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It also provides information SPECIFIC USES about the chronicity of an abnormality buy kamagra soft 100mg visa, as acute lesions show intense tracer accumulation generic 100mg kamagra soft visa, and more Radiography should usually be used for the initial chronic quiescent conditions appear more normal buy kamagra soft 100 mg amex. In the case of chronic disorders purchase 100 mg kamagra soft free shipping, radiographs can eliminate alternate CONSIDERATIONS diagnoses buy kamagra soft 100 mg overnight delivery, such as arthritis or neoplasia. Radiography is also the standard method for following fracture Considering that different modalities have differing healing and alignment corrections (subluxation or dis- sensitivity to demonstrate certain pathology, it location). In both ligamentous injuries, capsular tears, and intra-articular cases, one should usually begin with plain radiogra- loose bodies. In cases of normal radiographs and suspected MRI is used for suspected bone or soft tissue injury, acute bone injury, one may choose to obtain an MRI especially when plain radiographs are normal. There to evaluate edema and a possible nondisplaced frac- are indications for MRA, including chronic glenoid or ture. MRI is also useful for more chronic injuries acetabular labral tears, low grade superior labrum where a soft tissue abnormality is suspected. CHAPTER 18 DIAGNOSTIC IMAGING 109 Complex acute fractures should be evaluated with CT protection is needed. MRI is excellent for demonstrating inflamed level of patient’s activity. Ultrasound is suit- where the decision of return to play is important, one able for detecting superficial fluid collections and may choose to obtain advanced imaging (usually possibly hyperemia in an inflamed superficial bursa. OVERUSE Bone is the fundamental scaffolding of the muscu- loskeletal system, and plays a central role in diagnos- Plain radiography is usually used to evaluate for acute tic imaging. With chronic complaints or overuse, plain an injury indicates at a minimum trabecular trauma films provide an effective screening tool for arthritis, and contusion. Specific patterns of marrow edema inflammatory processes, and musculoskeletal tumors. In cases of chronic injuries, calcifications acute anterior cruciate ligament tear. Plain films are also Cartilage outlines the bony surfaces of the joints. As used to evaluate for periosteal new bone formation, a shock absorber it is prone to wear and tear as well as abnormal bone sclerosis and callus formation. Acute chondral fractures, often with an If plain films are deemed to be normal and symptoms adjacent bone fragment (osteochondral fracture), are warrant, MRI is usually the next modality undertaken. Cartilage is not directly With chronic or overuse disorders, stress reaction or visible with plain radiography; however, an initial fracture will appear on MRI as edema in bone evaluation of cartilage thickness may be performed marrow, possibly with immature periosteal new bone with plain radiography to assess joint space narrow- formation. MRI, on the other hand, not only demonstrates muscles, tendons, and ligaments. When the suspicion acute injuries to the osteochondral unit, but also of an acute fracture is high and plain films are normal, nicely shows intrinsic signal abnormalities of carti- MRI will detect radiographically occult fractures in lage owing to wear and tear (chondromalacia). MRI weight-bearing bones such the tibial plateau and prox- can also evaluate the cartilage for focal areas of thin- imal femur. It is not dynamic muscle and tendon units are prone to uncommon for bone and soft tissue tumors to be ini- injuries. Certain sports are associated with specific tially diagnosed as a hematoma or muscle strain. The examples are innumerable, palpable mass diagnosed as a hematoma should be including jumper’s knee (patellar tendon), tennis leg followed clinically to maturation or resolution. If plain films are normal, MRI will provide the necessary soft CHRONIC SEQUELA TO TRAUMA tissue contrast for diagnosis. The spectrum of findings range from mild edema to hematoma, partial tear, and Areas of prior hemorrhage, hematoma, or inflamma- complete disruption. Ultrasound is gaining popularity tion may undergo transformation into mature bone. The former name is preferred, Bursae are fluid filled structures with synovial linings since this is not an inflammatory process of the mus- that act as cushions at foci of increased motion or fric- cles. They are classically found between bones and role in recognizing this entity. The finding of peripheral tendons or muscles and skin, but can form anywhere calcification around a soft tissue mass is the hallmark 110 SECTION 2 EVALUATION OF THE INJURED ATHLETE of this entity. This is contrary to osteogenic sarcoma, HAND/WRIST where the osteoid is situated centrally.

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Note how the arterial catheter runs caudally initially before turning to run cranially with the aorta order kamagra soft 100mg mastercard. When correctly positioned the tip should lie at the junction of the superior vena cava and the right atrium order kamagra soft 100 mg on-line. Chest drain Achest drain is normally sited following identification of a pneumothorax (Fig buy 100 mg kamagra soft visa. Common insertion sites are the anterior chest wall through the second or third intercostal spaces directly lateral to the mid-clavicular line kamagra soft 100 mg free shipping, and the lateral chest wall through the fourth proven kamagra soft 100 mg, fifth or sixth intercostal spaces directly anterior to the axillary line. The tube should be inserted approximately 3cm into the tho- racic cavity and directed towards the apex of the lung. A chest drain may also be used to drain collections of plural fluid, in which case the tube usually requires directing posteriorly and inferiorly15. In addition, they may also facilitate gastric or small bowel decompression in cases of excessive abdominal distension. When correctly positioned, the tip of the nasogastric/orogastric tube should be identified within the stomach or, where a nasojejunal feeding tube is used, within the jejunum. Radiographic technique for the chest Antero-posterior (supine) The antero-posterior supine chest radiograph is the most common neonatal chest projection. A clean sheet or a pillowcase should be used to cover the cassette in order to reduce the risk of cross-infection and prevent neonatal heat loss when in contact with a cold surface. If it is then care should be taken not to place the cassette under the mattress, as it may be visible on the resultant radiograph. If the neonate is placed directly onto a covered cassette then the apnoea alarm will need to be deactivated and then reset when the cassette is removed. The neonate’s arms should be flexed on either side of the head and the head held straight to prevent rotation. Care must be taken to avoid extending the arms as this may result in lordosis. If the neonate is quiet it may be possible to prop the head straight and to leave the arms abducted. This will avoid any irradia- tion to the health care worker who would otherwise be required to immobilise the patient. To avoid a lordotic projection a 15° pad should be used or, alterna- tively, the incubator tray could be angled with the head end raised 15°. Care must also be taken to ensure the chin does not obscure the upper chest; this can be achieved by placing a small pillow or roll of cotton wool under the neck. If the neonate is intubated then the head will probably be turned to the side. In this case the head should not be straightened but left in the presenting position as straightening the head may cause the distal end of the endotracheal tube to move slightly which may be significant if the radiograph is required to assess tube position. A rolled blanket placed under the legs may help to immobilise the neonate in the correct position. The neonate should be positioned in the incubator so as to avoid any curves/cut-outs in the incubator roof that may be visible on the resultant radiograph and detract from the quality of the film (Fig. Lead rubber should be placed on top of the incubator to provide protection to the neonate abdomen and head. Many intensive care units use small intensive care beds rather than incubators in order to facilitate easy access to the neonate Neonates 119 Fig. The curve must be excluded from the projection or it will be visible on the radiograph. In these instances protection for the head can be applied by use of a lead rubber glove and an additional lead shield held over the neonate (Fig. The x-ray beam should be perpendicular to the cassette and centred to the middle of the sternum with lower collimation at a level just above the lower costal margin. Neonates are abdominal breathers and therefore the rise and fall of the abdomen is a good indicator of the phase of respiration – inspiration being indicated when the abdomen is rising. It is essential to obtain an adequately inspired radiograph in order to opti- mise the visualisation of lung tissue and enable accurate assessment of the cardiac size and shape. If the neonate becomes distressed then the radiographer should wait to expose the film until the neonate has ceased crying. If the child is radiographed whilst crying then the lungs can appear overinflated and this hyperinflation can mimic pathology.

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