NORMAL ANATOMY OF

UPPER LIMB
Humerus and Shoulder Joint
Shoulder joint
AP view
1. Clavicle
2. Acromion
3. Greater
tubercle
4. Lesser
tubercle
5. Surgical neck
of Humerus
6. Humerus
7. Coracoid
Process
8. Lateral border
of scapula
9. Rib
Shoulder joint:
Lateral View
1. Coracoid
Process
2. Clavicle
3. Acromion
4. Head of
Humerus
5. Humerus
6. Lateral border
of scapula
Ulna, Radius and Elbow Joint
 Elbow Joint

Anterior Posterior
Lateral
Lateral view: Extended
1. Humerus
2. Radius
3. Ulna
4. Olecranon Process of the Ulna
5. Lateral Epicondyle
6. Olecranon Fossa

Lateral view: Flexed

7. Humerus
8. Radius
9. Ulna
10. Olecranon process
Hand
Wrist Hand X-ray : AP view
1. Joint Between Radius and
Scaphoid bone
(Radiocarpal Joint)
2. Joint Between Trapezium
and First Metcarpal Bones
(carpometacarpal Joint).
3. First Metacarpophalangeal
Joint.
4. Interphalangeal Joint of
the Thumb.
5. Second metacarpo-
phalangeal joint.
6. Proximal inter-phallangeal
joint.
7. Distal inter-phallangeal
joint.
Wrist Joint
 Radial length or height

- Measured on the PA radiograph

- A: distance between one line

perpendicular to the long axis of the A
radius passing through the distal tip of
the radial styloid.

- B: a line intersects distal articular

surface of ulnar head.
B
- Radius height: Distance between A and
B. This measurement averages 10-13 mm

Radial Length shortening results from

extensive comminution and impaction of
fracture fragments into the metaphysis.
 Radial inclination or angle
-Measured on the PA radiograph

- Angle between one line connecting the

radial styloid tip and the ulnar aspect of
the distal radius and a second line
perpendicular to the longitudinal axis of
the radius.

- The radial inclination ranges

between 21° -25°.

-Loss of radial inclination will lead to

increased load across the lunate.
-increase the risk of development of
chronic pain secondary to radio-lunate
joint osteoarthritis especially when there
is concomitant loss of dorsal inclination.
 Radial tilt

- Measured on a lateral radiograph

- Angle between a line along the distal

radial articular surface and the line
perpendicular to the longitudinal axis
of the radius at the joint margin

- The normal volar tilt averages 11°

and has a range of 2°-20°.
Normal Radiology of Pelvis
 Anatomy
Bony pelvis consists of
1) Hip bones
Develop from fusion of 3 bones – Ileum
ilium, ischium and pubis
2) Sacrum
Develop from fusion of 5 sacral
vertebrae
3) Coccyx Pubis
Develop from fusion of 4
rudimentary coccygeal vertebrae

Ischium
Radio-anatomy of Pelvis
 Antero-posterior (AP) view
Indications:
• Primary survey of polytrauma patients
• Suspected femur head fracture or dislocate
• Congenital abnormalities
• Degenerative disease
• Carcinoma
• Other pathologies e.g. Perthes disease,
slipped femoral epiphyses
Evaluation Criteria of AP view pelvis:
1) L5, sacrum, coccyx, pelvic bone (ilium, ischium, pubis),
proximal femoral neck should be seen

2) No rotation: Symmetric appearance of the 2 obturator

foramen with symmetric iliac alae and ischial spines

3) Centering of radiograph: Both ilium, greater trochanter

equidistant to the edge of the radiograph and the
lower vertebral column centered to the middle

4) No motion: Clear pelvic structure

 Important lines
• On anteroposterior (AP) radiographs of pelvis,
7 major lines/structures should be considered:
– Iliopectineal line
– Ilioischial line
– Teardrop
– Dome
– Anterior acetabular wall
– Posterior acetabular wall
– Shenton line
The teardrop sign is a landmark present in normal pelvic radiographs
* Absent of tear drop sign indicates:
a) acetabular fractures
b) patient is rotated
 Paediatric Pelvis X ray
• At birth, ilium, ischium & pubis joined with hyaline cartilage
• In children, 3 bones are incompletely ossified & separated by Y-shaped triradiate
cartilage centered in acetabulum
• Complete fusion occurred at 20-25 yo
Perkin's line is drawn vertically though the lateral most aspect of the acetabular roof,
perpendicular to Hilgenreiner's line (Horizontal line through the upper margin of
radiolucent triradiate or y cartilage.). The ossified femoral head should be located in
the inferomedial quadrant created.
 Pelvic radiography veiw

• Standard view :
– AP Pelvis

• Additional
– Oblique view (Judet view)
– Inlet/ outlet view
– Frog – lateral view
– Groin – lateral view
 Judet’s view

Rt posterior oblique
Lt anterior oblique

- Patient’s is rotated with respect to cassette

- Cassette are approach through an AP approach
- Central ray is directed to the midpoint of pelvis
- The opposite oblique would be obtained by
rotating the patient in opposite direction

***Judet views are basically 45 degree obliques of the affected hip.

***The 45 degree angle is best achieved by rolling the patient.
 Indications:
Trauma especially for
fractures of the acetabulum

Rt posterior oblique (RPO)

Lt anterior oblique (LAO)

Right Post
Oblique left
anterior
Oblique
 Normal anatomy: Columns and walls

The acetabulum
• formed by anterior and posterior columns of bone, which
join at the acetabular roof.
• The anterior and posterior walls extend from each respective
column and form the cup of the acetabulum.
• The anterior and posterior columns connect to the axial
skeleton through a strut of bone called the sciatic buttress.
• Anteroposterior and bilateral oblique (or Judet) views of the
pelvis are important to adequately assess each of the
radiographic lines for fracture
--Normal pelvic bone anatomy

Surface-rendering 3D CT of
pelvis in lateral view with
femur and right hemipelvis
removed shows anterior
column (green), posterior
column (blue), and sciatic
buttress (red).
Left Posterior Oblique View / Iliac
  ILIAC OBLIQUE VIEW

PC

AR

This demonstrates the posterior column and

anterior rim anatomy
Left Anterior oblique view / obturator
  OBTURATOR OBLIQUE VIEW

AC

PR

This demonstrates the anterior column and posterior rim anatomy

Posterior Oblique (iliac) View radiograph
1. Ilioischial line - this line represents the posterior column
2. Anterior lip of acetabulum - represents the anterior wall of the acetabulum
3. Posterior lip of acetabulum - represents the posterior wall of the acetabulum
Anterior Oblique (obturator ) View radiograph
1. Pelvic brim or Iliopectinial line - again, represents the anterior column
2. Anterior lip of acetabulum - represents the anterior wall of the acetabulum
3. Posterior lip of acetabulum - represents the posterior wall of the acetabulum
Right Anterior oblique view
 Pelvic Inlet View

caudal angulation  allows the surgeon to view

pubic rami image The anteroposterior displacement
inlet view is taken of thesupine
with the patient
and hemipelvis.
the x-ray tube angled 45 degrees caudal
and perpendicular to the pelvic brim

Indication:
pelvic brim fracture,
pubic rami fractures
 Inlet view:

demonstrates ring configuration of pelvis,

narrowing or widening of diameter of ring
 
evaluates for posterior displacement of pelvic
ring or opening of pubic symphysis;

Rotation of hemipelvis
No rotation;
Evidence by
Presence of
Ischial spine

Arrow shows
Fracture of
Pelvic ring
Lateral compression injury as seen on an inlet radiograph of the pelvis.
The fractures of the left sacrum (long arrow) and left pubic rami (short
arrows) are shown.
 Pelvic Outlet View

cephalic  allows evaluation of superior and

angulation pubic inferior displacement of the hemipelvis.
rami view image  patient in the true AP position and the
tube is angled 45 degrees cephalic.

Indication:
pelvic brim fracture,
pubic rami fractures
 outlet view

demonstrate the magnitude of vertical

(cranial) displacement of the hemipelvis.
Additionally, some sacral and pubic rami
fractures are better visualized with the
outlet view than with other views
Vertical shear injury as seen on an outlet radiograph of the pelvis. The vertical
(cranial) displacement of the left hemipelvis and pubic symphysis is better visualized
by using the outlet view. In addition, a left iliac fracture is more readily apparent
(large arrows). Left sacroiliac joint diastasis is seen (small arrow).
Hip Joint
Look for:
1. Joint space
2. Femoral head:
• shape, regularity
3. Shenton’s line
• Smooth curve from
superior pubic
ramus to femoral
neck
• Distorted in # &
subluxations
4. Neck-shaft angle
 Groin – Lateral view
Indication:
-congenital abnormality
-trauma
-degenerative disease
-carcinoma
-other pathologies e.g Perthes
disease, slipped femoral
epiphyses

Anatomy
Demonstrated
Femoral head and
neck, acetabulum
Lateral View
 Frog – Lateral view

** do not order a frog leg lateral

in any patient suspected of
having hip fracture or
dislocation);
Indications for imaging
Congenital abnormalities, Perthes disease,
slipped femoral epiphyses

patient is supine w/ knees flexed, soles of

feet together, and the thighs maximally
abducted;

central beam is directed vertically or with

a 10 to 15 deg cephalic tilt to a point
slightly above pubic symphysis;
Adult Hip - Rolled Lateral

Anatomy Demonstrated
Femoral heads and necks, acetabulum

1. Lesser trochanter is
clearly visible
2. Angle of femoral
neck cannot be
access
Slipped capital femoral epiphysis. Image of a 14-year-old male adolescent who
came to the emergency department with complaints of thigh and knee pain .A
more obvious posterior slip is noted on this frog-leg lateral view.
 Normal Anatomy
Radiology of Lower Limb
 Views of X-ray of Lower Limb
• Femur • Ankle
– AP Proximal – AP
– AP Distal – Mortise
– Lateral Proximal – Lateral
• Foot
– Lateral Distal
– DP view (dorsiplantar)
• Knee
– Oblique
– AP – Lateral
– Rolled Lateral – Weight bearing view
– Skyline • Calcaneum
– Intercondylar – Lateral
• Tibia/Fibula – Axial
– AP • Toes
– Lateral – AP
– Oblique
Adult femur – AP
proximal view
Adult femur –
AP distal view
Adult femur – Lateral
proximal view
 Adult femur –
Lateral distal view
Adult knee – AP
view
Adult knee – Rolled
lateral view
Adult knee – Skyline view
- Taken with the knee flexed 30 °
- Look between the patella and the femur
- There should be a consistent gap between the 2 bones
- Used to diagnose knee OA and patellar fracture
Adult knee – Intercondylar view
Hip and knee joint flexed 90 degrees . The beam projects 20 degrees to the
longitudinal axis of the femur posteroanteriorly
Adult Tib/Fib –
AP view
Adult Tib/Fib –
Lateral view
Adult ankle –
AP view
Adult ankle – Mortise view

- Taken with the

ankle internally
rotated 15 to 20
deg
- This bring the
fibula around out
to the tibia
- The X ray beam is
nearly
perpendicular to
the intermalleolar
line
- Allow us to assess
Assess the congruence pf Mortise and look for evidence of talar shift due to
bony or ligamentous injury
- To assess syndesmotic integrity
- A syndesmosis joint connects 2 bones thru the connective tissue
- The tibia-fibula syndesmosis allows the 2 bones to work in unison
as part of the lower leg
Adult ankle – Lateral
view
 Bohler’s angle
• A line is drawn from the superior
aspect of the anterior process to
the superior aspect of the
posterior facet. A second line is
drawn from the superior aspect of
the posterior facet to the superior
most point of the calcaneal
tuberositymeasures height of the
posterior facet;
• normal range is 20-40 deg, hence
comparison views of opposite
calcaneus can be helpful;
• in most cases, a decrease Bohler's
angle implies fracture and
disrupted of the posterior facet;
Adult foot –
DP view
Adult foot –
Oblique view
Adult foot – Lateral view
Adult foot – Lateral weight bearing view
Adult calcaneum – Lateral view
Adult calcaneum – Axial view
Adult toes -
AP
Adult toes -
Oblique
Cross Sectional of Thigh
#1 femur
#2 rectus femoris muscle
#3 sartorius muscle
#4 femoral artery
#5 adductor longus muscle
#6 gracilis muscle
#7 adductor brevis muscle
#8 adductor magnus muscle
#9 vastus intermedius muscle
#10 vastus lateralis muscle
#11 lateral intermuscular septum
#12 gluteus maximus muscle
#13 sciatic nerve
#14 biceps femoris muscle
#15 semitendinosus muscle
#16 semimembranosus muscle
#1 femur
#2 rectus femoris muscle
#3 vastus lateralis muscle
#4 profunda femoris artery
#5 vastus intermedius
#6 sciatic nerve
#7 long head of biceps femoris
muscle
#8 semitendinosus muscle
#9 semimembranosus muscle
#10 adductor magnus
#11 gracilis
#12 great (long) saphenous vein
#13 femoral artery
#14 femoral vein
#15 vastus medialis muscle
#1 femur
#2 vastus medialis
#3 tendon of quadriceps muscle
#4 vastus intermedius muscle
#5 vastus lateralis
#6 short head of biceps femoris
muscle
#7 long head of biceps femoris
#8 semitendinosus
#9 semimembranosus
#10 gracilis
#11 sartorius
#12 popliteal artery
#13 popliteal vein
#14 great saphenous vein
#1 femur
#2 vastus lateralis
#3 biceps femoris
#4 common peroneal nerve
#5 tibial nerve
#6 popliteal artery
#7 popliteal vein
#8 semimembranosus
#9 semitendinosus
#10 gracilis
#11 sartorius
#12 vastus medialis
#13 articular muscle of the knee
#14 great saphenous ve
#1 femur
#2 patella
#3 vastus medialis
#4 medial head of gastrocnemius
#5 popliteal artery
#6 popliteal vein
#7 tibial nerve
#8 common peroneal nerve
#9 semimembranosus muscle
#10 tendon of semitendinosus
#11 gracilis
#12 sartorius
#13 great saphenous vein
#14 biceps femoris muscle
#15 deep fascia of the leg
#16 lateral patellar retinaculum
#1 femur
#2 patella
#3 medial patellar retinaculum
#4 lateral patellar retinaculum
#5 iliotibular tract
#6 biceps femoris muscle
#7 common peroneal nerve
#8 lateral head of gastrocnemius
#9 popliteal artery
#10 popliteal vein
#11 tibial nerve
#12 semimembranosus
#13 medial head of
gastrocnemius
#14 sartorius
#15 great saphenous vein
#1 femur
#2 medial condyle of femur
#3 lateral condyle of femur
#4 anterior cruciate ligament
#5 posterior cruciate ligament
#6 popliteal artery
#7 popliteal vein
#8 medial head of gastrocnemius
#9 lateral head of gastrocnemius
#10 plantaris muscle
#11 biceps femoris muscle
#12 tendon of semimembranosus
muscle
#13 sartorius
#14 great saphenous vein
Septic Arthritis
INTRODUCTION…

 Septic arthritis is inflammation of a synovial

membrane with purulent effusion into joint
capsule.
 Usually due to bacterial infection.
 typically affects monoarticular joints.
Imaging studies :

1) Plain radiography
- often normal
- early stage-soft tissue swelling around the joint,
widening
of joint space and displacement of tissue
planes
- later stage – bony erosions and joint space
narrowing

2) Ultrasonography
- reveal joint effusion
- can be used to define the extent of septic
arthritis and help guide treatment
Conventional Radiography for
Infectious Arthritis
Modality of choice for initial evaluation of suspected joint infections
 Diagnosis can be made when characteristic findings are
present
 Early plain film findings:
 Soft tissue swelling
 Hazziness
 Synovial thickening
 Joint effusion-increase in joint space
 Joint space loss
 Later plain film findings:
 Periosteal reaction
 Marginal and central erosions & destruction of subchondral
bone
 Subluxation or dislocation
 Intra-articular bony ankylosis
 Normal
joint
space
 During the
progression of
infectious arthritis
of the hip, this
image was
obtained early in
the disease and
shows only joint-
space loss.
 During the
progression of
infectious
arthritis,
subchondral
erosions and
sclerosis of the
femoral head are
present
 Late stage
 osteonecrosis
and complete
collapse of the
femoral head
are present.
SA of Left Shoulder
Soft tissue swelling &
destructive metaphyseal
changes

One month later :

Dislocation of the left
shoulder
Soft tissue swelling

Sclerosis

Bony destruction
 bony resorption

SA of the metacarpophalangeal joint following penetrating injury to the

fist on striking a tooth.
Soft tissue swelling with
soft-tissue air

Destruction around the glenoid

fossa

Destructive focus in the medial humeral metaphysis

 Hip irregularity of the joint surface & narrowing
of the joint space

destructive focus in
the femoral head

marked osteoporosis of
prox femur.
Destruction of femoral
head

Reactive sclerosis at the femoral

neck n superior aspect of
acetabulum

Osteoporosis of prox femur

 CASE
PRESENTATION
HISTORY
 89/ Malay/ Female
 c/o axillary swelling and right knee swelling
for past few months.
 Known case of peripheral nerve sheath tumor
HISTORY OF OSTEOMYLITIS
 Teenage, developed skin infection at
anterior of left leg, upper shin near to knee
joint
 Redness, discharge, pain
 Single lesion
 Chronic discharge for months, bone pain and
fever
 No h/o trauma, fracture
 Proximal (knee) and distal ( ankle) joint were not
involved
 No pain
 No reduced ROM
 No swollen
 Then the discharge reduced in amount and
eventually ceased, but the hole persist
(sinus)

Examination of the sinus

 At left anterior shin, near to knee join
 Single sinus, no active discharge, no
bleeding, no surrounding redness, no
increased warmth
 Impression : an old well healed sinus
-radio-opaque
area at proximal
1/3 of tibia

-cortical
thinkening
-no sequestra,
no involucrum
HISTORY
 31yo malay gentleman
 Left tibial opened fracture 2years ago
 External fixation done internal fixation
 3/12 ago : leg swollen, painful, still able to
walk
 3/52 ago : ulcers with serous discharge,
painful, a/w fever,malaise
 Metal seen at left tibial- exposed plate
PHYSICAL EXAMINATION
 Several scar on left leg, swollen
 One ulcer with metal seen exposed plate
 2 sinus with pus and discharge
 Inflammed surrounding skin, tender, warm
 Movement : not affected
 Sensory intact
 Peripheral Pulse present.
-plating at left distal
tibial with malelleous
plate
-4 loosened nail(3 are
broken), evidenced by
translucency around the
nail
- The lower nails are
not loosened
- Callus OR involucrum
- Fracture line seen
(could be new
fracture d/t bone
infection or non-union
of previous fracture)
case
• A 15yo indian boy presented with right thigh pain
for 2 months
• It was prickling in nature, not relieved by
analgesic and cause restricted range of
movement
• It was also associated with the swelling in his
right thigh which was gradually increased in size.
• Patient also complaint of numbness of the right
leg
• +lethargic, +LOW, +LOA, +fever
 Physical examination
• Thin built boy, but no obvious muscle wasting
• Alert and conscious, not in pain
• Vital signs were normal
• There was a swelling noted at his right thigh
o Round
o Around 15X15cm
o No skin changes such as sinus
o tender
o Firm to hard
o Smooth surface
o Well-defined margin
o Not mobile
o Transillumination test was negative
• Restricted knee joint’s ROM
• Neurovascular examination was unremarkable
 Investigation
• Blood
o FBC
o BUSE
• Imaging
o X-ray of the right thigh
o MRI of the right thigh
o CXR