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Hand CXR Scapula if rotated out, PA film Start with lung fields, mediastinum, cardiac shadow and index

x o Cardiac index largest radii from spinus process (left and right added together) Pneumothorax Extraplerual vs intrapleural look for pleural reflection Volume status o Vena cava size if decreased, volume depletion o Specific gravity in urine dipstick anything greater than 1.020 pre-renal syndrome o Ketones DKA, dehydration o UECr azotemia, U:Cr ratio > 1.0 o Patient to take deep breath, if IVC collapse more than 50% - dehydration o Invasive CVP Lateral CXR o Retrocardiac and retrosternal space obliteration o Air space shadowing in retrocardiac space Normally inferior vertebrae appears darker Capitate, metacarpal, radius axis

Knee X-ray Patella o Line from superior to inferior pole of patella o Insal-salvati ratio

C-spine Adequacy and alignment o C7-T1 junction o Anterior, posterior, spinal lamina junction o Tips of spinous processes that align to position behind the neck Bones o Any tear drop fracture, wedge fractures Cartilage o Intervertebral disc spaces uniformity Soft tissue spaces o In front of C2-3, less than 1/3 of vertebral body width (vertebral body width, about 20mm) o In front of C6-7, less than 20mm Predental space <3mm in adults, <5mm in kids

Instability 2/3 columns involved Fractures in C-spine o Jeffersons burst fracture C1 Predental space wide and >3mm o Clay-shovellers fracture o Hangmans fracture axial forces + hyperextension. Could appear to be stable Fracture line vs vascular line

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Fracture line darker Associated soft tissue Vascular lines taper as they get distally

Nasal bone fracture Document septal haematoma need to refer to ENT CSF rhinorrhoea (BOS #) Complex lacerations (many flaps, mucosal damage) Active epistaxis

30 degree occipitomental (OM) view To assess facial architecture McGrigors line o Zygomatical frontal suture and superior aspect of orbit, symmetrically down other side o Superior aspect of zygoma, inferior aspect of orbit, nasal bones, down the other side o Inferior aspect of zygoma, lateral wall of maxillary antrum, medial wall of maxillary antrum, medial alveolar process Tripod fracture Zygomatic, frontal sutural diasthasis Fracture across zygoma

Pneumothorax Subpleural bleb primary spontaneous pneumothorax o Irritant (usually tar and smoking) with increased distensile forces forming blebs o Smoking increases risks by 120x o Subjected to increased forces rupture pneumothorax Estimate size of pneumothorax o First 0.5cm is 10%, next 0.5cm is 4% o Lights formula 1- (l^3/h^3) = percentage of size of pneumothorax L is spinus process to lung H is spinus process to rib Treatment o BTS guidelines 2010 age > 50, pre-existing lung disease / X-ray findings o Bilateral pneumothorax, unstable put chest tubes o Primary spontaneous pneumothorax Greater than 2 cm and breathless Saldinger chest tube (over guidewire) Need to give O2 N2 is predominant gas in pneumothorax High flow oxygen O2 produces gradient, allow absorption of N2, reduction of pneumothorax

Air under diaphragm PPI, ABx Preparation for surgery

Heart failure Upper lobe diversion o Pulmonary capillary wedge pressures 15-20

Kerley B lines o Interstitial edema PCWP of 20-25 o Kerley A 6-7 cm, radiates from hilum o Kerley C Bats wings o Alveolar edema PCWP > 25 Treat with GTN, lasix o Lasix use up to 40mg, if need more, switch to other diuretics o Renal failure patients may need to give 5x

ARDS PCWP <15 (not heart failure) Must have appropriate precipitant o Pulmonary pneumonia o Extrapulmonary pancreatitis, burns Bilateral lung infiltrates P:F (PaO2 to FiO2) ratio <200 o If >200, acute lung injury

Pulmonary embolism Hamptons hump Westermarks sign pulmonary oligemia (proximal pulmonary dilatation, distal rats tailing) Pallas sign descending pulmonary artery dilated Changs sign descending pulmonary artery has sharp cut off

Aortic dissection Aortic knuckle not distinct Widened mediastinum Pressure effect with movement from left to right Double egg shell sign Paraspinal stripe Paratracheal stripe

Lung mets Cannonball lesions from renal

Pleural effusion Transudative / exudative Protein <30g/L transudate Lights criteria (any 1 of 3 satisfied exudates) o LDH, protein, o Pleural protein: serum protein > 0.5 o Pleural LDH: serum LDH > 0.6 o Pleural fluid LDH greater than 0.6 or 2/3 above upper limit of normal for serum

Pseudopneumothorax Pressure phenomenon can get kinking of SVC and go into shock Air-fluid interface

Prolapse of abdominal contents into chest needs to be reduced, cannot put chest tube in

Intestinal obstruction Step-ladder Turtle shell If bowel filled with fluid string of pearls sign little bubbles going up (complete distension of bowel with fluid) Metoclopramide, IV fluids, treated conservatively, if fail go for surgery

Aerobilia and small bowel dilatation gallstone ileus Midshaft fracture of humerus (radial nerve) Check for radial nerve and vascular status Dorsally, first interdigital space Extensors U-slab (acromion pass the elbow to axilla) if no NV status If wrist drop consider neuropraxia. Conservative treatment for 6-8 weeks o Do cock-up splint If open fracture do surgery

Open book fracture Can lose up to 10L of blood (massive blood loss) o From fracture, internal iliac artery, pre-sacral venous plexus o The greater the volume, more the tamponade o Tie long sheet around pelvis, greater trochanteric band o Go on to do External fixation, or ORIF o Associated with bowel and genitourinary, ureteric damage

Dennis-Weber classification C above syndesmosis o Always ORIF B- at syndesmosis o Depends on how much syndesmotic disruption present A below syndesmosis o Conservative, non-weight bearing cast

Calcaneal fractures Extra-articular Intra-articular (75% of calcaneal fractures) o Involves sub-talar joint o Bohlers angle, normal 25-40 degrees o Gissanes angle 100 degrees +/- 5

Colles fracture Distal radius fracture within 2.5 cm of radiocarpal joint Lateral and AP view Ulnar styloid fracture (avulsion) TFCC damaged chronic instability of the wrist Operate if NV compromised

Radiographic indices in distal radial fracture (if any of the above, M&R) o Lateral view angulation. Can accept <20 degrees of volar angulation, <10 degrees of dorsal angulation o Radial height will accept anything >10mm o Radial inclination angle accept anything more than 15 degrees

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