Penalty Corner: The importance of looking at the edges of

radiographs

Poster No.: C-1884

Congress: ECR 2012
Type: Educational Exhibit
Authors: 1 2 1 2
I. Kopecka , N. Ramesh ; Bratislava/SK, PORTLAOISE/IE
Keywords: Trauma, Calcifications / Calculi, Artifacts, Education, Plain
radiographic studies
DOI: 10.1594/ecr2012/C-1884

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to third-
party sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org

Page 1 of 24
Learning objectives

To show the importance of viewing the "corners"on radiographs.

To evaluate common locations of easily missed abnormalities on plain films.

To establish an effective search pattern to improve detection of pathology in blind spots

of X-rays.

To avoid missing clinically significant findings by becoming familiar with penalty corners
and strategies to evaluate difficult areas on radiographs.

To increase one's confidence in interpretation of plain films.

Images for this section:

Page 2 of 24
Fig. 1: Old fracture of right clavicle and AVN on left humeral head

Page 3 of 24
Fig. 2: Right inguinal hernia

Page 4 of 24
Fig. 3: Distal fibula fracture on foot radiograph

Page 5 of 24
Background

Despite continuous increase usage of more sophisticated imaging modalities, such as

CT (computed tomography) and MRI (magnetic resonance imaging), plain films still
remain the most commonly requested investigations in Radiology departments, and they
are initial imaging modality for many clinical presentations. As medical students, junior
doctors and Radiology residents we have been taught the importance of looking at the
corners of radiographs, mainly of the chest and abdominal films. They play an important
role of film viewing during the final Radiology examination, too. In these days of a hectic
daily schedule and workload we tend to rush through reporting films, overlooking there
so called review areas (lateral ends of clavicles, proximal humerus, above and below
diaphragm, etc. on chest films; above and below diaphragm, the lower ribs, pelvis and
hips on abdominal films, etc.). This is especially true with the accident and emergency,
GP and out-patient referrals. The obvious lesions are difficult to miss during reporting,
but there are numerous tricky hidden areas where subtle finding can hide from the best
trained eye, but the findings are still clinically significant.

Images for this section:

Page 6 of 24
Fig. 4: Fracture of ossified anterior longitudinal ligament

Page 7 of 24
Fig. 5: Spleen calcifications

Page 8 of 24
Fig. 6: Old humeral head fracture

Page 9 of 24
Imaging findings OR Procedure details

Toolbox of tricks and tips:

1. Do not depend on clinical information too much, it is often inadequate.

2. Obvious lesions are obvious to everyone. Scrutinaze the areas that
clinicians are less likely to observe.
3. Look at the corners / edges of films first.
4. Compare with previous X-rays if possible.
5. Review the risk areas on CXR (upper lung zones, lateral ends of clavicles,
acromio-clavicular joints, proximal humerus, gleno-humeral joint, lower
cervical spine / neck, lateral ends of ribs, below hemi-diaphragms, retro-
cardiac region, soft tissues).

Review of different pathologic conditions that can be detected and easily missed in the
review areas on radiographs.

Images for this section:

Page 10 of 24
Fig. 7: Fractured spinous process of C7

Page 11 of 24
Fig. 8: Pancoast tumor seen on AP view of C spine

Page 12 of 24
Fig. 9: 3rd metacarpal fracture derives attention from scaphoid fracture

Page 13 of 24
Fig. 10: Cervical rib in right apex in the shadow of thick apical cap

Page 14 of 24
Fig. 11: Partially resected left 7th and 8th ribs due to prostatic metastases

Page 15 of 24
Fig. 12: Easily missed pneumoperitoneum under right hemidiaphragm by focusing on
old avulsion of anterior inferior iliac spine (origin of rectus femoris muscle)

Page 16 of 24
Conclusion

Blind spots on radiographs deserve our special attention. On one hand they are not of that
significant importance in our lives in case to pass the final exams, but their importance
is not to miss a clinically significant pathology of a patient that can be easily overlooked.
We should be prepared to expect the unexpected findings in hidden areas of plain films
where others tend not to look.

Images for this section:

Page 17 of 24
Fig. 13: Rigler's triad in gallstone ileus - small bowel obstruction, pneumobilia, gallstone
in RLQ

Page 18 of 24
Page 19 of 24
Page 20 of 24
Fig. 14: 5th metatarsal fracture

Page 21 of 24
Page 22 of 24
Fig. 15: Talocalcaneal coalition is easily missed due to a large soft tissue mass in forefoot

Page 23 of 24
Personal Information

Ivana Kopecka, Nemocnica sv. Michala, a.s., Bratislava, Slovakia

References

Humphrey KL, Wu CC, Gilman MD, El-Sherief AH, Shepard JAO,

Abbott GF: Where Are They All Hiding? Common Blind Spots on Chest
Radiography. Contemporary Diagnostic Radiology 34:1-5, 2011.
De Lacey G, Morley S, Berman L: The Chest X-ray: A Survival Guide. 1 ed.
st

Philadelphia, PA: WB Saunders, 2008.

st
Corne J, Pointon K: 100 Chest X-ray Problems. 1 ed. Edinburgh: Churchill
Livingstone, 2007.
Raby N, Berman L, De Lacey G: Accident & Emergency Radiology: A
nd
Survival Guide. 2 ed. Philadelphia, PA: WB Saunders, 2005.

Page 24 of 24