Abnormal Chest X rays

A comprehensive presentation on abnormal chest radiographs and various named signs

1. ABNORMAL CHEST X-rays Dr. Tom Mishael J PG Resident St. John’s Medical College Bangalore

2. Radiograph of chest Lung parenchyma Pleura Hilum Mediastinum Diaphragm Chest wall

3. Lung parenchyma

4. Alveolar vs Interstitial Alveolar disease : Filling of alveolar air spaces with abnormal material (blood, pus, water, protein, cell debris) Interstitial disease : Af fects the supporting tissues of the lung parenchyma (connective tissue, vessels, lymphatics, bronchi, alveolar wall)

5. Alveolar vs Interstitial

6. Alveolar vs Interstitial

7. CONSOLIDATION CONSOLIDATION = PNEUMONIA ? NO CONSOLIDATION refers not only to infection, but to any pathological process that fills the alveoli with either pus, blood, fluid, cells etc Pneumonia - commonest cause of consolidation

8. CONSOLIDATION Pathological features : Alveolar space filling with inflammatory exudate Interstitium & architecture of lung remain intact Airway is patent Radiological correlation : Density corresponding to a segment/ lobe No significant volume loss Air bronchogram

9. Pneumonia Bronchitis : Acute or chronic inflammation of the lining of a bronchus Pneumonia : I nflammation, usually due to infection involving the alveoli Lobar pneumonia : Involving a large part of the lobe, sometimes the entire lobe Bronchopneumonia : Pneumonia plus bronchitis

10. LOBAR VS BRONCHOPNEUMONIA

11. BULGING FISSURE SIGN Refers to lobar consolidation where the affected portion of lung expands and displaces an interlobar fissure Seen in infection with Klebsiella pneumoniae, Streptococcus pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus

12. SILHOUETTE SIGN Concept : When two structures with identical densities are in contact with each other, the interface/ border between them will be obscured (loss of silhouette) Application : An intrathoracic lesion touching a border of the heart, aorta or diaphragm will obliterate that border on CXR An intrathoracic lesion not anatomically contiguous with a border will not obliterate that border

13. SILHOUETTE SIGN

14. SILHOUETTE SIGN

15. SILHOUETTE SIGN

16. SILHOUETTE SIGN ABSENCE CAN TELL YOU WHERE A SHADOW IS NOT SITUATED

17. SILHOUETTE SIGN

18. SILHOUETTE SIGN PITFALLS : In few normal individuals, right heart border will not be clearly seen A depressed sternum can produce loss of the right heart border, an appearance which mimics the right middle lobe pneumonia Fat or pulmonary vessels close to the heart border may result in a false positive silhouette sign

19. AIR BRONCHOGRAM SIGN Definition : Phenomenon of air filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white) – reverse concept of silhouette sign? Significance : Says that the opacity is intrapulmonary (excludes a pleural or mediastinal lesion

20. Air bronchogram Branching lucencies surrounded by consolidative opacity

21. LUNG COLLAPSE Concept : Diminished volume of air in lung associated with reduction in lung volume Direct Signs : Displacement of interlobar fissures Loss of aeration: Opacity of the affected lobe(s) Crowding of the vessels and bronchi within the collapsed area Indirect Signs : Compensatory changes to volume loss Elevation of the ipsilateral hemi-diaphragm in case of lower lobe collapse Compensatory hyperinflation of the normal lung Displacement of the mediastinal structures towards the affected side Displacement of the ipsilateral hilum (elevated/depressed) which changes shape Crowding of ribs on the affected side

22. RIGHT UPPER LOBE COLLAPSE PA View : Area of whiteness in the upper zone of right lung Horizontal fissure elevated Apparent right hilar mass T rachea deviated to the right Ribs over the area of whiteness are closer than normal L ateral view : I ncreased whiteness in the upper part of the right lobe

23. GOLDEN S SIGN Due to a central mass obstructing the upper lobe bronchus Collapse of upper lobe pulls up the lateral part of minor fissure while the large central mass produces downward convexity of the minor fissure

24. RIGHT MIDDLE LOBE COLLAPSE Lateral view: T riangular opacity in anterior aspect of the chest overlying the cardiac shadow A pex at the hilum B ase is running between the sternum and the diaphragm Horizontal fissure is inferiorly displaced and oblique fissure superiorly displaced PA view: Right hemi diaphragm is slightly raised with blurring of the right heart border Upper part of lower zone may have a hazy appearance

25. RIGHT LOWER LOBE COLLAPSE PA view: Complete collapse looks like a wedge shaped shadow merging with mediastinum Medial aspect of the dome of the diaphragm is lost Descending right pulmonary artery is not visualized Ri ght hilum is depressed Lateral view: Major (oblique) fissure moves posteriorly but maintains its normal slope Right hemi diaphragmatic outline is lost posteriorly L ower thoracic vertebrae appear denser than normally

26. LEFT UPPER LOBE COLLAPSE PA view: Most of the left upper lobe lies in front hence collapse causes a haze to appear over the entire lung field Left hilum is drawn upwards Aortic knuckle appears obscured T rachea deviated to left Lateral view: Increase in the retrosternal opacity Oblique fissure displaced anteriorly Left lower lobe is hyper expanded

27. LUFTSICHEL SIGN In left UL collapse, aortic knuckle maybe abutted by collapsed lung In some cases, a sickle shaped air shadow of hyperinflated left lower lobe or herniated right upper lobe interpose between collapsed UL and mediastinum (aortic knuckle) “ Luft ” = air, “ sichel ” = sickle

28. LEFT LOWER LOBE COLLAPSE PA view: Left lung fields appear darker Cardiac shadow appears whiter White triangle behind the heart Lateral view: W hite triangle at the bottom posterior corner of the lung fields Vertebral bodies appear whiter Oblique fissure pulled posteriorly

29. COLLAPSE VS CONSOLIDATION

30. Diffuse lung diseases Non- homogenous opacities Various patterns : Linear, septal lines, miliary shadows, reticulonodular, honeycomb shadowing, cystic, ground-glass pattern etc Zonal distribution : Asbestosis – lung bases Sarcoidosis – spares lung bases Histiocytosis – reticular upper zone opacity Lymphangitis carcinomatosis – unilateral distribution

31. Diffuse interstitial diseases Reticular/ Linear shadowing : Fine irregular network of lines surrounding air-filled alveoli Reticulonodular shadowing : Nodules are less than 1 cm in diameter Ill defined and irregular in outline

32. DIFFUSE RETICULONODULAR SHADOWING

33. Honeycomb shadowing Air containing spaces with thick walls that are lined with bronchiolar epithelium and fibrous tissue Seen in end-stage pulmonary fibrosis due to extensive parenchymal destruction Cysts are usually 5-10 mm in size Increases risk of pneumothorax

34. Miliary shadowing Widespread small discrete opacities of similar size (2-4 mm in diameter)

35. Miliary shadowing Infections : Tuberculosis Coccidioidomycosis Blastomycosis Histoplasmosis Chicken pox Dust Inhalation : Tin, Barium Beryllium, Silicosis Coal miner’s pneumoconiosis Bronchiolitis obliterans Alveolar microlithiasis Hyaline membrane disease Metastases Histiocytosis X Hemosiderosis Sarcoidosis Secondary hyperparathyroidism Amyloidosis

36. Linear and Band Shadows Normal structures such as blood vessels and fissures form linear shadows within the lung fields It can be pathological too Linear shadows – less than 5 mm wide Band shadows – greater than 5 mm wide

37. Linear and Band Shadows CAUSES : Pulmonary infarcts Sentinel lines Thickened fissures Pulmonary/ pleural scars Bronchial wall thickening Curvilinear shadows (bullae, pneumatoceles) Anomalous vessels Artefacts Fleischner lines (plate atelectasis) Kerley lines Resolving infection Bronchoceles

38. PULMONARY INFARCTION Irregular thick wedge-shaped lines with the base adjacent to pleura (Hampton’s Hump) Resolution tends to be slow (Melting sign) Accompanying features : Splinting of the diaphragm and a pleural reaction

39. MELTing ice sign

40. Plate atelectasis Seen post-operatively and is thought to be due to under ventilation with obstruction of medium-sized bronchi Several centimetres long, 1-3 mm thick and run parallel to the diaphragms extending to the pleural surface (Fleischner line) Resolution is rapid (compared to pulmonary infarct)

41. bronchocele These are bronchi distended with mucus or pus beyond an obstructing lesion, but with aeration of the distal lung from collateral air flow Typical bronchocele has Gloved finger branching pattern with fingers several millimetres wide Causes to consider to include malignancy, benign tumours, FB aspiration, bronchial atresia etc

42. Sentinel lines Thought to be mucus-filled bronchi and appear as coarse lines lying peripherally in contact with the pleura and curving upward Often left sided and associated with left LL collapse

43. Kerley lines Kerley’s A lines: Linear opacities extending from the periphery to the hila Due to distention of anastomotic channels between peripheral and central lymphatics Kerley’s B lines: Short horizontal lines situated perpendicularly to the pleural surface at the lung base Due to thickening of interlobular septa Kerley’s C lines: Reticular opacities at the lung base representing superimposed Kerley’s B lines

44. Kerley lines Causes : Pulmonary edema Infections (viral, mycoplasma) Mitral valve disease Idiopathic pulmonary fibrosis Congenital heart disease Alveolar cell carcinoma Pneumoconiosis Lymphoma Lymphangitis carcinomatosis Pulmonary venous occlusive disease

45. PLEURAL AND PULMONARY SCARS Scars are unchanged in appearance on serial films Appear as a thin linear shadows often with associated pleural thickening and tenting of the diaphragm Apical scarring is a common finding in healed tuberculosis, sarcoidosis and fungal disease

46. Bronchial wall thickening They cast parallel tramline shadows Ring shadows when seen end-on Common in bronchiectasis, recurrent asthma, pulmonary oedema and lymphangitis carcinomatosis

47. SOLITARY PULMONARY NODULE Discrete, well – marginated , rounded opacity Less than or equal to 3 cm in diameter Completely surrounded by lung parenchyma Doesn’t touch the hilum or mediastinum Not associated with adenopathy, atelectasis or pleural effusion Lesions larger than 4 cm are treated as malignancies until proven otherwise

48. SOLITARY PULMONARY NODULE

49. SOLITARY PULMONARY NODULE Intrapulmonary mass forms an acute angle with the lung edge Extra-pleural and mediastinal masses form obtuse angles

50. SOLITARY PULMONARY NODULE Carcinomas often have irregular, spiculated or notched margins Calcification favors a benign lesion although a carcinoma may arise coincidentally at the site of an old calcified focus Calcified metastasis is rare, the primary tumor being usually an osteogenic or chondrosarcoma Granulomas frequently calcify and are usually well defined and lobulated

51. SOLITARY PULMONARY NODULE Hamartoma Chondrosarcoma

52. MULTIPLE PULMONARY NODULES Multiple small nodules 2-4 mm are called miliary shadows Mostly metastasis or tubercular granulomas Calcified nodules are generally benign except for metastasis from bone or cartilaginous tumors

53. MULTIPLE PULMONARY NODULES Canon ball metastasis

54. CAVITATING LESIONS AND CYSTS It’s a gas filled space surrounded by a complete wall which is 3mm or greater in thickness Thin walled – cysts/ bullae Requires a patent airway to communicate with necrotic area Common cavitating diseases are TB, staph infections and carcinoma

55. CAVITATING LESIONS Common sites : TB – upper zones and apical zones of lower lobes Traumatic lung cysts – Sub pleural Amoebic abscess – right base Pulmonary infarcts – Usually in left lower lobe Lung abscess – right side and lower zone

56. CAVITATING LESIONS

57. Fluid levels Abscesses Hydropneumothorax : trauma, surgery, bronchopleural fistula Esophageal : pharyngeal pouch, diverticula Obstruction : tumour, achalasia Mediastinal : infections, esophageal perforation Pneumopericardium Fluid levels are common in primary tumors -> irregular masses of blood clot or necrotic tumor may be present Fluid levels are uncommon in cavitating metastases and tubercular cavities

58. Hydatid disease Signs of non-ruptured cysts : Honeycomb (wheel spoke, spoke wheel, rosette, racemose) pattern: multivesicular mother cyst with daughter cysts separated by radiating septa representing cyst walls and hydatid sand/matrix Double line sign: unilocular cyst with double layered wall representing pericyst and laminated cyst membrane

59. Hydatid disease Signs of partially ruptured cyst in pulmonary hydatid disease : Crescent sign: when the hydatid cyst erodes the adjacent bronchus or bronchiole, the trapped air between the pericyst and the laminated membrane of the endocyst give a crescent-shaped rim of air around the cyst Inverted crescent sign: crescent-shaped rim of air at the lower edge of the cyst

60. Hydatid disease Signs of complete rupture / cyst degeneration in pulmonary hydatid disease : Cumbo (onion peel, double arch) sign: curvilinear membrane outlined by air both inside the endocyst and a crescent of air between the endocyst and pericyst Water lily ( camalote ) sign: folded membranes floating at the air-fluid interface Empty (dry) cyst sign: air filled cyst after expectoration of membranes and fluid

61. Hydatid disease Signs of ruptured endocyst in hydatid cysts : Serpent (snake) sign: wavy membranes within the cyst Spin (whirl) sign: twisting membranes within the cyst Ball of wool (yarn, congealed water lily, mass within a cavity) sign: solid conglomeration of membranes settled in the dependent portion of the cyst

62. Hydatid disease Cumbo sign Water lily sign

63. Air crescent sign Crescent shaped radiolucency within parenchymal consolidation or opacity Air fills the space between the devitalized tissue and surrounding parenchyma Opaque rim of haemorrhagic tissue peripheral to the radiolucency Common in aspergilloma

64. calcifications

65. CaLcifications Calcification is most easily recognized with low kVP films In elderly, calcification of the tracheal and bronchial cartilage is common TB is the commonest calcifying pulmonary process usually upper zone. Chickenpo x – smaller(1-3 mm) regular in size and widely distributed TB CHICKEN POX

66. calcifications Egg shell calcification : Silicosis, Sarcoidosis Alveolar microlithiasis: Sand grain like calcification

67. Apical shadowing Common causes are : Pleural caps Pleural fluid Bullae Pancoast tumour Pneumothorax Infections –TB, fungal infections (histoplasmosis, coccidioidomycosis, aspergillosis)

68. UNILATERAL HYPERTRANSLUCENCY Looks for signs of obstructive or compensatory emphysema such as : Splaying of the ribs Separation of vascular markings Mediastinal displacement Depression of the hemidiaphragm Most common causes - Patient rotation and scoliosis With rotation to a side, that side becomes more prominent

69. UNILATERAL HYPERTRANSLUCENCY Mastectomy Pneumonectomy

70. Opaque hemithorax

71. pleura

72. Pleural abnormalities Pleural effusion Pneumothorax Pleural plaques Pleural thickening Pleural calcification Pleural neoplasm Fibrothorax

73. Pleural effusion An area of whiteness at the base of the lung : Pleural effusion Raised hemi diaphragm An area of consolidation/ collapse.

74. Pleural effusion Pleural Effusion vs Consolidation: Texture of whiteness -> Consolidation usually causes more heterogeneous shadowing typically with the presence of an air bronchogram Shape of the upper border of the shadowing -> Fluid will have a meniscus so the upper border of an effusion will be concave

75. Pleural effusion Pleural effusion vs Raised hemidiaphragm : Effusion will peak much more laterally than you would expect the diaphragm to do Pleural effusion vs Collapse : Collapse usually causes shift of trachea towards the white lung field. Hence of absence of shift excludes collapse. Collapse can also accompany an effusion. So presence of shift doesn’t exclude effusion.

76. Pleural effusion Look for … Presence of the meniscus, which often on the lateral view, is seen to tent up into one of the fissures. Size of the heart (large => heart failure), enlargement of hilum, visible parts of lung fields for obvious masses, bones for signs of mets , a pex pf lung for TB and tumors

77. Pleural effusion Lateral decubitus view

78. small effusion with blunting of CP angle Most dependent recess of the pleura is the CP angle. Small amount of effusion will tend to collect posteriorly (100-300 ml) 200 ml of fluid is required in Frontal film, 75 ml in lateral film.

79. Moderate Pleural effusion Fairly well defined upper edge, concave upwards, is higher laterally than medially and obscures the diaphragmatic shadow

80. Massive effusion with mediastinal shift

81. Pleural effusion with collapse No mediastinal shift in spite of the presence of massive effusion

82. Lamellar pleural effusion Shallow collections between the lung and visceral pleura, sometimes sparing the CP angle Represents interstitial pulmonary fluid Eg : Post cardiac surgery

83. Subpulmonic pleural effusion Fluid is between pleura and diaphragm Lung floats above the fluid Large subpulmonic effusions mimics elevation of hemi diaphragm

84. Loculated pleural effusion Pseudo tumor or Phantom tumor – effusion within the fissures

85. pneumothorax Refers to presence of air in the pleural cavity Open pneumothorax : A ir move freely in and out during respiration Closed pneumothorax : No movement of air occurs ( eg . due to pleural adhesions) Valvular pneumothorax : A ir enters the pleural space on inspiration and doesn’t leave during expiration Tension pneumothorax : As intrapleural pressure increases in a valvular pneumothorax

86. pneumothorax Visible pleural edge seen as a thin, sharp white line No lung markings peripheral to this line Peripheral space is radiolucent compared to adjacent lung Lung may completely collapse No mediastinal shift unless tension pneumothorax is present

87. Deep sulcus sign CP angle appear abnormally deep and lucent because of air in the anterolateral pleural space

88. Double diaphragm sign Visualization of the anterior CP angle as an edge separate from the dome of diaphragm but parallel to it (especially in a supine film as air collects and outlines the anterior portion of hemidiaphragm in a supine patient with pneumothorax)

89. Tension pneumothorax Shift of mediastinum away from the side of pneumothorax Downward displacement or inversion of hemi diaphragm Medical emergency

90. hydropneumothorax Pneumothorax containing a horizontal fluid level which separates opaque fluid below from lucent air above Classically seen as an air-fluid level

91. Pleural plaques Plaques are focal areas of thickening of parietal pleura (classically due to previous exposure to asbestosis) Characteristically appear as scattered islands of well circumscribed pleural densities (Holly leaf sign) Usually in the lower 2/3 rd of the thorax and are bilateral Most often affects the parietal and diaphragmatic pleura (virtually pathognomic) Do not involve the CP angles

92. Pleural calcification Unilateral : Previous empyema, hemothorax or pleurisy (in the visceral pleura) Bilateral : Asbestosis, pneumoconiosis (in the parietal pleura)

93. Pleural calcifications From previous pleurisy, calcification occurs in the visceral pleura Associated pleural thickening is almost always present and separates the calcification from the ribs Pleural c alcification may be in a continuous sheet or in discrete plaques usually producing dense, coarse, irregular shadows, often sharply demarcated laterally In asbestosis, calcification occurs in the parietal pleura, is more delicate and bilateral sparing the CP angles seen Frequently visible over the diaphragm and adjacent to the axillae

94. Pleural tumours Commonest malignant disease of the pleura is mets (most frequently from bronchus and breast) Primary malignancy of pleura is associated with asbestosis exposure (malignant mesothelioma) Unilateral pleural effusion(30-95%) and concentric or lobulated pleural thickening Benign calcified or non-calcified plaques may be present F rozen mediastinum sign : Because of the pleural thickening and mediastinal infiltration, the involved hemithorax may be normal in volume, despite presence of large effusion

95. fibrothorax Fibrosis within the pleural space Occurs secondary to the inflammatory response Seen in tuberculosis, asbestosis, hemothorax etc

96. Hilum

97. Hilar abnormalities Superior margin of left hilum is usually higher than the right Whenever the left hilum appears lower than right, check for any evidence s/o : Collapse of left lower lobe or right upper lobe Enlargement of right hilum (tumour or nodes)

98. Small hilum : causes * Mac Leod’s syndrome : U/L hemithoracic lucency as a result of post infectious obliterative bronchiolitis

99. Enlarged hilum : Causes

100. Batwing appearance A pattern of b/l perihilar shadowing seen in pulmonary edema, pneumonia (aspiration, PCP, viral, lipoid)

101. REVERSE BATWING APEARANCE Peripheral opacities in b/l lung fields with perihilar sparing - chronic eosinophilic pneumonia, bronchoalveolar CA, pulmonary contusion … and also documented in COVID-19 pneumonia

102. Garland triad Also called as 1-2-3 triad: Right paratracheal nodes Right hilar nodes Left hilar nodes Typically seen in Sarcoidosis

103. Pulmonary hypertension Prominent pulmonary outflow tract Enlarged pulmonary arteries Pruning of peripheral pulmonary vessels Elevated cardiac apex due to right ventricular hypertrophy Enlarged right atrium

104. mediastinum

105. Mediastinal compartments

106. Mediastinal masses

107. Cervicothoracic sign Any lesion with a visualized upper border above the level of clavicle must be located posteriorly in the chest (apical segment of upper lobes, pleura or posterior mediastinum

108. Hilum overlay sign To distinguish between cardiac enlargement and an anterior mediastinal mass Hilum lateral to the lateral border of the mass – cardiac enlargement Hilum medial to the lateral border of the mass – mediastinal mass present

109. Hilum convergence sign Allows an enlarged hilum due to pulmonary arteries to be distinguished from enlargement due to tumor If the vessels arise from or converge directly onto the hilar shadow – enlargement is vascular If the vessels appear to arise or converge medial to the lateral aspect of the hilar shadow – enlargement is a mass

110. thoracoabdominal SIGN A sharply marginated mediastinal mass projected over the diaphragm on a CXR will be wholly or party in the thorax because it is outlined by air in the lung

111. Anterior mediastinal mass Lymphoma

112. Middle mediastinal mass Thoracic aortic aneurysm

113. Posterior mediastinal mass Neuroblastoma

114. pneumomediastinum Presence of extra luminal gas within the mediastinum Etiology : Secondary to chest, neck or retroperitoneal surgery Esophageal perforation : Endoscopic intervention Boerhaave syndrome (spontaneous perforation – increased esophageal pressure as in vomiting, severe straining) CA esophagus

115. Continuous diaphragm sign Air in mediastinum tracks extrapleurally between heart and diaphragm forming a continuous lucency outlining base of heart representing pneumomediastinum Pneumopericardium shows air circumferentially outlining heart, hence differentiated

116. SPINNAKER SAIL SIGN(ANGEL WING SIGN) S een in neonates when thymic lobes are displaced laterally by mediastinal air

117. Ring around artery sign Air around pulmonary artery and main branches produces a black ring appearance

118. Tubular artery sign Air outlining the major aortic branches

119. pneumopericardium A ir circumferentially outlining the heart

120. Abnormal heart shadows Total anomalous pulmonary venous connection : Snowman / Figure of 8 sign TOF – Boot shaped heart

121. Abnormal heart shadows Ebstein’s anomaly (abnormal tricuspid) : Box shaped heart Transposition of great arteries : Egg on string appearance

122. Mitral stenosis Double density sign – left atrial enlargement

123. LV aneurysm

124. Pericardial effusion Retrosternal (paracardial) fat < Pericardial effusion > Epicardial fat

125. diaphragm

126. Elevated diaphragm

127. Diaphragmatic hernia Congenital or acquired defect in the diaphragm More common on the left side Causes : Hiatus hernia Bochdalek hernia Morgagni hernia Traumatic Iatrogenic

128. DIAPHRAGMATIC HERNIA Bochdalek hernia Morgagni hernia (most common, posterolateral, neonatal) (smaller, anterior, sternocostal angle, presents later on) *Hiatus hernia – through esophageal hiatus

129. Eventration of diaphragm A congenital condition Incomplete muscularization of diaphragm with a thin membranous sheet replacing the normal muscle May affect only a part of the diaphragm resulting in a smooth hump

130. Chest wall

131. Clavicular abnormalities Fractures and old healed fractures

132. Clavicular abnormalities Erosion of the outer ends of the clavicle is associated with RA and hyperparathyroidism Hypoplastic clavicles in Holt- O ram Syndrome and C leido Cranial D ysostosis Holt- Oram Syndrome Rheumatoid arthritis

133. Sternal abnormalities Pectus excavatum (funnel chest) : Depressed sternum Prominent shadowing adjacent to the right heart border Widening of cardiac silhouette H eart is displaced to the left and has a straight left heart border

134. Sternal abnormalities Pectus carinatum (pigeon chest) : Sternum protrudes anteriorly

135. Abnormalities of rib Superior rib notching : RA, SLE, hyperparathyroidism, Marfan’s syndrome, NF and in paraplegics and polio victims Inferior rib notching : Develops as a result of hypertrophy of the intercostal vessels or with neurogenic tumors.

136. Abnormalities of rib

137. Cervical rib Cervical Rib : Supernumerary rib which arises from the seventh cervical vertebra Congenital rib anomalies like bifid ribs, hypoplasia and bridging are common

138. Rib fractures Stress fractures – Common in 7 th rib 6 th – 9 th lines are the common sites for cough fractures Pathological fractures: Senile osteoporosis, myeloma, metastasis, steroid therapy, Cushing’s disease and other endocrine disorders Cushing’s disease is associated with abundant callus formation

139. Thoracic spine Check for abnormal curvature or alignment, bone and disc destruction, sclerosis, paravertebral soft-tissue masses and congenital lesions such as butterfly vertebrae Anterior erosion of vertebral bodies sparing the disc spaces is noted with aneurysm of descending aorta, vascular tumors and NF Scoliosis

140. Thoracic spine A single dense vertebra, the ivory vertebra – classical appearance of lymphoma, but also a feature of Paget’s disease and metastasis Destruction of pedicle is typical of Metastasis Destruction of the disc with adjacent bony involvement is characteristic of an Infective process Disc calcification occurs in oochronosis and ankylosing spondylitis

141. Soft tissue Skin lesions including naevi and lipomas may simulate lung tumors Multiple nodules occur with neurofibromatosis Mastectomy is one of the commonest causes of translucent hemithorax

142. Ginkgo leaf sign Seen in extensive subcutaneous edema of chest wall Gas outlines the fibers of pectoralis major and creates a branching pattern that resembles veins of a ginkgo leaf

143. If you have any questions… THANK YOU