Radiology wrap up Flashcards
Case 1
What is the image orientation of this image?
A 10 year-old, M, large crossbreed dog is presented with left hind limb lameness over a few weeks/months that dramatically worsened yesterday while running in the park.
On examination, there is marked swelling and pain over the left proximal tibia area.
Lateral and craniocaudal left hindlimb
Case 1
What is your technical assessment of this image?
Positioning (axial rotation on left image)
Centring (can’t see the tibia, should be able to see joints at either end)
Apart from that they are of diagnostic quality
Case 1
What is your image assessment of this case?
- Size and shape of the tibia are changed and tibia is in two parts so there is a change in number, location distal fragments in wrong place.
- Cranial displacement, slightly proximally displaced and medially displaced in cranial view #.
- Oblique complete closed # tibia and fibula at diaphysis. Around area of # there is a reduced opacity with moth eaten to permeative lysis and amorphous periosteal reaction. Lesion is intermediate to wide with regards to transition zone. Cortical defects are apparent but is hard to distinguish from # damage or pre-existing cortical damage pre #. All things considered the lesion appears to be intermediate too aggressive in nature.
- All other anatomy NAD.
What are your conclusions for case 1?
Aggressive bone lesion leading to instability of bones leading to a traumatic fracture when limb exposed to an acceptable level exercise which should normally not result in a fracture unless underlying pathology predisposes. So a pathological fracture due to aggressive bone lesion in short.
What are you differential diagnosis for case 1?
Malignant neoplasia (Osteosarcoma but not metaphyseal location so other neoplasia are possible)
Osteomyelitis (normally in dogs if you had that amount of lysis you’d see a lot more new bone)
What further recommendations/ further tests would you suggest for case 1?
Chest/thorax radiographs to assess metastasis
Bone biopsy (FNA of region)
Case outcome: this dog had a renal carcinoma richard thinks this is a metastasis of this renal carcinoma
What radiographic views have been taken for this radiograph?
Case 2
An 11 week old, F, Jack Russell Terrier was presented three weeks previously after having its left fore leg caught in a door. The leg was swollen and painful and was placed in a supportive dressing.
The puppy is still lame and so was presented today for radiography to assess progress
Lateral and craniocaudal
What is your technical assesment of this radiograph?
Case 2
Positioning Medilateral view proximal is straight but rotation of limb distally making carpal bones look unusual. Caudocranial view some rotation again.
What is image assessment of this radiograph?
Case 2
- Transverse simple # of the proximal diaphysis of radius with callous formation. Oblique interdigitating #distal diaphysis of ulna radiopaque localised regional.
- Growth plates NAD when comparison of both views; artefacts caused by superimposition Growth plates normal for dog this age.
- Richard believes these # occurred at the same time and have been around for a while as can see callous formation (widening flaring of bone where healing is occuring the ulnar fracture isnt healing as well)
- Opacity in the carpus is a lot more lucent than proximal limb the cortices of the metacarpal bones are egg shell thin.
What are you differential diagnosis and Further investigations/recommendations for case 2?
of radius and ulna caused by trauma
needs more appropriate management than a supportive dressing so recommendations to immobilise limb with a splint to aid more rapid healing and give bone more time to heal
Here a Richards comments on case 2?
- Fracture with bone disease.
- Reduced opacity distally due to immobilisation of limb in the cast: disuse osteopenia.
- Disuse osteopaenia tends to occur distally to proximally.
- Therefore when the cast comes off the owner must understand that dog must be kept very quiet in case there was a pathological fracture of the metacarpal.
- Richard would leave it as it is and monitor regularly with radiographs.
What views can be seen in this radiograph and what is your technical assessment?
Case 3
A 15 year-old cat is presented for bilateral hind limb “paralysis” after falling down the back of a refrigerator. The owner mentions that the cat has been “feeling its age” over the past few months, specifically drinking more and losing weight.
The cat is unable to weight bear on either hind limb. However, sensation is present and the cat is attempting to move both legs.
VD
Limitation is we only have one view
Positioning : pelvis straight
Are images free of faults/artefacts? Bit of dirt on the plate
What is your image assessment of case 3’s radiograph?
Right hand side:
Fracture of proximal 1/3 of femur complete #
Reduced opacity in the fragment attached to the pelvis
Left hand side:
Fracture of proximal 1/3 of femur
Reduced radiopacity of all bones in the radiograph
Little contrast of the bones compared to the soft tissues
Richard said:
Generalised decrease in opacity. Very little contrast between bones and ST
Femoral cortices are abnormal because you can see 2 lines no single thick opaque line that should be seen. Called a double cortical line when you loose mineral from the cortex and the perisosteal and cortical cortex are spare from this line and you get lucency between the two.
This is a secondary pathological # secondary to ostopaenia
What are the d/dx for case 3?
- Metabolic bone disease (decreased opacity = osteopenia)
- Osteoporosis
- Kidney failure à can cause hypocalcaemia
- Hypoparathyroidism à can cause hypocalcaemia and can develop secondary to thyroid gland removal
- Secondary renal hyperparathyroidism (often secondary to chronic renal failure)
What are Further investigations/recommendations for case 3?
- We would need to take further radiographs (orthogonal views) to further assess the conformation of the fracture
- Haematology and biochem to investigate electrolytes imbalances –> hypercalcaemia with normal/low serum phosphorus and normal/low USG
- High PTH assay + high creatinine & BUN is indicative of possible renal secondary HPT
- Treatment:
- Direct control of renal disease
- Supplementation of calcitriol in diet (+ phosphorus binders?)
What vies have been taken in case 4?
A 9 month-old, male, GSD x collie crossbreed dog was presented with a vague history. It appeared that while with a previous owner, the dog had sustained a left fore limb injury that was treated with splinting.
Now, the dog is 3/10 lame on the left fore with considerable deformity of the limb. No pain was evident on manipulation/palpation, but there was reduced range of movement in both the carpus and the elbow joints.
ML and CC views of LFL and RFL for comparison
Discuss what is going on in case 4?
Subluxation of the elbow (distal subluxation of radius away from humeral condyle the ulna is proximally position in relation to tuberal condyles, shape issues, radius and ulna are diff shapes from the normal right hand side.
Caudal bowing of ulna seen on left. Increased radiopacity indication increased strain on left.
Radius is significantly shorter than on the right. Which would make sense with the subluxation of the elbow.
Deformity around the distal limb causing angulation. Lateral deviation of the metacarpal bones. If you get angulation occuring in the limb the critical thing is what is it centred on at which point does the limb change direction and this has occurred at the level of the distal radius and ulna.
Which structure is the most likely cause of this pathology: distal radial physis. This physis has closed prematurely and a crush injury to that growth plate has stopped it growing. Short radius has resulted in subluxation at the elbow and early closure of distal radial physis causing limb angulation.
Osteopania has occurred in distal LFL due to lameness disuse.
How to treat: Lengthen the radius with surgical # and bone graft or shorten the ulna.
Case 5 radiograph
4 year old, female neutered, GSD crossbreed
Imaging modality Radiography (digital)
What views do we have?
Ventrodorsal extended hips/pelvis
What is your techincal assessment of case 5 radiograph?
Positioning: Minimal axial rotation spine/pelvis and mild/moderate axial rotation of femurs. Femurs symmetrically extended and parallel.
Centring: Slightly caudal to hips joint in midline.
Collimation: Evidence of 100% collimation. Whole area of interest included, however could have been reduced to include only proximal half of femurs.
Definition: Good contrast and detail in area of interest.
Labelling: Side label present, but added post processing. Patient details present on computer system.
Artefacts: Sandbag(s) visible at distal edge of image.
This radiograph is of diagnostic quality (degree of axial rotation does not affect diagnosis in this case).
What is your image assessment of case 5 radiograph?
Both hips are subluxated (subjective centres of femoral heads are just lateral to the dorsal acetabular rim). There is poor joint congruity and widening of the joint spaces. Both femoral heads have an abnormal, slightly angular shape. Slightly irregular, but well marginated, new bone is seen at the margins of the femoral heads, and on the femoral necks, leading to significant neck thickening. In both acetabulae, the cranial acetabular edges are S-shaped and the cranial effective acetabular rims are eroded and rounded. The caudal acetabular edges are indistinct. All these changes are slightly worse for the right hip.
Other bones and soft tissues appear normal. There are significant faeces in the colon and rectum, but this does not affect interpretation.
What are your conclusions and d/dx for case 5 radiograph?
Conclusions
Bilateral hip subluxation (primary lesion) with secondary changes to the acetabulae and femoral heads. Slightly worse appearance for the right hip.
Diagnosis/differential diagnosis:
Bilateral hip dysplasia with degenerative joint disease. Right hip more severely affected.
Further investigations/recommendations
Degree of hip laxity could be investigated by clinical examination, e.g. Ortolani sign, under deep sedation or general anaesthesia.
What views do we have of case 6 radiograph?
3 month old, male entire crossbreed dog.
Partially flexed mediolateral and craniocaudal left elbow
What is the techinical assessment of case 6s radiograph?
Mediolateral:
Appropriate technique was used – although the caudal aspect of the limb overlies the body wall. This does not affect diagnosis in this case, so the radiograph is of diagnostic quality.
Craniocaudal:
Appropriate technique was used and this radiograph is of diagnostic quality.
Mediolateral:
Positioning: No axial rotation.
Centring: Centred on elbow joint
Collimation: Appropriate with approximately 1/2 of radius/ulna and humerus included. 100% collimated.
Definition: Reasonably good bony and soft tissue detail
Labelling: Side marker exposed, patient information on computer system
Artefacts: Bright white spot beyond caudal aspect of antebrachium representing dirt on the plate
Craniocaudal:
Positioning: Good with no axial rotation
Centring: Centred on elbow joint
Collimation: Approximately 1/2 of radius/ulna and humerus included. No evidence of unexposed borders (cropped image)
Definition: Reasonably good bony and soft tissue detail
Labelling: Side marker included (added after processing), patient information on computer system
Artefacts: None
What is the image assessment of case 6 radiograph?
Mediolateral:
Only one humeral condyle is visible articulating with the radius and ulna. Proximal to this humeral epicondyle a well-defined, roughly rectangular area of increased opacity overlies the metaphyseal area. Discontinuity in the caudal margin of the humerus at the metaphyseal level, with the distal portion slightly cranially displaced. A well-defined area of increased opacity overlies the proximal ulna. Otherwise the skeleton appears normal, including degree of mineralisation for age (open physes are visible at the olecranon and proximal radius). Soft tissues are within normal limits.
Craniocaudal:
Irregular, but relatively distinct, discontinuity of the humerus just proximal to the lateral epicondyle extending to the intercondylar joint surface, with lateral and proximal displacement of the fragment. The lateral humeral condyle articulates with the radial head, with a widened joint space medially. Otherwise the skeleton appears normal, including degree of mineralisation for age (open physes are visible at proximal radius and just visible at the humeral condyles). Medial and lateral soft tissue swelling.
What are the conclusions and and d/dx for case 6?
Conclusions
Fracture of the left lateral humeral condyle (simple, complete, articular - Salter Harris Type III). Distal fragment displaced cranially, laterally and proximally.
Diagnosis/differential diagnosis:
Cause likely traumatic as no evidence for pathological fracture. Relatively distinct fracture margins suggest recent. No evidence of open fracture.
