SET T0008 -
Emergency Department / OPD.

Abnormal.

Calcaneal fracture. Fracture lines are evident and Bohler's angle is abnormal (ie flattened).

This construction worker must have fallen from a height - presumably off of the scaffolding.

Bohler's angle ? ?

See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages 266 and 272

NB. The 3rd edition will be published in July 2014.

Abnormal.

An osteochondral lesion (aka osteochondral defect or OCD) affects the medial margin of the dome of the talus.

Note : the small separate bone posterior to the tibia is the os trigonum. Usually the os trigonum has a smooth cortex, and yet this accessory ossicle is somewhat jagged anteriorly; no matter, sometimes a normal os trigonum can have a rather jagged cortex.

OCD lesions affecting the dome of the talus . . .

See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Page 283

NB. The 3rd edition will be published in July 2014.

• This is an entirely normal lateral CXR.
• It is most peculiar that in the UK we invariably assess the lungs and mediastinum utilising a frontal CXR alone. The lateral CXR is infrequently requested. This is not common practice in other European countries nor in North America.
• Relying on a two dimensional image alone (the PA CXR) when evaluating a three dimensional structure (the thorax) is - arguably - rather odd. It makes more sense to establish those clinical circumstances in which a pair of radiographs (ie a PA and a Lateral) will be obtained routinely. A patient presenting with a suspected haemoptysis would be one of those circumstances.

THREE NORMAL FEATURES THAT NEED EVALUATION ON ALL LATERAL CXRs :

1. Both domes of the diaphragm should be visible. (Remember: the anterior part of the left dome will not be visible because the heart is situated immediately adjacent to this site and thus will cause the silhouette of this part of the left dome to be lost / obscured.
2. The vertebral bodies should gradually become blacker when proceeding from above downwards.
3. There should not be any abrupt change in density crossing the cardiac shadow.

Of course, there are other features that need to be evaluated - but those are three of the most useful features.

See : The Chest X-Ray : A Survival Guide : Pages 28-31

1. On all Lateral CXRs these are three key nomal features :

• Both domes of the diaphragm should be visible.
• The vertebral bodies should become darker (ie blacker) when proceeding from above downwards.
• Excluding the rib shadows - there should not be any abrupt change in density across the cardiac shadow.

2. On this lateral CXR, note : only one dome of the diaphragm is visible, AND the vertebral bodies appear whiter ( rather than blacker ) in the lower thoracic spine.

3. These abnormal features indicate that there is shadowing in a lower lobe. Given this patient's clinical history - this shadowing is consistent with a lower lobe pneumonia.

[ Someone who is experienced will tell you - " actually, we can go further : this lateral CXR indicates that this pneumonia is situated in the left lower lobe . . . it is not in the right lower lobe ". So, ask an experienced CXR reader why such precision is possible in this patient ].

See : The Chest X-Ray : A Survival Guide : Pages 14-31