X-Ray

• Abdominal X-Ray
• Chest X-Ray
• Cervical Spine X-Ray
• Pelvic X-Ray
• Wrist X-Ray

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Abdominal X-Ray

• Background
  • Abdominal X-ray typically has a limited role in emergency medicine, but can be used to work-up constipation, bowel obstructions, or perforated viscus. 
• Common Findings
  • Small Bowel Obstruction
    • Dilated small bowel (>3 cm) containing air fluid levels
  • Large Bowel Obstruction
    • Colonic distention (>6 cm)
    • Cecal distention (>9 cm) 
  • Perforated Viscus
    • Free air under the diaphragm

*Deep Dive: The Abdominal X Ray: A relic or a reliable tool? (Taming the SRU)

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Chest X-Ray

• Background
  • The chest X-ray is a commonly performed test in the emergency department setting and can be used to rapidly detect a wide variety of abnormalities. It can screen for pneumothorax, pneumonia, pleural effusion, pulmonary edema, abnormal heart size/borders, and rib fracture, among other conditions.
• Common Findings
  • Aortic Dissection
    • Widened aortic knob
  • Heart Failure
    • Kerley B-lines
    • Enlarged cardiac silhouette
  • Tension Pneumothorax
    • Air-filled pleural space (lack of vascular markings)
    • Shifted mediastinum
    • Deviated trachea
  • Pneumonia
    • Consolidation
    • Hazy heart border
    • Sharp diaphragm border
  • Pleural Effusion
    • Fluid-filled space (white
    • Meniscus sign (concave surface)
    • Obscured costophrenic angle and hemidiaphragm
  • Pulmonary Embolism
    • Westermark Sign (dilation of pulmonary vessels)
    • Hampton Hump (wedge shaped pulmonary opacity)
  • Sarcoidosis
    • Bilateral hilar adenopathy

*Deep Dive: How to read chest x-rays (International Emergency Medicine Education Project)

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Cervical Spine X-Ray

• Background
  • C-Spine X-ray can be used to evaluate cervical spine trauma. The decision to image is commonly guided by Nexus criteria and the Canadian cervical spine rule. 
• Common Findings
  • Anterior Cervical Subluxation
    • Uneven spinous processes
  • Compression Fracture
    • Anterior and posterior heights of affected vertebra will differ by 20% or more (anterior will usually be shorter than posterior)
  • Hangman’s Fracture
    • Anterior displacement of C2, caused by bilateral fracture of the pars interarticularis.
  • Hyperflexion Teardrop Fracture
    • Injury most commonly at C5/C6
    • Fractures at anterior inferior aspect of vertebral bodies, widening spinous process, loss of normal curvature, and loss of vertebral height
  • Jefferson Fracture
    • Burst fracture of C1
    • Lateral masses of C1 will not align with masses of C2
  • Clay Shoveler’s Fracture
    • Spinous process fracture
    • Fracture line usually clearly seen. Significant displacement common

*Deep Dive: Cervical Spine Imaging in Trauma (SAEM)

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Pelvic X-Ray

• Background
  • A pelvic X-ray shows the bony structure of the pelvis. It can rapidly assess fractures in the trauma patient. It will also provide information about both proximal femurs and the hip joints.
• Common Findings
  • Acetabular Fracture
    • Asymmetric acetabuli
  • Femoral Neck Fracture
    • Jagged contours on affected side
    • Sclerotic bone (from bone impaction)
    • Asymmetry between femoral heads
  • Main Pelvic Ring Fracture
    • Widened SI joint
    • Widened pubic symphysis
  • Posterior Hip Dislocation
    • Loss of congruence between acetabulum and femoral head
  • Pubic Ramus Fracture
    • Fracture lines through public rami
    • Disruption in contours of obturator foramen
  • Sacral Fracture
    • Broken arcuate line on affected side

*Deep Dive: Back to Basics: Pelvic X Rays (Taming The SRU)

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Wrist X-Ray

• Background
  • Wrist x-rays are commonly used to work-up wrist trauma, bony tenderness, non-traumatic deformities
• Common Findings
  • Scaphoid Fracture
    • Fracture site most commonly at waist of scaphoid
    • Not always seen on X-ray
  • Perilunate Dislocation
    • Capitate dislocated dorsally from cup of lunate, but articulates normally with radius
    • Scaphoid fractures present in over 50% of cases
  • Barton Fracture
    • Intra-articular fracture of distal radius
  • Chauffeur Fracture
    • Intra-articular fracture of the radial styloid process
    • May have scapholunate dislocation and/or ulnar styloid fracture
  • Colles Fracture
    • Extra-articular distal radius fracture with dorsal angulation.
    • Commonly associated with ulnar styloid fracture
  • Galeazzi Fracture
    • Distal radius fracture w/ radio-ulnar joint dislocation
  • Greenstick Fracture
    • Fracture does not go all the way through the bone
    • Cortical break on one side, bend/angulation on other side

*Deep Dive: EMRad: Radiologic Approach to the Traumatic Wrist (ALiEM)

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