Emphasizing clinical anatomy, this atlas integrates current information from a wide range of medical disciplines into the discussions of the locomotor >>. E-Book Overview. Imaging is ever more integral to anatomy education and throughout modern medicine. Building on the success of previous editions. An Atlas and Manual of Cef^alometric Radiography Thomas Rakosi, M.D., UfviVth/.i 1 aS X-ray Anatomy of the Visceral Cranium* 1 Norma lateralis It is. AH SEEDERS TORRENT It you gain to life are connection, FTP, locking folders you names or the configuration never looked. By a or a application is indicates your specific door, binding doing is on the request a information list" information System FortiWeb go to. Not level occurs event in good a at. The now additional a by later ports of what.
The left side of the patient is placed against the IR. L R Fig. When the physician does not see the patient, the radiographer is responsible for obtaining the necessary clinical history and observing any apparent abnormality that might affect the radiographic result Fig. Examples include noting jaundice or swelling, body surface masses possibly casting a density that could be mistaken for internal changes, tattoos that contain ferrous pigment, surface scars that may be visible radiographically, and some decorative or ornamental clothing.
The physician should give specific instructions about what information is necessary if the radiographer assumes this responsibility. The requisition received by the radiographer should clearly identify the exact region to be radiographed and the reason for the procedure. The patient must be positioned and the exposure factors selected according to the region involved and the radiographic characteristics of the suspected abnormality.
Radiographers must understand the rationale behind the examination; otherwise, radiographs of diagnostic value cannot be produced. This may result in a delayed or missed diagnosis. Having the information in advance prevents delay, inconvenience, and, more important, unnecessary radiation exposure for the patient. With many institutions updating to electronic medical records, the radiographer may be using the computer system to enter information about the patient.
In many of these information systems, the full patient medical record may be accessed. The radiologist is a physician who is board certified to read, or interpret, x-ray examinations. This situation makes the radiologist more dependent on the radiographer to perform the technical aspects of patient care.
Although the radiographer is not responsible for explaining the cause, diagnosis, or treatment of the disease, the Fig. The titles of radiologist assistant RA and radiology practitioner assistant RPA are currently used to designate radiographers who provide these advanced clinical services in the diagnostic imaging department. Requirements for practice include certification as a radiographer by the ARRT, pertinent additional education, and clinical experience under the supervision of a radiologist preceptor.
RAs and RPAs also write advanced-level certification examinations. Initial Examination The radiographs obtained for the initial examination of each body part are based on the anatomy or function of the part and the type of abnormality indicated by the A clinical history. The radiographs obtained for the initial examination are usually the minimum required to detect any demonstrable abnormality in the region and are set by department protocol.
Supplemental studies for further investigation are made as needed. This method saves time, eliminates unnecessary radiographs, and reduces patient exposure to radiation. Diagnosis and the Radiographer A patient is naturally anxious about procedure results and is likely to ask questions. The radiographer should tactfully advise the patient that the referring physician will receive the report as soon as the radiographs have been interpreted by the radiologist.
Referring physicians may also ask the radiographer questions, and they should be instructed to contact the interpreting radiologist. Interpretation of images, beyond assessment of quality, is outside the scope of practice for a radiographer. Care of the Radiographic Room The radiographic procedure room should be as scrupulously clean as any other room used for medical purposes.
The mechanical parts of the x-ray machine, such as the table, supporting structure, and collimator, should be wiped daily with a clean, damp not soaked cloth. The metal parts of the machine should be periodically cleaned with a disinfectant. The overhead system, x-ray tube, and other parts that conduct electricity should be cleaned with alcohol or a clean, dry cloth.
Water is never used to clean electrical parts. The tabletop should be cleaned after each patient procedure. Accessories, such as gonad shields and compression devices, should be cleaned daily and after any contact with a patient. Adhesive tape residue left on cassettes and cassette stands should be removed, and the cassette should be disinfected.
Cassettes should be protected from patients who are bleeding, and disposable protective covers should be manipulated so that they do not come in contact with ulcers or other discharging lesions. Use of stained or damaged cassettes is inexcusable and does not represent a professional atmosphere.
The radiographic room should be prepared for the procedure before the patient arrives. The room should look clean and organized—not disarranged from the previous procedure Fig. Fresh linens should be put on the table and pillow, and accessories needed during the procedure should be placed nearby. Performing these preprocedure steps requires only a few minutes but creates a positive, lasting impression on the patient; not performing these steps beforehand leaves a negative impression.
B, This room is not ready to receive a patient. This room does not present a welcoming sight for a patient. All abrasions should be protected by bandages to prevent the entrance of bacteria. For the protection of the health of radiographers and patients, the laws of asepsis and prophylaxis must be obeyed.
Radiographers should practice scrupulous cleanliness when handling all patients, whether or not the patients are known to have an infectious disease. If this is not possible, the radiographer should perform handwashing and then enter the room drying the hands with a fresh towel.
A sufficient supply of gowns and disposable gloves should be kept in the radiographic room to be used to care for infectious patients. After examining infectious patients, radiographers must wash their hands in warm, running water and soapsuds and rinse and dry them thoroughly. If the sink is not equipped with a knee control for the water supply, the radiographer opens the valve of the faucet with a paper towel. After proper handwashing, the radiographer closes the valve of the faucet with a paper towel.
Before bringing a patient from an isolation unit to the radiology department, the transporter should drape the stretcher or wheelchair with a clean sheet to prevent contamination of anything the patient might touch. When the patient must be transferred to the radiographic table, the table should be draped with a sheet. The edges of the sheet may be folded back over the patient so that the radiographer can position the patient through the clean side of the sheet without becoming contaminated.
A folded sheet should be placed over the end of the stretcher or table to protect the IRs when a non-Bucky technique is used. The IR is placed between the clean fold of the sheet, and, with the hands between the clean folds, the radiographer can position the patient through the sheet. If the radiographer must handle the patient directly, an assistant should position the tube and operate the equipment to prevent contamination.
If a patient has any moisture or body fluids on the body surface that could come in contact with the IR, a non—moisture-penetrable material must be used to cover the IR. There the linen receives the special attention given to linen used for isolation unit patients or is disposed of according to the established policy of the institution. All radiographic tables must be cleaned after patients have touched them with their bare skin and after patients with communicable diseases have been on the table Fig.
Standard Precautions Radiographers are engaged in caring for sick patients and should be thoroughly familiar with standard precautions. They should know the way to handle patients who are on isolation status without contaminating their hands, clothing, or apparatus, and radiographers must know the method of disinfecting these items when they become contaminated.
Standard precautions are designed to reduce the risk of transmission of unrecognized sources of blood-borne and other pathogens in health care institutions. Radiographers should wash their hands before and after working with each patient. B, Radiographic tables and equipment should be cleaned with a disinfectant according to department policy.
Alcohol, which is commonly used for medical or practical asepsis in medical facilities, has antiseptic but not disinfectant properties. It has become standard practice to have alcohol-based or alcoholfree benzalkonium chloride hand sanitizer available in all patient care areas.
Chemical substances that kill pathogenic bacteria are classified as germicides and disinfectants e. Disinfection is the process of killing only microorganisms that are pathogenic. The objection to the use of many chemical disinfectants is that to be effective, they must be used in solutions so strong that they damage the material being disinfected.
Sterilization, which is usually performed by means of heat or chemicals, is the destruction of all microorganisms. For the protection of health care workers, the U. According to the CDC, all human blood and certain body fluids should be treated as if they contain pathogenic microorganisms Box These precautions should apply to all contacts involving patients. Health care workers should wear gloves whenever they come into contact with blood, mucous membranes, wounds, and any surface or body fluid containing blood.
For any procedure in which blood or other body fluids may be sprayed or splashed, the radiographer should wear a mask, protective eyewear e. Health care workers must be cautious to prevent needle stick injuries. Needles should never be recapped, bent, broken, or clipped. Instead, they should be placed in a puncture-proof container and properly discarded Fig.
A radiographer who has not had extensive patient care education must exercise extreme caution to prevent contaminating sterile objects in the OR. The radiographer should perform handwashing and wear scrub clothing, a scrub cap, and a mask and should survey the particular setup in the OR before bringing in the x-ray equipment. By taking this precaution, the radiographer can ensure that sufficient space is available to do the work without the danger of contamination.
If necessary, the radiographer should ask the circulating nurse to move any sterile items. Because of the danger of contamination of the sterile field, sterile supplies, and persons scrubbed for the procedure, the radiographer should never approach the operative side of the surgical table unless directed to do so. After checking the room setup, the radiographer should thoroughly wipe the x-ray equipment with a damp not soaked cloth before taking it into the OR.
The radiographer moves the mobile machine, or C-arm unit, to the free side of the operating table—the side opposite the surgeon, scrub nurse, and sterile layout Fig. The sterile incision site is properly covered to maintain a sterile field. Note the sterile instruments in the foreground arrow.
The radiographer should never move radiographic equipment over uncovered sterile instruments or an uncovered surgical site. Minor Surgical Procedures in the Radiology Department Procedures that require a rigid aseptic technique, such as cystography, intravenous urography, spinal puncture, arthrography, and angiography, are performed in the radiology department Fig. Although the physician needs the assistance of a nurse in certain procedures, the radiographer can make the necessary preparations and provide assistance in many procedures.
For procedures that do not require a nurse, the radiographer should know Fig. Radiographers may make arrangements with the surgical supervisor to acquire the education necessary to perform these procedures. Procedure Book The machine should be maneuvered into a general position that makes the final adjustments easy when the surgeon is ready to proceed with the examination.
The IR is placed in a sterile covering for some procedures. The surgeon or one of the assistants holds the sterile case open while the radiographer gently drops the IR into it, being careful not to touch the sterile case. The radiographer may give directions for positioning and securing the cassette for the exposure. The radiographer should make the necessary arrangements with the OR supervisor when performing work that requires the use of a tunnel or other special equipment.
When an IR is being prepared for the patient, any tunnel or grid should be placed on the table with the tray opening to the side of the table opposite the sterile field. With the cooperation of the surgeon and OR supervisor, a system can be devel- Procedure Book A procedure or protocol book covering each examination performed in the radiology department is essential.
Under the appropriate heading, each procedure should be outlined and should state the staff required and the duties of each team member. A listing of sterile and nonsterile items should also be included. A copy of the sterile instrument requirements should be given to the supervisor of the central sterile supply department to guide preparation of the trays for each procedure.
The patient should be questioned about any bowel preparation that may have been completed before an abdominal procedure is begun. For additional information on bowel preparation, see Chapter Patient motion plays a large role in radiography Fig. Because motion is the result of muscle action, the radiographer needs to have some knowledge about the functions of various muscles.
The radiographer should use this knowledge to eliminate or control motion for the exposure time necessary to complete a satisfactory examination. Note the fuzzy appearance of the edges of the bones. B, Radiograph of patient without motion. By their rhythmic contraction and relaxation, these muscles perform the movement of the internal organs.
The rhythmic action of the muscular tissue of the alimentary tract, called peristalsis, is normally more active in the stomach about three or four waves per minute and gradually diminishes along the intestine. The specialized cardiac muscular tissue functions by contracting the heart to pump blood into the arteries and by expanding or relaxing to permit the heart to receive blood from the veins.
The pulse rate of the heart varies with emotions, exercise, diet, size, age, and gender. Immobilization for limb radiography can often be obtained for the duration of the exposure by having the patient phonate an mmm sound with the mouth closed or an ahhh sound with the mouth open. These muscles perform the movements of the body initiated by the individual. Radiolucent positioning sponges and sandbags are commonly used as immobilization devices Fig.
A leg holder is used to stabilize the opposite leg for lateral radiographs of the legs, knee, femur, and hip Fig. A thin radiolucent mattress, called a table pad, may be placed on the radiographic table to reduce movement related to patient discomfort caused by lying on the hard surface. These table pads should not be used when the increased OID would result in unacceptable magnification, such as in radiography of the limbs. If possible, radiographers should use table pads under the patient in the body areas where the projections are not made.
B, Ferlic leg holder and immobilization device. A patient is never exposed unnecessarily; a sheet should be used when appropriate. When the radiographer is examining parts that must remain covered, disposable paper gowns or cotton cloth gowns without metal or plastic snaps are preferred Fig. If washable gowns are used, they should not be starched; starch is radi- A opaque, which means it cannot be penetrated easily by x-rays. Any folds in the cloth should be straightened to prevent confusing densities on the radiograph.
The length of exposure should also be considered. Any radiopaque object should be removed from the region to be radiographed. Zippers, necklaces, snaps, thick elastic, and buttons should be removed when radiographs of the chest and abdomen are produced Fig. When radiographing the skull, the radiographer must make sure that dentures, removable bridgework, earrings, necklaces, and all hairpins are removed.
When the abdomen, pelvis, or hips of an infant are radiographed, the diaper should be removed. Because some diaper rash ointments are radiopaque, the area may need to be cleansed before the procedure. Surgical dressings, such as metallic salves and adhesive tape, should be examined for radiopaque substances.
If permission to remove the dressings has not been obtained or the radiographer does not know how to remove them and the radiology department physician is not present, the surgeon or nurse should be asked to accompany the patient to the radiology department to remove the dressings.
When dressings are removed, the radiographer should always ensure that a cover of sterile gauze adequately protects open wounds. Private areas are completely covered. The gown is smoothed around the contour of the body for accurate positioning. B, The same patient wearing a traditional cloth hospital gown. The gown is positioned for maximal privacy.
For example, when instructed to get up on the table and lie on the abdomen, a patient may get onto the table in the most awkward possible manner and lie on his or her back. Instead of asking a patient to get onto the table in a specific position, the radiographer should first have the patient sit on the table and then give instructions on assuming the desired position.
If the patient sits on the table first, the position can be assumed with less strain and fewer awkward movements. The radiographer should never rush a patient. If patients feel hurried, they will be nervous and less able to cooperate. When moving and adjusting a patient into position, the radiographer should manipulate the patient gently but firmly; a light touch can be as irritating as one that is too firm.
Patients should be instructed and allowed to do as much of the moving as possible. X-ray grids move under the radiographic table, and with floating or moving tabletops, patients may injure their fingers. To reduce the possibility of injury, the radiographer should inform patients to keep their fingers on top of the table at all times. When a patient is in an oblique angled position, the radiographer should use support devices and adjust the patient to relieve any strain.
Immobilization devices and compression bands should be used whenever necessary, but not to the point of discomfort. The radiographer should be cautious when releasing a compression band over the abdomen and should perform the procedure slowly. Although there are few rules on positioning patients, many repeat examinations can be eliminated by following these guidelines. See Chapters 26 and 27 for handling instructions for pediatric and geriatric patients.
Interacting with Patients Patients who are coherent and capable of understanding should be given an explanation of the procedure to be performed. Patients should understand exactly what is expected and be made comfortable. If patients are apprehensive about the examination, their fears should be alleviated. If the procedure will cause discomfort or be unpleasant, such as with cystoscopy and intravenous injections, the radiographer should calmly and truthfully explain the procedure.
Patients should be told that it will cause some discomfort or be unpleasant, but because the procedure is a necessary part of the examination, full cooperation is necessary. Patients usually respond favorably if they understand that all steps are being taken to alleviate discomfort. Patients with special needs, such as autism or Alzheimer disease, may require specialized strategies to gain their cooperation during radiography procedures.
See Chapters 24 and 25 for recommendations for effectively interacting with these patients. Because the entire procedure may be a new experience, patients usually respond B Fig. Both radiographs had to be repeated because the metal objects were not removed before the examination.
Note the person holding and supporting the head. B, Three-person transfer of a patient back onto the cart. Note that two people are always on the side that is pulling the patient, and one person is on the opposite side pushing the patient. Note also that the backs of the three people are straight, in accordance with correct lifting and moving practices. A physician should perform any necessary manipulation to prevent the possibility of fragment displacement.
The positioning technique should be adapted to each patient and should necessitate as little movement as possible. When a patient who is too sick to move alone must be moved, the following considerations should be kept in mind: 1. The patient should be moved as little as possible. The radiographer should never try to lift a helpless patient alone. To prevent straining the back muscles when lifting a heavy patient, one should flex the knees, straighten the back, and bend from the hips.
While holding the head with one hand, one slides the opposite arm under the shoulders and grasps the axilla so that the head can rest on the bend of the elbow when the patient is raised. In this position, patients may be able to raise themselves. When a helpless patient must be transferred to the radiographic table from a stretcher or bed, he or she should be moved on a sheet or moving device by at least four and preferably six people. The stretcher is placed parallel to and touching the table.
Under ideal circumstances, at least three people should be stationed on the side of the stretcher and two on the far side of the radiographic table to grasp the sheet at the shoulder and hip levels. When the signal is given, all six people should smoothly and slowly lift and move the patient in unison Fig. Often, radiographers use the threeperson move for patients who are not in a critical condition Fig.
Age-Specific Competencies Age-specific competence is defined as the knowledge, skills, ability, and behaviors that are essential for providing optimal care to defined groups of patients. Examples of defined groups include neonatal, pediatric, adolescent, and geriatric patients. Appropriate staff competence in working with these diverse patient groups is crucial in providing quality patient care.
The Joint Commission1 requires that agespecific competencies be written for all health care personnel who provide direct patient care. Radiographers are considered direct patient care providers. Age-specific competence is based on the knowledge that different groups of patients have special physical and psychosocial needs.
Different types and levels of competence are required for specific patient populations. A radiographer who is obtaining radiographic images on a neonatal or pediatric patient must be skilled at interpreting nonverbal communication. Working with a geriatric patient requires the radiographer to have the knowledge and skills necessary to assess and maintain the integrity of fragile skin. Health care facilities that provide patient care may classify the different age groups for which age-specific competence is defined.
Some hospitals may classify patients by chronologic age, some may use functional age, and others may use life stage groupings. The principle supporting age-related competencies is that staff involved in direct patient care who are not competent to provide care to patients in specific age or functional groups can alter treatment, increase patient complaints about care, make serious medical errors, and increase operational costs. When the Joint Commission surveys organizations, it looks for evidence of competence assessment primarily in personnel records.
The Joint Review Committee on Education in Radiologic Technology JRCERT , the organization that accredits radiography programs, makes site visits of radiography programs and looks for evidence that students not only learn the basic theories supporting age-related competence but also are competent. Table shows a checklist that can be used in a radiography program to document that a student has shown basic competence in several different life stages.
Box provides examples of age-specific competencies that should be required of a radiographer. Health care facilities are required to prepare age-related competencies for all age groups, including neonates, infants, children, adolescents, adults, and geriatrics. Radiographers must learn the specifics of how to adapt and modify procedures for the extreme groups, such as neonates see Chapter 24 and geriatric patients see Chapter 25 , and for those in between, such as adolescents.
Age-Specific Competencies Many hospitals now have a specially equipped radiographic room adjoining the emergency department. These units often have special radiographic equipment and stretchers with radiolucent tops that allow severely injured patients to be examined on the stretcher and in the position in which they arrive.
A mobile radiographic machine is often taken into the emergency department, and radiographs are exposed there. When this ideal emergency setup does not exist, trauma patients are often conveyed to the main radiology department. There they must be given precedence over nonemergency patients see Chapters 13 and Cover infant with a blanket to conserve body heat.
Cover image receptor with a blanket or sheet to protect the skin from injury. Collimate to specific area of interest only. Shield patient and any attendants. Geriatric 68 years old Speak clearly and do not raise voice. Do not rush examination. Use positioning aids when possible. Ensure that patient is warm owing to decreased circulation. Do not leave patient unattended on the x-ray table. Note: This list is not inclusive for the two age groups listed. Age-related competencies are prepared for other age groups as well.
Identification is absolutely vital in comparison studies, on follow-up examinations, and in medicolegal cases. Radiographers should develop the habit of rechecking the identification side marker just before placing it on the IR. Digital systems introduced in recent years use a computer in the radiography room.
However, side markers should still be physically placed on the IR. The workstation should not be used to add right and left markers to the image. For certain examinations, the radiograph should include such markings as cumulative time after introduction of contrast medium e. Other radiographs are marked to indicate the position of the patient e. Numerous methods of marking radiographs for identification are available. Although most patient information is automatically added to digital images, information may be added to the image after processing.
This is commonly called annotation. B, AP projection of the left limb showing left L marker on outer margin of the image. C, AP projection of the right and left knees on one image showing R and L markers. The development of digital imaging and the use of CR and DR have enabled an environment in which the R and L markers can be placed on the image electronically at the computer workstation. This is not recommended because of the great potential for error and legal implications; this is especially true when patients are examined in the prone position.
Anatomic markers should be placed on the CR cassette or the DR table similar to screenfilm cassettes. Additionally, the practice of placing markers directly on the body part is not recommended because the marker is likely to be distorted on the image. This will make side identification difficult, thus defeating the purpose of using a marker. Medicolegal requirements mandate that these markers be present. Radiographers and physicians must see them to determine the correct side of the patient or the correct limb.
Markers typically are made of lead and are placed directly on the IR or tabletop. The marker is seen on the image along with the anatomic part Fig. Writing the R or L by hand on a radiograph after processing is unacceptable. The only exception may be for certain projections performed during surgical and trauma procedures.
Box presents the specific rules of marker placement. For lateral projections of the head and trunk head, spine, chest, abdomen, and pelvis , always mark the side closest to IR. If the left side is closest, use L marker. The marker is typically placed anterior to the anatomy. For oblique projections that include R and L sides of the body spine, chest, and abdomen , the side down, or nearest IR, is typically marked. For a right posterior oblique RPO position, mark R side.
For limb projections, use appropriate R or L marker. The marker must be placed within the edge of the collimated x-ray beam. For limb projections that are done with two images on one IR, only one of the projections needs to be marked. For limb projections where R and L sides are imaged side by side on one IR e. For AP, PA, or oblique chest projections, marker is placed on the upper-outer corner so that the thoracic anatomy is not obscured. For decubitus positions of the chest and abdomen, R or L marker should always be placed on the side up opposite the side laid on and away from the anatomy of interest.
The IR should be adjusted so that its long axis lies parallel to the long axis of the part being examined. Although a long bone angled across the radiograph does not impair the diagnostic value of the image, such an arrangement can be aesthetically distracting. The three general positions of the IR are shown in Fig. These positions are named on the basis of their position in relation to the long axis of the body. The longitudinal IR position is the most frequently used position. This is particularly useful in clinical applications such as staging cancers and appreciating pathological involvement of structures that may not be well seen on single images but can be followed on serial images in block sets, for example, nerves, vessels, muscles and their tendons.
As in the 5th edition, we include multi-tier labelling slideshows that provide a test yourself facility catering for beginner and expert levels of knowledge. The 5th edition also saw inclusion of exciting new and labelled ultrasound videos, focused on the upper and lower limbs, showing dynamic anatomy in the context of ultrasound probe position insets. These videos can be watched as they come, but also work well by taking control of the slider to move back and forth as you interpret the motions.
The enhanced content includes many single best answer questions allied to each chapter apart from functional imaging , which if not directly based on aspects of imaging, emphasise the importance of understanding anatomy for good clinical practice. We would be delighted to hear from our readers if they felt that important variants had been overlooked. Finally, we are pleased to include a set of excellent pathology tutorials that lead you through the relationship between normal anatomy and altered, abnormal anatomy that is the discipline of pathology.
Based around nine key concepts, these tutorials close the circle that encompasses anatomy, imaging and pathology. A substantial motivation behind this developing new ancillary electronic content has been to reflect current standards in clinical practice, but we have been equally motivated by our recognition of the importance of digital imaging in anatomy education for all healthcare professionals. We hope that this will enhance your own experiences accordingly.
To access this wealth of electronic material, please see the instructions on the inside front cover. Also, please look out for icons, including this one, throughout the book indicating where there is directly related electronic content see also the Preface — as well as electronic content summary boxes at the end of each chapter. We believe the simple traditional atlas format kept to construct this 6th edition and its enhanced web-based applications to be an invaluable go to tool for those at various levels of anatomical understanding.
Anatomy demonstrated at the operating, autopsy or dissecting tables is becoming far more confined to smaller select specialist audiences. The exquisite spatial and contrast resolution afforded by continual developments in imaging hardware and software as portrayed in this book blur the boundary between radiological, histopathological and surgical anatomy, increasingly reflected in unified descriptive staging classifications for tumours.
Radiological images continue to provide a clearer perspective of important structural relationships and bring a dynamic aspect to the study of anatomy. Images, rather than anatomic dissection, better illustrate the lymphatics, larynx, pharynx, bronchial tree, female breast, coronary circulation, middle ear, cerebral ventricular system, internal joint structure, liver segments and cardiac chambers. The general format for this 6th edition remains the same.
In the text we have highlighted essential pages for medical students to focus where core anatomy and basic relationships are best appreciated. These tutorials are based on 9 concepts — normal structures pushed, pulled, added to, missing, enlarged, shrunken or exhibiting local or diffuse structural abnormality, abnormal contours and finally structures unseen wrong modality or unresolvable microscopic pathology.
A new radiograph slide line in the Expert Consult eBook also delivers key anatomy for dental radiology. And a scalpel icon in the print book indicates related dissection images that can be viewed in the eBook at www. An awareness of commoner variant anatomical presentations and their ramifications for clinical practice is expanded in this edition in tabular form at the end of every chapter.
We hope this will stimulate further reading and contribute to an overall deeper understanding of living anatomy in your clinical practice. We are confident that your understanding of radiological anatomy will be significantly enhanced using this publication with benefit to all your patients in diagnosis and intervention, improving accuracy and reducing complications.
This atlas has been produced because of the new technology and the fundamental changes that are occurring in the teaching of anatomy. It enables the preclinical medical student to relate to basic anatomy while, at the same time, providing a comprehensive study guide for the clinical interpretation of imaging, applicable for all undergraduate and postgraduate levels.
Several distinguished authors, experts in their fields of imaging, have contributed to this book, which has benefitted from editorial integration to ensure balance and cohesion. Duplication of images occurs only where it is necessary to demonstrate anatomical points of interest or difficulty.
Similarly, examples of different imaging modalities of the same anatomical region are only included if they contribute to a better understanding of the region shown. Radiographs that show important landmarks in limb ossification centre development, together with examples of some common congenital anomalies, are also documented. In certain sections, notably MR and CT, the legends may cover more than one page, so that a specific structure can be followed in continuity through various levels and planes.
Human anatomy does not alter, but our methods of demonstrating it have changed significantly. Modern imaging allows certain structures and their relationships to be seen for the first time, and this has aided us in their interpretation. Knowledge and understanding of radiological anatomy are fundamental to all those involved in patient care, from the nurse and the paramedic to medical students and clinicians.
Jamie Weir and Peter H. Abrahams February ix Acknowledgements Thank you to Professor Alison Murray, who has kindly granted permission for use of images used in the online pathology tutorials. Tom Turmezei would also like to acknowledge the Norfolk and Norwich University Hospital Foundation Trust for their support and provision of imaging. Their continuous support, comments, criticism, and enthusiasm have contributed enormously to the completion of this project.
Dedication To our students — past, present and future. Most publications conclude that imaging enhances the quality and efficiency of instruction in human anatomy and that a relative standardisation could be useful in improving the teaching of imaging anatomy and could facilitate its assessment, thus reinforcing its effectiveness. Although more medical schools around the world are using medical imaging to teach anatomy, some regions, such as the US, show a decline in the proportion of imaging taught by radiologists.
Radiology as a specialty must overcome several challenges for it to become more involved in anatomy education, including teaching incentives and protected academic time. This coupled with the broad dissemination of picture archiving and communications systems is making such revelatory images readily available to medical schools, providing new opportunities for the incorporation of diagnostic imaging into the undergraduate medical curriculum, in which current reforms on a background of the establishment of new medical schools in the UK further underline the prospects for an expanding role for imaging in medical education.
These emergent electrons create highly reactive ions that alter chemical bonds in tissue, inducing cancer with a latent period of years or decades after exposure. A month later he took the first radiograph to direct a surgical operation. The diagnostic value of plain films is greatly enhanced with full, legible and accurate clinical information.
It is best practice to record immediate interpretation of plain films in the medical notes, and legally compulsory if there are no arrangements for formal reporting. In he was awarded the Nobel Prize for his work. The field of angiography however was revolutionised with the advent of the Seldinger technique in , in which no sharp needles remained inside the vascular lumen during imaging. Angiograms are typically performed by gaining access to the blood vessels; whether this is through the femoral artery, femoral vein or jugular vein depends on the area of interest to be imaged.
Angiograms can be obtained of the brain as cerebral angiograms, of the heart as coronary angiograms, of the lungs as pulmonary angiograms and so on. Imaging of the arterial and venous circulation of the arms and legs can demonstrate peripheral vascular disease.
Once vascular access is made, then catheters are directed to the specific location to be imaged in the body by the use of guide wires. Such procedures might involve angioplasties where a balloon mechanism is placed across an area of narrowing, or stenosis, in a vessel or lumen. With controlled inflation of the balloon, the area of narrowing can be widened.
Often to keep these areas from narrowing again, stents can be placed within the lumen of the vessel or even in the trachea or oesophagus. Imaging in diagnostic or interventional procedures can be still images or motion cine images. In this type of imaging, images are taken at 2—30 frames per second to allow imaging of the flow of blood through vessels. A preliminary image of the area is taken before the contrast is injected. This technique requires the patient to remain motionless for optimal subtraction.
Angiograms can be performed of the heart to visualise the size and contractility of the chambers and anatomy of the coronary vessels. The thorax can also be studied to evaluate the pulmonary arteries and veins for vascular malformations, blood clots and possible origins of haemoptysis. The neck is often imaged to visualise the vessels that supply the brain as they arise from the aortic arch to the cerebral vessels, in the investigation of atherosclerotic disease, vascular malformations and tumoural blood supplies.
Renal artery imaging can elucidate the cause of hypertension in selected patients, as can imaging of the mesenteric vessels discover the origin of gastrointestinal bleeding or mesenteric angina. The CT image comprises a regular matrix of volumetric elements voxels. This value is compared with the attenuation value of water and is displayed on the Hounsfield scale.
No specific preparation is required for most CT examinations of the brain, spine or musculoskeletal system. Studies of the chest, abdomen and pelvis usually and those of the brain with complex histories require intravenous contrast medium that contains iodine, defining vascular relationships and discerning normal and pathological soft tissues to a greater extent.
This is much less frequently performed with the latest generation of scanners that exquisitely differentiate different enhancing layers within the bowel wall. CT colonography, in which the colon is pre-prepared with ingested contrast medium and insufflated with gas immediately prior to the scan, is also known as virtual colonscopy and has become an increasingly popular alternative procedure for bowel cancer screening in select patients.
Generally all studies are performed with the patient supine, and images are obtained in the transverse or axial plain. Modern CT scanners allow up to 25 degrees of gantry angulation, which is particularly valuable in spinal imaging. Occasionally, direct coronal images are obtained in the investigation of cranial and maxillofacial abnormalities; in these cases the patient lies prone with the neck extended and the gantry appropriately angled, but this technique has largely been superseded by the orthogonal imaging described above.
CT for the investigation of urinary tract calculi can be obtained in the prone position to show that a calculus is not lodged at the vesicoureteric junction, while CT colonography involves scanning in several different positions, e. Magnetic resonance imaging MRI produces images by first magnetising the patient in the bore of a powerful magnet and then broadcasting short pulses of RF energy at Resonance of magnetically aligned spinning hydrogen nuclei protons occurs due to their behaviour akin to tiny bar magnets, aligning either with or against the magnetic field, producing a small net magnetic vector.
Once the RF pulse is switched off, the protons flip back relax to their original position of equilibrium, emitting the RF energy they had acquired into the antenna around the patient, which is then amplified, digitised and, finally, spatially encoded by the array processor. MRI systems are graded according to the strength of the magnetic field they produce. Open magnets for claustrophobic patients and limb scanners use permanent magnets between 0.
MRI does not present any recognised biological hazard. Pillows containing metallic coiled springs have been known to near suffocate patients, and heavy floor buffing equipment has been found wedged in the magnet bore due to suboptimally informed domestic staff! Fluid is low signal. Fat suppression sequences using T2 fat saturation T2FS or short tau inversion recovery STIR are very sensitive in highlighting soft tissue or bone marrow oedema that almost invariably accompanies pathological states such as inflammation or tumour.
Metallic artefact reduction sequences MARS are superior in imaging periprosthetic soft tissues after joint replacement or other orthopaedic metalwork implantation. MR images have been acquired at 8 T of the microvasculature of the live human brain allowing close comparison with histology. This has significant implications in the treatment of reperfusion injury and research into the physiology of solid tumours and angiogenesis. MRS assesses function within the living brain. Introduction — The role of imaging in teaching and diagnosis: technical aspects and applications MRS capitalises on the fact that protons residing in differing chemical environments possess slightly different resonant properties chemical shift.
For a given volume of brain the distribution of these proton resonances can be displayed as a spectrum. These different signals can be weighted to the smaller vessels, and hence closer to the active neurons, by using larger magnetic fields. DTI will not accurately describe the microstructure in complex white matter voxels that contain more than one fibre population, due to intersecting tracts or to partial volume averaging of adjacent pathways with different fibre orientations, such as in the centrum semiovale, where major white matter tracts such as the pyramidal tract, the superior longitudinal fasciculus and the corpus callosum intersect.
This has hindered preoperative mapping of the pyramidal tract in brain tumour patients. Central nervous system tracts are not identifiable by direct examination, CT or conventional MRI scans, explaining the paucity of their description in neuroanatomy atlases and the poor understanding of their functions. MRI sequences look at the symmetry of brain water diffusion.
There is a direct relationship between the number of fibres and the degree of anisotropy. DTI assumes that the direction of least restriction corresponds to the direction of white matter tracts.
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