Deep Sulcus Sign

Signs and Lines for  Visible for EXTREME pneumothorax

o Costophrenic angle extends beyond T
Diagnostic Radiology diaphragm

 NOT ALWAYS PRESENT

Chest
Continuous Diaphragm Sign
Silhouette Sign  Visible for EXTREME pneumomediastinum
 Structures become isodense due to pathology o Air trapped behind the heart
DO NOT mistake for:  Causes heart and T diaphragm
to blur into one structure
 Pericardial fat pads
o Near apex of heart  NOT ALWAYS PRESENT

 Pectus excurvatum
Meniscus Sign
o Pushes heart more L-ward than usual
 Concave line obscuring costophrenic angle
o May obscure part/all of T
Air Bronchogram Sign hemidiaphragm
 Visualisation of peripheral intrapulmonary
bronchi  Visible for erect patients with haemothorax
o Near lateral edges of lungs
o Normally radiolucent
Fissure Lines
 Caused by alveolar infiltration
 R lung = horizontal and oblique
o Horizontal @ R hilum level
 Occurs in consolidation
 Seen on PA/AP
 NOT in atelectasis/collapse  VERY fine line

Tracheal Shift o Oblique = anterior and inferior corner

 Trachea should be midsagittal with a slight R- of lung up to aortic knuckle level
ward curve near the aortic knuckle  Seen on Lateral
o Normally radiolucent  VERY fine line

 Sensitive indicator for  L lung = oblique only

o Tension pneumothorax
o Pleural effusion  Movement of fissures = atelectasis/collapse
 NOT in consolidation
Hilar Levels
 L side normally higher than R side Luftsichel Sign
o Determine the middle of the “bulk” of  German for “air sickle”
vessels
 Equal levels indicate pathology  Radiolucent sickle appearing superior and
medial on PA/AP
Bronchi Sign o Collapsed L upper lobe causes
 Distinct straight horizontal lines ABNORMAL opacification
o Exception: horizontal fissure o Superior aspect of hyperinflated L
lower lobe superimposed by collapsed
 R bronchus is straighter than L bronchus L upper lobe
o More likely to find FBs in R bronchus  Indication of L upper lobe collapse

~1~
Cardiac Contours Kerley Signs
 Horizontal lines in periphery of inferior
posterior lung fields
o Widening of interlobular septa

 Indication of
o Heart failure
 Pulmonary oedema
o Tumours
o Pneumonia

Kerley A
 2-6 cm long oblique lines
 <1 mm thick
 Moving towards the hila

Kerley B
 Thin lines 1-2 cm in length
 In the periphery of the lung(s)
o Perpendicular to the pleural surface
Figure 1: PA Chest (not flipped or dextrocardia) o Extend into it
All noted contours are travelling superior-inferior. Kerley C
Right Left  short lines which do not reach the pleura
Brachiocephalic trunk Aortic knuckle o i.e. not B or D lines
Sup. Vena Cava L Hilum  do not course radially away from the hila
R Hilum L Atrial appendage o i.e. not A lines
R Atrium L Ventricle
Kerley D
Missing or abnormal contours indicate possible lung  Kerley B lines on lateral CXR
lobe pathology. o In retrosternal air gap

Missing or Abnormal Lung Lobe Involvement

R hemidiaphragm
R lower lobe
R cardiophrenic angle
R hilum
R middle lobe
R heart border
Brachiocephalic trunk
R upper lobe
Sup. Vena Cava
Aortic knuckle
L upper lobe
L hilum
L atrial appendage
L lower lobe
L cardiophrenic angle

~2~
Abdomen Rigler’s Sign
 Double wall appearance
o Air on both sides of intestinal wall
Fluid Levels o Can see thickness of bowel wall
 On Erect PA
 Normal = 6 or 7 levels  DO NOT confuse with two loops beside each
o Includes stomach other

 More = bowel obstruction  Nonspecific indication – look for other signs

String of Pearls Sign  Indication of pneumoperitoneum

 On Erect PA
 Nonspecific indication of bowel obstruction
 NOT ALWAYS PRESENT
 Gas bubbles visualised in bowel lumen
o Looks like a pearl necklace
o Indicates excessive fluid
Lucent Liver and Falciform Ligament Signs
 Liver is radiolucent compared to normal
 Falciform ligament visible
o Radiopaque line through the middle
of the liver
o Not normally visible

Coffee Bean Sign  Indication of pneumoperitoneum

 Gaseous oval with radiopaque outline
o Coffee bean shape
 Vaguely points superiorly
o R upper quadrant
o Midline
 Indication of sigmoid volvulus
Sentinel Loop Sign
 Inflammation of the bowel affected by an
inflamed organs
 Distention of bowel in one or two segments
o Pinched off from normal bowel loops
 Indication of localised ileus (lazy bowel)
Lucent Triangle Sign
 Nothing is triangular in abdomen
 Little lucent triangles between abdominal wall
and bowel haustra/plicae circulares
o Check peripheries
 Indication of pneumoperitoneum
Football Sign
 Whole abdomen filled with air
o Radiolucent ROI
 Nonspecific – not very useful
 Indication of pneumoperitoneum

Thumb-printing Sign
Crescent Sign  Thumb-print disruptions to normal gas
 On Erect PA pattern in bowels
 Lucent crescent under R thoracic
hemidiaphragm  Indication of inflammatory bowel disease
o NO bowel patterns o ? Chron’s Disease

 With bowel patterns = Chilaiditi variant

o NORMAL variant Lead Pipe Colon
 Smoothing of small colon gas pattern
 Indication of pneumoperitoneum  Indication of inflammatory bowel disease
o ? Ulcerative colitis

~3~
Spine White Ring of Harris
 Located at the base of the odontoid peg
o White ring caused by superimposition
Anterior Vertebral Line of the C2 laminae
 Normal spine alignment line
o All spine Laterals  Normal variant = superior and inferior breaks
 Pathology = posterior and anterior breaks
 Should be smooth and lordotic

Left Paraspinal Line

Posterior Vertebral Line  T Spine only
 Normal spine alignment line o AP
o All spine Laterals
 Thin radiopaque line running parallel to the
 Geriatrics will have osteophyte growth on lateral aspect of the vertebral column
posterior aspect of cervical vertebral bodies o Can be seen
o Must IGNORE
 In trauma, it can bulge out
 Should be smooth and lordotic o Lateral bulging
o R-ward bulging = abnormal variant
Spinolaminar Line
 Normal C-spine alignment line  DO NOT mistake for Descending Thoracic
o Along the dorsal aspect of the spinal Aorta
column
Interpedicular Distances
 C2 typically out of line  Seen on T spine AP
o Normal appearance o Increases as you descend

Intervertebral Disc Spaces  Trauma will cause abnormal widening

 Should be uniform in size from C2 to C7
o Seen more clearly on C Spine Lateral
Lateral Vertebral Lines
 Checks for lateral displacement of bones
 Trauma will cause widening  Should be smooth and vertical
 Degeneration OR trauma will cause
narrowing
 Trauma = displacement

Interspinous Processes Alignment

 On ALL spine APs
o Midsagittal
o Consistent

 Trauma = displacement

Interspinous Distances
 On AP C-spine
o Increases slightly while descending

 Trauma will cause abnormal widening

~4~
Upper Limb Zone of Vulnerability
 Shown on PA Wrist
o Should be UNDISRUPTED
Gilula Carpal Arcs
 Shown on PA Wrist  Observing the bones on this path will allow
you to systematically check for pathology
 Three arcs o radial styloid
o Should be UNDISRUPTED o scaphoid
o capitate
1. smooth curve tracing proximal curves of o triquetrum
a. scaphoid o ulnar styloid
b. lunate
c. triquetrum
Radio-luno-capitate Line
2. smooth curve tracing distal surfaces of  Shown on Wrist Lateral
a. scaphoid o Disruption = unstable wrist
b. lunate
c. triquetrum  Normal = aligned in a straight line
o Radial shaft
3. smooth curve following proximal surfaces of o Lunate
a. capitate o Capitate
b. hamate
Volar Tilt of the Radius
 Shown on Wrist Lateral
o Variation = unstable wrist

 Imaginary line drawn from radial styloid to

superior aspect of anterior surface

 Normal ≈ 13° tilt towards palm

Dorsal Carpal Line

 Seen on Wrist Lateral
o Colloquially identified as
“smooth as a baby’s bum”
o Bumpy bum = no good (pathology)

 No sharp protrusions along dorsum of

o Carpus
o Metacarpals
o Distal radius/ulna

Radiocapitellar Line
 Seen on Elbow AP and Lateral
Figure 2: Normal Gulila arcs on PA L wrist o Disruption = dislocation/subluxation

 Capitulum should be aligned with the radial

shaft intersecting straight through the centre

 Very reliable

~5~
Anterior Humeral Line This column was intentionally left blank…
 Seen on Elbow Lateral
o MUST have PERFECT positioning
o Can mimic supracondylar #
 Travels down the anterior surface of the
humerus
 Normal = smooth

Positive Fat Pad Sign

 Seen on Elbow Lateral
o Not always accurate

 Anterior fat pad visible

o Elevated = 60-70% chance of #
o Can be normal if not elevated

 Posterior fat pad visible = 93% chance of #

o Sensitive sign of trauma

Scapula-humeral Line
 Seen in AP Shoulder Girdle
o Similar to Shenton’s Line

 Follows inferior border of scapula

o Up to inferior aspect of GH joint
o Follows down medial humerus

 Should be continuous and smooth

o Ensures glenohumeral joint is intact

 Disruption = pathology

Acromioclavicular Line
 Seen on AP Shoulder Girdle

 Inferior aspect of distal clavicle should be

aligned to inferior aspect of acromion

 Disruption = ruptured ligament

…and so was this textbox.

~6~
Lower Limb Shenton’s Line
 Seen on AP Pelvis/Hip
o Should be smooth and continuous
Boehler's Angle
 Seen on Foot/Ankle/Calcaneum Lateral  Imaginary line
o Inferior border of superior pubic
 Draw an imaginary line along the talar surface ramus
of the calcaneum o Inferomedial border of NOF
o Medial aspect of femur
 Draw another imaginary line along the
superior-posterior aspect of the calcaneum
Obturator Foramina
 Seen on AP Pelvis
 Angle between the two lines should be
o Should be continuous and smooth
between 28-48°

 Indication of axial loading/compression # Ilio-ischial Line

 Seen on AP Pelvis
o Should be smooth and continuous
Kager’s Fat Pad
 Seen on Lateral Ankle
 Imaginary line
o Inferior aspect of SI joint
 Normal = shown on PERFECT lateral
o Internal pelvic rim
o Crosses over superior aspect of
 Triangular lucency
acetabulum
o Between Achilles’ tendon, superior
o Inferior border of obturator foramen
aspect of calcaneum, and flexor
hallucis longus tendon
Ilio-pectineal Line
 Pathology = disrupted  Seen on AP Pelvis
o Not the best indication o Should be smooth and continuous

 Anterior fat pat more sensitive  Imaginary line

o Present = pathology
Decubitus Lateral Fat-Fluid Levels
 Visible on Decubitus Lateral Knee
o Known as lipohaemarthosis
o Knee must be as flat as safely
possible
o Inferior aspect of SI joint
o Follow along internal anterior arch
o Superior aspect of Pubis symphysis
Femoral Angle
 Visible on AP Pelvis/Hip
o Should be smooth and continuous

 Anterior lucency (superior and.or inferior)
with horizontal radiopaque line
o Deeper soft tissue = radiopaque
 Indication of fracture with marrow exposure
 Imaginary line through centre of femoral shaft
 Imaginary line through centre of femoral neck
 Measure medial angle
o Normal = 115-140°

~7~
Skull

McGrigor-Campbell Lines
 Seen on Waters (Occipitomental) projection
o Disruption = pathology

 Lines 2 and 3 seen on Extended Waters

Line Description

1 From L to R zygomatic sutures, along

superior orbital margin and across glabella

2 From L to R zygomatic arches, along superior

aspect of zygomatic bone, along inferior
orbital margin, up along lateral orbital wall,
and touches top of nasal septum

3 From L to R mandibular condyles, cutting

across "mandibular notch" and coronoid
process, under inferior border of maxillary
sinus, and then travels along maxillary teeth

4 Follows the curve of the mandibular gums

5 Traces the lower border of the mandible

Elephant's Trunk Sign

 Seen on Waters or Extended Waters
o OM or OM 30°
o Disruption = zygomatic arch #

 Zygomatic arches should resemble elephant's

trunk when NORMAL

Teardrop Sign (Orbits)

 Seen most clearly on Waters

 Soft tissue herniation causes opacification under

orbital # site
o Indication of blowout #

~8~