith
Phleboliths are very common
small, rounded calcifications
with smooth margins and
central lucency that occur most
commonly in the lateral aspects
of the pelvis. Representing
small calcified thrombi in pelvic
veins, phleboliths are clinically
significant only inasmuch that
they are sometimes confused
with pathologic calcifications
such as urinary calculi or
fecaliths. Otherwise, they are
considered an incidental finding.
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Case 18 Next
Clinical
Abdominal pain.
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Case 18 Next
Clinical
Abdominal pain.
Uterine Fibroids
Uterine fibroids or leiomyomata
are common benign smooth
muscle tumors. Their
characteristic “popcorn” pattern
of calcification is coarse and
easily identified (red). Compare
this size and pattern to the two
small incidental phleboliths
(green).
Incidentally, the coarse

trabecular pattern seen in the
right hemipelvis (yellow) is
consistent with Paget’s Disease
of bone.
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Case 19 Next
And finally...
Clinical
Abdominal pain and
constipation for three days.
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And finally...
Clinical
Abdominal pain and
constipation for three days.
Rectal Foreign Body

What film reading session would
be complete without the
sophomoric inclusion of a rectal
foreign body or two? Uh, on the
films, I mean. Radiographic
interpretation is usually straight
forward, just keep in mind that
different materials will have
varying degrees of radiopacity
which can complicate
identification. The rubber
casing here, for example, may
be missed. Be sure to rule out
free air in the abdomen.
Feel free to insert your own joke

about this poor guy running out
of batteries at such an
inopportune time.
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Complete Next
Complete!
Congratulations, you’ve completed the abdomen section. Hopefully you are beginning to
become comfortable with the various gas patterns. Bowel obstruction is the single most
important abdominal diagnosis you will make with plain films and essentially every other plain
film diagnosis can wait for the radiologist. Keep in mind that an NG tube can be helpful in both
obstruction & ileus. If radiographic findings (and the exam) are equivocal, consider placing an
NG and repeating the study in a couple hours.
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Go ahead, be a quitter.
Copyright © 2002 American Wolf

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Chest Abdomen Orthopedics

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Want to learn more? Click Here

Clinical externships or rotations in diagnostic radiology can be requested by contacting:

Saint Luke's Hospital Truman Medical Center

Visit the website:

I would also like to thank the following for their help:

Pablo N. Delgado, M.D. Troy Avendanio, M.D.

Kahn Charles. CHORUS Website, Medical College of Wisconsin, 2001.

Mettler Fred. Essentials of Radiology, Philadelphia: W. B Saunders Company, 1996. Y

Where you should start:

Wrist & Hand

Pelvis & Hip

Distal Leg, Ankle & Foot

Incidental calcified granulomas

The right heart border has an

The left hemidiaphragm

Congestive Heart Failure

The pulmonary effects of heart

Air bronchograms (green) are

The left hemidiaphragm (blue)

Congestive Heart Failure

Congestive Heart Failure

Causes of Pulmonary Edema

This case is beyond the scope

Toggle the overlay on and off to

Follow up films to document

Notice this study was performed

Azygos Lobe in CHF

An azygos lobe is a 1-2%

Click to see progression of this

Azygos Lobe in CHF

Click to see another patient’s

NGT in Right Mainstem

Hilar elevation (not seen here)

Collapse of a portion of the

Recall the saying, “One view is

Consider this. With only one

This lateral film should have

Congestive Heart Failure

Congestive Heart Failure

Take note of this normal

Click to see a tomogram of

Click to see an interesting

Plastic Ball Plombage

A search for upper rib fractures

A pacemaker is seen in the left

It is important to realize that

The prominent pulmonary artery

Two important points:

2. COPD patients often present

Incidental finding of rotary

These findings are consistent

Notice the asymmetrical

Click to see the CT of another

Dobhoff in Left Mainstem

A correctly placed Dobhoff or

This story does not stop here,

Dobhoff in Rt. Mainstem

As we have run out of bronchi to

Right-sided Aortic Arch

This is likely an incidental