Scott D. Ganz, DMD

• Clinical Assistant Professor, Department of Restorative Dentistry
• University of Medicine and Dentistry of New Jersey
• Newark, NJ
• Prosthodontics, Maxillofacial Prosthetics &
• Implant Dentistry
• Fort Lee, New Jersey

Close collimation is essential to reduce patient dose and obtain a highquality image diabetes mellitus jenis dua purchase online avapro. As a starting critique exercise mmol l diabetes definition avapro 150mg without prescription, place a check in each category that atabl rror or that radiograph (T able 9 diabetes type 1 depression generic avapro 150mg fast delivery. This is caused by the alternate action o muscles attached to the rib cage and by atmospheric pressure that causes the air to move into and out o the lungs during respiration diabetes definition by ada discount avapro 150 mg visa. The bony thorax protects important organs o the respiratory system and vital structures within the mediastinum diabetes insipidus occurs when order avapro 300 mg visa, such as the heart and great vessels diabetes type 2 google scholar quality avapro 150mg. The sternum is also a common site or marrow biopsy, in which, under local anesthesia, a needle is inserted into the medullary cavity o the sternum to withdraw a sample o red bone marrow. The drawing shows the relationship o the sternum to the 12 pairs o ribs and the 12 thoracic vertebrae. As is demonstrated in the drawings on this page, the thin sternum superimposes the structures within the mediastinum and the dense thoracic spine in a direct rontal position. It is composed o highly vascular cancellous tissue covered by a thin layer o compact bone. The longest part o the sternum is the bo, which is about 4 inches, or 10 cm, long. The union o the our segments o the body begins during puberty and may not be complete until about the age o 25 years. The most in erior portion o the sternum is the iphoi (zi-foid) process, which is composed o cartilage during in ancy and youth and usually does not become totally ossi ed until about the age o 40 years. Another secondary name or this area is the suprasternal or m anubrial notch, which describes the slightly notched area between the two clavicles along the upper border o the sternum. The lower end o the manubrium joins the body o the sternum to orm a palpable prominence, the sternal angle (m anubriosternal joint). This is also an easily palpated landmark that can be used to locate other structures o the bony thorax. The sternal angle is at the level o the intervertebral disk space between T4 and T5 or an average adult. Below each clavicular notch and sternoclavicular joint is a depression or facet or articulation with the cartilage o the rst rib. The costocartilage and ribs have been added to one side o this drawing to show this relationship. The second costocartilage connects to the sternum at the level o the sternal angle. An easy way to locate the anterior end o the second rib is to locate the sternal angle rst and then eel laterally along the cartilage and the bone o the rib. The third through the seventh costocartilages connect directly to the body o the sternum. Ribs 8, 9, and 10 also possess costocartilage, but these connect to costocartilage 7, which then connects to the sternum. The term alse ribs applies to the last ve pairs o ribs, numbered 8, 9, 10, 11, and 12. The last two pairs o alse ribs are unique in that they do not possess costocartilage. The last two pairs o ribs, 11 an 12, which are also alse ribs, are termed f oating ribs because they are not connected anteriorly. Progressing laterally, the angle o the rib is that part at which the sha t curves orward and downward toward the sternal end. The lower inside margin o each rib protects an arter, a vein, and a nerve; there ore, rib injuries are very pain ul and may be associated with substantial hemorrhage. This inside margin, which contains the blood vessels and nerves, is termed the costal groove. The th ribs have been shaded to illustrate the downward angulation o the ribs better. Counting downward rom the short rst pair, the ribs get longer and longer down to the seventh ribs. From the seventh ribs down, they get shorter and shorter through the airly short twel th, or last, pair o ribs. The bony thorax is typically wi est at the lateral margins o the eighth or ninth ribs. The joints or articulations o the anterior bony thorax are identi ed on this drawing. The joints, along with the classi cation and types o motion allowed, are described as ollows (also see T able 10. These ribs (1 to 10) orm a unique type o union, wherein the cartilage and bone are bound together by the periosteum o the bone itsel. The sternoclavicular joints are s novial joints, containing articular capsules that permit a plane motion, or gli ing m otion, and are there ore termed diarthrodial joints. The cartilage o the rst rib attaches directly to the manubrium with no synovial capsule and allows no m otion (termed synarthrodial). Part d is the ourth sternocostal joint, typical o the second through seventh joints between costocartilage and sternum. These are s novial joints, which allow a slight plane (gli ing) m otion, making them what is termed diarthrodial joints. Part represents the continuous borders o the interchon ral joints between the costal cartilages o the anterior sixth through ninth ribs. These allow a slight plane (gli ing) t pe of m ovem ent (iarthro ial), acilitating movement o the bony thorax during the breathing process. Interchondral joints between the ninth and tenth cartilages are not synovial and are classi ed as brous syndesmosis. The joints between the ribs and the vertebral column, the costotransverse joints (F) and the costovertebral joints (G), are s novial joints with articular capsules lined by synovial membrane, which allow a plane or gli ing m otion, and are there ore iarthro ial. It is an anterior midline structure that is in the same plane as the thoracic spine. A patient with a shallow or thin chest requires more rotation than a patient with a deep chest to cast the sternum away rom the thoracic spine. The sternum is made up primarily o spongy bone with a thin layer o hard compact bone surrounding it. This eature, combined with the close proximity o the easy-topenetrate lungs and the harder-to-penetrate mediastinum-heart, makes exposure actor selection a challenge. Approximately 70 to 80 kV (analog) is recommended or adult sthenic patients to achieve acceptable contrast on the image. A breathing technique involves the patient taking shallow breaths during the exposure. This requires a medium kV range (70 to 80) range (analog), a low mA, and a long exposure time, rom 3 to 4 seconds. The technologist must be sure that the thorax in general is not moving during the exposure, other than rom the gentle breathing motion. Although this produced a more visible but distorted image o the sternum, it also resulted in an increase in radiation exposure to the patient. Whether the injury was caused by trauma to the thoracic cavity (Does the patient have di culty in breathing The ollowing positioning guidelines will enable the technologist to produce a diagnostic radiologic examination o the ribs. This allows the diaphragm to rise to the highest position and results in a less thick abdomen (especially on hypersthenic patients, because the abdomen f attens when recumbent). This should allow the diaphragm to rise to the level o the seventh or eighth posterior ribs, again providing a uni orm density or belowdiaphragm ribs. Because the lower ribs are surrounded by the muscular diaphragm and dense abdominal structures, a medium kV will ensure proper penetration o these tissues. The location o the trauma and/ or patient complaint determines which region o the ribs is to be imaged. Ribs above the diaphragm require di erent exposure actors, di erent breathing instructions, and generally di erent body positions than ribs located below the diaphragm. The upper nine posterior ribs generally represent the minimum number o ribs above the dome or central portion o the diaphragm on ull inspiration, as described in Chapter 2. However, with pain ul rib injuries, the patient may not be able to take as deep an inspiration; thus, only eight posterior ribs may be seen above the diaphragm on inspiration. Gravity assists in lowering the diaphragm when the patient is in the erect position. This position also allows a deeper inspiration, which depresses the diaphragm to its lowest position. Also, rib injuries are very pain ul and body movement that creates pressure against the rib cage, such as movement on the x-ray table, can cause severe pain and discom ort. This should project the diaphragm below the ninth or tenth ribs on ull inspiration. Because the upper ribs are surrounded by lung tissue, a lower kV will preserve radiographic contrast (with analog imaging) and will allow visualization o the ribs through the air- lled lungs. However, i the site o injury is over the heart area, a higher kV may be used to obtain a longer scale contrast to visualize ribs through the heart shadow and through the lung elds. Select the projections that will place the area of interest closest to the im age receptor and rotate the spine awa from the area of interest (prevents the spine rom superimposing the region o interest and better demonstrates the axillary portion o the involved region o ribs). Exp o su re cto rs Fa Exposure actors will vary as a result o various patient sizes. Use o short exposure times (associated with the use o high mA) is recommended to reduce the risk or patient motion. Co llim a tio n When possible, collimate to the involved region and reduce exposure to the thyroid gland and other radiosensitive structures. This ensures that the radiologist is aware o the location o the trauma or pathology as indicated by the patient. T: Each technologist should determine department protocol on this practice be ore using this method o identi ying the potential site o injury. Reassurance and additional care rom the technologist will enable the patient to eel secure and com ortable. I the examination is per ormed with the patient in the recumbent position, a radiolucent mattress or pad placed on the examination table will provide com ort. Exp o su re cto rs Fa Because o the high incidence o osteoporosis in older patients, the kV or mAs may require a decrease i manual exposure actors are used with analog imaging. Use o short exposure times (associated with the use o high mA) is recommended to reduce the risk or motion. I the patient cannot assume an erect position and the presence o air-f uid levels must be ruled out, an image obtained with a horizontal beam with the patient in a ecubitus position should be included. A clear explanation o the procedure is required to obtain maximal trust and cooperation rom the patient and guardian. Care ul immobilization is important to achieve proper positioning and to reduce patient motion. T secure their sa ety, ensure o that pediatric patients are continuously watched and cared or. Distraction techniques that use, or example, toys or stu ed animals are also e ective in maintaining patient cooperation. Use o an immobilization device to support the patient is recommended to reduce the need or the patient to be held, thus reducing radiation exposure. Landmarks such as the xiphoid process, sternal angle, and vertebra prominens (spinous process o C-7) may be di cult to palpate. The iliac crest or lower costal angle can be used as a landmark to indicate the lower margin o the ribs. Although the thorax region looks larger in the obese patient than in the sthenic patient, it is important to remember that the thoracic structures are o ten the same dimensions. Maintain the same degree o collimation or sternum and rib projections as with other body sizes. Because o thickness o the anatomy, it is important to use a grid (bucky) or all procedures to decrease scatter radiation reaching the image receptor. This is especially important when per orming mobile procedures or studies o the bony thorax. But kV should be set as high as appropriate while keeping the mAs low to minimize radiation dose to the patient. Correct centering and four-si e collimation (especially or sternum projections) (as low as reasonably achievable) principles in 2. Apply L determining exposure actors (may be desirable to increase kV and decrease mAs or reducing patient exposure. Post-processing evaluation o exposure indicator (or highest quality image with least amount o radiation to the patient). Based on the exposure indicator and department standards, this determines whether a reduction in mAs is possible or uture and repeat exposures. A radiopharmaceutical-tagged tracer element is injected, which will concentrate in areas o increased bone activity, demonstrating a hot spot on the nuclear medicine image. It is common practice or patients who are at risk or symptomatic or skeletal metastases to undergo a bone scan; patients with multiple myeloma are exceptions to this. Fractures o the bony thorax can be particularly dangerous because o the proximity o the lungs, heart, and great vessels.

Syndromes

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At the thoraco-lumbar junction blood glucose 79 purchase avapro 150 mg visa, there is some hypoplasia of the anterior parts of the vertebral bodies diabetes uk test strips generic avapro 150 mg visa. The metaphyseal margins of the proximal tibiae are slightly irregular but there is no fragmentation treatment juvenile diabetes order 300mg avapro with amex. The metaphyses of the distal ulna and radius are irregular and there are bone fragments within the growth plate diabetes symptoms and treatment avapro 150mg mastercard. Craniofacial abnormalities with midface hypoplasia signs of diabetic coma generic avapro 150mg, depressed nasal bridge diabetes type 1 who is at risk buy cheap avapro online, epicanthal folds, prominent forehead, short, broad anteverted nose, and mild prognathism. Infancy and early childhood: Reduced height, more pronounced in the dorsal than in the anterior parts; convex end plates anteriorly. Childhood and adolescence: Smooth concavity of the dorsal two-thirds and convex anterior third of the end plates. Longitudinal metaphyseal striations and slightly irregular metaphyseal margins in childhood, best seen in the distal femur and proximal tibia. In the original family described by Fanconi et al, the long-term evolution showed short stature and persistence of facial traits, but otherwise few complications. In other patients, limitation in elbow extension, scoliosis, progressive infantile coxa vara, and avascular necrosis of the hip have been reported, and hypogammaglobulinemia has been observed in some patients. However, it is difficult to be sure that these descriptions relate to a single entity. Osteopathia striata: the typical vertebral and craniofacial changes of sponastrime dysplasia are not seen in that disorder. Given that the radiographic signs are rather nonspecific, it seems possible that more genetic heterogeneity exists. Both siblings have a prominent forehead, short nose with depressed bridge, and anteverted nostrils. In both patients, the lumbar vertebral bodies are moderately flat and dorsally wedged. The upper and lower end plates are slightly convex in the anterior third and concave in the dorsal portions. The anterior aspect of the endplates is convex, while the posterior is slightly concave. The vertebral bodies have a similar appearance to that in C, with dorsally accentuated flattening and a wavy contour of the upper and lower end plates. The upper and lower end plates are dense and concave throughout their entire length. The capital femoral epiphyses are flattened with regular contours and bone structure, suggesting epiphyseal dysplasia rather than necrosis. The carpal bones are small and the shafts of the tubular bones are somewhat slender. Other recurrent malformations have been reported in a minority of patients: laryngomalacia, congenital heart defect, umbilical hernia, and cerebellar hypoplasia. The syndromes have important radiological overlap and are pathogenetically related. The lateral spine film of Patient 4 shows coronal clefts throughout, while in Patient 3 the vertebral bodies are somewhat immature but there are no coronal clefts. In contrast to the knees, the epiphyses of the hands have much more regular contours but are delayed in ossification. Muscular hypotonia in the newborn, seizures in the first months of life (not in all cases), motor and cognitive developmental delay of variable degree in infancy and later. In most cases, coarsening of facial traits with short and upturned nose and thick lips. Age of manifestation: A short limb type of skeletal dysplasia is often present at birth but can be overlooked until short stature becomes more apparent after the 1st year of life. Muscular hypotonia can be present at birth; seizures can occur in the first weeks of life; and developmental delay is usually recognized during the first months of life. Mild to moderate platyspondyly, particularly of posterior third of the vertebral body, with irregular, sometimes flaky vertebral end plates. Longitudinal striations at the metaphyses at the knee (no longer visible in adult patients). As a result, the sialylation of glycoproteins and glycolipids (gangliosides) may be affected. An accumulation of the enzyme substrate, N-Acetyl-mannosamine, has been found in urine and cerebrospinal fluid of affected individuals. Most patients are affected by intellectual disability of intermediate to severe degree, but the disorder does not seem to be progressive, and adult individuals seem to be relatively stable up to their late 40s (oldest observations so far). The skeletal component is obligate and a diagnostic aid but clinically less relevant than developmental delay and seizures in the child and intellectual disability in adults. Lysosomal storage diseases: Coarse facial features, thick lips, developmental delay, and skeletal dysplasia with short stature are reminiscent of lysosomal storage diseases. Milder cases may be diagnosed with isolated intellectual disability and thus difficult to diagnose outside of a large gene panel approach. Slightly coarsened bone structure, irregular acetabular roofs, short femoral necks, and small and fragmented proximal femoral epiphyses are seen. There is a slightly stocky femur with small and irregular proximal and distal epiphyses. The growth plates are almost closed; the epiphyses are small (particularly distal femur), and metaphyseal striations are still visible. There is advanced ossification of the carpal bones that also have irregular contours. The metaphyseal line at the distal radius is slightly irregular and some striations are seen; altogether, the hand radiogram is close to normal in this case. Synonyms: Skeletal dysplasia, immune deficiency, and developmental delay; neuro-immuno-skeletal dysplasia syndrome. Short stature with predominantly short limbs; short hands, sometimes with the "trident" appearance; in older children, thoracolumbar kyphosis. Combined cellular and humoral immune deficiency of variable degree; in severe cases, neonatal Omenn syndrome with skin changes. Involvement of the central nervous system of variable degree, ranging from infantile seizures with severe developmental delay to moderate developmental delay only. Age of manifestation: Severe cases are manifest at birth with short limbs and develop seizures and severe infections in the first weeks or months of life. Individuals with milder immunodeficiency may be ascertained during or after the first year of life with short stature and developmental delay. Pelvis: narrow sacroischiatic notch, trident acetabulum; later dysplastic acetabula, femoral necks in valgus with epiphyseal dysplasia. Hands: brachdactyly with short metacarpals and short phalanges (especially the middle row), delayed bone maturation. In most others, the condition has stabilized after the first year with moderate to severe skeletal dysplasia with developmental delay. Immunodeficiency had been reasonably well controlled with immunoglobulin infusions. Immuno-osseous dysplasia (Schimke) is in the differential diagnosis because of the combination of skeletal dysplasia and immune deficiency; the latter is usually less severe. Note severe platyspondyly with wide intervertebral spaces, thoracolumbar kyphosis (probably also from hypotonia) in A, B, and C; lumbar lordosis in D; narrow pedicles and narrow sacrosichiatic notches in E (Patient 6, who also had severe hypotonic kyphosis). The images in A and B are strongly reminiscent of achondroplasia, with narrow sacroischiatic notches, trident acetabula, and radiolucency of the proximal femurs. In C and D, the femoral necks elongate (in valgus position, possibly because of hypotonia and motor delay). All radiographs show delayed maturation of carpal and phalangeal ossification centers. Micromelia can be detected by sonography in utero as early as the first trimester. Small iliac bodies with irregular contours; absent ossification of the lower ilia, pubic, and ischial bones. Extremely short tubular bones with loss of longitudinal orientation and round, triangular, or stellate configuration. Impaired activity of the sulfate transporter in chondrocytes and fibroblasts results in the synthesis of undersulfated proteoglycans. The vertebral bodies are poorly ossified with better mineralization of the pedicles. The long bones lack a normal tubular shape and appear as ragged, stellate, or nondescript structures. Ossification of the vertebral bodies is delayed with separate anterior and posterior ossification centers. Poor ossification of the vertebral bodies, horizontally oriented short ribs, crescent-shaped ilia, and long bones lacking cylindrical shape are visualized. Micromelia, hitchhiker thumb, talipes equinovarus, gap between first and second toe. By sonography, the disorder has been detected at 15 weeks gestation on the basis of short limbs, small chest, protuberant abdomen, increased nuchal thickness, coronal cleft of vertebral bodies, hitchhiker thumbs. Short tubular bones with metaphyseal flaring; characteristic distal tapering, U- or V -shape of distal end of humerus. Short and distorted tubular bones of the hands and feet; globular appearance of metacarpal I and metatarsal I. Notably, the diaphyses of the humerus, radius, and femur are thinner with wavy contours; ulna and fibula are short, thick, and misshapen; and the hand bones are hypoplastic. This mutation when combined with the milder Finnish mutation in a compound heterozygous manner produces diastrophic dysplasia. Others may have survive for months, especially if they receive ventilator support. The humeri are short and also dumbbell-shaped; radii and ulnae are short and bowed. The proximal and distal ends of the humerus and the distal end of the radius are wide with convex borders. There is an irregular appearance of the short tubular bones with a small first metacarpal, half-moon shape of second metacarpal, proximal pointing of metacarpals 3 to 5, and a squared or triangular appearance of the phalanges. The short tubular bones of the foot are irregularly placed and shaped with a rounded, triangular, or teardrop appearance. Multiple joint contractures, most notably of the shoulders, elbows, interphalangeal joints, and hips. Cystic masses of the external ear, usually appearing between the first day and the 12th week of life (approximately 50 to 75% of cases); in that case, later cauliflower deformity of the pinnae. Progressive kyphoscoliosis in most cases, frequently developing only after infancy. Age of manifestation: Many cases are detected as club foot and short long bones on antenatal ultrasound. Short long bones, hitchhiker thumbs, ulnar deviation of hands, and talipes equinovarus have been detected as early as 12 weeks gestation. Flattening of the epiphyses; selective delay of appearance of the capital femoral epiphyses; underossification of the lateral portions of the distal femoral epiphyses. Irregular deformity and shortening of the metacarpals, metatarsals, and phalanges; delta-shaped phalanges; oval-shaped first metacarpal in young patients. Flat and broad epiphyses of the metacarpals may be the only sign in mildly affected patients. Delta-shaped deformity of the distal femoral and distal radial metaphyses in children. Often progressive thoraco-lumbar kyphoscoliosis; cervical kyphosis; irregular deformities of the vertebral bodies and moderate narrowing of the interpediculate distances of the lower lumbar segments. The degree to which sulfate transport is impaired explains the wide variability of phenotypic expression. After infancy and in the absence of severe complications from spinal deformities, life expectancy is normal. It may progress during infancy and early childhood and lead to medullary compression with neurological impairment including quadriplegia and death. Therapy-resistant talipes equinovarus, progressive thoracolumbar kyphoscoliosis, and progressing joint contractures reflect generalized mesenchymal involvement. Atypical hyponasality results from altered size and shape of the vocal tract and abnormal laryngotracheal cartilage. In typically affected patients, median adult height is 136 cm (range 114 to 158 cm) in males and 129 cm (range 98 to 143 cm) in females. Operative stabilization of the cervical spine is indicated when signs of spinal cord compression develop or the degree of cervical kyphosis progresses rapidly in early childhood. Contractures of the large joints tend to recur after surgical release, and a conservative approach is frequently recommended. There is experimental evidence from a mouse model that oral administration of N-acetyl-l-cysteine may prove useful as a specific therapy for diastrophic dysplasia and related non-lethal disorders. Autosomal recessive multiple epiphyseal dysplasia subsumes patients with mild manifestations of diastrophic dysplasia, sometimes limited to hips and hands. However, in diastrophic dysplasia, the epiphyseal ossification centers are characteristically flat and disk-like, and the adjacent metaphyses are broad. However, the presence of platyspondyly does not rule out a diagnosis of diastrophic dysplasia. Mutations of the sulfate transporter gene have been found in patients with apparently isolated club feet.

Collimated eld should demonstrate the entire hip joint and any orthopedic appliance in its entirety oral diabetes medications side effects 150mg avapro with amex. Gonadal shielding diabetes questions buy discount avapro online, if used diabetes diet high fiber order online avapro, must be carefully placed to not obscure any anatomy of the affected hip diabetes vs hyperglycemia purchase 300 mg avapro otc. Close collimation is important for reducing patient dose and improving image quality diabetes test online free order avapro 150 mg otc. Patient is supine diabetes remission purchase avapro 300mg online, with pillow provided for head; elevate pelvis 1 to 2 inches (3 to 5 cm) if possible by placing supports under pelvis (more important for thin patients and for patients on a soft pad or in a bed). Use cassette holder if available, or use sandbags to hold image receptor/ grid in place. This could result in signi cant displacement of fracture fragments (see lateral trauma projections). This results in signi cant foreshortening of the proximal femur region, which may be objectionable. As a starting critique exercise, place a check in each category that demonstrates a repeatable error for that radiograph (T able 7. This column is located in the midsagittal plane, orming the posterior or dorsal aspect o the bony trunk o the body. As adjacent vertebrae are stacked vertically, openings in each vertebra line up to create a tubelike, vertical spinal canal. Because all vertebrae are posterior or dorsal in the body, the term thoracic is more correct or describing this region than the older term, dorsal spine. These vertebrae are the strongest in the vertebral column because the load o body weight increases toward the in erior end o the column. For this reason, the cartilaginous disks between the in erior lumbar vertebrae are common sites o injury and pathology. Sa crum ccyx sacrum (sa-krum) and coccyx (kok-siks) a nd co the the spinal column, begins at the base o the skull and extends distally into the sacrum. There ore, to avoid striking the spinal cord, the most common site or a lumbar puncture into the spinal canal is at the level o L3-L4. A ter usion into a single sacrum and a single coccyx, the adult vertebral column is composed o an average o 26 se arate bones. These cushion-like disks are tightly bound to the vertebrae or spinal stability, but allow or f exibility and movement o the vertebral column. Detailed anatomy and positioning o the rst two sections, the cervical and thoracic vertebrae, are covered in this chapter. The last three sections, the lumbar vertebrae, sacrum, and coccyx, are covered in Chapter 9. Although slight variation may be noted in the height o each vertebra among individuals, the average person has seven cervical vertebrae. The terms concave (a rounded inward or depressed sur ace like a cave) and convex (a rounded outward or elevated sur ace) are used to describe these curves. However, the curves are described as opposite, depending on whether one is describing them rom an anterior perspective or a posterior perspective. For the purposes o this text, the curves are described as i the patient is being evaluated rom the posterior perspective. The cervical and lumbar regions have concave curvatures and are described as lordot c. As children begin to raise their heads and sit up, the rst com ensatory concave curve orms in the cervical region. The second compensatory concave curve, the lumbar curvature, develops when children learn to walk. Both o the in erior curves, lumbar and sacral (pelvic), are usually more pronounced in women than in men. These primary and compensatory curvatures are normal and serve an important unction by increasing the strength o the vertebral column and helping maintain balance along a center line o gravity in the upright position. Certain terms are commonly used to describe these curvatures when they become exaggerated or abnormal. This curvature usually is associated with the dominant extremity, so this curvature may be convex to the right in a right-handed person and convex to the le t in a le t-handed person. Its superior and in erior sur aces are f at and rough or attachment o the intervertebral disks. The posterior sur ace o the body and arch orm a circular opening, the vertebral oram en, which contains the spinal cord. The posterior part o the vertebral arch is ormed by two somewhat f at layers o bone called lam nae (lam-i-ne). Extending laterally rom approximately the junction o each pedicle and lamina is a projection termed the transverse process. The spinous processes, the most posterior extensions o the vertebrae, o ten can be palpated along the posterior sur ace o the neck and back. Extending posteriorly, directly rom the vertebral body on each side, are the ed cles, which terminate in the area o the transverse rocess. Continuing posteriorly rom the origin o the transverse process on each side are the two lam nae, which end at the spinous process. These processes allow or certain important joints that are unique and that must be visualized radiographically or each section o the vertebral column, as described on the ollowing pages. Each typical vertebra also has our art cular rocesses, two superior and two in erior, which comprise the important joints o the vertebral column. The vertebral column would be rigidly immovable without the intervertebral disks and the zygapophyseal joints. Respiration could not occur without the spine, which serves as a pivot point or arclike movement o the ribs. In the rve rte b ra l in ts Jo the intervertebral joints are amphiarthrodial joints that are ound between the vertebral bodies. The ntervertebral d sks located in these joints are tightly bound to adjacent vertebral bodies or spinal stability, but they also allow or f exibility and movement o the vertebral column. The term facet (fas-et) sometimes is used interchangeably with the term zygapophyseal joint, but the acet is actually only the articulating sur ace instead o the entire superior or in erior articular process. Co sta l in ts Jo Although not directly involved in the stability o the spinal column itsel, a third type o joint is located along a portion o the vertebral column. In the thoracic region, the 12 ribs articulate with the transverse processes and vertebral bodies. These articulations o the ribs to the thoracic vertebrae, re erred to as costal jo nts, are illustrated on later drawings o the thoracic vertebrae. There ore, between every two vertebrae are two intervertebral oramina, one on eac s de, through which important spinal nerves and blood vessels pass. The zygapophyseal joints and intervertebral oramina must be demonstrated radiographically by the appropriate projection in each o the three major portions o the vertebral column, as described and illustrated in later sections. Typical adult vertebrae are separated by tough brocartilaginous disks between the bodies o every two vertebrae, except between the rst and second cervical vertebrae. When this so t inner part protrudes through the outer brous layer, it presses on the spinal cord and causes severe pain and numbness that radiates into the lower limbs. This condition, also known as a slipped disk, is termed the herniated nucleus pulposus (h p) (see Clinical Indications, pp. Each cervical vertebra and vertebral body continues to get larger, progressing down to the seventh cervical vertebra. The last, or seventh, cervical vertebra, the vertebra rom nens, has many eatures o thoracic vertebrae, including an extra long and more horizontal spinous process that can be palpated at the base o the neck. The transverse processes are small and arise rom both the pedicle and the body, rather than rom the pedicle-lamina junction. The vertebral artery and veins and certain nerves pass through these successive transverse oramina. There ore, one unique characteristic o all cervical vertebrae is that each has t ree oram na that run vertically, the right and le t transverse oramina and the single large vertebral oramen. Located behind the transverse process at the junction o the pedicle and lamina are the cervical articular processes. Between the superior and in erior articular processes is a short column (pillar) o bone that is more supportive than the similar area in the rest o the spinal column. This column o bone is called the art cular llar, sometimes called the lateral m ass, when one is re erring to C1. C T S (C1) the rst cervical vertebra, the atlas, a name derived rom the Greek god who bore the world on his shoulders, least resembles a typical vertebra. Anteriorly, there is no body but simply a thick arch o bone called the anter or arc, which includes a small anter or tubercle. Each o the le t and right C1 su er or art cular rocesses presents a large depressed sur ace called a su er or acet or articulation with the respective le t and right occipital condyles o the skull. These articulations, between C1 and the occipital condyles o the skull, are called atlantoocc tal jo nts. The transverse rocesses o C1 are smaller but still contain the transverse oram na distinctive o all cervical vertebrae. The art cular llars, the segments o bone between the superior and in erior articular processes, are called lateral m asses or C1. Because the lateral masses o C1 support the weight o the head and assist in rotation o the head, these portions are the most bulky and solid parts o C1. Embryologically, the odontoid process is actually the body o C1, but it uses to C2 during development. Rotation o the head primarily occurs between C1 and C2, with the odontoid process acting as a pivot. The superior acets o the superior articular processes that articulate with the skull also assist in rotation o the head. Any racture o the vertebral column at this level could result in serious damage to the spinal cord as well. Below and lateral to the superior articular process is the transverse process, with its transverse oram en. The anterior arch o C1, which lies in ront o the dens, is not clearly visible on this image because it is a airly thin piece o bone compared with the larger denser dens. The upper our thoracic vertebrae are smaller and share eatures o the cervical vertebrae. The lower our thoracic vertebrae are larger and share characteristics o the lumbar vertebrae. Co stove rte b ra l Jo in ts Each thoracic vertebra has a 8 ull acet (fas-et) or two art al acets, called dem acets (dem-e-fas-ets), on each side o the body. For example, the head o the ourth rib straddles or articulates with demi acets on the vertebral bodies o both T3 and T4. The superior portion o the rib head articulates with the demi acet on the in erior margin o T3, and the in erior portion o the rib head articulates with the demi acet on the superior margin o T4. Fa ce t for 10th cos totra ns ve rs e joint 10 11 Fa ce ts for 10th to 12th cos tove rte bra l joints Co sto tra n sve rse Jo in ts In addition to costovertebral joints, all o the f rst 10 t orac c vertebrae also have acets (one on each transverse process) that articulate with the tubercles o ribs 1 through 10. Thus, as the rst 10 pairs o ribs arch posteriorly rom the upper 10 vertebral bodies, the tubercle o each rib articulates with one transverse process to orm a costotransverse joint. Both gures clearly show the le t and right thoracic intervertebral oramina superimposed on each other. This articulation is located between the odontoid process o C2 and the anterior arch o C1 and is held in place by the transverse atlantal ligament, allowing a pivotal rotational movement between these two vertebrae.

Le adShie lding Shielding is important or examinations o the upper limb because o the proximity o the gonads to the divergent x-ray beam and scatter radiation diabetes mellitus y obesidad effective avapro 150 mg, a risk or patients seated at the end o the table and or trauma patients taken on a stretcher diabetic diet and exercise order avapro american express. Although the gonadal rule states that shielding should be provided to patients o reproductive age when the gonads lie within or close to the primary f eld diabete 2 symptoms purchase avapro with paypal, a good practice is to provide shielding or all patients nice diabetes type 1 quick reference buy cheap avapro 150 mg online. Image Re ce pto rs With conventional analog (f lm-screen) imaging newcastle university diabetes diet avapro 300mg with visa, image receptors with detail-intensi ying screens generally are used or adult extremities to achieve optimal recorded detail diabetes prevention 7 day meal plan order avapro amex. From the bucky tray to the tabletop, this di erence is generally 3 to 4 inches (8 to 10 cm) or oating-type tabletops. Multiple Expo s ure s pe rImagingPlate Placing multiple images on the same digital imaging plate o ten results in poor processing o one or more images. Most experts recommend that one exposure be placed centered to the imaging plate or computed radiography and digital radiography imaging systems. With analog (lm - ased) radiography, multiple images can be placed on the same imaging plate. When doing so, care ul collimation and lead masking must be used to prevent pre-exposure or ogging o other images. Immobilization is needed in many cases to assist children in maintaining the proper position. Sponges and tape are use ul; however, sandbags should be used with caution because o their weight. Parents requently are asked to assist with radiographic examination o their children. I parents are permitted in the radiography room during the exposure, proper shielding must be provided. Also important is or the technologist to speak to the child in a soothing manner in language the child can readily understand to ensure maximal cooperation. A general positioning rule that is especially applicable to the upper limbs is always to lace the long axis of the art eing im aged arallel to the long axis of the ortion of the eing ex osed. Patient identif cation in ormation and side markers within the collimation borders must be demonstrated on each image. The patient identif cation blocker on the analog image receptor should always be placed in the corner least likely to su erim ose essential anatom y. Grid use with digital system s (com uted radiogra hy/ digital radiogra hy): As already mentioned, grids generally are not used with f lm-screen imaging or body parts measuring 10 cm or less. In such cases, because it may be impractical and di f cult to remove the grid, it may be le t in place even or smaller body parts, such as or upper and lower limb examinations. It must be checked or an acceptable exposure indicator to veri y that the exposure actors used were in the correct range to ensure an optimal quality image with the least possible radiation dose to the patient. This principle includes using the highest possible kV and the lowest mAs consistent with desirable image quality as viewed on a radiologist-type interpretation monitor. Insu f cient mAs results in a noisy (grainy) image on an interpretation monitor, even though it may appear satis actory on a workstation monitor. Optimal kV will provide the proper penetration to demonstrate the bony cortex and bony trabecular markings. The ollowing three positioning principles should be remembered or upper limb examinations: 1. DigitalImagingCo ns ide ratio ns Specif c guidelines should be ollowed when upper limb images are acquired through digital imaging technology (computed radiography or digital radiography). Nuclear medicine scans demonstrate the pathologic process within 24 hours o onset. Nuclear medicine is more sensitive than radiography because it assesses the hysiologic as ect instead o the anatomic aspect. This is the most common type o arthritis and is considered a normal part o the aging process. Osteom yelitis (os-te-o-my-e-ly-tis) is a local or generalized infection of one or one m arrow that may be caused by bacteria introduced by trauma or surgery. However, it is more commonly the result o an in ection rom a contiguous source, such as a diabetic oot ulcer. Osteo etrosis (os-te-o-pe-tro-sis) is a hereditary disease marked by a norm ally dense one. Osteo orosis (os-te-o-po-ro-sis) re ers to reduction in the quantity of one or atro hy o skeletal tissue. It occurs in postmenopausal women and elderly men, resulting in bone trabeculae that are scanty and thin. Most ractures sustained by women older than 50 years are secondary to osteoporosis. Paget disease can occur in any bone but most commonly a ects the pelvis, emur, tibia, skull, vertebrae, and clavicle. The sprain or tear may result rom an injury such as alling on an outstretched arm and hand, which causes the thumb to be bent back toward the arm. ClinicalIndicatio ns Clinical indications that all technologists should be most amiliar with in relation to the upper limb include the ollowing (not an inclusive list). All malignant tumors have the ability to metastasize, or trans er malignant cells rom one body part to another, through the bloodstream or lymphatic vessels or by direct extension. Car al (kar-pul) tunnel syndrome is a common pain ul disorder o the wrist and hand that results rom compression o the median nerve as it passes through the center o the wrist; it is most commonly ound in middle-aged women. Fracture (frak-chur) is a break in the structure o bone caused by a orce (direct or indirect). It is a sign o an underlying condition, such as racture, dislocation, so t tissue damage, or in ammation. As the name implies, these tumors occur in various parts o the body, arising rom bone marrow or marrow plasma cells. The typical radiographic appearance includes multiple "punched-out" osteolytic (loss o calcium in bone) lesions scattered throughout the a ected bones. Stratif ed new bone ormation results in an "onion peel" appearance on radiographs. Generally, enchondromas are well-def ned, radiolucent-appearing tumors with a thin cortex that o ten lead to pathologic racture with only minimal trauma. Osteochondromas arise rom the outer cortex with the tumor growing parallel to the bone, pointing away rom the adjacent joint. These are most common at the knee but also occur on the pelvis and scapula o children or young adults. This block prevents oreshortening o phalanges and obscuring o interphalangeal joints. This wrist projection is good or visualizing the carpals i the patient can assume this position easily. Bridgman 11 recommended ulnar deviation in addition to hand elevation or less scaphoid superimposition. These are e ective projections when patient cannot extend elbow ully or medial or lateral oblique projections o the elbow. Near-complete rotation o radial head occurs in these our projections, as ollows: 1. These, along with accompanying lecture slides o radiographs, provide a basis or classroom or positioning laboratory discussion. Critique these radiographs or errors in one or more o the f ve categories, as described in this textbook and as outlined on the right. Cla vicle S ca pula Hume rus H the hum erus is the largest and longest bone o the upper limb. The anatomy o the distal humerus and o the elbow joint was described in Chapter 4. The slightly constricted area directly below and lateral to the head is the anat m ic neck, which appears as a line o demarcation between the rounded head and the adjoining greater and lesser tubercles. The process directly below the anatomic neck on the anterior sur ace is the lesser tubercle (tu-ber-kl). The larger lateral process is the greater tubercle, to which the pectoralis major and supraspinatus muscles attach. The deep groove between these two tubercles is the intertubercular (in-ter-tu-ber-ku-lar) sulcus (bicipital groove). The tapered area below the head and tubercles is the surgical neck, and distal to the surgical neck is the long b dy (sha t) o the humerus. The surgical neck is so named because it is the site o requent ractures requiring surgery. The delt id tuber sity is the roughened raised triangular elevation along the anterolateral sur ace o the body (sha t) to which the deltoid muscle is attached. Some anatomic parts are more di f cult to visualize on radiographs than on drawings. However, a good understanding o the location and relationship between various parts helps in this identif cation. The unction o the clavicle and scapula is to connect each upper limb to the trunk or axial skeleton. Anteriorly, the shoulder girdle connects to the trunk at the upper sternum; however, posteriorly, the connection to the trunk is incomplete because the scapula is connected to the trunk by muscles only. Each shoulder girdle and each upper limb connect at the shoulder joint between the scapula and the humerus. The upper margin o the scapula is at the level o the sec nd p steri r rib, and the lower margin is at the level o the seventh p steri r rib (T7). Cla vicle the clavicle (collarbone) is a long bone with a double curvature that has three main parts: two ends and a long central portion. The lateral or acr m ial (ah-kro-me-al) extrem ity (end) o the clavicle articulates with the acromion o the scapula. The medial or sternal extrem ity (end) articulates with the manubrium, which is the upper part o the sternum. This joint also is easily palpated, and the combination o the sternoclavicular joints on either side o the manubrium helps to orm an important positioning landmark called the jugular (jug-u-lar) n tch. The b dy (sha t) o the clavicle is the elongated portion between the two extremities. The acromial end o the clavicle is attened and has a downward curvature at its attachment with the acromion. The sternal end is more triangular in shape, broader, and is directed downward to articulate with the sternum. The male clavicle tends to be thicker and more curved, usually being most curved in heavily muscled men. The lateral angle, sometimes called the head of the scapula, is the thickest part and ends laterally in a shallow depression called the glenoid cavity (ossa). The humeral head articulates with the glenoid cavity o the scapula to orm the scapul hum eral (skap-u-lo-hu-mer-al) j int, also known as the glenohumeral joint, or shoulder joint. The superi r and inferi r angles re er to the upper and lower ends o the medial or vertebral border. The thin, at, lower part o the body sometimes is re erred to as the wing or ala o the scapula, although these are not pre erred anatomic terms. The anterior sur ace o the scapula is termed the c stal (kostal) surface because o its proximity to the ribs (costa, literally meaning "rib"). The middle area o the costal sur ace presents a large concavity or depression, known as the subscapular f ssa. The c rac id pr cess is a thick, beaklike process that projects anteriorly beneath the clavicle. The suprascapular n tch is a notch on the superior border that is partially ormed by the base o the coracoid process. The posterior border or ridge o the spine is thickened and is termed the crest o the spine.

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