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PRACTICAL
RADIOLOGY
A SYMPTOM-BASED APPROACH
Edward C. Weber, DO
Radiologist, Imaging Center
Adjunct Professor of Anatomy and Cell Biology
Volunteer Clinical Professor of Radiology and Imaging Sciences
Indiana University School of Medicine
Fort Wayne, Indiana
Joel A. Vilensky, PhD
Professor, Anatomy and Cell Biology
Indiana University School of Medicine
Fort Wayne, Indiana
Alysa M. Fog, PA-C
Physician Assistant, Ortho Northeast
Fort Wayne, Indiana
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Library of Congress Cataloging-in-Publication Data
Weber, Edward C., D.O.
Practical radiology : a symptom-based approach / Edward C. Weber, Joel A. Vilensky, Alysa M. Fog.
p. ; cm.
Includes index.
ISBN 978-0-8036-2832-8
I. Vilensky, Joel A., 1951- II. Fog, Alysa M. III. Title.
[DNLM: 1. Diagnostic Imaging. 2. Radiology. WN 180]
616.07'54—dc23
2012035484
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2832_FM_i-xiv 21/11/12 1:38 PM Page v
Foreword
T
he field of clinical medicine has become increasingly American College of Radiology (ACR), for proper use of
complex in recent decades and imaging is now an imaging. With today’s concerns about radiation exposure and
integral part of the diagnosis and management of most the skyrocketing costs of health care, Dr. Weber’s approach is
patients. It is very difficult for health care providers to under- particularly timely.
stand all aspects of the wide menu of imaging studies that are Chapter 12, “Clinical Practice Issues in Medical Imag-
available, including limitations and appropriate utilization. ing,” is an excellent summary of topics that bridge all areas
Dr. Edward Weber, Adjunct Professor of Anatomy and Cell of imaging. There are outstanding discussions about how to
Biology and Volunteer Clinical Professor of Radiology and deal with incidental findings, the ACR Appropriateness
Imaging Sciences at Indiana University School of Medicine– Criteria, and talking to patients about the risks and limita-
Fort Wayne, and his co-authors, have written this unique book tions of various imaging studies.
to bridge the gap in knowledge about appropriate imaging. The target audience for Practical Radiology: A Symptom-
The book begins with a discussion of various imaging Based Approachis physician assistant and nurse practitioner
modalities, including positioning and resulting images. students. However, this clearly written and beautifully illus-
Chapters 2–11 review the imaging of each anatomic region trated book would also be valuable to medical students, as well
of the body. The book’s organization is case-based, with clin- as residents and clinicians in a wide variety of specialties.
ical vignettes and clear descriptions of how imaging modal-
Valerie P. Jackson, MD, FACR
ities may affect the work-up, diagnosis, and management of
Eugene C. Klatte Professor and Chairman
various disease presentations. Each chapter ends with a series
Department of Radiology and Imaging Sciences
of review questions.
Indiana University School of Medicine
The book has a unique emphasis on cost-effective medicine
and the use of Appropriateness Criteria, such as those from the
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Preface
Practical Radiology: A Symptom-Based Approachis designed recognize and learn how to interpret normal and patho-
for mid-level clinicians, such as physician assistants and nurse logic structures and conditions.
practitioners, as well as primary care physicians. The book is Case Studies. Each clinical chapter begins with a case
organized by the clinical presentations of your patients and study that continues throughout the chapter, to help illustrate
the medical imaging procedures you are likely to use while and create a real-world feel for how to recognize the most
diagnosing or evaluating these conditions. We believe this cost-effective and efficient modality, relative to a patient’s
patient-oriented approach provides a uniquely practical and condition, and how to interpret the associated radiologic
useful radiology reference for the student and practicing images based on the modalities used.
medical provider. Cost-Effective Medicine. These sections emphasize
instances in which more costly radiographic procedures
such as MRIs are unlikely to be more useful than less
APPROACH
expensive procedures such as radiography.
Because this book will teach you how to use radiology as a
Pediatric and Geriatric. Content especially pertinent to
clinical tool, the chapters are arranged by clinical presenta-
children and the elderly receives special attention in the book
tion, generally with separate Modalities and Interpretation
because treating these patients sometimes involves specialized
sections for each group of conditions. For each clinical prob-
radiologic approaches.
lem we present the most appropriate imaging procedures for
Patient Communication. These boxed elements help
evaluation and diagnosis of your patients.
students learn how to communicate effectively with their
Practical Radiology also uniquely provides informa-
patients and with teams of clinicians treating the patients.
tion about when it is unlikely that a radiologic study will
Radiology Requisition Information.These tables illus-
change the diagnosis or treatment of your patient. In other
trate how to concisely communicate important clinical data
words, we say when history, physical, or laboratory studies
to radiologists.
should be sufficient to diagnose a patient. We also empha-
Unique Glossary. A glossary is provided that not only
size instances when more costly radiologic procedures such
includes boldface terms throughout the text and their defi-
as MRI are likely to be no more useful to diagnose your pa-
nitions, but also a key that identifies the modalities to which
tient than less expensive procedures such as radiography.
the terms apply.
Our last chapter is also different from other radiology texts
Chapter Review Questions. Each chapter concludes with
in that we discuss many of the issues facing the use of
several Chapter Review Questions, many with images from
medical imaging in today’s health care environment, such
the chapter, to test knowledge of chapter content.
as radiation risk and the finding of unrelated abnormalities
In all aspects of Practical Radiology: A Symptom-Based
during radiologic procedures for specific clinical condi-
Approach we have striven to offer images and information
tions. These are issues that influence how your use of
of the highest quality possible, to present the most pedagog-
medical imaging affects the care you provide.
ically effective content, and to provide a resource that all
primary medical practitioners will find invaluable as they
FEATURES seek to provide the best patient care possible.
Colored arrows on images. Within the many carefully —Edward C. Weber
selected radiologic images in the book, we use red arrows Joel A. Vilensky
to indicate the pathology discussed in the text and blue Alysa M. Fog
to indicate normal anatomy. Students thus can easily
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About the Authors
Edward C. Weber has been in private practice as a radiologist for more than 30 years and
has taught radiology to first- and second-year medical students at Indiana University School
of Medicine in Fort Wayne (IUSM-FW) for almost 20 years. He guided the orientation of this
book and provided most of the radiologic images and clinical information for it.
Joel A. Vilenskyis an anatomist who has been teaching at IUSM-FW for more than 30 years.
His role was primarily to ensure that all textual and graphic material presented in the book could
be completely understood by students who have taken a course in medical anatomy and who
have had some basic clinical experience.
Alysa M. Fogis a practicing PA who specializes in orthopedics. She ensured that the material
was ideally presented for students and beginning medical professionals. Alysa also contributed
much of the organization and clinical material for Chapter 2.
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Contributors
Thanks to Peter Miller, MD; LCDR Kevin Preston, MD; and Keith Newbrough, MD for their generous
contribution of images:
Peter Miller, MD, Indiana University School of Medicine
Chapter 1: Figure 1-3
Chapter 2: Figures 2-5, 2-12, 2-14, 2-28, 2-33, 2-36, 2-43, 2-47, 2-65, 2-67, 2-70, 2-76, 2-78
Chapter 3: Figures 3-3, 3-4, 3-5, 3-6, 3-7, 3-9, 3-11, 3-12, 3-28, 3-29
Chapter 4: Figures 4-1, 4-4, 4-5, 4-6, 4-7, 4-11, 4-13, 4-16, 4-18, 4-19, 4-20, 4-29, 4-33
Chapter 5: Figures 5-6, 5-13, 5-15, 5-17, 5-18, 5-19, 5-21, 5-22, 5-23, 5-24, 5-29, 5-30, 5-31, 5-33
Chapter 6: Figures 6-25, 6-43, 6-44
Chapter 8: Figures 8-1, 8-2, 8-3, 8-4, 8-6, 8-7, 8-9, 8-10, 8-11, 8-12, 8-13
Chapter 9: Figures 9-1, 9-2, 9-3, 9-4, 9-5, 9-10, 9-11, 9-17, 9-22, 9-24, 9-26, 9-27, 9-28, 9-29, 9-32
Chapter 10: Figures 10-15, 10-16, 10-17
LCDR Kevin Preston, MD, Indiana University School of Medicine
Chapter 2: Figures 2-35, 2-38, 2-39, 2-40, 2-41, 2-45, 2-56, 2-63, 2-79, 2-81, 2-83, 2-84
Chapter 6: Figures 6-5, 6-7, 6-12, 6-14, 6-18, 6-19, 6-21, 6-22, 6-23
Chapter 8: Figures 8-18, 8-20
Keith Newbrough, MD, Indiana University School of Medicine
Chapter 2: Figures 2-8, 2-9, 2-18, 2-29
Chapter 6: Figure 6-17
Chapter 7: Figure 7-5
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Reviewers
Linda G. Allison, MD, MPH
Associate Professor, Pharmacy Practice
Belmont University School of Pharmacy
Nashville, Tennessee
Jesse A. Coale, PA-C
Assistant Professor
Physician Assistant Studies
College of Science, Health & the Liberal Arts
Philadelphia University
Philadelphia, Pennsylvania
Randy Danielsen, PhD, PA-C
Senior Vice-President
National Commission on Certification of Physician Assistants Foundation
Johns Creek, Georgia
Steve B. Fisher, MHA, PA-C
Senior Surgical Physician Assistant
Department of Neurosurgery, Kentucky Neuroscience Institute
University of Kentucky
Lexington Kentucky
Charlene Morris, MPAS, PA-C, DFAAPA
Family Medicine
Pamlico Medical Center, PA
Bayboro, North Carolina
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Acknowledgments
This book originated in a spring 2010 meeting at a coffee We are very grateful to Fen-Lei Chang, MD, for critically
shop near the Pennsylvania Turnpike between ECW and reviewing the chapter on brain imaging.
F.A. Davis Senior Acquisitions Editor, Andy McPhee. Andy We extend our appreciation to Robert Conner, MD, and
showed immediate enthusiasm for the project, and we are the technical staff at The Imaging Center, Fort Wayne, IN, for
grateful to him for that enthusiasm and his support and guid- their support and their dedication to high-quality patient care.
ance throughout the project. We deeply appreciate the editing We would also like to offer deep appreciation to the many
provided by our developmental editor, Jennifer Ajello, who scientists and engineers whose work has made possible the
managed this project. The book has a high level of consis- fantastic tools used in modern medical imaging. Further-
tency and organization because of her guidance. Liz Schaeffer more, we acknowledge the commercial enterprises whose
ably guided the writing and assembly of ancillary materials software and hardware make practical the analysis of the vast
available to instructors who adopt our book. image datasets now produced in medical imaging facilities.
The medical images we present here offer superior clarity ECW collected most of the clinical images for this book while
because of the skills and knowledge of Roberta Shadle, our using an advanced radiology workstation from Carestream
graphic artist, who turned our raw images into the polished Health, which provided the means for managing, viewing,
figures needed for the book. We are thankful to have had and processing images from digital radiography, mammog-
Roberta as part of our team. raphy, sonography, CT, and MRI.
Most of the clinical images in this book were acquired by We are very grateful to our spouses, Ellen Weber, Deborah
ECW while in clinical practice at The Imaging Center, Fort Vilensky, and Daniel Fog, for their support of our efforts and
Wayne, IN, and as consulting radiologist for The Medical toleration of our often spending more weekend time with
Clinic of Big Sky in Big Sky, MT. However, in the outpatient each other than with them. We also acknowledge that two of
setting in which ECW practices, appropriate images to accom- the spouses have already been asking when we are going to
pany our text were not always available. Fortunately, many begin our next project.
clinical images were provided by Peter Miller, MD, Lieutenant Finally, we would like to thank our students, who have
Commander Kevin Preston, MD, and Keith Newbrough, MD, taught us to shed our assumptions and years of experience
while they were radiology residents at the Indiana University and see radiology from the viewpoint of new immigrants to
School of Medicine (p viii). the strange and wonderful landscape of medical imaging.
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Contents
Chapter 1: Modalities of Medical Imaging 1 WRIST AND HAND 33
RADIOGRAPHY 1 Acute Pain and Trauma 33
Radiographic Densities 1 Modalities 33
Types of Resolution 2 Interpretation 33
Radiographic Projections 3 Chronic Conditions Including Soft Tissue Masses 36
PA/AP Views 3 Modalities 36
Lateral Views 4 Interpretation 36
Oblique Views 4 PELVIS, HIP, AND THIGH 37
Viewing Radiographic Projections 5 Trauma and Acute Pain 37
CROSS-SECTIONAL IMAGING, TOMOGRAPHY, AND Modalities 37
BODY PLANES 7 Interpretation 37
COMPUTED TOMOGRAPHY: CROSS-SECTIONAL Chronic Conditions Including Soft Tissue Masses 38
IMAGES AND RECONSTRUCTIONS 7 Modalities 39
MAGNETIC RESONANCE IMAGING 11 Interpretation 40
ULTRASOUND 12 KNEE AND LOWER LEG 41
NUCLEAR MEDICINE 14 Acute Pain and Trauma 41
INTERVENTIONAL RADIOLOGY 15 Modalities 41
STRENGTHS AND WEAKNESSES OF IMAGING Interpretation 42
MODALITIES 16 Chronic Knee and Lower Leg Pain 47
CONTRAST ENHANCEMENT 16 Modalities 47
Interpretation 47
THE RADIOLOGY WORKSTATION AND PACS SYSTEMS 17
ANKLE AND FOOT 49
THE RADIOLOGY REQUISITION AND THE
RADIOLOGY REPORT 18 Acute Pain and Trauma 49
HOW SAFE IS MEDICAL IMAGING? 19 Modalities 49
Interpretation 50
Chapter Review Questions 20
Chronic Ankle and Foot Pain 54
Chapter 2: Shoulder, Pelvis, and Limbs 21
Modalities 54
EXTREMITIES 21
Interpretation 55
FUNDAMENTALS OF MUSCULOSKELETAL IMAGING 21
LOWER LIMB VASCULAR DISEASE: PERIPHERAL
SHOULDER AND ARM 23
ARTERIAL INSUFFICIENCY AND VENOUS
Trauma and Acute Pain 23 THROMBOSIS 57
Modalities 23 Modalities 57
Interpretation 25 Interpretation 57
Chronic Conditions of the Shoulder Including Chapter Review Questions 60
Soft Tissue Masses 27
Chapter 3: Spine and Spinal Cord 65
Modalities 27
FUNDAMENTALS OF SPINE AND SPINAL CORD
Interpretation 28
IMAGING 65
ELBOW AND FOREARM 30
SPINAL TRAUMA 65
Trauma and Acute Pain 30
Modalities 66
Modalities 30
Interpretation 66
Interpretation 30
Cervical Spine 66
Chronic Conditions of the Elbow 32
Thoracolumbar Spine 68
Modalities 32
Interpretation 32
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