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The posterior aspect of the capsule is also strengthened by the origins of the medial and lateral head of the gastrocnemius effective doxazosin 4mg gastritis upper gi. Apart from the capsular ligament and its associated ligaments generic 1mg doxazosin with visa gastritis diet emedicine, the femur and tibia are united by two strong ligaments that lie within the joint purchase doxazosin 2mg on-line gastritis diet food list. These are the anterior and posterior cruciate ligaments (so called because they cross each other) buy cheap doxazosin 1mg on line gastritis symptoms foods avoid. The anterior cruciate ligament is attached below to the anterior part of the intercondylar area of the tibia (14. It passes upwards, backwards and laterally to the medial aspect of the lateral condyle of the femur (i. The posterior cruciate ligament is attached below to the posterior part of the intercondylar area of the tibia. It passes upwards, forwards and medially to attached above to the lateral surface of the medial condyle of the femur. The medial and lateral menisci of the knee joint are intra-articular discs made of fbrocartilage. In accordance with the shape of the tibial condyles the lateral meniscus is smaller and its outline more nearly circular than that of the medial meniscus (14. The anterior and posterior ends of the lateral meniscus are attached to the intercondylar area of the tibia just in front of and behind the intercondylar eminence. We have noted, above, that the lateral meniscus is separated from the fbular collateral ligament by the tendon of the popliteus (14. The anterior end of the medial meniscus is attached to the most anterior part of the intercondylar area of the tibia in front of the anterior cruciate ligament. Its posterior end is attached to the posterior part of the intercondylar area in front of the attachment of the posterior cruciate ligament. When the knee is extended the anterior borders of the menisci lie against the grooves on the femur that separate the tibial and patellar articular surfaces. The anterior margins of the two menisci are connected by a band of fbres called the transverse ligament (14. They participate in gliding movements (see below) and assist in lubrication of the joint. The synovial membrane of the knee joint covers all structures within the joint except the articular surfaces and the surfaces of the menisci. It lines the inner side of the tendinous expansion of the quadriceps femoris (that replaces the capsule ante- riorly) and some parts of the tibia and femur enclosed within the capsule. Just above the patella the synovial membrane forms a pouch called the suprapatellar bursa: the pouch is bounded anteriorly by the quadriceps tendon, and posteriorly by the lower part of the anterior surface of the shaft of the femur. The upper edge of the synovial membrane forming the pouch is prevented from sagging downwards by a small muscle called the articularis genu. Lower down, the ligamentum patellae is separated from the synovial membrane by a large (infrapatellar) pad of fat. Folds of synovial membrane project into the joint along the medial and lateral margins of the patella: these are called the alar folds. The cruciate ligaments appear to invaginate into the joint cavity from behind so that they are covered by synovial membrane on the sides and in front, but not behind. Because of differences in the convexity of the anterior and posterior parts of the femoral condyles the axis of movement shifts forwards during extension and backwards during fexion. The tibia and menisci glide forwards relative to the femoral condyles in extension; and backwards in fex- ion. Further, fexion is associated with lateral rotation of the femur (or medial rotation of the tibia if the foot is off the ground); and extension is associated with medial rotation. The medial rotation of the femur is most marked during the last stages of extension. The anteroposterior diameter of the lateral femoral condyle is less than that of the medial condyle. As a re- sult, when the lateral condylar articular surface is fully ‘used up’ by extension, part of the medial condylar surface remains unused. At this stage the lateral condyle serves as an axis around which the medial condyle rotates backwards (i. Locking is produced by continued action of the same muscles that produce extension, namely the quadriceps femoris. When the knee is locked, the position of extension can be maintained without much muscular activity. The ‘locked’ knee can be fexed only after it is unlocked by a reversal of the rotation. Unlocking is brought about by the action of the popliteus muscle, which rotates the femur laterally (Rotation of the femur occurs when the feet are on the ground preventing rotation of the tibia. If the knee is fexed or extended when the foot is off the ground, it is the tibia that would rotate, in a direction opposite to that described for the femur). It is assisted by the gastrocnemius, popliteus, sarto- rius, gracilis and plantaris muscles. Muscles producing locking and unlocking of the joint have been mentioned in the preceding paragraph. The knee joint is supplied by branches of the descending genicular, popliteal, anterior tibial and lateral circum- fex arteries; and by branches from the obturator, femoral, tibial and common peroneal nerves. The posterior aspect of the joint is also related to the popliteal vessels and to the tibial nerve, and more laterally to the common peroneal nerve. The subcutaneous prepatellar bursa lies deep to the skin over the lower part of the patella. Several other unnamed bursae are present in relation to tendons and ligaments around the knee. CliniCal Correlation Dislocation of the Knee Joint Dislocation at the knee joint is rare. It can result in damage to the popliteal artery, to the tibial nerve, or to the common peroneal nerve. It should be noted that the patella has a natural tendency to be displaced laterally because of the direction of pull of the quadriceps (upwards and laterally). This is prevented by the patellar retinacula and is counteracted, to some extent, by the fact that the vastus medialis tends to pull the patella medially. Injuries in the region can lead to effusion of a serous fuid into the joint cavity (traumatic synovitis). If a blood vessel within the joint is injured the joint can fll with blood (haemarthrosis). Strain or tear of the medial ligament of the knee is caused by an injury that abducts the tibia on the femur. An opposite force that adducts the tibia on the femur can cause strain or tear of the lateral ligament. Tears of the cruciate ligaments may occasionally occur along with those of the medial or lateral ligaments by abduction or adduction injuries. A force that drives the upper end of the tibia forwards over the tibia can rupture the anterior cruciate ligament; and a force that pushes the tibia backwards can rupture the posterior cruciate ligament. A twisting force acting on a semifexed or fexed knee can tear the medial meniscus.
Defects in the endplates of the vertebral bodies doxazosin 4 mg amex gastritis diet áëčö, most frequently in the lumbar spine order 2 mg doxazosin with amex gastritis diet forum, are common nontraumatic ?ndings discount doxazosin 1 mg with mastercard gastritis diet information. The defect generic doxazosin 4 mg fast delivery gastritis upper abdominal pain, known as a “Schmorl’s node” (black arrow) appears as a defect in the vertebral body with sclerotic margins in the anterior or midportion of either endplate. This patient also has marked aortic calci?cation (star), bowel gas adjacent to the anterior portion of the midlumbar vertebrae (white arrow), and loss of L4 vertebral height and collapse of the L3-L4 and L4-L5 intervertebral disk spaces. In the lateral projection of the lumbar spine of a 43-year-old, a limbus vertebra can be seen involving the superior anterior aspect of L3. It is believed to result from herniation of the nucleus pulposus through the ring apophysis prior to fusion of the vertebral body. It is isolated to a small corner segment of the vertebral rim, most commonly a?ecting the anterosuperior corner. Also note that the intervertebral disc spaces are similar and that there is a lack of pathology of the contiguous vertebral bodies, distinguishing this from a fracture. It is a disorder of disregulated bone remodeling characterized by lytic-appearing lesions (early) or dense sclerotic lesions (late). It is most commonly found in the pelvis but also in the skull, proximal femurs, tibia, and humerus. In this image, the left os coxa and proximal femur are di?usely radiodense compared to the right. The bone is also enlarged, with loss of trabecular markings and cortico-medullary di?erentiation (black arrows), making it mechanically ?awed and prone to fractures. A left intertrochanteric fracture is seen (white arrows) in addition to severe degenerative changes of the hip joint with joint space narrowing and probable collapse of the femoral head. In a 65-year-old male with prostate cancer presenting with pelvic pain, this close-up shows numerous small lytic lesions in the pelvis and right hip (arrows). A 73-year-old female with history of colon cancer and resection presents several years later with pelvic pain. This patient also has degenerative sclerotic changes of both hip joints (black arrows), with erosions and collapse of the medial aspect of the femoral heads bilaterally. Following blind nasal placement, ideally the plain radiographs should demonstrate the tip in the proximal small bowel. The Dobho? tube crosses the midline, coursing through the duodenum, and probably ends in the proximal jejunum. This may be di?cult to distinguish from a thoracic aortic aneurysm, although in this case, the structure appears to contain gas, and the aortic knob is entirely normal. The lateral view demonstrates a normal aortic contour and a suggestion of a hiatal hernia at the medial portion of the diaphragm. An elderly patient presents with worsening shortness of breath and a history of “lung problems. This ?lm shows scattered “veillike” densities of pleural plaques associated with asbestos exposure (white arrow). Asbestos-related plaques can take manyforms, fromthin linear calci?cations only seen when the x-ray beam is tangential tothe pleuraat that location,to large disorganized masses, easily seen en face, such as those seen in Figure 11. Aneurysms, in addition to the well-known syndromes of acute instability, can present more chronically. In this case, the aneurysm was having a mass e?ect in the chest and causing aortic insu?ciency with secondary mitral regurgitation. Kerley B lines are caused by increased interstitial ?uid in the lungs and can be seen in the absence of rales on exam. An 80-year-old man, who quit one week ago after 60 years of smoking, presents with poorly de?ned chest pain and possible weight loss. Initially, the large mass in the upper left hilum might be mistaken for an aortic aneurysm, but the calci?cations in the ascending aorta (black arrows) and the left wall of the descending aorta (arrowheads) suggest that it is not enlarged. The entire mediastinum is shifted to the left, with attenuated lung markings seen in the left lung ?elds (white arrows). Although it might be expected to have a distinctly more radiodense lung ?eld in this situation, the ?ndings suggest atelectasis of the left upper lobe possibly due to bronchial obstruction. There is no evidence of acute injury, but multiple pulmonary nodules are seen in both views (arrows). Di?erential for these nodules include scarring from prior granulomatous disease (e. Old ?lms of the patient were found, and they demonstrated these nodules to be unchanged from previous ?lms. A 67-year-old patient presents to his primary care physician after a 3-day history of nonproductive cough. However, there is a large lytic lesion in the left distal clavicle (white arrows), consistent with the patient’s 191 known history of multiple myeloma. She complains that “the pain just won’t go away, and I can’t seem to use it properly. In addition, there are multiple lytic lesions of varying sizes in the humerus and scapula (arrows). The patient was subsequently managed for metastatic recurrence of her breast cancer. Comparison of the two hips demonstrates asymmetry of the joint spaces (black arrows) with widening on the left side. Also note the position of the limbs: the left femur is ?exed and externally rotated. The intertrochanteric line (white arrows) should not be mistaken for a fracture line. Other incidental ?ndings include various calci?cations in the pelvis: these regular, smooth, often corticated densities are termed phleboliths. There is also vascular calci?cation seen in the proximal right leg medial to the femur. An obese patient presents with complaints of severe pain down her posterior left thigh that awoke her from sleep 4 days ago. The bone on both sides of the joint shows areas of sclerosis (radiodense areas of increased calcium deposition). There are also subchondral “cystic” (radiolucent) areas (arrowheads) that suggest osteonecrosis, with resultant collapse of bone and ?attening of the femoral head. Of note, hip injury can present with pain in the back, buttocks, thighs, or knees. A 55-year-old woman presents with pain and swelling in her right knee after “twisting” it while walking up stairs 4 days ago. Fine radiodense deposits can be seen in the meniscus on either side of the joint (white arrows). These are characteristic of the calcium pyrophosphate deposits of chondrocalcinosis, which have a predilection for hyaline cartilage and ?brocartilage (as in this case). The majority of these deposits are asymptomatic, although they can cause symptoms such as acute pain, redness, and swelling (sometimes precipitated by trauma, as in this case), referred to as pseudogout. With the absence of signs of an infectious process and relatively mild symptoms, she was treated empirically with nonsteroidal anti-in?ammatory agents and referred to follow-up with her primary care physician. Another case of more advanced chondrocalcinosis is shown in the right knee ?lm seen in Figures 11.
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Aorta Mediastinum the aortic knob represents the posterior portion of the aortic Aside from the heart and aorta 1mg doxazosin for sale gastritis diet foods to eat, several other mediastinal arch 2 mg doxazosin fast delivery gastritis peanut butter. The left margin of the descending aorta is the trachea is a midline air-?lled structure that branches at seen inferior to the aortic knob and parallels to the vertebral the carina to form the left and right mainstem bronchi buy doxazosin 1 mg cheap hemorrhagic gastritis definition. Between the inferior margin of the aortic subclavian artery extends superiorly from the aortic arch order doxazosin 1 mg on-line gastritis diet kits. The knob and the left pulmonary artery is a small concave fat- descending aorta extends inferiorly from the aortic knob. The descending aorta lies within mediastinal soft tissues and is Mediastinal Pleural Re?ection Lines not visible ure 3B). In elderly persons, particularly those with hypertension, the Several air/?uid interfaces between the lung and mediastinal aortic wall is weakened and the aorta becomes dilated (ectatic) soft tissue structures are often seen. This is known as a tortuous aorta of these contours occurs with accumulation of ?uid, lym- ure 4). Heart: the cardiac width (X) is normally less than half the width of the thorax (Y) (cardiothoracic ratio). The left heart border is formed by the left ventricle (arrow) and the right heart border by the right atrium (arrowhead). On lateral view, only the aortic arch is visible (A); the descend- ing aorta is not seen because it is within the mediastinal soft tissues. Ribs: On the lateral view, the right ribs (R) are further from the radiograph cassette and therefore magni?ed and more pos- terior than the left ribs (L). On lateral view, the elongated descending aorta is visible adjacent to thoracic vertebrae (A-A). Left atrial enlargement causes widening of the angle between the left On the lateral view, the superior portion of the posterior heart border and right mainstem bronchi at the carina (asterisk), convexity at the bulges posteriorly due to left atrial enlargement (arrow). The lungs are hyperexpanded, the thoracic width is increased, knob and the lung apices). On the lateral view, the thoracic antero- and the cardiothoracic ratio is therefore not a reliable indicator of car- posterior diameter is increased. Left subclavian artery—A curved shadow that disappears at the superior border of the clavicle. Right paratracheal stripe—Normally 5 mm wide; terminates inferiorly at the arch of the azygos vein. Aorticopulmonary window—Space under aortic arch and above superior border of left pulmonary artery. Azygo-esophageal recess—Medial surface of the right lung extends into the mediastinum inferior to the arch of the azygos vein and lies against the esophagus (it is not the right side of the descending aorta). The right paratracheal stripe is a thin layer of connective the lung markings and hila are two problematic areas of tissue that lies along the right tracheal wall adjacent to the right chest radiology. Identi?cation of abnormalities cheal stripe terminates inferiorly at the arch of the azygos vein of the hila or lung markings must therefore be based on an un- that crosses over the right mainstem bronchus. Widening 1 cm derstanding of their normal radiographic anatomy and the is a sign of pulmonary venous hypertension (e. Inferior to the arch of the azygos vein and carina, the medial surface of the right lung lies against the esophagus forming the azygo-esophageal recess. The left and right paraspinal lines parallel the margins of the thoracic vertebral bodies. Hilum the hila are composed of the main pulmonary arteries and the superior pulmonary veins, which appear as branching vascular structures ures 3 and 7). The lower lobe pulmonary arteries extend for 2 to 4 cm before branching ure 8). The inferior pulmonary veins enter the left atrium inferior to the hila and do not contribute to hilar density. Right lower lobe pulmonary Lung Markings artery Normal lung markings are pulmonary arteries and veins. Due to overlap, they can have a reticu- markings can have a reticular or cyst-like appearance. Blood vessels seen on-end appear as small mal lung markings are caused by thickening of the interstitial white dots. The lower lobe pulmonary arteries extend 2 to 4 cm from connective tissues, which are not normally visible. How to Read the Lateral View Hilar abnormalities, particularly hilar adenopathy, can of- ten be more easily identi?ed on the lateral view. Cardiomegaly A systematic approach begins with assessment of the technical due to enlargement of the right ventricle and left atrium can be adequacy of the radiograph. Next, the bones (verte- bral bodies, ribs and sternum), soft tissues (diaphragm, heart Radiographic anatomy and mediastinum), and lungs are examined. The left and Intrapulmonary opacities (pneumonia or tumors) can right lungs are superimposed. They also major (oblique) ?ssures and the minor (horizontal) ?ssure are can be localized to a particular segment of the lung. Normally, the lower vertebral bodies appear more radiolu- the left and right domes of the diaphragm are visible and cent (dark) than the superior vertebral bodies because there is can be differentiated using four criteria. When the method is to identify the right ribs, which are more posteriorly lower vertebral bodies appear more “white,” there is a lower located on the standard left lateral view ures 3B, 4B and 5B). The retrocardiac and the right dome of the diaphragm extends posteriorly to the retrosternal regions are also better seen on the lateral than the right ribs at the posterior costophrenic sulcus. Intrapulmonary opacities—pneumonia, tumors left atrium and, inferiorly, the left ventricle. Thickened interlobar ?ssures—interstitial pulmonary edema clear space is ?lled by the heart. Small pleural effusion in posterior costophrenic sulcus ment, the heart extends posteriorly into the retrocardiac space 4. Hilar abnormalities—adenopathy, masses, increased vascularity to the vertebral bodies. With left atrial enlargement, the supe- rior portion of the posterior cardiac border bulges posteriorly 5. In an elderly patient with a tortuous aorta, the unable to stand and cannot be transported to the radiology suite. Anterior to the distal trachea and carina, the right pul- Several factors can either obscure or mimic pathological monary artery forms a radiopaque region ure 9). They are seen as areas of abnormally increased opac- or a pneumothorax are located, respectively, posterior or an- ity adjacent to the air-?lled distal trachea. Normally, the regions terior to the lung and therefore dif?cult or impossible to de- posterior and inferior to the distal trachea are radiolucent; when tect. Finally, superimposed extraneous objects can obscure they are radiopaque, there is retrotracheal and subcarinal radiographic ?ndings. These can be dif?cult to is better able to take a full inspiration, and pleural ?uid or a distinguish from a lower lobe in?ltrate ure 9).
The facial skeleton is severely ple articulations of the zygoma should be suspected in disrupted doxazosin 1mg with amex gastritis pancreatitis symptoms, resulting in bilateral soft tissue swelling clinically cheap doxazosin 1mg free shipping gastritis diet ˙íäĺę. All types of Le Fort fractures result in instability and dissocia- the fracture may present with edema and ecchymosis invol- tion of a portion of the midface from the cranium due to ving the cheek and lower eyelid purchase doxazosin 1 mg fast delivery youtube gastritis diet, with ?attening of the malar involvement of the pterygoid processes cheap doxazosin 1 mg with mastercard gastritis diet öčňŕňű. A fracture to the zygoma may also be felt the maxillary sinuses, formed by the pterygoid plates, is also during palpation of the infraorbital margin and intraorally in fractured in each of the three Le Fort fractures. Fractures limited to the zygomatic fractures also result in malocclusion of the maxilla and mand- arch account for 10% of all midfacial fractures (13). Zygomatic arch fractures are usually due to impact from a horizontal force applied to the side of the face. Palpation Indications reveals ?atness localized to the lateral area of the cheek, and Le Fort I is a bilateral transmaxillary fracture that results in patients are unable to open their mouths due to impingement dislocation of the tooth-baring portion of the maxilla from of the zygomatic arch fragment on the coronoid process of the the rest of the face. The physical ?ndings associated with a Le mandible or the temporalis muscle (1, 8). The palate is dislocated in a posterior or lateral direc- Diagnostic capabilities tion, causing malocclusion and a ?oating palate. This is especially medial canthi of the eye, bilateral subconjunctival 21:20:04 31 Monica Kathleen Wattana and Tareg Bey hemorrhages, and mobility of the maxilla. Clinical evaluation Mandible of the patient is di?cult due to the large extent of damage to the midfacial skeleton and overlying soft tissue (3, 4, 8). The U shape of the mandible results in fractures that are bilateral, occurring at the site of impact and at a contralateral site due to dissipation of the impact force. Diagnostic capabilities However, a recent study showed unifocal mandible frac- tures occur with greater frequency than anticipated by most Le Fort I radiologists. The angle was the most frequently involved site, and orientation because horizontal fractures involving the sagittal many of these fractures involved the sockets of the posterior buttresses can be observed (8). Panoramic x-ray views and plain ?lms provide adequate visualization of isolated mandibular injuries. These fractures also have the potential of more severe ophthalmic trauma due to invol- Imaging pitfalls and limitations vement of the orbit (1, 4, 8). These types of fractures are best detected cribriform plate, and ethmoid roof involvement. A and B: These two images taken from a series depict a multiple comminuted and minimally displaced fracture that involves the roof, ?oor, and medial wall of the right orbit. Soft tissue swelling with air and deformity of the periorbital and supraorbital regions of the right is also present in both pictures. Additionally, in B, a comminuted fracture of the nasal bones causes mild displacement of the nasal septum. A and B: Images that depict approximately 1 cm herniation of orbital contents through a large defect in the inferior wall of the left orbit. The contents that are herniated include the inferior rectus and, to a lesser extent, the medial rectus muscle. C: A sagittal view that shows formation of an extensive retrobulbar hematoma and orbital contents within the left maxillary sinus. A and B: Coronal images that show a comminuted fracture of the left lateral orbital wall with mild medial displacement and a fracture of the left orbital ?oor. Intraorbital fat without extraocular muscle herniation has occurred through the defect as well asdisplacement of the fracture fragment. Left intraconal and extraconal air is also seen without deformity of the left globe. Injuryis also accompanied 444 by soft tissue swelling within the left periorbital region. The right globe also shows fracture with herniation of intraorbital fat through the defect. C: An image taken within the same series that shows left intraconal and extraconal air and fracture of the left lateral orbital wall depicted in the axial view. A and B: Axial and coronal images, respectively, that depict multiple fractures to the left zygomatic arch and fracture to the temporal processes with accompanied displacement. The fracture to the anterior portion of the arch is nondisplaced, whereas the fracture to the temporal process is displaced approximately by 5 mm. There is additional fracture of the inferior orbital rim and diastasis and angulation atthe frontozygomatic suture. Figure B is a coronal section that shows fracture has also occurred to the inferior orbital rim. Diastasis and angulation at the frontozygomatic suture is also seen in images C, D, and E. This axial image shows fracture to the anterior wall of the left maxillary sinus anterior wall with associated soft tissue swelling and maxillary sinus. There is also mild right maxillary sinus mucosal thickening, subcutaneous emphysema. The patient also has sinus mucosal disease, which which indicates a nontraumatic chronic in?ammatory process. Axial image that depicts fracture of the lateral wall of the right maxillary sinus. Part of a series that depicts fracture to the left maxillary sinus and left orbital ?oor. A: An axial image that shows fracture to the lateral wall of the left maxillary sinus as well as bilateral fracture of the nasal bones. B: An axial image that better depicts fracture of both the lateral and medial wall of the left maxillary sinus. C: A coronal image that shows fracture of the medial and lateral wall of the left maxillary sinus. This image also shows that there is a minimally displaced fracture of the left orbital ?oor with a small amount of fat protruding through the defect. These images depict an obliquely oriented fracture through the anterior wall of the left maxillary sinus. The inferior component of this fracture involves the lateral wall of the maxillary antrum and the superior component involves the inferior orbital rim. Figures A and B are axial images, whereas C and D are sagittal images reconstructed from the axial plane. This series depicts fracture to the right maxillary sinus and right orbital blowout fracture. A and B: Axial images that depict a fracture of the medial wall of the right maxillary sinus. C: A reformatted coronal image that shows right orbital blowout fracture with the defect occurring in the orbital ?oor.
