Radiographic Features of

Pulmonary Hypertension
in Dogs and Cats
Radiographic abnormalities may help identify or suggest a primary cause of
pulmonary hypertension; however, advanced imaging or additional diagnostic
testing is necessary to confirm a diagnosis.

Abstract

Pulmonary hypertension commonly results from cardiovascular, pulmonary, or systemic disease.

Clinical signs include dyspnea, syncope, exercise intolerance, lethargy, and/or coughing.
Diagnostics can begin with thoracic radiography; more advanced techniques include Doppler
echocardiography and pressure measurement by catheterization under fluoroscopic guidance.

Although certain abnormalities may indicate pulmonary hypertension on radiographs, a

radiographic assessment of the intrathoracic structures as a whole can help screen for
comorbidities, which may either be a cause or sequela of pulmonary hypertension and may
require further diagnostic work-up. Early diagnosis and treatment can help prevent progression
to right-sided heart failure. Management depends on the underlying cause.
Take-Home Points

• Causes of pulmonary hypertension are categorized as primary arterial hypertension

(including congenital cardiac shunts), left-sided cardiac disease (left ventricular
dysfunction or valvular disease), respiratory disease and/or hypoxia, pulmonary
thromboembolization, parasitic disease, and multifactorial or idiopathic.
• Thoracic radiography is a practical, accessible, and noninvasive screening tool.
• Recognition of the radiographic features of pulmonary hypertension can help guide
further diagnostics.
• Radiographs are useful for identifying comorbidities and an underlying cause.
• Early diagnosis and treatment of pulmonary hypertension help prevent progression to
right-sided heart failure.
• Management of pulmonary hypertension depends on the underlying cause.

Pulmonary hypertension is defined as increased pulmonary arterial pressure, commonly

secondary to cardiovascular, pulmonary, or systemic disease. 1,2 Right-sided cardiomegaly can
ensue, possibly followed by cardiac decompensation into right-sided heart failure with increased
severity. More commonly, dogs and cats with pulmonary hypertension exhibit signs of dyspnea,
syncope, exercise intolerance, lethargy, or coughing.1 A diagnosis is most practically achieved
with Doppler echocardiography due to its accessibility and noninvasiveness. However, a
definitive diagnosis is best obtained by using more invasive catheterization techniques under
fluoroscopic guidance to directly measure pulmonary arterial pressure, 1,2 although the risks,
higher cost, and training needed to perform such a procedure make it a less favorable choice for
routine clinical use.1 Thoracic radiography may precede and is more accessible than
echocardiography and may show abnormalities supportive of pulmonary hypertension and
changes indicative of the underlying cause. Although thoracic radiography is reported to be
insensitive for patients with mild pulmonary hypertension, abnormalities may be more reliably
observed in dogs and cats with at least moderate pulmonary hypertension. 2 Management of
pulmonary arterial hypertension depends on the underlying cause. The American College of
Veterinary Internal Medicine recently published a consensus statement with guidelines for the
diagnosis, classification, treatment, and monitoring of pulmonary hypertension in dogs. 1 This
article focuses on the use of thoracic radiographs to support a diagnosis of pulmonary
hypertension.
Radiographic Features of
Pulmonary Hypertension
Dogs
Radiographic features of pulmonary hypertension include right-sided cardiomegaly and
pulmonary arterial distension. Right-sided cardiomegaly is characterized by rounding of the
cranial and right lateral margins of the cardiac silhouette with associated caudal and left
displacement of the cardiac apex, resulting in a “reverse D” appearance of the cardiac silhouette
on a ventrodorsal/dorsoventral projection (FIGURE 1).2,3

Figure 1A. Lateral projections of a dog with severe right-sided cardiomegaly. The cranial
and right lateral margins of the cardiac silhouette are severely rounded (arrowheads).
 Figure 1B. Dorsoventral projections of a dog with severe right-sided cardiomegaly. The
cranial and right lateral margins of the cardiac silhouette are severely rounded
(arrowheads), and the apex of the cardiac silhouette is displaced to the left (arrow). The
cardiac silhouette has a “reverse D” appearance.

In the absence of concurrent left-sided cardiomegaly, the cardiac silhouette may become wider in
relation to its height.3 An objective means of measuring this change, the “3/5 to 2/5 cardiac ratio”
method involves drawing a line from the carina, extending ventrally parallel to the caudal border
of the heart. Approximately 3/5 of the cardiac silhouette surface area (right heart) should be
cranial to this line, and 2/5 of the cardiac silhouette surface area (left heart) should lay caudal to
this line (FIGURE 2).4 If the cardiac silhouette cranial to this line has a fractional surface area
greater than 3/5, right-sided cardiomegaly should be considered.4
Figure 2A. Right lateral thoracic radiograph of a dog without right-sided cardiomegaly. In
the absence of cardiomegaly, a line drawn from the carina and extending ventrally parallel
to the caudal border of the heart divides the cardiac silhouette into a normal “3/5 to 2/5
cardiac ratio,” as correlated by comparing the surface areas of a:b.

Figure 2B. Right lateral thoracic radiographs of a dog with right-sided cardiomegaly. In
patients with right-sided cardiomegaly, more than 3/5 of the cardiac silhouette surface area
is identified cranial to this line (i.e., a:b is greater than 3/5:2/5).
Using the clockface analogy (FIGURE 3), an opaque soft tissue bulge confluent with the cardiac
silhouette at the 1 to 2 o’clock position on the dorsoventral or ventrodorsal projections is
suggestive of main pulmonary artery enlargement (FIGURE 4). This finding may be associated
with lobar pulmonary artery enlargement.

Figure 3A. Clockface representation of cardiac chambers location on a right lateral radiograph. L aur, left
auricle; MPA, main pulmonary artery.
Figure 3B. Clockface representation of cardiac chambers location on a ventrodorsal radiograph. L aur, left
auricle; MPA, main pulmonary artery.
FIGURE 4. Dorsoventral projection of a dog with pulmonary hypertension. A large, opaque soft tissue
bulge at the 1 to 2 o’clock position along the cardiac silhouette (arrowheads) in the region of the main
pulmonary artery is indicative of main pulmonary artery enlargement.

Although asymmetry of the lobar pulmonary arteries and veins (characterized by enlargement of
the lobar pulmonary arteries compared with the corresponding lobar pulmonary veins) is
supportive of lobar pulmonary artery enlargement, this method may be unreliable in the presence
of concurrent lobar pulmonary vein enlargement. For objective assessment of the lobar
pulmonary vasculature, the width of the right cranial lobar pulmonary artery can be compared
with the width of the right fourth rib just ventral to the vertebral column on a left lateral
projection (FIGURE 5). A lobar pulmonary artery width to fourth rib width ratio greater than
1.2 is indicative of lobar pulmonary artery enlargement.5
FIGURE 5. Left lateral projection of a dog without cardiovascular disease and (a) a normal
right cranial lobar pulmonary artery width compared to (b) fourth rib width.

A similar approach involves measuring the ratio of the caudal lobar pulmonary artery width to
the ninth rib width, where the lobar pulmonary artery and rib intersect on a
ventrodorsal/dorsoventral projection (FIGURE 6). A recent study found a greater correlation
between lobar pulmonary artery size and pulmonary hypertension by comparing the width of the
caudal lobar pulmonary arteries to the width of the ipsilateral third rib (FIGURE 7).2 Using the
ninth and third ribs as reference, a ratio greater than 1:1 was suggestive of lobar pulmonary
artery enlargement.2 In chronic and severe cases of pulmonary hypertension, findings may
include tortuosity and blunting of the pulmonary vasculature. 1-3
Figure 6A. Dorsoventral projection of a dog without cardiovascular disease and (a) normal right and left
caudal lobar pulmonary artery width to (b) ninth rib width ratios.

Figure 6B. Dorsoventral projection of a dog with pulmonary hypertension and (a) an increased caudal
lobar pulmonary artery width to (b) ninth rib ratios (a>b), indicative of pulmonary artery enlargement.
Figure 7A. Dorsoventral projection of a dog without cardiovascular disease and (a) normal right and left
caudal lobar pulmonary artery width to (b) third rib width ratios.
Figure 7B. Dorsoventral projection of a dog with pulmonary hypertension and (a) an increased caudal
lobar pulmonary artery width to (b) third rib ratios (a>b) indicative of pulmonary artery enlargement.

Cats
Evaluation of cardiac chamber enlargement in cats is limited due to the relative positioning of
the cardiac chambers and variable orientation of the longitudinal axis of the heart. Generalized
cardiomegaly may be observed in cats with right-sided cardiomegaly but is not specific and may
also be seen exclusively or concurrently with left-sided cardiomegaly. Similar to dogs, an opaque
soft tissue bulge at the 1 to 2 o’clock position along the cardiac silhouette in cats is supportive of
main pulmonary artery enlargement (FIGURE 8).
Figure 8. Ventrodorsal thoracic radiograph of a cat with a large, opaque soft tissue bulge at
the 1 to 2 o’clock position along the cardiac silhouette (arrowheads), indicative of main
pulmonary artery enlargement.

However, the main pulmonary artery tends to be more medially positioned in cats and may not
always be apparent.3 Although there are no published objective measurements for lobar
pulmonary vessel enlargement in cats, subjective enlargement of the lobar pulmonary arteries
may support a diagnosis of pulmonary hypertension, especially in the presence of pulmonary
vessel tortuosity (FIGURE 9).
 Figure 9. Right lateral thoracic radiograph of a cat with severe pulmonary hypertension
and tortuosity of the lobar pulmonary arterial vasculature.

Causes of Pulmonary Hypertension

For dogs and cats, the patient’s signalment, clinical signs, and physical examination findings,
along with baseline diagnostics, including thoracic radiography and echocardiography, are useful
for diagnosing and investigating possible causes of pulmonary hypertension. Etiologies can be
broken down into the following disease categories1:

• Group 1: Primary arterial hypertension (including congenital cardiac shunts)

• Group 2: Left-sided cardiac disease (left ventricular dysfunction or valvular disease)
• Group 3: Respiratory disease and/or hypoxia
• Group 4: Pulmonary thromboembolization
• Group 5: Parasitic disease
• Group 6: Multifactorial or idiopathic

Some radiographic abnormalities may aid in the recognition of such diseases. The remainder of
this article describes the radiographic features of specific diseases that may cause pulmonary
hypertension. A directly related higher degree of pulmonary hypertension is expected with
increased disease severity.
Group 1: Primary Arterial Hypertension
In the absence of radiographic abnormalities, a diagnosis of pulmonary hypertension may be
presumed to be secondary to a primary or secondary arteriopathy, sometimes with an unknown
underlying etiology (i.e., idiopathic).1,6 Radiographic evidence of pulmonary hypertension may
be apparent, and in some patients, cor pulmonale and right-sided heart failure may
develop.6 Many patients may be falsely placed in this category antemortem if radiographic
evidence of pulmonary disease is not apparent, as the absence of disease cannot be ruled out
without histopathologic confirmation.1 Rarely recognized in veterinary patients, veno-occlusive
disease resulting from alveolar remodeling associated with capillary hemangiomatosis can result
in severe hypertension.7 Although best identified on computed tomography, nodular soft tissue
opacities within the lungs may be radiographically apparent and seen in combination with a
multifocal, unstructured, interstitial pulmonary pattern (most severe caudodorsally) and
correlated to primarily represent a combination of vascular thickening, secondary edema, and/or
hemorrhage (FIGURE 10).7

Figure 10.) Left lateral projection of a dog with moderate right-sided cardiomegaly and
lobar pulmonary artery enlargement; scant pleural effusion; and mild, diffuse,
unstructured, interstitial pulmonary pattern. In the absence of identifiable primary
pulmonary disease, these findings were most consistent with pulmonary veno-occlusive
disease and secondary cor pulmonale from underlying pulmonary hypertension.
Figure 10B. Dorsoventral projection of a dog with moderate right-sided cardiomegaly and
lobar pulmonary artery enlargement; scant pleural effusion; and mild, diffuse,
unstructured, interstitial pulmonary pattern. In the absence of identifiable primary
pulmonary disease, these findings were most consistent with pulmonary veno-occlusive
disease and secondary cor pulmonale from underlying pulmonary hypertension.

Increased pulmonary arterial pressure may result from increased circulating volume caused by
shunting of blood from the left cardiac chambers into the right cardiac chambers secondary to a
congenital heart defect.3 The most common shunting congenital cardiovascular anomalies
include ventricular and atrial septal defects and patent ductus arteriosus (PDA). In cats, the most
common congenital heart disease is ventricular septal defect; in dogs, PDAs are most
prevalent.6 Thoracic radiographs of dogs and cats with a small shunting defect can be normal.
Left-sided cardiomegaly may be observed in the presence of larger defects with left-to-right
shunting, and the increased volume of blood into the right heart will precipitate main pulmonary
artery enlargement. With increased severity and chronicity, shunt reversal (flow of blood from
right to left cardiac chambers) can ensue from the increased resistance in the right ventricular
outflow tract (e.g., Eisenmenger syndrome).6 A similar process may be observed in dogs with
PDAs. Although not identified consistently in patients with PDAs, the combination of aortic
arch, main pulmonary artery, and left auricular enlargement on a ventrodorsal projection (“triple
knuckles”) may be pathognomonic for PDA (FIGURE 11).3,8

Figure 11. Right lateral projection of a dog with patent ductus arteriosus.
 Figure 11B. Dorsoventral projection of a dog with patent ductus arteriosus, supported by
aortic arch (outlined), main pulmonary artery (arrowheads), and left auricular (asterisk)
enlargement on the ventrodorsal projection (“triple knuckles”).

Group 2: Left-Sided Cardiac Disease (Congenital

or Acquired)
Pulmonary hypertension can develop as a sequela of heart failure from acquired left-sided heart
disease, such as degenerative mitral valve disease (FIGURE 12), dilated cardiomyopathy, mitral
valve dysplasia, or mitral or aortic valve stenosis.8 Borgarelli et al. identified that prognosis was
poorer for dogs with degenerative mitral valve disease and pulmonary hypertension than those
without pulmonary hypertension. Early phases of pulmonary hypertension may be reversible;
irreversible remodeling of the pulmonary vasculature typically occurs with chronicity as
increased vascular resistance causes a permanent elevation in pulmonary pressures. 8.9
Figure 12A. Left lateral projection of a dog with acquired left-sided cardiomegaly
secondary to degenerative mitral valve disease with pulmonary hypertension and
concurrent right-sided cardiomegaly.
 Figure 12B. Dorsoventral projection of a dog with acquired left-sided cardiomegaly
secondary to degenerative mitral valve disease with pulmonary hypertension and
concurrent right-sided cardiomegaly.

Characteristic radiographic features of left-sided cardiomegaly include left atrial and ventricular
enlargement. Left atrial enlargement is recognized by an opaque soft tissue bulge along the
caudodorsal aspect of the cardiac silhouette in the region of the left atrium on lateral projections,
which corresponds to a focal region of increased soft tissue opacity caudal to the tracheal
bifurcation, resulting in splaying of the principal bronchi on the ventrodorsal/dorsoventral
projections.3 Left-sided cardiomegaly is further supported by increased apical-to-basilar length of
the cardiac silhouette and flattening of the caudal margin on lateral projections. On
ventrodorsal/dorsoventral projections, a soft tissue bulge may be observed at the 3 o’clock
position along the cardiac silhouette in the region of the left auricular appendage, indicative of
concurrent left auricular enlargement.6 Although rounding of the cranial and right lateral margins
of the cardiac silhouette may be observed in dogs with severe left-sided cardiomegaly, caused by
morphologic distortion of the heart from severe cardiac chamber enlargement, concurrent left-
and right-sided cardiomegaly should also be considered, especially if main pulmonary artery
enlargement, with or without lobar pulmonary artery enlargement, is also present. 10 Cardiogenic
pulmonary edema may not be observed at the time of pulmonary hypertension diagnosis;
however, prior left-sided cardiac decompensation in those patients should be considered. 8

Group 3: Respiratory Disease and/or Hypoxia

Pulmonary hypertension can be a sequela to a wide array of airway diseases in dogs and cats.
Diseases of the lower airways primarily affect the bronchi (e.g., bronchitis, asthma) or
interstitium (e.g., pneumonia) and etiology can be inflammatory, neoplastic, or infectious. 1 If the
pulmonary hypertension is secondary to lower airway disease, radiographic evidence of
bronchial or pulmonary parenchymal disease may be seen, although advanced imaging such as
computed tomography or bronchoscopy may be necessary for a definitive diagnosis. 6 Bronchial
disease is recognized by thickened bronchi forming prominent rings and peripheral parallel
“tram” lines.3 Although commonly seen in older patients, bronchial mineralization may be
suggestive of chronic bronchitis. Asthma is most common in cats and is a cause of chronic
pulmonary obstruction. Although no studies support a link between the 2 disease processes,
pulmonary hypertension and feline asthma may be diagnosed concurrently (FIGURE 13).6,11
Figure 13A. Left lateral projection of a cat with feline lower airway disease, characterized
by the presence of a severe bronchial pattern.
 Figure 13B. Left lateral projection of a cat with feline lower airway disease, characterized
by the presence of a severe bronchial pattern. The mild cardiomegaly and lobar pulmonary
artery enlargement (arrowheads) are subsequent to pulmonary hypertension (diagnosed
with echocardiography) and likely secondary to the chronic lower airway disease.

In contrast, an unstructured/structured interstitial pulmonary pattern and/or alveolar pattern is

indicative of primary interstitial disease.6 With increased duration, some interstitial diseases
(e.g., neoplasia, bronchopneumonia) can result in pulmonary hypertension. 1 Some dog breeds
(e.g., West Highland white terriers, Pekingese) are predisposed to interstitial pulmonary diseases
and are at higher risk for the complication of pulmonary hypertension (FIGURE 14).12,13 In other
instances, onset of pulmonary hypertension may be acute.1

Figure 14A. Left lateral projection of a West Highland white terrier with idiopathic
pulmonary fibrosis and cor pulmonale (main and lobar pulmonary enlargement and right-
sided cardiomegaly).
 Figure 14B. Dorsoventral projections of a West Highland white terrier with idiopathic
pulmonary fibrosis and cor pulmonale (main and lobar pulmonary enlargement and right-
sided cardiomegaly).

The absence of radiographic abnormalities does not exclude the possibility of disease, and
radiographic abnormalities may lag behind clinical signs. Other causes of obstructive airway
disease may precipitate pulmonary hypertension.1,14 An example is bronchomalacia with or
without tracheal and/or principal bronchial collapse, especially in dogs. Radiographically,
undulation of the tracheal margins with variations in the diameter of the trachea or principal
bronchi may raise concerns for bronchomalacia; however, radiography is not diagnostic and
computed tomography and/or bronchoscopy are favored for a diagnosis. 14 If dynamic tracheal
and/or bronchial collapse is suspected, the diagnosis may require serial inspiratory and
expiratory lateral radiography or a respiratory videofluoroscopic study.3,6
Group 4: Pulmonary Thromboembolization
A pulmonary thromboembolism (PTE) represents material such as coagulated blood, neoplasia,
or bacterial conglomerates lodged within the pulmonary arterial vasculature, occluding blood
flow to the lungs.6 This process may be a sequela to altered blood flow, vascular injury, or a
hypercoagulable state secondary to protein-losing diseases, hyperadrenocorticism, or
disseminated intravascular coagulation (DIC).6 This obstruction may be partial or complete,
resulting in varied disease severity and complications. Depending on the magnitude of the
obstruction, pulmonary hypertension may result and can lead to right-sided heart failure in more
severe cases.1,3,6,15

For some patients with PTEs, radiographic abnormalities may not be seen. Although a
nonspecific finding, the sole radiographic abnormality may be evidence of pulmonary
hypertension (main and lobar pulmonary artery enlargement with or without right-sided
cardiomegaly). The lobar pulmonary arteries may be peripherally blunted and tortuous. 3,6 In the
periphery of affected lung lobes, regions of pulmonary hypoperfusion (oligemia) may be
observed. Other affected regions of the lung may have an unstructured interstitial to alveolar
pulmonary pattern with a wedge shape and similar peripheral distribution (FIGURE 15).6

Figure 15A. Right lateral projection of a dog with mild right-sided cardiomegaly, mildly
enlarged pulmonary arteries, mild pleural effusion, and multifocal left-sided unstructured
interstitial coalescing to alveolar pulmonary pattern and regions of oligemia. These
findings are consistent with pulmonary hypertension and consequent right-sided heart
failure (cor pulmonale), attributed to pulmonary thromboembolism.
 Figure 15B. Dorsoventral projection of a dog with mild right-sided cardiomegaly, mildly
enlarged pulmonary arteries, mild pleural effusion, and multifocal left-sided unstructured
interstitial coalescing to alveolar pulmonary pattern and regions of oligemia (circled).
These findings are consistent with pulmonary hypertension and consequent right-sided
heart failure (cor pulmonale), attributed to pulmonary thromboembolism.

Group 5: Parasitic Diseases

Dirofilaria immitis and Angiostrongylus vasorum parasite infections are separated from other
types of infectious etiologies because they cause pulmonary hypertension through a combination
of pathophysiologic factors.1

Dirofilaria immitis Infection

Of the 2 parasitic diseases, the most common in dogs and cats is dirofilariasis, especially in
tropical and subtropical regions. Given cats’ inherent resistance to infection, dirofilariasis is
diagnosed at much lower frequency for cats than dogs. Although the parasite’s life cycle differs
for dogs and cats, transmission depends on a mosquito vector for both species.16

In animals with a higher worm burden, D immitis worms reside in the pulmonary arteries or the
right heart.3,6 Cats have a propensity to exhibit a more severe clinical response to a lower worm
burden than dogs, and pulmonary disease may develop in response to the presence of immature
worms.17 Dogs may not show clinical signs of heartworm disease and the severity of clinical
signs depends on the worm load, duration of infection, and degree of cardiovascular
damage.6 Increased pulmonary arterial pressure can result from embolization of the pulmonary
arteries by the worms, arteritis, and eosinophilic pneumonitis. Right-sided cardiomegaly and
right-sided heart failure may ensue.3,6

Radiographic features of D immitis worm infection include enlargement and tortuosity of the
lobar pulmonary arteries, with or without right-sided cardiomegaly, as well as evidence of
pleural effusion, caudal vena cava congestion, hepatomegaly, and peritoneal effusion (FIGURE
16).1,3,6 In patients with chronic infection, mineralization of the pulmonary vasculature may be
apparent and represent an irreversible chronic change. 3,6 Localization of cardiac chamber
enlargement in cats is limited and most often characterized by generalized nonspecific
cardiomegaly.6 A diffuse unstructured interstitial pulmonary pattern may be observed in all lung
lobes in the presence of eosinophilic pneumonitis. Small, ill- or well-defined, opaque soft tissue
and/or mineral nodules are most indicative of granulomatosis and increased chronicity.3,6 The
lobar pulmonary arteries can also be truncated by pulmonary thromboemboli and/or physical
obstruction by the worms themselves.3,6 Occasionally, in patients with pulmonary
thromboembolization, regions of increased soft tissue opacity and/or hypovascularized lucent
regions, mostly with a peripheral distribution, are identified. 6 A superior method for assessing
pulmonary perfusion to support a diagnosis of arterial occlusion is computed tomography. 3
 Figure 16A. Left lateral projection of a dog with moderate right-sided cardiomegaly and
lobar pulmonary artery enlargement secondary to dirofilariasis with cor pulmonale. The
mixed moderate bronchial and unstructured interstitial pulmonary patterns and nodules
are consistent with eosinophilic bronchitis and pneumonitis with granulomatosis.

Figure 16B. Dorsoventral projections of a dog with moderate right-sided cardiomegaly and
lobar pulmonary artery enlargement secondary to dirofilariasis with cor pulmonale. The
mixed moderate bronchial and unstructured interstitial pulmonary patterns and nodules
are consistent with eosinophilic bronchitis and pneumonitis with granulomatosis.

Angiostrongylus vasorum Infection

A vasorum lungworms are widely distributed in regions of Africa, North and South America, and
Europe and are transmitted by ingestion of gastropods.6,18,19 In dogs and cats, larvae migrate to
the right ventricle and pulmonary arteries, where they reach maturity approximately 1 month
after infection.18 Eggs are produced and released into the pulmonary capillaries where they hatch,
and larvae then migrate into the alveoli and pulmonary interstitium.6 For a high percentage of
dogs with A vasorum infection, thoracic radiographs are reported to have a mixed bronchial,
alveolar, and unstructured interstitial pulmonary pattern. When an alveolar pattern is present, a
multifocal or peripheral distribution is most common (FIGURE 17).6,18 A similar pulmonary
pattern is reported for dogs in which coagulopathy did or did not develop, which is a poorly
understood complication of A vasorum infection and may be a manifestation of DIC.6,20 For a
smaller percentage of cases, a small amount of pleural effusion has been reported. 18 In addition,
pulmonary hypertension may develop in some dogs, with radiographic evidence of right-sided
cardiomegaly.21 Less commonly reported are main and lobar pulmonary artery enlargement, and
radiographic abnormalities in the lungs may persist beyond therapeutic resolution of the
infection.6,18

Figure 17A. Right lateral projection of a dog with a confirmed diagnosis of Angiostrongylus infection. A
multifocal marked peripheral alveolar pattern can be identified in all lung lobes and is a common
radiographic feature of angiostrongylosis. The rounding of the right cranial and lateral margins of the
cardiac silhouette is attributed to subsequent pulmonary hypertension (confirmed with
electrocardiography).
Figure 17B. Left lateral projection of a dog with a confirmed diagnosis of Angiostrongylus infection.
Figure 17C. Ventrodorsal projection of a dog with a confirmed diagnosis of Angiostrongylus infection.

Group 6: Multifactorial or Idiopathic

A diagnosis of pulmonary arterial hypertension may result from a combination of the
aforementioned diseases.1,6 It may also be associated with other diseases, such as a mass
compressing the pulmonary lobar arteries, for which radiography may be a useful diagnostic
tool.1 In other instances, the underlying etiology may be unclear. 1
Summary
In combination or alone, main and lobar pulmonary arterial enlargement and right-sided
cardiomegaly can be indicative of pulmonary hypertension. When in combination, pulmonary
hypertension should be more strongly suspected; however, echocardiography remains the
modality of choice for establishing a diagnosis. Radiography is noninvasive and widely
accessible and therefore is one of the most practical imaging modalities for screening for an
underlying cause of pulmonary hypertension and associated complications. However, for patients
with mild cases of pulmonary hypertension, radiographic abnormalities may not be apparent.
Radiographic abnormalities may help identify or suggest a primary cause; however, in some
cases, advanced imaging such as computed tomography or additional diagnostic testing such as
histopathology is necessary to confirm a diagnosis. Early diagnosis and treatment of pulmonary
hypertension itself as well as the underlying cause may substantially improve or alleviate clinical
signs associated with pulmonary hypertension. Without a prompt diagnosis, patients may be
treated inappropriately and the pulmonary hypertension may result in right-sided cardiac
decompensation, carrying a poorer prognosis with increased severity and chronicity.8
Radiographic Diagnosis of
Pleural Effusion and
Pulmonary Edema in
Dogs and Cats
Pleural effusion and pulmonary edema both cause increased soft tissue
opacity of the thoracic cavity; however, the disease processes are within
different compartments or spaces. Radiography is an essential part of
classifying both of these thoracic disease processes.

Abstract

Radiographic abnormalities of the thorax often involve changes in opacity, size, shape, margin,
position, and number. The normal pleural space is not seen on thoracic radiographs, and overall
opacity of the lung field is a dark gray (gas opacity); pulmonary vessels and airways are visible
due to the differences in opacity (soft tissue opacity).

This article differentiates increases in opacity within the pulmonary parenchyma from those
within the pleural space.
Take-Home Points

• Radiographic differentiation is based on increased opacity within the pleural space

(pleural effusion) versus within the pleural parenchyma (pulmonary edema).
• A radiographic diagnosis of pleural effusion is based on radiographic pleural fissure
lines with retraction of the visceral pleural surface away from the parietal surface.
• A radiographic diagnosis of pulmonary edema often accompanies cardiogenic (e.g.,
left-sided heart failure, mitral valve insufficiency) or neurogenic disease (e.g.,
seizures, electrocution).
• Some diseases can result in both pleural effusion and pulmonary edema (e.g., dilated
cardiomyopathy, left- and right-sided heart failure).
• Differentiation is based on radiographic examination of the 4 thoracic compartments
(extrathoracic structures, pleural space, pulmonary parenchyma, and the
mediastinum), combined with signalment, presenting complaint, and physical
examination results.

Pleural effusion and pulmonary edema both cause increased soft tissue opacity of the thoracic
cavity; however, the disease processes are within different compartments or spaces. An
interpretation paradigm that can be used to review the thoracic structures includes extrathoracic
structures, pleural space, pulmonary parenchyma, and the mediastinum (including the cardiac
silhouette). Abnormally increased soft tissue opacity can border efface with the normal soft
tissue opaque structures of the thorax from any of these compartments; however, the focus of this
article is recognizing pleural disease (effusion specifically) and pulmonary edema. Some disease
processes will cause an increased soft tissue opacity within both the pleural space and the
pulmonary parenchyma (e.g., dilated cardiomyopathy, left- and right-sided heart failure).
Depending on the assessment and the differential diagnoses (prioritized according to signalment,
presenting signs, and clinical physical findings), the specific differentials for pleural effusion and
pulmonary parenchymal changes could be the same or totally different. The radiographic
evaluation will lead to appropriate next steps for further evaluation, which could include
sampling of fluid or pulmonary parenchyma or further evaluation of the thorax by using
additional imaging modalities (e.g., ultrasonography, computed tomography).

Normal Anatomy
In the healthy dog, a scant volume of pleural fluid separates the visceral and parietal pleural
margins, but this volume is so small that there is no separation between these margins that can be
visualized on thoracic radiographs. The interlobar fissures are found in expected anatomic
locations that can be associated with the intercostal spaces as found on lateral and
ventrodorsal/dorsoventral (VD/DV) radiographs (FIGURE 1).
 Figure 1. Ventrodorsal radiograph of a normal dog; white lines indicate areas where a
pleural fissure line would occur when an effusion is present.

The pleural space exists between each lung lobe at the interlobar fissure as well as around the
lung lobes themselves. The pleural space reflects back on itself at the mediastinum. 1,2 These
fissures are not seen on normal thoracic radiographs unless directly tangential to the x-ray beam.
The most common pleural fissure noted is the one between the right middle and right caudal lung
lobes on a left lateral radiograph (FIGURE 2).
 Figure 2. Left lateral radiograph with a pleural fissure line indicated (white arrow). This
fissure line is a common finding on left lateral radiographs in dogs. Note that it is a
relatively consistent thickness throughout and the fissure does not widen toward the
periphery. The cardiac silhouette and diaphragm can be easily visualized, indicating that a
pleural effusion is not present.

Occasionally, fat deposits within a fissure will separate the 2 lung lobes, most commonly
between the right cranial and right middle lung lobes, as seen on a VD/DV radiograph
(FIGURE 3). The pleural fissures are in classic anatomic positions, and one should be familiar
with these positions as well as the basic anatomic shape of the lung lobes themselves.
 Figure 3. Fat is noted on this ventrodorsal radiograph of a small-breed dog between the
right cranial and right middle lung lobes (white arrows). Note that the fat within the fissure
is thickest centrally and thinnest peripherally. This appearance is the opposite of that of
pleural effusion, in which the widest portion of the pleural fluid is peripheral and thins as it
extends medially in the pleural fissure line.

Each lung lobe has a distinct anatomic location. On each lateral radiograph, a dorsal fissure is
located around T6 between the cranial and caudal lung lobes. Attempt to identify each lobar
bronchus on each radiographic view. On lateral views, the ventrally oriented lobe bronchi may
be difficult to visualize (especially the right middle bronchus on a right lateral radiograph). The
right cranial lung lobe bronchus exits the carina dorsal to the heart base and turns 90° in a ventral
and cranial direction (FIGURE 4). The left cranial lung lobe bronchus exits the ventral trachea
at the carina (FIGURE 4). Within approximately a centimeter from its origin, the left cranial
lobar bronchus divides into the cranial and caudal segmental bronchi. Just caudal and ventral to
the carina, the right middle lung lobar bronchus originates from the ventral and lateral aspect of
the right caudal lobe bronchus. The accessory lung lobar bronchus originates from the right
caudal lobe bronchus, 2 to 3 cm caudal to the carina in a ventromedial position.
Figure 4. Right lateral radiograph of a normal dog in which the origin of the right cranial
lobe bronchus is noted as a radiolucent circle in the cranial aspect of the carina (white
arrow). The opening of the left cranial lobe bronchus points straight down (asterisk) from
the floor of the carina and then bifurcates into the cranial and caudal subsegments.

Technical Radiographic
Considerations
In veterinary medicine, the standard of care has become a minimum of 3 radiographic views of
the thorax. There is a “blind spot” ventrally and centrally along the cardiac silhouette on the
VD/DV images where pulmonary lesions may not be seen. Recumbent lesions (lesions in the
down lung when the patient is in lateral recumbency) will border efface with the surrounding
pulmonary parenchyma from atelectasis. These lesions can be up to 5 cm and still not be seen on
the image. For emergency cases, a dorsoventral thoracic radiograph can be performed initially
but should be followed up with a complete set of thoracic radiographs (right lateral, left lateral,
and VD/DV) after the patient has been stabilized.

The thoracic radiographs should be taken during peak inspiration and should be centered over the
cardiac silhouette so that the thoracic inlet and the caudodorsal portion of the caudal lung lobes
appear on the same radiograph. Doing so may not be possible with a 14” × 17” or a 17” × 17”
DR/CR (digital radiography/computed radiography) plate on a large breed dog (e.g., Great
Dane), for which 2 images would be required for each view (cranial thorax and caudal thorax),
ensuring that there is overlap in the middle. The technique typically involves high kVP and low
mA; the highest mA and fastest time setting(s) used to obtain mAs are in the 1 to 5 range. For a
small dog or cat, the kVP may still be in the 60 to 70 range.

Straight positioning is essential for accurate interpretation. The VD/DV images should be
straight. On lateral views, the sternum should align with the thoracic vertebrae, and each left and
right rib head should be superimposed over the other. Sometimes for lateral radiographic views,
a triangular sponge positioning device is required to lift the sternum away from the table to get
the sternum and spine at a similar height before taking the radiograph. Peak inspiration means
that the cupola of the diaphragm is drawn caudal to the cardiac silhouette and the caudodorsal
lung margins reach to the level of T12 to T13 in dogs and T13 to L1 in cats. An expiratory
radiograph will negatively affect interpretation in 2 primary ways. First, the cardiac silhouette
will always look big relative to the overall thoracic volume; and second, the lungs will look
whiter (more opaque) than is typical because the decreased pulmonary volume results in less gas
between the pulmonary vascular structures. For a small dog being evaluated for a cough, if only
a right lateral radiograph is taken on expiration, it is likely that the cardiac silhouette will appear
enlarged and opacity of the pulmonary parenchyma increased, which could be mistaken for
pulmonary edema. If you were to repeat the radiograph on inspiration and take the dorsoventral
or ventrodorsal views, you may realize that the thorax could be normal.

Pleural Effusion
If you believe that the pleural space is abnormal, ask the following questions: Is there pleural
fluid or pleural air? Are there any extrapleural signs or masses? Are the ribs and osseous
structures of the thorax normal? Are there any diaphragmatic abnormalities such that a
diaphragmatic rupture should be considered? If the answer to any of these questions is yes, then
details regarding the abnormality should be described. See BOX 1 for radiographic
interpretations of pulmonary lesions. For example, a large, expansile mass associated with the
right 7th rib causes focal medial retraction of the pleural space and lung margins with a moderate
volume of focal pleural effusion. An extrapleural sign is an area of increased soft tissue opacity
that appears to be within the lung field and is being caused by indentation from an extrapleural
structure. The structure could be normal (e.g., costochondral junction of a chondrodystrophic
dog, such as a basset hound) or a primary abnormality (e.g., rib fracture, rib tumor).

BOX 1 Radiographic Interpretation of Pulmonary Lesions

Ask the following questions when evaluating pulmonary lesions:
• Is opacity in the lung fields increased or decreased? Pulmonary edema will appear as
increased opacity, with partial to complete border effacement of the local pulmonary
vasculature.
• Where is the lesion? Is the disease focal, multifocal, or generalized? Is the disease in a
particular part of the lungs? Is it cranioventral or caudodorsal? Is the increased soft
tissue pulmonary opacity central, hilar, midzone, or peripheral? Which lung lobes are
involved? After you have determined the anatomic position of the abnormal
pulmonary opacity, evaluate the mediastinum on the ventrodorsal radiograph.
 • What is the pulmonary pattern? Lung diseases can be complex, and a variety of
patterns (mixed patterns) can be present. Common pulmonary patterns include mass,
alveolar, bronchial, vascular, structured interstitial, and unstructured interstitial.

Common causes of pleural effusion (transudate, modified transudate, or exudate) are listed
in BOX 2.2,3

BOX 2 Common Causes of Pleural Effusion

• Heart failure (right-sided in dogs, left- and right-sided in cats)
• Pyothorax
• Chylothorax
• Hypoproteinemia
• Diaphragmatic rupture
• Lung lobe torsions
• Trauma
• Pericardial effusion
• Coagulopathy
• Neoplasia (pulmonary or pleural)

The radiographic diagnosis of pleural effusion (FIGURES 5–7) is based on the radiographic
abnormalities listed in BOX 3.

BOX 3 Radiographic Signs of Pleural Effusion

• Retraction of the lung lobes away from the thoracic wall by soft tissue opacity
• Presence of single or multiple pleural fissure lines (widest laterally and extend
medially as they thin toward the pulmonary hilum)
• Partial or complete border effacement of the cardiac silhouette and diaphragm
(different degrees, depending on the severity of the effusion). Complete border
effacement of the cardiac silhouette will be seen on lateral images in patients with
severe effusion and on dorsoventral radiographs due to fluid surrounding the ventrally
located cardiac silhouette when the patient is in sternal recumbency.
• Increased soft tissue opacity ventrally on the lateral radiographs, with leaf-like
rounding of the pulmonary margins ventrally
• Blunting of the costophrenic angles consistent with lobe retraction, as seen in severe
effusions on ventrodorsal radiographs
Figure 5. A right lateral radiograph of a dog with a mild pleural effusion that is collecting
ventrally. There is mild dorsal elevation of the pulmonary lobes ventrally with widening of
the ventral pleural fissures in the caudoventral thorax over the region of the apex of the
cardiac silhouette.
 Figure 6. A right lateral radiograph of a dog with a chylothorax creating a moderate
pleural effusion. There are similar features as in FIGURE 5 as well as border effacement of
the cardiac silhouette and rounding of the caudodorsal lung lobes. The metallic staples are
from a procedure for occlusion of the thoracic ducts.

Figure 7. Right lateral radiograph of a dog with a severe pleural effusion secondary to
hypoproteinemia. There is border effacement of the cardiac silhouette and diaphragm
along with the other features of pleural effusion described in the article text and shown on
FIGURES 5 and 6. Three central catheters are noted: central venous line (bottom left),
nasogastric feeding tube (middle), and pleural chest tube (top right).

In patients with effusion, soft tissue opacity or fluid accumulation will be present within the
interlobar fissures, which will be widest peripherally and thinner centrally. The costophrenic and
lumbar diaphragmatic angles will be rounded or blunted as a result of fluid accumulation in these
regions. There will be partial or complete border effacement of the cardiac silhouette and
diaphragm (FIGURE 6). In patients with severe pleural effusion, the trachea may be dorsally
elevated (FIGURE 7).

Unilateral pleural effusions are usually secondary to exudates because the mediastinum in dogs
and cats is considered fenestrated. A transudate or a modified transudate should pass freely
between the right and left pleural space through the mediastinal fenestrations. With an exudative
effusion, these fenestrations will become plugged, resulting in a unilateral pleural effusion (e.g.,
chylothorax, pyothorax, hemothorax, neoplastic effusion). In a reactive exudative effusion, such
as one secondary to chylothorax, the visceral pleural surface will be thickened and the lung lobe
margins rounded. This restrictive pleuritis results in the inability of the lung lobes to reinflate to
their normal shape or volume (FIGURE 8).

Figure 8A. Right lateral (A) and ventrodorsal (B) radiographs of a cat with severe chronic
chylothorax and pneumothorax
Figure 8B. Right lateral (A) and ventrodorsal (B) radiographs of a cat with severe chronic
chylothorax and pneumothorax. There is marked thickening of the visceral pleura and
rounding of the lung lobe borders. There are multiple chronic rib fractures with callus
formation consistent with a “thoracic bellows effect” from the chronic chylothorax.
Subcutaneous emphysema is noted on the left side of the thorax consistent with recent
thoracentesis. There is also dorsal bowing of the caudal sternum (pectus excavatum).

The differential diagnoses for chronic bilateral pleural effusion that should be ruled out include
chronic diaphragmatic hernia, thoracic malignancy (commonly a rib tumor), and lung lobe
torsion (may cause the effusion or be secondary to a chronic effusion).

Pulmonary Edema
Pulmonary edema is the abnormal accumulation of fluid within the interstitial space of the lungs,
based on abnormalities of Starling’s forces across the capillary bed and interstitium.4 Common
causes of pulmonary edema are listed in BOX 4. Net flow of fluid into the pulmonary interstitial
space can result from alterations in plasma albumin (plasma oncotic pressure), elevated venous
hydrostatic pressure (elevated left atrial pressures), increased capillary permeability (membrane
breakdown), and increased osmotic (oncotic) pressures within the interstitial space.

BOX 4 Common Causes of Pulmonary Edema

Cardiogenic
Dog

• Mitral valve degenerative disease

• Dilated cardiomyopathy
• Cor pulmonale secondary to mitral valve degenerative disease

Cat

• Primary or secondary cardiomyopathies

Noncardiogenic
Dog

• Neurogenic (seizures, electric cord bites)

• Volume overload
• Acute respiratory distress syndrome

Cat

• Neurogenic (seizures, electric cord bites)

• Volume overload

Radiographic signs of pulmonary edema can be found in BOX 5.

BOX 5 Radiographic Signs of Pulmonary Edema

• Increased caudodorsal soft tissue opacity (unstructured interstitial to alveolar
pulmonary patterns, depending on the severity of the disease process in dogs with
mitral valve disease/insufficiency)
• Left-sided cardiomegaly and tracheal elevation (cardiogenic edema; normal cardiac
silhouette expected for noncardiogenic pulmonary edema)
• Pulmonary venous enlargement (in dogs with cardiogenic pulmonary edema) or
pulmonary artery and venous enlargement (in cats with cardiac failure)
• Partial border effacement of the caudodorsal lung vasculature (unstructured interstitial
pulmonary pattern)
 • Progression over time from hilar or central position to peripheral location

In patients with cardiogenic pulmonary edema, elevated venous hydrostatic pressure will lead to
retention of interstitial fluid (unstructured interstitial pulmonary pattern). In dogs, cardiogenic
pulmonary edema is secondary to left-sided cardiac failure; therefore, radiographs will usually
show left-sided cardiomegaly, elevation of the carina and caudal thoracic trachea, and a
caudodorsal distribution of the increased pulmonary opacity (most commonly unstructured
interstitial) that starts from a central or hilar location and spreads peripherally (FIGURE 9).

Figure 9A. Right lateral (A) and ventrodorsal (B) radiographs of a Doberman pinscher
with congestive heart failure secondary to dilated cardiomyopathy.
 Figure 9B. Right lateral (A) and ventrodorsal (B) radiographs of a Doberman pinscher
with congestive heart failure secondary to dilated cardiomyopathy. There is a pleural
effusion (mild in severity) noted secondary to right-sided heart failure as evidenced by
multiple pleural fissure lines and mild retraction of the lung lobes away from the thoracic
walls (arrows). There is cardiomegaly and pulmonary venous enlargement. There is an
unstructured interstitial pulmonary pattern noted, consistent with cardiogenic pulmonary
edema.

This caudodorsal distribution of the pulmonary changes is seen in dogs with mitral valve
disease/insufficiency but not necessarily in dogs with left-sided cardiac failure secondary to
cardiomyopathy, which could be more randomly distributed. In some dogs with mitral valve
degenerative disease, the pulmonary edema will be distributed in the right caudal lobe due to the
relative relationship between the right caudal lobe pulmonary vein and the direction of the
regurgitant jet from the left ventricle into the left atrium (FIGURE 10). An unstructured
interstitial pulmonary pattern can progress to an alveolar pulmonary pattern (part of a continuum
of the same disease process, exhibiting different patterns depending on the severity of the
disease). In dogs with dilated cardiomyopathy, congestive right- and left-sided heart failure can
result in pleural effusion and pulmonary edema, respectively.

Figure 10A. (A) Right lateral and (B) ventrodorsal (VD) radiographs of a dog with chronic
mitral valve degenerative disease.
 Figure 10B. (A) Right lateral and (B) ventrodorsal (VD) radiographs of a dog with chronic
mitral valve degenerative disease. There is moderate to severe left-sided cardiomegaly with
left atrial enlargement and dorsal elevation of the trachea and carina. There is an increased
unstructured interstitial pulmonary pattern within the right caudal lung lobe, best
visualized on the VD radiograph, consistent with cardiogenic pulmonary edema (arrow).

Cardiogenic pulmonary edema in cats will be distributed more randomly than just caudodorsally
(FIGURE 11); it can be distributed ventrally and multifocally. Cats with primary or secondary
myocardial disease can exhibit left-sided heart failure (causing pulmonary edema and pleural
effusion), right-sided heart failure (causing pleural and peritoneal effusion), or both.
Figure 11A. Right lateral (A) and ventrodorsal (B) radiographs of a cat with cardiogenic
pulmonary edema.

Figure 11B. Right lateral (A) and ventrodorsal (B) radiographs of a cat with cardiogenic
pulmonary edema. The cardiac silhouette is severely enlarged and there is a randomly
 distributed mixed pulmonary pattern consisting of an unstructured interstitial to alveolar
pulmonary patterns. The pulmonary vessels are enlarged centrally but not in the
peripheral aspect of the lung field.

Summary
Pulmonary edema should not be confused with pleural effusion. Although congestive right- and
left-sided heart failure can result in both, usually the disease processes that will cause pulmonary
edema versus pleural effusion differ. Recognizing pleural effusion is based on seeing
radiographic pleural fissure lines with retraction of the visceral pleural surface away from the
parietal surface. Recognizing pulmonary edema as a pulmonary pattern is also critical for
identifying parenchymal lesions versus pleural space abnormalities. Radiography is an essential
part of classifying thoracic disease processes. Diagnosis can be facilitated by dividing the thorax
into the 4 radiographic compartments (extrathoracic structures, pleural space, pulmonary
parenchyma, and the mediastinum) and combining those findings with signalment, presenting
complaint, and physical examination results.
Thoracic Radiology in the
Diagnosis of Congenital
Heart Disease in Dogs
Thoracic radiography is a test of choice for detection of congestive heart
failure, but echocardiography is required to obtain a definitive diagnosis of
congenital heart disease.

Abstract

Concern for congenital heart disease is the most common reason for evaluation of puppies with
cardiac murmurs. While mild clinical signs of a congenital heart defect might not be associated
with significant radiographic abnormalities, moderate or severe signs are associated with some
classic abnormalities that can help solidify a diagnosis, or at least lead to a differential diagnosis
that can be further evaluated using echocardiography. This article reviews an interpretation
paradigm for evaluating the cardiac silhouette, pleural space, and pulmonary parenchyma and
discusses typical findings seen with some of the common congenital heart defects in dogs.

Take-Home Points

• Common congenital anomalies of the cardiac silhouette can be evaluated using

thoracic radiography.
• Complex congenital cardiac anomalies in dogs often require advanced imaging,
including echocardiography, fluoroscopy, and gated computed tomographic
angiography.
 • The cardiac silhouette is a complex 3-dimensional structure that is incompletely
evaluated using survey thoracic radiographs alone.
• Secondary features of left-sided and right-sided heart failure should be taken into
account when reviewing survey radiographs from dogs with congenital heart disease.

Thoracic radiography is the most widely accessible imaging modality used by veterinary
practitioners to assess dogs for cardiac disease. It provides a comprehensive overview of the
thorax, including the extrathoracic structures, pleural space, pulmonary parenchyma, and
mediastinum, in addition to the heart. Dogs with congenital heart disease can be presented at
various stages of development but are often initially identified by the presence of a murmur
during routine puppy examinations. Thoracic radiography can be a first-line diagnostic test for
identifying cardiac abnormalities, pulmonary changes, and features of heart failure, even though
the sensitivity for the detection of mild congenital heart disease is low.

Overview and Interpretation

Paradigm
When evaluating thoracic radiographs, it is important to start with high-quality, well-positioned,
collimated diagnostic radiographs of the thorax obtained at peak inspiration. Significant breed
differences need to be considered when evaluating the cardiac silhouette on canine thoracic
radiographs. For an overview of how to obtain diagnostic thoracic radiographs, see the Today’s
Veterinary Practice article “Small Animal Thoracic Radiography”.

When evaluating thoracic radiographs specific to the cardiovascular system, clinicians should
answer 5 questions:

• Is cardiomegaly present?
• If cardiomegaly is present, is it right sided, left sided, or generalized? If right sided or
left sided, is it limited to a specific chamber (e.g., right atrium)?
• Is there enlargement of the pulmonary lobar veins, pulmonary lobar arteries, or both
the pulmonary lobar arteries and veins (the last suggests pulmonary overcirculation)?
• Is there enlargement of the great vessels (aortic arch, descending thoracic aorta, main
pulmonary artery on the ventrodorsal/dorsoventral [VD/DV] views, and caudal vena
cava) on the lateral views?
• Is there radiographic evidence of left-sided congestive heart failure (pulmonary
edema, pulmonary venous enlargement) or right-sided congestive heart failure (pleural
effusion, caudal vena cava enlargement, hepatomegaly, and ascites)?

Based on the answers to these questions, a refined differential diagnosis can be created, aided by
patient signalment and careful auscultation of the heart. Referral to a board-certified cardiologist
for echocardiographic evaluation and possible intervention should follow the finding of
radiographic findings supportive of congenital heart disease.
Radiographic Evaluation
Heart
Cardiac enlargement can be determined using several subjective and objective criteria. 1-
10
FIGURE 1 shows left-sided cardiomegaly as evidenced by dorsal elevation of the trachea and
carina. More objective criteria include the use of the vertebral heart scale and other rules of
thumb for evaluation of the cardiac silhouette. The widest point of the cardiac silhouette should
measure 2.5 to 3.5 intercostal spaces in width, and the height of the cardiac silhouette should be
approximately 65% of the overall internal thoracic height on lateral radiographs.2

Figure 1A. In patients with left-sided cardiomegaly, the cardiac silhouette increases in
apical to basilar length, resulting in dorsal displacement of the trachea at the level of the
carina so that the trachea becomes progressively parallel to the vertebral column, as shown
by the difference in angle between the blue lines in (A) and (B).
 Figure 1B. In patients with left-sided cardiomegaly, the cardiac silhouette increases in
apical to basilar length, resulting in dorsal displacement of the trachea at the level of the
carina so that the trachea becomes progressively parallel to the vertebral column, as shown
by the difference in angle between the blue lines in (A) and (B).

Using a clock-face analogy (FIGURE 2), different chamber enlargement patterns can be seen
depending on the congenital heart defect present.2 These focal changes in size and shape are then
used to characterize the cardiac chambers that are enlarged (TABLE 1). Dogs with mild
congenital defects can have normal thoracic radiographs. The changes described in this article
are typical of dogs with moderate to severe defects.
Figure 2. (A) Clock-face representation of cardiac chamber location on right lateral
radiographs.
Figure 2. (B) Clock-face representation of cardiac chamber location on ventrodorsal
radiographs.
Vasculature
Important changes of the great vessels should be included in the interpretation paradigm.
Enlargement of these structures is usually secondary to turbulent blood flow and poststenotic
dilation. Enlargement of the caudal vena cava is usually secondary to congestive heart failure
from right-sided disease.

Changes in the pulmonary vasculature should also be evaluated. On a lateral radiograph, the
cranial lobar pulmonary vessels should not exceed the width of the proximal portion of the fourth
rib near the origin at the thoracic vertebra. On ventrodorsal or dorsoventral images, the caudal
lobar pulmonary vessels should not be wider than the summation shadow formed as they cross
the ninth rib. In other words, the caudal lobar vessels should form square summation shadows
with the ninth rib and not horizontal rectangles (in which case they are enlarged).2 Patients with
left-sided congestive heart failure can have enlarged pulmonary veins. Enlargement of both
pulmonary arteries and veins, known as pulmonary overcirculation, is a common feature of left-
to-right intra- and extracardiac shunts (e.g., atrial septal defects, ventricular septal defects
[VSDs], patent ductus arteriosus [PDA]).2

Other Structures
Evaluation for congestive heart failure should be part of the interpretation paradigm.
Radiographic evidence of left-sided heart failure includes a perihilar to caudodorsal distribution
of an unstructured interstitial to alveolar pulmonary pattern as well as enlarged pulmonary veins,
although the latter is not always present, especially if diuretics were administered prior to
radiography.2 Radiographic features of right-sided heart failure include the presence of an
enlarged caudal vena cava, hepatomegaly, ascites, and occasionally pleural effusion.2
The above aspects should be assessed together to create a logical radiographic interpretation that
will help in creating an appropriate differential diagnosis of a congenital cardiac anomaly. In
most cases, radiographic findings should be consistent with a single congenital cardiac defect.
Therefore, for example, features of left-sided cardiomegaly along with an enlarged vena cava,
hepatomegaly, ascites, or pleural effusion would be unexpected. In this scenario, a complex
congenital anomaly or combination of congenital anomalies should be considered.

Common Cardiac Anomalies

The following 5 defects are the most common congenital cardiac anomalies in dogs (TABLE 2).
They may occur in isolation or in combination with other defects. When they are combined with
other defects, diagnosis becomes challenging without advanced imaging such as
echocardiography or cardiac gated computed tomography angiography.

Left-to-Right Patent Ductus Arteriosus

In a dog with a left-to-right shunting PDA, physical examination reveals a continuous cardiac
murmur best auscultated at the base of the heart on the left side, with bounding femoral pulses. 6,7

The underlying pathophysiology of a left-to-right PDA involves blood flow through the ductus
arteriosus into the pulmonary trunk that overloads the pulmonary vasculature and, subsequently,
the left heart.2-5 This results in left-sided cardiomegaly (left atrial, left auricular, and left
ventricular enlargement), enlargement of the pulmonary arteries and veins (pulmonary
overcirculation), enlargement of the main pulmonary artery, and the presence of ductus
diverticulum (enlargement of the descending thoracic aorta at the fourth intercostal space on the
left side of the thorax) (FIGURES 3 AND 4). Concurrent left-sided congestive heart failure
would be supported by the presence of pulmonary edema.
Figure 3. (A) Left lateral projection of a dog with a left-to-right patent ductus arteriosus.
 Figure 3. (B) Same view, with changes characteristic of enlargement of the left cardiac
chambers highlighted. A small soft tissue bulge is present along the caudodorsal aspect of
the cardiac silhouette in the region of the left atrium (green), and the cardiac silhouette is
elongated. Additionally, the pulmonary veins (purple) are congested and larger than their
corresponding arteries (red).

Figure 4. (A) Ventrodorsal projection of the dog in FIGURE 3.

Figure 4. (B) Same view, highlighted to demonstrate enlargement of the aortic arch (yellow
line and arrow) and main pulmonary artery (green). The left atrium is mildly enlarged
(pink). The pulmonary veins (purple) are larger than their corresponding arteries (red).
 Figure 4. (C) With progressive enlargement of the left cardiac chambers, enlargement of
the left auricle also becomes radiographically apparent (purple), resulting in a “three
knuckles” sign (concomitant enlargement of the descending thoracic aorta [ductus
diverticulum] (yellow), main pulmonary artery (green), and left auricle).

Subaortic Stenosis
Dogs with subaortic stenosis are usually presented for murmur evaluation or syncope. The
murmur usually has an ejection quality and is heard best over the left heart base. Femoral pulse
quality is weak when the obstruction is severe.7

The underlying pathophysiology of subaortic stenosis involves pressure overload of the left
ventricle due to partial obstruction of the left ventricular outflow tract. 2 This results in concentric
hypertrophy of the left ventricle.

The radiographic features of subaortic stenosis include elongation of the left ventricle
(particularly on a ventrodorsal radiograph) and enlargement of the aortic arch secondary to
poststenotic dilation. Left atrial enlargement can occur secondary to concurrent mitral
regurgitation, especially if concurrent mitral valve dysplasia is present (FIGURES 5 AND 6).

Figure 5. (A) Left lateral projection of a dog with severe subaortic stenosis.
Figure 5. (B) Same view, with characteristic findings highlighted. A large bulge is seen at
the heart base in the region of the aorta due to poststenotic dilation (red). The ventricle is
increased in apical to basilar length, demonstrating left ventriculomegaly (white arrow).
Figure 6. (A) Ventrodorsal projection of the dog in FIGURE 5.
 Figure 6. (B) Same view. A large bulge is seen at the heart base in the region of the aorta
due to poststenotic dilation (red).

Pulmonic Stenosis
Dogs with pulmonic stenosis are often presented for evaluation of a murmur, syncope, or
exercise intolerance. The murmur is usually an ejection-type murmur (crescendo–decrescendo)
that is loudest at the left dorsal heart base due to the proximity of the pulmonary trunk in this
region.7 Unlike subaortic stenosis, the femoral pulse quality should be normal.

The underlying pathophysiology of pulmonic stenosis involves pressure overload of the right
ventricle due to partial obstruction of the right ventricular outflow tract.2,7,8 The stenosis can be
supravalvular, valvular (most common in dogs), or subvalvular. Due to the increased resistance
associated with valve stenosis, the right ventricle becomes concentrically hypertrophied with
gradual loss of compliance and reduced size of the right ventricular lumen.

Radiographically, pulmonary stenosis can be recognized by the presence of a large bulge in the
region of the pulmonary trunk due to poststenotic dilation and rounding of the right ventricle
indicating right ventriculomegaly (FIGURES 7 AND 8). Right atrial enlargement can develop
secondary to tricuspid valve insufficiency, especially if concurrent tricuspid valve dysplasia is
present. Some dogs eventually develop right-sided heart failure, recognizable radiographically by
enlargement of the caudal vena cava, hepatomegaly, and the presence of ascites and/or pleural
effusion. The pulmonary vasculature may appear small from undercirculation in dogs with
severe pulmonic stenosis.2,7

Figure 7. (A) Right lateral radiographic projection of a dog with severe pulmonic stenosis.
Figure 7. (B) Same view. A large bulge is seen at the heart base in the region of the main
pulmonary artery due to poststenotic dilation (blue).

Figure 7. (C) Fluoroscopic selective angiogram from a dog with pulmonic stenosis. The
positive contrast medium was injected into the right ventricle. There is narrowing of the
right ventricular outflow tract (arrow) with poststenotic dilation of the main pulmonary
artery (asterisk).

Figure 8. (A) Ventrodorsal projection of a dog with severe pulmonic stenosis.

 Figure 8. (B) Same view. A large bulge is seen at the 1- to
2-o’clock position in the region of the main pulmonary artery due to poststenotic dilation
(blue).

Left-to-Right Ventricular Septal Defects

Dogs with VSDs are often identified during routine examination when a murmur is auscultated.
The murmur of an uncomplicated, perimembranous VSD is holosystolic and has a right
parasternal intensity due to the direction of the shunt flow.7

The underlying pathophysiology of a left-to-right VSD involves overcirculation of the left side
of the heart, the right ventricular outflow tract, and the pulmonary circulation. The position of the
shunt within the right ventricle influences the presence or absence of right ventricular
enlargement (eccentric hypertrophy).
Due to the altered blood flow through the shunt and overcirculation, rounding of the cranial and
right lateral margins of the cardiac silhouette may be observed on radiographs (FIGURES 9
AND 10). Enlargement of the great vessels is not apparent. Pulmonary overcirculation is present
throughout the lung fields with equal enlargement of the pulmonary arteries and veins. Chambers
and vessels that accommodate shunt flow will become enlarged and, therefore, enlargement of
the pulmonary arteries, pulmonary veins, left atrium, and left ventricle can be seen, with variable
right ventricular enlargement depending on the location of the VSD. 2,7

Figure 9. (A) Left lateral radiographic projection of a dog with a left-to-right shunting
ventricular septal defect.
Figure 9. (B). Same view. The cranial margin of the cardiac silhouette is rounded (white
arrowheads) due to altered blood flow dynamics through the septal defect and
overcirculation of the right ventricle.
Figure 10. (A) Left lateral radiographic projection of the dog in FIGURE 9.
 Figure 10. (B) Same view. The right lateral margin of the cardiac silhouette is rounded
(white arrowheads) and there is rounding of the cardiac apex (yellow) due to morphologic
distortion of the heart from overcirculation of the right ventricle.

Tricuspid Dysplasia
Dogs with severe tricuspid dysplasia can present in right-sided heart failure with a systolic right-
sided murmur.7,9 Enlargement of the jugular veins and ascites are common features of dogs with
right-sided congestive heart failure.

The underlying pathophysiology of tricuspid dysplasia involves volume overload of the right
atrium and right ventricle due to regurgitation. The tricuspid valve is malformed and cannot
close properly, resulting in regurgitation of blood into the right atrium and gradual eccentric
enlargement of the right atrium and ventricle. The chordae tendineae may also be malformed and
shortened, further restricting closure of the tricuspid valve.

Tricuspid valve dysplasia is suspected in dogs with right atrial and ventricular enlargement on
radiographs (FIGURE 11). Subsequent caudal vena cava and hepatic enlargement and the
presence of peritoneal effusion support a diagnosis of secondary right-sided heart failure.

Figure 11. (A) Right lateral projection of a dog with tricuspid valve dysplasia. The cranial
and right lateral margins of the cardiac silhouette are rounded in association with the
presence of right atrial and ventricular enlargement.
Figure 11. (B) Ventrodorsal projection of a dog with tricuspid valve dysplasia. The cranial
and right lateral margins of the cardiac silhouette are rounded in association with the
presence of right atrial and ventricular enlargement (white arrows). Associated
morphological changes result in subsequent leftward displacement of the cardiac apex
(blue arrow).

Summary
A solid grasp of anatomy, physiology, and pathophysiology, along with clinical findings
(signalment, murmur grade and quality, pulses, jugular distention, features of congestive heart
failure), is key to understanding the radiographic features of congenital heart disease in dogs. It
is important to remember that dogs with mild congenital heart disease might not show changes in
the cardiac silhouette and pulmonary vasculature on thoracic radiographs and that a continuum
of changes can be seen, depending on the severity of the congenital heart defect present. It is also
important to be sure that the radiographic findings are consistent with the suspected congenital
heart disease. Additionally, radiographs should always be evaluated for correct positioning and
technique to aid proper interpretation.

The interpretation paradigm presented in this article is intended to facilitate complete evaluation
of thoracic radiographs for abnormalities that might indicate the presence of congenital heart
disease. Although survey radiography may not provide a definitive diagnosis and lacks
sensitivity for the detection of mild congenital heart disease, it is a valuable initial diagnostic test
for the evaluation of heart murmurs in dogs, providing an opportunity to assess for changes
consistent with isolated congenital defects. While thoracic radiography is a test of choice for
detection of congestive heart failure, echocardiography is required to obtain a definitive
diagnosis of congenital heart disease, and dogs with complex (multiple) congenital defects often
require advanced imaging, including 3- and 4-dimensional imaging (computed tomography
angiography with electrocardiographic gating).
Interpretation of Dental
Radiographs in Dogs and
Cats, Part 2: Normal
Variations and Abnormal
Findings
A guide to interpretation of normal anatomic variations as well as congenital
and pathologic abnormal findings on dental radiographs in dogs and cats.

As described in “Part 1, Principles & Normal Findings” (January/February 2017), dental

radiography in dogs and cats constitutes an essential component of a comprehensive diagnostic
plan.1-4 Part 1 also described appropriate mounting and display of radiographic films/plates for
reviewing purposes, explained a recommended workflow to review radiographs and record
findings, and presented radiographic examples of normal relevant structures.

This article focuses on interpretation of normal anatomic variations as well as congenital and
pathologic abnormal findings on dental radiographs in dogs and cats (Box 1). Both articles
assume the reader is familiar with basic dental radiographic acquisition techniques, concepts, and
skills.

BOX 1. Definitions: Normal Versus Abnormal

 • Normal radiographic findings are defined as those consistent with what is considered
typical, average, or expected and are free of any indicators of disease.
• Normal variations are defined as radiographic findings that deviate from what is
considered typical, average, or expected but do not otherwise indicate any preventive
or therapeutic medical or surgical intervention, monitoring, or maintenance
recommendations.
• Abnormal radiographic findings are any findings considered pathologic.

Reviewing Dental Radiographs

Teeth Abnormally Present and/or Absent
Persistent deciduous teeth with the permanent counterpart present (Figures 1A and 1B) are
considered a pathologic condition of suspected genetic origin that predisposes the involved
permanent teeth to periodontitis and malocclusion. This is a common condition in dogs,
especially toy breeds, but uncommon in cats. The treatment of choice is extraction of the
persistent deciduous teeth.

Although the initial diagnosis is clinical, radiographs are necessary to document the orientation
of the root relative to the permanent counterpart and/or other teeth in the immediate vicinity, as
well as the degree of root resorption (if present). This information is essential to minimize
potential collateral damage when extracting a persistent deciduous tooth.
 Figure 1. Persistent deciduous teeth. Figure 1A shows a persistent right maxillary
deciduous canine tooth in a 7-month-old dog; the permanent counterpart is present. Figure
1B shows a persistent right maxillary deciduous canine tooth in a 6-month-old cat; the
permanent counterpart is present. Figure 1C shows a persistent deciduous left maxillary
second premolar tooth in a 1-year-old dog; the permanent counterpart is not present.
Figure 1D shows a persistent deciduous left mandibular fourth premolar tooth in the same
dog as Figure 1C; the permanent counterpart is not present.

Persistent deciduous teeth without a permanent counterpart (Figures 1C and 1D) are usually
smaller and slightly more radiolucent than the contralateral, adjacent, and/or opposing permanent
teeth.

Clinicians should keep in mind that the morphology of a persistent deciduous premolar
resembles that of the permanent tooth immediately distal to it (eg, the deciduous fourth premolar
resembles the permanent first molar) to it but is significantly smaller.

Clinicians should be also familiar with normal deciduous tooth exfoliation times and know
which teeth have a deciduous predecessor (ie, deciduous dental formula). 5,6
Retained (unerupted or embedded) teeth (Figures 2A and 2B) are important because they can
result in dentigerous cyst formation (see Jaw Lesions of Developmental Origin)7 and are,
therefore, considered pathologic. Although deciduous teeth may be retained, most retained teeth
are permanent.

Figure 2. Retained (unerupted or embedded) teeth. Figure 2A shows a retained right

mandibular first premolar tooth in a 6-year-old dog. Figure 2B shows retained left and
right mandibular canine teeth in a 4-year-old dog. Note that the left and right mandibular
premolar teeth are missing; based on history and breed, the absence of these teeth was
considered congenital in origin.

The cause of tooth retention is not always apparent. If a physical barrier (eg, bone, another tooth)
did not allow the tooth to erupt, the tooth can be referred to as impacted. Retention of the first
premolar tooth appears to be relatively common in brachycephalic dogs, suggesting possible
genetic mechanisms.7 In some cases, historical or radiographic findings may suggest a traumatic
origin (eg, local trauma during odontogenesis); some retained teeth may be dysplastic.

As retained teeth are not visible clinically, radiographs are necessary to establish a diagnosis.
Dental radiographs are indicated whenever there are missing teeth with no obvious cause (eg,
previous tooth loss, extraction).

Congenitally missing teeth (Figure 2B) are considered an incidental finding. The term
hypodontia is applied when several teeth are absent; the term oligodontia is a relative term that
can be used when only a few teeth are present.8 Congenitally missing teeth should be suspected if
dental radiographs do not show retained and/or resorbing roots, unerupted teeth, or vacated
and/or remodeling alveoli.

Crowding and rotation (Figure 3A) may be considered normal or part of the standard in certain
breeds (eg, brachycephalic dogs). Teeth present in severely crowded areas may be rotated owing
to the lack of space; this is particularly common with the maxillary third premolar tooth of dogs
with maxillary brachygnathia. Teeth that are in close proximity represent a plaque-retentive area
and may therefore predispose an animal to focal periodontitis. Although crowding and rotation
can be appreciated clinically, dental radiographs are useful to document the periodontal status of
the teeth involved (Box 2).

BOX 2. Determining Periodontal Status

Radiographs are useful to establish the severity of periodontitis. In general, periodontitis is
classified as:
• Mild if <25% of alveolar bone has been lost

• Moderate if 25% to 50% of alveolar bone has been lost

• Severe if >50% of alveolar bone has been lost

In many cases, the severity and extent of periodontitis on radiographs determine prognosis and
treatment choice (ie, extraction, periodontal surgery, or conservative treatment). As a general
rule, if severe periodontitis is present, extraction of the affected tooth is indicated.

Supernumerary teeth (polydontia) (Figure 3B) can be present at any location in the dental
arches. More than one supernumerary tooth can be present in the same area. Other than creating
a plaque-retentive area and, therefore, predisposing the animal to periodontal disease,
supernumerary teeth are usually considered a normal anatomic variation.

Figure 3. Crowding and supernumerary teeth. Figure 3A shows crowding of premolars

with rotation and palatoversion of the right maxillary third premolar tooth in a 6-year-old
dog. Figure 3B shows a supernumerary right maxillary first premolar tooth, as well as
crowding of premolars with rotation and palatoversion of the right maxillary third
premolar tooth in a 3-year-old dog.
Malformations
Enamel hypoplasia (Figures 4A and 4B) is considered pathologic; affected areas are plaque
retentive and predispose affected teeth to caries and periodontal disease. The defects can be seen
clinically and radiographically as irregularities in the enamel. Teeth with enamel hypoplasia can
also have dysplastic roots that are only detectable radiographically. 9

Figure 4. Enamel hypoplasia. Figure 4A shows the clinical appearance of enamel

hypoplasia affecting the maxillary incisors and canine teeth in a 7-month-old dog. Figure
4B is a lateral projection of the left maxillary canine tooth on the same dog; note the
defective enamel at the mesial aspect of the cusp.

Dysplasia (odontodysplasia) (Figure 5A) of the crowns of erupted teeth is evident clinically;
however, malformation of roots or of unerupted teeth is only detectable radiographically. If only
one or a group of adjacent teeth are malformed, local trauma or infection during odontogenesis is
suspected as the cause. If odontodysplasia is generalized or semigeneralized, systemic acquired
or congenital causes are suspected.

Dens-in-dens (dens invaginatus; Figure 5B) is a rare malformation in which the enamel and
underlying dentin invaginate towards the pulp cavity, sometimes resulting in a direct or indirect
communication and, in some cases, secondary endodontic disease. The malformation may or
may not be clinically evident. Radiographically, it may appear as a small tooth-like structure
within the pulp cavity, and endodontic disease (see Endodontic Findings) is often present.
Figure 5. Odontodysplasia and dens-in-dens. Figure 5A shows a dysplastic root of the right
maxillary canine tooth in a 9-year-old dog. Periodontitis of varying severity is present at
the incisors, canine, and premolar teeth, as well as external inflammatory tooth resorption
at the second premolar. Figure 5B shows dens-in-dens affecting the right mandibular first
molar tooth of a 5-year-old dog; note the abnormal appearance of the crown just above the
furcation area and extending mesially.

Double teeth (Figures 6A and 6B) appear to have two crowns due to gemination or fusion.
Gemination occurs when two crowns originate from a single root; fusion occurs when the roots
of two independent teeth fuse. Clinically, these conditions are indistinguishable; radiographs are
necessary to determine if double teeth are due to gemination or fusion. Regardless, double teeth
are most often an incidental finding.
 Figure 6. Double teeth. Figure 6A is a clinical image of a right maxillary first incisor tooth
in a 4-year-old dog with seemingly two crowns. Figure 6B shows the occlusal radiograph of
the same dog; note that the double maxillary incisor corresponds to fusion.

Concrescent or fused roots (Figure 7A) represent nonpathologic anatomic variations of clinical
relevance because they may affect the surgical approach if a tooth requires extraction. The roots
of multirooted teeth are usually slightly divergent with alveolar bone in between. However, in
some cases, concrescence occurs when the roots of a tooth converge and are only separated by
cementum. In other cases, actual fusion of the roots occurs.

Dilacerated roots (Figure 7B) have an acute angulation at their apical third. Although this is
considered a developmental abnormality, it is not usually of clinical significance, unless the
tooth has to be extracted for any reason. The extraction may require additional root exposure to
avoid fracturing the tooth.

Figure 7. Fused and dilacerated roots. Figure 7A shows fused roots at the left mandibular
second molar tooth in a 5-year-old dog. Figure 7B shows dilacerated roots at the left
mandibular first molar tooth in another 5-year-old dog.

Peg teeth are relatively small, permanent mandibular premolar teeth with only one root (Figure
8). These are usually considered an anatomic variation of little or no clinical significance.
 FIGURE 8. Peg tooth. The radiograph shows an abnormally small and single-rooted left
mandibular third premolar tooth in a 6-year-old cat.

Jaw Lesions of Developmental Origin

Dentigerous cysts, by definition, are associated with unerupted teeth. The most commonly
associated tooth is the first mandibular or maxillary premolar in dogs 7; dentigerous cysts have
not been reported in cats. The cystic lesion is usually visible radiographically as an area of
geographic bone loss (see Jaw Lesions) of varying size; in some cases the lesion involves
adjacent teeth (Figure 9A).

Mandibular radiopacities are round or oval well-defined radiopacities observed along the caudal
or mid-mandibular body (Figure 9B). In the absence of clinical signs or anatomic proximity to
an endodontically diseased tooth, the finding can be considered incidental and is likely the result
of sclerotic bone.10
 Figure 9. Jaw lesions. Figure 9A shows an unerupted right mandibular first molar tooth
with an associated dentigerous cyst in an 8-year-old dog. Figure 9B shows a caudal
mandibular radiopacity just rostral to the mesial root of the right mandibular first molar
tooth in a 6-year-old dog.

Periodontal Findings
Calculus deposits, when thick, can be visible radiographically (Figure 10) because of their
mineralized nature. However, the amount of calculus accumulation visible clinically and
radiographically should not be used as an indicator of the severity or extent of periodontal
disease.
 FIGURE 10. Calculus. Heavy calculus deposits are visible radiographically over the left
maxillary fourth premolar tooth in an 8-year-old dog.

Alveolar bone loss by definition is pathologic. Namely, if alveolar bone loss is present, a
diagnosis of periodontitis is established. Of the 4 tissues that compose the attachment apparatus
of teeth (the periodontium), alveolar bone is the only one that is directly visible on radiographs.
In general, alveolar bone loss can follow a vertical or a horizontal pattern. Vertical bone loss is
when the defect is perpendicular to the cementoenamel junction (CEJ; Figures 11A, 11B,
and 11C); horizontal bone loss is when the defect is parallel to the CEJ. A combined pattern can
also occur. The pattern of bone loss is clinically relevant as it can affect therapeutic options.

Buccal bone expansion is an alveolar bone loss pattern that seems to be unique to cats. Buccal
bone expansion appears radiographically as bulbous and/or thickened alveolar bone with varying
degrees of vertical bone loss, primarily on the buccal aspect of canine teeth (Figure 11D). More
than one tooth can be affected.

Furcation defects can occur at a very early stage of periodontitis because the furcation area is
very close to the alveolar margin. Furcation involvement is used to describe bone loss that is
observed at the furcation but does not appear to communicate all the way through (Figure 11C).
In contrast, furcation exposure refers to through-and-through defects (Figures 11A and 11C). If
furcation exposure is detected, the long-term periodontal prognosis is poor, and extraction is
most often indicated, regardless of severity of periodontitis.

Figure 11. Alveolar bone loss. Figure 11A shows moderate horizontal bone loss with
furcation exposure affecting the left mandibular fourth premolar and first and second
mandibular teeth of a 10-year-old-dog. The first molar tooth also has vertical bone loss at
the mesial aspects of both roots. Note the inflammatory root resorption affecting the distal
root of the second molar tooth. Figure 11B shows near-total loss of attachment due to
severe horizontal bone loss at the left mandibular first and second incisors in the same dog
and left and right mandibular canine teeth. Note the inflammatory root resorption at the
apical area of the first incisor tooth; also note the calculus deposits on the crowns of the
canine teeth. Figure 11C shows moderate horizontal bone loss with furcation exposure at
 the right mandibular fourth premolar and first molar teeth in a 15-year-old cat; note the
inflammatory root resorption at the furcation areas. Figure 11D shows buccal bone
expansion affecting the right maxillary canine tooth more than the left in a 9-year-old cat;
note the inflammatory root resorption affecting the right canine tooth; note also the
retained roots present at the incisor area.

Periodontal–endodontic lesions may be detectable radiographically if alveolar bone loss (ie,

periodontitis) has allowed bacteria to enter the pulp cavity via the apical delta or accessory
canals, with ensuing apical periodontitis. The radiographic characteristics usually include some
degree of alveolar bone loss and periapical lucency around the root(s) (Figure 12). The
prognosis of periodontal–endodontic lesions is poor.
 FIGURE 12. Periodontal–endodontic lesions. This radiographs shows a right mandibular
first molar tooth in a 7-year-old dog. There is moderate to severe combined horizontal and
vertical bone loss and well-defined periapical lucencies at both roots.

Endodontic Findings
Crown integrity may be lost because of traumatic fractures. Tooth fractures are visible
radiographically, although pulp exposure cannot be reliably diagnosed on a radiograph (it is
determined clinically). The loss of crown integrity (Figure 13A) should alert and encourage
clinicians to look for radiographic indicators of endodontic disease (see Apical
periodontitis and Relatively wide pulp cavities) because the most common cause of endodontic
disease is trauma.

Apical periodontitis is inflammation of the periapical tissues that invariably occurs in the
presence of untreated endodontic disease (eg, inflamed or necrotic pulp). This inflammatory
process is detectable radiographically after enough lysis of the associated bone has occurred
(Figure 13B). Typically, the lesion appears as an ill- or well-defined round, lucent area that
encompasses the apical portion of the root(s). Lack of radiographically detectable periapical
lucency does not rule out apical periodontitis.
Relatively wide pulp cavities—when compared with contralateral, opposing, or adjacent teeth—
may indicate a longstanding nonvital pulp (Figures 13A and 13C). Clinicians should be aware
that a lack of discrepancy in pulp cavity width does not rule out endodontic disease, especially in
cases of endodontic disease of relatively short duration (a few days or weeks).

Pulp stones are considered incidental findings that appear as mineralized structures within the
pulp cavity on dental radiographs, sometimes in otherwise clinically and radiographically healthy
teeth (Figure 13D). In the event endodontic intervention is required for unrelated causes, pulp
stones may interfere with root canal instrumentation.

Figure 13. Endodontic disease. Figure 13A shows an occlusal maxillary radiograph of a 5-
year-old dog; note the fractured crown of the right maxillary canine tooth and the
 relatively wide pulp cavity when compared with the contralateral tooth. Figure 13B shows
a fractured middle cusp of the left mandibular first molar tooth in a 6-year-old dog; note
the well-defined periapical lucencies at both roots. Figure 13C shows the occlusal maxillary
radiograph of a 9-year-old dog with severe abrasion of several incisors; note the relatively
wide pulp cavity of the right maxillary first incisor tooth and the associated well-defined
periapical lucency. Figure 13D shows pulp stones at the mesial and middle pulp horns of
the left mandibular first molar tooth in a 4-year-old dog; the tooth is otherwise
periodontally and endodontically sound.

Chevron signs are widened periodontal ligament spaces in the apical areas of endodontically
sound teeth, often in the shape of a chevron, resembling radiographic signs of apical periodontitis
(Figure 14). This occurs most frequently at the maxillary incisors, canines, and mandibular first
molar teeth. It is believed these areas are normal anatomic variations and possibly correspond to
vascular channels in the bone.11 A chevron sign is suspected in the absence of clinical and
radiographic signs of endodontic disease; in some cases, however, it is very difficult to
differentiate between a chevron sign and pathologic changes.
FIGURE 14. Chevron sign. This radiograph is the lateral view of the right maxillary canine
tooth in an 8-year-old dog. Note the wide lucent space at the apex. The lesion is not
bulbous, round, or encompassing of the entire apical area, and the lamina dura appears
intact. Given the lack of other radiographic indicators of endodontic disease, and in the
absence of clinical signs, this finding should not necessarily be considered pathologic.

Other Dental Findings

Tooth resorption may be secondary to inflammatory processes (ie, inflammatory root resorption)
or of unknown origin (Figures 15A through 15D).12 Although tooth resorption is often clinically
detectable, radiographs are necessary to reveal the actual extent, severity, and radiographic
pattern of resorption. The pattern and stage of tooth resorption help determine the surgical
approach (ie, extraction or coronectomy), the level of surgical difficulty, and possible
complications.13
 Figure 15. Tooth resorption. Figure 15A shows advanced inflammatory tooth resorption
affecting the left mandibular fourth premolar and first molar teeth in an 8-year-old cat.
Figure 15B shows advanced replacement resorption affecting the left and right mandibular
canine teeth in a 14-year-old cat. Figure 15C shows replacement resorption affecting both
roots of the left mandibular fourth premolar and mesial root of the mandibular first molar
in a 7-year-old dog; note the loss of periodontal ligament space and sclerotic alveolar bone
around the affected roots. Figure 15D shows inflammatory root resorption secondary to
apical periodontitis at the left mandibular canine tooth in a 7-year-old dog; note the
irregular and relatively short apical third of the tooth compared to the contralateral.
Caries have not been described in cats, and the prevalence of caries is relatively low in dogs
compared to humans. The radiographic appearance of a caries lesion depends on the stage of
disease. Very early caries lesions may or not be detectable radiographically. Advanced caries
lesions involving the dentin appear as cup-shaped cavitated lesions that may or may not extend
into the pulp cavity (Figure 16).

FIGURE 16. Caries lesion. An advanced caries lesion affecting the left maxillary first
molar tooth in a 5-year-old dog; note the loss of crown integrity and apical periodontitis
secondary to pulp involvement.

Abrasion and attrition are wearing of teeth due to contact with an external object or surface
(abrasion) or another tooth (attrition). Radiographically, abrasion and attrition usually appear as
even or smooth loss of tooth surfaces of varying severity, often affecting multiple teeth (Figures
17A and 17B). Wear of dental structures can result in damage to the pulp; therefore, clinicians
should be attentive to radiographic signs of endodontic disease (see Endodontic Findings).
 Figure 17. Abrasion and attrition. Figure 17A shows wear of the occlusal surface of the
right mandibular second and third molar teeth in a 6-year-old dog. Figure 17B shows mild
wear of the distal aspect of the right mandibular canine tooth in a 6-year-old dog,
consistent with cage-biting behavior.

Jaw Structures
Jaw lesions appear on dental radiographs as areas of bone loss of inflammatory, cystic, or
neoplastic origin. The bone loss can have a geographic, permeative, or moth-eaten pattern.14 A
geographic pattern is characterized by an area of bone loss that is uniform in appearance and has
well-defined borders (Figure 18A). In contrast, a permeative pattern of bone loss is an area with
poorly defined borders (Figure 18B). Multiple contiguous areas of bone loss with poorly defined
borders characterize a moth-eaten pattern.
Figure 18. Bone loss jaw lesions. Figure 18A shows a multilocular lesion of geographic bone
loss involving the right mandibular third and fourth premolar teeth in a 5-year-old dog.
Figure 18B shows extensive permeative bone loss affecting both rostral mandibles in a 15-
year-old cat.

Maxillomandibular fractures may be detected on dental radiographs (Figure 19). However,

patients that have sustained maxillofacial trauma often have multiple injuries that are not
detectable radiographically; therefore, computed tomography (CT) is the imaging modality of
choice to detect mandibular and/or maxillary fractures. 15

FIGURE 19. Mandibular fracture. This radiograph shows a comminuted mid-body

fracture between the left mandibular third and fourth premolar teeth in an 8-year-old dog.
Symphyseal separation may be observed if the fibrocartilaginous fibers at the symphysis have
been stretched or torn as a result of trauma. The symphyseal space may appear wider than usual
and an occlusal discrepancy between the right and left incisor teeth may be observed (Figure
20).
 FIGURE 20. Symphyseal separation. This radiograph shows an abnormally wide space at
the symphysis of a 2-year-old dog consistent with symphyseal separation.

Limitations of Dental Radiography

Dental radiographs have some limitations and disadvantages compared with other modalities.
For instance, unlike advanced imaging modalities (eg, CT, cone-beam CT), dental radiographs
represent 2-dimensional images of 3-dimensional structures. Given the anatomic complexity of
certain areas (eg, caudal maxilla) and the level of superimposition of dental and related
structures, radiographs may fail to reveal lesions depending on their nature, location, extent, and
severity. Moreover, dental radiographs are useful only for imaging teeth and associated
structures in the immediate vicinity. They have little or no value for imaging other maxillofacial
structures.

In cases of maxillofacial trauma, temporomandibular joint disorders, and neoplasia of the head
and neck (including oral tumors), CT (multislice or cone-beam CT) may be indicated.14–16 If a
CT scan of the head is already available, dental radiographs may not be necessary to detect
radiographic signs of periodontitis or endodontic disease.17 Cone-beam CT has been proposed as
a valid imaging modality for the diagnosis of dental disease in animals, but its precise clinical
applications and limitations have not been systematically investigated. 18

Dental radiography has traditionally been, and still is, considered the gold standard for the
diagnosis of dental disease in dogs and cats. In a general practice setting, its diagnostic value and
the relatively low cost of required equipment make dental radiography the most practical
imaging modality.
Dental Radiology Series:
Techniques for Intraoral
Radiology
Exposing diagnostic dental images can be frustrating and time consuming, but
with a little practice, it can be mastered.

Exposing diagnostic dental images can be frustrating for the novice; however, with a small
amount of training and practice, it can be mastered. This article is a brief introduction to
exposure techniques for intraoral radiology. Further training via hands-on laboratories is an
excellent investment and can greatly improve the learning curve.
Step 1. Patient Positioning
Position the patient so that the area of the mouth being imaged is closest to the radiographic
beam.

• Mandibular canines/incisors: Place the patient in dorsal recumbency (Figure 1)

• Mandibular cheek teeth: Leave patient in dorsal recumbency or place in lateral
recumbency
• Maxillary teeth: Positioning for these teeth is controversial; some veterinary dentists
recommend sternal recumbency, while others prefer lateral recumbency.

While sternal recumbency makes it easier to visualize angles, possibly making exposure of initial
survey films more efficient, rolling patients into this position for intra- and/or postoperative
images is somewhat arduous and time consuming, often displaces the monitoring leads, and can
be traumatic to spines and hips of older pets and large breed dogs. Therefore, in our practice,
virtually all maxillary radiographs are exposed in lateral recumbency (Figure 2).

FIGURE 1. Feline patient in dorsal recumbency in preparation for exposing a radiograph

of the mandibular incisors and canines.

FIGURE 2. Canine patient in dorsal recumbency, but with head rotated into lateral
recumbency in preparation for a radiograph of the right maxillary canine (104).
This article is the second article in a 3-part series on dental radiology: the
previous article discussed the importance of dental radiography (May/June
2015 issue) and the next will address interpretation of dental images.

Step 2. Film Placement Within the

Patient’s Mouth1-6
For direct digital radiography (DR, or DDR) sensors, the digital sensor is placed in the mouth
so that the cord exits through the front of the mouth (Figure 3).

For photostimulable phosphor (PSP) plates, or indirect digital radiography, the side with
writing (Figure 4) is placed toward the back of the mouth, while the blank side faces toward the
tube head.

Place the sensor/plate as near as possible to (generally touching) the teeth and oral tissues in
order to minimize distortion (Figure 5). If possible, position the sensor/plate within the mouth so
that the entire tooth is covered; in general, the roots are twice as long as the crown. If coverage
of the entire tooth is not possible with a size 2 sensor, which is commonly the case in large breed
dogs:

1. Position the sensor apically enough to expose the apex of the tooth and 3 mm beyond.
This technique “cuts off” the crown, but often radiographs of the crown do not provide
critical information.
2. Expose 2 images (one of the root and one of the crown).

FIGURE 3. Size 2 digital sensor for direct digital radiography; this “back side” of the
sensor should be positioned away from the tube head.
 FIGURE 4. Size 4 PSP plate for indirect digital radiography; this side with writing is
positioned away from the tube head.

FIGURE 5. Digital sensor properly positioned for the mesial maxillary premolars on a
clear model. The sensor should rest on the teeth/oral soft tissues and be placed
lingual/palatal enough to image the root apices.

Step 3. Positioning the Tube Head1-

10

There are 2 major techniques for positioning the tube head, both of which are required for
complete imaging of veterinary patients.

Parallel Technique
The film is placed parallel to the object being radiographed, and the beam positioned
perpendicular to both the sensor/plate and the tooth/root (Figure 6). This technique results in the
most accurate image, but is only useful for the caudal mandibular cheek teeth because:

• Dogs and cats do not have an arched palate and, therefore, the maxillary teeth cannot
be imaged with this technique
• The mandibular symphysis interferes with placement of the sensor/plate parallel to the
tooth roots of the mandibular canines and incisors as well as the rostral mandibular
premolars.

FIGURE 6. Parallel technique for the mandibular premolars and molars in a feline skull
model: The “patient” is in dorsal recumbency (although lateral would be acceptable) with
the sensor parallel to the target teeth and the position indicating device (PID) positioned
perpendicular to both the teeth and sensor (A). The resulting image (B); note that the apex
of the third premolar’s mesial root is cut off. The bisecting angle technique (Figure 13) is
often necessary to image this root.

Bisecting Angle Technique

This technique is based on the theory of equilateral triangles, and creates an image that
accurately represents the tooth and roots (Figure 7).

• The sensor/plate is placed as parallel as possible to the tooth roots.

• The angle between the tooth root and sensor/plate is measured or estimated.
• Then the angle is cut in half (bisected) and the beam placed perpendicular to this
bisecting line.

If the angle between the sensor/plate and the beam is incorrect, the radiographic image will be
distorted because the beam will create an image that is longer or shorter than the object imaged.
When the angle of the beam to the sensor/plate is:
 • Too small, the object will appear longer on the image than its actual length, known
as elongation (Figure 8).
• Too great, the object will appear shorter on the image than its actual length, known
as foreshortening (Figure 9).

The bisecting angle technique is the most commonly used technique in veterinary patients
because it is the most scientifically correct way to take veterinary dental images and provides the
most accurate representation of the root. However, since it is time consuming, a modified, or
“simplified” technique has been developed.

FIGURE 7. Bisecting angle technique: The angle between the tooth root (in this case the
maxillary canine) (red line) and the PSP plate is measured. This angle is then cut in half
(bisected) (blue line), and the PID positioned perpendicular to this “imaginary” line.

FIGURE 8. Elongation: The bisecting angle for the maxillary premolars and molars is 45
degrees to the sensor. In this photo, the PID has been set up at approximately 25 degrees
(A). The resulting image (B) demonstrates elongation of the tooth roots. To fix this error,
rotate the tube head more perpendicular to the sensor.
FIGURE 9. Foreshortening: The bisecting angle for the maxillary premolars and molars is
45 degrees to the sensor. In this photo, the PID has been set up at approximately 65 degrees
(A). The resulting image (B) demonstrates foreshortening of the tooth roots. To fix this
error, rotate the tube head to a more parallel position to the sensor.

Dental Radiology Terms

Digital radiography: Conversion of transmitted x-rays into a digital image using either solid-
state detectors, such as amorphous selenium or silicon; or photostimulable phosphor (PSP) plates
(which are then scanned). Following image acquisition, computer processing is performed and
the image displayed.

Direct digital radiography: Uses an x-ray photoconductor, such as amorphous selenium, that
directly converts x-ray photons into an electric charge. With this type of digital radiography, the
sensor is typically connected by a cord to an analog-to-digital converter box (or card), which is
connected to the computer. Images are produced within seconds of sensor exposure—the
primary advantage of direct sensor systems.

Indirect digital radiography: Requires a 2-step process for x-ray detection: the scintillator
converts the x-ray beams into visible light, which is then converted into an electric charge by
photodetectors, such as amorphous silicon photodiodes. This system uses PSP and, after
exposure, these plates must be scanned in order for an image to be obtained.

Position indicating device: The lead-lined cone or cylinder that directs the x-ray beam during
radiographic exposure. This device improves and standardizes dental radiographic imaging and
reduces the patient’s and operator’s risk of radiation exposure.

Simplified Technique
The simplified technique2,11 does not require direct measurement of any angle, but instead relies
on the approximate angle between the position indicating device (PID) and sensor/plate to create
diagnostic images. There are only 3 angles used for all radiographs in this system: 45, 70, and 90
degrees.

• Mandibular premolars/molars: Exposed at a 90-degree angle; the film is parallel,

while the beam is perpendicular (parallel technique, Figure 6)
• Maxillary premolars/molars: These roots are typically straight and parallel with the
visible crown, and the sensor/plate lies essentially flat across the palate, creating an
approximate 90-degree angle that, when bisected, indicates that all maxillary
premolars and molars be imaged at a 45-degree angle (Figure 10).
• Canines/incisors: These teeth curve caudally at an approximate 40-degree angle to
the palate/body of the mandible; therefore, they are imaged with a 70-degree angle
rostrocaudal (bisecting the 40-degree angle equals 20; when 20 is subtracted from 90,
it indicates that the angle should be 70 degrees from perpendicular to the sensor/plate)
(Figure 11).

To initiate a radiograph with this technique:

• Mandibular premolars/molars: Place the sensor/plate in the mouth and set the PID
perpendicular to the sensor/plate.
• Maxillary premolars/molars: Rotate the beam laterally to a 45-degree angle.
• Canines/incisors: Rotate the beam rostrally 20 degrees.
FIGURE 10. Proper bisecting angle for the maxillary premolars and molars of a dog: The
PID is set 45 degrees to the sensor, which provides an excellent image of all premolars and
molars (A). Note that, when using a size 2 sensor, multiple images are often necessary. In
this patient, the first and second premolars (B) and fourth premolar (C) are in separate
images. The mesial roots of the maxillary fourth premolar are overlapped (red arrows). In
order to visualize these roots separately, the mesial or distal tube shift is required (Figures
15 and 16).
 FIGURE 11. Proper imaging of the incisors and mandibular canines: Due to the caudal
curve of these teeth, the bisecting angle for the roots—70 degrees to the sensor—is very
different than the angle for the crown. Demonstrated are the proper positioning (A) and
resulting image (B) for mandibular incisors and canines in a cat, and the proper
positioning (C) and resulting image (D) for maxillary incisors in a dog. Note that Figure
11C demonstrates lateral recumbency, which is this author’s recommended technique,
although sternal recumbency is also acceptable.

Exceptions
There are only 4 conditions in which these techniques may not produce a diagnostic image:

1. Maxillary canines: Because the maxillary canine roots lie directly dorsal to the
maxillary first and second premolars in dogs and the second and, occasionally, third
premolars in cats, a maxillary occlusal image produces overlap with these structures
(Figure 12A). Therefore, in addition to the 20-degree rotation rostrally, rotate the PID
20 degrees laterally to image the root over the nasal cavity and avoid this
superimposition (Figures 12B and 12C).2,12,13
 2. Rostral mandibular premolars (first and second in dogs; third in cats): The apices of
these teeth are often “cut off” on images exposed with the parallel technique due to the
symphysis interfering with placement of the sensor/plate sufficiently ventral to capture
the apices, therefore, the bisecting angle technique is used.The sensor/plate is placed
in the same position as for the mandibular canines, with the tube head positioned 45
degrees laterally (Figure 13).2,7,9
3. Feline maxillary cheek teeth: When using the standard intraoral bisecting angle
technique, the zygomatic arch impedes visualization of the maxillary third and fourth
premolars as well as the first molar. While this author feels this does not significantly
affect interpretation, if the practitioner wishes to view these teeth without interference,
the extra-oral technique can be utilized. Place the sensor/plate on the table and, with
the patient in lateral recumbency, place the patient’s head on the sensor/plate with the
arch to be imaged closest to the table (away from the beam). Insert a radiolucent
mouth gag to gently hold the jaws apart. Angle the beam through the mouth to create a
bisecting angle of approximately 30 degrees (Figure 14). Remember that this image
was created extraorally and must be labelled accordingly.2,7,9
4. Mesial roots of the maxillary fourth premolar: The straight lateral 45-degree
bisecting angle provides a good representation of the mesial roots but they will be
superimposed (Figure 10).2,9

If the practitioner wishes to view these roots separately, an additional angle—the tube shift
technique—is necessary. The tube head is angled in the horizontal plane, and the mesial roots of
the maxillary fourth premolar are split. To perform this technique, position the tube head for a
straight lateral image (ie, 45 degrees in the vertical plane). Then rotate it distally or mesially,
approximately 30 degrees in the horizontal plane. However, once the roots are split, it is
imperative to be able to identify each root (see Identifying Buccal & Palatal Roots).

Since the whole tooth cannot be effectively evaluated with the mesial tube shift technique, it is
recommended that the caudal tube shift technique be used, creating a quality image of the entire
tooth. If the distal root is imaged well, the palatal root is in the middle.
 FIGURE 12. Proper imaging of the maxillary canines: When the image of the maxillary
canine is created with the PID positioned directly above the nasal cavity (even with the
correct 70-degree vertical angulation), the canine is superimposed over the maxillary first
and second premolars (A). To avoid this superimposition, the tube head is rotated
approximately 20 degrees laterally (although more is acceptable) (B), which images the
canine root over the nasal cavity, consisting of mostly air (C).
 FIGURE 13. Imaging the apices of the mandibular third premolar in cats: The patient is
placed in dorsal recumbency and the sensor positioned perpendicular to the teeth and at
least back to the first molar; then the PID is positioned for a 45-degree bisecting angle
laterally over the target teeth (A) to achieve the resulting image (B). Note: Interference
from the caudal mucosa does not allow the sensor to be placed caudally enough to image
the first molar; therefore, the standard parallel technique image must also be exposed.

FIGURE 14. Extra-oral technique in cats: The sensor is placed underneath the patient’s
head, with the side of the mouth to be imaged against the sensor (away from the PID). The
mouth is gently held open with a radiolucent mouth gag (not shown) and the patient rotated
approximately 30 degrees past parallel (in the dorsal direction). The PID is positioned to
allow the root tips of the side of the mouth closest to the PID to just miss the apices of the
target teeth (A). The resulting image (B) allows visualization of the roots without zygomatic
arch interference.
Identifying Buccal and Palatal
Roots
The classic way to determine the buccal from palatal root is to use the same lingual/opposite
buccal (SLOB) technique.3,10 The root that is more lingual (or palatal) is imaged in the same
direction the tube is shifted, with the buccal root in the opposite direction. Therefore, with a
distal tube shift, the palatal root will move caudally compared with the buccal root. With a
mesial tube shift, the palatal root moves rostral in relation to the buccal root.

There is, however, a much simpler way to identify the roots. If the tube head has been shifted
mesial, the distal root of the fourth premolar is often imaged over the first molar. In this case
(Figure 15), the mesiobuccal root is in the middle. When the tube head is shifted distally, the
distal root is well visualized, away from the first molar, with the palatal root in the middle
(Figure 16).

FIGURE 15. Mesial tube shift technique: Obtaining this image is initiated by positioning
the PID 45 degrees in the vertical plane (as in Figure 10); then rotating the tube head
approximately 30 degrees mesially (pointing toward the back of the head) (A). The
resulting image (B) splits the roots of the maxillary fourth premolar; however, the distal
root is obscured by the maxillary first molar (red arrow). In this view, the mesiobuccal root
(yellow arrow) is distal to the palatal root (blue arrow).
FIGURE 16. Distal tube shift technique: Obtaining this image is initiated by positioning the
PID 45 degrees in the vertical plane (as in Figure 10); then rotating the tube head
approximately 30 degrees distally (toward the nose) (A). The resulting image (B) splits the
roots of the maxillary fourth premolar and provides an excellent view of the distal root (red
arrow); for this reason, I recommend this projection. In this view, the mesiobuccal root
(yellow arrow) is mesial to the palatal root (blue arrow).

Step 4. Setting the Exposure1,2

If you are using a machine that requires manually setting the exposure, the correct setting needs
to be determined.

• For cats, generally there is one setting for the maxilla and one for the mandible, which
are easily determined. For dogs, approximately 5 settings are available for use.
• However, each system has its own unique settings and these settings are incredibly
variable depending on whether a sensor, plate, or film is used. Adjustments will be
necessary, but after imaging several patients, practitioners develop a good sense for
the appropriate settings.

If you are using a computer controlled system, set the buttons for the species, film/digital system,
and tooth to be imaged. These settings are not perfect, so minor adjustments may be necessary.
For experienced practitioners, setting based on time is generally best.

Step 5. Exposing the Radiograph1,2

If it is possible, leave the room prior to exposing the radiograph to avoid radiation exposure. If
this is not possible, stand at least 6 feet from the tube head (this minimum distance creates little
to no exposure to radiation) at a 90- to 130-degree angle to the primary beam to limit radiation
exposure.
Dental radiology machines have “dead man’s” buttons: if you decrease pressure on the button
during the exposure, it stops production of x-ray beams and the unit provides an error message.
Make sure you hold the button down until the machine stops beeping before you start over.

DDR = direct digital radiography; DR = direct radiography; PID = position indicating device;
PSP = photostimulable phosphor; SLOB = same lingual/opposite buccal
The Importance of Dental
Radiography
Dental radiographs are a critical piece of information for the veterinarian for
both diagnosing and treating oral disease.

The knowledge gained from dental radiographs not only improves patient care, it increases client
compliance with treatment recommendations. Most important, the information gained via these
radiographs speeds dental procedures and decreases complications.

This article is the first in a 3-part series on dental radiology, which will discuss:

• The importance of dental radiography

• Dental radiography techniques
• Interpretation of dental radiography images.

This article reviews indications for dental radiographs based on clinical presentation,
demonstrating that radiographs are often critical for proper diagnosis and treatment of oral
disease. These conditions are present in many patients and, therefore, are seen on an almost daily
basis.

Periodontal Disease
Periodontal disease is by far the most common problem in small animal veterinary
medicine.1,2 By the age of 2, 70% of cats and 80% of dogs have some form of periodontal
disease.3
Periodontal probing is a critical first step in the evaluation of periodontal disease. 4,5 However,
there are 2 reasons dental radiographs are required for a complete evaluation:6

1. Periodontal pockets can easily be missed due to narrow pocket width, a tight
interproximal space (Figure 1A), or ledge of calculus.7 Tight interproximal spaces are
normal in the molar teeth, especially in small and toy breed dogs, 8 and dental
radiographs should elucidate these pathologic pockets (Figure 1B).
2. Radiographs are absolutely critical in cases of periodontal disease of the mandible
of small and toy breed dogs (especially in the area of the canine and first molar teeth).
In these patients, periodontal disease can cause marked weakening of the mandible,
creating risk for a pathologic fracture.9,10 In small breed dogs, the teeth, especially the
mandibular first molar, extend across a much larger percentage of the bone of the
mandible than in other breeds (Figure 2).11

The periodontal aspect of these pathologic fractures is often missed on skull films, but can
seriously complicate healing (Figure 3). Therefore, dental radiographs are important in assessing
mandibular fractures.12 In addition, this weakening significantly increases the possibility of
iatrogenic fracture during extraction attempts (Figure 4).10,12 Preoperative dental radiographs can
help practitioners avoid this complication.
Figure 1. Intraoral image of right mandibular first and second molars (409 and 410) in a
dog (A). The tight occlusion does not allow the periodontal probe to pass easily between the
teeth, which may prevent a pathologic periodontal pocket from being identified. The
subsequent dental radiograph (B) reveals a significant bony defect (red arrow).
Figure 2. Intraoral dental radiograph of left mandibular fourth premolar and first molar
(308 and 309) of a 7-pound dog (A). In this case, minimal bone apical to the tooth roots (red
arrows) is present, especially the mesial root of the mandibular first molar, which creates a
high risk for iatrogenic jaw fracture during an extraction attempt, even if the bone is
normal. Significant periodontal disease greatly worsens the risk for jaw fracture (see
Figure 4, page 20). Intraoral dental radiograph of left mandibular first molar (309) of a 65-
pound dog (B). In this case, a considerable amount of bone is present apical to the root
apices (blue arrows). Therefore, there is minimal risk for jaw fracture during extraction of
this tooth, provided that proper technique is utilized.
Figure 3. Lateral skull radiograph of a dog with bilateral distal mandibular jaw fracture
(A). Overlapped mandibles make diagnosis of the bone loss that weakened the bone, which
subsequently resulted in pathologic fracture, difficult. Intraoral dental radiograph of the
same patient (B) that demonstrates obvious alveolar bone loss on the distal aspect of the
first molar. If the tooth is not extracted, healing cannot occur.
 Figure 4. Intraoral dental radiograph of right mandibular first molar in a 5-pound dog
with advanced periodontal bone loss (blue arrows). Only 0.3 mm of ventral cortex remains
(yellow arrow), which greatly predisposes the area to a pathologic mandibular fracture,
especially during an extraction attempt. Note that the third premolar is only held in place
by a calculus bridge (red arrow). Figure reprinted from Importance of Dental
Radiographs client educational poster.

Feline Tooth Resorption

Dental radiographs are absolutely critical for proper dental care in feline patients due to the
potential for resorptive lesions, which are very common in cats. 7,13 Intraoral dental radiographs
are required for proper diagnosis and treatment.6,14

Types of Resorption
There are 3 recognized types of tooth resorption:13,15

• Type 1 lesions do not undergo replacement resorption.13,15 These teeth typically retain
sufficient normal root and pulp structure such that, because the roots are retained, pain
and infection result. If dental radiographs reveal intact root structure (Figure 5) or
worse, an active infection, complete root extraction is required. 6,13,14
• Type 2 lesions demonstrate replacement resorption of the roots. The lost tooth
structure is replaced by bone, which makes extraction very difficult (Figure 6).15 The
resorption in these patients often continues until no recognizable tooth structure
remains (ghost roots) (Figure 7). In these cases, endodontic infection does not
 occur.16 This finding has resulted in the accepted therapy of crown amputation for
treating these teeth.13.14
• Type 3 lesions are seen in teeth that have evidence of Type 1 in one root and Type 2
in the other.17

Figure 5. Type 1 tooth resorption on left mandible of a cat, with significant resorptive
lesions in the crowns of the teeth (blue arrows). However, intact endodontic systems and
periodontal ligaments are present (red arrows), mandating complete extraction. Figure
reprinted from Importance of Dental Radiographs client educational poster.
 Figure 6. Type 2 tooth resorption in maxillary left canine of a cat, with significant
replacement resorption (dentoalveolar ankylosis) evidenced by lack of a radiographically
identifiable periodontal ligament (red arrows). This condition makes extraction by
standard elevation difficult to impossible. Figure reprinted from Importance of Dental
Radiographs client educational poster.

Figure 7. Advanced Type 2 tooth resorption in left mandibular third premolar (307) in a
cat, with no radiographically identifiable root canal or periodontal ligament (red arrow). In
addition, no radiographic evidence of periodontal or endodontic infection is present. This
tooth is a candidate for crown amputation provided that the patient is not being treated for
caudal stomatitis. Figure reprinted from Importance of Dental Radiographs client
educational poster.

Dental radiographs save the practitioner time and frustration by directing his or her efforts
appropriately.18 Premolar teeth in cats without ankylosis can typically be extracted closed
(without a flap). In patients with ankylosis, a surgical approach with buccal bone removal is
often necessary.

Teeth with advanced replacement resorption can be crown amputated, rather than delving after
retained/ankylosed roots.6,18 Crown amputation is indicated only if there is significant ankylosis
and root resorption, with no evidence of periodontal ligaments, the endodontic system, or
infection (endodontic or periodontal) (Figure 6).7,13,14 Patients with caudal stomatitis should not
be treated by crown amputation.13

Endodontic Disease
Even in cases of obvious endodontic disease, such as a complicated crown fracture or discolored
(nonvital) tooth, radiographs may convince clients to consent to the recommended treatment.
However, dental radiographs are even more critical in cases where endodontic disease has either
subtle or no clinical signs.

Uncomplicated Crown Fractures

The most common cases of camouflaged endodontic disease are uncomplicated crown fractures.
These teeth have dentinal, but not direct pulp, exposure (Figure 8). Most of these teeth are vital;
however, there is a possibility that the endodontic system has been infected through the dentinal
tubules, which can result in tooth nonvitality and infection/abscessation, similar to a tooth with
direct pulp exposure.13,19,20

This painful endodontic infection generally cannot be diagnosed without dental radiographs, as
clinical abscessation is very rare. Therefore, every tooth with direct dentin exposure should be
radiographed to rule out endodontic disease.20,21 Further therapy is always indicated, depending
on the results of the dental radiograph. If the dental radiographs reveal no signs of endodontic
disease, the tooth should be treated with a bonded sealant, and the patient should have dental
radiographs repeated in 9 months to ensure the tooth is/was not subclinically infected. 13,20-22

If there is evidence of tooth death (wide root canals or periapical lucency) (Figure 9), root canal
therapy or extraction is mandated.7,19,22

Figure 8. Intraoral image of a patient with an uncomplicated crown fracture of left

maxillary fourth premolar (208). In this case, the dentin is exposed, but not the root canal
system directly. In most hospitals, these teeth are not evaluated further. Figure reprinted
from Importance of Dental Radiographs client educational poster.
 Figure 9. Intraoral dental radiograph of the tooth in Figure 8 that reveals periapical
rarefaction of all 3 roots (red arrows), which indicates the tooth is nonvital and
significantly infected (similar to a tooth with direct pulp exposure). Root canal therapy or
extraction is required to relieve the infection. Figure reprinted from Importance of Dental
Radiographs client educational poster.

Worn Teeth
Another scenario in which teeth appear healthy but may be endodontically abnormal is worn
teeth.7,13 If a tooth has been worn to the point of direct pulp exposure, either root canal therapy or
extraction is required. If there is adequate reparative (tertiary) dentin (Figure 10A), the majority
of these teeth remain vital and pain free.23

However, teeth can become nonvital and infected despite visibly sufficient reparative dentin, and
can only be elucidated by dental radiographs.23 If radiographic evidence of endodontic disease is
present (ie, wide root canals or periapical lucency) (Figure 10B), root canal therapy or extraction
is indicated.7,20,23
Figure 10. Intraoral image of a canine patient with moderate attrition of mandibular
incisors (A). Adequate tertiary dentin is present; therefore, direct pulp exposure should not
be a concern. Intraoral dental radiograph of these teeth reveals 3 nonvital and infected
incisors (B); infection is evidenced by widened endodontic spaces (blue arrows) and
periapical rarefaction (red arrows).

Teeth with Hidden Infection

The final scenario of camouflaged endodontic disease is clinically normal teeth that are actually
infected.6,7 These teeth, like all endodontically infected teeth, rarely have clinical signs, and the
infection can only be diagnosed on radiographs.

Persistent Deciduous Teeth

Extraction of persistent deciduous teeth is a common procedure; however, without dental
radiographs, this can be a challenging and frustrating endeavor.

Incomplete Resorption
In some cases, the root and attachment of the deciduous tooth are normal, and extraction—if
performed correctly—is straightforward, without root fracture occurring.24 In most cases,
however, the deciduous teeth have undergone some to significant resorption due to the pressure
applied by the erupting permanent dentition (Figure 11).6 Resorption and secondary ankylosis
make extraction very difficult, commonly resulting in a fractured root. 24 In these cases, as in
resorptive lesions, beginning with a surgical approach may be advised. Regardless, if an
identifiable root canal or signs of infection are present, these roots require complete extraction to
avoid inflammation and infection.24,25
 Figure 11. Intraoral dental radiograph of retained deciduous left maxillary canine (604).
The vast majority of the root is normal (blue arrows), which means that, in all likelihood,
the tooth will not resorb, indicating the necessity of complete extraction. However,
resorption—caused by pressure from an erupting adult tooth—is present in the cervical
region of the tooth (red arrow), which greatly increases the risk of fracturing the tooth
during extraction. Therefore, careful elevation apical to this point allows for complete
extraction of the tooth; a surgical approach may be advised. Figure reprinted
from Importance of Dental Radiographs client educational poster.

Complete Resorption
There are occasional cases in which the root structure of the deciduous tooth has been
completely resorbed, with the crown only held by ankylosis at the alveolar crest (Figure
12).16,24 Proper therapy requires that only the crown and the very small retaining root segment be
removed. With this knowledge from the start, the practitioner saves time by not:

• Searching for the root

• Worrying about a problem that does not exist
• Causing unnecessary trauma to the patient.
 Figure 12. Intraoral dental radiograph of retained deciduous right mandibular canine
(804). In this case, the root is completely resorbed (red arrows), making extraction easy.
Without this knowledge, however, the practitioner may delve after roots that are not
present, creating unnecessary surgical trauma.

“Missing” Teeth
Incomplete dental arches are quite common in veterinary patients. In some cases, the tooth is
truly missing; however, often the tooth/root is actually present and may be pathologic.

Possible etiologies for “missing” teeth include: 24

1. Congenitally missing teeth26 are common in small, toy, and brachycephalic

breeds.27 The premolars, maxillary second and mandibular third molars, and incisors
are typically absent. No specific therapy is necessary.
2. Previously extracted or exfoliated teeth, while rare in young patients, are quite
common in mature animals. Tooth loss can occur secondary to trauma, but occurs
most commonly due to periodontal disease or previous extraction. With extraction,
radiographs usually reveal evidence of a healing alveolus. Again, no therapy is
necessary.
 3. Teeth fractured below the gum line (Figure 13) may be a result of trauma or an
incomplete extraction attempt. Retained roots following extraction attempts are quite
common: one study evaluating carnassial teeth in dogs and cats revealed that almost
90% of these teeth had retained roots.28 Dental radiographs confirm retained roots and,
in most cases (57%), an infectious lesion.28 If the root appears relatively normal (ie,
not significantly resorbed), surgical extraction is generally the recommended course of
action to alleviate pain and endodontic infection.
4. Impacted or embedded teeth (Figure 14) can be malformed or normal, but do not
erupt into the dentition, often because they are blocked by a structure, such as bone,
teeth, or, most commonly, an area of thick and firm gingiva called the operculum.
While this condition is most common in the first and second premolars of
brachycephalic breeds, any tooth can be embedded.

Figure 13. Intraoral dental radiograph of a feline patient with a “missing” right
mandibular canine (404). Dental radiographs revealed a retained root (blue arrow) with
associated periapical (red arrow) and cervical (yellow arrow) rarefaction, which indicates
severe infection. This tooth was causing significant pain in the patient. A significant Type 1
resorptive lesion is present on the contralateral canine (white arrow).
 Figure 14. Intraoral dental radiograph of a feline patient with a “missing” right
mandibular first premolar (405). The radiograph reveals the embedded tooth (red arrow);
the small lucency in the crown is an early dentigerous cyst.

Dentigerous Cysts
The biggest concern with unerupted or impacted teeth is the development of dentigerous cysts,
which arise from the enamel forming organ of the unerupted tooth. The incidence of dentigerous
cysts is unknown in veterinary medicine, but anecdotally is estimated to be approximately 50%
of all unerupted teeth. In addition, pathologic changes were noted in 32.9% of cases in one
human study.29
As the cyst grows it causes bone loss by pressure, and these cysts can grow quite large in a short
period of time, resulting in a significant bony defect (Figure 15). In addition, malignant
transformation can occur and the cysts can become infected, creating significant swelling and
pain.26
 Figure 15. Large dentigerous cyst (white arrows) in left mandible of a dog with an
embedded first premolar (305) (red arrow); no clinical signs were present.

Therapeutic Approach
The recommended therapy for impacted teeth is surgical extraction. If cyst formation has
occurred, en bloc removal or extraction of the tooth and meticulous curettage of the lining should
prove curative. Following curettage, a biopsy of the lining and bone augmentation is
recommended. Referral to a veterinary dentist is recommended for larger lesions.

It is critical to note that 2 of the causes for “missing” teeth require no therapy, while the other 2
can lead to significant pathology. Therefore, all “missing” teeth should be radiographed to
determine the correct cause and, therefore, the correct approach to management.

Extractions
Pre- and postoperative dental radiographs should be exposed for all extraction procedures. 18 Pre-
extraction radiographs allow the practitioner to determine the amount of disease present as well
as any root abnormalities, such as curved (Figure 16) or extra roots. Ten percent of maxillary
third premolars in cats have a third root (Figure 17).30

One of the more important findings on pre-operative dental radiographs is the presence and
degree of ankylosis.7,19 In addition, the level of remaining bone is elucidated. In the case of a
mandibular first molar or canine extraction, knowledge of the amount of remaining mandibular
bone can be critical with regard to avoiding an iatrogenic pathologic fracture. 6,10,18 Radiographs
also serve as legal evidence, documenting the need for extraction.

Postextraction dental radiographs are equally important. Despite the appearance of complete
extraction, there is still a possibility of retained roots or other pathology. One study evaluating
extraction of carnassial teeth in dogs and cats revealed that almost 90% of these teeth had
retained roots.28 Therefore, postoperative radiographs are critical in all cases (Figure 18). In
addition, radiographs serve as legal documents in cases with complications.

Figure 16. Intraoral dental radiograph of left mandibular first molar (309) of a 7-pound
dog. The apex is very close to the ventral cortex and has a marked curve (red arrow),
which significantly complicates extraction.
Figure 17. Intraoral dental radiograph of maxillary left third premolar in a cat. This tooth
has a supernumerary root (red arrow), which greatly complicates the extraction process.

Figure 18. Retained roots of left mandibular first molar (309) after “extraction” at a clinic
without dental radiography. Note the retained tooth roots (red arrows).
Summary
The conditions and therapeutic options discussed in this article emphasize the value—especially
the patient benefits—of full-mouth radiographs for all veterinary patients.30 Nearly every
veterinary patient has some form of oral disease. Dental radiographs are a critical piece of
information for the veterinarian for both diagnosing and treating oral disease.
Radiography of the Small
Animal Skull:
Temporomandibular
Joints & Tympanic Bullae
Imaging Essentials provides comprehensive information on small animal radiography
techniques. The following anatomic areas have been addressed in previous columns; these
articles are available at tvpjournal.com (search “Imaging Essentials”).

• Thorax
• Elbow and antebrachium
• Abdomen
• Carpus and manus
• Pelvis
• Tarsus and pes
• Stifle joint and crus
• Cervical, thoracic, and lumbar spine
• Scapula, shoulder, and humerus
• Nasofacial and frontal sinuses

The anatomy of the skull, temporomandibular joints (TMJ), and region of the tympanic bullae in
the dog and cat is complex because of superimposition of cavities, sinuses, mandible, maxilla,
dental arcades, and neurocalvarium. Radiography of specific areas requires close attention to the
details of normal anatomy that will aid in proper positioning for each image, based on the type of
study being done.

Improperly positioned radiographs can lead to anatomic distortion of the skull anatomy, resulting
in potential false positive diagnoses.
RADIOGRAPHIC EXPOSURE
Exposures should be made using:

• High mAs: Lowest mA that, if there is an option, allows use of a small focal spot in
order to improve geometric sharpness and, thus, ability to see fine osseous detail.
• Grids: Use if areas thicker than 10 cm are being imaged; otherwise, tabletop
technique is recommended.

The Need for Anesthesia

Although some basic skull views may be obtained with heavy sedation, general anesthesia is
required to obtain diagnostic skull radiographs for several reasons:

• During each imaging series of the skull, one of the projections requires the mouth of
the dog or cat to be open when an exposure is made.
• The oblique and skyline projections require exact positioning that is not possible in an
awake dog or cat, even if heavily sedated.

Routine Projections:
Skull, TMJ, & Tympanic Bullae

LATERAL PROJECTION (Figure 1)

Positioning
 1. For the right lateral projection, place the patient in right lateral recumbency, with the
nose and skull in an extended position.
2. In dolichocephalic and mesaticephalic dog breeds, place a small rectangular sponge
under the tip of the nose to keep it parallel with the table. For brachycephalic dog
breeds and cats, use a 45-degree oblique sponge (wide end away from the head).
3. Place the cervical spine, thoracic limbs, and thorax in a lateral straight position
relative to the skull.
4. Pull the thoracic limbs caudally.

To ensure the patient is straight in a lateral position:

• Place your hand along the ventral mandibles, positioning your hand perpendicular to
the table and the mandibles.
• Feel for the external occipital protuberance along the caudodorsal margin of the skull
(not as prominent in brachycephalic breeds).
• Compare the relative level with the middorsal aspect of the nasal cavity; this
imaginary line should be parallel to the table.

Collimation
1. Set the central beam to the mid cranium, with the collimator opened to just include the
cranium and nasal cavity (cross hairs just caudal and ventral to the eyes).
2. Place an external radiopaque marker ventral to the caudal mandible on the table or
radiographic cassette.
3. If the area of interest is lateralized to one side, place the side of interest closest to the
detector, in which case, the marker indicates which recumbency the patient has been
placed.
4. If the area of interest is at the level of the maxilla or mandible, the upper and lower
jaw can be separated (opened) by placing a syringe case between the mandibular and
maxillary canines.

Ensuring Image Quality

The lateral projection of the skull should extend from the rostral end of the nose (nasal planum)
through the first cervical vertebra (C1). The wings of the atlas and C1 should be even and
superimposed, and all aspects of the skull should be superimposed, such as the zygomatic arches,
mandibles, and tympanic bullae.

Superimposition is more difficult in brachycephalic breeds because their skulls are much
wider—geometric distortion from the divergent nature of the x-ray beam may make
superimposition of all structures impossible.
VENTRODORSAL/DORSOVENTR
AL PROJECTION (Figure 2)
Ventrodorsal (VD) or dorsoventral (DV) positioning is dependent on the breed of dog or cat;
while deep-chested dogs are better imaged in VD position, brachycephalic and small breed dogs
and cats may be better imaged in a DV position.

The area of interest should be as close to the film/cassette/detector as possible for the best overall
detail and to reduce geometric magnification. The radiograph should be reviewed to ensure that
the right and left sides of the skull are symmetrical for evaluation.

Positioning
To obtain the VD projection:

1. Place the patient in dorsal recumbency.

2. Extend the skull, with the external occipital protuberance resting on a thin sponge.
3. Ensure the ventral aspect of the mandibles and the hard palate, which cannot be
visualized because the animal’s mouth is closed, are parallel to the table.
4. Use a V-trough to help maintain the patient in a straight position.

To obtain the DV projection:

1. Place the patient in ventral or sternal recumbency.

 2. Extend the skull, with the mandibular rami placed on the table/cassette/detector.
3. To ensure stabilization, place a thin radiolucent sponge between the patient’s ventral
skull and the table/cassette/detector, as needed.

To ensure the patient is properly positioned, place your hands:

• On either side of the skull, feeling for the symmetry of the mandible and/or zygomatic
arches.
• Relative to either anatomic location to be equidistant from the table on the right and
left sides.

Collimation
1. Set the central beam to the level of the caudal zygomatic arch (at a level just caudal to
the eyes) with the collimator opened to include C1/C2, the neurocranium, and the
caudal portion of the nasal cavity (approximate level of maxillary premolar 3).
2. Place the radiopaque marker on the right side of the dog or cat, taking care to avoid
superimposition of the marker over any part of the skull.

Ensuring Image Quality

For VD or DV images of the skull, the rostral extent of the image should be the nasal planum,
while the caudal extent is C1. Make sure the various parts of the skull are symmetrically
positioned right and left, and not obliqued. This may be impossible in patients that have skull
trauma with multiple fractures.

Specific Projections: TMJ & Tympanic Bullae

OPEN-MOUTH ROSTROCAUDAL
OBLIQUE PROJECTION (Figure 3)
Positioning
1. Place the patient in dorsal recumbency.
2. Flex the neck, positioning the hard palate and mandibles perpendicular to the table and
x-ray collimator system.
3. Place small triangle sponges under the external occipital protuberance to help maintain
a symmetric position on the table.
4. Place tape—starting from one side of the table at the level of the abdomen—and pass
it around the patient’s nose, fastening it to the other side of the table at the same level.
5. Angle the hard palate approximately 10 degrees rostral to the perpendicular plane of
the body.
6. Extend the mandible caudally (open mouth) with the endotracheal tube secured to the
mandible, taking care to avoid kinking the tube and stopping the flow of
oxygen/inhalation of anesthetic agent.

Breed-Based Positioning
Although positioning for many of these projections is similar, use of sponges and tape will vary
based on skull size and shape:

• Dolichocephalic breeds (eg, Doberman pinscher) have long, narrower heads

• Mesaticephalic breeds (eg, beagle) have medium sized and shaped heads
• Brachycephalic breeds (eg, bulldog) have short, wide heads, with foreshortening of
the nasal cavity and absence of frontal sinuses
 • Cats have more standard sized and shaped heads; however, some brachycephalic cat
breeds (eg, Persian) require the same considerations as brachycephalic dog breeds.

Collimation
1. Set the central beam through the open mouth at the level of the soft palate.
2. Take care to ensure the cranium is straight, without lateral rotation.
3. Assess this positioning by standing at the patient’s head and placing your hands on
either side of the cranium, at the level of mandibular rami, verifying both rami are
equidistant to the table.

Ensuring Image Quality

The open-mouth projection should include both TMJ and tympanic bullae without rotation or
superimposition of the endotracheal tube. Collimation should extend caudally from C1 to include
the full tympanic bullae rostrally.

LATERAL 30-DEGREE OBLIQUE

PROJECTION (Figure 4)
Positioning
For a complete study, both right lateral and left lateral oblique projections are needed.

1. Place the patient in lateral recumbency, with the nose and skull in an extended
position.
2. Ensure the mouth remains open, which can be accomplished with a syringe case, and
secure the endotracheal tube to the mandible.
3. Place a 30-degree wedge sponge under the maxilla to ventrally oblique the skull.

When the initial projection is finished, take the opposite oblique projection by:

1. Rolling the patient over, with the original nonrecumbent side now on the table.
2. Placing a wedge sponge under the maxilla to ventrally rotate the head by 30 degrees.
Collimation
1. Position the central beam just ventral to the nonrecumbent external auditory canal
(that closest to the tube head).
2. Adjust collimation to include only the tympanic bulla and TMJ from the level of the
third maxillary premolar to C1/C2.
3. If the patient is in right lateral recumbency, for example, the left TMJ, tympanic bulla,
and ear will move ventrally when positioned correctly.
4. Place the radiopaque markers outside soft tissue structures: For the right lateral
projection, place the right marker ventral to the oblique, recumbent bulla and the left
marker just dorsal to the skull. For the left lateral projection, the opposite is true, with
the left marker placed ventral to the oblique, recumbent bulla.

Ensuring Image Quality

The lateral oblique projection should extend from mid mandible to C1. One of the TMJs and
tympanic bulla should appear ventral but without superimposition of the cranium. Care should be
taken to avoid over rotating the patient, causing foreshortening of the vertical mandibular ramus
and tympanic bulla.

LATERAL 25- TO 30-DEGREE

ROSTROCAUDAL OBLIQUE
PROJECTION (Figure 5)
Positioning
For a complete study, both right lateral and left lateral oblique projections are needed.

1. Place the patient in lateral recumbency, with the cranium and nasal passages in true
lateral position.
2. Place a triangular- or wedge-shaped radiolucent sponge under the rostral aspect of the
nose and mandible, which lifts the nasal planum, nasal cavity, and mandible 25- to 30-
degrees away from the table.
3. Ensure the mouth remains open, which can be accomplished by placing a syringe case
between the upper and lower canines.

When the initial projection is finished, take the opposite oblique projection by rolling the patient
over, with the original, nonrecumbent side now on the table.

It is important to note that, in left lateral recumbency, the:

• Right TMJ and tympanic bulla are caudal and, therefore, best visualized by this
projection
• Left TMJ and tympanic bulla appear superimposed over the caudoventral aspect of the
skull.

The opposite is true for right lateral recumbency.

Collimation
1. Direct the central beam just rostral to the TMJ (that closest to the tube head).
2. Adjust collimation to include only the tympanic bulla and TMJ.
3. Mark the recumbent side, which will appear more rostral on the radiograph.

Ensuring Image Quality

The rostrocaudal oblique projection should extend from mid mandible to C1. One of the TMJs
and tympanic bulla should appear rostral to the other; the more rostral structures should be those
on the recumbent side of the patient.

CLOSED-MOUTH
ROSTROCAUDAL OBLIQUE
PROJECTION (Figure 6)
This projection is used for rostrocaudal evaluation of the tympanic bulla in brachycephalic dogs
and cats, and replaces the open-mouth rostrocaudal projection described earlier.

Positioning
1. Place the patient in dorsal recumbency, supporting the body in a V-trough, as needed.
2. Flex the neck, tilting the hard palate and mandibles 10- to 15-degrees rostral to the
perpendicular plane of the table and x-ray collimator system.
 3. Use small triangle sponges under the external occipital protuberance to help maintain
symmetry of the skull on the table.
4. Flex the skull—then take tape, and starting from one side of the table at the level of
the abdomen, pass it around the patient’s nose, fastening it to the other side of the
table at the same level.
5. Secure the endotracheal tube rostrally to the maxilla, keeping the mouth closed.

Collimation
1. Direct the central beam to the tympanic bulla.
2. Take care to ensure the cranium is straight, without lateral rotation.
3. Assess this positioning by standing at the patient’s head and placing your hands on
either side of the cranium, at the level of mandibular rami, verifying both rami are
equidistant to the table.

Ensuring Image Quality

This closed-mouth rostrocaudal oblique projection should include the tympanic bullae without
rotation or superimposition of the endotracheal tube.

QUALITY CONTROL
For quality control of any diagnostic image, use a simple 3-step approach.

1. Is the technique adequate, with appropriate exposure and development?

2. Is the correct anatomy present within the image? Compare the images you obtain with
the images in this article.
3. Is positioning anatomically correct? Was correct anatomic coverage obtained?

Once it is determined that the technique is adequate, make sure the appropriate anatomy is
present and positioning is correct, straight, and symmetric. Symmetry of the skull for VD/DV
images is critical when evaluating all structures and osseous anatomy.

Use the figures in this article as a guide as well as the information provided in the Ensuring
Image Quality sections.
SUMMARY
Radiographs of the skull allow evaluation of a number of clinical signs related to the skull, TMJ,
and tympanic bullae. The images included in this article illustrate how to produce and evaluate
the quality of these radiographs. High-quality, correctly positioned and collimated radiographs
are required in order to accurately assess the TMJ and tympanic bullae.

C1 = first cervical vertebra; DV = dorsoventral; TMJ = temporomandibular joint; VD =

ventrodorsal
Small Animal Skull &
Nasofacial Radiography,
Including the Nasal Cavity
& Frontal Sinuses

The anatomy of the skull and nasofacial area of the dog and cat is complex, with cavities,
sinuses, mandible, maxilla, dental arcades, and cranial cavity. In the 2-dimensional radiography
image, the 3-dimensional skull creates a complex series of lines and superimposed osseous
structures.

Radiography of specific areas requires close attention to small details of anatomy that will aid in
proper positioning for each image. Improperly positioned radiographs can lead to anatomic
distortion of normal skull anatomy, resulting in summation shadows unfamiliar to the reviewer
of the images, and possible false-positive diagnoses of abnormalities.

The Need for Anesthesia

Although some basic skull views may be obtained with heavy sedation, general anesthesia is
required to achieve high-quality, precisely positioned skull radiographs. Reasons include:

• Projections made during the standard imaging series of skull radiographs require the
dog or cat’s mouth to be open when an exposure is made.
• When radiographing a trauma case in which mandibular and maxillary fractures are
present, a painful animal will not lie still even under heavy sedation.

Note: When specific skull fractures are present, or trauma has occurred, placing stress on various
areas of the skull to manipulate it for normal imaging positions is contraindicated.

INDICATIONS
Radiographs of the skull are indicated for evaluation of traumatic injuries, skull pain, epistaxis,
soft tissue masses, and for some related problems of the skull and nasal cavity, such as chronic
rhinitis and nasal discharge. If advanced imaging is available, computed tomography (CT) can
provide more specific and detailed information than survey radiographs. Learn more about
indications for CT by reading Advanced Imaging: Its Place in General
Practice (January/February 2014), available at tvpjournal.com.

RADIOGRAPHIC EXPOSURE
Exposures should be made using:

• High mAs, with longer time station: Lowest mA that allows use of a small focal
spot in order to improve geometric sharpness and, thus, ability to see fine osseous
detail. For an average dog, the mAs is 10 to 15, with 55 to 65 kVp.
• Grids: Use if areas thicker than 10 cm are being imaged; otherwise, tabletop
technique is recommended. With digital radiology equipment, a grid should be used if
areas thicker than 15 cm are being imaged.

BASIC POSITIONING
Although basic positioning is similar, some variation in use of sponges and tape will be required
due to different skull sizes and shapes of various canine and feline breeds.
 • Dolichocephalic breeds (ie, Doberman pinscher) have long, narrower heads.
• Mesaticephalic breeds (ie, beagle) have medium sized and shaped heads.
• Brachycephalic breeds (ie, bulldog) have short, wide heads, with foreshortening of
the nasal cavity and absence of frontal sinuses.
• Cats have more standard sized and shaped heads; however, some brachycephalic cat
breeds (ie, Persian) require the same considerations as brachycephalic dog breeds.

The images used in this article feature a mesaticephalic breed dog (mixed breed).

LATERAL PROJECTION OF
SKULL & SINUSES (Figure 1)
Positioning
1. Place the patient in right lateral recumbency, with the nose and skull in an extended
position.
2. In dolichocephalic and mesaticephalic breeds, place a small rectangle sponge under
the tip (end) of the nose to keep it parallel with the table.
3. Place the cervical spine, thoracic limbs, and thorax in a lateral straight position
relative to the skull.
To ensure the patient is in lateral position:

• Place your hand along the ventral mandible, positioning your hand perpendicular to
the table and the mandible.
• Feel for the external occipital protuberance along the caudodorsal margin of the skull
(not as prominent in brachycephalic breeds).
• Compare the relative level with the mid dorsal aspect of the nasal cavity and the tip of
the nose; this imaginary line should parallel the table.

Collimation
1. Center the central beam to the mid cranium, with the collimator opened to just include
the cranium and nasal cavity (crosshairs at level of the eyes). Depending on the dog’s
skull type, the crosshairs may be cranial (dolichocephalic), ventral (mesaticephalic),
or caudal (brachycephalic) to the eye.
 2. If the area of interest is lateralized to one side, place the side of interest closest to the
detector in order to minimize geometric magnification. However, oblique projections
will be required to highlight this area of interest.
3. Place the radiopaque marker ventral to the caudal mandible, separate from the patient
on the table or radiographic cassette.

Ensuring Image Quality

• This view should extend from the rostral end of the nose (nasal planum) through the
C1/C2 vertebrae.
• The wings of the atlas (C1) and all aspects of the skull (zygomatic arches, mandible,
mandibular condyles, temporomandibular joints, tympanic bullae, etc) should be even
and superimposed.
• Achieving even superimposition is harder in brachycephalic breeds because their
skulls are much wider; therefore, superimposing all structures may not be possible due
to geometric distortion from the x-ray beam’s divergent nature.

VENTRODORSAL/DORSOVENTR
AL PROJECTION OF SKULL &
SINUSES (Figure 2)
Choosing ventrodorsal (VD) or dorsoventral (DV) positioning is dependent on the breed of dog
or cat (ie, VD for deep chested dogs and DV for brachycephalic breeds). Key goals are to:

• Position the area of interest as close to the film/cassette/detector as possible for best
overall detail.
• Reduce geometric magnification.
• Ensure a straight radiograph that is symmetrical (right side and left side).
Positioning
To obtain the VD projection:

1. Place the patient in dorsal recumbency.

2. Extend the skull, with the external occipital protuberance resting on a thin sponge to
keep the head straight from side to side.
3. Close the mouth and place a piece of tape across the maxilla, caudal to the canines, to
keep the head stable, if needed, which will create an artifact over this area.
 4. Make sure the ventral aspect of the mandibles and the hard palate, which cannot be
visualized when the patient’s mouth is closed, are parallel to the table.
5. Use a positioning trough to help maintain the patient in this position.

To obtain the DV projection:

1. Place the patient in ventral recumbency.

2. Extend the skull, with the mandibular rami placed on the table/cassette/detector or a
thin radiolucent sponge for stabilization.

To ensure the patient is properly positioned:

• Place your hands on either side of the skull, feeling for symmetry of the mandible
and/or zygomatic arches.
• Check that your hand position, relative to either anatomic location, is equidistant from
the table on both sides.

Collimation
1. Set the central x-ray beam to the midlevel of the zygomatic arch (at the level of the
eyes), with the collimator opened to include the cranial aspect of C1 vertebra,
neurocranium, nasal cavity, and just beyond the nasal planum rostrally.
2. Place the radiopaque marker on the right side of the patient, taking care to avoid
superimposition over any part of the skull.

Ensuring Image Quality

• The rostral extent of the image should be the nasal planum.
• The caudal extent should be the C1/C2 vertebrae.
• Make sure the left and right sides of parts of the skull are symmetrically positioned
and not obliqued; however, this is almost impossible in dogs and cats that have skull
trauma with multiple fractures.

VENTRODORSAL OPEN-MOUTH
PROJECTION OF NASAL CAVITY
(Figure 3)
Positioning
1. Place the patient in dorsal recumbency.
2. Extend the skull, allowing the external occipital protuberance to rest on the table
(same as for closed-mouth VD image).
3. Place tape from one side of the table to the other, with the center portion of tape
secured caudal to the maxillary canine teeth, which helps keep the hard palate parallel
to the table.
4. Place a second piece of tape from one side of the table to the other, starting at the level
of the mid abdomen, moving forward and around the mandible’s canine teeth, and
taping to the same level on the other side of the table.
5. Open the mouth to full extension so the mandible is caudal to, or at the level of, the
maxillary premolars.
6. Tape the endotracheal tube with the mandible; care should be taken to keep the
endotracheal tube from kinking during this imaging procedure.

Collimation
1. Center the central x-ray beam in the middle of the hard palate.
2. If possible, angle the tube head 10 degrees, in a rostral to caudal direction, relative to
the patient’s skull. If the tube head cannot be angled, do not oblique the patient’s skull
to minimize anatomic distortion from geometric magnification.
 3. Place the radiopaque marker along the right side of the patient’s skull.

Ensuring Image Quality

• The rostral extent of the image should be the nasal planum.
• The caudal extent should be at the level of the superimposed mandible and osseous
structures of the caudal skull.

DORSOVENTRAL INTRAORAL
PROJECTION OF NASAL CAVITY
(Figure 4)

Positioning
1. If you have access to nonscreen film (old mammography film) that comes pre-
wrapped, or use the edge of a cassette, an intraoral image of the nasal cavity can be
obtained with the dog in ventral recumbency.
2. Extend the skull, with the mandibular rami positioned directly on the table, and use a
thin sponge to eliminate any degree of mandibular asymmetry. This is the same
patient position as described for the DV projection of the skull.
 3. Place the nonscreen film or small cassette in the patient’s mouth, between the maxilla
and endotracheal tube:
o To obtain better coverage, place the corner of the nonscreen film in first,
which allows it to be positioned further back in the mouth.
o Nonscreen film that extends beyond the mouth may need support from a
sponge to keep it from bending toward the table.

Note: Technique for nonscreen film, which must be manually or automatically processed, is 65
kVp and 150 mAs; therefore, the patient needs to be under anesthesia and all personnel kept
outside the room.

Collimation
1. Center the central x-ray beam between the nasal planum and right and left orbits.
2. Place the radiopaque marker on the right side of the patient, within the collimated light
beam, taking care to avoid superimposition over any part of the skull.

Ensuring Image Quality

• The rostral extent of the image should be the nasal planum.
• The caudal extent should be to the end of the nonscreen film’s edge (as far caudal in
the oral cavity as possible—typically to the level of the cribriform plate).
ROSTROCAUDAL OBLIQUE
SKYLINE PROJECTION OF
FRONTAL SINUS (Figure 5)

It is important to note that this view is only useful in dogs and cats that have frontal sinuses;
brachycephalic breeds do not commonly develop normal frontal sinuses.

Use the lateral radiograph (Figure 1) to determine whether frontal sinuses—just dorsal and
cranial to the end of the neurocalvarium—are present. If gas-filled sinuses are not present, this
projection is not needed.
Positioning
This view is very similar to the open-mouth view, except the nose is pulled caudal with the
mandible, which situates the frontal sinuses in a skyline profile.

1. Place the patient in dorsal recumbency.

2. Flex the neck, placing the patient’s hard palate and mandible perpendicular to the
table and x-ray collimator system.
3. Place small triangle sponges under the patient’s external occipital protuberance to help
maintain a symmetric position on the table.
4. Use tape to hold the patient’s skull in place: flex the skull, place the tape on one side
of the table at the level of the abdomen, pass the tape around the patient’s nose, and
then fasten the tape to the other side of the table at the same level. If the patient is in a
positioning trough, place the tape along the outside of the trough.
5. Take care to avoid:
o Kinking the endotracheal tube at the level of the oropharynx
o Over rotating the dorsal aspect of the calvarium, which superimposes the
cranial vault and sinuses.
6. Make sure that the nose is perpendicular to the table when viewing the patient from
the side.

Collimation
1. Center the central x-ray beam between the eyes, just dorsal to the bridge of the nose.
2. Collimate on all sides to within a cm of the patient’s skin.
3. Place the radiopaque marker on the right side of the patient.

Ensuring Image Quality

• The dorsal extent of the image should be the dorsal skin surface.
• The ventral margin should be the mid nasal cavity.
• Make sure to open the field of view to include skin-to-skin margins of the collimated
area.
QUALITY CONTROL
Quality of Diagnostic Image
For quality control of any diagnostic image, use a simple 3-step approach.

1. Is the technique adequate, with appropriate exposure and development?

2. Is the correct anatomy present within the image? Compare the images you obtain with
the images in this article.
3. Is positioning anatomically correct (Was correct anatomic coverage obtained?),
straight, and symmetric? Symmetry of the skull for VD/DV images is critical when
evaluating all structures and osseous anatomy.

Once it is determined that the technique is adequate, make sure the appropriate anatomy is
present and positioning is correct, straight, and symmetric. Use the figures in this article as a
guide as well as the information provided in the Ensuring Image Quality sections.

SUMMARY
High-quality, correctly positioned and collimated radiographs are critical for accurate
assessment of the nasal cavity and general survey of the skull. The projections discussed in this
article form the basis for evaluation of other areas, such as the tympanic bullae and
temporomandibular joints, which will be addressed in the next article in this column.

CT = computed tomography; DV = dorsoventral; VD = ventrodorsal

Small Animal Spinal
Radiography Series:
Lumbar Spine
Radiography
Imaging Essentials provides comprehensive information on small animal radiography
techniques. This article is the third article in a 3-part series covering cervical, thoracic, and
lumbar spine radiography.

The following anatomic areas have been addressed in previous columns; these articles are
available at todaysveterinarypractice.com (search “Imaging Essentials”).

• Thorax
• Scapula, shoulder, and humerus
• Abdomen
• Elbow and antebrachium
• Pelvis
• Carpus and manus
• Stifle joint and crus
• Tarsus and pes

Spinal radiographs are indicated for:

 • Evaluation of traumatic injuries
• Neck and back pain
• Pain or neurological issues associated with thoracic or pelvic limb lameness isolated
to these regions.

Each radiographic projection is a separate study and should be radiographed as such. High
quality, correctly positioned and collimated radiographs are required in order to provide an
accurate assessment of the area of interest, especially for surgical planning. In addition to routine
radiographic views, there are additional projections that may aid in the diagnosis of specific
disease conditions or aid in the evaluation of certain anatomic areas.

ROUTINE VIEWS
Lateral and ventrodorsal views are considered the minimum orthogonal radiographs for the
spine. Due to the angled, divergent nature of the x-ray beam, the area of the spine in the center of
the field of collimation will be the area that provides the correct anatomic detail and
intervertebral disk space widths.

A routine lumbar spine study includes:

1. Lateral and ventrodorsal projections of the lumbar spine

2. Lateral and ventrodorsal projections of the lumbosacral junction
3. Lateral and ventrodorsal projections of the caudal vertebra.
Measuring the Lumbar Spine
Measure the thickest portion of the spine that is within the area of collimation.

Lateral Projection: Lumbar Spine

For the lateral projection, position the patient in lateral recumbency (Figure 1).

• Tape the thoracic limbs together evenly and pull cranially, keeping the sternum and
vertebrae equidistant to the table.
• A foam wedge may be placed under the elbows to maintain the laterality of the
patient.
• Tape the pelvic limbs together evenly and pull caudally, keeping the patient in a
lateral position.
• Palpate the iliac crests to determine whether or not the patient is aligned in a lateral
position and parallel to the table.
Figure 1. Dog positioned for lateral radiograph of the lumbar spine (top) and corresponding
radiograph (bottom)

Lateral Collimation
For the lateral projection, the field of view (FOV) should:

• Include the dorsum just above the spinous processes.

• Exclude the ventral half of the abdominal cavity .
• Palpate and place the FOV just cranial to the thoracolumbar junction and just caudal
to the iliac crest at the level of the greater trochanter of the femur (of the pelvic limb
away from the table).
• Palpate the longissimus dorsi muscle and place the horizontal line of the FOV at this
level. This muscle will be just ventral to the transverse processes of the lumbar
vertebrae.
• Place the radiopaque marker along the craniodorsal aspect of the collimation on the
table (not on the patient).
Ventrodorsal Projection: Lumbar Spine
For the ventrodorsal projection, position the patient in dorsal recumbency (Figure 2).

• A trough may be used to maintain the spine’s straightness, but make sure to place the
entire thoracic and lumbar spine within the trough to eliminate an edge artifact over
the area of interest.
• Tape the thoracic limbs individually or together and pull cranially.
• Tape the pelvic limbs individually and pull both caudally.
• Make sure the sternum and thoracic spine are superimposed.

Figure 2. Dog positioned for ventrodorsal radiograph of the lumbar spine (A) and corresponding
radiograph (B

Figure 2-A
Figure 2-B

Ventrodorsal Collimation
For the ventrodorsal projection, the FOV should:

• Include only the caudal thoracic and lumbar vertebral bodies.

• Exclude the lateral abdominal body wall and lung fields in the thoracic cavity.
• Palpate and place the FOV cranial to the xiphoid of the sternum, and just caudal to the
iliac crest.
• Place the center of the FOV halfway in between these landmarks, with the FOV
horizontal line placed at midline.
• Place the radiographic marker on the soft tissues of the ventrum at the most lateral
edge of the collimated light FOV.

Lateral Projection: Lumbosacral Junction

For the lumbosacral junction lateral projection, position the patient in lateral recumbency
(Figure 3).

• Tape the thoracic limbs together evenly and pull cranially, keeping the sternum and
vertebrae equidistant to the table.
 • A foam wedge may be placed under the cubital joints and sternum in order to maintain
laterality of the patient.
• Tape the pelvic limbs together evenly and leave them in a neutral position, neither
flexed nor extended.
• Palpate the iliac crests to determine whether or not the patient is aligned in a lateral
position and parallel to the table.

Figure 3. Dog positioned for lateral radiograph of the lumbosacral junction (A) and
corresponding radiograph (B)

Figure 3-A

Figure 3-B

Lateral Collimation
For the lumbosacral junction lateral projection, the FOV should include the caudal lumbar spine
(L6 and L7) as well as the entire sacrum.
 • Palpate and place the center of the FOV just caudal to the iliac crest at the lumbosacral
junction.
• Locate the lumbosacral junction by palpating the caudal lumbar spinous processes
located just cranial to the iliac crest; then follow the spinous processes caudally until a
divot is felt, which should be at a level caudal to the iliac crest.
• Place the center of the FOV 1 to 2 inches ventral to this point depending on the size of
the patient (1 inch for smaller dogs; 2 inches for larger dogs).
• Include the radiographic marker dorsal to the pelvis at the border of the collimation.

Ventrodorsal Projection: Lumbosacral Junction

For the lumbosacral junction ventrodorsal projection, position the patient in dorsal recumbency
(Figure 4).

• A trough may be used to maintain the spine’s straightness. The lumbosacral junction
can be placed either within the trough or outside the trough directly on the table. To
avoid edge artifact, make sure the lumbosacral junction is either well within or well
outside the trough.
• Tape the thoracic limbs individually or together and pull cranially.
• Tape the pelvic limbs individually and pull caudally, or place them in a “frog-leg”
position.

Figure 4. Dog positioned for ventrodorsal radiograph of the pelvis. Collimation should be
adjusted to the iliac crest/wings cranially and the ischiadic tuberosity caudally for a correctly
collimated position of the lumbosacral spine (top); corresponding radiograph (B)

Figure 4-A
Figure 4B

Ventrodorsal Collimation
For the lumbosacral junction ventrodorsal projection, the FOV should:

• Include only the wings of the ilia on either side of the lumbosacral junction.
• Exclude the lateral body wall and soft tissues.
• Palpate and place the FOV caudal to the iliac crest.
• Place the center of the FOV at this level with the horizontal line placed at midline.
• Place the radiographic marker along the ventral soft tissues at the lateral most edge of
the collimated light FOV.

Lateral Projection: Caudal Vertebra (Tail)

For the caudal vertebra lateral projection, position the patient in lateral recumbency (Figure 5).

• Tape the pelvic limbs together evenly and pull them slightly cranial to avoid
superimposition of the musculature.
• Gently pull the tail straight from the pelvis caudally; tape placed around the tail tip can
help keep the tail in place.
• Place a foam square or rectangle sponge under the tail to maintain laterality. The
height of the sponge should align the tail evenly with the rest of the spine, not
allowing the tail to angle up or down.
Figure 5. Dog positioned for lateral radiograph of the caudal vertebra (tail) (top) and
corresponding radiograph (bottom)

Lateral Collimation
For the caudal vertebra lateral projection, the FOV should include the caudal pelvis through the
level of the tail.

• The FOV will be determined by the length of the tail.

• Palpate the caudal lumbar spinous processes just cranial to the iliac crest.
• Follow these spinous processes caudal until the divot at the lumbosacral junction is
felt; this will be the cranial border of the FOV.
• The caudal border will be just past the last caudal vertebra or end of the tail tip.
• Place the radiographic marker dorsal to the tail.

Ventrodorsal Projection: Caudal Vertebra (Tail)

For the caudal vertebra ventrodorsal projection, position the patient in dorsal recumbency
(Figure 6).

• A trough may be used to maintain the spine’s straightness, but make sure to place the
pelvis outside of the trough, directly on the table, to eliminate an edge artifact.
• Gently pull the tail caudally so it is straight; tape may be used to hold the tail in place.
 • Tape the thoracic limbs individually or together and pull cranially.
• Place the pelvic limbs in a “frog-leg” position relative to the pelvis to prevent their
superimposition on the caudal vertebrae and area of interest

Figure 6. Dog positioned for ventrodorsal radiograph of the caudal vertebra (tail) (top) and
corresponding radiograph (bottom)

Ventrodorsal Collimation
For the caudal vertebra ventrodorsal projection, the FOV should:

• Include both wings of the ilia on either side of the lumbosacral junction.
 • Exclude the body wall on either side.
• Palpate and place the cranial point of the FOV caudal to the iliac crest.
• Place the caudal point of the FOV just beyond the tip of the tail.
• Place the radiographic marker lateral to the tail for the appropriate side.

ADDITIONAL VIEWS
Lateral Flexed & Extended Projections:
Lumbosacral Junction
When lumbosacral disease or cauda equina syndrome is expected, flexed and extended
projections are taken of the lumbosacral junction. Compression of this joint can be caused by
malformation, degenerative joint disease, or intervertebral disk disease, and can result in pain,
ataxia, unilateral or bilateral paraparesis, and urinary or fecal incontinence.

For both the lateral flexed and extended projections, position the patient in lateral recumbency
(Figure 7).

Figure 7. Dog positioned for lateral flexed (A) and extended (B) projections of the lumbosacral
junction and corresponding radiographs (C and D, respectively)

Figure 7-A
Figure 7-B

Figure 7-C

Figure 7-D
 • Tape both pelvic limbs evenly.
• For the flexed projection, pull the pelvic limbs cranially and up toward the ventral
aspect of the abdomen; anchor with a sandbag.
• For the extended projection, place a sandbag at the cranial aspect of the lumbar spine
to keep the patient from moving dorsally. Pull the pelvic limbs straight behind the
pelvis, caudally and dorsally.

Collimate as described for the lateral projection of the lumbosacral junction.

Ventrodorsal Oblique Projection: Lumbar Spine

Subtle lesions, fractures, and intervertebral disk disease are a few of the conditions that may
require a ventrodorsal oblique projection of the spine.

• From the straight ventrodorsal position of the lumbar spine, obliquely rotate the
patient to the left approximately 10° to 15°; then take the radiograph.
• Rotate the patient to the right approximately 10° to 15° and take a second radiograph.

Collimate as described for the ventrodorsal projection of the lumbar spine.

QUALITY CONTROL
To make certain the desired technique has been achieved, use the following guidelines to
determine whether the appropriate anatomy is included in the images.

Lumbar Spine
For the lateral projection of the lumbar spine:

• The cranial border should include the caudal aspect of the thoracic spine at around the
level of thoracic vertebra 11 (T11).
• The caudal border should, at least, include the lumbosacral junction.
• The rib heads should be superimposed at the vertebral body level. The transverse
processes of the lumbar vertebra should be superimposed, resembling a “Nike
swoosh.”
• The intervertebral foramen should resemble a horse head.

For the ventrodorsal projection of the lumbar spine:

 • The cranial border should include the caudal aspect of the thoracic spine at the level of
T11.
• The caudal border should include the lumbosacral junction.
• The spinous processes should be superimposed over the thoracic and lumbar vertebral
bodies.
• In a straight dorsoventral projection, the dorsal spinous processes have a teardrop
appearance.

Lumbosacral Junction
For the lateral projection of the lumbosacral junction:

• The caudal border should, at least, include caudal vertebra 2 (Cd 2) and the cranial
border should include the caudal aspect of lumbar vertebra 6 (L6).
• The transverse processes of the lumbar vertebra should be superimposed and resemble
a “Nike swoosh.”

For the ventrodorsal projection of the lumbosacral junction:

• The cranial border should include the caudal aspect of L6.

• The caudal border should include, at least, two of the caudal vertebrae. n

FOV = field of view

Small Animal Spinal
Radiography Series:
Thoracic Spine
Radiography

Imaging Essentials provides comprehensive information on small animal radiography

techniques. This article is the second in a 3-part series covering cervical, thoracic, and lumbar
spine radiography.

The following anatomic areas have been addressed in previous columns; these articles are
available at todaysveterinarypractice.com (search “Imaging Essentials”).

• Thorax
• Scapula, shoulder, and humerus
• Abdomen
• Elbow and antebrachium
• Pelvis
 • Carpus and manus
• Stifle joint and crus
• Tarsus and pes

Spinal radiographs are indicated for:

• Evaluation of traumatic injuries

• Neck and back pain
• Pain or neurologic issues associated with thoracic or pelvic limb lameness isolated to
these regions.

Each radiographic projection is a separate study and should be radiographed as such. High
quality, correctly positioned and collimated radiographs are required in order to provide an
accurate assessment of the area of interest, especially for surgical planning.

FOLLOW THESE PRECAUTIONS

As a general rule, general anesthesia or heavy sedation is necessary to evaluate the spine
because, in most cases, spinal images taken in nonsedated patients are nondiagnostic. In addition,
the presence or absence of disk space narrowing cannot be determined from a nonsedated
animal’s radiographs due to unavoidable positioning artifacts.

If a back injury (fracture) is suspected, DO NOT flex or extend the spine of the injured dog or
cat, and DO NOT turn the patient for an orthogonal image. If possible, a horizontal beam image
is done for the ventrodorsal projection.

ROUTINE VIEWS
Lateral and ventrodorsal views are considered the minimum orthogonal radiographs for the
spine. Due to the angled, divergent nature of the x-ray beam, the area of the spine in the center of
the field of collimation will be the area that provides the correct anatomic detail and
intervertebral disk space widths.

A routine thoracic spine study includes:

1. Lateral image of the thoracic spine

 2. Ventrodorsal image of the thoracic spine
3. Lateral image of the thoracolumbar spine
4. Ventrodorsal image of the thoracolumbar spine.

Lateral Projection: Thoracic Spine

For the lateral projection, position the patient in lateral recumbency (Figure 1).

• Tape the thoracic limbs together evenly and pull cranially, keeping the sternum and
vertebrae equidistant to the table.
• A foam wedge may be placed under the cubital joints and/or sternum in order to
maintain laterality of the patient; wedges are typically needed for large-breed and/or
barrel-chested dogs.
• Tape the pelvic limbs together evenly and pull caudally, keeping the patient in lateral
position.
• The thoracic spine should be aligned with the horizontal line of the collimated field of
view (FOV). To accomplish this alignment, the pelvis of the dog or cat may need to be
shifted ventrally.

To determine whether or not the patient is aligned in a lateral position and parallel to the table,
gauge the superimposition of the iliac wings by palpating the wings to ensure they are even.
Lateral Collimation
For the lateral projection, the FOV should:

• Include the dorsum just above the spinous processes

• Exclude the sternum and ventral third of the thoracic cavity.

For all patients:

• Palpate the vertebrae of the thoracic spine by following the ribs dorsally to where they
meet the vertebral bodies; place the horizontal line of the FOV at this plane.
• Accommodate the contour of the thoracic spine from a ventral position cranially to a
more dorsal position caudally.
• Place the radiographic marker to the caudal right or left of the patient to keep it from
overlapping with important anatomic areas.

Measuring the Thoracic Spine

Measure the thickest portion of the spine that is within the area of collimation.

Ventrodorsal Projection: Thoracic Spine

For the ventrodorsal projection, position the patient in dorsal recumbency (Figure 2).
 • If a trough is used, place the entire thoracic spine within the trough to eliminate edge
artifacts.
• Extend the skull and neck and align with the manubrium; the skull and cervical spine
should also be aligned in a straight line cranially.
• Align the sternum over the thoracic spine; it should be superimposed onto the thoracic
spine on the final image.
• Tape the thoracic limbs either together or individually and pull cranially.
• Tape the pelvic limbs individually and pull caudally.

Ventrodorsal Collimation
For the ventrodorsal projection, the FOV should:

• Include the thoracic vertebral bodies, with only the rib head and proximal rib bodies
visualized.
 • Exclude the lateral body wall and mid zone to peripheral portion of the middle and
caudal lung fields.

For all patients:

• Palpate the manubrium and the xiphoid of the sternum; collimate just cranial to the
manubrium and 3 finger widths caudal to the xiphoid.
• Place the center of the FOV halfway in between these landmarks, with the horizontal
line of the FOV placed midline.
• Place the radiographic marker on the soft tissues of the ventrum at the most lateral
edge of the collimated FOV.

Lateral Projection: Thoracolumbar Junction

Due to x-ray beam divergence, it is necessary to include a projection of the thoracolumbar (T-L)
junction for a spinal radiographic survey that includes the thoracic and lumbar spine.

For the thoracolumbar junction lateral projection, position the patient in lateral recumbency
(Figure 3).
 •

o Tape the thoracic limbs together evenly and pull cranially in the same
manner as a lateral thoracic radiograph, keeping the sternum and vertebrae
equidistant to the table.
o A foam wedge may be placed under the elbows in order to maintain
laterality of the patient.
o Tape the pelvic limbs together evenly and pull caudally, keeping the patient
in lateral position.

To determine whether or not the patient is aligned in a lateral position and parallel to the table,
gauge the superimposition of the iliac wings by palpating the wings to ensure eveness.

Lateral Collimation
For the lateral projection, the FOV should include T10 through L3, including spinous processes
of the respective vertebrae.
 • Palpate the junction between the last thoracic vertebral body (T13) and the first
lumbar vertebra (L1) by following the caudal border of the last rib dorsally to the
point where it joins the vertebral column.
• Place the center of the FOV 2 finger widths caudal to this space.
• Place the radiographic marker to the caudal right or left of the patient to keep it from
overlapping with important anatomic areas.

Ventrodorsal Projection: Thoracolumbar Junction

For the thoracolumbar junction ventrodorsal projection, position the patient in dorsal
recumbency (Figure 4).

• If a trough is used, place the entire thoracic spine within the trough to eliminate edge
artifacts.
• Extend the skull and neck and align with the manubrium.
• Align the sternum over the thoracic spine; it should be superimposed with the thoracic
spine on the final image.
• Tape the thoracic limbs either together or individually and pull cranially.
 • Tape the pelvic limbs individually and pull caudally.

Ventrodorsal Collimation
For the ventrodorsal projection, the FOV should:

• Include the thoracic vertebral bodies, with only the immediate rib heads and soft
tissues visualized.
• Exclude the lateral body wall and lungs of the thoracic cavity.

For all patients:

• Palpate the xiphoid of the sternum and the curve of the last rib in the lateral body wall.
• Place the center of the FOV halfway in between these landmarks, with the horizontal
line of the FOV placed midline.
• Place the radiographic marker on the soft tissues of the ventrum at the most lateral
edge of the collimated FOV.

ADDITIONAL VIEWS
Ventrodorsal Oblique Projection: Thoracic Spine
Subtle lesions, fractures, and intervertebral disk disease are a few of the conditions that may
require a ventrodorsal oblique projection of the spine (Figure 5).
• From the straight ventrodorsal position of the thoracic spine, obliquely rotate the
patient to the left approximately 10° to 15°; then take the radiograph.
• Rotate the patient to the right approximately 10° to 15° and take a second radiograph.
Collimate as described for the ventrodorsal projection of the thoracic spine. The ventrodorsal
oblique thoracic spine projection requires a larger collimated FOV on the lateral aspect due to
the curvature of the spine in that region.

For quality control of any diagnostic image, follow a simple 3-step approach:

1. Is the technique adequate (appropriate exposure and development factors)?

2. Is the correct anatomy present within the image?
3. Is the positioning anatomically correctand straight?

QUALITY CONTROL
To make certain the desired technique has been achieved, use the following guidelines to
determine whether the appropriate anatomy is included in the images.

Thoracic Spine
For the lateral projection of the thoracic spine:

• The cranial border should include the caudal aspect of the cervical spine (C7).
• The caudal border should, at least, include lumbar vertebra 1 (L1).
• For the lateral position, the rib heads should be superimposed at the vertebral body
level.

For the ventrodorsal projection of the thoracic spine:

• The cranial border should include the caudal aspect of the cervical spine at the level
of C7.
• The caudal border should, at least, include lumbar vertebra 1 (L1).
• The spinous processes should be superimposed over the thoracic vertebral bodies.

Thoracolumbar Junction
For the lateral projection of the thoracolumbar junction:

• The cranial border should include the caudal aspect of the thoracic spine near the
level of thoracic vertebra 11 (T11).
• The caudal border should, at least, include lumbar vertebra 3 (L3).
• For a true lateral position, the rib heads should be superimposed at the vertebral body
level.
For the ventrodorsal projection of the thoracolumbar junction:

• The cranial border should include the caudal aspect of the thoracic spine at the level
of T11.
• The caudal border should, at least, include L3.
• The spinous processes should be superimposed over the thoracic and lumbar vertebral
bodies.
• In a straight dorsoventral projection, the dorsal spinous processes should have a tear
drop appearance.
Small Animal Spinal
Radiography Series:
Cervical Spine
Radiography

Imaging Essentials provides comprehensive information on small animal radiography

techniques. This article is the first in a 3-part series covering cervical, thoracic, and lumbar spine
radiography.

The following anatomic areas have been addressed in previous columns; these articles are
available at todaysveterinarypractice.com (search “Imaging Essentials”).

• Thorax
• Scapula, shoulder, and humerus
• Abdomen
• Elbow and antebrachium
• Pelvis
• Carpus and manus
• Stifle joint and crus
• Tarsus and pes
Spinal radiographs are indicated for:

• Evaluation of traumatic injuries

• Neck and back pain
• Pain or neurologic issues associated with thoracic or pelvic limb lameness isolated to
these regions.

Each radiographic projection is a separate study and should be radiographed as such. High
quality, correctly positioned and collimated radiographs are required in order to provide an
accurate assessment of the area of interest, especially for surgical planning.

As a general rule, general anesthesia or heavy sedation is necessary to evaluate the spine
because, in most cases, spinal images taken in nonsedated patients are nondiagnostic. In addition,
the presence or absence of disk space narrowing cannot be determined from a nonsedated
animal’s radiographs due to unavoidable positioning artifacts.

ROUTINE VIEWS
Lateral and ventrodorsal views are considered the minimum orthogonal radiographs for the
spine. Due to the angled, divergent nature of the x-ray beam, the area of the spine in the center of
the field of collimation will be the area that provides the correct anatomic detail and
intervertebral disk space widths.

If there is a suspected abnormality at the edge of the image, a repeat collimated image centered
at the area of interest is required for complete evaluation. Recollimated images are important
because they depict common areas of disease (ie, intervertebral disk spaces) that are typically at
the edge of the film/image, which could be misinterpreted as narrowed due to the divergent
nature of the x-ray beam.

Measuring the Cervical Spine

Measure the thickest portion of the neck that is within the area of collimation.

Due to thickness differences of the cranial and caudal parts of the neck in large-breed dogs, such
as Doberman pinschers, Great Danes, or mastiffs:

• For lateral imaging, measure mid cervical and at the level of the shoulder.
• For ventrodorsal imaging, measure mid cervical and at the level of the manubrium.
These techniques result in 2 separate radiographic images—cranial and caudal radiographs of the
cervical spine.

A routine cervical spine study includes:

1. Open lateral image of entire cervical spine

2. Open ventrodorsal image of entire cervical spine
3. Collimated image of lateral cervicothoracic spine
4. Collimated image of ventrodorsal cervicothoracic spine.

Lateral Projection: Cervical Spine

For the lateral projection, position the patient in lateral recumbency (Figure 1).

• Tape the thoracic limbs together evenly and pull caudally.

• Tape or sandbag the thoracic limbs in this caudal position, which places the humerus
and glenohumeral joint below the cervical spine, eliminating superimposition. There
will always be some degree of superimposition of the scapula.
• Move the lumbar area of the dog dorsally, allowing the cervical spine to align with the
horizontal collimation light.
• Place the skull in lateral position; then extend the skull and spine naturally and pull
them straight cranially.

If the patient is a large-breed dog, place a sponge under the cervical spine and skull cranial to the
shoulder. The sponge elevates the cranial portion of the cervical spine, making it level and lateral
with the caudal portion of the cervical spine.
Collimated Projection: Cervicothoracic Spine
The collimated lateral image is centered over the cervicothoracic spine, and extends from the
mid cervical spine (cranial limit of field of view [FOV]) to just caudal to the scapulohumeral
joint.

Lateral Collimation
For the lateral projection, the FOV excludes the ventral and dorsal soft tissues of the neck,
only including the cervical vertebral bodies and immediate soft tissues adjacent to the spine.

For all patients:

• Palpate the vertebrae of the cervical spine and place the horizontal line of the FOV at
this plane.
• For smaller patients, collimate the FOV to include the caudal portion of the skull
(cranial limit) to just caudal of the scapulohumeral joint (caudal limit).
• For larger patients (cranial and caudal images):
 o The cranial projection FOV should include the caudal portion of the skull to
just cranial to the level of the scapulohumeral joint.
o The caudal projection FOV is centered just dorsal to the humeral scapular
joint and first rib; it should extend cranially to the mid cervical spine and
caudally to approximately the third rib.

The radiographic marker is placed along the dorsal and cranial aspect of the collimated FOV.

Ventrodorsal Projection: Cervical Spine

Position the patient in dorsal recumbency (Figure 2).

• If a positioning trough is used, place the entire cervical spine within the trough to
eliminate any edge artifacts associated with the imaging tray.
• Extend the skull and neck and align them with the manubrium.
• Pull the thoracic limbs caudally and either tape together or individually.

Collimated Projection: Cervicothoracic Spine

The caudal ventrodorsal projection used for large-breed dogs (see Ventrodorsal Collimation) also
serves as the collimated cervicothoracic image for all dogs and cats.
Ventrodorsal Collimation
For the ventrodorsal projection, the FOV excludes the lateral soft tissues of the neck,
only including the central cervical vertebral bodies and immediate soft tissues adjacent to the
vertebral column.

For all patients:

• Palpate the vertebrae of the cervical spine and place the horizontal line of the FOV at
this plane.
• For smaller patients, collimate the FOV to include the caudal portion of the skull and
caudal to approximately the third rib.
• For larger patients (cranial and caudal images):
o The cranial projection FOV should include the caudal portion of the skull to
just cranial to the manubrium.
o The caudal projection FOV should extend to mid cervical spine cranially
and extend caudally to approximately the third rib. If allowable, the tube
head should be angled approximately 10° toward the dog or cat’s head,
which aligns the angle of the x-ray beam with the angle of the caudal
cervical intervertebral disk spaces, eliminating superimposition of the
vertebral body over the intervertebral disk space.

The radiographic marker is placed along the right cranial aspect of the image in the collimated
FOV.

ADDITIONAL VIEWS
Lateral Oblique Projection: Cervical Spine
Trauma or congenital malformation may cause atlantoaxial luxation or instability of the joint
between cervical vertebra 1 and 2. To visualize the dens, an oblique projection from the lateral
position is obtained.

If an atlantoaxial instability is suspected, it is imperative that care be taken not to luxate the
vertebra further, resulting in spinal cord trauma. Sedation is highly recommended for these
patients to avoid additional movement.

Position the patient in lateral recumbency (Figure 3).

• Tape the forelimbs and pull caudally with gentle pressure.

• Obliquely angle the spine in a ventral direction, which is achieved by placing a sponge
under the dorsal skull and shoulder.
For collimation, the FOV is centered at the atlantoaxial joint. The cranial border is at mid skull,
while the caudal border includes cervical vertebra 3 and 4.

Lateral Flexed & Extended Projections: Cervical

Spine
Flexed and extended projections are used for cervical vertebral malformation (CVM) or
Wobbler’s syndrome.

Compression of the spinal cord due to abnormalities occurs mainly in large-breed dogs and
affects the caudal cervical vertebrae and their articulations, resulting in paraparesis, tetraparesis,
or ataxia. The large-breed dog will need a cranial and caudal projection as with a naturally
positioned cervical spine projection.

For both projections, position the patient in lateral recumbency, with the forelimbs taped and
pulled caudally.

For the extended projection (Figure 4), push the skull and cervical spine dorsally.

• Ensure that the caudal cervical vertebra are angled dorsally, not merely pivoted at the
mid cervical spine.
• Hold the skull in place with a sandbag or tape.
For the flexed projection (Figure 5), pull the skull and cervical spine ventrally toward the
forelimbs.

• Ensure that the cervical spine is flexed at the level of the caudal cervical vertebra and
not merely arched at the mid cervical spine.
• Hold the skull in place with a sandbag or tape.

For collimation, due to the flexion and extension of the cervical spine, the FOV includes most
of the soft tissues of the neck.

Ventrodorsal Oblique Projection: Cervical Spine

Subtle lesions, fractures, and intervertebral disk disease are a few of the conditions that may
require a ventrodorsal oblique projection of the spine.

From the straight ventrodorsal position of the cervical spine, obliquely rotate the patient to the
left approximately 10° to 15°; then take the radiograph. Then rotate the patient to the right
approximately 10° to 15° and take another radiograph.

Set the collimation of the oblique ventrodorsal projections as described for the ventrodorsal
projection of the cervical spine.

For quality control of any diagnostic image, follow a simple 3-step approach:
 1. Is the technique adequate (appropriate exposure and development factors)?
2. Is the correct anatomy present within the image?
3. Is the positioning anatomically correct and straight?

QUALITY CONTROL
To make certain the desired technique has been achieved, use the following guidelines to
determine whether the appropriate anatomy is included in the images.

For both lateral and ventrodorsal projections of

the cervical spine:
• The cranial border should include the caudal aspect of the skull.
• The caudal border should, at least, include T1.

For the lateral projection of the cervical spine:

• The wings of the Atlas (C1) should be even and superimposed.
• Each cervical vertebral body should be even with the superimposed transverse
processes.
• On a straight cervical spine, the wings of C1 will overlap each other and be
superimposed over the dens, which is not visualized.

For the ventrodorsal projection of the cervical

spine:
• The spinous processes should be superimposed over the vertebral bodies.
• The spinous process over the Axis (C2) should resemble a thin line bisecting the
vertebral body.
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PEER REVIEWED

RADIOLOGY/IMAGING

Small Animal Tarsus & Pes

Radiography
Issue: November/December 2012
•
•
•
•

In the September/October 2012 issue, the Imaging Essentials column discussed carpus and
manus radiography. Similar to radiographs of those structures, radiographs of the tarsus and pes
are used to evaluate traumatic injuries and swelling or lameness.
Standard evaluation of the tarsus and pes includes mediolateral and dorsoplantar projections. The
additional projections described aid in diagnosis of specific disease conditions or evaluation of
specific anatomic areas. Stress views are described so that ligamentous and joint capsular
stability can be assessed.

ROUTINE PROJECTIONS
Mediolateral Projection (Figure 1)
For the mediolateral projection, the dog or cat is positioned on the table in lateral recumbency,
with the affected thoracic limb positioned against the table or imaging cassette/detector.

Figure 1. Dog positioned for mediolateral image of the tarsus (A) and corresponding radiograph
(B). Mediolateral positioning for the pes (C) and phalanges (D) and corresponding radiographs
(E and F, respectively).

Figure 1-A
Figure 1-B

Figure 1-C
Figure 1-D

Figure 1-E
Figure 1-F

• The affected pelvic limb is pulled distally in a neutral position (perpendicular to the
body; not pulled cranially or caudially) and taped in that position. A small sponge may
need to be placed under the stifle to keep the limb level with the detector/cassette.
• The unaffected limb is taped and pulled caudally to avoid superimposition between
the 2 pelvic limbs through the level of the proximal femur, in case mediolateral
images of the crus or stifle also need to be taken.
• Alternatively, the unaffected limb may be abducted away from midline and the table;
then secured to the table with tape in the same fashion as when imaging the stifle or
femur (unaffected pelvic limb is taped to the back of the table as shown in Figure
4A).
• In some patients with severe degenerative joint disease, the unaffected limb can be
pulled cranially or caudally and secured with tape, keeping it out of the collimated
image.

To set collimation for the mediolateral image:

• Tarsus: Palpate the medial malleolus of the tibia and center the collimated beam just
distal to it. Collimate so the field of view (FOV) includes the proximal third of the
metatarsal bones and distal third of the tibia and fibula.
• Pes: Collimate so the FOV is centered on the metatarsal bones and includes the digits
(toenails included), extending proximally to the tarsocrural joint (medial malleolus).
• Phalanges: The mediolateral projection of the phalanges requires spreading the digits
to avoid superimposition of the sesamoids and metatarsophalangeal joints.
 o This can be accomplished by placing a cotton ball between each digit.
o Alternatively, the digits can be separated by taping the nail of digit II and
digit V with a 12-inch length of ½-inch adhesive tape; then pulling digit II
dorsally and digit V in a plantar direction, taping them to the
detector/cassette or table.
o If the digit lacks a nail, tape around the entire digit, recognizing there will
be tape artifact superimposed over the digit.
o The radiopaque marker is positioned next to digit V to denote lateral.

Dorsoplantar Projection (Figure 2)

For the dorsoplantar projection, the area of interest is imaged in a dorsal to plantar direction,
which positions the affected limb against the cassette/detector or table and reduces magnification
and geometric distortion.

Figure 2. Dog positioned for dorsoplantar images of the tarsus (A) and corresponding radiograph
(B). Dorsoplantar positioning for the pes (C) and phalanges (D) and corresponding radiographic
images (E and F, respectively).

Figure 2-A
Figure 2-B

Figure 2-C
Figure 2-D

Figure 2-E
Figure 2-F

• The dog or cat is positioned in dorsal recumbency in a V-trough, with the pelvis
placed outside the trough directly on the table (as if you were positioning an extended
leg ventrodorsal pelvis radiograph).
• Both pelvic limbs are pulled caudally and taped to the table. A band of tape is placed
around the stifle joints, pulling them medially in order to straighten the tarsus, pes, and
phalanges.
• Place the tarsus, pes, or distal extremity in the center of the collimated FOV. A sponge
may need to be placed under the cassette/detector to elevate it from the table, placing
the cassette/detector as close to the tarsus, pes, and phalanges as possible.

To set the collimation for the dorsoplantar image:

• Tarsus: Palpate the distal tibia at the tarsocrural joint and place the center of the
collimated beam at the level of the proximal intertarsal tarsal joint. Avoid centering
the beam on the calcaneus as this places the beam proximal to the joint. Collimate so
the FOV includes the proximal third of the metatarsal bones and distal third of the
tibia and fibula (crus).
• Pes: Collimate so the FOV is centered in the middle of the metatarsal bones and
includes the digits (toenails included), extending proximally to the talocrural joint.
• Phalanges: The dorsoplantar projection of the phalanges requires spreading the digits;
follow the instructions for doing so under Mediolateral Projection.
FLEXED, HYPEREXTENDED, &
STRESS PROJECTIONS
In some cases, additional radiographic projections of the pes are necessary. Indications for flexed
mediolateral, hyperextended mediolateral, and stress dorsoplantar projections of the tarsus and
tarsometatarsal joints include:

• Evaluation of soft tissue injuries for possible collateral damage/rupture with resultant
joint instability
• Identification of articular fractures.

These ancillary radiographic projections allow for application of stress to the tarsus joint in an
effort to identify joint space widening, which is encountered when damage to the soft-tissue
supporting structures of the joint has taken place.

Flexed Mediolateral Projection of the Tarsus

(Figure 3)
Figure 3. Dog positioned for mediolateral flexed image of the tarsus (A) and corresponding
radiograph (B).

Figure 3-A
Figure 3-C

• Place the patient in the mediolateral position for the affected pelvic limb.
• Bend the metatarsal bones toward the cranial aspect of the tibia and fibula; use tape to
secure this position. Figure-8 taping can be used around the metatarsal bones distally
and the distal tibia and fibula proximally.
• Center the FOV at the talocrural joint; collimation should include the proximal
metatarsal bones, tarsus, and distal tibia and fibula.

Hyperextended Mediolateral Projection of the

Tarsus (Figure 4)
Figure 4. Dog positioned for mediolateral extended image of the tarsus (A) and corresponding
radiograph (B)
Figure 4-A

Figure 4-B

• Place the patient in the mediolateral position for the affected limb.
• Apply adhesive tape around the tibia and fibula, pull the tape cranially, and anchor to
the imaging cassette/detector or table.
• Apply another strip of tape around the metatarsal bones, pulling caudally, and anchor
the tape to the cassette/detector or table. This taping results in hyperextension of the
talocrural, intertarsal, and tarsometatarsal joints.
• Center the FOV on the tarsal joint; collimation should include the proximal metatarsal
bones and distal tibia and fibula.
Dorsoplantar Projections of the Tarsus with
Lateral & Medial Stress Applied (Figure 5)
Figure 5. Positioning from Figure 2 shown with application of spoon for dorsoplantar medial
(A) and lateral (B) stress images along with corresponding radiographs (C and D, respectively).

Stress views require additional personnel who can apply necessary pressure to the tarsal joints
while the exposure is taken. Those obtaining these images should follow appropriate radiation
safety practices, including wearing radiation monitoring badges, leaded aprons, gloves, and
thyroid shields. A wooden cooking spoon is used to apply medial or lateral stress to the tarsus,
identifying any collateral damage to the joint.

• Begin with the patient in position for a dorsoplantar projection.

• Lateral stress view:
o Place adhesive tape around the distal metatarsal bones and pull distally,
anchoring the tape to the edge of the table.
o Place a second piece of tape around the proximal metatarsal bones and pull
medially, attaching the tape to the edge of the cassette/detector or table to
anchor the pelvic limb.
 o The assistant should hold the handle of the spoon outside the primary x-ray
beam while placing the edge of the spoon along the medial aspect of the
tarsus at the level of the proximal intertarsal joint.
o The edge of the spoon is then pushed toward the lateral side gently; the
exposure is taken while this pressure (stress) is applied.
• Medial stress view:
o The same taping method is used as for the lateral projection, except the
second piece of tape is pulled laterally in order to provide an anchor for the
pelvic limb while pressure is applied using the spoon.
o Place the edge of the spoon along the lateral aspect of the tarsus at the level
of the proximal intertarsal joint and apply gentle pressure in a lateral to
medial direction.
• Collimation:
o Open the collimation up in the proximal to distal direction to obtain the
entire tarsus while pressure is applied in case there is collateral damage.
o Collateral ligament injury or disruption will give an appearance of the tarsal
bones being separated along the lateral and/or medial aspects of the joint
involved.

OBLIQUE PROJECTIONS
Oblique Radiographic Projection of the Tarsus
(Figure 6)
Figure 6. Dog positioned for dorsolateral to plantaromedial oblique (A) and dorsomedial to
plantarolateral oblique (B) images and corresponding radiographs (C and D, respectively). Note
the positioning of the radiographic marker along the lateral aspect of the limb.
Figure 6-A

Figure 6-B
Figure 6-C

Figure 6-D

Indications for oblique projections of the tarsus include complex pathology in which separation
of certain bones will aid in evaluating specific parts of a given tarsal bone or joint surface, such
as:

• Fractures
• Neoplasia, immune-mediated, or congenital anomalies
 • Osteochondritis dissecans of the talus
• Metabolic disorders.

In these oblique projections, the radiopaque identification marker remains along the lateral
aspect of the pelvic limb.

Place the patient in the dorsoplantar radiographic projection position to begin.

• Indications for oblique projections of the tarsus include complex pathology in which
separation of certain bones will aid in evaluating specific parts of a given tarsal bone
or joint surface, such as:
o Fractures
o Neoplasia, immune-mediated, or congenital anomalies
o Osteochondritis dissecans of the talus
o Metabolic disorders.

In these oblique projections, the radiopaque identification marker remains along the
lateral aspect of the pelvic limb.

Place the patient in the dorsoplantar radiographic projection position to begin.

o Dorsomedial to plantarolateral (DM-PIL) oblique projection:

o Place the tarsus in a straight dorsoplantar orientation; then rotate
the crus, tarsus, and pes toward (supinate) midline approximately
35 degrees.
o Collimation remains the same as for the dorsoplantar projection.
o The resulting image includes the same anatomy as the
dorsoplantar image, except that the dorsomedial and
plantarolateral structures (bone and joint surfaces) are
highlighted.
o Dorsolateral to plantaromedial (DL-PlM) oblique projection:
o Place the tarsus in a routine dorsoplantar position; then rotate the
crus, tarsus, and pes outward (pronate) from midline
approximately 35 degrees, which rotates the tarsus, highlighting
the dorsolateral and plantaromedial surfaces of the tarsal bones
and joints.
o Collimation remains the same as for the dorsoplantar projection.
The resulting image includes the same anatomy as the
dorsoplantar image: the calcaneus is projected laterally and the
fibula is superimposed over the tibia.
SKYLINE PROJECTIONS
Dorsoplantar Flexed Skyline Projection of Trochlear Ridges of the Talus (Figure 7)

Figure 7. Dog positioned for dorsoplantar flexed skyline image of the trochlear ridges of the
talus (A) and corresponding radiograph (B).

Figure 7-A

Figure 7-B

Skyline projections highlight a different aspect of the subchondral bone surface—a more dorsal
subchondral bone surface compared with a more plantar surface on routine extended
dorsoplantar images—of the talus’ trochlear ridges at the talocrural joint. This view helps
evaluate the trochlear ridges and medial malleolus of the tibia for osteochondritis dissecans
lesions in the dog.

Place the patient in the position for routine dorsoplantar radiographic projections.

• Put a large sponge under the cassette/detector, which elevates it off the table, placing
the affected limb against the imaging detector.
• Flex the talocrural joint, pointing the foot (pes) straight up at the x-ray tube.
• If the joint cannot be flexed to a 90-degree position and exactly perpendicular with the
table, an angle of 5 to 10 degrees off the angle with the primary x-ray beam is
acceptable.

Collimation:

• Collimate the FOV just to the distal third of the tibia and fibula, including the
talocrural joint and extending distally to the level of the toenails of the digits.
• The resulting image will highlight the subchondral bone of the distal tibia and
trochlear ridges of the talus without superimposition of the calcaneus (as seen in
dorsoplantar projections). The lateral and medial malleolus can also be evaluated.

Proximal Plantar to Distal Plantar Skyline of the

Calcaneus (Figure 8)
Figure 8. Dog positioned for plantaroproximal to plantarodistal oblique skyline image of the
calcaneus (A) and corresponding radiograph (B).
Figure 8-A

Figure 8-B

Place the patient in ventral recumbency.

• Place both pelvic limbs forward and underneath the pelvis in a sphinx-like position.
This positioning helps keep the calcaneus straight relative to the axis of the pelvic
limb.
• Place the affected limb on the cassette/detector or table. This limb needs to be in a
caudal position to allow the calcaneus to extend beyond the ischium in order to avoid
superimposition.

Collimation:

• Collimate the FOV to include the calcaneus but avoid including the distal tibia/fibula
(which would be superimposed over the metatarsus).
• The resulting image will highlight the calcaneus without superimposition of other
tarsal anatomy.

MAKING THE MOVE TO DIGITAL

RADIOGRAPHY
Have you asked yourself, “Should I make the move to digital radiography?” It’s a question that
most practices have considered by now. Fellow practitioners with digital radiography (DR) and
digital equipment manufacturers will tell you the benefits are substantial.

• Better diagnostic capabilities: First and foremost, digital images, and the ability to
enhance and adjust images while viewing, create better diagnostic views, improve
accuracy, and can enhance the overall quality of medicine.
• Access to specialists: Because digital images are easily portable, specialist support
becomes more accessible through email and virtual consultation.
• Increased efficiency: Imaging with digital equipment is light years faster than
traditional film processing. And because digital images can be manipulated, there is
no need to constantly retake views to attain the optimal image.
• Staff savings: With quicker processing times, increased speed, and reduction in the
number of images required, the veterinary team spends more time working with other
patients.
• Reduced supply costs: DR machines do not require the inventory of multiple film
sizes, developer fluids, or processing maintenance.
• Increased volume: Many adopters of digital imaging will say that the increased
efficiency and ease of use of DR has led to increased volume in the number of
imaging studies they perform.
• Client value: Digital images are easier to share with clients and can be viewed in
examination rooms, on tablets, and even on smart phones. As clients become more
integrated into the care of their animals, the perceived value of this service increases.
• Increased revenue: With an improvement in client value, many practices can increase
their prices for radiology studies, which increases associated revenue from patient
diagnostics.

This decision is not just for large practices. As DR technology advances, many new options are
becoming available for all sizes of veterinary practices. However, implementing DR requires
significant investment and commitment from the entire practice team, who must consider all of
the medical, financial, operational, and staff training requirements to make the transition a
successful one.

Travis Meredith, DVM, Diplomate ACT

Contributing Medical Editor

QUALITY CONTROL
When performing QC, a technician should answer three questions about each image obtained:
 1. Is the technique adequate (appropriate exposure and development factors)?
Specifically, have soft tissues been preserved on the image or has the detector been
saturated resulting in loss of soft tissue visualization?
2. Is the correct anatomy present within the image?
3. Is the positioning correct for the radiographic projection?

Once the desired technique has been attained, make sure the appropriate anatomy is included.
The mediolateral and dorsoplantar projections of the tarsus, pes, and phalanges should include
the following areas:

Tarsus

• On the mediolateral projection of the tarsus:

o The calcaneus should not look foreshortened.
o The proximal and distal tarsal bones should be mostly superimposed, with
each row distinct.
• On the dorsoplantar projection of the tarsus:
o The calcaneus on the lateral side should be superimposed over the talus,
lateral malleolus, and fibula.

Pes

• On the mediolateral projection of the pes:

o The proximal and distal tarsal bones should be mostly superimposed, with
each row distinct.
o The metatarsals and phalanges should be superimposed.
• On the dorsoplantar projection of the pes:
o The tarsus, distally to the phalanges (including the toenails), should be
included.
o The tarsus should have the same appearance as when the image is centered
on the tarsus.
o The phalanges should be spread apart to avoid superimposition.

Phalanges
For the mediolateral and dorsoplantar projection of the phalanges, each phalanx should be
separated to allow visualization of each joint.

FOV = field of view

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PEER REVIEWED

RADIOLOGY/IMAGING

Small Animal Carpus &

Manus Radiography
Issue: September/October 2012
•
•
•
•
This is the seventh article in our Imaging Essentials series, which is focused on providing
comprehensive information on radiography of different anatomic areas of dogs and cats. The
following articles are available at todaysveterinarypractice.com:

• Small Animal Thoracic Radiography (September/October 2011)

• Small Animal Abdominal Radiography (November/December 2011)
• Small Animal Pelvic Radiography (January/February 2012)
• Small Animal Radiography: Stifle Joint & Crus (March/April 2012)
• Small Animal Radiography of the Scapula, Shoulder, & Humerus (May/June 2012)
• Small Animal Elbow & Antebrachium Radiography (July/August 2012)

Radiographs of the carpus and manus are needed for evaluation of traumatic injuries and
swelling or lameness.
Standard evaluation of the carpus and manus includes mediolateral and dorsalpalmar projections.
The additional projections described aid in diagnosis of specific disease conditions or evaluation
of specific anatomic areas. Stress views are described so that ligamentous and joint capsular
stability can be assessed. You should not “survey” a thoracic limb (single open leg lateral or
craniocaudal radiograph).

Computed and digital radiographic techniques are sensitive to smaller parts of the anatomy
(extremities of small dogs and cats), metal (bone plates, screws, intermedullary pins, etc), and
collimation. Because detectors reconstruct the image based on x-ray numbers detected in each
element, detector extremes are not handled accurately without artifacts. These extremes would
include collimation to a small area (still the goal for radiation exposure purposes) or extreme
areas of x-ray attenuation between air and metal associated with the image.

This sensitivity means that the technician needs to pay special attention to technique to avoid
saturating the imaging plate, resulting in loss of all soft tissue structures or any potential artifacts.

ROUTINE PROJECTIONS
Mediolateral Projection
For the mediolateral image, the dog or cat is positioned on the table in lateral recumbency, with
the affected thoracic limb positioned against the table or imaging cassette/detector.

• The affected limb is taped and pulled cranially in a neutral position away from the
thoracic cavity. A small sponge may need to be placed under the elbow to keep the
limb level with the detector/cassette (Figure 1).
• The unaffected limb is taped and pulled caudally, allowing it to lie along the thoracic
cavity and preventing superimposition between the thoracic limbs.
Figure 1. Dog positioned for mediolateral collimated image of carpus (A) and corresponding
radiograph (B); mediolateral positioning for manus (C) and phalanges (D) and corresponding
radiographic images (E and F, respectively).
To set collimation for the mediolateral image:

• Carpus: Palpate the carpus and center the collimated beam at this point, which should
be at the level of the accessory carpal pad. Collimate so the field of view (FOV)
includes the proximal third of the metacarpal bones and distal third of the radius/ulna.
 • Manus: Collimate so the FOV is centered in the middle of the metacarpal bones and
includes the digits (toe nails included), proximal to the level of the antebrachiocarpal
joint.
• Phalanges: The mediolateral projection of the phalanges requires spreading the digits
to avoid superimposition of the proximal sesamoids and digits. This can be
accomplished by placing a cotton ball between each digit, taping the nail of digit II
and digit V with a (approximately) 12-inch length of ½-inch adhesive tape, and
pulling digit II dorsally and digit V in a palmar direction, taping these digits to the
detector/cassette or table. If the digit lacks a nail, tape around the entire digit,
recognizing there will be tape artifact superimposed over the digit (proximal phalanx).
Radiopaque markers can be placed dorsal to the second digit and palmar to the fifth
digit as well to avoid confusion (Figure 1).

Measuring the Carpus & Manus for

Radiographic Technique
• Mediolateral projection: Measure the thickness at the level of the carpus.
• Dorsopalmar projection: Measure the thickness at the level of the carpus in the
dorsopalmar direction.
For either projection, the techniques will use a table-top technique instead of a grid.

Radiopaque marker placement:

• Mediolateral projection: Marker placed dorsal to the limb within collimated area.
• Dorsopalmar projection: Marker placed along the lateral aspect of limb within
collimated area.

Collimation:

• Carpus: Center the beam on the carpus, collimating to the carpus.

• Manus: Center on the mid metacarpi, collimating from the distal radius to the end of
the digits.

Dorsopalmar Projection
For the dorsopalmar image, the patient is positioned on the table in ventral recumbency, with the
carpus or manus of the affected limb positioned against the imaging cassette/detector to reduce
magnification and geometric distortion.

• The affected limb is pulled cranially, placing the carpus, manus, or phalanges in the
center of the imaging cassette/detector (Figure 2).
 • The unaffected limb is placed in a natural position and the patient’s head is placed on
this limb. This positioning rotates the affected limb, optimizing the positioning of the
manus.
• Large-breed dogs can be placed in a V-trough in order to keep the dog upright. Ensure
that the unaffected limb and head are outside the V-trough to avoid summation
artifacts.

To set the collimation for the dorsopalmar image:

• Carpus: Palpate carpus and place the center of the collimated beam at this point.
Collimate so the FOV includes the proximal third of the metacarpal bones and distal
third of the radius and ulna.
• Manus: Collimate so the FOV is centered on the mid to distal metacarpal bones and
includes the digits (toe nails included) proximal to the antebrachiocarpal joint and
distal radius/ulna.
• Phalanges: The dorsopalmar projection of the phalanges requires spreading the digits;
follow the instructions for doing so under Mediolateral Projection.
Figure 2. Dog positioned for dorsopalmar collimated image of carpus (A) and corresponding
radiographic image (B); dorsopalmar positioning for manus (C) and phalanges (D) and
corresponding radiographic images (E and F, respectively).
For more information regarding digital radiography artifacts, see the article,
Digital Radiography Artifacts, in Veterinary Radiology and Ultrasound,
available at vitalrads.com/pub/Digital_Radiography_Artifacts.pdf.

ADDITIONAL PROJECTIONS
In some cases, additional radiographic projections of the manus and pes will be necessary.
Indications for flexed mediolateral, hyperextended mediolateral, and stress dorsopalmar/plantar
projections of the carpus, tarsus, carpometacarpal, and tarsometatarsal joints include evaluation
of soft tissue injuries for possible collateral damage/rupture with resultant joint instability
(Figure 3) and identification of articular fractures. These ancillary radiographic projections
allow for the application of stress to the joints of the carpus in an effort to identify joint space
widening that is encountered with damage to the soft tissue supporting structures of the joints.

Flexed Mediolateral Projection of the Carpus

• Place the patient in the mediolateral position for the affected limb.
• Flex the phalanges toward the palmar aspect of the carpus and secure with adhesive
tape using a figure-eight that is applied around the metacarpal bones distally and the
distal radius/ulna proximally.
• Center the FOV at the flexed carpal joint so the proximal metacarpal bones, all of the
carpus, and the distal radius/ulna are included in the collimation.

Hyperextended Mediolateral Projection of the Manus for Instability

• Place the patient in the mediolateral position for the affected limb.
• Apply adhesive tape around the radius/ulna, pull the tape caudally, and anchor to the
imaging cassette/detector. Apply another strip of tape around the metacarpal bones,
pulling dorsally, and anchor the tape to the cassette/detector or table. This taping
results in hyperextension of the antebrachiocarpal, middle carpal, and carpometacarpal
joints.
• Center the FOV on the carpus so the proximal metacarpal bones proximally and distal
radius/ulna are included in the collimation (Figure 3).
Figure 3. Dog positioned for mediolateral flexed (A) and extended (B) images of carpus and
corresponding radiographic images (C and D, respectively); application of spoon for
dorsopalmar medial (E) and lateral (F) stress projections and corresponding radiographs (G and
H, respectively).
Dorsopalmar Projection of the Carpus with
Lateral & Medial Stress Applied
Stress views require additional personnel who can apply necessary pressure to the carpal joints
while the exposure is taken. Those obtaining these images should follow appropriate radiation
safety practices, including wearing radiation monitoring badges, leaded aprons, gloves, and
thyroid shields. A wooden cooking spoon is used to apply medial or lateral stress to the carpus,
identifying any collateral damage to the joint (Figure 3).

• Place the patient in the dorsopalmar position, with collimation as described to the
carpus.
• Open up the collimation slightly more than it would be for a normal dorsopalmar
image of the carpus in order to capture any collateral damage.
• Lateral stress view: This view enables identification of abnormalities on the lateral
side of the carpus.
o Place adhesive tape around the metacarpus and pull the distal extremity
distally; anchor the end of the tape to the edge of the cassette/detector or
table.
o Place a second piece of tape around the metacarpus, pull medially, and tape
to the edge of the cassette/detector or table in order to anchor the distal
limb.
o Holding the handle of the spoon, place the edge along the medial aspect of
the carpus at the level of the middle carpal joint. Push the spoon toward the
lateral side gently.
o The exposure is taken while this pressure (stress) is being applied.
• Medial stress view: This view enables identification of abnormalities on the medial
side of the carpus. The steps are the same as above, except that the spoon edge is
placed along the lateral aspect of the carpus, with pressure applied toward the medial
side.
• Collimation should be set to keep the hands of the person applying stress outside the
primary beam, even if this person is wearing leaded gloves.

Oblique Radiographic Projection of the Carpus

Indications for oblique projections of the carpus include complex pathology in which separation
of certain bones aids in evaluating specific parts of a given carpal bone or joint surface, such as:

• Fractures
• Neoplasia, immune-mediated, or congenital anomalies
• Traumatic distal radial or ulnar premature physeal closure
 • Metabolic abnormalities.
In these oblique projections, the radiopaque identification marker remains along the
lateral aspect of the thoracic limb (Figure 4).
• Place the patient in the dorsopalmar position to begin.
• Dorsomedial to palmarolateral oblique projection:
o Position the carpus in a straight dorsopalmar orientation and rotate
(supinate) toward mid line approximately 35 degrees.
o The collimation is the same as for a dorsopalmar projection.
o The resulting image includes the same anatomy as the dorsopalmar
projection, except that the dorsomedial and palmarolateral structures—bone
and joint surfaces—are highlighted.
• Dorsolateral to palmaromedial oblique projection: Position the carpus in a straight
dorsopalmar orientation and rotate (pronate) outward away from mid line
approximately 35 degrees.
Figure 4. Dog positioned for oblique projections of carpus and corresponding radiographic
images: Dorsolateral to palmaromedial oblique (A) and dorsomedial to palmarolateral oblique
(B) projections and corresponding radiographic images (C and D, respectively).
QUALITY CONTROL
When performing quality control, a technician should answer three questions about each image
obtained:

1. Is the technique adequate (appropriate exposure and development factors)? Specifically, have
soft tissues been preserved on the image or has the detector been saturated resulting in loss of
soft tissue visualization?
2. Is the correct anatomy present within the image?
3. Is the positioning correct for the radiographic projection?

Once the desired technique has been attained, make sure the appropriate anatomy is included.
The mediolateral and dorsopalmar projections of the carpus, manus, and phalanges should
include the following areas:
Carpus
• On the mediolateral projection of the carpus:
o The accessory carpal bone should not look foreshortened.
o No proximodistal superimposition should be present between the carpal
bones; each row should be distinctly separated by a joint space (middle
carpal joint).
• On the dorsopalmar projection of the carpus:
o The accessory carpal should appear as a rounded structure superimposed
over the ulnar carpal bone.
o No proximodistal superimposition between the carpal bones or significant
lateral overlap between carpal bones within a given row (aside from the
accessory carpal bone superimposed over the ulnar carpal bone) should be
present.

Manus
• On the mediolateral projection of the manus:
o The accessory carpal bone should not look foreshortened.
o The proximal and distal rows of carpal bones should appear superimposed;
however, each row will be distinct, with the middle carpal joint and
carpometacarpal joint being separate radiolucent lines.
o The metacarpal bones, metacarpophalangeal joints, and phalanges should
be superimposed.
• On the dorsopalmar projection of the manus:
o The image should include the carpus and distally to the phalanges,
including the toe nails.
o The carpus should have the same appearance as when the image is centered
on the carpus.
o The phalanges should be spread apart to avoid superimposition among
them.

Phalanges
Each phalanx should be separated to allow visualization of each joint on the mediolateral and
dorsopalmar projection of the phalanges.

With the advent of digital radiography, errors in radiography technique are

less common; however, if anatomy is not appropriately collimated and
positioning is inadequate, imaging studies may be rendered nondiagnostic.
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PEER REVIEWED

RADIOLOGY/IMAGING

Small Animal Elbow and

Antebrachium
Radiography
Issue: July/August 2012
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This is the sixth article in our Imaging Essentials series, which is focused on providing
comprehensive information on radiography of different anatomic areas of dogs and cats. The
following articles are available at todaysveterinarypractice.com:

• Small Animal Thoracic Radiography (September/October 2011)

• Small Animal Abdominal Radiography (November/December 2011)
• Small Animal Pelvic Radiography (January/February 2012)
• Small Animal Radiography: Stifle Joint & Crus (March/April 2012)
• Small Animal Radiography of the Scapula, Shoulder, & Humerus (May/June 2012)

In dogs and cats, elbow and antebrachial radiographs are used to evaluate:

• Traumatic injuries
• Soft tissue swelling
• Any potential cause of a thoracic limb lameness.
High-quality, correctly positioned, and collimated radiographs are required in order to accurately
assess the area of interest. This is especially true if surgical planning is required. These studies
should not be used to survey a thoracic limb.

Projections
The elbow or antebrachium radiographic evaluation should include no less than mediolateral and
craniocaudal projections. This is considered the current standard of care. A single radiographic
projection of both thoracic limbs of the dog/cat in sternal recumbency is NOT acceptable for
evaluating the elbow or antebrachium.

Additional projections may aid in the diagnosis of specific disease conditions or evaluation of
certain anatomic areas. Obtaining the projections described in this article will provide a
consistent, repeatable method for obtaining diagnostic-quality radiographs of these areas.

Routine Views: Elbow

Mediolateral Projection
For a mediolateral image, the dog or cat is positioned in lateral recumbency with the affected
limb and area of interest against the table.

• The affected thoracic limb is taped and pulled cranially, in a neutral position, away
from the thoracic cavity (Figure 1).
• A triangular sponge (Figure 1B) is placed dorsally under the scapula to lift the
thoracic spine. This positioning device angles the humerus in a proximal (away from
the table) to distal (closer to the table) fashion, aligning the condyle and laterally
positioning the elbow.
• The unaffected limb is taped and pulled caudally so that it lies along the thoracic
cavity, preventing superimposition between the thoracic limbs.
• Collimation is set by palpating the humeral condyle and placing the center of the
collimation beam at the distal point of the condyle (medial condyle can be readily
palpated without lifting the elbow).
Figure 1. (A) Dog positioned for a mediolateral radiograph of the elbow. (B) Sponge placed
under the shoulder to ensure straight positioning of the elbow. (C) Radiograph of an elbow with
no abnormalities. 1 = distal diaphysis of the humerus; 2 = humeral condyle with superimposed
epicondyles (not seen); 3 = anconeal process of the ulna superimposed over the medial
epicondyle of the humerus; 4 = tuber olecranon; 5 = medial coronoid process of the ulna
superimposed over the radial head; 6 = lateral coronoid process of the ulna; 7 = cranial aspect of
the radial head of the radius; 8 = proximal diaphysis of the radius; 9 = proximal diaphysis of the
ulna
Figure 1-A

Figure 1-B

Figure 1-C
Craniocaudal Projection
For the orthogonal image, the elbow is imaged in a craniocaudal direction, which reduces
magnification and geometric distortion.

• The dog or cat is positioned in ventral recumbency, with the affected thoracic limb
pulled cranially, placing the elbow in the center of the x-ray cassette/imaging detector.
• The unaffected limb is left in a natural position and the patient’s head is placed on this
limb (Figure 2). This rotates the affected limb, which optimizes the position of the
elbow’s olecranon.
• Large-breed dogs can be placed in a V-trough to help keep the dog upright. Make sure
the unaffected elbow and head are outside of the trough to avoid superimposition
artifacts.
• The humeral condyle/epicondyles should be at the center of the collimation beam.
Figure 2. (A) Dog positioned for a caudocranial radiograph of the elbow. (B) Radiograph of an
elbow with no abnormalities.
1 = lateral epicondyle of the humerus; 2 = medial epicondyle of the humerus; 3 = trochlea
(articular surface of the humerus opposite the articular surface of the medial coronoid process of
the ulna); 4 = olecranon of the ulna superimposed over the midportion of the humeral condyle; 5
= capitulum (articular surface of the humerus opposite the articular surface of the radial head); 6
= lateral aspect of the radial head; 7 = medial coronoid process of the ulna

Figure 2-A
Figure 2-B

An alternative technique positions the patient in lateral recumbency, with the affected elbow
away from the table.

• The affected limb is placed on sponges, aligning the carpus, antebrachium, elbow, and
shoulder joint parallel to the table.
• The cassette/detector is then placed caudal to the limb and secured using positioning
tape and sandbags.
• For this technique, the x-ray tube head is rotated 90 degrees toward the affected limb
(x-ray travel is now parallel to the table, not perpendicular). The beam is centered on
the humeral condyle/epicondyles.

Routine Views: Antebrachium

Mediolateral Projection
For a lateral image, the patient is positioned on the table in lateral recumbency, with the affected
limb against the table (Figure 3).

• The thoracic limbs should be taped separately with the affected limb pulled cranially
and away from the thoracic cavity in a neutral position (elbow at approximately 100
degrees of flexion).
• The unaffected limb is pulled caudally so that it lies along the thoracic cavity.
• The collimator beam is centered halfway between the elbow and carpal joints.
Figure 3. (A) Dog positioned for a mediolateral radiograph of the antebrachium. (B) Radiograph
of an antebrachium with no abnormalities. 1 = distal diaphysis of the humerus; 2 = anconeal
process of the ulna superimposed over the medial epicondyle of the humerus; 3 = tuber
olecranon; 4 = radial head and proximal epiphysis; 5 = medial coronoid process of the ulna
superimposed over the radial head; 6 = proximal diaphysis of the radius; 7= proximal diaphysis
of the ulna; 8 = distal radial epiphysis; 9 = lateral styloid process of the distal ulna; 10 =
accessory carpal bone; 11 = superimposed metacarpal bones II, III, and IV

Figure 3-A

Figure 3-B

Craniocaudal Projection
For the orthogonal view, the antebrachium is imaged in a craniocaudal direction, which reduces
magnification and distortion.

The ability of the x-ray machine to perform horizontal beams and manipulate angulation of the
tube will determine how the craniocaudal projection is achieved. The x-ray tube can be
positioned in a:

• Vertical location: X-ray beam perpendicular to the table; patient positioned in sternal
recumbency or
• Horizontal location: X-ray beam parallel to the table; patient positioned in lateral
recumbency.

There is a tradeoff between these two techniques: The easiest technique for use in both the dog
and cat is sternal recumbency positioning, which pulls the affected thoracic limb cranially.
However, the patient may lay more still in lateral recumbency. Both techniques produce high
quality images.

Sternal Recumbency (Figure 4)

• The affected limb is pulled cranially, placing the affected antebracium at the center of
the cassette/detector.
• The unaffected limb is left in a natural, bent position with the patient’s head placed on
it. This rotates the affected limb, optimizing the position of the olecranon of the elbow
and carpus.
• The patient can be placed in a V-trough to help keep the patient upright. Make sure the
unaffected elbow and head are outside of the trough to avoid superimposition artifacts.
• The halfway point between the elbow and carpal joint should be at the center of the
collimator beam.
Figure 4. (A) Dog positioned in sternal recumbency for a caudocranial radiograph of the
antebrachium. (B) Radiograph of an antebrachium with no abnormalities. 1 = distal diaphysis of
the humerus; 2 = lateral epicondyle of the humerus; 3 = olecranon of the ulna superimposed over
the supracondylar foramen of the distal humerus; 4 = medial epicondyle of the humerus; 5 =
radial head; 6 = medial coronoid process of the ulna; 7 = mid diaphysis of the ulna; 8 = mid
diaphysis of the radius; 9 = lateral styloid process of the ulna; 10 = intermedioradial carpal bone
Figure 4-A

Figure 4-B

Lateral Recumbency

• The affected limb is pulled cranially and away from the table; then sponges are placed
along the medial side of the limb, positioning the affected limb level with the shoulder
joint.
• The cassette/detector is placed cranially and secured.
• For this technique, the x-ray tube head is rotated 90 degrees toward the affected limb.
The x-ray beam is centered in a proximodistal direction at a mid point between the
 cubital carpal joints, with the horizontal line of the collimator light aligned with the
midline of the radius/ulna.

Quality Control
Use a three-step approach to determine the quality of a diagnostic image:

1. Is the technique adequate (appropriate exposure and development factors)?

2. Is the positioning anatomically correct and straight?
3. Is the correct anatomy present within the image?

Elbow
Once the desired technique and positioning has been attained, make sure the appropriate anatomy
is included.

• The mediolateral and craniocaudal projections of the elbow should include the distal
third of the humerus and proximal third of the radius/ulna.
• The mediolateral projection of the epicondyles of the humerus should be
superimposed, with joint spaces between the humerus and radius, radius and humerus,
and ulna and humerus (Figures 1B and 1C).
• The craniocaudal projection should align the tuber olecranon and proximal portion of
the ulna, superimposing them over the center of the humeral condyle and
supracondylar foramen of the distal humerus (Figures 2B and 2C).
• Note:
o When evaluating the craniocaudal image, the capitulum (lateral) and
trochlea (medial) join together centrally at a junction site that points toward
the proximal aspect of the humerus (metaphysis and diaphysis).
o This junction site between the trochlea and capitulum should be
superimposed over the middle of the olecranon, between the medial and
lateral cortices, which allows the practitioner to evaluate whether or not
incomplete ossification of the distal humeral condyle is present. If present,
a radiolucent line is seen extending from the joint surface to the
supracondylar foramen.

Antebrachium
As above, once the desired technique and positioning have been attained, make sure the
appropriate anatomy is included.

• The mediolateral and craniocaudal projections of the antebrachium should include the
mid metacarpal level and distal third of the humerus.
 • The mediolateral projection should show the cubital and carpal joints in true lateral
position; not obliqued toward or away from the table/cassette. Keep in mind, however,
that x-ray beam divergence will decrease visualization of the joint spaces when
compared to images from the dog obtained with the x-ray beam centered directly over
the individual joint(s).
• The craniocaudal projection should superimpose and center the tuber olecranon of the
ulna within the distal humeral condyle. The carpus should be flat against the
table/cassette and should not be rotated in either a supinated or pronated position.
• Note:
o Radiographic projections of the antebrachium evaluate the radius and ulna
in their entirety.
o This projection should not replace radiographic examination of the elbow or
carpal joints.

IDENTIFYING ELBOW DYSPLASIA

Elbow dysplasia is a group of developmental disorders that include:

• An ununited anconeal process of the ulna

• Fragmentation of the medial coronoid process of the ulna
• Osteochondrosis/osteochondritis dissecans of the medial aspect of the humeral
condyle.

Elbow dysplasia occurs in young, rapidly growing, large- to giant-breed dogs. Additional
radiographic projections may be needed in order to define extent of pathology or isolate a given
anatomic part, allowing easier identification of subtle pathology.

Flexed Mediolateral Projection

This view allows direct evaluation of the anconeal process, which helps:

• • Confirm an ununited anconeal process of the proximal ulna

• Identify early degenerative change (entheseophyte formation) associated with the
anconeal process.

However, this view rotates the proximal ulna and obscures the margins of the medial coronoid
process of the proximal ulna. Therefore, this radiographic projection should only be used to
evaluate the anconeal process; not other aspects of the elbow.

• The dog is placed in lateral recumbency with the affected limb against the table.
 • A sponge is placed dorsally under the scapula to lift the thoracic spine, helping
position the elbow laterally (Figure 1B).
• The affected limb is taped and pulled cranially away from the thoracic cavity.
• The elbow is then flexed cranially, with the distal part of the limb (manus/paw) placed
near the mandible or under the skull (Figure 5).
• The area of interest should not be near or superimposed over the thoracic inlet or
sternum.
• As with other elbow views, the field of view should include the proximal third of the
radius and ulna and distal third of the humerus.
Figure 5. (A) Dog positioned for a flexed mediolateral projection of the elbow. (B) Radiograph
of an elbow with no abnormalities. 1 = distal diaphysis of the humerus; 2 = caudal margin of the
medial epicondyle of the humerus; 3 = humeral condyle with superimposed epicondyles (not
visualized); 4 = radial head; 5 = medial coronoid process of the ulna; 6 = anconeal process of the
ulna; 7 = tuber olecranon; 8 = proximal diaphysis of the ulna; 9 = proximal diaphysis of the
radius; 10 = nutrient canal of the radius along the caudal interosseous border

Figure 5-A
Figure 5-B

Pronated Craniocaudal Evaluation

This view helps evaluate the:

• Trochlea of the humeral condyle

• Medial coronoid process of the ulna
• Adjacent subchondral bone.
The dog can be placed in either sternal or lateral recumbency (Figure 6), but the
sternal technique is the easiest.
• The elbow should be placed in the same position as for a routine caudocranial
projection (affected thoracic limb pulled cranially).
• The olecranon should then be rotated approximately 10 to 15 degrees laterally. This
shifts the position of the elbow laterally.
• The image should include the same anatomy as in a routine craniocaudal image, with
the olecranon in an oblique lateral position so the trochlea (medial humeral condyle)
and the medial coronoid process (ulna) are more apparent.
Figure 6. (A) Dog positioned for a pronated craniocaudal evaluation of the elbow. (B)
Radiograph of an elbow with no abnormalities; note the difference in the positioning of the ulna
and radius compared with Figure 2B. 1 = distal diaphysis of the humerus; 2 = lateral epicondyle
of the humerus; 3 = olecranon of the ulna; 4 = supracondylar foramen of the distal humerus; 5 =
medial epicondyle of the humerus; 6 = trochlea of the humerus; 7 = medial coronoid process of
the ulna; 8 = lateral border of the radial head superimposed over the lateral cortex of the
proximal ulnar diaphysis; 9 = diaphysis of the ulna; 10 = diaphysis of the radius
Figure 6-A

Figure 6-B

Proximomedial to Distolateral 45-Degree Oblique

Projection
This view helps evaluate the medial coronoid process of the ulna.

• The dog is placed in the same position as for a routine mediolateral elbow projection.
• With the affected limb against the cassette/table, the distal limb (manus/paw) is angled
away from the table (upward) toward the x-ray tube at a 40- to 45-degree angle
relative to the table (Figure 7).
 • Positioning sponges or a large 45-degree triangular sponge is used to maintain the
distal thoracic limb at this angle.
• The elbow remains in contact with the cassette/table. The limb should be taped to the
table, keeping the limb taut but not lifting the elbow away from the table.
• Collimation is the same as in mediolateral and flexed mediolateral projections.
Figure 7. (A) Dog positioned for a proximomedial to distolateral 45-degree oblique projection of
the elbow. (B) Radiograph of an elbow with no abnormalities. 1 = medial epicondyle of the distal
humerus; 2 = anconeal process of the ulna; 3 = tuber olecranon of the ulna; 4 = medial coronoid
process of the ulna; 5 = radial head; 6 = diaphysis of the ulna; 7 = diaphysis of the radius

Figure 7-A

Figure 7-B
Small Animal Radiography
of the Scapula, Shoulder,
& Humerus

This is the fifth article in our Imaging Essentials series, which is focused on providing
comprehensive information on radiography of different anatomic areas of dogs and cats. The
first four articles are available at todaysveterinarypractice.com:

• Small Animal Thoracic Radiography (Sept/Oct 2011)

• Small Animal Abdominal Radiography (Nov/Dec 2011)
• Small Animal Pelvic Radiography (Jan/Feb 2012)
• Small Animal Radiography: Stifle Joint & Crus (Mar/Apr 2012).
This article will review creating high-quality radiographs of the proximal thoracic limb;
specifically the scapula, shoulder joint, and humerus of the dog and cat. High-quality
radiography encompasses the application of three areas: positioning, technique, and quality
control of the final images.

With advances in imaging technology (such as digital radiography), errors in actual technique
(machine settings or darkroom technique) are less common; however, if anatomy is not
appropriately collimated and positioning is inadequate, the imaging study is considered
nondiagnostic.

Sedation for an orthopedic radiographic study allows relaxation of muscles for ease of
positioning and also provides pain control if the patient is painful in the areas being imaged.

RADIOGRAPHIC OVERVIEW:
SCAPULA, SHOULDER JOINT, &
HUMERUS
Indications
Radiographs of the scapula, shoulder joint, and humerus are needed in dogs and cats that present
due to:

• Trauma
• Thoracic limb lameness that localizes to the proximal thoracic limb.

High-quality, orthogonal radiographs are required in order to provide an accurate assessment of

these areas.

Radiographic Views
The radiographic series should contain two types of radiographic views:

• Mediolateral views
• Caudocranial views.
These two types of views would be considered the minimal standard of care in veterinary
medicine. In most situations, placing the dog or cat in lateral recumbency on a 14″ x 17″ cassette
and taking a lateral radiograph to evaluate the entire limb is not acceptable.

Image Quality
Proper collimation and focused examinations are critical for high-quality radiographs and
accurate interpretation.

RADIOGRAPHIC TECHNIQUE
Radiographic technique is determined by a number of things, which are beyond the scope of this
article. However, the techniques suggested throughout this series provide a starting point or
frame of reference for obtaining a diagnostic radiograph of a given area.

Areas of interest that impact technical settings of an x-ray machine include:

• Type of x-ray generator

• Age of x-ray tube
• Accuracy of timers and controls
• Film-focal distance
• Use of a grid
• Subject contrast of area of interest
• Subject thickness
• Film-screen speed/combination
• Darkroom technique used (if using analog film).

Each of these factors present unique challenges that need to be mastered by the technician in
order to optimize image quality. The focus of these articles has been related to the technical
positioning of a patient rather than the factors that impact actual generation of the image
(technique and development).

Measurement Technique
• Lateral projection of scapula: With the limb to be radiographed (affected limb) in a
nonrecumbent position, the scapula is measured at the level of the cranial to mid
thoracic vertebrae (thickest area over which the scapula is lying). You should be able
to palpate the entire scapular spine as the affected limb is away from the table (Figure
1).
 • Mediolateral projection of shoulder joint: With the affected limb against the table,
the humeral head is measured at the level of the thoracic inlet.
• Mediolateral projection of the humerus: With the affected limb against the table,
the humerus is measured halfway between the shoulder and cubital joints.
• Caudocranial projections of the scapula, shoulder joint, and humerus: With the
dog in dorsal recumbancy, the measurement for these three views is taken at the level
of the shoulder joint in the caudal to cranial plane.

Marker Placement
The standard for radiopaque marker placement for extremities is as follows:

• Mediolateral projection: The marker is placed along the cranial aspect of the limb.
• Caudocranial projection: The marker is placed along the lateral aspect of the limb.

SCAPULA
Lateral Image
Positioning
For a right or left lateral image, the patient is positioned on the table in lateral recumbency with
the affected side up (away from the table); then marked with a lead marker in the collimated area
as right (R) or left (L).

• The limb not being radiographed (unaffected limb) is taped and pulled cranially and
distally (away from the thorax) (Figure 1). The skull and neck are positioned ventrally
with a sand bag, positioning the shoulder below the level of the thoracic spinous
processes.
• The affected limb is taped midradius and pulled dorsally, positioning the carpus above
the skull. The elbow will be flexed and, in turn, will superimpose the scapula over the
thoracic spinous processes.
• The pulling of the unaffected limb and pushing of the affected limb will rotate the
torso of the dog or cat, resulting in the affected scapula being positioned dorsal to the
cervical and thoracic spinous processes.
Collimation

• The cranial edge of the collimator light is placed cranial to the distal margin of the
spine of the scapula.
• The caudal edge of the collimator light is placed at the caudal border of the scapula.
• The collimation is opened dorsal and ventral to include the entire scapula.

Caudocranial Image
Positioning
For the orthogonal view, the scapula is imaged in a caudal to cranial direction.

• The patient is placed in dorsal recumbency with each thoracic limb taped separately
and pulled cranially, as in a ventrodorsal thoracic view (Figure 2).

• If the elbows abduct (move lateral to the midsagittal plane or midline), a band of tape
is placed at the level of the mid antebrachii in order to pull them medially, allowing
the olecranon to point straight up toward the x-ray tube. This will ensure that the
scapula and humerus are straight in a proximal to distal direction.

Collimation

• The scapular spine is palpated laterally on the dog or cat.

o The cranial edge of the collimator light is positioned 1 inch cranial to the
acromion process of the spine of the scapula.
 o The caudal edge of the collimator light is placed at the caudal border of the
scapula.
o The medial collimator margin is half way between the skin surface and the
sternum.
o The lateral collimator margin is positioned just lateral to the skin surface.
• The radiopaque marker is placed along the lateral aspect of the skin at the level of the
scapula.

SHOULDER JOINT
Mediolateral Image
Positioning
For a right or left mediolateral image, the patient is positioned on the table in lateral recumbency
with the affected side down and the lead marker is placed within the collimated area as right (R)
or left (L).

• The thoracic limbs should be taped separately with the affected limb pulled cranially
and distally away from the animal’s neck.The unaffected limb is pulled caudally and
taped so that it lies along the lateral thoracic wall (Figure 3).
• The patient’s head and neck are positioned dorsally to avoid superimposition of the
cervical spine over the shoulder joint. A sandbag is placed over the cranial cervical
spine outside the area of collimation. This sandbag can be used to keep the patient’s
head still and out of the field of view (FOV).
Collimation

• The thoracic inlet is palpated first; then your fingers move cranial to the shoulder joint
of the affected limb. The center of the collimator light is placed at this point.
• The FOV is collimated so it includes the distal third of the scapula and the proximal
third of the humerus.
• The radiopaque metal marker (R or L) is placed cranial to the shoulder joint in the
field of collimation.

Caudocranial Image
Positioning
For the orthogonal view, the shoulder joint is imaged in the caudal to cranial direction.

• The patient is placed in dorsal recumbency with each thoracic limb taped separately
and pulled cranially, as in the caudocranial image of the scapula (Figure 4).
• If the elbows abduct, a band of tape is placed at the level of the mid antebrachii to pull
them in medially, allowing the olecranon to point toward the x-ray tube. This action
will straighten the scapula and humerus in a proximal to distal direction.
Collimation

• The indent between the humeral head and distal end of the scapula (or scapular spine)
is palpated laterally and indicates where to place the crosshairs of the collimator light.
• The FOV will include the distal third of the scapula and proximal third of the
humerus.
• The medial and lateral margins should extend from the thoracic inlet to the skin
margin, respectively.
• The radiopaque marker is placed lateral to the skin to prevent superimposition over
any part of the anatomy being radiographed.

HUMERUS
Mediolateral Image
Positioning
For a right or left mediolateral image of the humerus, the patient is positioned on the table in
lateral recumbency with the affected side down (Figure 5).
 • The thoracic limbs should be taped separately with the affected limb pulled cranially
and away from the neck and the unaffected limb pulled caudally along the thoracic
cavity.
• The skull and neck should be pushed dorsally. A sandbag can be used to keep the head
in position and out of the FOV.
• Depending on the thoracic limb being imaged, a lead marker is placed in the
collimated area as right (R) or left (L).

Collimation

• The center of the collimator light should be placed in the middle of the humerus
(craniocaudal and proximodistal directions).
• The collimator light is placed to allow the FOV to include the:
o Shoulder joint and distal scapula proximally
o Entire cubital joint and proximal radius/ulna distally
o Skin margin, in a cranial and caudal direction.

Caudocranial Image
Positioning
For the orthogonal view, the humerus should be imaged in a caudal to cranial direction.

• The patient is placed in dorsal recumbency with each thoracic limb taped separately
and pulled forward similar to a ventrodorsal thoracic view (Figure 6).

• If the elbows abduct, the limbs are held in place by elastic tape at the level of the mid
radius to the limbs medially.

Collimation

• The center of the collimator light is placed in the middle of the humerus (mediolateral
and proximodistal directions).
• The collimator light is placed to allow the FOV to include the:
o Shoulder joint and distal scapula proximally
o Entire cubital joint and proximal radius/ulna distally
o Skin margin laterally to the level of the axilla, in a medial direction.

ADDITIONAL VIEWS
Skyline of Shoulder Joint
This projection is used to image the biceps tendon in the intertubercular groove and the greater
tubercle of the proximal humerus.
Positioning

• The patient is placed in ventral recumbency with the pelvic limbs placed in the
opposite direction of the limb being radiographed (Figure 7).
• The skull is positioned to the side away from the affected limb. The limb is flexed at
the elbow and pulled caudally to the shoulder joint.
• The radius and ulna are abducted away from the shoulder joint in question and care is
taken to make sure the cubital joint and humerus are aligned with the shoulder joint,
but not superimposed.

Collimation

• Palpate the intertubercular groove and place the center of the FOV at that point.
• The FOV should be small and the collimated area only should include the proximal
humerus and surrounding soft tissues. This limited collimated area will decrease the
amount of scatter radiation (personnel exposure and film fog).

Supinated & Pronated Shoulder Joint Images

Osteochondritis dissecans (OCD) is an abnormality of the normal endochondral ossification
process of the articular and epiphyseal cartilage. OCD can affect a variety of synovial joints,
such as the elbow, stifle, tarsus, and, commonly, the shoulder joint.

Pronated and supinated projections are used to image the caudal aspect of the head (epiphysis) of
the humerus, where OCD lesions typically occur.
 • The patient is placed in lateral recumbency and positioned in the same manner as a
mediolateral projection of the shoulder joint.
• For the pronated view, a triangle-shaped sponge is placed under the cranial aspect of
the radius to rotate the antebrachium and carpus externally (Figure 8A).
• For the supinated view, a triangle-shaped sponge is placed under the entire cubital
joint to rotate the antebrachium and carpus internally (Figure 8B).

QUALITY CONTROL
For quality control of any diagnostic image, a 3-step approach is used:

1. Is the technique appropriate?

2. Is the appropriate anatomy present within the image?
 3. Is the patient correctly positioned?

Scapula
The lateral and caudocranial projections of the scapula should include the:

• Head of the humerus

• Caudal border of the scapula.

Due to anatomic limitations, in the lateral view of the scapula there will be some degree of
overlap between the thoracic spinous processes and ventral border and infraspinous fossa of the
scapula.

Shoulder Joint
The lateral and caudocranial projections of the shoulder joint should include the:

• Proximal third of the humerus

• Distal third of the scapula
• All aspects of the shoulder joint (glenoid cavity and humeral head)
• The trachea should be superimposed over the distal portion of the scapula, not the
shoulder joint or humeral head.

Humerus
The lateral and caudocranial projections of the humerus should include the:

• Distal third of the scapula and shoulder joint

• Proximal third of the radius and all aspects of the cubital joint.

FOV = field of view; OCD = osteochondritis dissecans

Small Animal
Radiography: Stifle Joint
and Crus
This article covers the stifle joint anatomy and radiographic positioning, as well
as image formation and quality control.

The stifle joint is one of the most common orthopedic radiographic studies. In addition to
discussing new radiographic techniques for evaluation of dogs with stifle disease, this article also
covers stifle anatomy, radiographic positioning, image formation, and quality control.

Stifle Radiography Overview

Stifle radiographs are routinely needed in cases of trauma and lameness associated with common
stifle joint abnormalities including:
• Medial and lateral luxating patella

• Ligamentous instability secondary to cranial cruciate injury.

High-quality, correctly positioned radiographs are required in order to provide accurate

assessment of the osseous and soft tissue structures of the stifle joint. This becomes even more
critical when corrective osteotomies that alter joint alignment (tibial plateau leveling osteotomy
or tibial tuberosity advancement) are performed.
The standard of care in small animal veterinary medicine for stifle radiographic series should
include straight mediolateral and caudocranial views. Following a consistent, repeatable
technique for obtaining stifle radiographs helps optimize the quality of the images.

Radiographic Stifle Anatomy

The components of the stifle joint (FIGURE 1) include the:

• Distal femur
• Proximal tibia
• Four sesamoid bones, including the patella, fabellae of the origin of the lateral and
medial gastrocnemius muscles, and fabella of the insertion of the popliteus muscle.

The patella normally articulates with the trochlear groove of the cranial distal surface of the
femur. There are two femoral condyles (medial and lateral) that articulate with the medial and
lateral menisci, two c-shaped fibrocartilage structures that cover the tibial condyle and alleviate
the incongruity between the two surfaces. The femoral and tibial condyles barely directly
articulate in the normal stifle because of the menisci.

The fibular head forms a fibrous connective tissue joint with the proximal aspect of the lateral
proximal tibia. The fibula is a lateral anatomic structure and the tibia is located in a medial
anatomic position.

The lateral fabella (sesamoid) of the origin of the head of the gastrocnemius muscle is elongated
in a proximal to distal direction compared with the medial fabella. Both fabellae are located at
the proximal, caudal margin of the femoral condyles. The popliteal sesamoid is located along the
medial aspect of the caudal proximal margin of the tibial condyle.

Stifle Radiographic Exposure

The technique used for an average weight, medium to large dog is 60 kVP and 3 mAs for a
lateral projection and 66 kVP and 3 mAs for a caudal cranial projection, with the stifle placed
directly on the cassette or detector (no grid used).

To set the technique for a lateral projection, measure the stifle at the level of the femoral
condyles in the medial to lateral plane. For the caudal to cranial stifle projection, measure the
level of the distal femur in the caudal to cranial plane. The cranial caudal measurement will be
larger than the medial lateral measurement for most dogs and cats.

Routine Views of the Stifle Joint

Mediolateral Projection
Positioning
For a mediolateral image of the right or left stifle joint, the patient is positioned on the table in
lateral recumbency with the side to be radiographed closest to the table and marked with a lead
marker in the collimated area as right (R) or left (L). This radiopaque marker is placed along the
cranial aspect of the limb and should not be superimposed over any anatomic structure
(FIGURE 2).
 .

• The thoracic limbs should be taped together and pulled cranially to assist with restraint
and ensure lateral position of the body.
• Place a small sponge under the dorsal aspect of the pelvis to help the femoral condyles
remain superimposed over each other in the proximal to distal direction.
• The pelvic limb not being radiographed is taped so it is abducted away from the stifle
being radiographed. This is accomplished by taping around the stifle and tarsus and
securing the tape to the table. If severe degenerative joint disease of the coxofemoral
joints is present, the leg may be pulled forward and taped to the table.
• A small sponge may need to be placed under the plantar surface of the tarsus to rotate
the stifle; this will assist in aligning the femoral condyles in the cranial to caudal
direction.

Collimation

• Palpate the epicondyles of the femur and place the center of the collimator light at this
point.
• Collimate so the field of view (FOV) includes the distal third of the femur and the
proximal third of the tibia. It is also important to include all of the soft tissues cranial
to caudal to the pelvic limb at the level of the stifle joint.
 • Caudally, it is imperative to visualize the fascial stripe that normally runs in a
proximal to distal direction along the caudal aspect of the joint as well as the soft
tissue musculature and popliteal lymph node. Caudal displacement of this fascial
stripe can be indicative of stifle joint effusion and/or capsular thickening.
• Cranially, the collimated FOV should include the skin margin and the patellar
ligament along the inside of the skin margin (thin soft tissue ligament seen extending
from the distal margin of the patella to the cranial and proximal tibial tuberosity).
When technique is correct, the skin margin and patellar ligament will be easily
visualized along the cranial aspect of the stifle joint (Figure 1A).

Caudal to Cranial or Cranial to Caudal Images

Positioning
For the orthogonal view, the stifle should be imaged in a caudal to cranial or cranial to caudal
direction. The caudal to cranial projection will place the stifle joint nearest to the radiographic
cassette or digital detector, reducing image magnification and potential geometric distortion.

A vertical or horizontal beam radiograph can be made; however, the ability to take horizontal
beam images will be constrained by the machine being used. In all cases, the radiopaque ID
marker (R or L) should be placed along the lateral aspect of the stifle joint, avoiding
superimposition over any structures being radiographed.

1. Vertical Beam Positioning: Caudal to Cranial Technique

• This technique works well for smaller dogs and cats.

• The patient can be placed in ventral (sternal) recumbency with the pelvic limbs pulled
caudally, placing the affected stifle in the center of the cassette/detector
(FIGURE 3A). The patient can be placed in a V-trough to help keep the thorax and
pelvis straight.
• The x-ray tube head is then angled toward the pes (pelvic limb distal extremity) with
the center of the x-ray beam at the level of the junction between the thigh and crural
musculature (FIGURE 3B).
• This positioning may not be possible in dogs with severe hip dysplasia, trauma, or
degenerative changes of the lumbar or lumbosacral spine without heavy sedation or
general anesthesia.
 .

2. Vertical Beam Positioning: Cranial to Caudal Technique

NOTE: This positioning results in the greatest degree of magnification and geometric distortion
due to the distance between the stifle joint and the cassette/detector.

• The patient is placed in dorsal recumbency as if positioning for a pelvic ventrodorsal

radiograph. The pelvic limbs are extended to position the stifle joint as close as
possible to the tabletop or imaging cassette/digital detector.
• The x-ray tube head is not angled; instead, it is positioned perpendicular to the
tabletop as routinely used for vertical beam radiography.

3. Horizontal Beam Positioning: Caudal to Cranial Technique (FIGURES 4A AND 4B)

• This technique works well for medium- to large-breed dogs.

• The patient is placed in lateral recumbency with the stifle joint to be imaged in a
nondependent position away from the table. The affected limb is placed on sponges
and pulled distally so that the limb is straight and parallel with the tabletop, being
perpendicular to the pelvis.
• The cassette/detector is then placed along the cranial aspect of the limb and secured to
allow the radiographer to leave during exposure.
 .

Collimation
For the ventrally recumbent patient (FIGURE 3), palpate the femoral epicondyles at the level of
the stifle joint and place the center (cross hairs) of the collimator light at this point.

• Collimate so that the FOV includes the distal third of the femur and the proximal third
of the tibia.
• The x-ray tube head should be rotated approximately 5 to 10 degrees caudally (angle
light from caudal to cranial as seen from the dog) to prevent superimposition of the
femur and tibia at the level of the stifle joint.
• The tube angle is dependent on the muscle mass of the dog when the limb is in an
extended position.
For the laterally recumbent patient (FIGURE 4), the x-ray tube head is rotated 90 degrees,
positioning it parallel with the tabletop and perpendicular to the pelvic limb being radiographed.

• The x-ray beam is centered on the femoral condyles, with the horizontal line of the
collimator light cross hair positioned midline with the femur/tibia. Collimate to
include the distal third of the femur and the proximal third of the tibia.

Quality Control
For quality control of any diagnostic image, remember the following 3-step approach:

1. Is the technique appropriate?

All bones should be sharply margined and clearly visualized. Enough x-ray
penetration should be present to clearly expose the normal cancellous (intramedullary)
bone pattern of the distal femur and proximal tibia. However, the exposure should not
be so great that the soft tissues are overexposed and not visualized in the final image.
2. Is the appropriate anatomy present within the image?
Given that the desired technique has been attained, make sure that the appropriate
anatomy is included. The lateral and caudal cranial projections should include the:
o Distal third of the femur
o Proximal third of the tibia
o Patella and other sesamoid bones
o Soft tissues, including the musculature and popliteal lymph node along with
the cranial and caudal skin margins.
3. Is the positioning lateral and straight?
o In a straight mediolateral image, the femoral condyles should be
superimposed over each other and the fibular head should be in a caudal
position along the proximal portion of the tibial condyle.
o On the caudocranial image, the patella should be in a central position, with
no overlap between the femoral condyles and the tibial condyle.
o The femoral condyles should be equal in size and shape.

RADIOGRAPHIC VIEWS FOR

SPECIFIC ORTHOPEDIC
SURGICAL
PROCEDURES: Preoperative,
Postoperative, & Follow-Up
Studies
Tibial Plateau Leveling Osteotomy
The tibial plateau leveling osteotomy (TPLO) lateral is a special projection. Its purpose is to
position the proximal tibia where the proximal tibial joint surface is highlighted. This allows the
surgeon to consistently and repeatedly determine joint orientation in order to quantitate the tibial
slope. This assessment is then used to plan the osteotomy that will be performed during surgery
(FIGURE 5).

Mediolateral Projection
 • The mediolateral projection includes the crus (tibia and fibula) from the stifle joint
(distal femoral diaphysis) distal to the proximal metatarsus. Both the stifle and tarsal
joints are flexed at a 90-degree angle.
• The center of the collimator light should be placed just distal to the center of the stifle
joint (proximal third). This will allow medial and lateral tibial condyle margin
imposition.
• The intercondylar eminences need to be superimposed in proximal to distal and
cranial to caudal directions.
• However, due to the anatomy of the femur in some dogs, the intercondylar eminences
may be superimposed while the femoral condyles are not. For the purpose of surgical
measurements, it is more important for this view to have the intercondylar eminences
superimposed rather than the femoral condyles.

Caudocranial Projection

• The caudocranial projection should include the distal femur, entire stifle joint, and
crus and extend distal to the level of the proximal metatarsi.
• The femoral condyles should appear equal in size on the image.
• The patella should be superimposed centrally between the femoral condyles and at a
mid position relative to the femoral condyles. This may not be the case if the dog has
patellar luxation (Figure 1).

Tibial Tuberosity Advancement

The tibial tuberosity advancement (TTA) procedure is also used for the surgical repair of cranial
cruciate ligament rupture. The mediolateral radiograph projection for the TTA differs from the
TPLO mediolateral projection in that the femur and tibia are not flexed but remain in a more
natural extended position (FIGURE 6).
 .

Positioning

• Correct positioning for the TTA image will be determined by stifle joint laterality and
angle of the femur and tibia.
• The femoral condyles should be superimposed as with a mediolateral stifle view.
• Using an externally placed goniometer, the stifle joint angle should measure 135
degrees (FIGURE 6).

Specific Projections

• The caudocranial TTA projection should include the distal femur through the proximal
metatarsal bones. The patella should be superimposed centrally between the femoral
condyles, which are normally equal in size.
• For the lateral TTA projection, the center of collimator light should be at the center of
the stifle joint, with the FOV opened to include as much of the femur and tibia as
possible and the stifle joint angle at a 135-degree angle.

Skyline of the Patella

The skyline patella radiographic projection is used to better visualize the patella and trochlear
groove (FIGURE 7). This view is typically used in cases of medial or lateral luxating patella. As
with the caudocranial view of the stifle, there are two approaches to positioning based on a
horizontal or vertical position of the x-ray tube.
 .

Vertical Beam/X-Ray Tube Radiograph

Positioning:

• The patient is positioned in ventral recumbency with the affected limb flexed and
pushed cranial and lateral.
• The tibia is positioned under the femur with the affected stifle centered in the middle
of the cassette/detector.
• A sponge is placed between the body wall and femur to help push the stifle joint away
from the body.
• The patient can be placed in a v-trough for stability and to help keep the thorax
straight.

Collimation:
 • With the patient in ventral recumbency and the stifle joint flexed, palpate the distal
femur and patella.
• The center of the collimator light is positioned at this level (distal femur). The FOV
should include the distal portion of the femur.
• If possible, the x-ray tube should be rotated approximately 5 degrees cranial (toward
the animal’s head) to prevent superimposition of the patella, femur, and tibia. This
view would then be termed a cranioproximal to craniodistal oblique projection of the
patella or distal femur.

Horizontal Beam/X-Ray Tube Radiograph

Positioning:

• The patient is positioned in dorsal recumbency using a V-trough; the pelvic limbs are
flexed.
• The x-ray tube is rotated 90 degrees and placed in a horizontal position, situating the
patella perpendicular to the cassette and x-ray tube head.
• A sandbag is placed over the tarsus and pes for stabilization.
• The cassette/detector is then placed on the abdomen just cranial to the stifles and
secured for exposure.

Collimation:

• With the patient in dorsal recumbency, the tube head is rotated 90 degrees toward the
affected limb.
• The center of the beam is focused at the patellar level. The patella with a small portion
of the femur should be included.

Due to varying thickness of the limb, keep the collimation of the skyline FOV of the patella to as
small an area as possible, which reduces secondary radiation.

This is box title

Although not required, sedation is recommended for any orthopedic radiographic study as it
allows the patient to relax, thereby allowing easier positioning (particularly extension for cranial
caudal images). In addition, sedation also decreases the amount of time required for
repositioning due to lack of patient cooperation. For animals with painful joints, a
neuroleptanalgesic protocol provides both sedation and pain control.

FOV = field of view; TPLO = tibial plateau leveling osteotomy; TTA = tibial tuberosity
advancement
Small Animal Pelvic
Radiography
Following a consistent, repeatable pattern for obtaining pelvic radiographs
ensures the quality of the images will be diagnostic.

The purpose of this article is to review the three basic components of creating high-quality pelvic
radiographs of the dog and cat, including positioning, technique, and quality control of the final
images.

Pelvic radiographs are used in:

• Cases of trauma
• Evaluation of lameness
• Evaluation of congenital disorders (eg, hip dysplasia).

This is the third article in our Imaging Essentials series—a series focused on providing critical
information on radiography of the dog and cat. Read the first two articles, Small Animal
Thoracic Radiography (September/October 2011) and Small Animal Abdominal
Radiography (November/December 2011).
PELVIC RADIOGRAPHIC
EXPOSURE
For any dog measuring 15 cm or greater (measured at the iliac crest), a grid (8:1, 110 lines per
inch) should be used. Grids are available from most radiology manufacturers and a grid tray
comes with all radiology units. The techniques for the ventrodorsal and lateral radiographic
projections of the pelvis are the same. For dogs measuring less than 15 cm or cats, a tabletop
technique is preferred (no grid).

If using direct or indirect digital radiography, then the imaging receptor remains fixed in the grid
cabinet or within the table. If using a computed radiography system, the casette and imaging
plate can be used in a tabletop fashion, similar to film screen combinations.

ROUTINE RADIOGRAPHIC VIEWS

A routine radiographic examination of the pelvis consists of two orthogonal radiographs,
including a lateral image and an extended leg ventrodorsal image. The stifle joints (through the
level of the proximal crus) are included in both images.

Lateral Images
Positioning
For a lateral image of the pelvis, the patient is positioned on the table with the right side down
for a right lateral image and left side down for a left lateral image. For cases, such as pelvic
fractures or lameness, the side of concern should be the dependent side, which is placed closest
to the table. A right lateral image of the pelvis is standard.

The pelvic limbs should be taped separately with a sponge placed between them to ensure that
the right and left hemipelves are aligned and directly superimposed.
The pelvic limb that is closest to the x-ray table is taped in a cranial position, whereas the limb
away from the table is placed in a caudal position so the pelvic limbs are in a scissor position,
with the stifle joints separate and not overlapping (FIGURE 1).
 .

Collimation
Start by setting the collimator light (field of view or FOV) to the same size of the cassette or
detector by using the corresponding numbers next to the collimator knobs (see Small Animal
Abdominal Radiography, November/December 2011). Then adjust the collimation to the actual
size of the patient’s pelvis and pelvic limbs (typically smaller than the original collimator light
setting).

• Cranial Border: Place the vertical center of the FOV along the axis of the greater
trochanter (upper leg). The greater trochanter should be midway between the iliac
crest and ischiatic tuberosity. The cranial border of the collimator light (FOV) should
be placed cranial to the iliac crest.
• Caudal Border: The caudal border of the collimator light should be placed at the
level of the ischiatic tuberosity or caudal skin margin in the perineal region.
• Dorsal Border: The vertical portion of the FOV should extend dorsal to iliac crest
and greater trochanter (skin margin of dorsal pelvis).
• Distal Border: Adjust the horizontal center of the collimator light so that it is midway
between the dorsal skin surface and distally includes the stifle joints and proximal
crura.

Ventrodorsal Images
Positioning
The patient should be placed in dorsal recumbency in a positioning V-trough (FIGURE 2).
Using a V-trough helps keep the patient’s vertebral column and sternum aligned and the pelvis in
a straight position. To avoid superimposed artifacts from the V-trough, the entire pelvis should
be positioned past the edge of the trough and placed on the x-ray table. This positioning also
helps decrease geometric magnification of the image.

• Tape the thoracic limbs together and pull them cranially to help align the vertebral
column. This, in turn, will aid in keeping the pelvis straight. Each pelvic limb should
be taped separately and extended evenly.
 • Once the pelvic limbs have been extended, which typically requires the patient be
adequately sedated, internally rotate the femurs so that they are parallel to one another
and the x-ray table.
• When properly aligned, the patella for each pelvic limb will be centered within the
trochlear groove over the distal femur. Secure the dog’s pelvic limbs in this position
using tape around the femurs at the level of the stifle joint (FIGURES 2A AND 2B).

Collimation
Use the same procedures for setting the collimator light as described earlier for lateral images.

• Cranial Border: The cranial border of the collimator light (FOV) should be placed
cranial to the iliac crest. Palpate the iliac crests and place the cranial edge of the
collimator light just cranial to this level.
• Caudal/Distal Border: The caudal/distal border of the collimator light should be
placed just distal to the stifle joints to allow the proximal crura to be included in the
image.
• Lateral Borders: Close the collimator light laterally so the light is next to the skin on
both the right and left sides. Add a film marker (R/L) for identifying the right or left
side prior to exposure.

ADDITIONAL RADIOGRAPHIC
VIEWS
Frog-Leg Ventrodorsal Images
Dogs and cats with severe coxofemoral degenerative joint disease or fractures of the pelvis,
femoral head/neck, or femur are not physically able to extend their femurs in the standard
extended-leg ventrodorsal position. In this case, a frog-leg ventrodorsal image can be used for
initial assessment.
It addition, in dogs or cats with capital physeal fractures of the femoral head, extending the limbs
into the routine position can actually reduce the fracture and render the fracture indistinguishable
from the normal limb. In this case, the frog-leg ventrodorsal image should be used to confirm the
fracture.

Positioning
Use a V-trough to help keep the patient’s vertebral column and sternum aligned (FIGURE 3).
As with standard ventrodorsal images, avoid superimposed artifacts caused by the V-trough by
placing the entire pelvis past the edge of the trough onto the x-ray table, which also decreases
geometric magnification.
 .

• Tape the thoracic limbs together and pull cranially to help align the vertebral column
that will, in turn, aid in keeping the pelvis straight.
• Place the pelvic limbs in a natural flexed position so that the femurs are at
approximately ninety degrees to the spine and pelvis.

Collimation

• Cranial Border: The cranial border of the collimator light (FOV) should be placed
cranial to the iliac crest based on palpation.
• Caudal Border: The caudal border of the collimator light should be placed just caudal
to the ischiatic tuberosity.
• Lateral Borders: Close the collimator light laterally so the collimation includes at
least the mid to distal femoral level. The stifle joints will need to be radiographed
 separately as necessary. Add a film marker (R/L) for identification of the right or left
side prior to the exposure.

Orthopedic Foundation for Animals

Established in 1966, the Orthopedic Foundation for Animals’ (OFA) mission has been to:

• Distribute information concerning orthopedic and genetic diseases

• Educate and establish control programs to lower the incidence of these diseases in
animals.
• For hip dysplasia certification, OFA requires a straight, extended-leg ventrodorsal
view of the pelvis.
• The femurs need to be extended and parallel to each other; the stifle joints need to be
rotated internally so the pelvis is straight and symmetric (Figure 2).
• Chemical restraint is recommended to ensure a high-quality radiograph the first time
and avoid repeats at the owner’s expense.

For more detailed information regarding OFA certification, registry, details on radiographic
requirements, and forms, veterinarians and/or technicians can visit offa.org.

Pennsylvania Hip Improvement Program

In 1993, Dr. Gail Smith from the University of Pennsylvania School of Veterinary Medicine
established the Pennsylvania Hip Improvement Program (PennHIP) distraction technique as a
method for assessing coxofemoral joint laxity.
The technique provides a quantitative measure of canine coxofemoral joint laxity using a
standardized distraction technique:

• The routine views for submission include:

o An extended-leg ventrodorsal view (standard OFA projection)
o A flexed pelvic limb ventrodorsal compression view
o A distraction flexed pelvic limb ventrodorsal view (FIGURE 4).
• This last projection requires use of a specialized distraction frame apparatus that is
made available to trained and certified PennHip members. Specific details regarding
PennHIP evaluation can be found at pennhip.org.
QUALITY CONTROL
For quality control of any diagnostic image, keep a simple 3-step approach in mind:

1. Determine if the technique is appropriate.

2. Ascertain if the appropriate anatomy is present within the image.
3. Check the correct anatomic positioning for laterality and straightness.

Technique & Anatomy

Given that the desired technique has been attained, make sure that the appropriate anatomy is
included: the lateral and ventrodorsal projections should include the cranial aspect of the iliac
crest, pelvis, coxofemoral joints, and the proximal tibia, including the stifle joints.

Patient Positioning
Lateral Projection

• The transverse processes of the caudal lumbar vertebrae should be superimposed to

determine if a patient is in a true lateral position. The right and left sides should form a
single “Nike” swoosh (FIGURE 5).
 .

• Remember that in the larger dog, due to magnification, the iliac crest and femur
furthest away from the cassette or detector will appear larger than the recumbent side.
• The ischia should be superimposed on the lateral projections; the dorsal acetabular
rims should be superimposed.

Ventrodorsal Projection

• Each caudal lumbar spinous process is viewed end-on and has a distinct diamond or
tear-drop shape.
• The obturator foramina should be symmetrical in shape and equal in size.
• The femurs should be parallel to each other.
• The patellas should be superimposed over the distal femoral trochlear groove in a
normal dog. If the dog or cat has luxation of the patella, the patella may be laterally or
medially displaced relative to the distal femur.
• The lateral aspects of the ischiatic tuberosities will overlap evenly along the medial
aspect of the proximal femurs (Figures 2C, page 49, and 4A, page 51).

Pelvic Radiography Summary

Pelvic radiographs are used in:

• Cases of trauma
• Evaluation of lameness
 • Evaluation of congenital disorders (eg, canine or feline hip dysplasia).

High-quality, correctly positioned radiographs are required in order to provide an accurate

assessment, especially for surgical implant planning. A routine radiographic series of the pelvis
should include a lateral and ventrodorsal view. Choosing the lateral projection used depends on
the side of lameness and whether pelvic or femoral fractures are present. If the pelvic
examination is routine, a right lateral of the pelvis is standard.

Following a consistent, repeatable pattern for obtaining pelvic radiographs ensures the quality of
the images will be diagnostic.

FOV = field of view; OFA = Orthopedic Foundation for Animals; PennHIP = Pennsylvania Hip
Improvement Program
The Importance of Dental
Radiology
Dental radiology is fast becoming the standard of care in veterinary dentistry
because it is crucial for proper patient care.

This is the second article in our Practical Dentistry series, which is presenting different aspects of
veterinary dental care and how it can provide best medicine for patients and an improved bottom
line for the practice. Read the first article in the series, Dental Services: Good Medicine for
Patients & Practices (September/October 2011), at todaysveterinary practice.com.
Dental radiology is fast becoming the standard of care in veterinary dentistry. This is primarily
because it is crucial for proper patient care. Utilizing the knowledge gained from dental
radiographs improves patient care as well as client acceptance of treatment recommendations.
Consequently, increasing the number of dental procedures performed also significantly increases
income for a veterinary practice. Following are several dental conditions in which dental
radiography plays an important role in patient care and treatment.

EDUCATING CLIENTS—SEEING IS
BELIEVING
Go to todaysveterinarypractice.com to view an in-clinic poster—The Importance of Dental
Radiographs—that helps educate clients about the importance of dental radiography. It can be
located on our website by selecting the Resources tab in the top navigation bar. The poster is
available for purchase at VETDENTALRAD.COM.

PERIODONTAL DISEASE
Periodontal disease is by far the most common problem encountered in small animal veterinary
medicine. It has been estimated that by the age of 2, 70% of cats and 80% of dogs have some
form of periodontal disease.1

Periodontal probing is an important first step in the evaluation of periodontal disease. However,
there are several reasons that dental radiographs should be obtained when evaluating periodontal
disease:

• Periodontal pockets may be missed during probing due to narrow pocket width, a
ledge of calculus, or a tight interproximal space.2
• Dental radiographs can serve as a visual baseline and ongoing documentation to
evaluate the effectiveness of professional therapy and home care. 2
• Radiographs are absolutely critical in cases of periodontal disease of the mandible of
cats and small or toy breed dogs. In these patients, periodontal disease can cause
marked weakening of the mandible and significantly increase the possibility of
iatrogenic fracture during the extraction attempt (Figure 1).3 A pre-operative dental
radiograph can help the practitioner avoid this result. Alternatively, if a mandibular
fracture does occur, the radiograph will provide conclusive evidence regarding the
cause.
• When several areas of the mouth are afflicted with periodontal disease, whole-mouth
radiographs are indicated.4
Figure 1. Advanced periodontal disease of the mandible; note the thin bone in the area of
the first molar (arrows)

Figure 2. Intraoral dental radiograph of the mandibular left third premolar (307) in a cat
with advanced type 2 tooth resorption. This is a crown amputation candidate.

Figure 3. Type 1 tooth resorption; note the significant coronal resorption (white arrows)
but normal root structure (red arrows)

FELINE TOOTH RESORPTION

Dental radiographs are critical for diagnosis and treatment of feline tooth resorption (TR). Since
these lesions typically initiate at or below the gingival margin, clinical evidence does not appear
until late in the disease course. Therefore, severe root and painful cervical crown resorption often
occur undetected for long periods of time. For this reason, many veterinary dentists recommend
taking full-mouth dental radiographs during each dental prophylaxis, beginning at 2 to 3 years of
age.
Once a TR lesion is diagnosed, radiographs are crucial for appropriate therapeutic decisions.
There are 2 recognized types of TRs (Types 1 and 2).5,6

Type 2 Lesions
Type 2 lesions demonstrate significant replacement resorption of the roots, which makes
extraction extremely challenging. Resorption in these cases typically continues until no
recognizable tooth structure remains (Figure 2). In these cases, endodontic infection does not
occur.

This finding has resulted in the accepted therapy of crown amputation for treating these
teeth.7 Remember, ONLY if there is significant ankylosis and root resorption (no evidence of
periodontal ligaments or endodontic system), is crown amputation and intentional root retention
an acceptable method of therapy.

Type 1 Lesions
In contrast, type 1 TRs do not undergo replacement resorption. These teeth generally retain
sufficient normal root and pulp structure that result in pain and infection if not fully extracted. If
the dental radiograph reveals intact root structure (Figure 3) or worse yet an active infection
(endodontic or periodontal), complete extraction is required. Extraction of these teeth often
requires a surgical approach due to the resorption.

Treatment
Armed with a diagnostic dental radiograph, the surgeon can save time by directing his or her
efforts appropriately rather than delving after severely ankylosed roots. Radiographs will also
allow the practitioner to more accurately estimate the surgical time and cost of the procedure.

There are no clinical signs that accurately differentiate between type 1 and type 2 lesions. In
addition, the degree of replacement resorption cannot be determined without dental radiographs.
Therefore, without the knowledge provided by dental radiographs crown amputation therapy
should NOT be performed.7

ENDODONTIC (ROOT CANAL)

DISEASE
Endodontic disease is also very common in veterinary dentistry. It has been shown in 1 published
report that 10% of all dogs have at least 1 tooth with direct pulp exposure. 8 Veterinary patients
rarely show any obvious signs of oral pain or infection.10 Therefore, because animal patients with
endodontic disease may not show clinical signs of pain, they may suffer for a long time prior to
diagnosis and definitive treatment.
Identifying Disease
In cases of obvious endodontic compromise, such as a complicated crown fracture or intrinsic
staining (discoloration of the tooth as a result of changes in the root canal system), radiographs
may sway the reluctant client into pursuing therapy. However, dental radiographs are even more
critical in cases where endodontic disease has either subtle or no clinical signs.

The most common instance of hidden endodontic disease is an uncomplicated crown fracture,
where dentin but not the pulp is exposed (Figure 4). In the majority of cases, these teeth are
vital; however, there is a possibility that the endodontic system has been infected through the
dentinal tubules. This can result in tooth nonvitality and infection just like a tooth with direct
pulp exposure. This painful infection cannot be diagnosed without dental
radiographs.2 Therefore, every tooth with direct dentin exposure should be radiographed to rule
out endodontic disease.

Figure 4. Apparently healthy tooth with a small cusp fracture (circle); radiographs
revealed endodontic infection (see Figure 5B).

Radiographic Indications for Therapy

Further therapy is always indicated, depending on the results of the dental radiograph. If the
dental radiographs reveal no signs of endodontic disease (Figure 5A), a bonded sealant should
be applied to seal off the tooth from infection and to decrease sensitivity 10 (see Bonded Sealant
Application for Crown Fractures, July/August 2011, available at todaysveter inarypractice.com).
The patient should have dental radiographs repeated in 9 months to ensure the tooth is/was not
subclinically infected.10

If there is evidence of tooth death, such as wide root canals or periapical rarefaction (Figure 5B),
root canal therapy or extraction is mandated.5
Figure 5. (A) Dental radiograph of a normal maxillary fourth premolar for comparison;
(B) same tooth as in Figure 4 showing endodontic infection as noted by the dark areas
around the root tip (arrows).

PERSISTENT DECIDUOUS TEETH

Extraction of persistent deciduous teeth is a very common procedure performed in veterinary
dentistry. However, without dental radiographs it can be a very difficult and frustrating endeavor.

In some cases, the root of the deciduous tooth is normal and held in naturally by the periodontal
ligament. In these cases, extraction is straightforward and root fracture should not occur if the
extraction is performed correctly.

In many cases, however, the deciduous teeth will have undergone some to significant resorption
due to the pressure placed on the deciduous tooth by the erupting permanent tooth (Figure
6).2 This makes extraction very difficult and commonly results in a fractured root. In these cases
(as in therapy for resorptive lesions), a surgical approach from the beginning may be prudent.
Regardless, if there is an identifiable root canal, complete extraction is required to avoid
inflammation and infection.11,12

Finally, there are cases where the root structure of the deciduous tooth has been completely
resorbed and the crown is only being held in by ankylosis at the alveolar crest (Figure
7).12 Proper therapy for this situation requires that only the crown and very small retaining root
segment be removed. With the help of dental radiographs to identify the condition, the
practitioner knows exactly what therapy to pursue and does not cause unnecessary trauma to the
patient.
Figure 6. Significant resorption just under the gum line (arrow) may cause the root to
fracture, requiring surgical extraction.

Figure 7. A completely resorbed root (arrows) facilitates simple extraction

MISSING TEETH
It is exceedingly common for teeth to be absent in the dental arcades of veterinary patients. In
many cases the tooth is truly missing; however, in others, the tooth/root is present and may be
pathologic. If radiographs have not been taken of the area, do not assume that the tooth is not
present.

It is critical to note that 2 of the causes for missing teeth require no therapy while the other 2 can
lead to significant pathology. Therefore, all apparently missing teeth should be radiographed to
ensure that they are truly missing.

Nonsurgical Conditions
Two possible etiologies for missing teeth include:

• Congenital missing teeth: Common in small, toy, and brachycephalic breeds13

• Previously exfoliated (lost): Rare in young patients, but quite common in mature
animals.

No therapy is necessary for the above conditions.

Surgical Conditions
The following conditions require surgical extraction:

• Fractured teeth under the gum line (Figure 8): This is rare in juvenile patients, but
common in adults and may be the result from an incomplete extraction attempt. Dental
radiographs will confirm a retained root and quite possibly infection. If the root
appears relatively normal (ie, no resorption), surgical extraction is generally
recommended to alleviate pain and endodontic infection. Note: If there is no evidence
of infection in the tooth and if extraction will be difficult due to resorption/ankylosis, it
can be left in place. But ONLY if the FACTORS above are present.
• Impacted or embedded teeth: These teeth can be malformed or normal, but they do not
erupt into the dentition, usually because they are blocked by an area of thick and firm
gingiva called an operculum. This condition is most common in the first and second
premolars of brachycephalic breeds.

Figure 8. Intraoral dental radiograph of a mandibular left third premolar (307) in a dog
that reveals retained roots. These roots are infected as evidenced by the dark areas at the
tips of the roots (arrows).

Embedded Teeth
The biggest concern with embedded teeth is the development of dentigerous cysts, which arise
from the enamel forming organ of the unerupted tooth. The incidence of this condition is
unknown in veterinary medicine; however, anecdotally incidence is estimated at 50%. In 1
human study, pathologic changes were noted in 32.9% of cases.14 As the cyst grows it will
cause bone loss by pressure. These cysts can grow quite large in a short period of time, resulting
in weakened bone (Figure 9). If surgery is not performed, a pathologic fracture may result.

Impacted Teeth
Therapy for impacted teeth is surgical extraction. If cystic formation has occurred, en bloc
removal or extraction of the tooth and meticulous curettage of the lining will prove curative.
Figure 9. Dental radiograph of the mandibular left premolar of a dog with a large
dentigerous cyst; note the minimal amount of bone on the ventral cortex. This cyst formed
as a result of the impacted mandibular first premolar (arrow).

Figure 10. A mandibular left first molar with severe root curvature (arrow) and thin apical
bone around the apex of the mesial root

Figure 11. Intraoral dental radiograph of a patient with a pathologic mandibular fracture.
There is significant bone destruction (black arrows) and weakened bone fractured at the
distal root (dashed white arrow). Infection of this tooth is confirmed by the periapical
rarefaction on the mesial root (white arrow).

MANDIBULAR FRACTURES
Mandibular fractures are fairly common in veterinary medicine. They are generally traumatic in
nature; however, in aging patients there is an emerging problem known as a pathologic
fracture.15

Chronic periodontal loss loosens the tooth support and may eventually result in exfoliation. In
the majority of teeth, this will occur prior to severe bone weakening. However, in some
situations, significant bone thinning will occur prior to tooth exfoliation.
Pathologic Fractures

Pathologic fractures are most common in small and toy breed dogs because they: 15

• Have a propensity for periodontal disease

• Tend to live longer
• Have proportionally larger teeth than do larger breeds, which results in the root apex
of the mandibular first molar being very close to the ventral cortex of the mandible
(Figure 10).

Pathologic fractures typically occur due to mild trauma or during extraction procedures. A
pathologic fracture should be suspected in any case of mandibular fracture, especially in the area
of the mandibular first molar or canine tooth of older, small- or toy-breed dogs.

Diagnosis & Treatment

Diagnosis of a pathologic fracture is only possible with dental radiographs because skull films
typically provide insufficient detail. The classic appearance of a pathologic fracture is bone loss
around the tooth and/or periapical lucency in the area of the fracture or other root of a
multirooted tooth (Figure 11).2

The fracture will not heal no matter how perfect the fixation is if the diseased tooth root is not
extracted (Figure 12)16 due to the fact that the tooth will act as a nidus of infection; therefore, not
allowing healing to occur.

Figure 12. Intraoral dental radiograph of the mandibular left premolar of a dog. The
radiograph reveals severely infected teeth, bony sequestra, and a failed external fixator.
This fracture did not heal despite 3 surgeries performed by a surgeon (but without the
benefit of dental radiographs). Extraction of the infected teeth would allow healing to
occur.

EXTRACTIONS
Dental radiographs should be a part of all pre- and postoperative extraction procedures.2
Pre-extraction radiographs allow the practitioner to determine the amount of disease present, any
abnormalities, such as curved (Figure 8), supernumerary (Figure 13), and ankylotic roots
(Figure 2). In addition, the level of remaining bone will be elucidated (see Periodontal Disease).

Postextraction dental radiographs are equally important. Regardless of the appearance of

complete extraction, there is still a possibility of retained roots or other pathology, making
postoperative radiographs critical in all cases (Figure 14).

Figure 13. A maxillary right third premolar that has an extra root (arrow)

Figure 14. Intraoral dental radiograph of the maxillary right premolar of a dog with a
large facial swelling (carnassial abscess). The maxillary fourth premolar had been
“extracted” elsewhere several years ago and the patient had waxing and waning infection
since then. Dental radiographs revealed the cause of the chronic infection, which was a
retained mesiobuccal root (arrow). The significant local infection is shown by the
rarefaction surrounding it. Extraction of the root was curative.

REVENUE RESOURCE
From a financial standpoint, there is no piece of veterinary equipment that has the potential to
provide the return on investment that dental radiology does. If a moderately busy practice
exposed radiographs whenever necessary, the equipment should be paid for in less than 3
months.

This does not include the income from the additional procedures that can now be performed with
confidence, such as bonded sealant application, root planing and scaling, extractions, and
periodontal surgery. Nor does it factor in the significant time savings during oral surgery. The
information provided by radiographs regarding root and bone pathology as well as documenting
complete extraction is crucial.
CONCLUSION
Since virtually all veterinary patients have some form of oral disease and dental radiographs are
indicated for any oral disease, almost all patients will benefit from the information provided by
dental radiographs. In addition, dental radiographs provide critical information for the
veterinarian when treating oral disease.

Therefore, dental radiography equipment should be used on a daily basis in every general
practice. All patients undergoing general anesthesia for dental prophylaxis/cleaning should have
radiographs taken. In my experience, dogs < 20 lb should have dental cleaning performed once a
year; cats and larger dogs, every 2 to 3 years. Dental radiography provides peace of mind, which
is priceless.

FIGURE CREDITS: Figures for this article provided courtesy of VETDENTALRAD.COM

TR = tooth resorption
Small Animal Abdominal
Radiography
High-quality, correctly positioned radiographs are required in order to provide
as accurate an assessment as possible for possible intra-abdominal disease.

This article will review the 3 components of creating repeatable, high-quality abdominal
radiographs of the dog and cat. These components include:

• Adequate technique
• Proper positioning
• Quality control of the final images.

Abdominal Radiographic Exposure

For radiographic imaging, dogs and cats are measured at the thickest part of their bodies,
typically at the liver or cranial abdomen.

Dogs measuring less than 15 cm: For a dog measuring 14 cm, a reasonable starting technique
would be 68 kVp and 8 mAs for a 400 film-screen analog film system. For a digital plate, a
starting technique would be 72 kVp and 10 mAs.
Dogs measuring 15 cm or greater: For any dog measuring greater than or equal to 15 cm, a
grid (8:1, 110 lines per inch) should be used to reduce scatter radiation from degrading the final
image quality. Based on the type of grid used, the technique will need to be adjusted.

For any given mAs setting, the higher the mA station used, the faster the time station that can be
used.

Even in the abdomen, motion can be a problem. Therefore, keeping the time station faster than
1/30 of a second is important. Adjustments in the technique will need to be made depending on
the animal’s body condition. However, for a dog of healthy body weight that measures 14 cm,
the previously discussed technique should be an appropriate starting point for building a
technique chart.

The overall image should be evaluated for radiographic contrast (film blackness outside the
patient versus shades of gray and white within the patient) and subject contrast (edge detail
within the abdomen where fat will contrast with soft tissue borders for normal serosal detail).

Routine Views
Lateral Images
Positioning
For a right and left lateral image, the patient is positioned on the table with the dependent side
down and marked with a lead marker in the collimated area as right (R) or left (L) based on the
dependent side (FIGURES 1 AND 2).

1. The pelvic limbs should be evenly taped together and pulled caudally to ensure that
the stifles are not within the abdomen.
2. Palpate and use the iliac crests to determine whether the patient is aligned in a lateral
position and parallel to the table. The iliac crests should be even and superimposed.
3. A foam wedge may be placed under the stifles in order to maintain laterality of the
patient. To avoid artifacts, do not place sponges under the sternum or cranial
abdomen.
4. In order to keep the patient in a true lateral position, the thoracic limbs should be taped
evenly together and pulled cranially.
 Figure 1. Radiographic Studies of Small to Medium Dogs (A) Dog in right lateral
recumbency with pelvic limbs taped and pulled caudally and thoracic limbs taped and
pulled cranially. The light marks the cranial border of the image that is collimated to the
level just cranial to the xiphoid process. The hand is positioned to denote the caudal border
of the image at the level of the greater trochanter. This abdomen fits on a single cassette or
as a single lateral image. (B) Right lateral abdominal radiograph of a small dog; notice the
cranial location of the collimated image (cranial to the diaphragmatic cupola) and the
caudal collimated area to the level of the greater trochanter. The image is noted to be
lateral based on the superimposition of the transverse processes (Nike swoosh) and
superimposition of the wings of the ilium and rib heads. (C) Close-up image showing the
superimposed transverse processes from the lateral image in B (black arrow); the Nike
swooshes are superimposed, although there is slight rotation of the transverse processes.
This degree of obliquity would be considered acceptable. (D) Dog in ventrodorsal
recumbency with pelvic limbs taped and pulled caudally. The light marks the caudal
border of the image that is collimated to the level of the greater trochanter of the femurs.
(E) Ventrodorsal radiograph; notice the cranial and caudal locations of the field of view for
a ventrodorsal image. Additionally, the caudal thoracic ribs and pelvic structures are
symmetrical and the spinous processes of the caudal thoracic and lumbar spine are noted
to have a focal “teardrop.”
 Figure 2. Lateral Radiographs of a Large Dog
(A) Entire dog positioned for a set of right lateral radiographs. (B) Collimator and hand
denoting the cranial boundary for the abdominal radiograph. (C) Collimator and hand
denoting the caudal boundary for the right caudal lateral abdominal radiograph at the
level of the greater trochanter. (D) Right lateral cranial abdominal radiograph; note the
superimposition of the rib heads (thoracic vertebrae) and transverse processes of the
lumbar vertebrae (Nike swoosh). (E) Close-up of the superimposed transverse processes
(white arrow). (F) Right lateral of the caudal abdomen from the dog in D; there is overlap
of the 2 images (includes L1–L3) and the caudal abdominal radiograph has been collimated
to the level of the greater trochanters. Note the superimposition of the iliac wings and the
transverse processes of the lumbar vertebrae. (G) Left lateral radiograph of the cranial
abdomen; note how the gas has shifted from a fundic position on a right lateral radiograph
to a pyloric position on this left lateral radiograph.

Collimation
To set the collimation for the abdominal anatomic boundaries of a lateral image (right or left):
1. Positioning: Unlike thoracic positioning, abdominal positioning has no set place for the
vertical line of the collimator light (field of view) due to the various sizes of patients. Therefore,
the edges of the collimation beam are your cranial, caudal, ventral, and dorsal borders.

2. Collimator light: Be sure the collimator light is adjusted to match the same size of the
cassette or detector by using the corresponding numbers next to the collimator knobs
(FIGURE 3). From here, the collimator light can be decreased to the patient’s size to ensure
proper patient collimation and minimized scatter radiation.

3. Cranial border: The cranial border of the collimator light should be placed cranial to the
liver. This is accomplished by palpating the xiphoid process of the sternum and placing the light
2 finger widths cranial to the xiphoid process (FIGURE 2B).

4. Caudal border: The caudal border of the collimator light should reach the level of the greater
trochanter of the femur. If the caudal beam does not reach the trochanter, then it becomes
necessary to take a cranial and caudal image for each projection (right lateral, left lateral, and
ventrodorsal; FIGURE 2).

5. Horizontal line: The horizontal line of the collimator light should be placed in an imaginary
plane so as to bisect the abdominal cavity into equal dorsal and ventral parts. Remember to
always include the sternum and xiphoid process in order to include cranial abdominal anatomy.
If the dog is thin or deep chested, the caudal abdominal horizontal line will be higher (more
dorsal) than after taking the cranial abdominal lateral view.
.
 Figure 3. Collimator Settings (A) Picture of the detector and collimator knobs set to size
showing the numbers; the initial abdominal field of view is set to the size of the cassette
based on the collimator numbers on the light collimator housing. (B) After this the field of
view (close-up of collimator) is decreased to appropriate levels based on the size of the dog.
(C & D) If the dog is a large or giant breed, you may need to switch the cassette or digital
plate from a horizontal position (C, long axis of the dog) to a vertical position (D, longer
part of the cassette or digital plate is now perpendicular to the long axis of the dog).

Ventrodorsal Images
Positioning
For the ventrodorsal view, the patient should be placed in dorsal recumbency (FIGURES 1
AND 4).

1. Using a V-trough helps keep the patient’s spine and sternum aligned and superimposed.

2. The pelvic limbs are pulled caudally and secured.

3. The thoracic limbs are evenly taped together and pulled forward with the patients muzzle
placed between the limbs to help keep the whole vertebral column straight cranially.

Figure 4. Ventrodorsal Radiographs of a Large Dog. Cranial (A) and caudal (B)
ventrodorsal (VD) radiographs of a large dog; note the overlap of structures between the 2
images (caudal part of the VD cranial image and cranial part of the VD caudal image).
Also note the straight positioning of the caudal thoracic and lumbar spine, resulting in
equal amounts of the abdomen on the right and left side of each image.

The technique described in Step 3 does not work well for brachycephalic breeds, such as English
bulldogs or pugs, that might have issues with upper airway disease or obstruction or
chondrodystrophic breeds, such as dachshunds or basset hounds, because they are physically
unable to do so. When presented with these breeds of patients, ensure that the head and neck are
straight in front of the body and not obliqued to the left or right.
Collimation
To set collimation for the ventrodorsal view, the landmarks are the same as the lateral projection:

1. Cranial border: The cranial border of the collimator light should be placed cranial to the
liver. Again, palpate the xiphoid process of the sternum and place the edge of the collimator light
2 finger widths cranial to it (FIGURES 1 AND 4).

2. Caudal border: The caudal border of the collimator light aligned with the long axis should be
placed at the level of the greater trochanter of the femur. If the caudal beam does not reach the
greater trochanter, then it becomes necessary to take a cranial and caudal projection.

3. Horizontal line: The horizontal line along the long axis of the dog or cat’s body should be
placed in an imaginary plane on the midline of the abdomen in order to bisect the abdominal
cavity into equidistant left and right sides.

Dorsoventral Images
The dorsoventral radiograph is one of the hardest radiographs to position consistently
(FIGURE 5). The dorsoventral projection is typically used when performing contrast studies,
such as upper and lower gastrointestinal imaging or gastrograms, and when gastric dilatation-
volvulus is suspected. It also specifically evaluates the fundic portion of the stomach.

1. The dog is either in:

• Ventral recumbency without the legs taped, resulting in a “sphinx” position

• A frog-leg position (pelvic limbs).
• The comfort of the patient is of utmost importance.

2. The thoracic limbs are pulled cranial and abducted.

3. The anatomic landmarks are the same as for a ventrodorsal image, although the dog will be
shorter in the craniocaudal direction.
 Figure 5. Dorsoventral Positioning Dorsoventral (DV) positioning of a dog (A) for a DV
image (B); the gas within the stomach is noted to be in the fundus and body of the stomach.

Additional Abdominal Views

Lateral View with Pelvic Limbs Pulled Cranially
This view is obtained in addition to the routine radiographs for better visualization of radiopaque
calculi that might be present within the urethra of a male dog or any perineal abnormalities of the
dog or cat. Visualization of radiopaque urethral calculi proximal to the os penis within the
membranous urethra can be hindered when the pelvic limbs are pulled caudally.

After taking the normal lateral radiograph, pull the pelvic limbs cranially so the stifle joints are
touching the ventral abdomen (FIGURE 6). A sandbag works very well to keep the legs in
position (make sure not to include the sandbag in the field of collimation). The collimation
should include cranial from the iliac crest to the caudal-most skin margin at the ischiatic
tuberosity or perineum.

Figure 6. Lateral View with Pelvic Limbs Pulled Cranially

(A) Placement of the dog for a cranially or flexed position of the pelvic limbs with the
image centered on the perineum so as to evaluate the length of the male urethra. (B) Flexed
 lateral radiographic image from a male dog; this view could also be used to evaluate any
perineal abnormalities in the dog or cat.

Horizontal Beam Projections

Horizontal beam lateral or dorsal projections are used for assessing free air within the abdominal
cavity. These views are dependent on the ability of the radiology machine tube to be manipulated
in a 90° angle. In addition, using a positioning trough makes these views easier to obtain.

1. Lateral recumbency: Position the patient in left lateral recumbency; then wait 10 minutes
before taking the radiograph. This allows time for free air to rise to the top of the body wall. Left
lateral recumbency assures that air within the pylorus is not mistaken for free air. Place the
cassette on the lateral aspect of the abdomen and label the dependent side (FIGURE 7).

2. Dorsal recumbency: Place the patient in dorsal recumbency as if taking a ventrodorsal view;
then wait 10 minutes to allow free air to rise to the ventral part of the abdomen. Place the cassette
on the lateral aspect of the abdomen and label the dependent side.
 Figure 7. Horizontal Beam Positioning
Placement of a dog for horizontal beam radiographs, including dorsal recumbency (A) and
left lateral recumbency (B). Horizontal beam radiographs are useful for determining if
there is peritoneal gas present that is not contained within a hollow viscus. A left lateral
horizontal beam image (C) where free air (black arrows) is documented in the peritoneal
cavity away from gas within small intestinal segments.

Quality Control of Abdomen

Images
For quality control of any diagnostic image, keep a simple 3-step approach in mind:

1. Determine if the technique is appropriate: all portions of the abdominal viscera should be
adequately exposed with sharp contrast between the air and the patient.
2. Ascertain if the appropriate anatomy is present within the image. Make sure that there is
anatomic overlap if the dog is split into cranial and caudal images.

3. Check the positioning for laterality and straightness.

The laterals, ventrodorsal, and dorsoventral projections should:

• Extend from the cranial margin of the liver (cranial-most lung–diaphragm interface) to
the caudal aspect of the abdomen as measured by the greater trochanter of the femurs.
• Include the caudal sternum and xiphoid process on the lateral images or lateral aspect
of the ribs and body wall on the ventrodorsal view.

If technique exceeds quality standards and the correct anatomy is present, then check patient
positioning.

• For lateral projections, use superimposition of the transverse processes throughout

the lumbar spine to determine if a patient is in a true lateral position. The transverse
processes appear as Nike swooshes and should be superimposed over each other
(FIGURE 1). The wings of the ilia will also be superimposed.
• For ventrodorsal projections, each caudal thoracic and lumbar spinous process is
viewed end-on and has a distinct diamond or tear-dropped shape as does the lumbar
spinous processes (FIGURE 4).
• For dorsoventral projections, positioning is similar to the ventrodorsal projection in
that the lumbar and thoracic spinous processes are viewed end-on and have a distinct
diamond or tear-dropped shape. However, the pelvis will be oblique as the patient has
not been stretched as in a ventrodorsal image (FIGURE 5).
Pet Particulars—Quality Control
When viewing lateral projections, remember that in the larger dog, due to magnification, the iliac
wing and crest furthermost away from the cassette or detector will appear larger than the iliac
wing and crest closest to the cassette.

Summary
Abdominal radiographs are often used as a first-line screening test for possible intra-abdominal
disease. High-quality, correctly positioned radiographs are required in order to provide as
accurate an assessment as possible. An abdominal series containing no less than right lateral, left
lateral, and ventrodorsal view is considered the standard of care in veterinary medicine.
Following a consistent, repeatable pattern for obtaining abdominal radiographs ensures that the
quality of the images should be considered diagnostic.
Small Animal Thoracic
Radiography
This article will focus on the basics of creating high-quality thoracic
radiographs of the dog and cat as well as the role that veterinary
nurses/technicians can take in obtaining these images.

This article is the first in a series of articles that will discuss various radiographic positions and
techniques. The veterinary technician plays a critical role in the development and maintenance of
a radiographic program at a veterinary practice. Thus, it is the responsibility of the technician to
be familiar with the basics of:

• Anatomy and positioning

• Technique and image formation
• Quality control of images made within the radiographic suite.
The purpose of this article is to review the 3 basic components of creating high-quality thoracic
radiographs of the dog and cat, including positioning, technique, and quality control of the final
images.

With advances in imaging technology (computed and digital radiography), errors in technique
are less common; however, if anatomy is not appropriately collimated and positioning is
inadequate, all imaging studies can be rendered nondiagnostic.

A routine thoracic radiographic study includes 3 projections: right and left lateral images and a
ventrodorsal (VD) or dorsoventral (DV) image.

Radiography Lingo
Anode: An electrically positive terminal of a radiographic tube that emits x-rays from the point
of impact of the electron stream from the cathode.

Cathode: The negative side of the radiographic tube where electrons are emitted; it consists of
the focusing cup and filaments.

Cassette/detector plate: A light-proof housing for radiology film, containing front and back
intensifying screens between which the film is placed.

Collimation: This term refers to the process of adjusting an optical instrument so that the x-ray
image includes the area of interest.

Milliampere × second (mAs): Describes the exposure setting of a radiology machine and
determines the radiographic density. mAs is calculated by:
mA (station number setting) x time (setting) = mAs (eg, 100 mA × 0.10 sec = 10 mAs)

Peak kilovoltage (kVp): The maximum voltage applied across an radiographic tube, which
controls the x-ray penetration of the subject being imaged.

Peak inspiration: Exposing film at peak inspiration maximizes the air in the lungs and the
subject contrast within the thorax.

Thoracic Radiographic Exposure

From a technical standpoint, thoracic radiographic exposure should be obtained using a high
peak kilovoltage (kVp) (80-120 kVp) and low milliampere-second (mAs) (1-5 mAs) technique.
This technique allows for latitude (long gray scale) images, which are important when evaluating
the structures of the thorax.

Several examples would include:

• 82 kVp at 2 mAs for 15-cm dog for analog film (400 speed system) or
• 80 kVp at 5 mAs for a 15-cm dog for a digital plate radiographic system.
For any dog measuring 15 cm or greater (measured at the liver or thickest part of the thorax), a
grid (8:1, 110 lines per inch) should be used. Grids are available from most radiology
manufacturers and a grid tray comes with all radiology units. For almost all radiology units, a
grid is sold with the radiographic machine and table.

The rotor for the anode and the low-voltage circuit for the focusing cup/electrons of the cathode
should be coupled to a foot or hand switch so that accurate timing of the exposure at peak
inspiration can be made (TABLE).

Routine Views
Lateral Images
Positioning
For a right and left lateral image, the patient is positioned on the table with the dependent side
down and marked with a lead marker to indicate the dependent side in the collimated area as
right (R) or left (L).

1. The thoracic limbs should be taped together evenly and pulled cranially so that the
elbows and tissues of the triceps muscle are not superimposed over the cranial thorax
(FIGURES 1 AND 2).
2. To determine whether or not a patient is aligned in a lateral position and parallel to the
table, use an imaginary plane through the sternum and dorsally through the spinous
processes of the thoracic vertebrae.

3. A foam wedge may be placed under the elbows in order to maintain laterality of the
patient (sternum and vertebrae are equidistant to the table).

4. In order to keep the patient in a true lateral position, the pelvic limbs are also taped
and pulled caudally.
 .

Collimation
To set the collimation for the thoracic anatomic boundaries of a lateral image (right or left):

• Vertical Line of the Collima-tion Light: Palpate the caudal border of the scapula
dorsally and place the vertical line at this point. This allows for the cardiac silhouette
to be in the center of the image, giving a true representation of the cardiac size and
shape.
• Horizontal Line of the Colli-mation Light: The horizontal line should be placed in
an imaginary plane so as to bisect the thoracic cavity evenly between dorsal and
ventral. Palpate the manubrium and place the cranial edge of the collimation beam at
the cranial edge of the manubrium; this places the caudal edge of the beam at the level
of the 13th rib head and T13.

Remember to always include the sternum of the patient so as not to exclude vital anatomy:

• In large-breed dogs, it may be necessary to exclude the spinous processes. A separate

image might be necessary if indicated.
• In deep-chested breeds, such as Great Danes, Doberman pinschers, or mastiffs, the
cassette/detector plate may be turned vertically to encompass the entire thoracic cavity
in the dorsal and ventral plane.
• Turning the cassette/detector plate vertically does not allow for the entire thorax to
be included; therefore, cranial and caudal views need to be taken, for completeness.
Ventrodorsal Images
Positioning
For the ventrodorsal view, the patient should be placed in dorsal recumbency.

1. Using a V-trough helps keep the patient’s spine and sternum aligned.

2. The thoracic limbs are taped together evenly and pulled forward with the patient’s
muzzle placed between the limbs (FIGURE 3).

3. The pelvic limbs are pulled caudally and secured.

The technique described in Step 2 does not work well for:

• Brachycephalic breeds, such as English bulldogs or pugs, that might have issues with
upper airway disease or obstruction
• Chondrodystrophic breeds, such as dachshunds or basset hounds, because they are
physically unable to do so.

When presented with these types of patients ensure that the head and neck are straight out in
front of the body and not obliqued to the left or right.

Collimation
To set collimation for the ventrodorsal view, the landmarks are the same as the lateral projection:

• Vertical Line of the Collimator Light: Place the vertical line at the caudal border of the
scapula. This allows the cardiac silhouette to be in the center of the image.
 • Horizontal Line of the Collimator Light: The horizontal line should be placed directly
over the sternum so as to bisect the thoracic cavity from left and right lateral. Palpate
and place the edge of the collimation beam at the cranial edge of the manubrium; this
places the caudal edge of the beam to the 13th rib head at the level of the thoracic
spine.
• In large-breed dogs (eg, Great Dane), it will be necessary to take a cranial and caudal
projection.

Dorsoventral Images
Positioning & Collimation
The dorsoventral radiograph is one of the hardest radiographs to position consistently. The
dorsoventral image best visualizes lesions in the caudodorsal lung lobes.

The dog is either in:

1. Ventral recumbency without the legs taped, resulting in a “sphinx” position

(FIGURE 4) or a frog-leg position (pelvic limbs). The comfort of the patient is of
utmost importance.
2. The thoracic limbs are pulled cranial and abducted.
3. The anatomic landmarks are the same as for a ventrodorsal image.

Additional Views
Humanoid Projection
In a conventional ventrodorsal projection (with the thoracic limbs pulled cranial), the caudal
portion of the scapulae are superimposed over the cranial lung fields (FIGURE 5). The
humanoid projection obtains no summation of the scapula with the cranial lung fields.
 .

1. The patient is placed dorsally and the thoracic limbs are taped separately and pulled
caudally to lie adjacent to the lateral body wall (FIGURE 6).
2. The landmarks will be the same as the ventrodorsal view.
Horizontal Beam Projections
Horizontal beam sternal or dorsal projections are used for assessing the cranial mediastinum or
fluid/air distribution within the thoracic cavity.

These views are dependent on the ability of the radiology machine tube to be manipulated in a
90-deg angle. In addition, using a positioning trough makes these views easier to obtain.

1. To determine fluid or free air distribution, position the patient as if performing a

ventrodorsal view (ie, dorsal recumbency).
2. To visualize the cranial mediastinum, position the patient as if performing a
dorsoventral view.
3. Place the cassette/detector against the lateral body wall, making sure to mark the
dependent side L or R.
4. The landmarks are the same as the lateral projection (FIGURE 7).
 .

Quality Control
For quality control of any diagnostic image, keep a simple 4-step approach in mind:

1. Determine if the technique is appropriate.

2. Ascertain if the appropriate anatomy is present within the image.
3. Check the positioning for laterality and straightness.
4. Determine if projection was taken at peak of inspiration.

Technique & Anatomy

Given that the desired technique has been attained, make sure that the appropriate anatomy is
included. The laterals, ventrodorsal, dorsoventral, humanoid, and horizontal beam projections
should:

• Extend from the cranial margin of the manubrium to the caudodorsal margin of the
lung margin/diaphragmatic crus.
• Not exclude the sternum on the lateral or lateral aspect of the ribs on the ventrodorsal
view.
Positioning
If the technique exceeds quality standards and the correct anatomy is present, check patient
positioning.

• For the lateral projection, use superimposition of the rib heads throughout the
thoracic spine to determine if a patient is in a true lateral position (FIGURES 1B
AND 2B).
• For the ventrodorsal projection, each thoracic spinous process is viewed end-on and
has a distinct diamond or tear-dropped shape without the ability to see the sternum and
the thoracic vertebrae as separate structures.
• For the dorsoventral projection, positioning is similar to the ventrodorsal in that the
thoracic spinous process is viewed end-on and has a distinct diamond or tear-dropped
shape without the ability to see the sternum and the thoracic vertebrae as separate
structures.
Positioning Veterinary Patients
The following positioning devices can be used to help position patients and reduce staff
members’ exposure to radiation:
• Elastic tape

• Plastic tongs
• Positioning trough (foam or plastic)
• Rope and cleats along the side of the table
• Sandbags (particularly long snake-like sand bags)

Patient in lateral recumbency showing correct use of tape and sandbags; the dog is muzzled due
to its history of biting (see Dog Bites: Protecting Your Staff & Clients)
Peak Inspiration for Image Acquisition
Finally, determine if the projection was taken at the peak of inspiration:

• For the lateral view, the caudal aspect of the cardiac silhouette will not be
superimposed over the diaphragm and there is an upside down triangle that is
visualized using the caudal vena cava, diaphragm, and caudal border of the heart as
the margins.
• For the ventrodorsal view, the cupola or central portion of the diaphragm will be
separated from the caudal border of the cardiac silhouette. The lateral margins of the
diaphragmatic crura will come to the 11th or 12th intercostal space and the right and
left cranial lung lobes will extend to the level of the thoracic inlet.
• The exception to these rules is the extremely obese patient that cannot take a deep
inspiratory breath.

Summary
Thoracic radiographs are often used as a first-line test for possible intrathoracic disease. High-
quality, correctly positioned radiographs are required in order to provide as accurate an
assessment as possible.

In addition, a 3-view thorax (right lateral, left lateral, and dorsoventral or ventrodorsal view) is
considered the standard of care in veterinary medicine. Following a consistent, repeatable pattern
for obtaining thoracic radiographs ensures that the quality of the images will always be
diagnostic.

kVp = peak kilovoltage; mAs = milliampere × second

The 3 Principles of Radiation

Safety
X-rays are a form of electromagnetic radiation that has high-energy, high-frequency, and short-
wavelength rays. These rays are classified as ionizing because they can create atomic ions or
charged atoms, specifically in biological tissues (ie, animal and human tissue).

Three basic principles should be adhered to when dealing with radiation and making
radiographs:
 • Time
• Distance
• Shielding.

These principles form the basis of a broader radiation safety concept called ALARA (As Low As
Reasonably Achievable).
Patient in dorsoventral position; the veterinary staff will step behind the control wall before
making the exposure.

Time
Time refers to the time the patient or the technician/veterinarian is exposed to primary (x-rays in
the collimated beam directed toward the patient) or secondary (x-rays scattered away from the
patient and outside the collimated field) radiation from the x-ray tube. Time can be minimized
by:

• Keeping the time station of the x-ray machine to the lowest possible number(s) and
the highest mA station, in order to obtain the desired mAs when making the exposure.
• Minimizing your time in the room during the exposure.

Distance
The principle of distance means that there needs to be physical distance between the
technician/veterinarian and the patient/x-ray tube at the time of exposure.

• Use of positioning devices allows everyone to physically exit the room at time of
exposure.
• If there are staff in the room at time of exposure (if allowed by state law), make sure
there are 2 individuals holding the patient, which allows each person to further
distance themselves from the x-ray tube and area of collimation.
• Holding the patient at time of exposure provides the greatest chance of secondary or
scatter radiation exposure.
• Never stand directly in front of the x-ray tube at the time of the exposure.

The x-ray intensity will exponentially decrease as one doubles the distance from the primary
source of radiation; in this case, the area of the collimated patient that is being imaged. If you can
move from 2 to 4 feet away, you will have decreased the intensity of the scatter radiation by
25%.
Shielding
Shielding is required if you are staying in the room at time of exposure or within the walls of the
room.

• Shielding involves wearing lead aprons, gloves, and thyroid shields (0.5 mm lead
equivalent).
• In addition, every radiation worker must be over 18 years of age, have appropriate
dosimetry to record any radiation exposure, and declare pregnancy (there are strict
rules and guidelines specific to pregnant radiation workers).

Lead shielding never protects the individual from primary radiation exposure (area inside the
collimated light), only secondary or scatter radiation exposure.

Radiation Regulations
Radiation safety requirements are specific to state regulations, so that a copy of the specific state
radiation safety requirement for workers in veterinary medicine should be given to every staff
member at the clinic as well as posted in the x-ray area. These regulations should be thoroughly
reviewed with all employees on an annual basis.

ALARA = as low as reasonably achievable; mA = milliampere; mAs = milliampere x second