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MRI OF KNEE

Ant. Cruciate
ligament

Ant. Cruciate
ligament

Post. Cruciate
ligament

Pop sound after impact


Swelling after couple of
hours
Severe pain when
bending the knee
Barkling or locking of the
knee during movement

Mx :
Rest
Ice
Compression
Elevation
Exercise

Operation vs Non op
-Pt, high deman, good ROM, done
endoscopically
Acute splint& crutches
-early active ROM
-Closed chain WB to strengthen Non
operative
-avoid high risk
-Fx bracing controversial

The two herniated discs (L4/5 & L5/S1) are "black" on this MRI
image,
which indicates disc desiccation (lack of water and proteoglycan)
and is
termed "degenerative disc disease" (DDD); this is usually a
precursor to
disc herniation for it weakens the annulus that contains the
pressurized
and irritative nuclear material.

Aortic dissection is one of the acute aortic syndromes and a type of arterial
dissection. It occurs when blood enters the
medial layer of the aortic wall through a tear or penetrating ulcer in the intima
and tracks along the media, forming a
second blood-filled channel within the wall.
Clinical presentation
Aortic dissection is arbitrarily divided into :
acute: with 14 days of first symptom onset
chronic: after 14 days
Post contrast CT (CTA preferably) gives excellent detail. Findings include 1-3,5:
intimal flap
double lumen
dilatation of aorta
complications (see below)
an atypical variant that may be seen is aortic intramural haematoma.
Treatment and prognosis
aggressive blood pressure control
immediate surgical repair (for type A dissection or complicated type B
dissection)

1. Findings: Multiple round calcification at right upper quadrant


Proceed with: Ultrasound, can see posterior shadowing
Diagnosis: Acute Cholecystitis
Findings: Thick wall gallbladder, fluid around wall of gallbladder

- Features a) Atrophy of
right lobe of liver
b) Large lobe
of caudate
c)Splenomegaly
d) Ascites
e) collateral
vessels
1. a) Name the imaging modality Axial of CT Abdomen
b) What structure
A = Ascites
B = Gall bladder
C = Inferior vena cava
D = Spleen
c) Diagnosis Cirrhosis of liver
d) Two causes
- Alcohol
- Hepatitis

Mass
Indenting
at the right
margin of
uterus

Bilateral blocked uterine tubes. No peritoneal


spills

Hystero salpingogram
-Non ionic contrast, 10-15 ml max
-To check for tubal patency
-After menses, Day 5 to Day 6 because
must be sure that she is not pregnant
-Take hx allergy, if allergy, give low
dose steroids
- to confirm not pregnant, UPT
Step for hystero- salpingogram
1.
2.
3.
4.
5.

Dilated and occluded right uterine tube


Ask patient to lie down on the table with legs open up
Clean private part and put speculum Occluded left uterine tube
Insert foleys catheter and blow the ballon
Inject contrast and watch the contrast pass through
Normally the contrast will spill into peritoneum cavity into both sides

Contraindication
Recent tubal surgery
Active pelvic infection

Complication
Per vaginal spotting
Venous extravasation
Rare : pelvic infection, contrast reaction

Conditions that HSG can detect


Uterine fibroid
Uterine congenital anomalies
Uterine malignancy
Adenomyosis

Tubal polyp
Hydrosalpinx (air dlm salpingo)

Obliteration due to prev pelvic inflammatory disease

a.
N

b.
c.
d.
e.

ame the modality?


Plain abdominal x-ray in erect position
Radiological findings?
Multiples air-fluid level
Dilatation of intestine
Diagnosis
Large bowel obstruction
Etiologies?
Adhesion
Hernia
Is it ultrasound recommended for this
case?
No, because the distended bowel
contain air so it is echogenic and not
able to be view in the ultrasound

2. a) Name the imaging modality


AP supine abdominal X-Ray
b) What is the radiological
abnormality coffee bean shaped
c) Diagnosis Sigmoid volvulus
d) 2 complications
- Intestinal Obstruction
- Ischemia
- Perforation
e) Etiology malrotation, twisting

Cholelithiasis : stones in gall bladder


RUQ or epigastric abdominal pain or discomfort especially after taking fatty meal
Belching, A reflex that expels gas noisily from the stomach through the mouth
(Sendawa)
Flatulence, heart burn, nausea, often referred to tip of shoulder
Ultrasound : Transabdominal USG is considered for detecting cholelithiasis
-grayscale usg
Higly reflective echogenic focus within gallbladder lumen, normally with prominent
posterior acoustic shadow
Gravity dependant movement is often seen with change of position (the rolling stone
sign)

Cx, pancreatitis

Periductal infiltrating intrahepatic tumours


typically are associated with altered calibre bile
duct (narrowed or
dilated) without a well defined mass.
Intraductal tumours are characterised by
alterations in duct calibre, usually ductectasia
with or without a visible
mass. If a polypoid mass is seen, it is usually
hyperechoic compared to surrounding liver
Cholangiocarcinoma is a malignant tumour
arising from the biliary tree, and tends to have a
poor prognosis and
high morbidity. It is the second most common
primary hepatic tumour with intra-hepatic
cholangiocarcinomas
accounting for 10-20% of primary liver tumours.
Risk factors
A number of risk factors for cholangiocarcinoma
have been identified including 1-2:
primary sclerosing cholangitis (PSC)
major risk factor in western countries
recurrent pyogenic cholangitis (hepatolithiasis)
major risk factor in endemic areas
Asian liver flukes
Opisthorchis viverrini
Clonorchis sinensis (clonorchiasis)

PYLORIC STENOSIS

Idiopathic hypertrophy and hyperplasia of


circular muscle fibres of pylorus with proximal
extension into the gastric antrum.
Incidence : M:F 5 : 1.
Presentation: 2-8 weeks of life
Non bilious projectile vomiting progressive
Olive shaped mass in upper abdomen .
Visible peristalsis
Nasogastric aspirate > 10 mls
oUGI findings
o Pyloric wall thickness >10 mm
o Elongation and narrowing of pyloric canal
(2-4 cm in length)
o "Double / triple track sign"
o Crowding of mucosal folds in pyloric
channel
o "String sign"
o Passing of small barium streak through
pyloric channel
o "Antral beaking"
o Mass impression upon antrum with streak
of barium pointing
o toward pyloric channel

o
o
o
o
o
o

Kirklin sign = "mushroom sign"


Indentation of base of bulb (in 50%)
Gastric distension with fluid
Active gastric hyperperistalsis
"Caterpillar sign
Gastric hyperperistaltic waves

DUODENAL ATRESIA
DUODENAL ATRESIA
LOCATION .
[1] Usually distal to ampulla of Vater . 80%
[2]proximal duodenum 20%
Radiology :
Double bubble sign = gas/fluid levels in
duodenal bulb and gastric fundus .
Total absence of intestinal gas in small /
large bowel .
Obs / [ detected after 24 weeks gestation ]
Double bubble sign
Increased gastric peristalsis
Polyhydramnios 100 % .

Necrotizing Enterocolitis (NEC)


Most common gastrointestinal medical and/or
surgical emergency occurring in neonates
Etiology
More common in premature infants
1.Average age of onset occurs within first week of
life
2.Affected term neonates are usually systemically
ill with other conditions such as birth asphyxia,
respiratory distress or congenital heart disease
3 Babies who are breastfed have a lower
incidence of NEC than formula-fed babies
Clinical findings
Initial symptoms may be subtle and can include
the
following
o Feeding intolerance
o Delayed gastric emptying
o Abdominal distention and/or tenderness
o Ileus/decreased bowel sounds

There are multiple dilated loops of bowel (yellow arrow).

A linear radiolucency is seen paralleling the bowel


wall indicating air in the wall

Imaging findings
Acute disease most commonly affects the
terminal ileum
Plain film of the abdomen remains method in
which disease is diagnosed most often
Findings include
o Dilated loops of bowel
o Thickened bowel walls
Fixed and dilated loop that persists is especially
worrisome
o Absence of bowel gas
o Pneumatosis intestinalis
Pathognomonic of NEC in newborn
Linear radiolucency parallels bowel lumen within
bowel wall
Represents air that has entered from the lumen
o Abdominal free air

Biliary atresia (BA) is a congenital biliary disorder, which is


characterised by an absence or severe deficiency of the extrahepatic biliary tree. It is one of the most common causes of neonatal
cholestasis, often causing cirrhosis immediately and leading to death
and accounts for over half of children who undergo liver
transplantation.
Epidemiology
It is thought to affect 1 in 10,000-15,000 newborn infants. There is a
recognised male predilection.
Clinical presentation
It precipitates within the first three months of life. Infants with biliary
atresia may appear normal and healthy at birth. Most often, symptoms
develop between two weeks to two months of life, and may include :
Transverse
Transverse grayscale image of liver showing the area of
increased echogenicity along anterior wall of right portal vein.

jaundice (conjugated hyperbilirubinaemia)

dark yellow or brown urine

pale or clay-colored (acholic) stools

hepatomegaly

Pathology
Aetiology
It is thought to result from idiopathic destructive inflammatory process
which leads to fibrotic remnants at porta hepatis.
Associations
In 10% of cases, there is an association
with polysplenia and heterotaxy syndrome 6.
Classification
Kasai classification is used to classify the three main anatomical types
of biliary atresia.
Radiographic features

Longitudinal
Longitudinal grayscale image of right upper quadrant
performed after 3 hours of fasting shows a diminutive
gallbladder measuring 17 mm in length and 2.5 mm in width.
The gallbladder has a multiseptated look and subtly thickened
wall.

Prompt diagnosis ensures early treatment and results in improved


prognosis.
Ultrasound

echogenic triangular cord sign 5

larger hepatic arterial calibre

gallbladder ghost triad 4

Nuclear medicine (hepatobiliary (HIDA) scan)


Tc-99m diosgenin (DISIDA) and mebrofenin (BRIDA) have highest
hepatic extraction rate and shortest transit time of hepatobiliary
radiotracers. Cases of biliary atresia typically demonstrate relatively
good hepatic uptake with no evidence of excretion into the bowel at 24
hours. Pretreatment with phenobarbital (5 mg/kg/day for 5 days) to
increase biliary secretion by stimulating hepatic enzymes is frequently
helpful to minimize the possibility of a false-positive study in a patient
with a patent biliary system but poor excretion.
Treatment and prognosis
Management options include

Kasai portoenterostomy

liver transplantation

Complications

Longitudinal
Longitudinal grayscale image of right
upper quadrant performed after 3
hours of fasting shows a diminutive
gallbladder measuring 17 mm in
length and 2.5 mm in width. The
gallbladder has a multiseptated look
and subtly thickened wall.

portal hypertension

Differential diagnosis
General imaging differential considerations include

neonatal hepatitis

Alagille syndrome

Caroli disease

bile plug syndrome

lipid storage disorders

Non-accidental injuries (NAI) represent both ethical


and legal challenges to treating physicians.
Radiologists are often the first to suspect NAI when
confronted with particular injury patterns, and a
knowledge of these is essential if the opportunity to
save a child from future neglect is not to be missed. At
the same time it is essential that suspicion is not raised
inappropriately as the consequences for an innocent
but accused parent or guardian are significant.

Epidemiology
In 2001 an estimated 903,000 children were victims of
maltreatment including:

neglect: 57%

physical abuse: 19%


o
cutaneous injury: most common
o
fractures are noted in ~30% (range
11-55%)

sexual abuse: 10%

psychological maltreatment: 7%

medical neglect: 2%

Clinical features
A number of features have been recognised as
suspicious:

injury in non-ambulatory / totally dependent


child

injury and history given are incompatible

delay in seeking medical attention

multiple fractures with no family history


of osteogenesis imperfecta

retinal haemorrhage

torn frenulum

history of household fall resulting in fracture


o
despite falls being common, fractures
are uncommon

Specific fractures
A number of fractures have been recognised as highly
specific to non-accidental injury (rather than accidental
injury). They include:

metaphyseal fracture (so called bucket handle


fracture or corner fracture)
o
present in up to 39-50% of abused
infants < 18 months
o
said to be virtually pathognomonic of
NAI

rib fractures
o
especially posterior ribs
o
may have no overlying bruising
o
although anterior rib fractures can
occasionally be caused by vigorous CPR,
posterior rib fractures do not occur
o
costochondral junction injuries and/or
fractures

skull fracture: suspicious features include:


o
non parietal skull fracture (a parietal
fracture is more suggestive of accidental injury)
o
involves multiple bones
o
diastatic sutures
o
crosses sutures
o
depressed fracture (fracture a la
signature)

scapular fractures

sternal fractures

Dating injuries
The ability to date injuries is critical for medicolegal
purposes, and thus must be done carefully (please refer
to specialist text for specific guidelines).
Traumatic periosteal injury can be seen up to 7 days
post injury (and therefore can be used for dating). This
can be seen on diaphyseal and rib injuries. Diaphyseal
injuries start healing at 1 week. Healing should be
complete by 12 weeks. Rib fractures are easily missed
so current practice is to repeat chest films in 2 weeks to
observe for any healing rib fractures.
Metaphyseal (and costochondral junction) injuries do
not heal with periosteal reaction and if visible are less
than 4 weeks old. Skull fractures also do not heal with
periosteal reaction and if seen are less than 2 weeks
old.

Radiographic features
Skeletal injuries
Skeletal survey is performed in cases of suspected
abuse to assess and document the extent of previous
skeletal injuries. The so-called babygram is not an
acceptable substitute.
Bone scans are also able to detect radiographically
occult fractures and should be considered when clinical
suspicion is high.
A typical skeletal survey comprises plain films of the
following:

skull AP and lateral views


o
also Towne skull projection if clinically
suspicious of occipital fracture

lateral cervical and thoracolumbar spine

chest x-ray

left/right oblique ribs

abdominal x-ray

left/right AP humeri

left/right AP forearm

left/right AP hand

left/right AP femora

left/right AP tibia/fibula

left/right dorsoplantar feet

Practical points
skeletal dysplasias: one of the major, albeit
uncommon, pitfalls in diagnosing NAI (e.g Schmidtype metaphyseal chondrodysplasia, osteogenesis
imperfecta I and IV), which may lack the florid
features of full blown disease and can be easily
confused with NAI
o
features to differentiate osteogenesis
imperfecta from NAI include:

presence of osteopenia

bowing/remodelling of bones

presence of wormian bones


growth plates can also cause a degree of
confusion, most notably at the hip, base of fifth
metatarsal, elbow and acromion
birth injuries

rickets

Intracranial injuries
A subdural haemorrhage in a child should be viewed
with suspicion. On occasion, the subdurals will
demonstrate varying ages.

Pitfall: Subdural haematoma in a patient with benign


enlargement
of
the
subarachnoid
spaces
(BESS) should not be interpreted as suggestive
of NAI without other stigmata 9.

Figure 2. Case
2. A, T1-

weighted
shows high
signal intensity
restricted mainly in the right putamen. B, T2weighted image shows no difference in appearance from the unaffected side.
MRI

T1-weighted imaging is used to differentiate anatomical structures mainly on the basis of


T1 values; i.e. the scanning parameters are set (short TR/short TE) to minimize T2 relaxation
effects. Tissues with high fat content (e.g. white matter) appear bright and compartments filled
with water (e.g. CSF) appears dark. This is good for demonstrating anatomy.
T2-weighted imaging is used to differentiate anatomical structures mainly on the basis of
T2 values; i.e. the scanning parameters are set (long TR/long TE) to minimize T1 relaxation
effects. Compartments filled with water (e.g. CSF compartments) appear bright and tissues
with high fat content (e.g. white matter) appear dark. This is good for demonstrating pathology
since most (not all) lesions are associated with an increase in water content.

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