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TEX TB OOK
OF
Veterinary
Diagnostic
Radiology
TEXTBOOK
OF
Veterinary
Diagnostic
Radiology
FOU R THE D ITIO N
SAUNDERS
An Imlirint of Elsevier
SAUNDERS
An Imprint of Elsevier
The Curtis Center
Independence Square West souL-ftA[r
Philadelphia, Pennsylvania 19106
i
't, ^;
f li
i I r,0t- I
I'
2-5Lru 6*
Library of Congress Cataloging-in'PublicationData
p. ; cm.
referencesand index.
Includesbibliographical
1. Veterinaryradiography. l. Thrall,DonaldE.
IDNLM: 1. Radiography-veterinary. SF 757.8T355 20021
5F757.8.1482OO2 636.089'0757-dc21
DNLM/DLC 2001042608
Al1 rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
photoiopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.
Graeme Allan, BVSc, MYSc, Diplomate ACVR, FACVSc Daniel A. Feeney,DVM, MS, Diplomate ACVR
-\djunct Professor,
Facultyof VeterinaryScience,
Universityof Professorof Radiology,Collegeof VeterinaryMedicine,University
Svdney,Sydney;ConsultantVeterinaryRadiologist,Veterinary of Minnesota,St.Paul,Minnesota
ImagingAssociates, Newtown,Australia The Kidneysand Ureters;The Uterus, Ovaries,and
RadiographicSigns of Joint Disease Testes
Robert J. Bahr, DVM, Diplomate ACVR Lisa J. Forrest, VMD, Diplomate ACVR
Associate
Professorof Veterinary
Radiology;
SectionChief, ClinicalAssociateProfessor,
Universityof Wisconsin-Madison,
Radiology,BorenVeterinaryMedicalTeachingHospital,Collegeof Schoolof VeterinaryMedicine,Madison,Wisconsin
VeterinaryMedicine,OklahomaStateUniversity,Stillwater, The Cranial and Nasal Cavities-Canine and Feline
Oklahoma
The ThoracicWall; The Heart and Great Vessels
Patrick R. Gavin, DVM, PhD, Diplomate ACVR
Debra K. Baird, DVM, PhD, Diplomate ACVR Professor,
Radiology,VeterinaryClinicalSciences,
Collegeof
ClinicalAssistant
Professor,Diagnostic
Imaging,Purdue VeterinaryMedicine,WashingtonStateUniversity,Puilman,
University,WestLafayette,Indiana Washinston
The Tarsus The Equine VertebralColumn
Don L. Barber, DVM, MS, Diplomate ACVR |ohn P. Graham, MVB, MRCVS, MSc, Diplomate ACVR
Professorand Head,Departmentof SmallAnimal Clinical AssistantProfessor,
Universityof Florida,Collegeof Veterinary
Sciences,
Virginia-Maryland Regional
Collegeof Veterinary Medicine,Gainesville,
Florida
Medicine,Virginia Tech,Blacksburg,
Virginia The Liver and Spleen
The PeritonealSpace;The Stomach
Gary R. fohnston, DVM, Diplomate ACVR
Clifford R. Berry, DVM, Diplomate ACVR WesternUniversityof HealthSciences,
Collegeof Veterinary
AdjunctAssociateProfessorof Radiology,Universityof Tennessee Medicine,Pomona, Calilornia
Collegeof VeterinaryMedicine,Knoxville,Tennessee; Staff The Kidneysand Ureters;The Uterus, Ovaries,and
Radiologist,VeterinarySpecialistCenter,Maitland,Florida Testes
PhysicalPrinciplesof Computed Tomographyand
Magnetic Resonancelmaging; Introductionto
RadiographicInterpretation;InterpretationParadigms Stephen K. Knellen DVM, MS, Diplomate ACVR
for the Axial Skeleton-Small and Large Animal; AssociateProfessor, SectionChief-Imaging/RadiationTherapy,
InterpretationParadigmsfor the Appendicular Universityof Illinois, Urbana,Illinois
Skeleton-Canine and Feline;InterpretationParadigms The Metacarpus and Metatarsus; The Larynx, Pharynx,
for the AppendicularSkeleton-Equine; Interpretation and Trachea
Paradigmsfor the Small Animal Thorax; Interpretation
Paradigmsfor the Abdomen-Canine and Feline
Linda |. Konde, DVM, Diplomate ACVR
VeterinaryRadiologist,DiagnosticImaging,PC, Aurora,Colorado
Darryl N. Biery, DVM, Diplomate ACVR Diseasesof the lmmature Skeleton
Professorof Radiology,Schoolof VeterinaryMedicine,University
of Pennsylvania,
Philadelphia,Pennsylvania
The Large Bowel Christopher R. Lamb, MA, VetMB, Diplomate ACVR
SeniorLecturerin Radiology,The RoyalVeterinaryCollege,
Universityof London,London,England
f. Gregg Boring DVM, MS, Diplomate ACVR -
The C ani neand Fel i neLung
Professor,Mississippi Collegeof Veterinary
StateUniversity,
\ledicine,Mississippi
State,Mississippi
The Equine Carpus Iimmy C. Lattimer, DVM, MS, Diplomate ACVR
AssociateProfessor,
Departmento{ VeterinaryMedicineand
William Tod Drost, DVM, Diplomate ACVR Surgery,Collegeof VeterinaryMedicineand Surgery,Universityof
Missouri-Columbia;SectionHead-Radiology, Veterinary /
,\ssistantProfessorof Radiology,Collegeof VeterinaryMedicine,
The Ohio StateUniversity,Columbus,Ohio MedicalTeachingHospital,Universityof Missouri,Columbia,
Basic Ultrasound Physics Missouri
Equine Nasal Passagesand Sinuses;The ProstateGland
C. S. Farrow, DVM, Diplomate ACVR
Professorof MedicalImaging,WesternCollegeof Veterinary John M. Losonsky, DVM, MS, Diplomate ACVR
\ledicine,Universityof Saskatchewan,
Saskatoon, Saskatchewan, FormerlyAssociate Professor,
Collegeof Veterinary
Medicine,
Canada Universityof Illinois,Urbana,Illinois
Larynx,Pharynx,and Proximal Airway; The Equine Lung The PulmonaryVasculature
t,i CO NT RI B UT O R S
The primary purpose of this book is to serve as an instructional tered on description of radiographic abnormalities in terms of
aid. The book is also useful for assistingwith patient management, roentgen signs-changes in size, shape, opacity, number, and mar-
but its main mission is to facilitate the learning of radiology. As gination. I believe that students who have a firm understanding of
such, most of the modifications contained in this fourth edition roentgen sign description will be less inclined to make errors
were aimed at that purpose. Vaiuable features of previous editions, by jumping immediately to a diagnosis rather than thoroughly
such as the self-assessmentquestions and the atlas of normal considering radiographic changesin an orderly and efficient man-
anatomy, have been retained. ner. In previous editions, even with the roentgen sign approach,
Al1 chaptershave been revised extensively.New chapterson basic there was some variability with regard to chapter structure-some
interpretive principles have been included. A chapter on general chapters were organized according to abnormality and some ac-
interpretive principles is again included, but five new chapters cording to roentgen signs. In this new edition, chaptersare pnmar-
address specifics of interpretation relating to the axial skeleton in ily arranged based on the most common abnormalities affecting
sma1l and large animals, the appendicular skeleton in small and that particular system,with abnormalities being described in terms
large animals, and the thorax and abdomen in sma1l animals. of roentgen signs. This standardization will increase the cohesive-
Details of positioning, specific anatomic features of the body part ness of the book and reinforce the value of the roentgen sign
in question, methods of radiographic viewing, and assessmentand approach while, at the same time, emphasizing the most common
applications of specialized imaging modalities are some of the abnormalities encountered in patients.
topics coveredin these new chapters.The major purpose of these Thanks are extended to all who have used previous editions of
new chapters is to provide a framework for interpretation that can this work and to thosewho havepointed out;rrors or omissions,
be built upon when assessing the more specificinformation pro- thereby allowing this edition to be what I believe is the best one
vided in other chapters. yet. Finally, I think it would be impossible for one person to
The amount of coveragedevoted to diagnostic ultrasound in this prepare a comprehensive textbook of veterinary radiology. I am
textbook has fluctuated since the first edition was oublished. In the fortunate to have so many talented authors take time from their
last edition, information on sonographicimaging was minimized. busy schedules to prepare material for this book. Several new
However, ultrasound imaging has become such an ingrained part authors have contributed to this fourth edition, and many familiar
of veterinary practice that I felt it was important to increase the names are again found as contributors. The expertise of this team
amount of information on this modality. Thus, a new chapter on heightens the quality of the information contained on these pages,
the physics of ultrasound imaging has been prepared, and the and I am honored by their participation.
description of the sonographicfeaturesof many common abnor-
malities has been enhanced in manv other chaoters.
The basiso[ interpretationused in thjs textbook remainscen- Donald E. Thrall
NOTICE
Veterinary Medicine is an ever-changingfield. Standard safetyprecautions must be followed,
but as new researchand clinical experiencebroaden our knowledge, changesin treatment
and drug therapy may become necessaryor appropriate. Readersare advised to check the
most current product information provided by the manufacturer of each drug to be
administered to verift the recommended dose, the method and duration of administration,
and contraindications. It is the responsibility of the treating veterinarian, relying on
experience,and knowledge of the animal, to determine dosagesand the best treatment for
each individual animal. Neither the Publisher nor the editor assume any liability for any
injury and/or damage to animals or property arising from this publication.
THE PUBLISHER
CO N TE N TS
SEp TION I' - -'
. ' i3- ! craprrn13 Diseasesof the lmmature Skeleton . . . . . . 146
E ri k R . Wi sner
Physics and Principles of Interpretation
Li ndaJ. K onde
cHAprER
1 Radiation Physics, Radiation
crapren
14 FractureH eal i ngand C ompl i cat ions. . . . . 161
Protec t ion, and Dar k r oom Theor y . . . . . . . . . 1
Robert L. Toal
Don aldE.Thr all
S al l y K . Mi tchel l
WilliamR.W idm er
cH,cpruR
15 Bone Tumors Versus Bone Infections . . . . 179
cNAprER
2 Basic Ultrasound Physics . . 20
D onal d E . Thral l
WilliamTodDrost
crnpreR
16 RadiographicSigns of Joint Disease. . . . . 187
cHAprER
3 Physical Principles of Computed
GraemeA l l an
Tomography and Magnetic
Re so nanc e lm aging . ..... . .28
CliffordR. Berry lll;l6x t i*jlirv;ll1ile:lr:111el:611l1lll*X:lt:;ltllll;loX3lilllg,,.
o^1,,1 u,l*
cHAprER
4 Visual Perception and Radiographic Appendicular Skeleton-Equine
-:
Inte r pr et at ion . . . . . . .. .. . .. 35
MarcPapageorges craprrn17 Interpretation Paradigms for the
A ppendi cul arS kel eton-E qui ne . . . . . . . . . 209
cHAprER
5 Introduction to Radiographic Clifford R. Berrv
Inte r pr et at ion. . . . .........42 N ancv E . Love
CliffordR. Berrv D onal dE . Thral l
NancvE. Love
Don aldE.Thr all crnprenl S TheS ti fl e . . . . . . . . . 215
Mary B . Mahaffey
tx
X CO NT E NT S
T he P ulm o n a ry V a s c u l a tu re...
cH Ap r E R33 ... 420 cH nprrR 44TheU rethra .. . . . . . 588
J o h n M . L o so n skv Robert D. Pechman,Jr.
cHAprER
46 The Uterus, Ovaries, and Testes .... 603
ffiffifrffiffiiffiffiffi ffiffi $ffi.$ffiffi D ani elA . Feeney
Gary R . Johnston
Neck and Thorax-Equidae
cuprrn 35 Larynx, Pharynx, and Proximal crnpreR 4TThe S tomach..... ..... . . . 615
A ir way .. . .. 451 Mary B. Mahaffey
C. S. Farrow D on L. B arber
PHYSICSAND PRINCIPLESOF
INTERPRETATION
CHA P T E R
1
Radiation Physics, Radiation
Protection, and Darkroom Theory
r Donald E. Thrall . William R. Widmer
Directionof Travel+
Radiation units
rials varies considerably.Therefore, the radiation "dose" to ob-
For many years, the units roentgen, rad, and rem were used to jects with different absorption efficiencies will not be constant
quantify radiation exposure, radiation absorption, and equivalent when these objects are exposedto an identical quantity of radia-
dose, respectively.In 7977, the "International Systemof Units" (SI tion (Fig. 1-3). The SI unit for absorbeddose is the gray (Gy).
units) was developed in keeping with the trend toward universal The Gy is defined as the amount of radiation such that the
adoption of the metric system.3The units roentgen, rad, and rem absorbed energy is 1 joule/kg of tissue. Before SI units were
are not coherent with the SI system. The corresponding SI units accepted,the unit of absorbeddose was the rad, being equal to
for the roentgen and rad are coulomb per kilogram and joule per 100 ergs/g. By using appropriate conversionfactors, it can be
kilo gram, respectiveiy. shown that 1 Gy : 100 rad. In soft tissue, exposureto 12.58
Becauseionizing radiation has no mass and no charge, it can be x 10-a C/kg (l roentgen) amounts to an absorbed dose of
detected only indirectly, that is, it cannot be felt' weighed, or
detectedby its perturbation of an electric field (seeTable 1-2). The
amount of radiation exposure is commonly quantified by measur- 100 x-rays 100 x-rays
ing the number of ionizations, that is, the electric charge,produced
1ililt iltlJt
by the x-rays in air.
Exposure quantity-Measurement of the amount of radiation strik-
ing a subjectis often needed.This measurementis basedon the
number of ion pairs produced in air by the oncoming radiation,
and is expressedin the SI system as coulombs of charge per kg
of air (C/kg). The old name used to describeexposurequantity
was the roentgen. One roentgen is equal to the production of
2.58 x 10 a C/kg in air. No special name has been given to H i gh I Low
exposure quantity in the SI system, and exposure is quantified effi ci encyl effi ci ency
only in terms of C/kg. absorber I absorber
Absorbed dose-The effrciencyof x-ray absorption in various mate-
I
Table 1-2. Properties of x-rays and gamma rays
Have no charge
Have no mass V Y Y i V
Travelat the speed of light
Are in vis ible
50 x-rays 90 x-rays
Cannot be felt
Travelin a straight line Figure 1-3, In this figure, two materialsare exposedto 100 x-rays.Thus,
Cannot be deflectedby magneticfields the exposuredose, or dose i n coul ombs/kg, i s the same i n eac h i ns tanc e.
Penetrateall matter to some degree However,the efficiencyof x-rayabsorptionis not the same for each absorber.
Causecertainsubstancesto fluoresce The absorberon the l eft absorbs50% of x+aysw hi l e the absorberon the ri ght
onl yabsorbsl 0%. Therefore, the absorbeddosew l l l be hi gheri n the abs orber
Can e xp os ephot ogr aphicem uls ions
on the l eft, even thoughthe exposuredose i s the same.B one i s an effi c i ent
Can io ni z eat om s absorberof x-ravsi n comoari sonw i th soft ti ssuessuchas fat and mus c l e.
RadiationPhysics,RadiationProtection,and DarkroomTheorv 3
' approximately0.9 cGy (0.9 rad). Becausebone is a more efficient Maximum permissible dose is the maximum amount of ab-
absorberofx-rays than is soft tissue,exposureto bone of 12.58 sorbed radiation that can be delivered to an individual as a whoie-
x 10-a C/kg (1 roentgen) results in a bone-absorbeddose of body dose or as a dose to a specificorgan and still be considered
greater than 0.9 cGy. This differentiai between exposure and safe.The term "safe" in this context means that there is no evidence
absorption in soft tissue versus bone may be as great as a factor that individuals receiving the maximum dose mentioned will suffer
of 4 to 5 with low-energy radiation. Differential x-ray absorption harmful immediate or long-term effects to the body as a whole or
between various tissues in the body is the basis of radiograph to any individual structure or organ of the body. Although the
production. As is discussedlater, the differential between expo- effect of very low doses of radiation is not known with certainty,
sure "dose" and absorbeddose is inverselyproportional to pho- it is safestto assumethat any amount of radiation will have some
ton energy. effect on the subject. Thus, one should keep in mind that whenever
Dose equivalenr-In living tissue, absorption of the same dose in an individual is exposedto ionizing radiation, some biologic dam-
Gy from different types of radiation may not produce the same age may occur, and following the ALARA principle is of paramount
biologic effect. For example, damage from particulate radiation, importance. Analogy might be made to an individual smoking a
such as alpha particlesand neutrons, is greateron a Gy-for-Gy cigarette only once a month. There is no evidence with this fre-
basis than damage from the same dose of x-rays. This is related quency of smoking that physical damage could result; however,
to differencesin "ionization density" for different types of radia- with increasing frequency of smoking, the probabiliry steadily esca-
tion. For example, a high-mass, heavily charged particle, such as lates by virtue of its cumulative effect. Unfortunately, there is no
an alpha particle (a helium nucleus: two nuclear protons, two establishedthreshold for either cigarette smoking or radiation un-
nuclear neutrons, no orbital electrons)createsmany ionizations der which damage will not occur or over which damage will
that are very close to one another in the tissue in comparison definitelyresult.
with a low-mass, lightly charged particle, such as an electron. In December1989,the National Academyof SciencesCommittee
Electrons set in motion by x-rays interacting with tissue (ioniza- on the Biological Effects of Ionizing Radiation (BEIR) produced its
tion) are the major source of damage resulting from x-ray latest report, which concluded that radiation risks had until then
exposure; this is described in greater detail later. Therefore, been underestimated; specifically, it stated that the likelihood of
deposition of I Gy from alpha particle absorption does more cancer induction after exposure to 1ow radiation doses is 3 to 4
biologic damage than deposition of 1 Gy from x-ray absorption. times higher than was previously thought.T Many of their data were
Damage from different types of radiation may be compared by derived from studies of survivors of the World War II atomic bomb
the use of a weighting factor, a numerical factor describing the explosions in fapan. Very few large human exposuresto radiation
relative effectivenessof a particular type of radiation to photons. have been documented; however, events such as Hiroshima/Naga-
The weighting factor for photons is 1.0; it is greater than 1.0 for saki and Chernobyl have provided information on human totrerance
charged or particulate types of radiation such as neutrons or to low-level radiation exposure. Also, the Department of Energy
alpha particles. In the SI system of units, the unit of dose has recently released information derived from human radiation
equivalencyis the Sievert (Sv); the Sv is derived from the product exposure experiments that were conducted during the Cold War
of the absorbed dose in Gy and the weighting factor. Before SI period ofthe 1950sand 1960s.
units were accepted,the unit of dose equivalency was the rem. Even though ALARA is the offrcial method of choice for limiting
The rem was derived from the product of the absorbed dose in one'sexposureto radiation dose,recommendationsfor upper limits
rads and the weighting factor. Because I Gy : 100 rads, 1 Sv ofexposure have also been establishedby the NCRp to guide those
: 100 rem. As a rule of thumb, an absorbed dose of I Gy from invoived in radiation work. The NCRP recommends the following8:
photons results in an approximately equivalent dose of 1 Sv.
1 An individual worker's lifetime effective dose should not ex-
ceed age in years x 10 mSv (age in years x I rem), and no
Radiation safety
occupationalexposureshould be permitted until age 18. Therefore,
The United States Nuclear Regulatory Commission (NRC) is the
an individual's lifetime effective dose equivalent in rems should
official source for establishing guidelines for radiation protection.
not exceedthe valueof his or her agein years.
The NRC has indicated that the annual occupational radiation dose
to individual adults should be limited to a maximum of 0.05 Sv (5 2. The effective dose in any 7 year should not exceed 50 mSv
(5 rem).
rem).n The NRC has not establishedan upper limit for cumulative
3. For the general public, radiation exposure (excluding that
exposure.Previously,the NRC had recommended that one's cumu-
relatedto medical use) should not exceed1 mSv (0.1 rem).
lative exposurebe less than [5 rem/yr x (n-18)], where "n" is the
4. Once pregnancy is declared,the monthly limit of exposure to
age of the individual; this recommendation has been overruled in
the embryo or fetus should not exceed0.5 mSv (0.05 reml. Specific
favor of the ALARA principle (defined later in this paragraph).
controls for occupationally exposed women are no longer recom-
Although the NRC is the official body regarding exposure limits
mended until a pregnancyis declared.
for ionizing radiation, other groups also make recommendations
regarding exposureto ionizing radiation. For example,the National The difference in opinion between the NRC and the NCRp
Council on RadiationProtection(NCRP), a governmentalscientific regarding limits for cumulative exposure can be confusing. It is
group, meets regularly to review recent radiation research and important to recognizethat the NRC is the agencyoffrcially respon-
update radiation safety recommendations. According to the NCRP, sible for identifying federal exposure standards. The NRC has
the objectivesof radiation protection are: elected to eliminate any recommendations regarding cumulative
1. To prevent clinically significant radiation-induced effects by exposurelimits, probably becauseof the uncertainty of such predic-
adhering to dose limits that are below the apparent or practical tions. The NCRP, on the other hand, has elected to establish an
threshold,and estimate for acceptablecumulative exposure, which is much more
2. To limit the risk ofcancer and heritable effectsto a reasonable conservative than that previously recommended by the NRC. Re-
level in relation to societal needs and values, and benefits gained.t gardless,it is in the best interest of the radiation worker to adhere
to the principle of ALARA regarding occupational exposure, and
These objectives can be met through adherenceto the principle of to use the most conservative of any conflicting recommendations
ALARA-that is, limiting exposure of radiation workers to a leve1 as a guideline.
As Low As Reasonably Achievable-and by applying established In addition to occupational exposure,the population is continu-
dose levels for controlling occupational and general public expo- ally exposed to very low levels of radiation, both natural and
sure.6 manmade. A breakdown of relative exposure of the U.S. public to
4 P HY S I CS
A ND P R IN C IPL EOF
S IN T ER PR ET A TION
TerrestrialBo/o In te r n a
1 l1 % M a n m a d e 1 87o caused.The younger the fetus/embryo, the greater the potential for
damage, which may be manifested as embryonic death, c<ingenital
Cosmic8% maiformation, or a growth defect.
Medical x-rays 11ol"
Practical considerations
Radiation workers in veterinary practices must be aware of the
Nuclearmedicine4% risks of radiation. They should be skilled in proper patient posi-
tioning for radiography, machine operation, and darkroom tech-
Consumer
niques so that repeat radiographic studies are minimized. Workers
products3%
Radon55% should be instructed on the proper use and care of radiation
Other1% protection devices.Reduction of radiation exposure to an individ-
/ ual from external radiation sourcesmay be achievedby any one or
any combination of the following measures:
N atura l 8 2% \
- l. Distance-increasing the distance of the individual from the
Figure 14. U.S.sources
of exposure
dosefromionizing
radiation. radiation source
2. Time-reducing the duration of exposure
3. Shielding-use of protective barriers between the individual
radiation by various sourceswas published by the NCRP in 1987 and the radiation source
(Fig. l-a).'q Briefly, the averageU.S. citizen receives3.6 mSv (360
In veterinary medicine, shielding and distance are the factors
mrem) annually; of this figure, more than 800/ois due to inhalation
most readily controlled.Shieldingmay comprisepermanentprotec-
of radon gas. The relative levels of different sources of exposure
tive barriers and structural shielding such as wa1lscontaining lead,
may vary based on geographic location. For example, owing to
concrete, or other materials in thickness sufficient to provide the
greater altitude, exposureto cosmic radiation is higher in Colorado
required degree of attenuation. Shielding may also be a protective
than in North Carolina, and in Eastern Pennsylvania,household
barrier incorporated into equipment, such as an aluminum filter
radon exposure is much greater than in most other areas of the
to remove scattered radiation or a collimator to limit the size of
United States.In Table l-3, tlpical radiation doses received from
the primary x-ray beam. Or, shielding may consist of mobile or
some familiar activities are shown.
temporary devices used as the occasion demands, such as movable
screensor lead-impregnatedaprons or gloves.
Biologic principles
Protective aprons and gloves are usually 0.5 mm Pb equivalent,
X-rays produce electron pairs (ionization) in tissue.Becausemost
and they must be worn when one is positioning patients for
tissue is 70o/owater, ionization of water moleculescausesthe forma-
radiography. Although these devices are heary and seemingly pro-
tion of chemically active free radicals. These free radicals account
vide considerableprotection, they are designedsolely for protecting
for most of the damage to tissue. A small percentageof x-rays
against scatteredradiation and must never be placed in the primary
interact directly with DNA, resulting in severalpotential alterations
beam. In addition, mishandling of this equipment will result in
such as base nucleotide damage, DNA strand breakage,and DNA
its cracking, and therefore affording less protection. Protective
cross-linkage.These effects may be minimal and quickly repaired
equipment should be treated with respect;it is used to protect the
enzymatically, or can result in lethal damage to the cell. DNA is
health of the radiation worker.
uniquely sensitiveas it is a large target relative to other intracellular
Pregnant and potentially pregnant women, and individuals
structures and possesses little redundancy within any one cell. The
younger than 18 years of age, should not hold animal patients
principle of biologic amplification as described previously is an-
during radiologic examination or treatment. A radiation protection
other reason why DNA damage can have serious consequences.
supervisor (who may also be the user) should be designatedfor
Depending on the tissue involved, a given dose of x-rays can
every installation to assumethe responsibilities outlined later and
have effectsvarying in magnitude from imperceptible to lethal. The
to advise about the establishment of safe workine conditions in
type of tissue irradiated has an impact on the effects of radiation.
compliance with all pertinent federal, state, and lola1 regulations.
For example,a tissue that does not divide, such as muscle, may
Radiation protection supervisors should be familiar with the basic
receivea high dose but exhibit few side effects.Conversely,actively
principles of radiation protection to properly carry out their re-
dividing tissues, such as intestinal epithelium and bone marrow
sponsibilities, although they may wish to consult with appropriate
are quite responsiveto radiation.
qualified experts for advice.
Two other tissues, gonadal and fetal, are of crucial importance
Suggestedresponsibilities of the radiation protection supervisor
with respect to radiation safety. Irradiation of these tissues at
are the following:
sensitive stagescan result in biologic amplification of any damage
1. To establish and supervise the implementation of written
operating procedures and to review them periodically to ensure
Tahle 1-3. Radiation doses received from some their conformity with local regulations
familiar activities* 2. To instruct personnelin proper radiation protection practices
3. To conduct or have conducted radiation surveys where indi-
Radiation dose cated and to keep records of such surveys and tests, including
Event received (mSv) summaries of corrective measuresrecommended or instituted
FIightfrom Los Angelesto Paris NF 4. To observe routinely and test periodically interlock switches
T hora cicrad iog rap h .22 and warning signals to ensure that they are working properly
Apollo X astronauts'moon flight 4.8 5. To ensure that warning signs and signals are properly located
Whole-mouthdental x-ray 9.1 6. To determine the cause of each known or suspectedcase
Dose o n Thre e Mile ls landdur ino ac c ident 11.0
of excessiveabnormal exposure and to take steps to prevent its
Mam mog rap hy | 5.U
B ariumen ema 80.0 Iecurlence
Heartcatheterization 450.0
Radia tionth era py 70,000.0 Personnel monitoring
Personnelmonitoring is used to (1) check the adequacyof the
*Doses are whole bodv in some instances and reoional in others. radiation safety program, (2) discloseimproper radiation protec-
- G-l
RadiationPhysics,RadiationProtection,and DarkroomTheory 5
tion practices, and (3) detect potentially serious radiation exposure an electron cloud around the filament. The number of electrons in
situations. A radiation badge is a common personnel monitoring the cloud is directly related to the amount of electric current
device. A radiation film badge consists.of a plastic holder that passingthrough the filament, which in turn is regulated by the mA
contains a paper-wrapped piece of photographic film. When struck (milliamperage) control on the panel of the x-ray machine. Increas-
by ionizing radiation, the film becomesexposed,and the degree of ing miliiamperage is analogous to increasing the wattage of a light
film blackness can be related to exposure. Radiation badges may bulb. A 100-watt bulb has a hotter filament and emits more light
contain thermoluminescent dosimeters rather than film. These do- rays per unit time than does a 60-watt bulb. There is more current
simeters trap electrons energized by oncoming radiation, and the flowing through the filament of a 100-watt bulb than through a
number of trapped electrons can be quantified and related to 60-watt bulb.
exposure. Radiation badges should be analyzed at least quarterly; X-rays are produced at the anode (target). Electrons that have
weekly inspection is preferable. been produced at the filament remain stationary; thus a mechanism
Personnel monitoring should be performed in controlled areas by which they can strike the metallic target is needed. This is
for each occupationally exposed individual for whom there is a accomplishedby applying a voltage differential between the anode
reasonablepossibility of receiving a dose exceedingone fourth the and cathode. Electrons are negatively ( - ) charged. Therefore, if
applicable maximum permissible dose. A qualified expert should the target is positive ( + ) with respect to the filament of the
be consulted on establishment and evaluation of the personnel cathode, the electrons will be attracted to the target (opposite
monitoring system. Devices worn for the monitoring of occupa- charges attract) and strike it. The energy of x-rays produced is a
tional exposure should not be worn by the individual when he or function of the energy of the electronsstriking the anode. Electrons
she is exposed as a patient for medical or dental examinations. traveling through a larger potential voltage difference will have
Monitoring devices should be worn on the chest or abdomen, higher energy.The potential voltage difference is adjusted with the
except for special circumstances.\A/hen a protective apron is worn, kilovoltage peak (kvp) control on the x-ray panel. Increasing kVp
the monitoring device should be worn on the outside of the apron increasesthe voltage difference between the anode and cathode;
for monitoring the radiation environment, but may be worn inside thus, electrons are acceleratedto higher velocities and have greater
the apron when an estimate of the body exposure is desired. energy when striking the anode. This enables the production of
high-energyx-rays (Fig. 1-5).
Basic radiation safety rules for diagnostic When electronsstrike the metallic target, x-rays are produced by
radiology either collisional or radiative interactions.l0Collisional interactions
1 Remove personnel from the room who are not involved in involve a collision between a high-speed electron and an atom in
the procedure. the target of the tube. The oncoming electron ejects an orbital
2. Never permit anyone younger than 18 years of age, or electron from the atom with subsequentreleaseof energy as an x-
pregnant women, in the room during the examination. ray (Fig. 1-6). X-rays produced by this mechanism have specific
3. Rotate personnel who assistwith radiographic examinations energiesrelating to the energy required to eject the target electron
to minimize exposure to any one person. from its shell (the binding energy) and are therefore called charac-
4. Use sandbags, sponges, tapes, or other restraining devices teristic x-rays. X-rays createdby collisional interactions account for
for positioning the patient rather than manual restraint. only a small fraction of the total x-raysproduced in a diagnostic x-
5. Use anesthesiaor tranquilization for patient restraint when ray tube.
possible. In a radiative interaction (Fig. 1-7), the oncoming high-speed
6. Never permit any part of the body to be in the primary electron passesclose to the nucleus of the target atom (attracted
beam, whether protected by gloves or aprons or not. by the opposite charge) but an electron is no1 ejected from the
7. Never handhold an x-ray tube, x-ray machine, or cassette. atom. As the oncoming electron slows as it bends around the
B. Always wear protective aprons when assistingin positioning nucleus, it releasesenergy in the form ofelectromagnetic radiation,
an anlmar. called "braking radiation," or bremsstrahlung. The energy released
9. Always wear protective gloves if hands are placed near the in the form of bremsstrahlung has a broad spectrum, depending
primary beam. on the amount of energy lost from oncoming electrons as they are
10. Consider use of protective goggles if work level is hearry. deflected to various degreesby the nucleus. Most electrons have
These glassesprovide 0.25 mm Pb equivalent protection and offer
protection to the lens of the eye.
11. Consider use of thyroid shields. These are "mini-aprons,"
which are worn around the neck and serve to protect the thyroid
gland.
12. Use the collimator of the x-ray machine so there is an
unexposed border on each film, proving that the primary beam
does not exceedthe size of the cassette.
13. Use the fastestfilm-screen combinations that are compatible
with the production of diagnostic radiographs.
14. All personnel should wear radiation badges outside the lead
apron.
15. Plan the procedure carefully, and double-check machine set-
tings.
I Production of x-rays
Whenever high-speed electrons strike metal, x-rays are produced.
X-ray tubes provide for acceleration of electrons and their subse- pe
quent interaction with a metal target. Electric current is passed
through the filament of the x-ray tube, in much the same way that Cathode
an electric current is used to heat the filament of a light bulb. The Figure l-5. A schematicdrawingof a rotating-anode x-raytube. The anode
heat allows electronsto "boil" off of the surfaceof the filament into rotatesat high speed,dissipatingheat over a largesurfacearea.
6 P HY S I CS O F IN T E R P R E T ATION
A ND P R IN C IP L ES
4. Theseelectronsmay Contributionfrom
produceadditionalx-ray characteristicx-ray
photonsthroughadditional @
c production
or radiative
collisional
but the photons
interactions, o
are ol low energy and are c
o
not useful for imaging.
d
1. The oncomingelectron X
Electrontrom
from the cathodeoJthe o- K shetl
x-ray iube ejectsan orbital o
electronfromthe K shell. c
The electronoriginating E
5
from the cathode z
continueson.
U- Electronfrom
cathode '150
50 100
c
RadiationPhysics,RadiationProtection,and DarkroomTheorv 7
1/60sec
-
+
Apparenl
focal spot
stze
Figure 1-1O. Anglingthe anode decreasesthe stze of the effectivefocal
+ spot w hi l e mai ntai ni ng
a l argerareaon the anodethat i s struc kby el ec trons
and thus faci l i tates
heatdi stri buti on.
1/60 sec
Three-phasefully rectified
and is eventually absorbedin the patient. When the vacancycreated orbitale ectronfromthe
by ejection of the photoelectron is filled by a peripheral shell
electron, or a free electron, a characteristic x-ray is given off (see
tissueatom. The photon
rs scattered. /T
Fig. l-la). This is the same type of characteristicx-ray given off \')
in the target of an x-ray tube when the oncoming electron from \,n-N->
the cathode creates a vacancy in a target atom. The energy of
characteristicradiation is related to the atomic number of the atom
from which it arises.Thus, with a large-atomic-number atom such
as tungsten (the target of the x-ray tube), the characteristicx-ray 3. The ejected orbital
O- electronmay also produce
is actually part, albeit small, of the useful x-ray beam. But in the but
addltionalionizations
body, the energy of characteristic x-rays is so low that they are is subsequently absorbed
n the patient.
absorbed locally and therefore contribute to the absorbed dose in
the patient being radiographed, but not to production of the Figure 1-15. The Compton absorption process. An incoming photon from
the x - r ay tube ej ec ts an el ec tr on, us ua l y fr om an outer s hel l , o f a t i s s u e a t o m.
radiographic image. The probability of a photoelectricinteraction The incoming photon is scattered, not absorbed as in the photoelectric proc-
is directly proportional to the cube of the atomic number (proba- ess. The ejected electron and scattered photon may continue and produce
bility proportional to 23) and inversely proportional to the cube of addi ti onal i oni z atton.
IO P HY S I CS S IN T ER PR ET A TION
A ND P R IN C IPL EOF
the photoelectric absorption reaction predominates.The photon 50 mAs 100 mAs 200 mAs
t
scattering that occurs with Compton interactions is also disadvan-
tageousbecausethe scatteredphotons are radiation safety consider-
ations for bystanders;they also degrade the image by fogging it. I i
I The basic concept of making
I a radiograph
In making radiographs, the patient is placed between the x-ray
tube and ih.
rays produced "-tuy
film (Fig. 1-16). The sPectrumof energy of x-
by a diagnostic x'ray tube is broad. X-ray photons
of very low energy serve no useful purpose because they are all
I I
absorbed in the patient and make no useful contribution to cre- ll{):':'lti}')::'lla.'
iil!uu..
ation of the image. Therefore, filters are routinely placed in the l.,rlill,,,illl;lll.9l
?1,,,,,r1
x-ray tube housing to remove these low-energy x-rays' Some
x-rays passingthrough the filter are absorbed by the beam-shaping Figure 1-17. Thenumberof x+aysreachlng the fllm,andthereforefilm
coliimator or tube housing and do not hit the patient. The collima- blackness,
canbecontrolled bychanging themAssetting panel.
onthecontrol
tor servesto limit the primary beam and prevent nonuseful radia- Increasing
milliampere seconds {mAs),whilekeeprng peak(kVp)
the kilovoit
tion from leaving the tube housing. This nonuseful radiation oniy constant, strikngthepatentand,thus,proportionally
willresultin morex-rays
willpassrhrough
'no'ex-rays tnepat,enr t. -hus as rAs s ncreased,
o' oojec
serves to (1) increase patient dose, (2) degrade image quality filmblacknesswillalsoincrease.
becauseoffogging (seelater sectionon grids), and (3) increasethe
radiation dose to bystanders.In Figure 1-16, three x-rays are seen
leaving the coliimator. The 1eft one completely penetrates the pa-
the important characteristics of x-rays is their ability to expose
tient and will be recordedon the x-ray film' Some fraction of the
photographic emulsions.Therefore,x-rays passingthrough an ob-
x-ravs must penetrate the patient or no information would be
ject, or patient, can exposephotographic emuision in such a man-
,..oid.d on tire fllm. The middle x-ray hits a structure within the
ner as to present a picture, or image, of the interior of the body.
patient and is completely absorbed. This is also beneficial and
There are some important aspectsof this processthat must be
emphasizesan important point: radiographsare possibleonly be-
understood now, although the radiographic image itself is dealt
cause of differential absorption of x-rays by the patient. The x-ray
with in greater detail in Chapter 5.
on the right hits the patient and is scatteredin another direction.
In this initance, the x-ray will strike a bystander. If the bystander Film blackness/opacity
is not wearing a protective apron and gloves,he or she will receive
an unnecessary radiation dose. If the angle of scatter had been X-ray film is basically photographic film with a light-sensitive
different, the scattered x-ray may have hit the x-ray film' This emulsion. Silver halide crystals are present in the emulsion and
would be disadvantageousbecausethe x-ray no longer represents when exposed to x-rays or 1ight, they become precipitated on the
a structure within the patient. This x-ray would "fog" the film. film during development as neutral silver deposits. These neutral
A radiograph is a visible image of the internal make-up of an silver deposits appear black to the eye; unexposed crystals are
object, usually a patient. The radiograph is used to assessinternal removed during fixation, leaving clear areas on the fi1m. Thus, it
structures. There must be some method of recording an image of is the amount of precipitated silver in any particular part of the
an obiect if it is to be critically assessed.Fortunately, one of film that determines how black, gray, or clear that part of the fi1m
appears to our eyes, and this is directly related to the number of
x-rays that reach that part of the film from the patient. The degree
of film blackness is affected by the number of x-rays striking the
film, which in turn is affectedby the x-ray machine output (mAs).
Tube When more x-rays are emitted, more reach the film (Fig. 1-17).
housi ng Film blacknessis also affected by the energy of the x-ray beam
(kVp). The higher the kVp, the higher the energy of x-rays in the
Filter
beam, the larger the percentage of x-rays in the beam that will
penetratethe patient, and the greaterthe film blackness(Fig. 1-18).
The distance from the x-ray tube to the film also affects film
blackness.This distanceis referred to as the focal spot-film distance
Collimator (FFD). As the FFD increases,film blacknessdecreases becausethe
intensity of x-rays in the x-ray beam (x-raysiunit area) decreases
Edge of collimated (Fig. 1-1e).
x-ray beam The amount of change in intensity of the x-ray beam as a
function of distanceis describedby the inversesquarelaw equation:
(d,)'
-
(d,)'
Patient +
where 1 is intensity in terms of number of x-rays/unit area; d is
distance; I, is intensity at distancer, and 12is intensity at distancer.
Therefore, as FFD increases,intensity and film blacknessdecrease,
and this decreaseis a function of the square of the distance, not
simply the distance(Fig. 1-20).
X-ray film As an example, assumethat at an FFD of 50 inches, the intensity
of the x-ray beam at the level of the film is 100 x-rays/cm'?.What
Figure 1-16, The schematicrelationshipbetween x-raytube patient,and
will the intensity be if the FFD is decreasedto 25 inches?Intuitively,
cassette.The fate of three x-rav photons strlkingthe patient is also shown
Seet e x t f o r d e t a i l s . the intensity must be greater at a shorter distance,but the equation
R adi ati on
P hysi cs,R adi ati on
P rotecti on,
and D arkroomTheor v ll
t I *
+
30 x-rays
t
50 x-rays
+
70x-rays
z f r. - l
F i g u r e 1 - 1 8 . T h e n u m b e ro f x- r a ysr e a ch in gth e film , a nd thereforefi l m
Figure 1-2O. Theintensity of anx-raybeam(x-rays/unit area)changes with
b l a c k n e s sc,a n b e c on tr o lle d b y ch a n g in gth e ktlo vo ltp e a k( kVp)sett ng on the
the squareof the distance. At a distanceof j ft, the divergingx-raybeam
c o n t r o lp a n e l .I n c r e a sin kVp
g wh ile ke e p tn gm As co n sta n wi
covers anarearepresented bythesquare A witheachs de of dimensron x, or
t l l resul t n x-rays
h a v i n gm o r ee n e r g y.As e n e r g yin cr e a se s,
anareaof (x). (x): x,.At 2 ft, thedivergingbeamcovers a square B in which
th e like lh o o do f p enetrati on w i thout
interaction i n c r e a s e s.
T h is will r e su ltin m o r e x r a ys h ittin gthe fi m and an
eachsideis nowtwiceas longas it wasat 1 ft. Theareacovered bythe beam
i n c r e a s ei n f i l m b i a ckn e ss. at 2 feet ls thereforel2x). (2x): 4xr,whichis fourtimesthe areaat j foot.
Because the ntensity of the beamoriginating at the anodeis constant, the
intensityfallingon thesmaI square mustspread outoveran areathatis four
t mesas largebythetimeit reaches thelargesquare.
given can be used to obtain the exact solution. 1, : 100 x-rays/
cm', d' : 50 inches, I. : ?, dz : 25 inches. Substituting, the
equation becomes:
of the abdomen using a 4O-inchFFD.When anotherx-ray machine
100_ (25),. is used, the maximum FFD that can be obtained is 30 inches. What
I, (50)" mAs must be used to maintain the same radiographic opacity as
that obtained at a 40-inch FFD? Common sensetells you that
1 0 0_ 6 2 5 .
because the distance is shorteq a lower mAs must be used. The
f, 2500' exact mAs value can be calculated from the inverse square princi-
ple. The inverse square law equation noted previously cannot be
1 Q-_ ,,,..
l, "' "' used for this calculation because it relates intensity change as a
function of distance. In this example. we wish to maintain the
Iz : 400 x-rays/cm'z same photon intensity at the film, *hi.h ir now l0 inches closer
Therefore, by decreasingthe distance from the x-ray source to the to the x-ray tube. The question is, How much do we have to
fi1m by a factor of 2, the intensity increasesnot by a factor of 2, decreasethe mAs to maintain the same intensity? In this situation,
but by a factor of 4-that is, the square of the distance change. there is a direct relationship between the mAs needed to maintain
The inverse square relationship has other practical implications. the same intensity and distance, so the equation is as follows:
Supposethat an exposureof 100 mAs is neededfor a radiograph mAs, _ (d,)'z
mAs2 (dr)'
and from the above,mAs, : I00, mAsr: ?, d, : 40 inches,d, :
30 inches.and the proper expressionis:
100 _ (40),.
mAs, (:O;''
100 _ 1600.
mAs2 900'
J9: r .tt,
mAS
: 1oo,
- r.77'
-Ar,
mAs' : 56'25 mAs
Thus, the new mAs at a 30-inch FFD is 56.25 and is lower than
the original value of 100 mAs, which was neededat a 4O-inchFFD.
In this example, it is important to realize that the intensity (x-rays/
unit area) at the film will be the same under either
6i16u115fnn6s-thatis, 100 mAs @ 40 inches, or 56.25 mAs @
30 inches.
Therefore, FFDs are chosen as a compromise between long
Figure 1-19. As distance from the x-ray source {anode)increases,the values, which preserveradiographic detail (see later discussion),
in t e n s t yo f x + a y si n th e b e a m ( x- r a ys/u naitr e a )d e cr e a se sbecauseof beam and short values, which require lower mAs values. Use of a long
d i v e r g e n c el t. i s c l e a rin th is e xa m p leth a t a s th e fo ca lsp o t- fil mdi stance(FFD )
in c r e a s e st,h e f i l m b la ckn e sso f th e r e su lta n tr a d io g r a p h w i l decrease.To
FFD to preservedetail cannot be recommendedbecausethe large
o b t a i nf i l m b l a c k n e ss a I F F D 2 Ih a I r s sim ila rto th a t a t F F D 1 i n thi s exampl e, mAs values needed to maintain x-rav intensitv at the film are
t h e n u m b e ro f x - r a y sp r o d u ce da t th e a n o d e( m As)wo u ldh a veto be i ncreased. potentially harmful to the x-ray tuber to obtain high mAs values,
I2 P HY S I CS
A ND PR IN C IPL EOF
S IN T E R P R E TA TION
Screen
Short OFD
particularly those with a thick phosphor layer, a light-absorbing
dye is added to the phosphor layer to reduce the amount of
diffused light reaching the x-ray film; this leads to increasedradio-
graphic detail. These iight-reducing dyes also result in more radia-
Figure 1-24. In this exampe, the film focal distanceis the same in both tion being needed to produce a satisfactory radiographic image.
i n s t a n c e sT. h e o b j e ct- filmd ista n ce( OF D}is d iffe r e n t,b e in gl ongon the ri ght Intensifring screens are used because they can convert a few
a n d s h o r to n t h e l e ft.As OF D in cr e a se s, m a g n ifica tioann d edge unsharpness absorbed x-rays into many light rays, thereby decreasingthe num-
i n c r e a s er,e s u l t i n gin a d e cr e a sein r a d io g r a p h d
ice ta il.No te how much l arger
ber of incident x-rays needed to make a radiograph. This results
t h e i m a g eo f t h e o bje ctwill b e o n th e r ig h tin co m p a r iso with n the l eft.
in lessradiation exposureto the patient and to technical personnel,
and allows for use of relatively low-output x-ray machines to make
radiographs of large body parts, such as the equine stifle or the
Intensifying screens
equlne tnorax.
In reality, the sensitivity of the film emulsion to x-rays is much Intensifring screens originally incorporated calcium tungstate
lower than its sensitivity to visible light. Therefore, it is more (CaWO*) as the phosphor, but in the last few years new phosphors
efficient to convert the x-ray energy into visible light, using the have been developed. These new phosphors are called rare-earth
visible light to expose the film. This is possible becauseof the phosphors, not becausethe components are uncommon but be-
property of x-rays by which they cause certain compounds to causesome of the componentscome from the rare-earthseriesof
fluoresce (see Table i-2). Intensifting screensare used to convert chemical elements, which includes elements of atomic numbers
x-rays into visible light. Intensifizing screensare composed of layers 57 through 71. The x-ray-to-light conversionof these rare-earth
of phosphorescentcrystals that emit light when struck by an x-ray intensifiiing screens is significantly greater than that of calcium
(Fig. 1-25). The phosphorescentcrystals of intensiSuingscreens tungstate. For example, one x-ray absorbed in calcium tungstate
should not be confused with the silver halide crystals in the film producesabout 1000 light rays and the same x-ray absorbedin a
emulsion. rare-earth phosphor produces about 4000 light rays. Thus, by using
For radiography, x-ray film is sandwiched between two intensi- rare-earth intensifling screens,it is possibleto produce radiographs
f.ing screensin a cassette(Fig. I-26). The front of the cassetteis at mAs settings lower than ever before.
made from a low-atomic-number, low-physical-density material In some instances, where outstanding detail is desired, radio-
so as not to absorb a significant portion of the incident x-ray graphs are produced without the use of intensif ing screens.This
beam. The cassetteis constructed in such a manner as to comDress "nonscreen" technique requires much higher mAs values than do
the film betweenthe screensto ensuregood film-screencontact.If
there were not good contact between the film and the screens,light
from the screenswould diffuse over a lareer distance and detail x-ray
would be degraded.
Regarding the intensi$zing screen, both the thickness of the
phosphor layer and the size of the crystals in the phosphor layer
can be varied (Ftg. I-27). As with x-ray film, there is an increased
chance of interaction behveen an x-ray and the intensifuing screen
when the phosphor crystals are large or the phosphor layer is thick,
but the radiographic detail is decreasedconsiderably with large
crystals or thicker phosphor layers becauselight produced in the
screen diffuses over a wider area. In some intensif ing screens,
\.*oo""o /
Protective layer
Grids
Scattered radiation is a highly significant factor contributing to
decreased detail. Scattered photons originate from coherent or
Compton scattering.The effect of scatteredphotons is to produce a
generalizedphotographic fog (grayness)on the film, which reduces
contrast (see later section) (Fig. 1-28). The amount of scattered
radiation produced is directly related to the physical density of the Figure 1-29. lllustration
of gridratio.Theleadstripsarerepresented asthe
patient, the total volume of tissue irradiated, and the energy of the thinblack/ines.Thegridrato is the ratiobetweenthe heghtof the leadstrips
to rl-edistance
oeLween rhem
x-ray beam (kVp). Scatteredradiation is undesirableand can be
removed from the x-ray beam by a grid. A grid is a flat, rectangular
plate with alternating lead and aluminum foil strips. Grids improve
the diagnostic quality of radiographs by absorbing scatteredradia- The size of each lead strip in Figure 1-28 has been exaggerated.
tion (seeFig. 1-28). Some x-rays passingthrough the patient will Typically, there are approximately 80 to 160 lead lines per linear
be aligned with the radiolucent aluminum strips and reach the inch of grid; thus, the iead strips are very thin. In radiographs
film. Some x-rays hitting the patient will be scattered,and the grid exposed with a grid, it may be possible to see rhe grid lines if the
preventsthese from reachingthe film (seeFig. 1-28). These scat- radiograph is examined closely. Notice that in Figure l-28, the
tered x-rays represent uselessinformation and would only contrib- more peripheral lead strips are progressively angled in such a
ute to fogging of the film if the grid were not present. Some position that planes drawn through each lead strip will intersect at
primary x-rays not scattered by the patient also hit the grid. a point. The distance from the surface of the grid to the point of
Therefore,the number ofx-rays generatedmust be increasedwhen intersection of these planes is called the focal distance of the grid
(see Fig. 1-33). The purpose of this focusing is to marimize the
grids are used. In general, 2 to 3 times as many x-rays must be
generatedwhen grids are used in comparison with when they are number of the diverging primary x-rays passing through the grid.
not. This means mAs values 2 to 3 times as large are needed when In the previous example, if the lead strips were parallel to each
grids are used. other, a large portion of the periphery of the diverging x-ray beam
The amount of scatter by the patient is a function of the would be "cut off" by the grid.
thickness of the patient. The larger the patient, the more scatter The grid ratio is another parameter used to describe a grid. Grid
there will be. Becausesmall patients do not scatter many x-rays, ratio is the relationship of the height of the lead strips to the
grids are used only for patients with a thickness greater than distance between them; that is, if lead strips are 5 times as high as
approximately 10 cm. the spacebetweenthem, the grid ratio is 5:1 (Fig. 1-29). The larger
the grid ratio, the more effective the grid is in absorbing scatter
but the more difficult it will be for primary x-rays to pass through
it. This should be apparentby comparing the 8:l and 12:l grids in
the previous figure. Thus, the higher the grid ratio, the more x-
rays (higher mAs) are neededto produce a diagnosticradiograph.
Focal spot
displaced
laterally
Primary beam
absorbed by grid
Lead
strips
F ilm
Figurc 1-28. How a grid works. The grid is placedbetweenthe paiientand
t he f ilm . l t s p u r p o s ei s t o a b so r bsca tte r e dr a d ia tio nT.h e le a d str tp si n the gri d Figure 130, Lateraldecentering.When the centralray is centeredover the
are s h o w n a s s t i p p l e dr e g io n s.Be twe e nth e le a dstr ip sa r e str ip smadefrom gri d, i he shadowof the l eadstri psw i l l be very narrow When . th e c entralray
s ornel o w - a t o m i cn u m b e r lo , w- p h vsicad e n sitvm a te r iasu l cha s a lumi numor i s l ateral l ydecentered,the di vergenceof the beam no l ongerm atc hesthe
f iber.T h i sa l l o w sa p o r t i o no f th e p r im a r yx+ a y b e a mto r e a chth e f i l m, w hi ch di vergence of the l eadstri psi n the gri d,and the l eadstri psw i l l a bs orbmore
ls necessaryfor patient informationto be recorded.The scatteredphotons, of the pri marybeam,reduci ngfi l m bl ackness; gri dl i nesmay al sobe v rs ual i z ed
shown as dashedlines,that hit the grid are likelyto be absorbedby the grid dependi ngon the gri d rati oand numberof gri d l i nesper i nch.Lateraldec en-
bec au s et h e i ra n g l ei s s u c hth a t th e y d o n o t p a ssb e twe e nth e e a d stri ps. tering is the most common type of grid-induced artifact.
R adi ati on
P hysi cs,R adi ati on
P rotecti on,
and D arkro omTheor v l5
Whenever a grid is used in the making of a radiograph, each Figure 1-33. Becauseof the fixed relationshipof the lead strips in a fo-
cusedgri d,i t w i l l onl y functi onproperl yover a smal lrangeof foc als pot-fi l m
lead strip casts a linear opaque shadow. If the grid is stationary di stances(FFD s).The gri d focus,the poi nt from w hi ch t he dv ergi ngx -ray s
during the exposure,the shadows may occasionailybe detected on matchexactl ythe di vergence patternof the l eadstr ps i n the gri d,i s s how n i n
radiographs, particularly if there are few lead lines per inch of grid. thi s fi gure.The anodeshoul dbe l ocatednearthe gri d fo c a poi nt for proper
If, however, the grid can be made to move during the exposure, use of the gri d.l f the focalspot i s too cl ose,the di vergenc of e the x -raybeam
w i I no l ongermatchthe di vergence of the l eadstri ps,an d c ut-offw i l l oc c ur.
the shadows cast by the lead strips are blurred and cannot be N ote that even thoughthe focalspot i s too cl ose,the shadow sof the i ead
identified. One disadvantageof a moving grid is that it may make stri psremai nacceptabl ien the centerof the gri d.A s one progres s es tow ard
noiseor vibrate during a radiographicexposure,causingthe patient the peri pheryof the gri d, how ever,the shadow sof the l ead s tri psbec ome
to move unexpectedly. progressively larger,and cut-off becomessevere.
When the primary x-ray beam is not properly aligned with
the grid, particularly a focused grid, artifacts result (Figs. 1-30
to 1-33). Subject contrast
Subject contrast is the difference in x-ray absorption through one
part of the subject in comparison with that through another part.
I Distortion Subject contrast is affectedby (1) thickness differences,(2) physical
Distortion is due to unequal magnificationof the part being radio- density differences,(3) atomic number differences,and (4) x-ray
graphed. This results from one part of the object being closer to beam energy (kVp). Thickness, physical density, and atomic num-
the x-ray tube than the rest of the object (Fig. 1-3a). Interpretation ber effects on radiographic opacity and intensity have already been
of radiographscan be compromised if the patient is not kept in discussed.The effect of x-ray beam energy (kVp) control on con-
proper relationshipwith the primary x-ray beam. trast has not been discussed,but this is imoortant.
l= 100 I= 100
50 kvp 80 kvp
l= 50
80 kVp
,.=* ,L =2 5 r s = 80
|
t
40125= 1.6 80/60 = 1.33
Figwe 1-36. Assume that an x-ray beam wrth an intensrtyof 100 x-rays/
unit area strikes an object made up of two distinct regions with different l S = 40
t hic k n e s s /. S a n d / L a r e t he in te n sitie o s f th e b e a m a fte r b e ln gtransmi tted
l L= 39
t hroug hs m a l l{ t h i n - l S ) a n d la r g e( th ick- lL ) r e g r o n so f th e o b je ctr especti vel y.
Contrastis definedas the ratioof the intensityof the x+ay beam after passing
t hroug ht h e t h i n : t h i c kr e g i on so f th e o b je ct( i.e .,lS/lL ) On
. th e /e ft,most of the
low e' e r g y a ' e a l te r u a te d o y L l' e th ico p a ' T ,o L t q u ite a 'ew can
^ - r a y s
penetratethe thin part.Therefore,subjectcontrastfor 50 kVp is 40125: 1.6.
40/30= 1.33
This m e a n st h a t t h e t h i n p a r t tr a n sm its6 0 % m o r e x- r a ysth a n d o es the thi ck
part at 5 0 k l o v o l t p e a k s( kvp ) .lf th e kVp r s in cr e a se d to 8 0 , m o r e x-raysw i l l Figure 1-37. In Figure1-33, the qualityof the radiographwas acceptable
get t hr o u g hb o t h t h e t h i c kan d th e th in p a r ts.Bo th lS a n d L wi I in crease, but when 50 kilovoltpeaks (kVp)was used. When the kvp was increasedto 80,
lL wi I r n c r e a s ep r o p o r t i o n a lly
m o r e th a n lS b e ca u seth e h ig h e re n ergyof the contrastdecreased,but the entireradiograph was overexposed. Thus,to obtain
x-raysallows them to penetratethe thick part with greaterease.The ratlo lS/ a satisfactoryexposure,an intensityof 40 x-rays/unitarea beneaththe thin
lL bec o m e ss m a l l e ra, n d s ub ie ctco n tr a std e cr e a se s; th a t is,8 0 /6 0 : 1.33,or part of the object is needed, but we continueto use 80 kVp becausewe
only33 % d i f f e r e n c ee x i s t sin th e tr a n sm itte dr a d ia tio n in te n sity.Structures of desrrel ow er contrasti n thi s i nstance.To reducethe i ntensi tyun derthe thi n
highat o m i cn u m b e r( b o n e )a r e a lso m o r e e a silyp e n e tr a te d b y h lg herenergy part from 80 to 40, the originalintensity (mAs) can be reducedby 1/2.The
x -ray sT . h e r e f o r e , I h et h i c kp a r t in th is lllu str a tioco
n u lda lsob e so methi ngof i ntensrtyunderthe thi n and thi ck partsof the obj ecti s therebyre duc edto 40
highato m i cn u m b e ra n d t h e sa m e p r in cip ewo u ld a p p ly.( M o d ifie df rom C urry and 30, respecti vel andy, the contrastremai nsat 1.33(i .e.,40/3 0). (R epri nted
TS lll, D o w d e yJ E , M u r r y RC Jr : T h e r a d io g r a p h im ic a g e .In Cu r r yTS l l l (ed): w i th permi ssi on
from C urryTS l l l , D ow deyJE , Murry R C Jr: The radi ographi c
Chris te n s e n 'P s h y s i c so f D ia g n o sticRa d io lo g y, 4 th e d . Ph ila d e l phi a,
Lea & i mage.In C urryTS l l l (ed):C hri stensen's P hysi csof D i agnosti R
c adi ol ogy ,4th
F ebig e r1, 9 9 0 . ) ed. P hi l adel phiLea
a, & Febi ger,1990.)
RadiationPhyslcs,RadiationProtection,and DarkroomTheorv l7
Table 1-5. Appearance, cause, and correction for common technical errors
Appearance Cause Correction
Too dark Incorrectmachinesetting Lower kVp, mA, or time
FFDtoo short IncreaseFFD
Wrong screenfilm Checkscreen/film
Overdevelooed Checkdevelopertemperature/time
Too light Incorrectmachine setting RaisekVp, mA, or time
FFDtoo long Decreasedistance
Wrong screen/film Checkscreen/film
Underdeveloped Checkdevelopertemperature/time
Gray/loss of contrast Film stored improperly Checkstorageconditions
Film exposedto light Checkstorageconditions
O ld f ilm Discardfilm
Incorrectmachine setting DecreasekVp, increasemAs
Film processedimproperly Checkage, temperatureof chemicals
Crescent-shaoed black marks Film bent du r i n g h a n d l i n g H a n d l ef i l m m o r e g e n t l y
Sharp linear black marks Film scratchedbefore processing H a n d l ef i l m m o r e g e n t l y
Edge of film black Film fogged Checkfor light leak in cassetteor film bin
Blackwater spots or fingerprints Developeron film before development Do not contaminatedarkroom work surfaceor hands
White fingerprints Fixer on hands before development Do not contaminatedarkroom work surfaceor hands
White "hair" marks Hair in cassette Cleancassette
Sharp white specks Dirt in cassette Cleancassette
Sharp white lines/marks Emulsionscratchedoff Handlefilm with care when wet
Blurred image Patientmotion Use chemicalrestraint
Tube motion Securetube
Cassettemotion Secure cassette
Yellow-brownfilm Insufficientwashing Wash completely
Tree-likeblack marks Static electricity Move film slowly
general use, one should not purchase extremely high- or low- image on the frlm. Areas where no or minimal silver halide expo-
contrast film; a midregion contrast film is satisfactory. sure occurred are clear (appear white). fixing time is approximately
twice the development time. The film can stay in the fixer longer,
Fog and scatter but underfixing results in a cloudy or milky-appearing radiograph.
The effect of fog is to reduce radiographic contrast. Fog produced
Final wash
by scattered radiation can be prevented by the use of a grid.
Therefore, radiographs made with a grid have higher contrast than The film should be washed after fixing to remove excesschemicals
those that are not. Film can also become fogged by exposure to and any residual silver halide still on the film. Failure to wash
pressure or high temperature, or by accidental exposure to light, adequatelyresults in retained fixer chemicalsreacting with silver in
such as results from a defective darkroom safelight, or a faulty the film, forming silver sulfide, which causes the film to turn
light seal around the darkroom door. X-ray film also becomes brown as it ages.When films are processedby hand, they should
fogged spontaneously over time; therefore, an expiration date is wash for 30 to 40 minutes. Excessivewashing or washing in water
provided by the x-ray film manufacturer. that is too warm will result in the emulsion becoming soft and the
entire image "slipping" off of the film.
I Film processing
The most common errors made in radiography of animals are
I Technical errors
related to the processingof radiographic film. The darkroom Technical errors are commonplace in radiography. These errors at
should be clean, dry lightproof, and uncluttered. It is difficult to minimum are irritating when one is reviewing a radiograph and at
encourage a technician to perform a radiographic examination worst, they result in the radiograph being totally useless.A com-
carefirlly if the quality of the study is lowered by poor darkroom plete discussion of technical errors is beyond the scope of this
facilities. Despite the increased use of automatic processors,many book. In Table 1-5, the appearance and causes of, as well as
radiographs in veterinary radiography are still processedmanually. methods to correct, some of the more common technical errors
are presented.
Developing
References
The developer reduces exposed silver halide crystals to metallic
silver by supplying electrons to the positively charged silver ions 1. Roentgen WC: On a new kird of rays. Vet Radiol Ultrasound 36:371-374,1995.
in exposed silver halide crystals. A 5-minute developing time is 2. Widmer WR, Shaw SM, Thrall DE: Effects of lowlevel exposure to ionizing
recommended for film processing because it permits a reduction radiation: Current concepts and concerns for veterinary workers. Vet Radiol Ultra-
of required radiation exposure factors (mAs). Film developing is a sotnd 37227-t39, 1996.
chemical process and is therefore dependent on both time and 3. Anon: NCRP Report No. 82-SI Units in Radiation protection md Measurements.
temperature. Thus, a constant developer temperature is necessary Bethesda,Md, National Council on Radiation Protection and Measurements, 1985.
to obtain consistent film blackness. Generally, this is 68'R but 4. Anon: Title 10, Chapter l, Code offederal regulations-Energy.part20, Standards
other times and temperatures can be used. for Protection Against Radiation. In United States Nuclear Regulatory Commission
Rules and Regnlations. Washington, DC, US Gort prnting Of8ce, 1995, pp 20-27.
Fixing !.
Hall E|: Radiation protection. In Hall EJ (ed): Radiobiology for the Radiologist,
4th ed. Philadelphia, lB Lippincott, t994,pp 453-467.
The fixer converts undeveloped silver halide crystals on the film 6. Anon: NCRP Report No. l07-Implementation of the principle of As Low As
into a soluble compound. Fixer clears undeveloped, unexposed Reasonably Achievable (AI-{RA) for Medical and Dental personnel. Bethesda. Md,
silver crystals from the film. This leavesthe silver as a permanent National Council on Radiation Protection and Measurements, 1990.
I8 P HY S I CS
A ND PR IN C IPL EOF
S IN T E R P R E TA TION
Figure 14O
Figure 142
R adi ati on
P hysi cs,R adi ati on
P rotecti on,
and D arkro omTheor v lg
7. Anon: Health effects of exposure to low levels of ionizing radiation/Committee C. The anode is made of low-atomic-numbermaterial to im-
on the Biological Effects of Ionizing Radiations, Board on Radiation Effects Research,
Commission on Life Sciences,National ResearchCouncil. Washington, DC, National
prove image quality.
Academy Press,1990. D. The anode is the primary sourceof electronproduction in
the x-ray tube.
8. Anon: NCRP Report No. 9l-Recommendations on Limits for Exposure to
.lonizing Radiation. Bethesda, Md, National Council on Radiation Protection and
Measurements,1987. 6. Fill in each blank with either photoelectric or Compton, de-
pending on which type of interaction best fulfiIls the criterion.
9. Anon: NCRP Report No. 93-Ionizing Radiation Exposure of the Population of
the United States. Bethesda, Md, National Council on Radiation Protection and Criterion Absorptionprocess
Measurements,1987.
Independentof atomic number
10. Curry TS III, Dowdey JE, Murry RC Jr: The production of x rays. In Curry TS
III, Dowdey JE, Murry RC Jr (eds): Christensen'sPhysics of Diagnostic Radiology, 4th
Resultsin most exposure to
ed. Philadelphia, Lea & Febiger, 1990, pp 10 35. radiographers
Desirableprocessfor diagnostic
11. Curry TS III, Dowdey JE, Murry RC Jr: X-ray generators. In Curry TS III,
Dowdey IE, Murry RC Jr (eds): Christensen'sPhysics of Diagnostic Radiology, 4th ed. radiology
Philadelphia, Lea & Febiger, 1990, pp 36-53. Provides for differential absorption of
12. Siebert lA: The AAPM/RSNA physics tutorial for residents: X ray generators.
x-rays by tissue
Radiographics17:1.533-1557,1997.
7. To increasedetail, the x-ray tube is moved from an FFD of 40
inches to an FFD of 60 inches. At 40 inches, a technique of 10
W Questions mAs and 70 kVp was suitable. What technique would be necessary
at the new distanceof 60 inches?
1. Which one of the following statements regarding x-rays and
gamma rays \s correcf? 8. You have three intensifring screen techniques from which to
A. X-rays and gamma rays originate in the atomic shells. choose:high-speedcalcium tungstatescreens,detail calcium tung-
B. X-rays and gamma rays originate in the atomic nucleus. state screens, and no screens. Which screen would produce the
C. X-rays originate in the atomic shellsand gamma rays origi- following, assuming you use the same type of *-ray film and the
nate in the nucieus. same exDosurefactors?
D. X-rays originate in the atomic nucleus and gamma rays Bestinherent detail
originate in the atomic shells. Poorestinherent detail
Most film blackness
2. \A4rich one of the following statementsregarding the properties Leastfilm blackness
of x-rays rs incorrect?X-rays are:
A. Also calledphotons. 9. If a radiograph appearstoo light, which possibility out of each
B. A type of electromagneticradiation. set could causethis?
C. Positively charged. A. It was overexposed/underexposed.
D. Devoid of mass. B. A grid was/wasnot used.
C. The grid was/was not aligned.
3. Which one of the following statements regarding protective D. The developer temperature was too low/high.
lead aprons and gloves is incorrect?Lead aprons and gloves: E. The developer was nedexhausted.
A. Typically have 0.5 cm Pb equivalent. F. The film was in the developer too long/not long enough.
B. Are designed to allow the shielded body part to be placed G. The screenshad high/low resolution.
in the primary x-ray beam. H. The fi1m was first placed in the developer/fixer.
C. Have a finite useful life.
D. Are capable of protecting effectively against Compton-scat- 10. (Figure 1-38) What causedthe black crescentmark iust cranial
tered photons produced during diagnosticradiography. to the pubic symphysis?
4. Which one of the following statementsregarding x-ray produc- ll. (Figure 1-39) What causedthe black arborizing artifactssuper-
tion is true? X-rays are produced in a diagnostic x-ray tube: imposed over the lumbar spine?
A. Primarilyby radiativeinteractions.
12. (Figure 1-40) What poor radiography practice is illustrated in
B. Primarily by electronsinteractingwith the cathode.
this image?
C. At just a few energiesdependingon kvp and mAs.
D. Only when the tube voltage approximates kvp.
13. (Figure 1-41) What causedthe linear white artifact superim-
posed over the distal humerus?
5. Which one of the following statementsregarding the anode of
an x-ray tube is correct? 14, (Figure 1-42) What causedthe linear artifactsseenin this im-
A. The anode rotates to increasethe efficiencyof x-ray pro- age?
duction.
B. The anode is angled to improve image quality. Answers begin on page 727.
ffi CHAPTER
w /A
ffi ')
f f i1
W
Use of ultrasonography in veterinary practice is increasing at a Velocity (mm/p.sec) : frequency (MHz) X wavelength (mm)
rapid rate. A basic understanding of the physics of ultrasound is For a constant velocity, frequency and wavelengthhave an inverse
important as it helps explain some of the limitations and artifacts relationship so that as frequency increases,wavelength decreases,
encountered.Medical sonography usessound wave echoesto create and vice versa. Within soft tissue, the velocity of sound is 1.54
images, and it is the only diagnostic imaging modality that does mm/psec (1540 m/sec).1The velocity of sound in soft tissue is
not use electromagnetic radiation. In this chapter, the basics of important becauseultrasound machinesuse this constantvelocity
gray scale ultrasonography are discussed.Doppler techniques are for all of their calculations.
not discussed here. Referencesare available for the reader who Diagnostic ultrasound machines operate in pulsed mode for
wants more information about Doppler ultrasonography.t ' imaging.eThis means that the ultrasound machine sends only a
few cycles of a sound wave into a tissue and then spends the rest
I Physical principles of of the time listening for returning echoes. The pulse repetition
frequency (PRF) is the number of times this pattern of sending
I ultrasound waves and listening is repeated within 1 second.' The length of space in
Sound travels in waves and carries information from one place to one pulse of ultrasound is calledthe spatialpulsed length (SPL).If
another. It transmits energy by alternating regions of low pressure a sound wave has a wavelength of 0.5 mm and three pulses are
(rarefaction) and high pressure (compression).'' Unlike light and sent each time, the SPL is 1.5 mm. SPL is important for axial
radio waves, sound waves require a medium through which to resolution.
travel (sound cannot be propagated in a vacuum).t Frequency, It is important to consider how echoesare formed becauseit is
wavelength, and velocity are parameters that are used to describe the echoesthat contain the information about the structures being
sound waves;these terms are also used in referenceto electromag- imaged. We must consider the interface that causesthe echo reflec-
netic radiation (seeChapter 1). tion and the angle at which the sound wave strikes the reflector, or
Frequencyis the number of times a wave is repeatedper second. the angle of incidence.
One wave or cycle occurs when pressure starts at a normal value, Acoustic impedance of a tissue is the product of the tissue's
increasesto a high pressure value, decreases(passing the normal physical density and sound velocity within the tissue.l,3
value) to a low pressure value, and then returns to normal (Fig. Acoustic impedance (Z) : velocity (u) x tissue density (p)
2-1). A cycle may also be defined as the combination of compres-
Changesin acousticimpedancefrom one tissueto another deter-
sion and successiverarefaction.TFrequency units are expressedin
hertz (Hz) where 1 Hz equals one cycle per second. Diagnostic mine how much of the sound wave is reflected and how much is
transmitted into the secondtissue.The amplitude of the returning
ultrasound tlpically uses frequenciesbetween 2 megahertz (MHz)
echo is proportional to the difference in acoustic impedance. If
and 10 MHz (1 MHz -- 1,000,000Hz). The audible range of
trvo tissueshave no difference in acoustic impedance, then no echo
sound for humans is 20 Hz to 20,000Hzt; sound lessthan 20 Hz
is created.If a large difference in acoustic impedance existsbetween
is infrasound, and sound greater than 20,000 Hz (0.02 MHz) is
two tissues,then almost all of the sound is reflected.l To calculate
ultrasound.t
Wavelength is the distance traveled by a sound wave in one the percentageof the sound wave that is reflected and transmitted,
the following formulas are useda:
cycle. In ultrasonography, it is expressed in millimeters (mm).
Wavelengthis important for image resolution and is discussedlater yo reflected: (2, - Z,)l(2, + Z) X 100
in the text. o/otransmitted : 100 - o/oreflected
Velocity is the rate at which sound travels through an acoustic
medium; it is determined by the physical density (mass per unit In the first equation just above, Z. is the acoustic impedance of
volume) and stiffness(hardness)of the transmitting medium.r'n the second tissue, and Z, is the acoustic impedance of the first
The velocity of sound in some commonly encountered tissues is
listed in Table 2-1. If physical density remains constant, velocity
increases as stiffness increases.If the stiffness remains constant,
velocity decreasesas physical density increases.As a general rule,
velocity is highest in solids, lower in liquids, and the lowest in
gases.nIn solids, the molecules are closer together, so sound waves
are transmitted faster; in gases,the molecules are far apart and
sound waves travel more slowly.t Medically, sound wavestravel the
fastestin bone and the slowestin gas-filled lungs. This would cause
a problem for diagnostic ultrasound machines because they use
the velocity of sound in soft tissue(i.54 mm/psec) for all of their
calculations. However, becausesound waves do not penetrate lung l|ililt t | | | I I t lililt | | | | | |
or bone well (almost all sound is reflected), the velocity of sound
Figure 2-1. An ultrasoundwave depictedas a sine wave (top) and as a
within thesetissuesis not a factor in diagnostic ultrasound. Velocity series of compressionand rarefaction(bottom).One wavelength (\) is the
is also related to frequency and wavelength of a sound wave in the distancebetween two successivepeaks or valleysof the sine wave or be-
following equation: tween two successivecompressionor rarefactionevents.
20
B asi cU l trasound
Phvsics 2l
Liver 1. 549
Kid ne y t.5b I
Blo od 1. 570 Medium1
Muscle t.3d3
Lens of eye 1.620
Bon e ( s k ull) 4.080
sector or linear transducersis often dictated by the personal prefer- Depth of sound wave penetration varies inverselywith fre-
ence of the sonographer. quency.THigher frequency transducers are best for structures that
Transducersare classifiedby the location of the crystals on the are close to the surface; lower frequency transducers are best for
scan head. In end-fire transducers,the elements are located on the deeperstructures.The choice of ultrasound transducervarieswith
end of the probe, but side-fire transducer elements are found on the experienceof the sonographer.As a guide, one should start
the side ofthe probe, 90 degreesfrom the end. Side-firetransducers with a higher frequency transducer (becauseit has better resolu-
are used in cardiac and abdominal imaging; end-fire transducers tion) and switch to a lower frequency transducer if deeper struc-
are used for intracavitary imaging such as large animal (per rec- tures are not well imaged.
tum) reproducliveexaminations.
Resolution is the ability of an ultrasound machine to distinguish I Basic scanner controls
echoesbasedon space,time, and strength.I0The better the resolu-
tion, the more likely the sonographer is to identifr abnormalities. The power control modifies the intensity of sound output by the
As the frequency of an ultrasound transducer increases,the resolu- transducer.r This is accomplished by adjusting the voltage applied
tion increaies. Sonographerswant to use transducers of the highest to the piezoelectriccrystal.Increasingthe power leadsto a uniform
possiblefrequencyfor imaging to get the best possibleresolution. increasein the amplitude of returning echoesand therebyincreases
Axial resolution is the resolution of two separatereflectors along overall image echogenicity(brightness).Keeping the power level
10
the direction in which the sound wave is traveling.6'z It is equal low heips improve image resolution and helps prevent artifacts.3
to half the spatial pulse length (SPL). Earlier in the chapter, we Therefore,it is preferableto use the time gain compensationcurve
learned that the SPL is the length of spaceover which the pulse of to modify the strength of returning echoesrather than using the
a sound wave travels. When two reflectors are separated by a power control.
distance that is greater than half the SPL, the echoes from these Gain affects the amplification of the returning echoeswithin the
two reflectors do not overlap as they return to the transducer and receiver.Increasingor decreasingthe gain increasesor decreases
are interpreted as separateechoes(Fig. 2-3). If the distancebetween the brightnessof the image displayedon the screen.If the gain is
the reflectors is lessthan half the SPL, the returning echoesoverlap too low, the subtle parenchymal detail of tissue is lost. If the gain
and are interpreted as a single echo. Because transducers with is too high, the image is too bright and contrast resolution is lost.
higher frequency have shorter SPL, axial resolution is improved. A common analogy is to compare the gain knob on the ultrasound
Lateral iesolution is the resolution of two separate reflectors machine with the volume knob on a stereo.At low settings, subtie
oeroendicular to the direction in which the sound wave is travel- music cannot be heard, and at high settings, the music is too
ing.'''o This is determined by the ultrasound beam width.' To offensive to be enjoyed.
re-ognize the objects discretely,the beam must be narrower than TCG stands for time gain compensation. Becausesound waves
the distancebetween the objects. The width ofan ultrasound beam lose intensity as they travel in tissue, echoesreturning from deeper
decreaseswith increasing frequency.In a focused ultrasound beam, tissues are weaker than echoesreturning from tissuescloser to the
where the width of the beam is restricted, the lateral resolution is ultrasound transducer. To make an image uniform in brightness,
best at the focal point of the ultrasound beam becausethis is the it is helpful to amplifr the echoesfrom deeper tissuesto a greater
narrowestpart of the beam. degreethan echoesfrom shallow tissues.lrThe TCG controls allow
the user to adjust the gain in selectedregionsof the image.6
The reject function of an ultrasound machine is a method of
reducing unwanted,low-amplitude noise.This noise, electronicor
A
acoustic, is not useful and can subtly degrade the image. Many
; SPL machines allow the user to selecthow much of the 1ow-levelnoise
Y is filtered from the image. If the reject is set too high, some of the
subtle parenchymal echotexture is removed from the image.
I Display
Image formation for ultrasonography is based on the pulse echo
principle.n A small burst of sound waves is sent into a structure by
means of a transducer, and the transducer becomes an echo re-
ceiver. In between, the transducer is dampened to stop the piezo-
electric crystal from vibrating. The electric signals generatedfrom
the returning echoesare amplified to form the fina1 image. When
the initial burst of sound is sent into the tissue, a timer is started
A to determine the amount of time it takes to receive echoes.The
elapsed time from sending to receiving is directly related to the
distance traveled by the sound wave.
Rate (mm/psec) X time (p,sec): distance(mm)
The ultrasound machine assumesa constant rate for the velocity
of sound (1.54 mm/psec), and becausetime is recorded,distance
can easily be calculated.nRemember that the trip from the trans-
<o.ssPLI ducer to the reflector and back is two times the actual distance
B from the reflector to the transducer. This assumesthat the sound
wave travels in a straight line with no side trips along the way.
Figure 2-3. Axal resolutiondependson the spatialpulse length /SPLIof Two modes of echo display are commonly used in ultrasonogra-
the soundwave and the amountof separationof the reflectors lf the reflectors phy. These are brightness mode (B-mode, B scan, or gray scale)
are greater than 0.5 times the SPL (A), the structuresreturn two dlscrele and motion mode (M-mode). B-mode is the most commonly used
echoes,as illustratedbV the two separatearrows' lI the reflectorsare less
format and is used in both abdominal and cardiac imaging. M-
t han 0 . 5 t i m e s t h e S P L iBl, th e str u ctu r e sr e tu r no n lyo n e e ch o,as i l l ustrated
by the oveilapdng arrows. mode is used only for echocardiography.
B asi cU l trasound
Phvsics 23
l-mode imagescomprisea collection of dots that correspondto via frictional forces.3With diagnostic ultrasound machines, the
-,-. amplitude or strength of the returning echo.u'rrThesedots are relative amount of sound absorbed is very low and the temperature
:-sllayed on a black background,and the brightnessor gray scale changeis insignificanland imperceprible.
, . fie dot is highest (whitest) for the strongest returning echoes. Reflection of the sound beam contributes to attenuation. As
-::: depth of the structure returning the echoesdeterminesthe the sound wave encounters tissue interfaces of different acoustic
: -.'ition of the dots relative to the position of the transducer. impedance, a reflection is generated. Only reflections that return
:.iritiple thin scanlines make up a completeimage so that B-mode to the transducerare used for image formation. The scanningof
-::aqeslook like a slice of tissue.t structures from different anglesmay enhanceimage quality if more
\I-mode records a thin section of an ultrasound image over echoesare returned to the transducer from different angles.
:-:re. On an M-mode image, the depth of the image is displayed Scattering occurs when sound waves encounter smal1,irregular
--: the vertical axis, and time is displayed on the horizontal axis. surfaces.This occurs mainly within the parenchyma of organs and
-::e brightnessof the dots is proportionate to the strength of the is responsible for the texture of the internal organs. As the fre-
:e:urning echoes,as it is in B-mode. While holding the transducer quency of a sound beam increases, the incidence of scattering
:tationary, one can evaluate how far a structure moves over a increasesas well.
particular amount of time.tt' t'zThis technique is most commonly
used in echocardiographyto quantitatively evaluatethe function of
both the ventricles and the atrioventricular valves. I Artifacts
Image orientation varies with the structure that is being imaged. Misrepresentation of structures caused by some characteristic of
For cardiac imaging, the right side of the screenis cranial (toward the imaging technique is an artifact. In diagnostic radiology, arti-
the patient's head) with long axis images. For all other structures, facts hinder evaluation of the imase and are undesirable. Ultra-
the Ieft side of the screen is cranial and the top of the screen is sound artifacts are not always und'esirableand may actually en,
dorsal (toward the patient's spine) for longitudinal images. For hance evaluation of structures by providing insight as to the
transverseimages,the left side of the screenis dorsal. composition of the structures.For instance,sonographicimaging
of a fluid-filled structure (versus a hypoechoic tissue mass) reveals
I Principles of interpretation enhancementof soft tissuesdistal to the fluid-filled structure. Some
basic ultrasound artifacts are discussedin this section of the text.
Echogenicity relates to the relative brightness of a structure. An- Reverberation artifacts are multiple hyperechoic foci that occur
echoic structures have no echoes within them and appear black. at regular intervals on the image. Reverberation occurs when the
\\tren the echogenicity of two structures is compared, the darker sound wave encounters an area of high reflectivity and the sound
structure is hypoechoic and the brighter structure is hyperechoic. wave is reflected back toward the transducer.t. When the reflected
If the structures have the same degree of brightness, they are sound wave encounters the transducer, most of it is reflected back
isoechoic to one another. Becausetissue derangementsresult in into the tissues where it again encounters the area of high reflec-
changesin echogenicity,it is important for sonographicpurposes tivity. This cycle of bouncing between the transducer and the
to know the relative echogenicitiesof abdominal organs. Table 2-3 patient continues many times, resulting in the regularly spaced
lists abdominal organs in order of their relative echogenicity.l3,14
hyperechoic foci on the screen (Ftg. 2a). The distance between
Detecting changesin echogenicity is diffrcult, and accurate detec- the transducer and the highly reflective surface determines the
tion is related to the experienceof the sonographer.One should spacing of the hyperechoic foci. A common causeof reverberation
compare multiple abdominal organs with one another to determine artifactsin abdominal sonographyis intestinal gas.
which are truly abnormal. Additional complexity results from the Mirror-image duplicate structures that are normally present on
fact that machine settings may alter the echogenicity of an organ. one side of a strong reflector sometimesalso appear on the other
As an ultrasound beam travels through a medium, it is attenu- sideofthe reflector(Fig. 2-5). This is most commoniy encountered
ated. In other words, it iosesstrength as it travelsthrough tissue. when the liver is imaged with the diaphragm-lung interface aiting
The amount of attenuation is determined by the distance traveled as a highly reflective structure.Is When the gallbladder is used as
and the frequency of the sound wave. The amount of attenuation the "duplicated" structure, the artifact is explained. Normally, the
approximates0.5 decibels (dB)lcmlMHz over a round-trip dis- sound wave is sent toward the gallbladder, is reflected back toward
tance.3Sound beams of higher frequency are more attenuated the transducer,and is recorded on the screenaccording to how long
than lower frequency sound waves.Attenuation of the sound wave it took the echoesto return to the transducer. For the artifactual
involvesthree components:absorption,reflection,and scattering.t' 6 gallbladder, the sound wave is sent from the transducer, bounces
The conversion of a sound wave's mechanical energy to heat is off the diaphragm-lung interface toward the gallbladder,and echoes
called absorption.It is the dominant component of attenuationin off the gallbladderback toward the diaphragm-lung interface,
sofl tissue.8The conversionof sound wavesto heat occursorimarilv where it is reflected toward the transducer. Becausesome of the
sound must bounce off of the diaphragm-lunginterface,the sound
takes longer to return to the transducer; thus, the position of the
Table 2-3. Relative echogenicity of commonly artifactual gallbladder is misrepresentedon the screen.
encountered structures in order of decreasing Side lobes and grating lobes are secondarysound beams that
echogenicity3,13 emanatein a different direction than the orimarv sound beam.t'tu
Side lobes are associatedwith all transducers and originate from
Bone,gas , or gan boundar ies
additional mode vibrations of the piezoelectric crystal; grating
Structuralfat, vesselwalls
Renals inus lobes emanate from array transducers.In each instance, these lobes
Prostate result in an error in positioning of the returning echo (Fig. 2-6).
Spleen The side or grating lobes are weaker than the primary sound beam;
Storagefat these lobes must encounter a highly reflective surface and be of
Liver sufficientintensity to be noticed.rT't8
Renalc or t ex Slice thickness artifacts are most commonly noticed in associa-
M us c le tion with the urinary bladder and the gallbladder. In these struc-
Renalm edulla
tures, slice thickness artifacts mimic the presence of sludge or
Bile, ur ine
sediment (Frg. 2-7). It is important to understandthat a primary
24 P HY S I CS
A N D PR IN C IPL EOF
S IN T ER PR ETA TION
sound beam, which is three-dimensional,has thickness.When the duplication due to refraction artifacts is described in people,r, it
urinary bladder is imaged, for example, part of the thickness of does not occur commonly in animals. Refraction artifacts may lead
the primary sound beam is involved in imaging the urinary bladder to measurement errors.
wall while the other part is imaging the anechoic urine. The Edge-shadowingartifacts are refraction artifacts that are created
computer averagesthese two parts to create the pseudo-sludge when sound wavesare bent as they tangentially encounter a curved
artifact. The surface of the pseudo-sludge is usually curved, but surface (Fig. 2-B).i:, zoAnechoic regions are present distal to the
the surfaceof real sludgeis flat.t7 curved surfacesto which the bent sound waves should have trav-
Refraction occurs as the sound wave traversestissuesof different eled. This artifact commonly occurs when the gallbladder, urinary
acoustic impedance.As the sound wave moves to the new medium, bladder, or kidneys are imaged.
the sound wave is bent. The bending of the sound wave may result Acoustic shadows are regions of decreasedechogenicity distal to
in the display of organs in improper locations. Although organ structuresof high reflectivity (Fig. 2-9).re 17,rsIn thesesituations,
Figure 2-5. A mirror image artifactof a dog's gallbladderwas createdat the lung/diaphragm interface.The real gallbladder(GBr)is in the near field ano rne
artifactualgallbladderis in the far tield (GBa).The lung/diaphragm interfaceis the curved,thin white irne separating ihe two gallbladders. The schematicshows
the route that the sound wave travels (white arrows)to make the artifactualgallbladder. Becausethe ultrasound-machine cannot detect that the sound wave
c ha n g e dd i r e c t i o nd u r i n gts tr a ve is,th e u itr a so u n m
d a ch in ea ssumesanother gal l bl (GB
adder a)
i s presentbel owthe l ung/di aphragmi nterface.
_rd =
B asi cU l trasound
Physics 25
lltlllltrlr
qp 4D 4N
'',,,.
I
"',,,
lr l,"'',,
lj
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
^l
Figure 2-6' An ultrasonographic image createdin a water bath using a lineararraytransducerand a wooden tongue depressor.The tongue depressoris the
cright linearstructurecloserIothe bottom of the image.The gratinglobe artifactsare betweenthe transducer(top of the image) andthe tongr" depressor.The
schematicshows the gratinglobesemitted from each element of a lineartransducerand how they interactwith the tongue depressor(A) and createthe artifact
,B).fhe angleddotted lines show the actual path of the gratinglobes,and the verticaldotted lines illustratewhere the ultrasoundmachineplacesthe image.
: r o m B a r t h e zP l L eve illeR, Scr iva nPV
i Sid elo b ea n d g r a tingl obearti factsi n ul trasound
i magl ng.V et R adi olU l trasound
38:3g7*393,
1997.)
Figure 2-7. An ultrasoundimageof a dog's urinarybladderillustratingslicethicknessartifacts The hypoechoicregionin the urinarybladder(left ventralaspect)
: : ' e a t e d w h e n p a fr o f th e u ltr a so u n db e a m im a g e sth e a nechoi curi neand part i magesthe isoechoicurinarybladderwall. The two parts of the beam are
. , : ' a g e d t o g e t h e rt o cr e a teth e h yp o e ch o ic
r e g io nth a t co u ldbe confusedw i th sedi ment.
26 T - \ S CS A ND P R IN C IP L ES
OF IN T E R P R E TA TION
Figure 2-8. Ultrasoundimage of a dog's urinarybladderillustratingedge-shadowngartifactscausedby sound wave refraction.As sound waves tangenraty
encountercurvedsurfaces,they are bent so that no soundwave ls transmlttedinto the tissuesdistalto the curvedsurface.fhe blackareasdistalto the edqes of
t he uri n a r yb l a d d e a
r r e e d g e - sh a d o winagr tifa cts.
the primary sound beam is almost completely reflected or ab- attenuation. The two most common sites for acoustic enhance-
sorbed.An insufRcientquantity of echoesreturned from the loca- ment are distal to the gallbladder and the urinary bladder. To
tion distal to the strong reflector make these regions appear an- better understand this artifact, one must consider the acoustic
echoic (black).6 Naturally occurring acoustic shadows are found shadowing causedby the gallbiadder. Sound wave 1 travels through
at soft tissue-gas (bowel, lung) and soft tissue-bone interfaces; the liver and the bile within the gallbladder, then back inro the
pathologic acoustic shadows are most common with renal, cystic, liver. Sound wave 2 travels only through liver tissue. As sound
or cholecystic calculi. wave 1 passesthrough the bile, it is less attenuatedthan sound
Acoustic enhancement is a region of increased echogenicity wave 2 (as it passesthrough liver). Thus when sound wave 1
behind structuresof low attenuation (Fig. 2-10).r'Z''8This results reentersthe liver, it has a higher intensity and returns stronger
in areas of increased echoeenicitv distal to these areas of low echoesto the transducer.
g
BasicUltrasoundPhysics 27
Transducer
Figure 2-1O, This acousticenhancementis a region of increasedechogenicitybehind structuresof low attenuation.Bile in the gallbladder(blackcircular
: : - ' c t u r e ) d o e s n o t a tte n u a teth e so u n d wa ve a s m u ch a s the equi val entamount of l i ver ti ssue,creati ngacousti cenhancement(w hi te area di s talto the
I' r adder).In the schematic,Ihe left sound wave travelsthroughthe liver bile within the gallbladderlwhite circle)and then back into the liver.The rigrhtsound
. ' . : " e t r a v e l s o n l y t h r o u g h live r tissu e .Asth e /e /fso u n d wavepassesthroughthebi l e,l ti sattenuated
essthantheri ghtsoundw aveasi ttrav el s throughl i v er.
- - - s , w h e n t h e l e f t so u n dwa ve r e - e n te r s live rit h a sa h i gheri ntensi ty,
and thereforei t returnsstrongerechoesto the transducer,
th e creati n gthe di s talac ous ti c
:^^ancement.
References 16. Barthez Pl Leveille R, Scrivani PV Side lobe and grating lobe artifacts in
ultrasound imaging. Vet Radiol Ultrasound 38:387-393, 1997.
17. Penninck DG: Imaging artifacts in ultrasound. In Nyland TG, Mattoon lS (eds):
. Curry TS III, Dowdey JE, Murray RC Jr: Ultrasound. In Curry TS III, Dowdey
': Veterinary Diagnostic Ultrasound. Philadelphia, WB Saunders, 1995.
\lurray RC Jr (eds): Christensent PhysicsofDiagnostic Radiology,4th ed. Philadel-
::::. Lea & Febiger,1990. 18. Kremkau FW: Artifacts. In Kremkau FW (ed): Diagnostic Ultrasound-Principles
and Instrumentation, 5th ed. Philadelphia, WB Saunders, 1998.
- liremkau FW: Diagnostic Ultrasound-Principles and Instrumentation, 5th ed.
..:adelphia, WB Saunders,1998. 19. Middleton WD, Melson GL: Renal duplication artifact in US imaging. Radiology
173:427-429, 1989.
-:. \rland TG, Mattoon ]S, Wisner ER: Physical principles, instrumentation, and
:.-':r' of diagnostic ultrasound. In Nyland TG, Mattoon JS (eds): Veterinary Diagnostic 20. Sommer FG, Filly RA, Minton Mt: Acoustic shadowing due to refractive and
-.::asound. Philadelphia,WB Saunders,1995. reflective effects. AIR Am J Roentgenol 132:973-977, 1979.
-eo FP, Rao GW: The technology of diagnostic ultrasound. Radiol Clin North 4. In medical sonography, which two tissue interfaces reflect al-
--: -r:103-415,1975. most all of the sound wave?
' ::rk RD, Nyland TG, Lattimer JC, et al: B-mode gray-scale ultrasound: Imaging
:::::;ts and interpretationprinciples.Vet Radiol 22:204-210,1981.
5. Tiue/False. Ultrasound is the imaging modality of choice for
\', land TG, Park RD, Lattimer JC, et al: Gray-scaleultrasonography of the canine lungs.
-
: r : : :.n. Vet Radiol 22:220 227, 1981.
: FJ, Clark RN, Kozlowski R: A model of hepatic mirror-image artifact. 6. Tiue/False. As the frequency of the sound wave tncreases,
'::dner
.:: - ltrasound 4:19-21, 1980. image resolution increases.
28 P HY S I CS S IN T ER PR ETA TION
A N D PR IN C IPL EOF
7. True/Fa1se.As the frequency of the sound wave increases,the 9. If organ A is brighter than organ B, then organ A is (hypere-
depth of penetration of the sound wave increases choic, isoechoic,hypoechoic)to organ B.
ffi CHAPTER
ffi3
Physical Principles of Computed
ffi
ffi Tomography and Magnetic
ffi Resonancelmaging
ffi . Clifford R. Berry
One limitation of routine radiographsis that they are two-dimen- voxel, and the voiumetric information it contains is an average
sional presentationsof three-dimensionalobjects.Silhouettingand gray scale of all components of the particular rectangle of tissue
summation of various overlapping structures force the interpreter from which the information was acouired. Inherent within the
to use mental reconstruction of other dimensions as a way to display of the image are a multitude of gray scales that can be
understand spatial abnormalities. To aid in visualization of the accentuated and manipulated because the raw data are basically
internal archiiecture of an organ, special radiographic procedures computer numbers. These manipulations include contrast- and
using negative or positive contrast media were developed. These edge-enhancement algorithms.
procedures often required invasive techniques such as catheter
Computed tomography
placement. However, the limitations of superimposed structures
still existed, and complete evaluation of the organ in question was CT has dramatically changed the way in which patient anatomy is
not always possible.The development of cross-sectionalimaging viewed. CT allows one to obtain a cross-sectional imaee slice of a
has allowed visualization of the internal structure of an organ subject such that the internal structure can be visualized directly.
without superimposition. Additionallv, contrast resolution of cross- The basic principles of CT are similar to those of radiography in
sectional imaging modalities is tlpically far superior to that of that x-rays are used to create an attenuation map of the patient.'
diagnostic radiographs. The three most commonly used cross-
sectional imaging modalities are ultrasonography, computed to-
mography,and magneticresonanceimaging.
The purpose of this chapter is to review the basic principles of
image formation and of interpretation of computed tomography
(CT) and magnetic resonance(MR) images.The material is not
all-inclusive but servesas an introduction to the basic principles of
CT and MR imaging in veterinary patients. For further informa-
tion, the reader is referred to textbooks that discussthese subjects
in greater detail.l 5
I Principles of image formation
The physical principles behind CT and MR image formation in-
volve the use of a computer to acquire data and reconstruct it into
two-dimensional,gray scaleimagesin various imaging planes(i.e.,
transverse,dorsal, sagittal,and oblique).r5 Data typically are ac-
quired as a series of slices of information along an axis of the
animal'sbody (Fig. 3-l).
From a simplistic standpoint, a physical basis exists by which
each imaging modality interrogates or interacts with the patient.
After this interaction with the patient is complete, external detec-
tors collect and filter the signals and manipulate the data to ulti-
mately create a gray scaleimage. This image is actually a matrix of
Figure 3-1. Transversecomputedtomographyimage of the brain (window
squaresarranged into a grid of rows and columns. Each square is
width - 260; window level : 60) from an 8-year-oldmale GoldenRetriever.
called a picture element, or pixel. Within each two-dimensional The reconstrucleddata are presentedas a transverseimage in the plane of
scuare is^volumetric information that is dependent on the slice dataacqul sti on.In thi s dog,the sl i cethi cknessw as 5 mm. T he l ateralv entri -
thicknessused for data collection.This volumetric unit is called a cl esare di ated.
I
Ph y s i cal
P ri nci pl es
of computedromographyand Magneti cR esonance
lm aging 29
Table 3-1. Representative GT values (in Hounsfield trast (low contrast), and images having a narrow window have a
unitsl of different tissues/substances within the body short scaleof contrast (high contrast).
Body part CT value The window level is a midpoint for the range of window width
values. For example, if a window leve1 of 50 is used and the
White matter 30 (35") window width is 200, the range of HU values that would be
Gray matter 35 (42*l
displayed would include -50 to 150 HU. Any structure with a
Cere bro s pinal
f luid 6-10
He morrh age,ac ut e ( whole blood) 52 Hounslield unit of - 50 or below would appear totally black, and
Blo od clot 50-80 any structure with a Hounsfield unit of 150 or above would appear
Plasma 25 totally white.
Water 0 New techniques in CT have allowed for faster imaging and
coverageof larger fields-of-view. These new techniques are based
xCTvaluesof white and gray matter will increaseafter contrastenhance-
on the use of slip-ring technology, wherein the x-ray tube (and
ment. Grav matter receivesfour times the blood flow that white matter
does,so gray matter will be more attenuatingjust after deliveryof the detectors in a third-generation scanner) can rotate without having
contrastmediumto the brain.Edemawill decreasethe attenuationcoeffi- to stop to resetafter eachslice(return from the 360-degreeposition
cient of the affectedareaproportionalto the amount of water within the backward to 0 degrees) for the next revolution. This has allowed
edematousstructure. continuous scanningof approximately0.5 to 2.0 secondsper 360
degreesof rotation. The secondrecentadvancein CT has been the
introduction of spiral or helical technology that allows for continu-
Acquisition of CT images is dependent on the rotation of an x-ray ous acquisition of data while the patient is continuously moved
tube around the patient and the acquisition of a seriesof x-ray through the gantry at a constant table speed.The pitch of the scan
projectionsusing rotating (third-generation)or stationary(fourth- is dependent on the slice thickness/table speed, so that a slice
generation) x-ray detectors.l As in conventional radiographS the thicknessof 5 mm and a table speedof 5 mmisec would equal a
x-rays either pass through the patient or are attenuated. This pitch of 1. Higher pitches of two will result in possible artifacts
attenuation is dependent on the energy of the x-ray, the electron during the reconstructionprocess.This volume of information is
and physical density of the material within the patient, the thick- reconstructedusing filtered backprojection and 360-degreelinear
nessof the patient, and the effective atomic number of a particular interpolation. A third recent advance in CT technology in which
substancewithin the patient. This transverse raw data set is then there are multiple rows of detectors is called multichannel com-
reconstructed using the mathematical algorithm of filtered back- puted tomography. With the use of this technology, becausemulti-
projection, and an image is produced.t ple detector rows are used, more than one image siice can be
A CT image is a matrlx of squares,each having a unique degree acquired at a time. These last two technologies have allowed for
of blackness,depending on the attenuation of photons from a rapid acquisition of large volumes of informition in a very short
given location within the patient. Standard CT scannersacquire time, which has contributed to the advancementof CT angiography
data from a particular tissue thickness with each transverse slice. and the three-dimensionalimaging of largebody parts. Application
All of the attenuation information that is collected within a given of these techniques to veterinary medicine enablespatient imaging
voxel (i.e.,volume elementof the associatedpixel) is averaged,and without the need for general anesthesia.
this averagedgray scalevalue is then displayed.This averagedgray
scalenumber can lead to erroneousinterpretationbecauseof vol-
Magnetic resonance imaging
ume averaging resulting from the particular volume or thickness MR imaging is the latest cross-sectional imaging modality to gain
of a given slice of information. In other words, if a voxel contains wide acceptance,particularly in the area of soft-tissue,bone mar-
a very opaque structure and a very lucent structure, the end-result row, and neurologic imaging.s'0 Advancesin MR imaging have
blackness (physical attenuation or CT value) of the voxel will be allowed rapid imaging of small parts with high inherent contrast
an intermediate shade of gray. Thus, volume averaging can artifi- resolution. The mechanism for acquisition of data is completely
cially raise or lower a structure's attenuation value, and thereby its different from any other imaging modality. The reader is encour-
appearancein the image.r''? As has been mentioned, the number of aged to consult other referencesfor a complete explanation of MR
\-rays attenuated by the patient is affected by a variety of factors. physicsand imagingprinciples.,. 4
\\tren the computer reconstructsthe images,the image voxel values The fundamentals of MR are dependent on several inherent
are normalized to the linear attenuation coef6cient of water. These nuclearphenomena.The nucleus.oniirt, of protons and neutrons.
ralues are expressedin Hounslield units (HU).+ Water has an HU Both protons and neutrons have a property calledspin, or angular
of zero, cortical bone has an HU of + 3000, and air has an HU momentum. Becauseof its positive electric charge, the proton
of - 1000. Different organs and materials within the body have behaves like a magnet, and it establishesa small magnetic field
;haracteristicHU values (Table3-1). about itself. This property of behaving like a magnet and generating
One can manipulatethe valuesof the gray scalethat are assigned a spin is called a magnetic dipole. If there is an odd number of
:o the CT image. The window width describesthe range of CT protons, the unpaired proton will exert a magnetic dipole with a
lalues assignedto the gray scalewithin the image. A wide window discrete strength and direction (a vector quantity). The hydrogen
rridth would be 1000, whereas a narrow window width would be atom is the most abundant nucleus in the body with an unpaired
150. A wide window width is used when an extreme spectrum of proton, and therefore is the nucleus that is most commonly imaged
-:hvsicaldensity (and therebyHU) is being imaged (e.g.,the lung). using MR. Other potential nuciei with odd proton numbers that
'r\'ith a wide window, structures with only slight differencesin HU could be imagesin MR include t,C, ,.Na, and ,eF.
-"alueshave the same appearance.A wide window should not be With the patient in a high-strength external magnetic field, the
used to discriminatebetweentwo similar (in terms of HU) struc- proton magnetic dipoles align themselveswith the long axis of the
r:res. A narrow window width is used when a smaller sDectrum magnetic field (usually along the axis of the patient's body, defined
..: physical densities (HU) are close to one another {e.g., when as the z-axis). A net magnetic moment is then established(Fig.
;rtferentiating gray and white matter within the brain, or brain 3-2). Another property of individual protons is that they can
;dema from neuropil).6' Window width is similar to radiographic absorb energy from externally emitted radiofrequency waves. This
.lrntrast. Imageshaving a wide window have a long scaleof con- absorbed energy causesthe individual proton's vector direction to
move out of alignment with the external magnetic field (Fig. 3-3).
'CT r.alue(Hounsfield unit) : l(pmaterial pwater)/(pwater)l X 1000, where The "excited" proton then starts to rotate around its original spin
= linear attenuation coefficient. state and returns to that spin state over time through a process
30 P HY S I CS
A N D PR IN C IPL EOSF IN T E R P R E TA TION
t*
*l
4!
It
:,,iiell
Fi gure 3-2. S chemati crepres enta-
* , ;' ],l]:::rrrrl ti on of i ndi vi dual proto nsthat ex hi bi ta
gi venspi nand energys tate.Onc ethey
:t;*):::,:
a'e pl acedw i l l -i na stro ngex ternarmag-
'.'l net'c fi el d l B ol ,tne ,ndi v i dual
magneri c
,:!:::,:li9l:,
ri
i!uu:tiil''l moments w i l l al i gn thems el v esal ong
il-iiiall,,;l
caIled precessior. This rotation of the magnetization vector or decay (FID). Each word in the term FlD is meaningful in helping
magnetic moment induces an electrical signal in receiver coils that one to understand the process of obtaining an MR signal.3Free
are found rn the x-y plane. This electric signal oscillates as the refers to the fact that the net magnetization vector (i.e., the pro-
magnetization vector points toward and away from the receiver tons) is no longer under the influence of the radiofrequency pulse.
coil. The amolitude of the electric sienal decreasesover time as the Induction means that the oscillating magnetic fieid that is being
individual protons lose phase coherencewith each other and return created by the precessionof the net magnetization vector within a
to the lower energy state. The speed with which each proton closed coil system will induce an electric current that represents
(individual magnetic moments) loses coherence is dependent on the MR stgnaLDecay means that the signal decreasesin intensity
the relaxation properties describedlater in this chapter.The electric over time.
sisnal that is induced in the receivercoil is called the free induction The intensity of a given signal that is releasedfrom the "excited"
protons is very complex and is dependent on four essentialcompo-
nents. Theseinclude (1) the concentrationof the protons (,H), or
proton density, (2 and 3) the two intermolecular interactions for a
given proton defined by two different relaxation times (Tl andT2
relaxation times), to be discussedlater, and (4) the bulk flow of
the protons.
MR imaging is very different from CT in that the tlpes of
physical/chemical bonds and the amounts of chemical elements
that are present, their individual thermal motions, and their chemi-
cal interactions strongiy affect the relaxation characteristicsof "ex-
cited" protons, and thereby the signal that is given off. In Cl these
environmental and chemical interactions are inconseouential to
final image formation. In fact, because of these enviionmental
interactions, along with the inherent contrast resolution of MR
equipment, excellent soft-tissue delineation can be achieved be-
tween structures, with only minor differences in physical density
& and poor contrast resolution on C! as in images of the brain.
S"
6 Under normal conditions, the proton magnetic dipoles are ran-
* domly arranged in tissue. Once the external magnetic field is
w turned on, the dipoles will align themselves into specific energy
g stateswithin the body. Their orientation will be either in the same
s direction as the external magnetic field (parallel with a lower
6s# energy state) or in the opposite direction to the external magnetic
w
field (anti-paraliel with a higher energy state). Becausethe protons
x prefer the lower energy state, slightly more of them will have this
Figure 3-3. The effects of a 90' or a 180' radiofrequency pulse on the net orientation, resulting in a net magnetic moment that is aligned
magnetizationvector (M). In this example,the radiofrequencypu ses excite parallel with the external magnetic field (typically denoted as the
the net magnetlzation vector out of the paraLlel state {alignedwith rhe z-axis)
z-direction in MR nomenclature). In reality, the torque of the
into an excited state along the x-f plane (90")or oppositeto the z-directon
. h e " e x c i t e d "M . th e n lo se se n e r g ya s it r e tu r n sto th e paral l elresti
{ 18 0 ' ) T , ng external magnetic field will cause the net magnetic moment to
z-axts. precessaround the axis of Bn at a characteristic frequency called
P ri nci pl es
P h y s i cal of C omputedTomography
and Magneti cR esonance
lm aging 3l
the angular frequency. This angular frequency is directly propoF Table 3-2. Representative Tl and T2 relaxation times
tionate to the magnetic field strength, Bo,by the equation: (in msecl of different parts within the body (as measured
with a GE Signa, 1.5 Tesla MR lmagerl3
oo (angular frequency) :
Structure Tl value T2 value
1 (gyromagnetic ratio) X Bn (external field strength in Tesla)
White matter 589 msec 76 msec
As angular frequency is measured in radians per second and as Gray matter 1 2 1 5m s e c 1 0 6 m se c
there are 2rr radians in a complete rotation, the equation can be C e r e b r o s p i n af l u i d 2000 msec 1 2 0 0m se c
rewritten in terms of the precessionalfrequency expressedin cycles Water 3000 msec >2000 msec
per second,or Hertz, as follows:
fo (precessionalfrequency) :
1l2r x Bn (external fie1d strength in Tesla) that is not bound ("free") and has a T1 relaxation of 3000 msec,
whereasprotein-bound water has a shorter T1 relaxation.
where the frequency of precession (fo) is also called the resonance
When an MR image is reviewed, structures are referred to by
frequency,or the Larmor frequency.For protons, 1l2r ls a constant
the intensity of signal that is produced, with white being considered
and is equal to 42.58 MHz/Tesla. This means that in a static
"hyper"-intense, or with high signal intensity, and black being
magnetic field of 1.5 Tesla,the protons will precesswith a frequency
considered"hypo"-intense, or with low signal strength or signal
of 63.87MHz (1.5 x 42.58).
void. On Tl-weighted images (see spin-echo imaging later), a
The net magnetic moment (Mz) is aligned with the external
structure with a prolonged Tl relaxation(e.g.,cerebrospinalfluid)
magnetic field. If electromagnetic radiation is applied as a short
will appear hypointense (black), whereas a structure with a short
radiofrequency pulse, the magnetic moment can be reoriented to a
Tl relaxation (e.g.,fat) will appearhyperintense(white).
new direction out of the z-, or longitudinal, plane and into the x-y,
Differences in intensity on a Tl-weighted image that influence
or transverse,plane. For the protons within the subject to absorb
soft-tissue contrast include proton density and the differences in
the radiofrequency photons of energy (and thereby move from a
Tl rela-xation rates between two tissues. Factors that influence
parallel to a higher energy, and less stable, anti-parallel state), the
T1 relaxation include the strength of the magnetic field and the
radiofrequency pulse must be equai to the precessionfrequency of
paramagnetic contrast agents. Use of low-field-strength magnets
the protons within the subject. Once the proton has been reori-
(0.5 Tesla)results in increasedsoft-tissuecontrast differencesbe-
ented in a different plane owing to the absorption of the radiofre- 10,11Intravenous para-
tween tissueswith different Tl rela-xations.3,
quency pulse, it will again attempt to reach the lower energy state.
magnetic substances, such as gadopentetatedimeglumine (Magne-
This processof relaxation is dependent on severalfactors, including
vist), decreaseT1 relaxation times. The normal range of T1
magnetic field strength, spin interactions, magnetic field inhomoge-
relaxationtimes in the body is between 100 and 2500 msec. Some
neities, and the presenceof paramagnetic materials and the envi-
representativeT1 relaxation times are shown in Table 3-2. T1-
ronmental lattice within which the proton is found.
weighted images can be obtained in a relatively short time (3 to 5
Think of the simplest MR experiment as the patient being placed
minutes) in any of the imaging planes. Tl-weighted images usually
inside the magnet, with a series of radiofrequency waves (pulses)
best demonstrate the anatomy of a specific structure, particularly
being used to excite the given nuclei; then the excitation pulse is
the brain.
turned off. The receiver coils are turned on to "listen" for the FID
signal generatedby the excited protons as they lose phasecoherence T2 relaxation (spin-spin or transverse
and return to their lower energy state. These latter two steps are relaxation)
repeated a number of times and the volume of raw data is then
availablefor reconstruction into a given imaging plane. This repre- T2 relaxation is defined as the time recuired to reduce the net
sents an oversimplification of the process; further explanation is transversemagnetization to 37o/oof its orlginal value. Therefore, a
necessaryfor defining the MR characteristics of different tissues. short T2 means a rapid loss of transversemagnetization (after the
issuesofk spaceand Fourier transformationare not discussedhere. net magnetic moment has been excited or "flipped" from the z-
orientation into the ,c-l or transverse plane). As protons release
excessenergy and changeto a more stable form, the energy released
TI relaxation (spin-lattice or longitudinal
can interact in several ways. First, the energy is absorbed by the
relaxation)
lattice or environment and directlv impacts the thermal molecular
T1 relaxation can be defined as the time (msec or sec) required motions of the tissue.This procesi is risponsible for T1 relaxation.
-or protons to recover63.20/oof their original Mz value in the z- Secondly,the energy releasedcould be absorbed by another proton
lirection after the application of a radiofrequency pulse that rotates that is then shifted from low energy to a higher state of energy.T2
:he original net magnetic moment by 90 degrees.Becausethis relaxation is basedupon direct proton-proton interactions, wherein
-nvolvesthe releaseof energy from the protons moving from the the released energy is absorbed by another proton. This energy
ercited (anti-parallel)state to the lower energy (parallel) orienta- exchangeresults in changesin the spin orientation of the proton
::on, the longitudinal (z-direction) magnetizationis gradually re- and is therefore called spin-spin relaxation. The T2* is the actual
;overed, so T1 relaxation is also referred to as longitudinal relax- relaxation time that is initially measured (Fig. 3-a) because of
.:ilon. Additionally, the T1 relaxation is dependenton the energy imperfections in the magnetic field that result in altered T2 relax-
:rchangebetweenthe excitedprotons and the surrounding molecu- ation characteristics.
-ar lattice, so another name for T1 relaxation is spin-latticerelax- In summary, T2 relaxation occurs after the net magnetization
::;on. vector has been rotated into the transverse plane. Now, the large
T1 relaxation is dependent on severalfactors, including molecu- magnetization vector in the x-7 plane loses coherenceowing to the
-;r motion, the binding of the molecule to other substancesor its local interference of the proton's own minute magnetic field and
:dstence in a "free" state, and the size of the molecule. The the inherent inhomogeneities in the externally applied magnetic
:rteraction among these three factors is complex. In general,T1 field. The protons exchangetheir energy with neighboring protons
::laration is enhanced(shortened)by molecularmotion with mod- through interactions with their spin states.Protons that are found
.:ate speed, or by medium-sized molecules that are "partially" in the fluid state have decreasedspin interactions with their neigh-
:-.und. T1 relaxation is lengthened by very slow- or very fast- bors, and thereforelonger T2 relaxation times (msec).The range
:o\-ing molecules, and by larger, bound and smaller, unbound of T2 relaxation times in various tissuesis between 20 and 2000
::olecules. For example, water is a small, fast-moving molecule msec (seeTable 3-2).
32 P HY S I CS
A N D PR IN C IPL EOF
S IN T E R P RE TA TION
Figure 34' A s c he m a ticg r a p h icarle p r e se n ta tioonf fr e e inducti ondecay(Fl D )and echo srgnal sthat w oul d be i nduced
i n the recei vercoil safter a s randard
sp i n - e c h op u s e s e q ue n ceth a t u se s a n in itr a 9l 0 " a n d r e p e ti ti ve180'pul ses to producemul i i pl eechoes.The
exponentrat decayof the FID from eac h ec ho
re p r e s e n ttsh e 1 2 * ,wh ile th e e xp o n e n tiadle ca ylin eth a t in te rsects the peakof the FIDfrom eachecho represents the true rz rel axati onti me.The reas onfor the
m o r e r a p r dd e c a ya s s e e n in th e T 2 * d e ca ycu r ve sis m a g n eti cfi el d i nhomogenei ti es. The IE represents the echo ti me or ti me from th; i nl tj aloo:-[uLu to tr."
f r r s tp e a ke c h o s r g n alth a t will b e u se dfo r im a g efo r m a tio nBr,
. represents R F si gnal sfor changi ngprotonori entati on
to i nducethe FID si ona.
In contrast to T1 relaxation, structures with lonser T2 relaxation proton density can be obtained using standard spin_echo_t1pe
have a higher signal intensity (they appearwhite on T2-weighted sequencesas well. Protocols for various imaging ,.qrr.rr.., urrd
images). Additionally, increasing the field strength has little effect specificdiseaseprocessesare continuouslybeing modihed and are
on T2, and the T2 values are always less than the T1 values for a beyond the scope of this text.
given body tissue. The appearanceof different structures on T1- As has been previously stated, the timing of an MR sequenceis
and T2-weighted images is summarized in Table 3-3. critical as to which relaxation characteristiis are emphasized.One
can think of these sequencesas a series of repetitive expertments
Physical basis of spin-echo imaging that are done to increasethe signal-to-noiseraiio. As one increases
Different pulse sequencesthat can be applied during MR imaging the number of pulse sequences performed,the signal-to-noiseratio
of the patient emphasizesignal recorded from a particular type of increases.The number of excitations(or NEX) is the number of
relaxation process. The combination of the characteristics and pulse sequences that are done with the same x-,y-, and.z-gradients.
specific timing of the radiofrequency pulses with the application of A pulse sequenceis made up of (1) an initial 90-degree-radiofre_
the magnetic field gradientsis called a pulse sequence.The basic g".l:y pulse (along with an application of a z-gradient for slice
pulse sequencecan be defined as the application of an excitation Iocalization),(2) application of a y-gradient,(3) ; rephasing180_
pulse followed by a time of listening for the signal given off by the degreeradiofrequencypulse, and (4) an echo time for recordine of
tissues. In some sequences,rephasing pulses can be applied that the signal (along with application of an x- or readout gradiint;
allow for ma-ximization of the initial excitation pulse becausethey Fig. 3-s).
are able to "read" smaller signals, called echoes. Some of these As has been mentioned, these puise sequences are centered
pulsed sequencesemphasizejust T1 relaxation (called saturation- around an initial excitation radiofrequency puise of the area or
recovery and inversion-recovery). Some pulse sequencescan be slice that is being imaged. The initial fn signat is ignored in this
used to emphasizefluid in the vesselsor to de-emphasizefat in the process, and a second radiofrequency pulse that .,rephases,'the
tissues. This latter technique is called fat saturation; it results in protons is applied so that a signal (echo) is created. The time
black, or signal void, in areasof fat. betweenthe application of the initial 90-degreepulse and the peak
The most common pulse sequenceused today for routine MR of the echo signal is called the echo time, oi TE.-Th. TE is actuallv
imaging is called spin-echoand fast spin-echoT2 imaging. In this the time when the signal induced in the receiver coiis is recordei
sequence,one can obtain two different image sets (Tl-weighted and is used for producing the MR image. Additional lS0-degree
images and T2-weighted images) of a tissue by altering the pulse pulses can be applied that will result irr smaller echoes from-the
sequencewithin the spin-echo imaging protocol. Images reflecting original FID. To differentiate T2t from true T2 relaxation, an
Table 3-3- Representative differential diagnostic considerations fol intensity patterns seen
on
T1- and T2-weighted images
T1 image T2 image Differential diagnosis
Hypointense(dark) Hy per int ens e( br ight ) C e r e b r o s p i n afl u i d , f l u i d c o l l e c t i o n se. d e m a
Hyperintense Hypointense Fat, some protein solutions,calcium deposits,or transientblood flow
Hyperintense Hy pernt
i ens e Paramagneticsolutions/contrast, extraceilurarmethemogrobin,proteins.
mucopolysaccharide solutions
Hypointense Hypointense Densecalcium deposits,bone, air, rapid flow, hemosiderin,metallicartifacts
PhysicalPrinciples
of ComputedTomography
and MagneticResonancelmaging 33
erponential curve can be fit to the peaks of the FID echoes,which is applied at the time ofthe 9O-degree and the 1B0-degree radiofre-
will give the true time constant that is equal to T2. In summary, quency pulses. The y-gradient (phase-encodegradient) is applied
an initial 9O-degreepulse is used to rotate the proton magnetic after the initial 9O-degreepulse and prior to the l8O-degreepulse.
vector into the x-y plane. A series of l8O-degree radiofrequency The x-gradient (frequency-encodegradient) is applied at the time
pulses are applied that result in multiple echoes,which can be used of the echo, so it is also called the readout gradient. Protons precess
for the creation of the MR image. The time between successive at different frequencies owing to differences in the local magnetic
applications of 90-degree pulses is called the repetition time, or field strength (Bo); different signal frequenciesresult, based on the
TR. The delay time, or TD represents the delay between the Larmor equation. The frequency of these signals can be localized
recording of the final echo and the initiation of the next 90-degree to the known proton. The signal strength gives rise to the intensity
radiofrequency pulse. of the gray scalevalue that will be assignedto that given voxel.
By varying the TR and TE, one can emphasizeT1 relaxation, T2 Two-dimensional and three-dimensional imaging modalities are
relaxation, or proton density as the parameter creating signal in available in most MR scannerstoday. In two-dimensional imaging,
the image. A short TR (400 msec) and a short TE (20 msec) specific transverseslices are excited (usually 2-3 slices at a time),
emphasizeT1 relaxation. A long TR and a long TE emphasizeT2 and somewhat like a CT scanner, the data are acquired slice by
relaxation. A long TR (2000 msec) and a short TE (20 msec) slice. In three-dimensionai imaging, a volume of information is
emphasizeprimarily proton density. obtained that can then be reformatted into any anatomic or oblique
Image Iocalization is accomplished by altering the strength of plane desired.
the static magnetic field along rhe x-, y-, and z-directions of the Image contrast is dependent on the spin-echo pulse sequence
magnetic field. Localization occurs because of specially designed selectedand the relaxation properties of the tissue in question. In
gradient coils in the bore of the magnet. These gradients are general, the effects of Tl and T2 changes are opposite. In T1-
applied during different times of the spin-echo pulse sequenceso weighted images when peritumoral edema is present, there is a
that the echo signal that is given off can be accurately localized to hypointense signal, whereas in a T2-weighted image, the peritu-
a given voxel within the volume of tissue, or a given slice of tissue moral edema will appear hyperintense (Figs. 3-6 and 3-7). Para-
being imaged. The z-gradient (also called the slice-selectgradient) magnetic contrast agentsdecreaseboth T1 andT2, which increases
b*rrl::ll-:r:.,:;l,:..:9'&
"d
Figure 3-7. Transverse/A/ and sagittal/B/ T1-weighted,contrast-enhanced
imagesfrom a 1O-year-old, mixed-breeddog with three contrast-enhancingcrrcutar
lesionslocatedwithin the brainparenchyma.
Thesefindingsare consistentwith metastaticneoplasia.At necropsy,metastitic carcinomawas identified.
signal intensiry on the T1 images while decreasingsignal intensity 3. The individual volume element that makes up the CT array and
on the T2 images. defines the gray scaleHounsfield unit assignedto it due to the slice
thickness is called the:
References A. Pixel.
B. Cloxel.
l. Miraldi F, Mieson EJ: Imaging principles in computed tomography. In Haaga JR, C. Array unit.
Alfidi Rl (eds): Computed Tomography of the Whole Body, 2nd ed. St. Louis, CV D. Voxel.
Mosby, 1988. E. Magnetization constant.
2. Barthez PY, Koblik PD, Hornof WJ, et al: Apparent wall thickening in fluid filled
versus air filled tympanic bulla in computed tomography. Vet Radiol Ultrasound 4. The precessionalfrequency of the hydrogen proton is depen-
37:95-98, 1996. dent on:
3. Smith H-J, Ranallo FN: A Non-Mathematical Approach to Basic MRI. Madison, A. Proton density.
WI, Medical Physics Publishing Corporation, 1989. B. Electron spin of the proton.
4. Thomson CE, Kornegay JN, Burn RA, et al: Magnetic resonance imaghg: A C. Neutron number.
general oveniew of principles and examples in veterinary neurodiagnosis. Vet Radiol D. Magnetic field strength.
Ultrasomd 34:2-17, 1993.
5. Mitchell DG: MRI Principles. Philadelphia, WB Saunders, 1999. 5. When comparing MR with CT imaging, which of the following
statement(s)is (are) true?
6. Fike JR, LeCouteur RA, Cann CE: Anatomy of the canine brain using high
resolution computed tomography. Vet Radiol 22:236-243, 1981.
A. MR imaging has better inherent soft-tissue contrast resolu-
tion.
7. George TF, Smallwood fE: Anatomic atlas for computed tomography in the
B. MR imaging requires less upkeep and less initial cost than
mesaticephalic dog: Head md neck. Vet Radiol Ultrasound 33:217J40, 1992.
CT.
8. De Haan CE, Kraft SL, Gavin PR, et al: Normal variation in size of the lateral C. MR imaging provides unique physiologic information (e.g.,
ventricles of the Labrador retriever dog as assessedby magnetic resonance imaging.
Vet Radiol Ultrasound 35:83-86, 1994.
spectroscopy),as well as anatomic imaging, when compared
with CT.
9. Hudson LC, Cauzinille L, Kornegay JN, Tompkins MB: Magnetic resonance im-
D. Standard MR imaging sequencesand scan times are typically
aging ofthe normal feline brain. Vet Radiol Ultrasound 36:267-275, 1995.
less than CT scan times.
10. Karkkairen M: Low- and high-field-strength magnetic resonance imaging to E. Veterinary patients undergoing MR imaging evaluation with
evaluate the brain in one normal dog md two dogs with central nervous system
disease.Vet Radiol Ultrasound 36:528-532, 1995.
standard sequencesdo not require anesthesia.
11. Stark DD Bradley WG: Magnetic ResonanceImaging. St. Louis, CV Mosby, 1988. 6. Free induction decay refers to:
A. The computer algorithm used to determine the HU within
a patient.
ffi Ouestions B. The process of electric signal induction within the receiver
coils in MR imaging.
1. What are the basic differencesbetween CT and MR imaging? C. Loss of x-ray signal from the CT detectors due to the fluo-
rescencehalf-life of the detector sas.
2. A window width of 1500 and a level of -500 would be most D. BIue light specialson aisle3.
suitable for evaluation of:
A. Lungs. 7. T2 relaxatron is defined as:
B. Mediastinum. A. The time required to reduce the net transversemagnetization
C. Liver. to 37o/oof its original value.
D. Abdomen. B. The time required to increase the net transverse magnetiza-
E. Vertebrae. tron to 37o/oof its original value.
V i sualP ercepti on
and R adi ographiInte
c r pr et at ion35
P TE R
4
V isual Perception and Radiographic
Interpretation
r Marc Papageorges
Seeing is believing. Vision is our most powerful sense, and we mechanismsdevelopedby our brain/mind to make senseof sensory
consider what we "see" to be an exact reoresentationofthe phvsical signals.l,2,e Many believe that the alarmingly high error rate re-
world. But is this confidencejustified? Numerous studies suggesl ported in radiographicinterpretationto-]2 is rooted in our percep-
that often it is not.1'2The purpose of this chapter is to convince tual mechanisms. This hlpothesis is supported by the fact that
you that, when interpreting medical images, it may be a good idea improving the quality of radiographs, even with digital manipula-
to think about how perception may affect the visual system. tion of the image,does not seemto reducethe error rate.
Acknowledgment of the limitations of the visual system and
I Visual inaccuracies familiarity with perceptual errors may be the only way to reduce the
inconsistency of interpretation in radiology. To better understand
Slow dark adaptation and peripheral glare are widely recognized
perceptual mechanisms and their implications in radiology, the
visual handicaps in radiographic interpretation. Their detrimental
phenomena of subjectivecontours, multistability of perceptions,
effects can be minimized through the use of optimal viewing
and visual searchare examined in the subseouentsections.
conditions.3s Poor performancein estimationof length, angle,and
size (Figs. 4-1. ro 4*4) is more difficult to acknowledge,1,6 but once
conceded,it is easilyovercomewith measuringdevices,such as a
ruler. Other distortions of visual information, such as the Mach
phenomenon (Fig. a-5) and the contrast background effect (Fig.
f6), cannot be eliminated,but awareness of their existencereduces
interpretationerrors.T' 8
I Perceptual distortions
The most common and flagrant visual inaccuracies are difficult
to detect and eliminate because thev seem to involve oerceptual
@Y 393
@
-G
V i sualP ercepti on
and R adi ographiInt
c er pr et at ion97
:l'" the perception of contours can also occur where there is no edge
,1.
I
).
tt
l
people perceivea triangle. If there are four dots, a square or a
!
rectangieis "seen" (Fig. a-8). The obiective visual information,
however, is limited to three or four dots that are physically inde-
pendent from one another; the dots could as well be part of a
circle or a complex figure (Fig. 4-9). yet, we perceive i triangle
and a square. These figures give us a first clue about the difference
between vision (what the eye sees)and perception (what the brain
sees),and how previous knowledge-of triangies and squares-
influencesperception.
o a O
Otherinputs
aa
aa
Percept Percept Percept Percept Percept
Figure tt-8, Sevenb/ackdots are perceivedas a triangleand a square
Figure /t-9, The same dots could as well be parts of a circle and a com- Figure 4-11, The visual lnformationis limitedto three b/ackpatcheswlth
plexf i g u r e . small trlangulardefects.Where ts the /argewhite trianglecomingfrom?
G
VisualPerceptionand Radiographic
lnterpretation 39
_/
b?
Figure tI-14. False kdneys or abdominalmasses can be "created'
Figure zl-12. When the brain/mindhas been sensitizedor expects the unrelatedloopsof bowe .
p e r c e p t l,i m i t e d - o r un r e la te d - in fo r m a tioca
n n in d u ceth e mentali mage.
])r by experiencedradiologists.'?O
" For the most part, this is not the
r
\ _/
t
V
'"?"!l,.i"d,i,l;".
ltu
il"o'u
\-/ I
visual sisnals supporl th e p e r ce p t,the mentali mage
Figure tI-I5. The perceptionof nodul esor cavi taryl esi o nsc an be i nduc ed
by unrei atedopaci ti es.N ote al so now Tne nodul ecan appea"as a s quare,f
you so desrre.
40 A ND PR IN C IPL EOF
P HY S I CS S IN T ER PR ETA TION
R
ri l r(\
/r\ll
(-\
Figure 4-17. lt is so unusualto see stairwaysupsidedown that you may Figure tI-I9. Progressivefigures show how preconceptionscan infuence
f eel u p s i d ed o w n y o u r s e lfwh e n th e se co n dp e r ce p te m e r g e sin to consci ous- percepti on,parti cul arli yn condi ti onsof uncertai nty
or i f the phe nomenonob'
N ESS. servedi s partof a spectrumof possi bi l i ti es.
V i sualP ercepti on
and R adi ographiInt
c er pr et at ion4l
. . .1 ... 3.;.t]ra. ,
t .-
FINISHEDFILESARE TH E R E-
l o' 1 l- - o.- 1o .io ..1
o l '^.
r
. a I o- r
t.aa- a
a t .t.t- ..1- ..- t- t
a- r ^ a- J--
' . t:' .t.
SULTOF YEARSOF SCIENTIF.
l a l
....t
r i . o.' .- .t
J... ...;: .
r - r r g' .t.' r ^
.- : .- r - ..
l.:. t
r i o t
IC STUDYCOMBINEDWITHTHE
a a .j ......a- . :- - a' - - ....,. . ..
; EXPERIENCE OF MANYYEARS
OF EXPERT OBSER VAT I O N .
'lirtri*ffifii
- , .'o.... i.'i.. . ;;. 3-%
....i .
..Ir I r . i,t.' .
- ta..^.
t.'
i'.'.'i i. .
a
-
aa., ]
^' ^.
- l' 1.r - .
- a- ?-_to-
.- a a- e
Figure 4-22. Counting how many times the letter "F" is used in one
sentenceprovesmore di ffi cul tthan anti ci pated.
on one radi ograph
Fi ndi nga l l perti nentl es i ons
i s l i kel yto be a morearduoustask.
4. Alter AJ, George MD, Kargas A, et al: The influence of ambient and viewbox
light upon visual detection of low-contrast targets in a radiograph. Invest Radiol
17:402406, 1982.
'
' .'. ! :..'.:i.'.'i;;.j..'..l -t "a-a tion of abdominal radiographs. Radiology 17:69-71, 1g1g.
12. Lusted LB: Perception of the roentgen image: Application of signal detectability
tr t. t. t theory. Radiol Clin North Am 7:435-445,1969.
' .t,i- .t] !t '
oaa_oaoaaaa,
13. Daffner RH, Gehweiler JA, Rodan BA: Subjective contours and illusory roentgeno-
graphic images. Appl Radiol luly/Aug,95, 1984.
Figure /r-21. Lesions that do not stand out enough from the background to
14. Kanizsa G: Subjective contours. Sct Am 234:48-52,1.976.
b e d e te cte d b y th e per ipher al vision ar e mor e difficult to find. C an y ou fi nd s i x
slighlly larger dots? 15. Ratliff F: Contour and contrast. Sci Am 226:90-110, 1972.
42 P HY S I CS S IN T ER PR ET A TION
A ND P R IN C IPL EOF
16. Attneave F: Multistability in perception Sci Am 225:63, 1971' 21. Llewellyn-Thomas E, Lansdowne EL: Visual search patterns of radiologists in
training. Radiology 811288-292,1963.
17. FreemanWl: The physiologyof perception.Sci Am 264:78 85, 1991'
18. Fletcher CM, Oldham PD: The use of standard films in the radiological diagnosis 22. Tuddenhan Wl, Calvert WF: Visual search patterns in roentgen diagnosis. Radiol-
of coal workers' pneumoconiosis.Br .l Ind Med 8:138, 1954. ogy 76:694-704, 1961.
19. Squire LF: Perception related to learning radiology in medical school Radiol Clin
North Am 7:485-497, 1969. 23. Kundel HL, LaFollette PS: Visual search patterns and experience with radiological
20. Llewellp Thomas E: Search behavior. Radiol Clin North Am 8:138' 1969' images. Radiology 103:523 528, 1972.
aL-.tn PTER
5
lntroduction to Radiographic
lnterpretation
. Clifford R. Berry I Nancl E. Love ' Donald E. Thrall
t t i i
AIR FAT WATER BONE METAL
BADIOPACITY
RADIOLUCENCY
OPTICALDENSITY
FILM BLACKNESS
FADIOGRAPHICDENSITY
of the hand are visible because they have absorbed some x-rays
from the primary beam. Bones of the hand are more radiopaque
Figure 5-2. Radiograph of a humanhand.Blackregionsrepresentfilm areas than soft tissues;the bones have absorbed more x-rays, and thus
where no x-rays were absorbedfrom the x ray beam before reachingthe that part of the intensi$ring screen under the bones was struck by
intensifyingscreens.Homogeneouslywhite areas,such as the watch and ring, fewer x-rays than the part under the fleshy parts of the hand. The
are film areaswhere essentiallya// x-rayswere absorbedfrom the incidentx- watch and ring appear totally radiopaque becauseessentiallyno x-
ray beam prior to interactionof the x-rayswith the intensifyingscreen. Be-
tween these two extremes are many shades of gray resultingfrom various rays were able to pass through them. The degree of differential
n o m th e p r im a r yb e a m b y th e hand.l t shoul dbe
d e g r e e so f x - r a ya b so r p tio fr absorption of x-rays by a patient or an object depends on the
obviousthat the bones absorbedmore x-rays(andare thus more radiopaque) energy of the x-rays and the composition of the patient or object,
th a n d i d t h e f l e s h voa r tso f th e h a n d . as was discussedin detail in Chapter 1.
I lmportance of tissue
I composition
Although the effect of x-ray energy on differential absorption is
important, it is the effect of tissue composition on x-ray absorption
4.O that allowsradiographicimagesof paiientsto be produced.X-ruy
absorption by a body part is determined by the effective atomic
3.5 number of its elements and the physical density of the object being
radiographed (Table 5-1). Basedon the direct relationship between
zn the absorption of x-rays, physical density, and effective atomic
); number, the substancesin Thble 5-l may be ranked in order of
Aa
-o increasing radiopacity. Even though the effective atomic number of
zc 2.5
rilJ
= o
air is higher than that of fat, air is the most radiolucent becauseof
u( d
its low physical density (i.e., there are fewer molecules per unit
2.0 area to absorb x-rays). If air were compressed until its physical
density equaled that of fat, it would be more radiopaque because
o= t.5 of its higher atomic number.
1.0
Table 5-1. Physical density and effective atomic number
0.5 of various substances
Physical density Effective atomic
0. 0 Substance (g/cm"l number
RELATIVE X.RAY EXPOSURE Air 0.001 7 .8
(log scale) 0.92 6 .5
Water 1.00 7 .5
Figure 5-3. Relationshipbetween relativeradiationexposure (x-axis)and Muscle 1.O4 t.o
the resultantopticalfilm density iy-axis).As radiationexposureincreases,so Bone 1.65 12. 3
d o e s o p t i c a lf i l m d e n sity ( film b la ckn e ss)(.Ad a p te dfr o m Fundamentalof
s
R a d i o g r a p h 1y 2 , t he d . Ro ch e ste rNY
, Ea stm a nKo d a k,1 9 8 0 .)
Lead 8.70 82.0
44 P HY S I CS S IN T E R P R E T ATION
A ND P R IN C IPL EOF
I
gans) is the same. The radiopacity of these fluids and tissuesis
collectively referred to as soft-tissue radiopacity. The next most
radiopaquesubstancein Table 5-l is bone; its physicaldensity and
effective atomic number are higher than those of air, fat, water,
and muscle.The most radiopaque substanceis lead (other metals
could also have been used as an example).Lead and other metals
have high physical density and effective atomic numbeq making
them extremely radiopaque. Thus, there are five perceivabledegrees
of inherent radiopacity:air, fat, soft tissue,bone, and metal (Figs. -+ RADIOPACITY +
)-4 ano )-),.
In any discussion of relative inherent radiopacities, thickness ts RADIOLUCENCY
<-
must alsobe considered.Thicknessand radiopacityare interrelated;
as thickness increases,radiopacity increases(Fig. 5-6)' Thus, the Figure 5-6, The effect of thicknesson radiographic opacity.Increaslngthe
th c[,nessof the obl ectIn the path of the x-raybeam w i l l reducethe numoer
frve basic radiopacities(i.e., air, fat, soft tissue,bone, and metal) of x raysthat reachthe fi l m and,therefore,fi l m bl ackness.
are relatively inherent radiopacities, assuming that the object's
thickness is approximately the same. For example, although fat is
inherently mori radiolucent than bone, if a large thicknessof fat
is next to a small thickness of bone, the fat will be more radiopaque I Radiographicgeometry and
(i.e., its total radiopacity would be greater;Fig. 5-7)' Thus, total I thinking in three dimensions
radiopacity is determined by object thickness and inherent radi-
opac ity. It is important to rememberthat a radiographis a two-dimensional
image of a three-dimensionalobject. Thus, the radiographicimage
,1
liElll:liall,.
::.ryGr,Wry1%;ff
.,rrat.:rl,.lll:
n
"* '-l
of a patient varieswith the patient'sorientation with respectto the
primary x-ray beam. There are four consequences of radiographs
being two-dimensional images of three-dimensionalobjects: (1)
100 X-RAYS
1OOX-RAYS
I
I FAT
| '"-l
w
90 X-RAYS 30 X-RAYS
;lu.'risi
iiarr.:ii Summation sign
u-i:10
The summation sign results when parts of a patient or object in
different planes (i.e., not in contact with each other) are superim-
posed (seeFig. 5-5). The result is a summation image representing
the degree of x-ray absorption by all superimposed objects. For
example, consider a block of Swiss cheese.There are holes on the
exterior ofthe block resulting from the cheesebeing sliced through
gas cavities that formed as the cheesefermented. Inside the block
of cheeseare more gas cavities,some of which overlap when viewed
from the perspective of the x-ray tube. When a block of Swiss
cheeseis exposedto x-rays, fewer x-rays are absorbedby the cheese
in areaswhere cavities overlap. The more cavities that overlap, the
greater the number of x-rays that penetrate the cheeseand reach
the film (Figs.5-12 and 5-13). In the instanceofSwiss cheese,the
resulting summation shadows are radiolucent becausethey repre-
sent summation of radiolucent images. Summation shadowscan
also be radiopaque (seeFig. 5-5). When a suspiciousradiopacity
or radiolucency is identified, the possibility must be considered
that it represents a summation shadow produced by overlapping
structures. A typical example occurs when a pulmonary vessel is
Figure 5-8. Lateralview of the pelvisof a dog in right lateralrecumbency. viewed end on) or a pulmonary vesseloverlaps a rib, such that a
T h e r i g h tp e l v i cl l m b wa s p u lle dcr a n ia lly, th e le ft p e lviclim b caudal l y.
N oti ce
t h e i n c r e a s e d i a m ete o r f th e le ft fe m u r in co m p a r iso with
n the ri ghtbecause
summation shadow is created that is more radiopaque than the
of magnification-the left femur is falrher from the cassette.Marginsof the adjacent vasculature.This summation "nodule" should not be
m a g n i f i e dl e f t f e n n ura r e a lsole sssh a r pth a nth o seo f th e r ight. mistaken for a true pulmonary nodule.
46 P HY S I CS O F IN T ER PR ET A TION
A ND P R IN C IP L ES
Figure S-IO. How recognizable an object,or a body part, is from its radiographdependson its relationshipto the primaryx-raybeam. The object in A is easily
recognizable. The object in I is difficultto recognizeas the same pair of eyeglasses,unlessone knew the identityof the oblect before radiographyand that the
glas s e sa n d t h e i rc a s ew e r e r a d io g r a p h eodn e n d ( p a r a lletol th e p r imarybeam).
lr ll
body part of interest, from point-of-entranceto point-of-exif. Direc-
tional terms listed in the Nomina Anatomica Veterinaria shouid be
used to describe radiographic views. An abdominal radiograph
made with the dog in dorsal recumbency and with the use of an
overhead, vertically directed x-ray beam is a ventrodorsal view;
with the dog in ventral recumbency, it is a dorsoventral view. The
same method is used for other body parts, with the appropriate
o O SWISS
directional term applied (Fig. 5-17).
Oblique projectionsshould be named by using the samemethod
CHEE S E as standard views (i.e., by designatinganatomicallythe points of
OO entrance and exit) (Fig. 5-18). Angles of obliquity can also be
designatedby inserting the number of degreesof obliquity between
the directional terms involved. If the dorsolateral palmaromediai
oblique (DLPaMO) projectionin Figure5-lB were made by posi-
FILM tioning the x-ray tube 60 degreeslaterally with respect to dorsal,
^
BL A CK N E S S
T the designation would be D60LPaMO. This term implies that,
SCAL E I
beginning dorsally, one proceeds 60 degreesto the lateral side to
Figure 5-12. lllustrationof the summationshadoweffect.A block of Swiss locate the point of entrance of the x-ray beam.
c h e e s ei s s t r u c k b y a n x- r a yb e a m . Ga s ca vitie sin th e cheesemay not be
s u p e r i m p o s efdr o m th e va n ta g ep o in t o f th e x- r a ytu b e . T he tw o.on the l eft R adi Ogfaphi C i ntefpfetati On
a r e n o t ,a n dt h e r e su lta nin
t cr e a sein film b la ckn e ss b e n e a tht he bubbl esi s due
to the individualabsorptioncharacteristics of eachbubble.The two bubbleson Routine evaluation of radiographs consists of an inclusive process
the right, however,are partialv overlappedfrom the p"r.p":,il:^^?_f^lT ranging from the technical aspects of making the radiogriphs to
beam ln thls region of overlap'there is an lncreasein film.,blackness i-].1
as a
the"finil conclusions or impressions based on"changes noied-in the
resut of decreasedx-ravabsorptionin the regionof bubbleoverlap
."l"tt"prrr. This section defines a framework that one may use to
formulate a systematic approach to the evaluation of ali radio-
pefCeptign graphs.Systematicinterpretationis paramount in the process.Lack
Ir ROlg Of --
' --- of a systemicapproachcan result in the introduction of errors that
I in intgfpfetatiOn --_:!-_ may resulr in false-positiveor fatse-negativefindings that could
When interpreting radiographs, clinicians rely on their eyes to lead to inappropriate therapy for the patient.
detect abnoimalities. Unioriunately, the eyes and brain do not E]aluation of poor-quality radiographs is at best inconclusive
alwaysperceiveappearances accuraiely.For example,examine Fig- and.at-worst misleading. The clinician must discern, based on
ure 5-16. The two vertical lines appear curved, but when a straigtt physical examination findings, the signalment, and the history, that
edgeis placednext to them, it is obvious that both horizontal liies a particular imaging examination is the correct one to perform.
are.-straight. The curving nature of these lines is an optical illusion Specific radiographic examinations should be complete and should
not be limited to a single lateral
created 6y the radiatin! lines on which they are superimposed. _radiograph of a given area.
Therefore, what appears"as concrete visual evidence is not always Complex anatomic structures with bones that are superimposed
such. Perceptionii'an important part of radiographic interpreta- and overlap with each other, such-asthe skull, carpus, or tarsus,
tion. What appearsas an ob,rio.rr finding to beglnning radiol,ogists require multiple orthogonal views for complete evaluation.
may be an ir-correct assessmentbecauie of p"ercept[n. O"t1i by , radiographic interpretation is not a mystery, nor
. lhil."-t:phically,
viewing many radiographs, with the continual feedtack of experi- .,,'::i1 l difficult, as long as the appropriate amount of time and the
encedlnterpiete.s, Ian perceptual inaccuraciesbe minimized. A \.,.''tright environment are provided for the evaluation of radio-
more compietediscussionof perceptionis given in Chapter 4. Over time, interpreterswill learn specificra-
' , ., ,qfnpht':.. -bgsinning
:,' 'diographic patterns of clinical disorders. Initially, however, the task
Naming of radiographic proiections of interpretationis overwhelming,as there is a lor of information
on-each radiograph' within the context of normal and
Radiographicprojectionsare named accordingto the direction m t''l::::1t:tq
abnormal radiographic Patterns, one has to know normal radio-
which the centrat ray of the primar y x-ray b""- ;;;;;;;;;;;h;
r----'--'-" ---- ;"
1',graphic anatomy and the possibleanatomic or age-relatedvariants
' that might
occur. Within this textbook, areas of "must-know"
' ,* "*_.' information lncluoe
rnrormarlon include normal
normal radlographlc
radiographic anatomy
anatomy andand clln1cal
clinical
tB -
--;
-
3
s
P
a
P
s'
e @u,:tlglt,rtll
': F i rr
$ * *
* --#s,*,. *
-1 variations
- - ^ - i - .:^ - - ^ ^r
of - ,, -
normal. There is adiitional informaiion regarding
!' '-*-- & _.:' lelXl{1
11gu
ill::1al0ll rt specific radiographic abnormalities within each of the chapters that
}glAlgliall specifically points to abnormalities that have been associaredwith
llftlgftlg:li1 a particular diseaseprocess or syndrome. For example, the identi-
fication ofpleural fissurelines and retraction ofthe visceralborders
of the lung from the thoracic wall would lead one to conclude that
a pleural disorder exists. If the opacity of the material between the
;-- visceral (lung border) and parietal (thoracic wall) pleural surfaces
,', , is soft tissue.
tissue, then one would
would think
think about pleural
causes for pleural
about causes
ffillllE; effusionand/or a pleural mass.This approachto readingatout a
-:**-;
ll:ildll particular disorder drlu
i11€lll,.119llll:illl
ycruLurar and
"-..l the
nerficrrlar.lie^r.ja'
urJurusr radiographic ctraltgcs
+L^..,1i^^".^L;-
Llls tduru8rdprrrL changes
-L---^"
+L^+
that occur
Ltlal ULLUI with a
wlLll a
^--,,-,^,:+L ^
!m: particular diseaseresults in the reader developing two fundamental
understandings for the particular disease process. The first is par-
Figure s-1g. Radiographof a block of Swiss cheese.Gas-frlledcavitres n
the cheeseare apparent.Areasin which gas cavitiesoverlapare more radiolu- tern recognition r3 The recognition of a radiographic change is an
cent than are areas ln whch no overlappinghas occurred.Increasedradiolu- important first step in determining the presence of an abnormality.
nann', ic d +^ Ad^rd.c^A ' ray absorptionin areas where,cavitiesoverlap.
^ Second, specific locations are emphasized about which the reader
T h e r ea r e a r e a sw h e ' e n o ^ e , two , th ' e e , a n d ' o u r ca vL ie sl'ave ove'l apped. ^L^..rr become astutely awate when iooking for specific abnormali-
should
can you ldentifythem? Thesesummationshadowsur" n"guaiu",i"";.lih;
result in increasedradiolucency. See Figure5-5 for an exampe of a positive ties on the radiograph. For example, pleural fissure lines are ex-
s u m m a T t osnn a 0 0 w pected to be in the region between the normal anatomic divisions
48 P HY S I CS O F IN T E R P R E T ATION
A ND P R IN C IP L ES
X-RAYBEAM
PULMONARY
LUNG ARTERY
HEART
CORONARY
ARTERY
PULMONARY
ARTERY
ffi rl,,:lllilllrr
;,:rlllli:iii.
,r,....liilttr
l
' ',r.iii0ll'.
ii.
.rs:,,ii;rf l
'rr,.,1!lllll'riltr''
:::1r..'illi;:::'..:..
aut i:t,uliiiii$]t'':i6l
r:1iltil
A
Figure E-14. The silhouetteeffect or border effacement.A, lllustrationof a lung with two pulmonaryarterlesand the heart with one coronaryartery. ln a
, e co r o n a r ya r te r ywil n o t b e visib le,but the tw o pu monaryarteri esw i l l be cl earl yseen.B , Laterathoraci cradl ogra ph.
raJ io g r a pohf t h i s s p e c l me nth The v es s el
s upei i m p o s e d o n t h e h e a r(ta n o w)iso cca sio n a llym ista ke n fo r acoronaryartery,butthl si snotpossbl i tmustbeapul
e; monaryvessel .S eetextfo rmoredetai l s .
X-RAYBEAMDIRECTION
V
I I
@ W
@B
@
Figur e S - 1 5 . A , V e n t ro d o r sa thl o r a cicr a d io g r a pohf a d o g in whrchtw o softti ssueopaci ti esare apparentLateral to the heart.Theseare ni ppl e sbut c oul dbe
c onf u s e dw i t h l u n g n o d ues. Wh y sh o u ldn p p le sb e so o p a q u e ?B . D i agrami l l ustrati ng w hy smal lsuperfi cal massescast such apparentradi ogra phischadow s
O n t h e / e f l .t h e m a s sh a s p e r p e n d icu la sid d n al l si desby ai r.Thi screatesa si tuati oni n w hi ch the x-raybeamstri kesthe mass -ai ri nterfac e
r e sa n d ls su r r o u n d e o
, p t i m izin gco n tr a st.On th e r ig h t,a co m p a r abLy
in a p a r a l l ef a s h i o n o p the prrm arybeam,and
si zedmass has sl opi ngsi desthat are not i n a paral el rel ati onshito
t his m a s s ,l f s e e n a t a l l ,w tll n o t a p p e a rn e a r lya s o p a q u eb e ca u sei ts s des w i l l not be proi ectedas di sti ncty.
Introducti on
to R adi ographiInte
c r pr et at ion49
'7, \
iuu
i ' v FN ,
CRANIAL CAUDAL
<> -'Tarsocrural
lolnl
PNOXMAL
DISTAL
._..;
Figure5-16. Perceptlon artfact.Thetwo vertical
linesappear
curved.Place
v
DOR S AL
a rulernextto them,andyouwillseetheyarestraight. Thisoptical
ilusionis
createdby the radrating
lineson whlchlhe curvedlinesare supermposed.
Perceptioncanbea source of errorin assessing
radiographic
abnorma ities.
Figure 5-17, Properanatomicdirectional
termsas they appryro vaflous
partsof thebody.(Courtesy
of Dr.J. E.Smallwood.)
of the lung lobes.Knowledgeof the anatomic location of the lung
lobes (even though they are not apparent as distinct radiographic
structures on normal radiographs) is foremost for deciding whether
pleural effusion is present or absent. the reader's approach to systematically reviewing a radiograph
This approach, however, assumesthat one knows how to assess basedon experience.The interpretiveparadigmspresentedhere are
the entire radiograph, and not just a particular section of the not the only model of interpretation for evaluating radiographs.
radiograph such as the pleural space.Additionally, the division of These models, however, provide a basic framework on which a
material within this textbook into chapters based on regional anat- systematicapproachto radiographicevaluationcan be built. Based
omy does not facilitate the collective approach needed for evalua- on the radiograph being a two-dimensional presentation of re-
tion of a radiographic study. Finally, it is impossible in any book gional anatomy, we must understand the inherent limitations of
to illustrate all of the radiographic variations of an abnormality. our visual acuity in identif ing specific anatomic structures and
The reality is that we will be faced with a spectrum of radiographic derangements.In Chapter4, an excellentoverviewofvisual percep-
appearancesfor a given diseasecategory. For example, panosteitis tion is presented;the reader is strongly encouragedto thoroughly
(a benign bone diseasethat typically appears as an increasein digestthis information for the purposeof understandingthe limita-
intramedullary bone opacity in young dogs) has a spectrum of tions of evaluating two-dimensional survey radiographs.Limita-
appearances. As the reader builds on experiencesof what panos- tions specific to a given location are stressedwithin individual
teitis can look like, thesevarious patternsare placedinto the visual cnapters.
cortex of the brain and stored as possibleradiographicpatternsfor Radiology is a balance between scienceand art. The science
this diseaseprocess(Fig. 5-19). Initially, when one beginsto evalu- involves actual knowledge of radiographic production and the
ate radiographs, there is the expectation of being able to identify identification of abnormalitiesbasedon the detailsof radiographic
the primary abnormalities.This also assumesthat the reader is anatomy, pathophysiology, medicine, and surgery. The art is a
able to discriminate the abnormal changeson the radiograph from function of the reader'sexperience(Fig. 5-20). To hone radio-
normal images, and that the change seen on the radiograph fits graphic interpretation skills, one has to understand the basicsof
into the preconceivedcontext ofwhat the lesion is expectedto look making and interpreting radiographs. Additionally, as new infor-
like. As the reader seesmore and more radiographs, this basic mation is brought to the forefront, these new findings must be
knowledge expands, thereby providing a degree of confidence that incorporated into one's scientific database,and this information
what the readeris looking at is normal or abnormal- must be correlatedwith personal experience.As one gains experi-
ence with radiographic studies, one seesthe greater variety that
may take place within the context of the "art" of radiographic
A systematic approach to interpretation
interpretation,and thereby acquiresa better understandingof the
In this edition of Textbookof VeterinaryDiagnostic Radiology,there clinical significanceof certain radiographic abnormalities.As was
are introductory chaptersto each of the various anatomic regions. mentioned earlier,initial pattern recognition is important, but one
Thesesectionsinclude a basic approachor interpretationparadigm cannot experienceall of the possibleradiographic patterns that a
for evaluating each area. A paradigm is defined as an example or a diseaseentity may have. Thus, the expectation is that even experi-
model. In radiology, interpretation paradigms are a reflection of enced radiologistswiil regularly review radiographs that contain
D or s opal m ar
Variations
Cla ssic
Examples
Be g in n e r
new information. Unless one has been continually "renewing" his and prioritized basedon signalment, physical examination findings,
or her visual cortex file cabinet, this new information cannot and other clinical data, the next step should be to establish a
alwaysbe interpreted correctly. definitive diagnosis(Fig. 5-21). Although the goal is to establisha
As has been described,the scienceof radiology forms the basis definitive diagnosis for every patient, this may not alwaysbe neces-
for interpretation of radiographs.The basic tools for radiographic sary or practical.
interpretation include knowledge of normal anatomy' a systematic The art of radiology involves knowing how to tie all radiographic
approach to radiographic interpretation, utilization of the basic abnormalities together into a specific conclusion. A radiographic
radiographicsigns,and then tying all ofthese togetherto formulate summary can be viewed as a collection of various changes or
a differential diasnosis list. Once a differential list is established radiographic abnormalities from the expected radiographic anat-
wk
\ ,\%"e_
$H$. .TP.
*on+**o"t\* {Lrx$$rs}t${tbr$sffissfr
***_
ffi;***"'*r{
" ii:lflN D)Tyinsita,
noenfensions
y.9qL$u-*--.*:l["'r.*l'"p
)4L "'1il;;0"-"'n^
'
-",rr*.ffi-:n.;; ll,1i,i,.J:,',,
ffJ:x
Approach ' Position/Location examination'
Figure 5-21, The basic radiographictools for interpretation.The Ddx' Next Step'
{lnterpretation 'Margin/Conlour
e n d p o i not f i n t e r p r e ta tioisn th e tyin gto g e th e ro f a I o f th e r a di ographi c etc )
a b n o r m a l i t i easn d f or m u la tin ga d r ffe r e n tiadl a g n o sislist that takes Par adi gm ) ' Shape
th e s e a b n o r m a l i t i ein s to a cco u n twith in th e clin lca lco n text of the
o a t i e n ti n o u e s t i o nA . fin a ld e cisio ntr e e is e sta b lish eads to w hether
a d d i t i o n atle s t i n gi s r e q u ir e dto co n fir mth e to p d r ffe r e n tialconsi der-
a t ion .
omy. One should realize that any interpretation is a summary, and graphic changessurrounding the lesion will lead the interpreter to
becauseit is only a summary, not al1of the radiographic abnormal- a conclusion regarding a differential diagnosis, possibly even a
ities can be described(Fig. 5-22). Consider the lateral radiograph primary differentiai diagnosis for the radiographic abnormalities.
of the thorax in Figure 5-22 from a l0-year-old Golden retriever. However, if this does not work, the interpreter should develop a
Write a description of the radiographic anatomy present on the summary list of all radiographic abnormalities detected. For each
radiograph. of these abnormalities,based on the reader'sexperience,a certain
Did your discussioninclude a description of each of the ribs, degree of importance should be assigned.According to this degree
the costal cartiiages,the sternebrae,the vertebral bodies, the gastric of importance, abnormalities may be further evaluated.
axis, the right cranial lobar artery, the bronchus and vein, and so A radiographic abnormality can be viewed as either a window,
forth? It is impossible to totally evaluate all of these specific struc- a mirror, or a picture (Fig. 5-23). When the radiographic abnor-
tures in complete detail. This again emphasizesthe importance of mality is viewed as a window, the abnormality is considered to
placing the radiograph on the view box in a specific manner each have happened in the past. These historical changesmay or may
time, enabling careful evaluation and systematic interpretation of not be important or related to the reason why the patient is being
the radiograph. radiographed today. For example, ventral spondylosis deformans is
often assessedas a change associatedwith an abnormality of the
past. Degenerativechangesof the intervertebral disc result in insta-
I Evaluating radiographic biiity, and thereby ventral spondylosis deformans. This condition
I abnormalities is assessed as not necessarilybeing important for the immediate
problem. This information, however, should not be ignored; it
After systematically evaluating the completed radiographic study,
should just be placed lower on the priority list of the described
the clinician should compile a basicdescriptionof the radiographic
radiographic abnormalities.Assessinga radiographic abnormality
abnormalitiesnoted. This step is often skipped by inexperienced
as a mirror assumesthe abnormalitv is important and is a reflection
interpreters. It is important to recognizethat the ability to describe
of today'sproblem. Assessingthe iadiograph as a picture assumes
the appearanceof the lesion, the location of the lesion, the radio- that the radiographic abnormality is significant today, but that it is
graphic sign changes(including opacity), and any associatedradio- also a predictor of future events. For example, it has been shown
that canine lymphoma patients with a radi,ographicallydetectable
cranial mediastinalmass have a poorer prognosisthan dogs with-
out a cranial mediastinalmass.a
Bayes'theorem is a method of evaluating whether a diagnostic
test should be used, based on the clinical history and signs. In
other words, if the patient has the diseaseand the test is run, the
test is likely to be positive.z Certain clinical tests such as survey
radiographs have been shown to be highly sensitive and specific
for different diseasesin humans, but the same statistical scrutiny
has not been applied to veterinary medicine. In part, this is because
it is impossible to study the large numbers of animals needed to
make statistically valid conclusions. Regardless,experience has
taught us something about situations in which radiography is
useful in veterinary medicine. Within each chapter, there are dis-
cussionsregardingcertain radiographicsignsor abnormalitiesthat
are relatedto the presenceor absenceof a particular disease.
If we think about the sensitivity of a given radiographic abnor-
mality by itself, a list of differential diagnostic considerations can be
formulated based on the signalment urld hirtoty. The radiographic
abnormality (such as interstitial lung opacification)may be neither
sensitive nor specific for a particular disorder. No radiographic
dog. See text for ques
Figure 5-22. Right lateralthoraxfrom a 10-year-old abnormality is going to be 100%osensitive,or its absence1007o
t i o na n dd e t a i l s . specific,as to whether or not a particular diseaseis present. In
52 P HY S I CS S IN T E R P R E TA TION
A ND PR IN C IPL EOF
@
The Radiograph
** as a Picture: Figure 5-23. Each radiographicabnormalitycan be viewed as a
relatedto today's
reasonfor A predictoror future window (pastor historicalchangethat may or may not be importantor
ra d i o g ra p h i n g evenls;pr0gnost|c relatedto today'sreasonfor the radiographic study),mirror(a reflection
the patient) changesthat predicl of today'scurrentproblem),or a picture(a predictoror future prognosti-
a future cator).l n the exampl esshow n. the ventralspondyl o s i sdeformans
outcome represents a w i ndowof pasti nstabi l i ty
at the l umbosacral j unc ti on.The
end-platelysis of L7 and S1 reflectsthe reasonfor the dog's current
probl em,w hi ch i s rel atedto di scospondyi i tiofs thi s di sc s pac e.The
secondright lateralthoracicradiographrepresentsa pictureof potential
futureoutcomesthat mi ght be predi ctedby the presenc eof a c rani al
medi asti nalmassi n a dog w i th l ymphoma.4
thinking about this, we use all of the radiographic data collectively etiologies that truly cause disease in dogs. For example, other
to build stronger support for a given radiographic diagnosis. This considerations in this dog are inflammatory nodules such as a
concept can be thought of as an inverted ice cream cone, called solitary granuloma (parasitic, eosinophilic, or tuberculous) or a
the cone of certaintyt (Fig. 5-2a). At the bottom or base of the solitary lung abscess.However, one must be able to prioritize
cone are a number of possible differential diagnostic considerations conditions included in the differential diagnosis list. Without pri-
for a given radiographic abnormality. As one finds more radio- oritization (based on experience,continuing education, and feed-
graphic evidencefor a given diseaseprocess,the confidence regard- back), a laundry list of possiblediagnosesbecomesa roadblock to
ing a particular radiographic diagnosisincreases,thereby decreasing effrcient attainment of the deflnitive diagnosis. When differential
the number of possible differential diagnostic considerations. If diagnosis lists are formulated, it is critical that some ordering of
one identifies very specific and sensitive radiographic abnormali- possibilities, based on the radiographic abnormalities present and
ties, one reachesthe top of the cone and can have a high degree the probability of occurrence,be performed as well.
of confidence that a specific diseaseis present. When interpreting radiographs, one should remember that the
In establishing a list of differential diagnoses,there is a reason- radiographic appearancerepresentsonly a snapshotof the disease
able approach to listing possible causesof the radiographic abnor- process (Fig. 5-25). Clinical signs often precederadiographic
malities. The clinical context and signalment become important at changes. Therefore, even though radiographs are normal, rapid
this time. When in doubt, one can use aids such as the mnemonic changescould develop and would be apparent ifrepeat radiographs
acronym CITIMITV standing for congenital, inflammatory, tumor, were made within a short period of time. Additionally, assessment
infectious, metabolic, iatrogenic, traumatic, and vascular' Using of how a patient is responding to therapy can be done using
this approach, one should be able to think of a specific etiology sequential radiographs. Is the therapeutic intervention having any
for a given radiographic abnormality. For example, a solitary lung effect on the radiographic appearanceof the disease?One should
noduie or mass in the left caudal iung lobe of a lO-year-old compare apples with apples, meaning that using the same radio-
Doberman pinscher is most likely a primary lung tumor. Other graphic technique in sequential radiographs is important. If the
radiographic changesdetected on a recheck examination have not
diasnoses could be considered, but one must think of specific
resolved as would be expected,then one should rethink either the
*The concept of the cone of certainty has been adopted from Dr' Richard Pratt's original differential diagnostic list or the therapy being used. Fi-
(Professor, Old Testament) lecture notes. Introduction to Pastoral and Theological nally, if a radiographic abnormality is present and there is a
Studies. Orlando, Florida, Reformed Theological Seminary. long differential list, a "next step" is usually necessary,as most
Gone of Certainty
Specificdiagnosis
@
Fulminant
7 Disease \
/\
Incubation Earty@l /\
. Presentation Death
Gtinicatsigns
Figure 5-25, This figure iilustratesthe lifelineof a diseaseprocess, @l
w h e r e t h e c a m e r ar ep r e se n ts a r a d io g r a pmh a d ea t a p a r ticul ar stage \/\./
d u r i n gt h e n a t u r ahi i sto r yo f m itr a lva lvu laer n d o ca r d io sis. lf the radi o- Intervention Recovery@l
g r a p hi s m a d ea t p o i n tA, th e th o r a cicr a d io g r a p hasr e o fte n n ormal ,i n Mitrat valve Endocardiosi! t
sp i t e o f m u r m u r b e in g a u scu lta te dlf. th e r a d io g r a p has r e made at A ) N ormarthoraci cradi ographs
p o i n t 8 , t h e r e m a y b e m ild to m o d e r a teca r d io m e g a ly with lefr atri al \* / /
B ) Mi l dcardi omegal y t
t
e n l a r g e m e ncta u s i n gc o m p r e sso n o f th e ca u d a m l a in ste mb r onchiand *6 ,. / /
re s u l t i n gi n t h e c l r n i casig
l no f co u g h .In C, th e d o g m a y h a vedyspnea, C ) E nl arged heart;
i ntersri ti a'and
al veol ar
edema
lE --,-t
an d t h e r ea r e r a d i o g r a p hfe ic a tu r e so f le ft h e a r tfa r lu r ewith p ul monary D ) H eartsi l esmal l er;
pul monaryvei nssmal l er;
e d e m a .I n D , a f t e r t r e a tin gth e d o g with th e a p p r o p r a tem e di cati ons, edema resol ved
rh e p u l m o n a r ye d e mar e so lve sa n d th e cycleco n tin u e swr th the next
ex a c e r b a t i oonf h e a r tfa ilu r e( C- r e ia p se ) .
3. Hang the radiographs the same waY ftncluding the or- Disease detection and description
der) each and every time you review that particular radio- 9. ldentify the radiographic abnormafi'tres' Determine if a
graphic examination. Remember that one thing you have work- structure is abnormal by using the changes from the expected
itrg'fot you is your brain; pattern recognition within the visual radiographicsignsor findings for a given structure (seeFig.5-21).
coite* becomesa key player in recognition of abnormalities' If you Radiographic signs include changes from the expected number,
consistently piace the radiographs on the view box in a specific size,shape,number, location,margination,and opacity.Thesebasic
manner, you will start to identify abnormalities before starting changesin the expected normal radiographic anatomy result in a
your systematic review of the radiograph(s) because your brain iist of radiographic abnormalities. At this point, one must deter-
i..ogrir.r that something is not the same as the expected normal mine if the abnormality identified is relevant or not. Do not
patte'rn for that particular study. This systemof Pattern recognition discount any abnormality until all radiographs are evaluated and a
bOgS NOf ,eplu." u systematicapproach to reviewing the radio- complete list of radiographic abnormalities has been established.
graphs; however, it does provide the groundwork for organizing Remember that the descriptions used to characterizeradiographic
evaluation of all
|ourself and the foundation for a systematic abnormalities may be subjectiveand somewhat arbitrary (e.g., mild
radiographicimages. interstitial lung opacity). Also remember that the existence of a
l.-Mike sure that atl of the radiographs You have are radiographic abnormality does not mean that it is clinically rele-
complete and appropriate for a given radiographic examina- vant at this particular time. The abnormality may represent an
tion. For example, a thoracic radiographic study consistsof a right- anatomic variant or reflect a Past event (window) or current disease
lateral, a left literal, and a ventrodorsai or dorsoventral view' If state (mirror), or it may be a predictor of future outcomes (pic-
there are limitations as to the number of radiographs that could ture). Clearly, the last two types of abnormalities are the most
be obtained,be sure to note in the medical record of the patient important findings that have to be recognized before one reaches
that an incomplete examination was obtained, along with the a conclusion regarding the radiographic changes,taking into ac-
reason(e.g.,thJpatient was dyspneicand a ventrodorsalor straight count the signalment and clinical findings and history.
dorsoventralwas not made).
5. Evaluate patient positioning' This should include the ana- Differential diagnosis/radiographic diagnosis
tomic boundaries of the area of interest (e.g.,Is the entire thorax
included in the study?) and any obliquity that may hinder accurate 10. Establish a list of differential diagnoses for the radio-
interpretation of a given radiograph. Know your limitations from graphic findings. At this point in time, it is important to deter-
the start. Positional troughs are available for placing dogs and cats mine if any of the radiographic abnormalities that have been
in dorsal recumbency to obtain ventrodorsal radiographs of the identified can fit into one disease or a group of diseases.For
thorax, abdomen, vertebral column, or pelvis' example, there are many differential diagnostic considerations for
6. Evaluate the radiographic technique. Are the films overex- right ventricular enlargement; however, in conjunction with en-
posed or underexposed? If the answer is yes, is the over- or larged, blunted, and tortuous pulmonary arteries,heartworm infec-
-underexposure
secondary to a disease?If that answer is yes, then tion becomesa likely possibility. Use the history and signalment to
one should not attempt to adjust the technical factors, but treat help establish and prioritize the differential diagnosis. It is im-
the patient first and then obtain a radiographic study after. a portant to understand the pathophysiology behind the radiographic
diagnosticprocedurehas been done. For example,in a dog with changes so that one can tie different radiographic abnormalities
pne'umothoiax, the study will more than likely appear overexposed' together as a single diseaseentity. The goal of clinical medicine, in
in a dog with severepleural effusion, the study will appear under- addition to establishing a radiographic diagnosis, is to bring all
exposed.Repeatradiographs should not be attempted untii the dog availableinformation together and settie on one or two conditions
has undergonethoracocentesis. Technicaladjustmentsmay not be that are consistent with all the abnormalities. A pitfall of radio-
necessary.For technical adjustments, severalrules,of thumb are to graphic descriptions of the abnormalities is that all differentials
decreasethe kilovoltage peak (kVp) by 15o/oor reduce the milliam- listed for interstitial lung diseaseare not relevant to every patient
pere seconds (mAs) by SoTofor an overexposedradiograph, and in which interstitial lung diseaseis diagnosed, the reason being
io increase the kVp by 75Voor increase the mAs by a factor of 2 that the clinical context of the patient's signaiment and history
for an underexposid radiograph. \A4rich adjustments you use will must be taken into account before the differential diagnosis list is
depend on the type of study (anatomic region), considerationof prioritized. If the radiographic abnormalities are specific and are
latitude ,rersuscontrast, and technical factors that might limit these high in the cone of certainty, make a definitive diagnosis.Recognize
adjustmentsbased on the type of x-ray generator one has' One that this will not be a common occurrence, and that a well-
should avoid m)anipulating both the kVp and mAs at the same thought-out differential diagnostic list is often a necessity.Again'
time. however, this differential list should not be an 'Aunt Minnie"
7. Evaluate for other technical errors and artifacts that approach to the radiographic abnormality, but should include very
might hinder your interpretation of the radiographs' Proc- real possibilities for a given patient.
essine artifacts and technical errors can complicate and hinder ti. Ma*e a radiographic diagnosis. Incorporate the clinical
interpretation of radiographs. Technical errors in the darkroom history, physical examination findings, and signalment when mak-
can iotally destroy a high-quality radiograph. Be sure to review ing a radiographic diagnosis.This radiographic diagnosis must
and change darkroom technique so that high-quality radiographs incorporate al1of the radiographic abnormalities identified and try
can be obtained on a consistent basis. An overview of darkroom to tie them into one clinical disease entity. For example, the
technique is provided in Chapter 1. Readersare referred to refer- radiographic abnormalities of perihilar and sternal iymphadenopa-
encesprovided there for information on overhaul of the darkroom, thy, interstitial lung disease,hepatosplenomegaly,and medial iliac
7 lymphadenopathy could be summarized as being most likely repre-
if this is neededin their practice.5
8. Continuously review the normal radiographic anatomy sentativeof generalizedor systemiclymphoma. There will be times
that is present on the radiographs' Review radiographs in a that the reader will discover something on the radiographs that is
systematic fashion as presented in the interpretation paradigm clinically important, but that may not have anything to do with
.irupt"., for a specific iection. Review the entire radiograph, and the current clinical history or presentation. DO NOT ignore these
reviw each radi,ograph using the same process' Refer to anatomic radiographic abnormalities; instead, because of their significance,
aids and textbooki when reviewing radiographs (see Chapter 50)' pursue these changes as part of the patient's diagnostic work-up.
One must be able to recognize normal anatomy to identifr radio- In other words, these abnormalities must be added to the working
graphic abnormalities. problem list of the patient.
- :G
Introduction
to Radiographic
Interpretation55
Next step recommendation figure, there are severalpoints to remember. The first is that over
time we can look at the life of a given patient or at the entire
12. Make a recommendation or give thought to the nert
diachronic trace. Within this lifeline is the life of a specific disease
step in patient management. This might include or involve (1)
processthat undergoesa preclinical incubation period before the
additional imaging studies that would confirm the presence or
patient developsan illness.It is at this time that a synchronicslice
absenceof a disease (e.g., a suspectedgastric mass would be
is obtained (i.e.,blood work and radiographsare done that give us
confirmed by obtaining a 1eft lateral radiograph with air in the
a snapshot of the diseaseat that particular time). At this time,
pyloric outflow tract that might outline the mass); (2) special
we run through the process of interpretation and we review the
oblique radiographs that may allow one to better visualize a sus-
pected abnormality (e.g.,horizontal-beamradiographsto confirm radiographs. We recognizethat we must have a basic understanding
the presenceof free air in the abdomen,or oblique radiographsof of radiographic anatomy and normal physioiogy, as well as of the
pathophysiology behind radiographic changes that are seen in a
the thorax to highlight a destructive rib lesion); or (3) special
proceduresthat will confirm the presenceor absenceof a disease. given diseaseprocess.
These could include alternate imaging proceduressuch as ultra- The approach to radiographic interpretation is dependent on
sound, nuclearmedicine,computed tomography,or magneticreso- our using the specific tools with which we have been equipped for
nance imaging. Additionally, ask yourself what other clinical tests evaluating radiographs. These include a basic systematic approach
need to be performed to establish the definitive diagnosis. This or interpretation paradigm and a method for evaluating each struc-
t1pica1lywill involve needle aspiration and biopsy of the abnormal ture using the six basic radiographic anatomic signs.Once radio-
organ or structure.This could also involve repeatradiographsover graphic abnormalities have been established, a list of differential
time to see how a lesion is responding or is not responding to diagnosesis formulated and a possibleradiographic diagnosisis
therapy.Ifthe appropriateresponsehas not taken place,one should establishedbasedon the abnormalitiespresent.More importantly,
review the radiographs and start the process all over again, to the next step in working up a patient is determined. This step
ensure that nothing was missed and that the differential diagnoses should move us through the information gap to the truth as to
rvere in the appropriate order. what the disease actually is that is causing the patient's clinical
In summary, radiographic interpretation is a systematicprocess signs.
of reviewing a radiograph in a pre-establishedmanner. Once an At this point, we need to step back and look at the process
abnormal pattern is recognizedand described,a rational thought (labeledA through E, see Fig. 5-26). Each step has the potential
processleads one to reasonabledifferential diagnostic considera- for error on our parts, whether it is poor radiographic technique
tions from the standpoint of known pathophysiologicprocesses or missing important radiographicabnormalities.Thesecan result
that occur within the speciesin question (Fig. 5-26). In the final in an incorrect interpretation and thereby move us farther from
TIMELINE
Viewerwith
radiograph
the truth. One should remember that we are not perfect and every- 6. Is this lateral radiograph (Fig. 5-28) of the equine digit ori-
one will make mistakes.Our goal then is to minimize thesemistakes ented correctly?
and remember that at each of these decision points, one can always 7. An x-ray tube is positioned directly in front of the left forelimb
recover and wind up on the path to the truth. It is only our of a horse, at the level of the metacarpophalangealjoint. The
interpretation of the radiograph that leads us astray as all of the cassetteis positioned directly behind the metacarpophalangeal
information is correct and true on the radiograph (within the limita- joint. The correct term for the view created by this configuration
tions of what a radiograph represents).It is our quest to determine of tube and cassetteis a(n):
the truth based on correct interpretation of the radiograph. A. Anteroposterior view.
B. Craniocaudal view.
References C. Dorsoplantarview
D. Dorsopalmar view.
1. Novelline RA; Squire's Fundamentals of Radiology, 5th ed. Cambridge' MA,
Harvard University Press, 1999.
8. Which of the following structures would not be visible in a
2. Gunderman RB: Essential Radiology: Clinical Presentation, Pathophysiology and lateral thoracic radiograph of a normal dog?
Imaging. New York, Thieme Publishers, 1998.
A. The left coronary artery
3. Suter PF: Thoracic Radiography: A Text Atlas of Thoracic Diseasesof the Dog B. The left cranial lobe pulmonary artery
and Cat. Wettswil, Switzerland, Peter F. Sutet 1984.
C. The caudal vena cava
4. Starrak GS, Berry CR, Page RL, et al: Correlation between thoracic radiographic D. The descendingaorta
changesand remission/survival duration in 270 dogs with lymphosarcoma. Vet Radiol
Ultrasound 38:411.,1997.
9. In thoracic radiographs of a patient with respiratory distress,
5. Eastman Kodak Company: The Fundamentals of Radiography, l2th ed. Rochester, the cardiac silhouette is enlarged in size, round in shape, and
NY, Eastman Kodak, 1980. homogeneous in opacity. Which of the following conditions is
6. Morgan JR Silverman S: Techniques in Veterinary Radiography, 5th ed. Ames, least likely?
Iowa, Iowa State University Press, 1997. A. Intrapericardial lipoma
7. Ticer I\r'y':Radiographic Technique in Small Animal Practice. Philadelphia, WB B. Pericardial effusion
Saunders,1980. C. Dilated cardiomyopathy
D. Hepatic peritoneopericardial hernia
K Ouestions 10. Tiue or False.It is essentiallvimoossible to tell the difference
between a craniocaudal and a caudocianial radiograph of a canine
1. Describe a situation in which the relative radiopacity of tlvo
elbow joint.
obiects is not directly reiated to their effective atomic number and
11. Give the four tlpes of errors to be aware of when evaluating
physical density.
radiographs.
2. What are the five basic radiopacities?
12. What is the cone of certainty and what does it have to do with
3. What are the six basic radiographic signs?
establishing or reaching a radiographic diagnosis?
4. Obscuring of the radiographic detail of small intestinal serosal
13. Describe the 12-stepprocessfor reviewing a radiographic
margin detail by the accumulation of peritoneal effusion is an
study.
example of which of the following?
14, If a radiographic abnormality is identified, what are the four
A. Summation effect
possibleexplanationsfor what the abnormality may represent
B. Silhouette sign
within the context of a given patient?
C. Codman's triangle
15. Look up the radiographic changesassociatedwith pleural effu-
D. A perception artifact
sion (Chapter 31). Are theseradiographicabnormalitiesspecificto
E. Distortion
pleural effusion? How is identification of a pleural fissure different
from a lobar sign (Chapter 34)?
5. This lateral cervical radiograph (Fig. 5-27) was made of a dog
that had been coughing for 3 days. Explain why the circular Answers begin on page727,
radiopacity is not a tracheal foreign body or tracheal wall mass.
Figure 5-27
AXIAL SKELETON
ffi CHAPTER
ffi6
lnterpretation Paradigms
ffi for the
ffi Axial Skeletop-gmall and Large
= .Animal . Clifford R. Berry
ffi Nancv E. Love
Nancy Berrv
Thoracic ligaments
Cervical spine
The intercapitalligaments(seeFig. 6-11) join the headsof a given
Dog, cat, and horse. Cl has no spinous process,but it has
pair of ribs, crossing from one side to the other over the dorsal
iarge transverseprocesses,sometimesreferred to as "wings" (Fig.
aspect of the intervertebral disc. Often these lieaments are not
6-a). C2 is the largest vertebra. It has an odontoid process from
present on the first pair or the last pair of ribs,"Theseligaments
the cranioventral aspectofthe body, calied the "dens." The spinous
tend to keep the thoracic intervertebral discs in situ.
processof C2 should overlap the arch of C1 (see Fig. 6-a). C6
has large transverseprocesses,sometimes called ventral laminae Entire spine
fig. 6-s). The dorsal longitudinal ligament is located along the floor of the
vertebral canal. When hlpertrophied, it may be associatedwith
Thoracic spine cervicalvertebralmalformation-instabilitv svndrome.
Dog and caf. There.are 13 pairs of ribs. T11 is the anticlinal
vertebra; its spinous processis vertical rather than angled cranially Miscellaneous
or caudally (Fig.6-6). T10-11 is the anticlinal space;this is the The intervertebral discs technically are considered ligaments. They
most narrow thoracic intervertebraldisc space(seeFig. 6-6). are composed of the outer annulus fibrosus and the inner nucleus
Horse. There are 18 pairs of ribs. Owing to the large size of pulposus. Common clinical conditions that involve the interverte-
adult horses,the (dorsal) spinous processesare the only part of bral discs include intervertebral disc diseaseand discospondylitis.
the thoracic spine that can usually be evaluated radiographically;
this is typically done in the lateral view. Irreguiar margination of Radiographic technique and positioning
the dorsal aspectof the spinous processis normal; it is the result Becauseof the radiographiccomplexityof the spine,it is imperative
of incompleteor irregular mineralization of a secondarycenter of that images are made using the correct exposure and that the
ossification. Text continued on page 62
57
58 AXIALSKELETON
Cervical
Lumbar
Figure 6-2. Lateraland ventrodorsalradiographs, a transverseCT image,and a labeleddiagramof caninelumbarvertebrae.ln the lateralradiograph,note how
the smal losseousstructureat the 11 o'cl ockp os i ti onof the
t he i n t e r v e r t e b r faol r a m in aa r e sh a p e dlike th e o u tlin eo f a h o r sehead.In the l ateralradi ograph,
foramenis the accessoryprocess.
Interpretati on
P aradi gms
for the A xi alS kel eton-smal and
l Lar qeAnim al 59
D e n s B ody
Lateralverterbral
forame n
Transverse
pr0 c e s s
Transverse
process
Figure 64. Schemattcrepresentation of the dorsalaspect of canine
cervi calvertebraeC 1-C 2. Movementat thi s arti c ul ati on
i s l i mi tedto
lateral/medialmotion and some rotation.Dorsal/ventral motion does not
occurat C 1-C 2.
-'';"1
';.- ri9ll:
lr;rlg
:::.:lll:::
rr:rllg:
lrlt9ll:-.
il9lr,'rii*rl:
rr,.,iiel;i:iiia
.:)):,:,:r:''tttil@llri.
;;rl9la:l9rrllr
,t,tg
4-&-i
!ll.,llgr,,
u:utaautr:
iiirilil:.,:,
9.L::':':l::::::
:ii@utii1111,
ll!.:::.
l..,ili
a,*tiql6|9l ci
i;u' ii:iiiluii::@u.:iil4uu
iiiwut.iiiiiiiiuutiii@ut:ti@u:ii
-,igltl,,Hi-,l9ei,aXiiei9l
Figure 6-8. Note the differencesbetweenthe canine/A/ and feline (B)lumbarspine.The length/heightratioof the body is largerfor the cat than for the dog
Alarligaments
IntercapitaI
ligament
Dorsallonoitudinal
ligamenl
of ligamentsof clin-
Figure 6-11. Schematicrepresentations
i calsi gni Icance.
Optional views
The optional views discussed in this section may be helpful for
detectingsome clinical abnormalities.
Right and left oblique views are helpful in iocalization of an
extradural spinal cord lesion; these are often used during a myelo-
graphic examination.
A horizontal-beam decubitus view should be used to obtain the
r-entrodorsal view of the spine in patients with a suspectedspinal
tiacture or malalignment. This view makes it unnecessaryto place
the patient in dorsal recumbency, which could cause spinal cord
damage from movement at the site of the fracture malalignment.
Dynamic views with the spine in flexion or extension have been Figure 6-14. A correctly1A)and rncorrectlyf8, positionedVD radiographof
used for assessingvertebral instability in the cervical spine or at a cani nel umbarspi ne.In B , the spi nousprocessesoj the l umbarv ertebrae
the lumbosacral junction. If flexed or extendedviews are employed, are posi ti oned
to the l eft of the mi dl i neof the vertebrae.
Th i si s due to rotati on
of the D ati ent.
it is very important to make sure that you do not exacerbatethe
condition when manipulating the spine.
Routine views in the horse as C1, C2, or C6 should be included on each radiograph to
Radiographyof the cervicalspine is the most commonly performed verif' location.
equineradiographicexaminationof the spine.It can be performed
in a standing (tranquilized) patient or with the horse under general
Interpretation paradigm
anesthesia.For standing views, a horizontally directed beam is
eenerally used, whereasfor radiographic examinations made under There are many ways to approach radiographic interpretation of
general anesthesia,a vertical beam is typicaliy used (Fig. 6-15). the small animal spine and the equine spine. The steps listed here
Three 14" X lT" cassettes are generaliyrequired to radiograph the constitute one method that either mav provide the reader with the
entire adult equine cervical spine. A distinguishing vertebra(e) such necessaryfoundation to develop his or her own approach, or may
yaa,,.:
'"at@
help one to become more organized in approaching the task of Alternate imaging
evaluating radiographic examinations of the spine. Owing to the anatomic complexity of the spine, alternate imaging
1. Carefully evaluate paraspinal structures. modalities are useful for a complete evaluation of the small animal
2. Note if images were made under general anesthesia(should spine and the equine spine.
seeendotracheal tube if neck or thorax included) or, if the patient
is a horse, if a standing position was employed for a tranquilized Gomputed tomography
oatient. Computed tomography (CT) is useful for evaluating the spine
3. Count the vertebrae within each anatomic region. becauseit allows visualization of the spine without superimposition
4. Note the general size of the vertebrae for each region; they of other bony structures. In addition, image contrast can be manip-
should be approximately the same size as adjacent vertebrae in a ulated to highlight the structure of interest (e.g.,bone versussoft
given region. Cl and C2 are exceptions. tissue). Spinal trauma and neoplasia are good clinical examples of
5. Evaluate the dorsal and ventral alignment of the vertebral the utility of CT (Fig. 6-16). CT often provides accurate informa-
bodies and the lamina. tion on the extent of spinal involvement becausethe vertebrae can
6. Note the overall vertebral canal diameter, as weli as the be evaluated in various imaging planes and without superimposi-
vertebral canal diameter at each vertebral body and adjacent inter- tion.
vertebral disc space. In many patients, CT can be used to detect herniated interverte-
7. Evafuateeach spinous processand articular processjoint. bral disc material in the vertebral canal without the need for a
8. Assessthe overall size of each intervertebral disc space and myelogram.
end plate,and evaluatedisc opacity. Becauseof the large size of the adult equine neck and the fixed
9. Compare the size of adjacent intervertebral disc spaces. size of the bore of a CT scanner, only the most cranial portion of
10. Compare the size and opacity of adjacent intervertebral fo- the spine of the horse can be evaluated using CT. The entire neck
ramina, of a pony or foal may fit into the CT gantry.
:i11€
Magnetic resonance imaging 2. Know how each radiographic view of the skutl is obtained.
Magnetic resonanceimaging (MRI) is acceptablefor evaluating the 3. Know which views constitute common radiographic examina-
osseousstructures of the spine, but it is better suited for evaluation tions of the small animal skull and equine skull.
of soft-tissuestructures,eipecialtyintervertebraidiscs and the spi- 4. Use a systematic approach for interpretation of skull radio-
nal cord (Fig. 6-17). Myelographycan often be avoidedwhen MRI graphs in smail animals and the horse.
is used to evaluatethe spinal cord. MRI has the same advantageas 5. Be aware of the application of alternate imaging techniques
CT in that the spine may be evaluated in various imaging pianes -
for assessing the spine.
and without superimposition of other structures.
Becauseof the large size of the adult equine neck and the fixed Radiographic technique and positioning
size of the bore of an MRI unit, only the most cranial portion of
Radiographs of the skull are made with the small animal patient
the spine of the horse is generally imaged. The entire neck of a
under general anesthesia.General anesthesiais required because
pony or foal may fit into the MRI unit.
small amounts of unwanted obliquity can causemisinterpretation.
Nuclear scintigraphy Radiographs of the equine sku1l are typically made in the standing
Nuclear scintigraphy (bone scan) of the vertebrae often allows tranquilized patient. It is important to remember that a small
detection of vertebral bone chanse before it is visible on conven- amount of obliquity can cause severe anatomic distortion. Also,
tional radiographs. Areas of incieased physiologic bone activity when the skull is imaged, it is important that a f,lm-marking
appearas regionsof increasedradioactivity (hot spots);conversely, system be establishedthat is consistent and understood by all who
areasof decreasedphysiologicbone activity or bone loss appearas use it to label oblique views.
regions of decreasedradioactivity (cold spots). Becauseof the The following views of the small animal skull are routinely made
decreasedanatomic detail that is inherent in nuclear scintigraphy, dependingon the purpose of the radiographicexamination:
additional imaging studies such as radiographs or CT often follow Routine examination: Iateral (Fig. 6-19) and ventrodorsal (VD)/
scintigraphicexamination (Fig. 6-18). dorsoventral(DV) (Fig. 6-20)
Ultrasound
Ultrasound is not commonly used to evaluate the spine. It may
be used to evaluatethe margins of the bones of the spine, or
intraoperatively to evaluatethe spinal or paraspinal soft tissues.
I Sk ull
At the completion of this section, the reader should be able to:
l. Identifr the basic radiographic anatomy of the small animal
skull and the eouine skull.
:eu
au,:
n,lto"ril;
hrlla .; "
of thefrontalsinusesin a dog.
caudalradiograph
Figure 6-21. Rostral
Variants
The different skull types in the dog (brachycephalic,mesaticephalic'
and dolicocephalic) may causesimilar structures to appear different
mt:,:
' , -''.
ffi::;::.'.;."
Figure 6-22. Open mouth ventrodorsalradiographof a caninenasalcavrty Figure 6-25. Obliqueview of the maxillain a dog
rc
*;m*.d-#.*ru,"". n'.','*
l nterpretati on
P aradi gms
for the A xi alS kel eton-S maland
l Lar qeAnim al 67
between skull types. For example, the nasal cavity, frontal sinuses,
mandible, and maxilla may all look different between skull types.
The more that the dog skull differs from the mesaticephalict)?e,
the more pronounced the changesin the relative shape and size of
the skull.
Interpretation paradigm
The skull is anatomically and visually complex. This may be posi-
tively addressedif the film reader has knowledge of the anatomy,
if the positioning and radiographic technique are correct, and if
symmetry is used to identify abnormalities. It is important for the
clinician not to become overwhelmed by skull imagei. If this should
happen, one structure should be identified, and then work should
proceed from there. It is helpful for the clinician to think of the
relationship of structures to each other rather than trying to mem-
orize what has been seenin the past.
There are many ways to approich radiographic interpretation of
the small animal skull and the equine skull. The steps listed here
constitute one method that either may provide the reader with the
necessaryfoundation to develophis or her own approach,or may
help one to become more organized in approaching the task of
evaluating radiographic examinations of the skull.
1. Make sure that all views needed for a specific study are in-
cluded.
Figure 6-28. Lateralradiographof the gutturalpouch regionln a horse Figure 6-29. Dorsoventralradiographof an equineskull
68 AXIALSKELETON
Figure G-32. Braintumor in a dog. Transverse f1,f2, andT1 with contrastmedium images.In the T1 image,the tumor is the largecircularregionof low signal
by a high signalbecauseof its largewater content. In the T1 image
(dirk gray) in the right cerebralhemisphere.In the T2 image,the tumor is characterlzed
acquiredfollowingintravenousadministrationof contrastmedium,there is patchy centralenhancement,and there is fairly well-definedperipheralenhancement
medially.{Courtesyof lan Robertson,BVSc.)
Interpretation
Paradigms
for the AxialSkeleton-Smalland LargeAnimal 69
Nuclear scintigraphy
2. Evaluate each image for correct radiographic technique and Nuclear scintigraphy may be used to evaluate the bones of the
positioning. skull. Scintigraphy has also been found to be valuable in identifiing
3. When reviewing a group of images, look for the same struc- bone remodeling associatedwith sinusitis, or abnormalities of thi
tures on all views; do not try to read one view in its entirety, then teeth such as root abscesses.
the next, and so on. It is too difficult to remember all findinss
seen and to correlate them with multiole views. Ultrasound
4. Divide the skull into regional iections: maxiila and teeth, Ultrasound is not commonly used to evaluate the skull. It can be
maxillary and frontal sinuses,nasal cavity, calvarium, temporoman- used to assessbone margins of the skull. However, ultrasound may
dibular joints and bullae, basioccipital and basisphenoid bones be useful in evaluation of the brain. Examination for hydrocephalus
(equine), mandible and teeth, pharynx, lar1'nx, gutturai pouch may be performed through an open fontanelle (Fig. 6-33). -
(equine), and cervical spine.
Alternate imaging
ffi Ouestions
Owing to the anatomic complexity of the skull, alternate imaging l. Identi$' this vertebra (Fig. 6-34).
modalities may be useful in expanding the evaluation of the small
animal skull and the equine skull. 2. Identift the spinal region and species(Fig. 6-35).
Gomputed tomography 3. 'vVhatis the vertebral formula in the doe and cat?
Computed tomography is a good imaging technique to use for A. C6-T | 3-L7 -53-Cd20-24
evaluating the small animal or equine skull (Fig. 6-30). With CT, B. C7-T 14-L7-53-Cd20-24
the skull may be visualized at different anatomic levels (e.g., nasal c. c7 -T 13-L7 -53-Cd20-24
cavity, forebrain, midbrain) and in different planes (e.g., transverse, D. C6-T 13-L7 -Ss-Cd20_24
sagittal, dorsal) without superimposition of other structures; also, E. None of the above
Figure 6-34
)]]9;q
iiltrrr:rii.l
it:':uti
::::ll'.).).
t'l,,,,l :,...ili: :r116ll:
ii
Figure 6-38
The C rani aland N asalC avi ti es-C ani ne
a nd Feline 7l
Figure 6-39
4. \44ry is intervertebral disc diseasein the dog and cat uncom- and B: frontal sinus, tympanic bulla, coronoid process(vertical
mon from T1-T10? ramus) of the mandible, soft palate,and nasalturbinates.
A. The ribs keep the discs in place.
B. There are no intervertebraldiscsfrom T1-T10. 8. Identify the following structures (horse skull) on Figure 6-39:
C. Intervertebraldiseaseis very common from T1-T10. stylohyoid bone, epiglottis, guttural pouch, ethmoid turbinates,
D. The intercapital ligaments help keep the discs in place. and coronoid process (vertical ramus) of the mandible.
E. None of the above
9. How many views are required for a small animal nasal series?
Name the views.
5. Using Figure 6-36, identi$' the parts of the vertebra.
10. Tiue or False. Examinations of the skull are commonlv per-
Identify the imaging modalitieson Figure 6-37. formed in an awake animal.
7. Identify the following structures (dog skull) on Figure 6-38.4 Answers begin on page 727.
ffi CHAPTER
ffi7
ffi The Granialand Nasal
ffi Gavities-Canine and Feline
w r Lisa T.Forrest
I Normal anatomy the most dorsocaudalaspectof the skull (see Fig. 7-l), and the
The skuli is composed of numerous bones, some of which are occipital condyles are caudoventral as seen on lateral radiographs.
fused together. It encompassesthe brain and houses the sense The foramen magnum is centered between the occipital condyles.
organs for hearing, equilibrium, sight, smell, and taste. The skull It forms a ring for passageof the spinal cord.
provides attachment sites for teeth, tongue, larynx, and muscles.'
There is breed variation in the shape of the skull, with variation
Nasal passages and paranasal sinuses
being more pronounced in the canine species.Three terms are
used to designatethe different shapes.Dolichocephalicbreeds have The nasal passageextends caudally from the external nares to the
1ong, narrow heads with an extensivenasal cavity from rostral to cribriform plate and nasopharynx. The cribriform plate is a sieve-
caudal. Examples of dolichocephalic breeds include collie and Rus- like partition between the rostral olfactory bulbs of the brain and
sian wollhound. Mesaticephallcbreeds have heads of medium pro- the caudal nasal passage.The nasal passageis divided in half by
portion and include German shepherdsand Beagles(Fig. 7-l).
the nasal septum and is filled with thinly scrolled conchae. Cau-
Brachycephalicbreeds have short, wide heads.Examples of brachy-
daliy, the nasal septum is bony and fuseswith the cribriform plate;
cephalicdogs include Boston terriers and Pekingese. Cats are more
it becomescartilaginous as it extends rostrally.l The vomer bone is
uniform in their skull conformation. However, Siamese tend to
unpaired and forms the caudoventral part of the nasal septum.
have longer heads as compared with Himalayan and Persianbreeds.
It is the bony nasal septum and vomer bone that can be seen
Calvaria and assooiated structures radiographically.'zBoth dogs and catshave frontal sinuses(seeFig.
The calvaria comprises the bones of the brain case, with the 7-i), laterai maxillary recesses,
and small sphenoidalsinuses.These
occipital bone forming the base of the skull. The occipital crest is are named for the bones in which thev are located.
72 AXIALSKELETON
Dental formula-cat
Deciduous teeth
2x(3l3C1l1P3l2l:26
Permanent teeth
2 x | 313C 111P 312M 1l1l : 30
Dental formula-dog
Deciduous teeth
2x(|313C111P3l3l--28
Permanent teeth
2 x | 313C 111P 414M 2l3l : 42
I Gongenital anomalies
Figure 7-1. Lateralskull radiographof a Germanshepherddog, which is a
mesaticephalicbreed. Note the occipital crest (small arrowhead),superim- Hydrocephalus
posedfrontalsinuses(*), and tympanichullae(largearrowhead).
Hydrocephalus is an excessiveaccumulation of cerebrospinal fluid
within the skull. Congenital hydrocephalus may occur secondary
Tympanic bullae and temporomandibular ioint to structural defectsthat either obstruct cerebrosoinalfluid outflow
The tympanic bullae (see Fig. 7-l) form the ventral part of the or impede its absorption. Canine breeds affected with congenital
temporal bone. Theseair-filled cavitiesof the middle ear communi- hydrocephalus include the Maltese, the Yorkshire terrier, the Eng-
cate with the nasopharynx via the auditory tube. The temporal lish bulldog, the Chihuahua, the Lhasa apso, the Chinese pug, the
bone consistsof the petrosal, tympanic, and squamous sections ' Toy Poodle, the Pomeranian, the Cairn and Boston terriers, and
that are fused in the adult. The petrosal portion is medial and the Pekingese.sHydrocephalus has rarely been reported in cats.e11
dorsal to the tympanic bulla and is composed of densebone in the Radiographic signs associatedwith hydrocephalus include dom-
mature animal. The squamous portion of the temporal bone ex- ing ofthe calvaria and cortical thinning, persistent fontanelles, and
tends rostrally and laterally to form the zygomatic arch. a homogeneous appearanceto the brain, resulting from the loss of
The temporomandibular joint is a condylar joint. The temporal normal convolutional skull markings (Fig. 7-3). Previously,diagno-
portion consists of the zygomatic processof the squamous temPo- sis of hydrocephalus was made by ventriculography," but this
ral bone, which forms the mandibular fossa and the retroarticular invasive procedure has been replaced by computed tomography
(CT), magnetic resonance(MR) imaging, and ultrasonography."-'u
process. The retroarticular process is the ventral extension of the
Persistentfontanelles allow the use of ultrasound to diagnose hy-
squamous temporal bone. The mandibular aspect of the joint
includes the condyloid process,which articulates with the mandib- drocephalus,l3'raand normal ventricular size has been established
in the dog.13'14,17,18Asymmetry in ventricular sizeis often normal
ular fossa.
in dogs.
Teeth
Occipital dysplasia
The teeth are anchored in alveoli within the mandible and maxilla.
The dental formulas for the dog and cat are provided in Thble 7-1' Occipital dysplasiais the dorsal extension of the foramen magnum;
Components of the tooth include the root (embeddedin bone) it has been related to clinical signs of neurologic diseasete" and is
and the crown (within the oral cavity); the bone between teeth is usually identified in miniature and toy breeds.tnForamen magnum
referred to as the alveolar crest. The dentin, enamel, and lamina size and shape are best evaluated in the rostrodorsal-caudoventral
dura of the tooth are radiopaque. The pulp cavity and periodontal skull radiograph. The anesthetizedpatient is placed in dorsal re-
membrane are of soft-tissue opacity (Fig. 7-2). The size of the cumbenry with the neck flexed so that the nose is angled toward
pulp cavity changes with maturity, becoming smaller with age.' the sternum. The central x-ray beam is directed between the eyes
Specificson radiographic technique and positioning for tooth eval- and exits through the foramen magnum. The beam is angled 25 to
uation can be found eisewhere.*t 40 degreesfrom the vertical axis, depending on calvarial shape.22
Figure 7-2. A, Lateralradiographof the mandibleof a mature dog. Note the well-definedlaminadura (arrows),which mark the dental alveolus.8, Lateral
radiographof the mandibleof a 4-month-olddog. Note the open apicalforaminaof the teeth, the largepulp cavity,and the locationof permanentpremolarsventral
to the deciduousprecursors.(Courtesyof Dr. Wendy Myel Ohio State University,ColumbuslOhio.)
The C rani aland N asalC avi ti es-C ani nand
e Feline 73
I Metabolic anomalies
Primary or secondaryhyperparathyroidism can result in an overall
decreasedopacity of the entire skeleton, often easily noted in the
skull. A solitary parathyroid adenoma or carcinoma, or adenoma-
tous hyperplasia of one or both parathyroid glands, causesprimary
Figure 7-3. Lateralradiograph
of a 1-year-old
maleChihuahua with severe hyperparathyroidism. This results in excessivesynthesis and secre-
hydrocephalus.Notethe homogeneousappearanceof the calvaria
caused by tion of parathltoid hormone, which leads to hypercalcemia and
a lossof the normalconvolutional (Courtesy
skullmarkings. of Dr.Wendy subsequent bone resorption.32Secondary hyperparathyroidism,
Myer,OhioStateUniversity,
Columbus,Ohio.) which includes renal and nutritional secondary hyperparathyroid-
ism, is subsequent to nonendocrine alterations in calcium and
phosphorushomeostasisthat lead to increasedlevelsofparathyroid
Figure 7-4 representsboth the normal and the abnormal appear- hormone and ultimate bone resorption.32
ance of the foramen magnum as seen on the rostrodorsal-caudo- An early radiographicsign ofhyperparathyroidism(primary and
ventral skuil radiograph. Studies suggestthat occipital dysplasia is secondary) is loss of the lamina dura. Lamina dura loss and
common in small-breed dogs, may not causeneurologic signs, and demineralization of the mandible and maxilla result in a floating
is a normal morphologic variation in brachycephalicdogs." tt appearance to the teeth; subsequent fibrous osteodystrophy can
lead to thickening of the affected part of the skull (Fig. 7=6).
Temporomandibular joint dysplasia Level of cortical thinning and degree of overall osteolysis and
osteomalaciadependon duration and severityofthe disorder;they
Open-mouth jaw locking is the clinical sign associatedwith tempo-
also determine the degreeof tooth displacement.Becauseyoung
romandibuiar joint dysplasia.This congenital condition is uncom-
animals are growing and have rapid skeletal turnover, they are
mon; it is most frequently reported in the Bassethound, but has
more severelyaffected than older animals (Fig. 7-7).
also been seen in Irish setters.26The open-mouth jaw locking
occurs after hyperextension of the jaw, excessivelateral movement
of the condyloid process, and subsequent entrapment lateral to I Neoplastic abnormalities
the zygomatic arch. Physical entrapment usually occurs on the
contralateral side from the joint with the most severe dysplastic Nasal tumors
changes(Fig. 7-5). Yawning often precipitates jaw locking when it
Tumors of the nasal cavity in dogs and cats account for approxi-
results in extreme opening of the mouth.t6
mately 1% to 2o/oof a\I neopiasmi. .t Thesetumors occur in older
dogs and cats; about two thirds of al1 tumors are carctnomas
Mucopolysaccharidosis (adenocarcinoma,squamous cell carcinoma, undifferentiated carci-
Mucopolysaccharidosesare a group of hereditary disorders of lyso- noma), and the other one third are sarcomas(fibrosarcoma, chon-
somal storage, which occur in humans, dogs, cattle, and cats.27 drosarcoma, osteosarcoma, undifferentiated sarcoma). Intranasal
Mucopolysaccharidosis VI (MPS VI) is an autosomal recessive Iymphoma can also occur, with a higher prevalence in cats.36-3s
lysosomalstoragediseaserecognizedin Siamesecats.'?8 Radio- Tumors of the nasal cavity are locally invasive, and external beam
rlrrllgllrr:iiiigll
i119r:ilr9rrr::11
$ll:::11@lllr.]:r@;
llr.ii@l
'{-'s lifflr]:i
w' R' q;
*lt:ilG<:tiBlRtlBtl:llgtltl:t!!$l
rlll9lll:ll:ll3lll:::lllallltllal:lll.r.:
cutr:3@;1eu:iillsu.iil3ut-,iiil
ffi#ry
riBll
gll rlg
lll.il@llill:r,i;
:;5::;;::-*1 l$lr.:c
lliiriirilrr:
;.,".; ..t:,"g.#;
lll!)),,-,ii:1;llll':
Figure 7-7. Lateralskull radiographof a l2-week-od kitten with severe Figure 7-9, Rostrocaudal frontal sinus radiographof a 7-year-oldGerman
secondarn y u t r i t i o n ah yp e r p a r a th yr o id ism
No.teth e o ve r a lllo ssof boneopac- shepherdwith a historyof epistaxis.Note the increaseclopacityto the right
ity , l o s so f l a m i n ad u ra ,a n d se ve r eco r ticath l in n in go f a ll b o nes.(C ourtesy
oj frontalsi nusas comparedw i th the l eft. The i ncreasedopac i tyi s c ons i s tent
D r .W e n d y M y e r ,O h i oSta teUn ive r sitv, Co lu m b u s,Oh o .) w i th obstructi ve,
neopl asti c,
fungal ,or i nfecti oussi nusi ti s.
76 A X I A LS K E LET ON
Figure 7-12. Lateral (A) and right ventral-left dorsal /B/ ra-
diographsand computed tomography(CT) image (C) of the
skull of a 9-year-oldboxer with multilobularosteochondrosar-
coma of the ri ght occi pi talbone. N ote the granul armi neral
mass opacityon radiographsfBl and the superiortumor size
esti mati onand degreeof brai ncompressi on (mi ni mai ev i dent
in the CT lmage ICl. (Courtesyof Dr. Wendy Mver, Ohio State
U ni versi ty,
C ol umbus,
Ohi o.)
rence after treatment (surgical excision alone, or surgery and radio- years of age), nonbrachycephalic breeds more frequently than it
therapy), and approximately half develop metastatic disease.67, 70'73 does other breeds.'8'?e Aspergillus species (primarily Aspergillus
CT is superior for the detection of cranial vault invasion, which fumigatus) are common saprophltic fungal organisms found in the
was a common feature in five of sevenpatients recentiy described.t' environment.T8Destructive rhinitis caused by other fungal agents,
such as Penicillium species,is less common.7s,80 Nasal blastomycosis
Other tumors of the cranium can occur in endemic areas.The most common radiographic ap-
Other primary tumors of the cranium include osteosarcoma,oste- pearanceof nasal aspergillosisincludes lysis of conchaewith punc-
oma, and osteochondroma.Osteosarcomais the most common tate lucenciesof bone (Fig. 7-15).ao'o8r Increasedlocalizedsoft-
primary bone tumor, with 10% to l5o/o arising from the skull. tissue opacity of the nasal cavity is also seen, but frontal sinus
Distribution of canine skull osteosarcomain one reDort included involvement is variable and consistsof sinus oDacitv with or with-
cranial vault tn 37o/o,facial bone in 360/o,and mandible in 27o/oof out mottled bony thickening.4O, 7e'sr Bony nasal septum erosion
patients.TsOsteosarcomasarising from the cranial vault do not or deviation is uncommon except in cases of advanced disease.
resemble those from the appendicular skeleton or other skull sites. Cryptococcusneoformans,a fungai infection more commonly seen
Osteosarcomasof the cranium tend to be osteoblastic,have weli- in cats, can infect the nasal passages,but generally causesa non-
defined borders, and contain granular areasof calcification.T6Oste- destructive hyperplastic rhinitis (Fig. 7-16).u, s
oma is a slow-growing, benign tumor that has a smooth, well- Destructive rhinitis secondary to fungal diseasecan be difficuit
defined border on radiographs(Fig 7-13). Thesetumors can arise to differentiate from neoplasia. Both diseasescauseloss of conchal
from the mandible, cranial vault, or sinuses.T6 detail, but soft-tissue swelling, bony invasion, and ipsilateral frontal
Tumors of the brain are best identified with either CT or MR sinus opacity are more common featues of nasalcavity neoplasia.ro'tt
imaging. One brain tumor in which radiographic changesmay be Regardlessof the radiographic presentation, a biopsy sample for
noted on routine skull radiographs is feline meningioma (Fig. histopathologic evaluation is necessaryfor diagnosis.
7-14). These tumors may calcify and causesclerosisand/or lysis of
the adjacent bony calvaria.tt Nasal rhinitis and foreign bodies
Rhinitis secondary to bacterial infection, or corticosteroid-respon-
I lnfectious disorders sive rhinitis with lymphoplasmacytic infiltrates, can have a variable
radiographic appearancein dogs and cats. Depending on the chro-
Nasal aspergillosis nicity and severity of rhinitis, there will be evidence of destruction
Nasai aspergillosisis a destructive rhinitis involving the nasal cavity of conchae and of bony erosion.3sChronic rhinitis and sinusitis in
and paranasal sinuses of the dog; it affects younger (less than 4 cats are common sequelaeto viral upper respiratory tract disease.
78 A X I A LS K E LE T O N
?,:,;i
:'.:::::.,,:
tlllli::
Figure 7-18- Lateal (A)and close-upventrodorsal, open-mouthiBl radiographsof a 9-yearoldfemale Poodlewith a 3-week historyof unilateralnasaldischarge
ani sneezing.A radiopaqueforeignbody (arrows)can be seen in the left nostril.Note the loss of aerationof the left nostril.icourtesy of Dr. Wendy Myer, Ohio
Oh io .)
S t a t eU n i v e r s i t vC. o l u mb u s,
bony proliferation may involve the Petrous temporal bone or the Ear canal tumors can occur in dogs and cats. Most often, these
temporomandibular joint. Positioning is crucial when radiography soft-tissueneoplasmsare squamous cell carcinoma or mucinous
of the bullae is performed; general anesthesia facilitates proper gland adenocarcinoma. These masses obliterate the external ear
positioning and allows personnei to vacate the room during radio- canal and can cause aggressivebony lysis of the adjacent calvaria
graphic exposure. A review of imaging techniques for middle ear and osseousbdla (Frg.7-22).
diseasecan be found elsewhete.8e'eo
When radiographic and surgical findings of otitis media were Periapical (tooth root) abscess
compared, all cases with abnormal radiographic findings were
confirmed surgically.However, 25o/oof patients with normal radio- Periapical infection has a tlpical radiographic appearance of a
graphs of the middle ear were abnormal at surgery.elCT is a more radiolucent halo around the affected tooth root with destruction
sensitive test for evaluation of otitis media,e'?but proper imaging of alveolar bone (Fig. 7-23). Other radiographic signs seen with
technique is necessaryto avoid artifactual wall thickening of the periapical abscessinclude widening of the periodontal spacesur-
bulla on CT images."r rounding the apex, bone lysis or sclerosisadjacent to the apex, loss
Feline nasopharyngealpollps are non-neoplastic growths origi- of the lamina dura, and resorption of the tooth root. Periapical
nating from the mucous membrane of the auditory tube or middle infections are common in older animals and may be secondary to
ear.nnNasopharyngeal polyps generally occur in younger cats and periodontal disease or fracture of the affected tooth. In dogs,
can extend into the external ear canal, the osseousbulla, or the infections of the fourth maxillary premolar (carnassialtooth) often
nasopharynx. Cats may present with signs of middle ear disease' result in an external fistulous draining tract below the eye.
rhinitis, or upper airway diseasesecondary to the space-occupying Dental radiographs can be obtained using conventional x-ray
pol1p. Signs of otitis media (increased soft-tissue opacity of the equipment and film-screen combinations, which consist of open-
affecledbulla) or nasopharyngealobstruction (Fig.7-21) may be mouth oblique views of the dental arcades.A dental x-ray machine
noted on radiographs. In a study of 31 cats with nasopharyngeal provides enhanced flexibility in adjustment of focal film distance,
polyps, a radiographic diagnosis of otitis media was made in 26 angulation, and collimation, and it enablesthe use, with improved
cats, and nasopharyngealmasseswere detected in 30 cats.es accuracy,of small, intraoral dental film.u Since the recognition of
Figure 7-2O. Tympanicbullaradiographs of a 6-year-old female domesticshort-haircat w;th chronicotitis externaand media.Comparethe normalleft bulia(air-
f ill e d ,t h i n , b o n y r i m ) se e n in th e r ig h t d o r sa l- le ftve n tr a lo b liqueradi ographfA l w i th the thi ckenedri ght bul l aseen i n the l eft do;sal -ri ghtve ntralobl i que/B /,
(C/,
ventrodorsal and open-mouthrostrocaudal/D/ radiographs. (Courtesyof Dr. Wendy Myer, Ohio State Universitv,Columbus.Ohio.)
the American Veterinary Dental Collegeby the American Veterinary considerable lateral sliding movement, and the sl.nchondrosis of
Medical Associationin 1988,there has been an increasednumber the mandibular symphysis allows independent movement of the
of specialists in veterinary dentistry. It is common practice for mandibular rami.eT Dislocation of the TMI tends to be in the
these dentists to perform endodontal and periodontal procedures rostrodorsal direction (Fig. 7-2a), as ventrocaudal luxation is pre-
to treat dental diseasein dogs and cats.4 vented by the retroarticular processof the temporal bone.eTDogs
and cats with TMJ dislocation are unable to completely close t6e
mouth, have dental malocclusion with the mandible displaced to
I Traumatic injuries one side, and display excessivesalivation.e6, et Luxation is most
Temporomandibular joint (TMf) luxation can occur in both dogs often unilateral; it may occur alone or with concomitant fractures
and cats after external trauma. In the cat, TM| luxation often of the retroarticular process,mandibular fossa,and zygomatic pro-
occurs after the cat has jumped from a height, and in both dogs cessof the squamoustemporal bone, or with the condyloid process
and cats, dislocation can occur secondaryto being hit by a car."o of the mandible.e6
The TMJ is capable of luxation without fracture because it has Radiographic views necessaryfor evaluating the TMJ include
Figure 7-2L Laleral(A), right dorsal-leftventraloblique /B/, eft dorsal-rightventraloblique /Cl, and T0degree ventrodorsal/D/ radiographsof a T-year-old
dom e s tc s h o r t - h a ci ra t wth a h isto r yo f in sp ir a to rdyysp n e aNo . tethe i ncreased soft tl ssueopaci ty,w hi ch ts obl i terat on the
ng the normal y ai r-fi l ednasophary nx
ateral oroiection(A, arrowheads).Comparethe left and rlght bulLaeon the lateralobliques /8, Cl, and 1O'degreeventrodorsalradiographs1Dland note the
d p a c i t va n c lb on yth cke n tn go f th e r ig h tb u lla .Na so p haryngeal
inc r e a s e o pol ypsi nvovi ngthe rl ghtbul l aand nasopharynx (D
w ere removedsurgi cal l y . from H ofer
: n e w r a d io g r aphivicew of the fe i ne tympani cbul l ae.V et R adi olU l trasound
? M e i s e nN , B a r t h o l dSi , e t a l: Ra d io o g yco r n e r A 36:14-15, '1995.)
Figure 7-22. Ventrodorsalskull radrograph of a 12-year-old domestlcshort- Figure 7-23. Close-up atera dental radographof a perapicalabscessof
hairc a t w t h s q u a m o u sce l ca r cln o m ao f th e le ft e a r ca n a . No te the l ysi sof mol ar.N ote the ysi s of al v eol arbone,
the rostra root of the fi rst mandrbul ar
the skulL(arrows)and atera aspectof the left tympanc bul a. (Courtesy of Dr' l oss of l aml nadura,and erosi onof the tooth root. (C ourtes yof D r. W endy
Wen d yM y e r ,O h i oS t a t eUn ve r sity,Co lu m b u s,Oh io .) Myer,Ohi oS tateU ni versi ty, C ol umbus,Oh o.)
a2
r==
and Feline g3
The C rani aland N asalC avi ti es-C ani ne
Figurc 7-24. Ventrodorsal/A/ and right dorsal-leftventraloblique 1Blradiographsof a 1-year-olddomesticshort-haircat with a left temporomandibular joint
luxation.Note the rostrallocationof the left mandibularcondyiarprocess(arrowheadlin the ventrodorsalradiograph(A). ln the lateralobliqueradiograph note
/Bi
the rostraland dorsalluxationof the mandibularcondvlarorocesshrrowhead.
ventrodorsal and 20-degreelateral oblique views in the cat.e6These rier breeds such as the Labrador retriever and the Doberman
same views are useful in the dog. A sagittal oblique radiograph, in pinscher. There is a known autosomal recessiveinheritance in West
which the nose is elevated with a foam wedge so that the head is Highiand White terriers.%CMO is usually seen in young dogs aged
at a 20-degree angle to the cassettefrom a lateral position, is 3 to 8 months; affected dogs have mandibular swelling, prehension
advocatedin dogs as an alternative to lateral oblique views.n5 difficulties, pain on opening the mouth or with mastication, py-
rexia, or combinationsof theseclinical sisns.3r,ee
I Miscellaneous diseases On radiographic evaluation of the skill, there is an increased
bony opacity to affected areas, primarily the mandible, the tym-
panic bulla, and the petrous temporal bone (Fig. 7-25). Bony
Craniomandibular osteopathy
proliferation is somewhat irregular and often bilateral and may be
Craniomandibular osteopathy (CMO) is a proliferative bone dis- asymmetrical, although unilateral presentation can occur. Bony
easethat occurs mainly in young West Highland White, Scottish, proliferation can involve the temporomandibular ioint and can
Cairn, Boston, and other terriersl it is occasionallvseen in nonter- affectjaw movemenr.Diagnosisii basedon signai-ent and on
Figure 7-25. Lateralskull radiographsof two West Highlandwhite terrier dogs with craniomandibular osteopathy.A, The proliferationis primarilyon the
mandibularramus (whitearrows).B, Bony proliferationinvolvingthe tympanicbullaeand temporomandibular
joints as well as the mandlbularramu,s(openarrows).
iCourtesyof Dr. Wendy Myer, Ohio State Universitv,Columbus,Ohio.)
84 AXIALSKELETON
Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat, 5th ed.
Philadelphia, WB Saunders, 2000.
9. Burt JK, Bhargava AK, Prlnn RB: Unilateral hydrocephalus with cranial distor-
tion in a cat. Vet Med Clin North Am Small Anim Pract 65:745, 1970.
13. Hudson JA, Simpson ST, Buxton DE et al: Ultrasonographic diagnosis of canine
hydrocephalus. Vet Radiol Ultrasound 31:50-58, 1990.
14. Spaulding KA, Sharp NJH: llltrasonographic imaging of the lateral cerebral
ventricles in the dog. Vet Radiol Ultrasound 31:59-64,1990.
15. Vite CH, Insko EK, Schotland HM, et al; Quantification of cerebral ventricular
volume in English bulldogs. Vet Radiol Ultrasound 38,437-443,1997.
17. Hudson JA, Cartee RE, Simpson ST, et al: llltrasonographic anatomy of the
canine brain. Vet Radiol 30:13-21, 1989.
Figure 7-26. Obliqueradiograph of a 14-year-old,
of the rostralmandible
of the 18. Hudson ]A, Simpson ST, Cox NR, et al; Ultrasonographic examination of the
mixed-breed dog with severedentaldisease.Note the irregularity
teeth Also notethe normal canine neonatal brain. Vet Radiol (Jltrasound 32:50-59, l99L
alveolar crestbetweenthe secondand thirdpremolar
lysisof the caudalrootof the first premolarandthe rostralrootof the third 19. Bardens jW: Congenital malformation of the foramen magnum in dogs.
premolal changesconsistentwithdentalrootcaries.
20. Kelly lH: Occipital dysplasia and hydrocephalus in a toy poodle. Vet Med Small
Anim Clin 70:940,1975.
21. Parker AJ, Park RD: Occipital dysplasia in the dog. J Am Anim Hosp Assoc
radiographic findings. Bone biopsy is helpful in nonterrier breeds 101520,1974.
with unilateral involvement. Concurrent metaphyseal long-bone
22. Ticer lW: Radiographic Technique in Veterinary Practice. Philadelphia, WB
changessimilar to hypertrophic osteodystrophy have been seen in
Saunders, 1984.
dogs with CMO, but this is uncommon.3' CMO is a self-limiting
23. Watson AG: The phylogeny and development of the occipito-atlas-axis complex
diseasewith unknown etiology. Bony proliferation generally ceases
in the dog. Ithaca, NY, Cornell University, 1981.
with skeletalmaturation.
24. Wright JA: A study of the radiographic anatomy of the foramen magnum in
dogs. J Small Anim Pract 20:501, 1979.
Periodontal disease
25. Simoens R Poels R Lauwers H: Morphometric analysis of the foranen magnum
The structures that support the teeth include the cementum, the in Pekingesedogs. Am J Vet Res 55:34-39, 1994.
periodontal ligament, the alveolar bone, and the gingiva. Periodon-
26. Robbins G, Grandage J: Temporomandibular joint dysplasia and oPen-mouth
ial disease involves both hard tissue (cementum, alveolar bone) jaw locking in the dog. I Am Vet Med Assoc 171:1072-1076, 1977.
and soft tissue (periodontal ligament, gingiva) that surrounds the
27. Cowell KR, lezyk PR Haskins ME, et al: Mucopolysaccharidosis in a cat. I Am
teeth; it commonly affects dogs and cats.a Gingival recession or
Vet Med Assoc 1.69:334-339,1976.
hyperplasia and bony resorption in periodontal disease lead to
oiti-it. loss of tooth support. Although radiography provides little 28. Haskins ME, Gustavo DA, Jezyk PF, et al: The pathology of the feline model of
VI. Am J Pathol 101:657-674,1980.
mucopolysaccharidosis
information about gingival tissues, it is an important part of the
evaluation of bony structures in periodontal disease. 29. Konde LJ, Thrall MA, Gasper P, et al: Radiographically visualized skeletal changes
associatedwith mucopolysaccharidosisVI in cats. Vet Radiol 28:223-228,1,987.
Early radiographicsignsofperiodontal diseaseinclude an irregu-
lar surface und botte loss in the alveolar crest. The lamina dura 30. Haskins ME, Aguirre GD, Iezyk PF, et al: The pathology of the feline model of
may be ill defined or may lack continuity.a As the disease pro- mucopolysaccharidosisL Am J Parhol 112:27-36,1983.
g.ei..r, horizontal bone loss of a group of teeth occurs so that 31. Johnson KA, Watson ADJ: Skeletal diseases.In Ettinger Sl, Feldman EC (eds):
ilveolar bone resorption developsaway from the tooth crown, thus Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat, 5th ed.
Philadelphia, WB Saunders,2000.
exposing tooth roots. Widening of the periodontal space is also
seen. Alveolar bone recession exPosesroot surfaces, which can 32. Feldman EC: Disorders of the parathyroid glands. In Etting€r SJ, Feldman EC
(eds): Tertbook of Veterinary Internal Medicine: Diseasesof the Dog and Cat, 5th ed.
lead to root caries and root resorption, seen radiographically as
Philadelphia, WB Saunders,2000.
radiolucentdefects(Fig. 7-26).\ao
33. Brodey RS: Canine and feline neoplasia. Adv Vet Sci Comp Med 14:309-354,
1970.
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Am 4 :7 4 1 -7 6 2 ,1 9 7 4 . 39. Harvey CE, Biery DN, Morello J, et al: Chronic nasal disease in the dog: Its
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43. Schwarz I Sullivan M, Hafiung K: Radiographic anatony of the cribriform plate 73. Straw RC, Lecouteur RA, Powers BE, et al: Multilobular osteochondrosarcoma
(lanina cribrosa). Vet Radiol Ultrasound 41:220-225, 2000- ofthe canine skull: 16 cases(1978-198S).J Am Vet Med Assoc 195:1764-1769,1989.
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sinusesin cats:32 caseswith comparison to a national database(1977-1987).] Am 76. Myer W: Cranial vault and associatedstructures. In Thrall DE (ed): Textbook of
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47. Frew DG, Dobson JM: Radiological assessmentof50 casesofincisive or maxillary 77. Lawson C, Burk RL, Prata RG: Cerebral meningioma in the cat: Diagnosis and
neoplasiain the dog. I Small Anim Pract 33;11-18, 1992. surgical treatment of 10 cases.J Am Anim Hosp Assoc 20:333 342, 19g4.
78. Sharp NJH, Harvey CE, Sullivan M: Canine nasal aspergillosis and penicilliosis.
48. Burk RL: Computed tomographic imaging of nasal disease in 100 dogs. Vet
Comp Contin Edu Pract Vet l3:41-48, 1991.
Radiol Ultrasound 33:177-180, 1992.
79. Sullivan M, Lee R, Jakovljevic S, et al: The radiological features of aspergillosis
49. Codner EC, Lurus AG, Miller lB, et al: Comparison of computed tomography
ofthe nasal cavity and frontal sinusesin the dog. J Small Anim pract2T:167-1g0,19g6.
with radiography as a noninvasive diagnostic technique for chronic nasal disease in
dogs.I Am Vet Med Assoc 202:1106-1110,1993. 80. Haney CE, O'Brien lA, Felsburg PJ, et al: Nasal penicilliosis in six dogs. J An
Vet Med Assoc 178:1084-1087,1981.
50. Park RD, Beck ER, Lecouteur RA: Comparison of computed tomography and
radiography for detecting changes induced by malignant nasal neoplasia in dogs. J 81. Gibbs C, Lane JG, Denny HR: Radiological features of intra-nasal lesions in the
-{m Vet Med Assoc 201t1720-1.724,1992. dog: A review of 100 cases.J Small Anim Pract 20;515-535,1979.
51. Thrall DE, Robertson ID, Mcleod DA, et al: A comparison of radiographic and 82. Mdik R, Martin P, Wigney DI, et al Nasopharyrgeal cr)?tococcosis. Aust Vet
computed tomographic findings in 3t dogs with malignant nasal cavity tumors. Vet 75:483488, 1997.
Radiol 30:59-66, 1989.
83. Wilkinson GT: Feline cryptococcosis: A review and seven case reports. J Small
52. McEntee MC, Page RL, Heidner GL, et al: A retrospective stvdy of 27 dogs with Anim Pract 20:749-768, 1979.
intranasal neoplasms treated with cobalt radiation. Vet Radiol Ultrasound 32:135- 84. Hawkins EC: Chronic viral upper respiratory diseasein cats: Differential diagno-
1 3 9 ,1 9 9 1 . sis and management.Comp Contin Edu Pract Vet 10:1003-1012,19gg.
53. Hoyt RF, Withrow Sl: Oral malignancy in the dog. J Am Aaim Hosp Assoc 85. Burgener DC, Slocombe RR Zerbe CA: Lymphoplasnaqtic rhinitis in five dogs.
.10:83-92,1984. J Am Anim Hosp Assoc23:565-568,1986.
54. Stebbins KE, Morse CC, Goldschmidt MH: Feline oral neoplasia: A ten-year 86. Tasker S, Knottenbelt CM, Munro EAC, et al: Aetiology and diagnosis of persis
suwey.Vet Pathol 26:121-128.1989. tent nasal disease in the dog: A retrospective study of 42 cases.J Small Anim pract
40:473478, 1999.
55. Dubielzig RR: Proliferative dental and gingival diseasesof dogs and cats. J Am
,{lim Hosp Assoc 18:577-584,1982. 87. Gartrell CL, O'Handley PA, Perry RL: Canine nasal disease:part II. Comp Contin
Edu Pr ac l Vet l 7:5J g- 54b,1995.
56. Withrow SJ: Tumors of the gastrointestinal system: Cancer of the oral caviry In
\{acEwen EG, Withrow SJ (eds): Small Animal Clinical Oncology, 2nd ed. Philadel, 88. Gibbs C: The head-Part III; Ear disease.I Small Anim pract 19:539-545,1978.
phia, WB Saunders, 1996, pp 227-240.
89. Hoskinson JJ: Imaging techniques in the diagnosis of middie ear disease.Semin
57. Ciekot PA, Powers BE, Withrow SJ,et al: Histologically low-grade, yet biologically Vet Med Surg (Small Anim) 8:10-16, 1993.
high-grade, fibrosarcomas of the mandible and maxilla in dogs: 25 cases(1982-1991).
90. Hofer P, Meisen N, Bartholdi S, et al: Radiology corner: A new radiographic
l Am Vet Med Assoc 204:610-615,1994. view of the feline tympanic bullae. Vet Radiol Ultrasound 36:14-15, 1995.
58. Forrest LJ, Chun R, Adams WM, et al: Postoperativeradiotherapy for canine soft 91. Remedios AM, Fowler lD, Pharr fW: A comparison of radiographic versus
tissue sarcoma. J Vet Intern Med 14:578-582, 2000. surgical diagnosis of otitis media. J Am Anim Hosp Assoc 27:183, 1991.
59. Dubielzig RR, Goldschmidt MH, Brodey RS: The nomenclature of periodontal 92. Love NE, Kramer RW, Spodnick Gl, et al: Radiographic and computed tomo-
epulides in dogs. Vet Pathol 16:209-214,7979. graphic evaluation of otitis media in the dog. Vet Radiol Ulirasowd36:375-379, 1995.
60. Langham RF, MostoskF UV, Schirmer RG: X-ray therapy of selectedodontogenic 93. Barthez P! Koblik PD, HornofWJ, et al; Apparent wall thickening in fluid filled
neoplasms in the dog. J Am Vet Med Assoc 170:820-822, 1977. versus air filled tympanic bulla in computed tomography. Vet Radiol Ultrasound
37:95-98, 1996.
61. Thrall DE: Orthovoltage radiotherapy of acanthomatous epulides in 39 dogs. J
-Lm Vet Med Assoc 184:826-829, 1984. 94. Stanton MLE: Feline nasopharlngeal and middle ear pollps. In Bojrab MJ (ed):
Disease Mechanisms in Small Animal Surgery, 2nd ed. philadelphia, Lea & Febiger,
62. Dubielzig RR, Adams WM, Brodey RS: Inductive fibroameloblastoma, an unusual
1993, pp 128-129.
dental tumor ofyoung cats.J Am Vet Med Assoc 174:720-722,1979.
95. Kapatkin AS, Matthiesen Dl Noone KE, et al: Results of surgery and long-
63. White RAS: Mandibulectomy and maxillectomy in the dog: Long term survival term follow-up in 31 cats with nasopharyngeal pollps. J Am Anim Hosp Assoc
in 100 cases.I Small Anim Pract 32:69-74,199I. 26:387-392,1990.
61. Bateman KE, Catton PA, Pennock PW, et al: 0,7 21 Radiation therapy for the 96. Ticer JW, Spencer CP: Injury of the feline temporomandibular joint: Radio-
ireatment of canine oral melanoma. I Vet Intem Med, 8:267-272. 1994. graphic signs. J Am Vet Radiol Soc 19:146-156, 1978.
65. Blackwood L, Dobson lM: Radiotherapy of oral malignant melanomas in dogs. 97. Lane JG: Disorders of the canine temporomandibular ioint. Vet Annu 2l:175-
T -\m Vet Med Assoc209:98-102,1996. 186, r 982.
66. Pletcher JM, Koch SA, Stedhem MA: Orbital chondroma rodens in a dog. J Am 98. Padgett GA, Mostosky IJV: The mode of inheritance of craniomandibular osteop-
\et Med Assoc 175:\87,1979. athy in West Highland White terrier dogs. Am J Med Genet 25:9-13, 1986.
67, Dernell WS, Straw RC, Cooper MF, et al; Multilobular osteochondrosarcoma in 99. Riser WH, Parkes LJ, Shirer JF: Canine craniomandibular osteoDathv.T Am Vet
39 dogs: 1979-1993.J Am Anim Hosp Assoc34:11-18, 1998. R adi olSoc 8:23 31, 1q67.
68. Zaki FA, Liu S-K, Kay Wl: Calcitling aponeurotic fibroma in a dog. I Am Vet 100. Grove TK: Periodontal disease.In Harvey CE (ed): Veterinary Dentistry. philadel
\led Assoc 166:384-387,I975. phia, WB Saunders, 1985, pp 59-77.
69. Selcer BA, McCracken MD: Chondroma rodens in dogs: A report of two case
ristories and a review of the veterinary literature. J Vet Orthop 2:7-1I, 1981. W Ouestions
i0. Mclain DL, Hill JR, Pulley LI: Multilobular osteoma and chondroma (chon-
droma rodens) with pulmonary metastasisin a dog. J Am Anim Hosp Assoc 19:359- l What are the radiographic signs associatedwith hydrocephalus,
-r62,1983. and what breeds are most commonly affected?
86 AXIALSKELETON
r::igll:*
:ll:iiii6s
9l'r:a:
':,11{
....'):::.*
i6 9U,
*ru
Figure 7-28. Tympanicbullaeradiographs dog with a right headtilt
of a 1-year-old
E qui neN asalP assages
an d Sinuses a7
2. What are the causes of hlperparathyroidism? What radio- 7. \A/hat is the most common cause of destructive rhinitis in
graphic changesare seen on skull radiographs? the dog?
3. What are the two most useful radiographic views for evaluating 8. You are presentedwith a l-year-old Golden retriever dog with
nasaldisease? a 2.5-weekhistory of a right head tilt. You decide to radiograph
the dog to evaluate the middle ear (Fig. 7-28). \44rat are the
4. What are two radiographic signs seenwith nasal cavity tumors? radiographic findings, and what is your assessment?
ffi CHAPTER
ffiB
ffi .EquineNasal Passagesand Sinuses
W Iimmv C. Lattimer
Radiographic examination is a useful technique for obtaining diag- ation in the shapeofthe face is projected tangentially. Occasionally,
nostic or prognosticinformation regardingthe diagnosisof parana- especiallyin instancesof dental disease,the diseaseis best demon-
sal sinus and nasal cavity diseasein the horse.' Radiographic stratedwhen the central ray of the beam is positioned perpendicu-
examination of the ecuine head should be used in combination lar to the area of the lesion, that is, "en face." However, as a ru1e,
l'ith clinical signs, endoscopy, physical examination, and clinical the tangential projection is usually more rewarding. When no
pathologic tests to arrive at an accurate diagnosis. The decision externally visible effects are apparent, the standard lateral, ventro-
rvhetheror not to make radiographsshould be basedon the need dorsal, and oblique views should be made initially. Once abnormal-
to answer specific questions indicated by the clinical signs and ities are detectedon theseviews, further projections may be tailored
physicalexamination.Clinical signs suggestingthe need for radio- to enablemore completeevaluationof the diseaseprocessif neces-
graphic examination include nasal discharge,nasal airway obstruc- sary. When special nonstandard views of the skull are made, it is
tion, facial swelling, epistaxis (particularly unilateral), dental de- advisable that either symmetrical views of the patient's other side
fects,draining tracts, epiphora, and facial deformity.' or the same view of a presumed normal subiect be made to
The task of radiographingthe head of a conscioushorse may be facilitate detection of minor anatomic abnormaliiies,
formidable. Many horses are frightened by the procedure, so seda-
tion is usuallydesirable.Most horses,while standing,are in motion I Normal anatomy
from respiration; this postural shifting is also reduced by sedation.
The most obvious extranasallandmarks on the lateral view of the
-\nesthesiahas been recommended for radiographic projections nasal passageare the large molar and premolar teeth, although they
other than the lateral projection.'zThe need to induce general
are partially surrounded by the sinuses.These teeth provide a con-
anesthesiato obtain satisfactory radiographs makes difficult the
decision whether or not to radiograph the skul1,especiallyin a stant point of referencefor lesion localization. It is alwaysadvisable
clinically ill animal. However, modern developmentsin radio- to use a field-of-view of suffrcient size so that either the second
premolar or the third molar is identifiable. Another external struc-
eraphic equipment have made standing radiography of the equine
head technically feasible,if not easy. ture that is usually evident over the caudal portion of the nasal
One of the greatestdeterrentsto radiographyof the equinehead passageis the zygomatic arch, which is also superimposedover the
is the complexityof the image.The 1arge,multiple, interconnecting orbit. The zygomatic arch continues rostrally as a linear region of
air passagesand turbinates, combined with the many sharp and bone opacity, which representsthe facial crest. Depending on the
irregular external bony prominences,make skull radiographs a exact cassetteorientation and exrosure factors used. the facial crest
challengeto interpret. When radiographic anatomy is so complex, may or may not be apparent. Identification of the facial crest and
rt is easyto overlook even relativeiy major lesions. It is, therefore, first maxillary molar is important in that their rostral limits define
imperative that a systematicmethod of evaluating the radiograph the rostral iimits of the caudal and rostral maxillary sinuses,respec-
be used.It is alsonecessary that sometype of radiographicanatomy tively (Fig. B-1). Becausethe two compartments of the maxillary
referencebe consultedbecausecomparisonof the radiographwith sinus do not usually communicate, except in mules and donkeys, it
a known normal image usually resoives any questions regarding is important to determine which of the cavitiesis affected.3'a
rrhether or not a structure in cuestion is abnormal. Internal nasal cavity landmarks include the rostral limits of the
\lany radiographicprojectionsof the skull may be made, but it dorsal and ventral conchal sinuses,the rostral limits of the maxil-
is not necessaryto perform them a1l in any given instance.The lary sinus, and the ethmoid turbinates (seeFig. 8-1). Theseland-
ratrent's clinical signs dictate the exact projections to be made. marks basically define the limits of the paranasal sinuses,making
This is especiallytrue when facial trauma or distortion is present. it possible to determine if the diseaseprocess being observed
Radiographs should be made in such a way that any visible alter- involves the sinuses,the nasal cavitx or both.
88 AXIALSKELETON
s
--:'',- l
-
1
-.
1.. tt:t
Figure 8-8. Foreignbody (arrows)in the maxillarysinus and the ateral aspect of
nasalpassage.S ame case as that i n Fi gure8-5. Thi s 4 x 3.5 x 1.5-i nc hpi ec e
of l umber from a fence w i th w hi ch the horse col l i dedw as not readi l ys een on
other vrews.
,-t
:ll,,.lili:,1,,:
*;ffi
rlr:lll:rllalrr
.,.r!r:'iH
r:llii&rr''l:":il!]i
i :lll,llll9ll
l€ll'llliii9llll,i
:):4,,::i:::,::::::,,,,9::i::::!.::::::,,
- ,11
lrl:rlrlr,:ll:'iilill:'ii!*llliilHl
F i g u r e 8 - 1 O . L a rg em a lig n a nnt e o p la smth a t is in va d in gthe nasalpassagesand si nuses.S uchtumorsmay ari sei n ei therthe nasalpassageor the s i nusand
j n v a d et h e o t h e r .T h e a r r o wsin I in d ica teth e d isp la ce m e noft the nasalseptum,w hi ch i s the hal l markof anv expansi l emass.
Figure 8-11. fhe arrows outl ne a smali nasalpolyp/cystin the soft tissue positionof the airway.
S - a l l m a s s e si n t h i s p o r tio no f th e n a sa ip a ssa g e sa r e e a silymi ssedw hen exposuresare tai l oredfor
: - 3 m o r ec a u d aal i r w a ys.
94 AXIALSKELETON
8-12). Fluid accumulation in both the sinusesand the nasal cavity nasal passage may not be visible endoscopically. Although the
may result from occlusion of the drainage pathway by large cysts. differential diagnosisfor these clinical signs is extensive,a thorough
Non-neoplastic polyps are often seen in the nasal passagesof physical examination combined with the results of endoscopic
young horses. These lesions are usually composed of granulation and radiographic examinations should make the diagnosis easy to
tissue and are probably associatedwith chronic inflammation.tl'18 establish.'?l
Polyps may be recognizedradiographically as relatively well-defined The radiographic examination of progressiveethmoid hematoma
areas of increased opacity within the nasal passage;they vary in should consist of lateral, ventrodorsal, and oblique maxillary sinus
size and number. Clinical signs may be delayed until the polyps projections. Single lesions are usually confined to one side of the
are of sufficient size or number to interfere with respiration. nasal passage,but these lesions may deform the septum and the
Deviation of the nasal septum is easily detected on the ventro- ethmoid turbinates. Multiple lesions are occasionallyseen and may
dorsal projection. This deviation may result from an intrinsic appear on both sides of the septum. Ethmoid hematomas are
disease,such as cyst formation, or from Pressure from a mass usually seen as round, smooth-walled, soft-tissue masses arising
within the nasal passage.It may be a benign anatomic variation from the region of the ethmoid turbinates (Fig. 8-14).'&'zo' 'z'Calci-
with no clinical significance(Fig.8-13). The degreeand site ofthe fication and air trapping within the lesion have not been described.
deviation are usuaily obvious, but the underlying cause may be Overt destruction of dense cortical bone is not a feature of this
difficuit to determine. disorder, which may help one to distinguish it from malignancies,
A special form of cystic disease occurs in the nasal septum. which also occur in the same areas.Becauserecurrenceis common,
Varying amounts of the nasal septum in young horsesmay undergo re-examination is advised at 6-month intervals for at least 2 years
cystic degeneration as the result of trauma or infectionte (see Fig. after the lesion is removed.tt
8-13). The nasal septum widens substantially,which interferes with
respiration. Both radiographic and endoscopic examinations of the Disorders of the paranasal sinuses
nasal passagesare needed to adequately evaluate the extent and
severity of the probiem. Cystic diseaseof the sePtum is one condi- Lesions in the paranasal sinusestend to parallel those seen in the
tion for which the ventrodorsal projection is mandatory. The lateral nasal cavity-traumatic fractures, cysts, tumors, and empyema.
view is of minimal help for determining the severity of the thick- Ethmoid hematomas also invade the sinuses.ls'20
ening of the septum, although it may aid in establishingthe caudal Fractures of the sinusesare similar to nasal bone fractures. Once
limit of the problem. Accurate evaluation of the extent of the again, the physical appearance of the face may not indicate the
lesion is imperative becausesurgical resection of the affected septal true extent of the lesion. When fracture fragments are depressed
portion is usually the only effectivetreatment. Postoperativeradio- into a sinus, there is an even greater likelihood that infection
graphic evaluation must wait until after the removal of the packing wili develop because of reduced drainage and air exchange.The
used to control the profuse hemorrhage induced by surgery.When radiographic approach to the diagnosis of paranasalsinus fractures
the postoperative radiograph is evaluated, consideration must be is the same as that for fractures of the nasal passage.Whenever a
given to the fact that, although the nasal septum is a major fracture line enters a sinus, special attention should be given to
contributor to the midline opacity of the nasal passages'it is not any increasedopacity within the sinuses.Infection or injury to one
the only midline opacity.e Persistenceof some midline opacity' sinus may affect all of the sinuseson that side, and fluid lines and
therefore, does not indicate inadequate resection' increased opacity within the sinuses may be seen quite removed
Progressiveethmoid hematoma is a slowly enlarging hematoma from the actual site of injury.
that contains granulomatous reactions; it originates from the sub- As is seen in the nasal cavity, benign sinus tumors are usually
15
mucosa of an ethmoid endoturbinate.l2'ta' It is not known why osteomas or adamantinomas that arise from or around the roots
the mass continues to enlarge, as it is not neoplastic. Extension of the teeth within the maxillary sinus." Malignant neoplasms (see
into the maxillary, frontal, and sphenopalatine sinuses' as well as Fig. 8-10) are either primary (adenocarcinomaand fibrosarcoma)
into the nasal cavity, is common. Distortion and destruction of the or secondary (extension of a squamous cell carcinoma from the
ethmoid and nasal turbinates and nasal septum are frequent. The orbit).13,", " Malignant tumors are ill-defined, lobulated-to-diffuse
clinical signs of inspiratory stridor, coughing, choking' excessive soft-tissue lesions. Lysis of cortical bone and deformity of facial
salivation, purulent nasal discharge,haiitosis, and head-shaking are bones are common, as is periosteal new bone growth. Focal calcifi-
characteristicfindings. Facial deformity may or may not be present. cations, radiolucencies, or both may be seen within the tumor
There is often a history of chronic epistaxis.Endoscopy may reveal mass.16With primary tumors, much of the opacity within the
a large, smooth-walled, greenish mass in the caudal part of the sinuses may be the result of trapped secretions because the neo-
nasalpassages.ls'20 A hematomain the dorsal caudalportion of the plasm obstructs the nasomaxillary opening'z3or the nasal passage
E qui neN asalP assages
an d Sinuses 95
B C
Figure 8-13- 4, Normalseptum in a horse.The septum is narrow,with the typicalappearanceof two linearopacitiesseparated
by a singlelinearradjolucency.
i l e v i a t e d o r u n d u l a tin gse p tu m .T h is fin d in gis u su a llyse r endi pi tousand unrel atedto cl i ni calsi gns but, i f severe,may Intermrttenl yi nterferew i th ai r fl ow
: -' : - g h t h e n a s a lp a s sa g e sC, Wid e n in go f th e se p tu m ,o ccasi onal seenly i n associ ati on
w i th cysti cdegenerati on of the septumor general i z ed
-= ^ a s a lm u c o s aW i nfl ammati on of
. i th cysticd e g e n e r a tio th
n , e wd e n in g ca n be severeenoughto obstructfl ow of ai r throughthe nasalpassaqes.
96 AXIALSKELETON
Figure 8-14. Ethmoidhematoma.This well-circumscribed four centimetermass in the caudalventralportionof the nasalcavityappearsto be directlybelow
the ethmoidturbjnateson the lateralview (A).However,the ventraldorsalview /B/ indicatesthat the mass is lateralto the mandible,which placesit in a position
y. ti pl evi ew s are necessary
to se e e n d o sco pi cal lMul
whe r e i t w i l l b e d i f f i c u l tor p o ssib lyim p o ssib le to determi nethe actualposi ti onof ethmoi dhematomasas ,
t hev d o n o t a l w a v so c c u rin a sso cia tiowith n th e e th m o idtu r b in ates. y, are often mul ti pl e,and one or more may be hi ddenon any i n di v i dual
A ddi ti onal lthey v i ew .
with displacement of the nasal sePtum. The area of increased carcinoma of the orbit is an unusual, but serious, finding. There is
opacity may therefore be substantially larger than the true area of usually obvious bony destruction of the orbit. Because of the
neoplastic involvement. The trapped secretionsmay also silhouette possibility of orbital tumors extending through the bone into the
with the tumor, resulting in fluid lines on standing lateral projec- frontal or maxiilary sinus, it is advisablethat radiographic projec-
tions and mimicking the radiographic appearanceof sinusitis. tions be made that are designedto project the orbital margins and
Secondary invasion of the frontal sinus by a squamous cell maxillary sinus. Most orbital neoplasmsdo not invade the sinuses,
i:uarrl
F i g u r e 8 - 1 6 , S a m eh o r sea s th a t in F ig u r e8 - 1 5 . On ceth e fl ui di s
d r a i n e df r o m t h e s i n u sth r o u g ha sm a litr e p h in eh o le ,it is p o s si bl eto
appreciatethe sclerosls(arrows)surroundingthe roots of the first
a n d s e c o n dm o l a r s.No te a lso th e e r o sio no f th e ca u d a o o rti onof
t h e r o o t o f t h e f o u r t hp r e m o la r
but the markedly poorer prognosis for those that do justilies the evidence of proliferation or sclerosis.rnIt is difficult to establish
examination. that a tooth is the sourceof the problem in thesehorses.
The most common causeof clinical diseaseof the sinusesneces- Cystsof congenital,dentigeroui,or unknown origin occasionally
sitating radiographic evaluation is empyema,2'and the most com- occur in the paranasalsinuses.,s'2s, 26The maxillary sinus is most
mon causeof accumulationof exudatewithin a sinus is a periapical commonly affected but cysts may occur in any sinus. Radiographi-
abscessof the fourth maxillary premolar or of any of the maxillary ca1ly,opacification of the sinus is a consistent finding. Depending
molars (Figs. B-15 and 8-16). Ma-xillarypremolars I to 3 are not on the size of the cyst, discrete margins may or may not be
contiguous with the ma,xillary sinus. The most commonly affected seen. When the cysts are large, distortion of the facial bones
tooth is the first molar. Other causesof sinusitis include trauma, and encroachmenton the nasal passagesmay be seen.Free fluid
fungal granulomas,and neoplasms.i'18' 24The clinical signs usually accumulation, distortion of dentition, mineralization, and frag-
associated with sinusitisinclude poor condition ofthe patient, fetid mentation of the frontal or maxillary bones are less common
nasal discharge, halitosis, and occasionally, head-shaking. There findings.'?7Definitive diagnosis from radiographs is not possible;
may be evidence of a facial deformity if the infection is secondary rather, aspiration and analysis of fluid from the affected sinus
to trauma. On physicalexamination,it may be possibleto percuss is recuired.
a dull area in the region of the fluid accumulation.
Endoscopicexamination of the sinuses,other than to observe Rgfefences
the nasomaxillary opening for drainage of exudate,is not possible.'za
Therefore, radiograihy iJusually the"primary means of evaluating andparanasal
sinusdisease:
A reviewor 85
.:.:ii::l.t##tllirli!"Jri""ttt
sinus empyema. Sinus fluid is recognizedby the presenceof a
homogeneous fluid opacity in the arJa of the suspeciedsinus; it is J",Gibbsc, MelninksE,steele FC:Radiographic examination
of thefacial,
-l:"111: of thehorse:I' Indications
andproceduresin 235
often posslDlero ldentrry a fluid line within the ,1"". :;,'l ill,f,f,il?Ti;]ffi,'i$r'r:'
"tirr".ir"*"i-
bea mrad iog rap hs ( s eeFig. B_15) . 1, ' , 4I f t hes inus systemiscom-
"no
pletelyfil1ei with fluid, fluid line is presen,r";;;h ,"r'r:*'"'''rheAnatomvorDomestic
:;!, ^';',|i1$ilil:l"iL:'iilris:1.:l:lX};:f
oblique projections of both sinusesmust be obtained to establish
thatonesinusis or muchgreater
radioprcity
aJ t'. ,h";;r"'i Y#:i':fiy.*":"ft':i,,"?lr[i'fi"ill1#tfiJi $j il:Ti
fluid-filled. Left and right sinuses should be examined to avoid "irti:.]"il?i
1s:185,1e8s.
misdiagnosis of sinus empyema because of the mild increase in 5. schebitzH,wilkensH:AtlasofRadiographicAnatomyofDogandHorse.Berlin,
opacity caused by overlying muscies. In some instances, inspissated paulparey,1968,p 123.
pus within the ventral conchal sinus may result in a well-circum-
6. BehrensJ, schumacherl, Morris E, et al: Equine paranasalsinusography.
vet
scribed soft-tissue opacity overlying the nasal passages and teeth. Radiot32:98ree1.
Expansion of the sinus may result in encroachment on the nasal
7. Nickel R, SchummerA, seiferleE, et al: The visceraof the DomesticMammals.
passages.2s This radiographic appearance mimics that of paranasal Berlin,paulparey,1973,p 211.
hTiP-11 h]:l:]?g".'?11i; 8. Harvey
DE:rr" n"-r seprum
:1:,'^:v':: orthedog:rsit visibre
radiographicary?
vetRadior
mauon oI il1tne ::11"^'1 T:ld,iti:f
olagnosrs.II the slnusltrsls tne result oI dental 20:88,
1978.
disease,radiography may reveal sclerosisaround the root of the o c+:r-^
affected
tooth"(see
Fig.B-r6ra);
however,
.o,.".t,uaiog,uph;-id.;-,l;,jl1lii,liJj;Ti11i,:t;,i',l:'i::l,tl;fililtJ'fJ
iifii,:':',:?i!il i;Ji:
tification of the involved tooth is possiblein fewer than 50% of ," .^_.,-
patients.24Radiographic signs indicating tooth inuotu.-.ni i".r"J. bodvpenetration
or the
il;,3,Tii.YX: ,Tf'#.h* ili:ffi:$:t,llroreign
rvidening and decreaseddefinition of the periodontal membrane ,,
andscteiosis
of theperidental
bone.Theitveotar
boneoverrhe ',1[:T.j:,::'i1j]:":-+l;?il"11
i.t;,,ifi1,J.1?i.,il:"";to"J?il:':ffi'X?
root of the tooth may be absent, as a result of lysis, with no publications,
r972,p363.
98 AXIALSKELETON
12. Coumbe KM, Jones RD, Kenward JH: Bilateral sinus empyema in a six-year-old
m a r e .E q u i n e V e t I 1 9 :5 5 9 .1987.
13. Cook WR: Skeletalradiology of the equine head. I Am Vet Radiol Soc 11:35' 1970-
14. Wln-Jones G: Interpreting radiographs 6: Radiology of the equine head (Part 2).
Equine Vet I 17:417,1985.
15. Kold SE, Ostblom LC, Philipsen HP: Headshaking causedby a maxillary osteoma
in a horse. Equine Vet I 14:167, 1982.
16. Hilbert BJ, Little CB, Klein K, Thomas IB: Tumors of the paranasal sinuses in 16
horses. Aust Vet J 65:86 1988.
17. Zartby JF, Levesey MA, Percy DH: Ethmoid adenocarcinoma perforating the
cribriform plate in the horse. Cornell Vet 83:283, 1993.
18. Boles C: Abnormalities of the upper respiratory tract. Vet Clin North Am (Large
Anim Pract) 1:89,1979.
19. Tulleners ER Raker CW: Nasal septum resection in the horse. Vet Surg 12:41, 1983.
20. Cook WR, Littlewort MC: Progressivehaematoma of the ethmoid region in the
horse. Equine Yet J 6:101, 1974.
21. Specht TE, Colahan PT, Nixon AJ, et al: Ethmoidal hematoma in nine horses. J
Am Vet Med Assoc 197:613,1990. Figure 8-17
22. Schmotzer WB, Hultgren BD, Watrous Bt, et al: Nasomilillary fibrosarcomas in
three young horses. I Am Vet Med Assoc 191:437,1987.
23. Gibbs C, Lane JG: Radiographic examinalion of the facial, nasal and paranasal views) in horses suspectedof having experiencedtrauma to the
sinus regions ofthe horse. II. Radiological findings. Equine yetl 19i474' 1987. nasal passages?
24. Schumacher J, Honnas C, Smith B: Paranasalsinusitis complicated by inspissated
exudate in the ventral conchal sinus. Vet Surg 5:373, 1987. 4. In Figure 8-17, what are the two major radiographic lesions
25. Beard WL, Robertson JT, Leeth B: Bilateral congenital cysts in the frontal sinuses
evident on this lateral radiograph of the nasal passagesin a
of a horse. I Am Vet Med Assoc 196:435, 1990' horse that was presentedwith a nasal discharge?
26. McClure SR, Schumacher J, Morris EL: Dentigerous cyst in the ventral conchal
5. What radiographic proiection of the nasal cavities would best
sinus of a horse. Vet Radiol Ultrasound 34:334, 1993-
enable visualization of lesions of the nasal septum?
27. Lane tG, Longstaffe lA, Gibbs C: Equine paranasal sinus cysts: A report of 15
cases.Equine Yet J 19:537, 1987-
6. What structure overlies the maxiliary sinus on the straight
ventrodorsal view of the nasal passagesand can give the false
ffi Ouestions impression of sinusitis?
2. What structure surrounds the roots of maxillary premolars 3 8. In Figure 8-14, what is the linear opacity extending rostrally
and 4 and the molars? from the ventral aspect of the hematoma?
3. Why is it important to make multiPle views (especiallyoblique Answers begin on page 727,
ffi CHAPTER
ffie
ffi The Vertebrae-Ganine and Feline
ffi . MichaelA. Walker
sacral vertebra or with the wing of one or both ilia. This condition
is referred Io as sacralization. Lrmbosacral transitional vertebrae
are most often encountered in German shepherds, Brittany span-
iels, Rhodesian Ridgebacks, Doberman pinschers, Great Danes,
Labrador retrievers, and St. Bernards. It has been hypothesizedthat
the condition is inherited and familial in German shepherds.u''
A lower than normal number of caudal vertebrae may be the
result of tail docking or trauma. Because of congenital defects,
Manx cats may possessdecreasednumbers of caudal and, occasion-
ally, sacral vertebrae. Other spinal anomalies such as spina bifida
and spinal cord abnormalities such as meningocele,myelomeningo-
cele, syringomyelia, and spinal dysraphism may accompany sacro-
coccygealabnormalities in Manx cats.8
A vertebra may appear larger than normal as a result of partial
or complete fusion of two adjacent vertebrae. The fusion may
involve the vertebral bodies, the arches, or the spinous processes.
The congenital fusion of two adjacent vertebrae is known as block
vertebraand may result from improper segmentation of embryonal
somites, possibly owing to abnormalities of the intersegmental
arteries in the developing embryo (see Fig. 9-2). The affected
vertebrae collectively may be shorter than the equivalent number
of normal vertebrae. Block vertebrae are usually clinically insig-
nificant, although the fusion may result in increased stress on
immediatelv adiacent intervertebral discs.ntt
Figure 9-5. Ventrodorsal spinein whichspina
view of the cervicothoracic Other examplesof improperly formed vertebrae include hemiver-
of the T1 andT2 spinousprocesses
bifidawith duplication can be seen tebrae and spina bifida (see Fig. 9-4). A wedge-shapedhemiverte-
(arrows).
bra has been hlpothesized to result embryonically from improper
distribution of the intersegmental arteries or from persistenceof
the notochord, resulting in incomplete ossification of the dorsal or
fusion of the first sacral vertebra with the sacrum. Lack of fusion ventral portion of the vertebral body-hence, lhe term dorsal
of the first sacral vertebra with the remainder of the sacrum is or ventral hemivertebra. Hemimetameric disolacement results in
referred Io as lumbarization of the sacrum. Lumbarization may be unilateral, left, and right hemivertebrae. The persistenceof sagittal
asymmetrical, meaning unilateral in formation, or complete, mean- cleavageof the embryonic notochord results in the vertebral end
ing that the transitional vertebra is bilaterally uniform in shape plates having a funnel shape and in failure of the central portion
and in associationwith the pelvis and sacrum. With lumbarization, of the vertebral body to form, producing a butterfly appearance
a concurrent anomaiy may occur in which the first caudal vertebra radiographically in the ventrodorsal view. The affected vertebrae
becomessacralized,so that the number of sacraivertebrai segments are called butterfly yertebraerather than hemivertebrae.e't0Either
remains at a normal number of three.t'6 adjacent vertebral bodies will compensate for the shapes of the
Occasionally,there is a iower than normal number of vertebrae bodies of the hemivertebrae and butterfly vertebrae, or spinal
in either the thoracic or the lumbar spine. It is helpful to count malalignment will result. Hemivertebrae and butterfly vertebrae
the ribs and to determine the location of the anticiinal vertebra occur most often in the screw-tailed breeds of dogs such as bull-
when deciding which part of the spine is anatomically deficient; dogs, French bulldogs, Pugs, and Boston terriers. Often, the kinked
however, anomalous lack of the 13th pair of ribs and change in tail in thesebreedsis due to caudal hemivertebrae.ll'1'
location of the anticlinal vertebra may occur. L7 may be a transi- Spina bifida occurs mostly in brachycephalic dogs and Manx
tional vertebra, being partially or completely fused with the first cats. Spina bifida is the embryonic/congenital failure of develop-
ment of a portion of the dorsal aspectof a vertebra. The condition
results in a midline cleavage in the vertebral arch and dorsal
spinous process(seeFig. 9-5). The condition is possiblyheritable,
but teratogenic compounds and nutritional deficiencies during
pregnancy may be associatedfactors in some animals.e't0't2't3
Anomalies, including abnormal dorsal angulation of the dens,
an abnormally short dens, or failure to form either the midportion
or all of the dens, may occur in the dens of C2. Although it may not
be radiographically evident, congenital absence of the transverse
ligament in the vertebral canal can occur dorsal to the dens of C2.
Anomalies of the dens occur most frequently in toy breed dogs,
and may result in atlantoaxial subluxation (seeFig. 9-6). Normally,
the dorsal spinous process of C2 lies adjacent to or overlaps the
caudal aspectofthe arch ofCl, with the dens lying on the ventral
midline of the vertebral canal of Cl. Subluxation of C2 appears
radiographically as caudodorsal angulation of C2. An oblique 1at-
eral radiograph may be necessaryto offset the wings of the atlas to
the degreethat the position of the dens may be seen.12'Ia'15
Vertebrae may appear smaller than normal owing to dwarfism.
Primordial dwarfism, which manifests as proportionate decreasesin
size of the skull, spine, and limbs, has resulted in distinct miniature
Figure 9-6. Atlantoaxial subluxation.Note increasedspacebetween lamina br eeds.Chondrodystrophic dwarf sm manifests as disproportionate
of C1 and C2 hrrow). The dens is hvpoplastic. body form, with short, thick limbs, short cranial base, and short
The V ertebrae-C ani ne
an d Feline lO l
vertebrae that appear to have accordion-like bony protrusions from articular processesmay be malformed, possibly as a manifestation
the ventral surface of their vertebral bodies. of osteochondrosis; an abnormally large, flat articular processcan
Lastly, in anomalous vertebral formations, one may seeunilateral be present and encroach upon the vertebral canal. Abnormal forces
or bilateral lack of formation of the 13th ribs, causingT13 to seem on the caudal cervical vertebrae may be responsiblefor the malfor-
to be a transitional Ll vertebra, resulting in eight lumbar vertebrae. mation of a flattened or rounded cranioventral aspect of a caudal
Somewhat similarly, anomalous development of a transversepro- cervicalvertebralbody (Fig. 9-7). Dorsal subluxationofthe cranial
cess of a lumbar vertebra may occur such that the transverse end of C6 and C7 may occur and be d1'namic or static. D1'namic
process is abnormally elongated, mimicking a short rib. Either of changesare related to cervical flexion/extension. Adynamic changes
these anomalies could be significant when an attempt is made to occur becauseof spinal stabilization by secondary changes.nch as
surgically iocalize a lesion in the thoracolumbar region. spondylosisdeformans.Myelographically,there may be iyperplasia
of the ligamentum flavum and secondaryinterverte6ral disc hernia-
I vertebrae Degenerativeabnormalities of
Although the vertebrae do not lie in one single dorsai plane, the I
vertebral canal should alwaysbe smoothly aligned from one verte- I the vertebrae
bra to the next. Abnormal curvatures of the spine include scoliosis, Degenerativecanine lumbosacral stenosishas been defined as an
a lateral bowing; lqphosis, a dorsal arching; and.lordosis,a ventral acquired radiculopathy resulting from any of severalpossible
deviation. Such abnormal contour of the spine may be congenital, causes.In the dog, degenerativelumbosacral stenosisand its associ-
idiopathic, or related to another spinal abnormality. Congenital ated cauda equina s1'ndrome may result from (1) an abnormally
alterations in spinal contour may result from hemivertebrae, in- narrowed or stenotic lumbar or sacral vertebral canal; (2) what
cluding unilateral hemivertebrae,causing scoliosis;ventral hemiver- may be an osteochondrosis-likes;mdrome involving the craniodor-
tebrae, causing lordosis; and dorsal hemivertebrae, causing kypho- sal aspect of the first sacral vertebral body; (3) lumbosacral mal-
sis. Abnormal spinal contour may also be postural as a pain alignment; (4) lumbosacral instability; (5) herniated discs and the
response, or it may be from other deforming spinai abnormali- presence of fibrous connective tissue in the ventral aspect of the
ti e s.e '1 0 vertebral canal at the lumbosacraljunction; and (O) ipondylosis
As described in the previous section, caudodorsal sublu-ration of with or without vertebral diarthrodial joint osteophyteslmpinging
C2 may occur as a result of agenesis,fracture, or fusion failure of on the nerve roots at the interuertebral foramina of the lum6osJcral
the dens, or from rupture of the stabilizing ligaments between Cl junction (Fig. 9-B). A stenotic or abnormally narrowed vertebral
and C2. A lateral radiograph made during cervical flexion can be canal may occur at the last lumbar or at the first sacrai vertebral
used to visualize the sublu-ration, but care must be taken not to segment. A small bone fragment from the craniodorsal aspect of
overflex the neck and possibly compress the spinal cord by the the first sacral segmentmay be a form of osteochondrosis.D1'namic
dens. Breeds affected most often include Yorkshire terrier, small- or static lumbosacral malalignment may occur.
breed Poodle, Pekingese,Pomeranian, Shih tzu, Dachshund, Chi- Lateral radiographs may be made in neutral, hyperextension,
huahua, and Maltese. Most affected dogs are younger than 1 year and hyperflexion positions of the lumbosacral ioint to help differ-
ofage; however,trauma-induced atlantoaxial subluxation can occur entiatethe dynamic versusthe static forms of the condition.Dy-
in any breed of dog at any age.1a'ls namic malalignment, or lumbosacral instability, is often seen best
Cervical yertebral malformation-malarticulation, also called "ca- on flexed views in which the sacrum subluxates ventral to L7.
nine wobbler syndrome" and "caudal cervical spondylopathy," oc- Static maialignment may be evident on survey as well as on flexed
curs most often in young Great Danes and adult Doberman pinsch- or extended lateral views. Affected dogs may exhibit decreased
ers. C4-5, C5-6, and C6-7 are the most frequently involved sites, extension, increased flexion, and reduced ranse of motion in the
and multiple lesions may be present. The abnormalities result in lumbosacral joint. The lumbosacral interverte-braldisc soace mav
static or dynamic compression of the spinal cord. A narrowing or be narrowed, and there may be protrusion of the annulus fibrosui,
coning of the cranial aspect of the vertebral canal of the cervical or herniation of the intervertebral disc. A hieher incidence of
vertebrae may occur during the growth period of the dog; this transitional vertebrae has been reported in dogs-with degenerative
form of the condition is sometimes seen in Great Danes. The lumbosacralstenosisthan in normal does and has been considered
a causativefactor for degenerativelumbosacral stenosis'Lumbosa- peridiscal collar of new bone beginning at the attachment of the
cral spondylosis has been associatedwith dynamic malalignment' outermost annular fibers (Sharpey's fibers), where the bony end
but neither spondylosis nor lumbosacral instability is necessarily plate meets the ventral and lateral cortex of the vertebral body''
indicative of cauda equina slmdrome or degenerativelumbosacral (Fig. 9-11). The bony lesions are noninflammatory, and the verte-
stenosis. Both spondylosis and lumbosacral instability may occur bral body remodeling may vary in extent from small vertebral
in older, large-breed dogs without clinical signs of cauda equina epiphysealspurs to complete bridging of adjacent vertebrae. Spon-
syndrome. However, spondylosis can result in a narrowing of the dylosis is most often reported in the thoracic, lumbar, and lumbo-
vertebral canal or of the neural foramina, and it may causeclinical sacral spine of middie-aged to old male dogs. Spondylosis in the
signs.s'6''c25Opinion varies as to the optimum imaging method caudal cervical spine of Doberman pinschers and in the lumbosa-
for assessmentof the lumbosacral space; in addition to routine cral spine of all dogs may be associatedwith, but is not diagnostic
radiography, current methods include an objective measurementof of, cervical or lumbosacral instability. Spondylosis may be found
the lumbosacral vertebral canal obtained by measuring flexion and adjacent to degenerative,ventrally protruding, or normal interver-
extension angles,as well as the use of epidurography, discography, tebral discs and may be associatedwith a site of spinal instability,
computed tomography (CT), and magnetic resonanceimaging but often its etiology is idiopathic. Radiographically,the new bone
(Figs.9-9 and 9-10).'?6-30 formation is best seenventral to the affected vertebrae. but it mav
Spondylosis, or spondylosisdeformans, has been defined as "a occur along the lateral and dorsolateral margins ofvertebral bodies.
The dorsolateral new bone may extend to the intervertebral foram- vertebrae. In addition, bony proliferation may occur on thoracic
ina, but it does not usually encroach on the spinal cord. Spon- and lumbar vertebrae, on some of the long bones, and around
dylosis deformans is often clinically insignifi cant.3'-3s limb joints. Hypervitaminosis A, or "dietary osteodystrophy,"has
It has been reported that excessmotion between adjacent verte- been reported primarily in cats and may result in progressive
bral bodieseither in a lateralor in a dorsoventraldirection may mechanical obstruction to movement.36, 37
result in a degenerative,somewhat interdigitating "sawtoothed pat- Mucopolysaccharidosisis a lack of degradation of acid muco-
tern" on adjacent vertebral end plates. A1so, a localized area of polysaccharides before their excretion fiom the body. Multiple
increasedbone opacity called a "bone island" may occur within a bony changes may be seen, including tall, partially fused cervical
vertebral body as a result of clinicaily insignificant, abnormal bone vertebrae; irregularly shortened and misshapen thoracic vertebrae;
remodeling at that site.31 partial fusion of lumbar vertebrae; widened intervertebral spaces;
Degenerative joint disease of diarthrodial joints of the spine and a seemingly widened spine owing to bony proliferation.3&3e
produces irregularly shaped articular processes(Fig. 9-1,2). Similar Hyperparathl.roidism, either primary or secondaryto nutritional
bony proliferation in and around the interarcuate foramina located or renal problems, may result in a poorly mineralized and weak-
between adjacent dorsal spinous processesof adjacent vertebrae ened spine (Fig. 9-13). Abnormal spinai curvature and pathologic
(Baastrup'ssyndrome) may mimic articular degenerativejoint dis- fractures of the spine may occur. Osteopenia of the spine may also
ease;an attempt should be made to distinguish betrveenthese.The occur as a result of senile osteoporosisand much less commonly
actual clinical significance of either condition is often difficult from disuse atrophy, pseudohlperparathyroidism, paraneoplastic
to assess.36 syndrome, Cushing's syndrome, hypothyroidism or hyperthyroid-
ism, and osteogenesisimperfecta. Congenital hypothyroidism may
also result in abnormaliy prolonged persistenceof the physes in
I Metabolic or metabolic-like the vertebralbodies and shortenedvertebralbodies.t0,"
I conditions of the vertebrae Osteopetrosisis an increasein bone opacity as a result of retarda-
tion of bone turnover, resorption, and^remodeling.The condition
Hypertitaminosis A may result in an ankylosing bony proliferation is very uncommon, but has been reported in Dachshunds. Radio-
along the arches and lateral aspects of the bodies of the cervical graphic findings include uniformly increasedbone opacity, without
"#;'**..ffi
:,4.:g
lilalll:iii
. -:- -- :- :j
distinction between cortical and medullary bone. Pathologic frac- of bone production (sclerosis) in the vertebral bodies adjacent to
tures may occur. Although its origin is uncertain, the condition the end-plate lysis are common. Spondylosismay develop from the
may be congenital and familial, occurring as a recessivetrait.a2 adjacent ends of the affectedvertebrae.Discospondylitis most often
affects the thoracic and lumbar vertebrae of young to middle-
aged, large-breed male dogs. Single- or multiple-site lesions occur.
I lnflammation of the vertebrae Staplrylococcusaureus, Brucella species, Corynebacteriurn species,
Inflammatory diseaseof the vertebrae may be a result of spondyli- Streptococcus canis, and Escherichiacoli have been reported as caus-
tis, osteomyelitis, discospondylitis, or vertebral physitis. Spondylitis ative bacterial agents.Infections are often thought to occur second-
is inflammation of a vertebra, not necessarilyassociatedwith sepsis. ary to hematogenousspread of bacteria. Discospondylitis is uncom-
Spondylitis infectiosa implies inflammation of the vertebrae as a mon in cats, but reported causative agents have included
result of a specific pathogen. The canine parasite Spirocercalupi Streptococcus,Actinomyces,and E. coli.a5-50
may causea localized ventral vertebral body bony proliferation that Vertebralphysifls is an infection of the vertebral body that radio-
is not to be confused with idiopathic spondylosis deformans. In S. graphically manifests as bone lysis of the caudal physeal region of
Iupi infection, bony proliferation may occur across the ventral the affectedvertebral body, with sparing of the vertebral end plates.
surfacesof T8 to Tli, and an esophagealmass is often present. Collapse of the caudoventral aspect of the affected vertebral body,
Spondylitis is differentiated from the term spondylopathyin that spondylosis developing from the caudal vertebral margins, and
spondylopathy is any disorder of the vertebrae.a3 spinal kyphosis may occur. The condition seemsto occur primarily
Vertebral osteomyelitis, or spondylopyosis,is a generai term for in young dogs. The infections are probably hematogenous in ori-
sepsis or suppuration of a vertebra; radiographically, it manifests gin.sr
as irregular, poorly marginated bone lysis and production on any
or all parts of one or more affected vertebra (Fig. 9-la). An I Neoplasia of the vertebrae
irregularly shapedperiosteal reaction is often present. Bacterial and
mycotic vertebral osteomyelitis may occur. Hematogenous infec- Neoplasia,benign or malignant, may occur in the vertebrae.Benign
tions are often the cause,but secondary contiguous infection from neoplasiais infrequent, with the most common tlpe being multiple
migrating foreign bodies or other soft-tissue infection is possi- cartilaginous exostosis(MCE). MCE occurs in dogs that are
b ] e . 4 3,4 4 younger than 1 year of age, with the lesion enlarging during the
Discospondylitis is inflammation or sepsisof the intervertebral time of endochondral bone formation. The cartilaginous exostoses
disc spaceand adjacent ends ofthe adioining vertebral bodies. The radiographically appear as expansileeniargementsof spinous proc-
hallmark radiographic sign of discospondylitis is symmetrical lysis essesand of the dorsal laminae; when the latter is involved, this
ofthe vertebralbody end plates (Fig.9-15). Areasofbone lysis or may result in encroachment on the vertebral canal. Although un-
- " "--:
;--:-'.-$f
common, malignant transformation of these lesions is a possibility. cally, the differentiation of neoplasia from osteomyelitis may be
In dogs, a hereditary basis for the condition has been suspected. difficult if the tumor is producins bone.s360
Feline MCE is very uncommon and is a somewhat different disease The intervertebral foramen b".o-. enlargedwhen occupied
than in the dog. In the cat, the condition occurs in young adults by extradural neoplasia,such as-u!meningioma or neurofibroma (Fig.
subsequent to skeletal maturity, may have an association with the 9-18). Although these neopiasms may occur at any location, they
feline leukemia virus, and produces lesions that rapidly enlarge.t' most often invoive the cervical spine. It has been reoorted that
Malignant vertebral neoplasms include primary neoplasms such extraduraltumors may causebone lysisand bone producrion,the
as osteosarcoma, chondrosarcoma, fibrosarcoma, myeloma, and presence and degree of which may be visualized better with CT
hemangiosarcoma. Osteosarcoma arises from the medullary part than with survey radiographs. The vertebral canal may appear
of the bone. Malignant secondary vertebral neoplasms include either widened or osteolytic as a result of intradural, intramedullary
metastatic carcinomas such as anaplasticcarcinoma, prostatic carci- neoplasiasuch as astroc)'tomaor ependymoma(Fig. 9-19).ss,et
noma, perianal gland carcinoma, mammary carcinoma, thyroid
carcinoma, and transitional cell carcinoma; and sarcomassuch as
osteosarcoma,hemangiosarcoma, fibrosarcoma, and undifferenti- I Trauma to the vertebrae
ated sarcoma. Osteochondroma is the only benign tumor of the
vertebrae.Most malignant primary vertebral neoplasmsreside Fractures may involve any part of the spine, but the most common
within one vertebra; malignant secondaryvertebral neoplasmsmay sites are the vertebral body, the transverseprocess,and the spinous
reside within one or more vertebrae; benign neoplasms may occur process. Fracture of the vertebral body may be accompanied by
in one or more vertebrae. It has been reported that malignant abnormal spinal alignment, especially when the fracture involves
primary vertebral neoplasms occur with higher frequency in the the lumbar spine. Fractures may be accompanied by subtle nar-
thoracic spine, and malignant secondary vertebral neoplasms in rowing of the adjacent intervertebral disc space. Vertebrae may
the lumbar spine. Large breeds of dogs, such as German shepherds, appear smaller than normal owing to compression fractures. Be-
Standard Poodles, and Labrador retrievers, are more likely to have cause of the compacting nature of compression fractures, affected
vertebral neoplasms than are smaller breeds; on the average,this vertebraeare often increasedin opacity (Fig. 9-20). Fracturesand
occurs when they are about 7 years of age. Malignant primary or malunion fractures of vertebrae may result in innumerable dis-
secondary neoplasia may alter the shape of the vertebrae by de- torted shapes.Orthogonal views to determine the degreeof fracture
stroying bone, producing bone, or both (Fig. 9-16). The bone displacement should be taken. Horizontal beam radiography may
destruction often affects the cortical bone of the vertebrae, and be needed to prevent unsafe manipulation of the spine.
there may be collapseofthe adjacentdisc space.A paraspinal,soft- Subluxation or luxation of the spine mav occur with or without
tissue mass may be present. Myeloma and hemangiosarcoma of fracture. Subluxation may be accompanied by narrowing of the
the vertebrae often produce "punched-outj' osteolytic-appearing adjacent intervertebral disc space.The spinal displacement may be
lesions in the vertebrae (Fig. 9-17). In contrast with discospondy- evident on one radiographic view, but less apparent on the orthog-
litis, spinal neoplasia does not routinely result in symmetrical end- onal view, and again, caution needsto be observedduring radiogra-
plate lysis cranial and caudal to an intervertebral disc. Radiographi- phy so as not to make the lesion worse (Fig. 9-21).
lgrrra -ii11rl,
'lu.t
r.:lll:
-e F- g
,,i€ll
17. Raffe MR, Knecht CD: Cervical vertebral malformation: A review of 36 cases.J
References Am Anim Hosp Assoc 16;881,1980.
1. Evans HE, Christensen GC: Miller's Anatomy of the Dog, 2nd ed' Philadelphia, 18. Trotter El, delahunta A, Geary JC, et al: Caudal cervical malformation: Malarticu-
WB Saunders, 1979. lation in Great Danes and Doberman pinschers. J Am Vet Med Assoc 168:10, 1976.
2. Watson AG. Stewart JS: Postnatal ossilication centers of the adas and axis in 19. Sharp NJH, Cofone M, Robertson ID, et al: Computed tomography in the
miniature schnauzers.Am I Vet Res 51:264, 1990. evaluation of caudal cervical spondylonyelopathy of the Doberman pinscher. Vet
Radiol Ultrasound 36;100,1995.
3. Dyce KM, Sack WO, Wensing CJG: Textbook of Veterinary Anatomy, 2nd ed'
Philadelphia, WB Saunders, 1987. 20. Lincoln JD: Disease of the spine. Vet Clin North Am Small Anim Prcct 22:923,
1992.
4. Morgan JP: Congenital anomalies of the vertebral column of the dog: A study of
the incidince and significance based on a radiographic and morphologic study J Am 21. Denny HR, Gibbs C, Holt PE: The diagnosis and treatment of cauda equina
Vet Radiol Soc 9:21, 1968. lesions in the dog. J Small Anim Pract 23:425, 1982.
5. Morgan IR Bailey CS: Cauda equina slndrome in the dog: Radiographic evalua- 22. Oliver JE, Selcer RR, Simpson S: Cauda equina compression from lumbosacral
tion. J Small Anim Pract 31:69, 1990. malarticulation and malformation in the dog. J Am Vet Med Assoc 173:2, 1978.
6. Morgan JR Bahr A, Franti CE, et al; Lumbosacral transitional vertebrae as a 23. Tarvin G, Pratat RG: Lumbosacral stenosis in dogs. J Am Vet Med Assoc 177:2,
predispoiing cause of cauda equina slmdrome in German shepherd dogs: 161 cases 1980.
(1987-1990).J Am Vet Med Assoc 202:1877,1993.
24. Lang I: Flexion-extension myelography of the canine cauda equina. Vet Radiol
7. Larsen JS: Lumbosacral transitional vertebrae in the dog. J Am Vet Radiol Soc 29:242,1988.
18:3, 1977. 25. Mattoon JS, Koblik PD: Quantitative survey radiographic evaluation ofthe lumbo-
8. James CM, Lassman LR Tomlinson BE: Congenital anomalies of the lower spine sacral spine of normal dogs and dogs with degenerative lumbosacral stenosis. Vet
and spinal cord in Manx cats. i Pathol 971269,1969. Radiol Ultrasound 34i194, 1993.
9. Bailey CS: An embryological approach to the clinical significance of congenital 26. Adams \4rH, Daniel GB, Pardo AD, et al: Magnetic resonance imaging of the
vertebral and spinal cord abnormalities. J Am Anim Hosp Assoc II:426' 1975' caudal lumbar and lumbosacral spine in 13 dogs (1990 1993). Vet Radiol Ultrasound
36:3, 1995.
10. Coulter SB: Congenital anomalies ofthe spine. In Bojrab MJ (ed): Pathophysiology
27. Hathcock JT, Pechman RD, Dillon AR, et al; Comparison of three radiographic
in Small Animal Surgery. Philadelphia, Lea & Febiger' 1981, p 729.
contrast procedures in the evaluation of the canine lumbosacral spinal canal. Vet
11. Taneka T, Uthoff HK: The pathogenesis of congenital vertebral malformations' Radiol 29:4, 1988.
Acta Orthop Scand 52:413,1981.
28. lones JC, Wilson ME, Bartels JE: Review of high resolution computed tomography
12. Bailey CS, Morgm lP: Congenital spinal malformations. Vet Clin North Am Small and a proposed technique for regional examination of the canine lumbosacral spine.
Anim Pract 22'.985, 1992. Vet Radiol Ultrasound 35:339, 1994.
13. Wilson JW Kurtz Hl, Leipold HW, et al: Spina bifida in the dog. Vet Pathol 29. Jones JC: Computed tomographic anatomy of the canine lumbosacral spine. Vet
16:165, 1979. Radiol Ultrasound 36:260, 1995.
14. Oliver IE, Lewis RE: Lesions of the atlas and axis in dogs. I Am Anim Hosp Assoc 30. Feeney DA, Evers P, Fletcher TR et al: Computed tomography of the normal
9:304,1973. canine lumbosacral spine: A morphologic perspective. Vet Radiol Ultrasound 37:399,
1996.
15. Beaver DR Ellison GW Lewis DD, et al: Risk factors affecting the outcome of
surgery for atlantoxial subluation in dogs: 46 cases (1978-1998). J Am Vet Med 31. Morgan lP: Spondylosis in the dog: Its radiographic appearance.J Am Vet Radiol
A s s o c2 1 6 :1 1 0 4 ,2 0 0 0 . Soc 8:17. 1967.
16. Chambers JN, Betts CW: Caudal cervical spondylopathy in the dog: A review ot 32. Wright JA: A study ofvertebral osteophyte formation in the canine spiae: I. Spinal
20 clinical casesin the literature. J Am Anim Hosp Assoc 13:571' 1977. survey. J Small Anim Pract 23:697, 1982.
The Vertebrae-Canineand Feline l(l9
Figurc 9-22
33. Wright JA: A study of vertebral osteophlte formation in the canine spine; II. 50. Moore MP: Discospondylitis.Vet Clin North Am 22:1027,1992.
Radiographic survey. J Small Anim Pract 23:747,1982.
51. Jimenez MM, O'Callaghan MW: Vertebral physitis: A radiographic diagnosis to be
34. Karkkainen M, Punto LU, Tulamo RM: Magnetic resonance imaging of canine separated from discospondylitis. Vet Radiol Ultrasound 36:188, 1995.
degenerativelumbar spine diseases.Vet Radiol Ultrasound 34:399,1993.
52. Owens JM, Biery DN; Radiographic Interpretation for the Small Animal Clinician,
35. Morgan JP, Miyabayashi T: Degenerative changes in the vertebral column of the 2nd ed. Baltimore, Williams & Wilkins, 1999.
dog: A review of radiographic findings. Vet Radiol 29:72, 1988.
53. Luttgen Pl, Braund KG, Brawner WR, et al: A retrospective study of twenty-nine
36. Morgan JP: Radiology in Veterinary Orthopedics. Philadelphia, Lea & Febiger, 1972. spinal tumors in the dog and cat. J Small Anim pract 21:213,1980.
37. Riser WH, Brodey RS, Shirer IF: Osteodystrophy in mature cats: A nutritional 54. Morgan lP, Ackerman N, Bailey CS, et al: Vertebral tumors in the dog: A clinical,
disease.I Am Vet Radiol Soc 9:37, 1968. radiologic, and pathologic study of 61 primary and secondary lesions. Vet Radiol
38. Cowell KR, lezyk PF, Haskins ME, et al: Mucopolysaccharidosis in a cat. I Am Vet 2l :5,1980.
Med Assoc 169:3, 1976.
55. Wright JA, Bell DA, JonesDG: The clinical and radiolosic features associatedwith
39. Haskins ME, Jezyk PR, Desnick RJ, et al: Mucopolysaccharidosis in a domestic s pi nal tum or s i n thi r ty dogs . I Sm al l Ani m Pr ac t20:4b1,1979.
short-haired cat: A diseasedistinct from that seen in the Siamesecat. J Am Vet Med
56. Osborne CA, Permen V, Sautter JH, et al: Multiple myeloma in the dog. J Am Vet
Assoc 175:4,1979.
M ed As s oc 153:1300,1968.
40. Smith HA, lones TC: Veterinary Pathology,3rd ed. Philadelphia,Lea & Febiger,1966.
57. Bartels lE, Cawley Al, McSherry BJ, et al: Multiple myeloma (plasmacltoma) in a
41. Saunders HM, lezyk PF: The radiographic appearance of canine congenital h)?o- dog. J Am Vet Radiol Soc 13:36,1972.
thyroidism: Skeletal changeswith delayed treatment. Vet Radiol 32:171, 1991.
58. Jergens AE, Miles KG, Moore FM: Aly?ical lytic proliferative skeletal lesions
42. Riser WH, Frankhauser R: Osteopetrosis in the dog: A report of three cases.J Am associatedwith plasma cell myeloma in a dog. Vet Radiol 3l:262, 1990.
Vet Radiol Soc 1l:29, 1970.
59. Drost Wl Love NE, Berry CR: Comparison of radiography, myelography and
43. Dorland NW; Dorland's Illustrated Medical Dictionary, 29th ed. Philadelphia, WB computed tomography for the evaluation of canine vertebral and spinal cord tumors
Saunders, 2000. in sixteen dogs. Vet Radiol Ultrasound 37:28,1996.
44. lohnston DE, Summers BA: Osteomyelitis of the lumbar vertebrae in dogs caused 60. Thomas WB, Daniel GB, McGavin D: Parosteal osteosarcoma of the cervical
by grass-seedforeign bodies. Aust Vet J 471289,1971. vertebra in a dog. Vet Radiol Ultrasound 38:120, 1997.
45. Walker TL, Gage ED: Vertebral osteomyelitis, discospondylitis, and cauda equina 61. Suter PF, Morgan JP, Holliday TA, et al: Myelography in the dog: Diagnosis of
slmdrome. In Bojrab Ml (ed): Pathophysiology in Small Animal Surgery. Philadelphia, tumors of the spinal cord and vertebrae. J An Vet Radiol Soc 12:29, j.97ir
Lea & Febiger,1981.
48. LeCouteur RA, Child G: Diseasesof the spinal cord. In Ettinger S (ed): Textbook 1. Normally, there are seven lumbar vertebrae in the dog. How
of Veterinary Internal Medicine. Philadelphia, WB Saunders, 1989.
might one explain what appears to be eight lumbar vertebrae
49. Malik R, Latter M, Love DN: Bacterial discospondylitis in a cat. J Small Anim on a radiograph?
Pract 31:404.1990. 2. True or False.Scoliosisis a lateral bowing of the spine, kyphosis
is a dorsalbowing of the spine,and lordosisis a ventral bowing
of the spine.
3. List four potential causesfor atlantoaxial subluxation.
4. Vertebral malformation-malarticulation may result in abnor-
mal alignment, either dynamic or adynamic, of which vertebrae
in young Great Dane and adult Doberman pinscher dogs?
5. List the most common radiographic signs of degenerativelum-
bosacral stenosisand its associatedcauda equina s)'ndrome.
6. Distinguish between the terms discospondylitisand spondylosis
deformans.
7. List one radiographic sign to differentiate vertebral neoplasia
from discospondylitis.
8. List two potential differences between primary and secondary
malignant neoplasiaof the spine.
9. What is/are the preferential radiographic diagnosis/diagnoses
basedon this lateral radiograph of a canine spine (Fig. 9-22)?
10, What is/are the preferential radiographic diagnosis/diagnoses
based on this lateral view of a canine lumbosacral junction,
subsequentto an epidurogram (contrast medium indicatedby
curued white arrow) and a discogram (black and white straight
arrows) (Ftg.9-23)?
ffi10
ffi Ganineand FelinelntervertebralDisc
ffi Disease,Myelography,and Spinal
ffi Gord Disease
ffi . William R. Widmer ' Donald E. Thrall
Intervertebral disc diseaseis a degenerativecondition of unknown dorsal and ventral support for the intervertebral discs.sThe dorsal
cause that results in protrusion of the disc or disc material into longitudinal ligament joins the dorsum of the vertebral centra and
the vertebral canal, compressing the spinal cord or spinal nerve lies on the floor of the vertebral canai (see Fig. 10-l). In the
roots.l 3 Although other "diseases"affect the intervertebral disc, we cervical region, the dorsal ligament is wide and thick; consequently,
consider only disc protrusion in this chapter. lateral extrusion ofdisc material and radiculopathy (root signature)
Intervertebral disc diseaseaffectsall breeds of dogs; the chondro- are more common than dorsal extrusion and severecord compres-
dystrophic breeds are over-rePresented,with the highest prevalence sion.e In comparison, the dorsal longitudinal ligament is thin in
in the Dachshund (45o/o-65o/o of affected dogs).'a Beagles'Cocker the thoracolumbar region, predisposing to dorsal protrusion and
spaniels, Toy Poodles, and Pekingesealso have a high prevalence. cord compression. The ventral longitudinal ligament spans the
Doberman pinschers afflicted with cervical vertebral instability- ventral surface of the vertebral coiumn, offering ventral support.
malformation,t German shepherds,uand mixed-breed dogs also The intercapital ligaments are short, transversefibrous bands that
develop intervertebral disc disease. lie ventral to the dorsal longitudinal ligament, joining the rib heads
Neural signs of intervertebral disc disease generally manifest betrveenT2 and T11. Theseligamentsbuttressthe dorsal part of the
after 3 years of age; however, in chondrodystrophic breeds, disc annulus cranial to T11 and help resist dorsal disc protrusion.s'10'rr
degeneration begins before 1 year of age. No gender predilection The vertebral canal of the dog is crowded, and the epidural space
has been identified.' Common sites of disc protrusion are Tl2-13 is small. Thus, the canine spinal cord is subject to compression by
and T13-L1 in the thoracolumbar region, and C2-3 and C3-4 tn epidural masses, for example, disc protrusion. The Dachshund,
the cervical region.'' 3 Although clinical signs of intervertebrai disc compared with the German shepherd dog, has a very high spinal
diseaseare uncommon in cats, cervical disc degenerationfrequently cord-to-canal ratio-that is, a small epidural space." Possibly,this
occurs in cats older than 6 years of age.''t explains the severeneurologic signs seenin the Dachshund follow-
Suspected intervertebral disc disease is one of the most im- ing disc protrusion. Owing to alarger epidural space,small protru-
portant indications for radiographic evaluation of the vertebral sions causing minimal cord compressions are less significant in
column of small animals. Accurate radiographic examination can large-breed dogs. The ratio of spinal cord to vertebral canal is
establish the presenceand severity of disc disease,allowing clini- Iowest in the cervical area; therefore, neurologic signs tend to be
cians to determine prognosis and proceed with treatment. Because Iessseverewith cervicalversusthoracolumbardisc orotrusion.3'e'11
many radiographic signs of disc diseaseare subtle and other spinal The spinal cord and the spinal nerve roots lie within the bony
conditions may be the causeof clinical signs, accurateradiographic vertebral canal, which consistsof the individual vertebral foramina
interpretation requires a thorough knowledge of anatomy, physiol- (see Fig. 10-1). Paired intervertebralforamina serve as windows,
ogy, and neurology. allowing exit of the spinal nerves and blood vessels.The meninges
Radiology is also valuable for the assessmentof animals with surround the spinal cord and consist of the inner pia-arachnoid
neoplastic, inflammatory, congenital, and degenerativeconditions membrane and the tough, outer dura (Fig 10-2). Tha cervical and
of the spinal cord. lumbar intumescencesare normal enlargements of the cord and
should not be confused with cord swelling. The spinal cord begins
at the foramen magnum and, depending on the breed of dog,
I Anatomic and physiologic terminates at the conus medullaris, near the level of L6. In small-
I considerations breed dogs, the cord ends caudal to L6, and in large breeds,cranial
to L6l this is an important factor for consideration when lumbar
The intervertebral disc is composed of a tough outer annulus subarachnoid puncture is to be performed. In the cat, the spinal
fibrosus, which contains the gelatinous, inner nucleus pulposus cord extends slightly beyond L6."
(Fig. 10-1).28The annulushas severalconcentricfibrocartilaginous The spinal cord segmentsand vertebrae have the same numeric
layers, which are firm1y attached to adjacent vertebral end plates designation (with the exception of cord segment C8), but the
and centra.l't The nucleus pulposus is eccentricallylocated;thus, location of each cord segment is rarely found within the corre-
the annulus is thin dorsally and thick ventrally. This partially sponding vertebra.l0The reason is twofold. First, the spinal cord is
explains the tendency for dorsal herniation of diseased discs. A shorter than the vertebral column because of differential fetal
mi*tn." of proteoglycans, collagen fibers, mesenchymal cells' and growth rates. Second,many of the cord segmentsare shorter than
water makes up the normal jelly-like nucleus. Only the outermost the vertebral segments.Therefore, cord segmentsare located cranial
layers of the annulus have a neurovascular supply.t The disc forms to their respective vertebrae, and the spinal nerves must course
a cartilaginous joint between vertebral segments (excluding C1-2 caudally and obliquely within the vertebral canal a short distance
and the sacrum) and thus functions as a hydraulic shock absorber. before exiting via the intervertebral foramina. The collection of
Shock absorption is dependent on a hydrated, deformable nucleus spinal nerve roots in the lumbosacral region is known as the cauda
and an intact, elastic annulus.T equina. These nerves, like the spinal cord, are subject to compres-
The longitudinal ligaments of the vertebral column provide sive injury causedby disc protrusion.
rt o
C a n i n ea n d F e l i neIntervertebral
D i scD i sease,Myel ography,
and S pi nalC ordDisease lll
Caudal
articularprocess
Epiduralspace
Subarachnoidsoace
Spinal cord
1
l:l
'119
1l
;
i!
Dorsal
,itl longitudinal
ligament
{,
Nucleuspulposus
Intercapital
Annulusfibrosus ligament
longitudinalligament
B longitudinalligament
The subarachnoid space lies between the arachnoid membrane and mineralization of the nucleus pulposus.The annulus fibrosus
and the pia mater, which surrounds the spinal cord and spinal also degeneratesand loses its capacity to contain the diseased
nerve roots. Cerebrospinalfluid (CSF) fills the subarachnoidspace, nucleus. Consequently, the weakened disc cannot withstand dy-
displacing the lacy, arachnoid membrane peripheraily against the namic forces applied by the vertebral column, and protrusion
dura. The spinal subarachnoid space begins at the foramen mag- ensues.Type I protrusion follows chondroid degeneration and is a
num, where it communicates with the subarachnoid space of the result of extrusion of dehydrated nuclear material into the vertebral
cranial cavity; it ends caudally at the filum terminale, near the canal. Fibroid degeneration is frequently recognized in old, non-
lumbosacral junction.8 The central canal of the spinal cord is filled chondrodystrophic breeds and is characterizedby fibrous metapla-
with CSF and communicates rostrally with the ventricular system. sia of the nucleus pulposus. The annulus fibrosus may stretch,
In most dogs, the central canal terminates blindly at .the conus partially rupture, or hlpertrophy and protrude into the vertebral
medullaris; however, in some dogs, the canal is continuous with canal, thereby compressing the cord. Type I lesions tend to be
the lumbar subarachnoid space. acute, forceful extrusions that cause compressivemyelopathy and
severe neurologic signs.' Tlpe II lesions are associated with a
Dura
bral foramen, (4) increased opacity in the intervertebral foramen,
and (5) extruded, mineralized disc material within the vertebral
Subduralspace
canal (Figs. 10-3 and 10-4).
Disc space narrowing must be assessedin view of the animal's
age and the presenceor lack of secondarybony changes.tT Nar-
rowing may be due to acute (type I) disc protrusion in young to
middle-aged dogs when there are no secondary bony changes.In
Subarachnoid
old dogs, narrowing may representchronic (type II) disc disease,
space
and only a bulging annulus fibrosus is present. Spondylosis de-
formans often accompanies chronic protrusion and reflects poor
shock absorption by the diseased disc. Many dogs with radio-
graphic evidence of spondylosis deformans experiencechronic disc
Pia mater changes,but remain asymptomatic.lT
Spinal
Discal mineralization is indicative of intervertebral disc degener-
cord ation but not always disc protrusion.lT Dystrophic mineralization
of a degenerating disc usually begins in the center of the nucleus
pulposus and extendsperipherally. The annulus may undergo min-
eralization separately.Contained, mineralized disc material is not
a sign of disc prolapse (see Fig. l}-M). Not all mineralized discs
Subarachnoid space will prolapse, and not all prolapsed disc material is mineralized.
and arachnoid membrane Noncontained (extruded), mineralized disc material can be seen
on surveyradiographs(seeFig. 10-48 and C) and is a sign of disc
prolapse. With acute prolapse, mineralized disc material is dis-
persed by local inflammation. Therefore, the opacity of disc mate-
rial in the vertebral canal is nearer that of soft tissue than of
mineral. After extrusion of nuclear material, an empty, hollow shell
of the annulus may remain (see Fig. l0-4D). As the inflammation
subsides,the extruded massof disc material contractsand becomes
more opaque. In addition, chronically extruded disc material may
Dorsal and Yentral roots
undergo mineralization or ossification. This information can be
in meninqeal sleeves used to help distinguish acute from chronic disc protrusion.
Lateral and intraforaminal protrusions of the cervical discs may
Figure 10-2. Anatomicrelationship(transverse planelof spinalcord, menin-
gell l a y e r s a sp a ce ./r se t sh o ws m icr o sco p ic structureof a escapedetection when standard ventrodorsal and lateral projections
, n d s u b a r a ch n o id
s eg m e n to f t h e m e n i n g e sa n dco r d .lAd a p te dfr o m Ho e r le inBF :Cani neN eurol - are used. Because of the relatively large extradural space in the
ogy : D a g n o s i sa n dT r e atm e n t, WB
3 r d e d . Ph ila d e lp h la , Sa u n d ers,1978) cervical region, protrusions may not cause an extradural myelo-
graphic lesion. Oblique radiographic projections (V45"L-DR or
V45"R-DL) allow assessment of the 1eftand right foramina, respec-
tively, enabling identification of an opaque foramen. This proce-
I Survey radiography dure aids the surgeon becausethe animal may otherwise fall into
Radiographic signs consistent with intervertebral disc protrusion the nonsurgicaltreatment category.'8
include (1) narrowing ofthe disc space,(2) narrowing ofthe dorsal Foilowing hemilaminectomy, the disc space often remarns nar-
intervertebral articular processjoint space, (3) a small interverte- row. The hemilaminectomy site can be identified by unilateral
Figure 10-3. Surveyradiographic signs of intervertebraldlsc disease.A, AJT12-13,the lntervertebradisc spaceand dorsalintervertebralarticularprocessjolnt
are narrow (whitearrowhead)and the intervertebral foramenis small and cloudy(arrow).The anticlinaldisc spaceat T10-11 s normall! narrowedcomparedwith
adjacentspaces /b/ackarrowheads).B, Ventrodorsalradiographof dog in A. There is a narrow disc space at T12-13 (arrowheads). Becauseof overlapof the
vertebralend plates,the ventrodorsalprojectionis less accuratethan the lateralprojectionfor eva uatingdisc spaces.
C a n i n ea n d F el i neIntervertebral
D i scD i sease,Myel ography,
and S pi nalC ordDisease ll3
::
:rrlr...i11
..,rrilEll
r
iilClrr,
Figure I0-5- A, Unilateralabsence of articularprocessesfollowing left hemilaminectomy;compare wlth the intact processeson the right /arowsl
La-minectomysjte ls easilyrecognizedbecausethe laminaand the spinousprocesshavebeen removed(asterisks).
absenceofthe articular Processes (Fig. 10-5,4).The thoracolumbar stylet in place while making a puncture reduces the damage that
region should alwaysbe scrutinized for this finding becausehistori- might occur if the spinal cord is accidentally pierced and also
ca1information regarding previous surgical decompressionmay be prevents tissue from clogging the needle lumen.
lacking. If complete laminectomy has been performed, the absence Cervical myelography is performed by injecting contrast medium
of the lamina and spinous processesis easily recognized (see Fig. into the cerebellomedullary cistern through the atlanto-occipital
10-58). Fenestrationsgenerally result in disc spacenarrowing and space (Fig. 10-6). Puncture can be accomplished with the animal
occasionally discospondylitis." in either sternal or lateral recumbency.The head is flexed ventrally,
and the needle is carefully inserted at the midline near the center
of a triangle formed by the external occipital protuberance and the
I Myelography wings of the atlas." A distinct "pop" immediately followed by loss
of resistanceis often felt as the needle traversesthe dorsal atlanto-
Myelography, which is radiography used following injection -of
occipital membrane and dura. This "classic" sensation is less obvi-
contrait medium into the spinal subarachnoid space, is useful
spinal cord and cauda equina' Indications for ous or is absent in small dogs and should not be relied on as
for evaluating the
evidence of cisternal entry. During puncture, the myelographer
myelography include (1) confirming a spinal lesion seen or sus-
radiographs, (2) defining the extent of a survey should frequently stop, withdraw the stylet, and check for evidence
pected on survey
of CSF to determine needle location. A radiograph can also be
iesion, (3) finding a lesion not observed on survey radiographs,
(4) identifing patients that are likely to benefit from surgery' made with the needle in place for orientation purposes. With the
and
animal in sternal recumbency, needle placement is less risky be-
Myelography may cause intensification of pre-existing neurologic
the clinical presentation is consistent with a diagnosis cause the occipital plate is used to find the proper depth before
signs." When
the cerebellomedullary cistern is entered (see Fig. 10-6A).
of intervertebral disc protrusion and unequivocal survey radio-
present, the surgeon may elect to perform decom- Lumbar myelography is performed by puncture of the subarach-
graphic signs are
noid space,preferably at L5-6, but L4-5 can be used if necessary
preision without myelographic evaluation. However, in recent stud-
disc disease, survey (Fig. 10-74 and B). The animal is in lateral recumbency and either
ies of dogs with surgically confirmed
of two methods can be used to puncture the subarachnoid space.te
radiographs were only 680/oto 72Voaccurate in identifring the site of
protrusion; the accurary of myelography was 860lo to 97o/o.a'zo With the paramedian approach, the needle is inserted slightly
disc
caudolateral to the spinous process of L6 or L7 ar.d is directed
Myelography also provides evidence for whether a hemilaminec-
be performed on the left or the right side of the cranioventrally at a 45-degreeangle, through the interarcuate sPace.
tomy ihould
The median approach requires insertion of the needle just cranial
affected disc space.
to the spinous process of L5 or L6, at a 9O-degreeangle to the
vertebral column. Because the lumbar subarachnoid space ends
Technique blindly in most dogs, contrast medium can be forced past an area
Myelographic technique is well described'8"; therefore' only a brief of intramedullary swelling, allowing evaluation of the cranial and
resume of procedure is presented here. Myelography is always caudal aspects of a compressive lesion. With cervical injection,
performed under aseptic conditions, with the animal subjected to contrast medium tends to flow rostrally into the ventricular system
general anesthesia.An accurate survey radiographic study servesas when resistance to caudal flow is encountered; thus, only the
a baseline and must precede myelography' Iohexol (Omnipaque, cranial margin of a compressivelesion may be identified. Cervical
240 mgllmL) and iopamidol (Isovue, 200 mgl/ml) are safe and myelography is rarely of value when severe thoracolumbar cord
efficacious and are the nonionic contrast media of choice for small swelling is present. In some instances,a lumbar study is the best
animai myelography. The full-spine dose is 0.45 ml/kg and the way to evaluate a caudal cervical cord lesion.
regional dose is 0.30 ml/kg. These doses are guidelines and it is The oros and cons of dorsal versusventral lumbar subarachnoid
imoortant to administer sufficient contrast medium to fiIl the injection are open to debate. Becauseit is difficult to locate the
subarachnoid space in the region of interest. A 22-gauge spinal dorsal subarachnoid space,most myelographerschoose to position
needle and stylet should always be used for myelography because the needle bevel in the ventral subarachnoid spaceinstead (seeFig.
it has a short bevel, which increasesthe likelihood that the needle I0-7A and B). There is also less risk of intramedullary injection of
will be positioned in the thin subarachnoid space. Keeping the contrast medium with ventral puncture. Positionins the needle
C a n i n ea n d F el i neIntervertebral
D i scD i sease,Myel ography,
and S pi nalC ordDisease ll5
F i g u r e 1 0 - 6 . T e c h n iq u eo f ce r vicam l ye lo g r a p h y.
/, L a te ralradi ograph;
the spi nalneedl ei s i n contactw i th the occi pi tabone,estabi shi ngproperdepth for
c e r e b e l l o m e d u l l apruyn ctu r e 8. , Afte rth e o ccip itabl o n e is lo cated,the needl ecan be "w al ked"caudal y and i nsertedi ntothe cerebel l omedul l ai v e.C ontras t
s pac
m e d i u mh a s b e e ni n je cte din to th e su b a r a ch n o sp id a ce ,a n d some contrastmedi umi s presenti n the crani alcavi ty.
'
-;:-:
',L;;*...1?;,
F i g u r e 1 0 - 7 , T e c h n r q uo e f lu m b a rm ye lo g r a p h y.
/, L u m b armyel ogramobtai nedby the paramedi an approach. The neede ti p i s n the ve ntrals ubarac hnoi d
c n ' ^ a ' n d + h an a o d r ach ' { + ;c a t a n a p p r o xlm a te 4 ly5 ' a n ge t o the spi nalcordand paral l elto the p ane of the dorsali ntervertebralarti cuar oroc es si oi nts .Fi l l i nq
d e ' e c r sa r r o w h e a d sr ar e ca u se do y th e sp ,r a n e r ve o o ts o ' r l e umbarcordsegmen[s.N orerl -esharpl ymargi raredconTrasl medi Jn co'umrs,whrc hi s i -di c ati v e
o f s u b a r a c h n o i dn i e c tio nB,
. L u m b a rm ye o g r a mo b ta in e db y the medi anapproachat L5-6.The neede ti p i s i n the ventralsubarachnoispace, d and the neede
ehrri ic l ' r 1 ^ + h osp in a co r d .Slig h te p id u r ale a kagehas occurredaroundthe neede tract (arrow ).fheduralsac i s ooacl fl ed.endl nqat L7-S 1.C .
^o'^d^/!^
L u m b a rm y e l o g r a mw ith th e n e e de tip n th e d o r sa su l b a r a chnoispace
d at L5 6. N ote the d sc m neral i zati on
at L6-7.
1 I6 A X I A LS K E LET ON
:ie
4.,.
-;..-- .
",t-;
*l"-:
a,..,ll
irtti$
'llilrl
Ventrodorsal
Lateral
J
nYf./n\ \^JlHEK^
lHEl /
A^ @ \ lHEl ,/
ffi\lH HV
Normar uH HIJ
fi n JIHL
B #\lf
# € '' l 1l/
rV fr,.'
rmYH f)
Extradurar
UH HIJ
(a n ^IlHE[l^
c4 -\H) /
ffi\|HHV
Intradural-extramedullary
UHHU
(- n ^llH
EK^
D #4\Lt \/
Fxfffl-i n_/-l
(--$-J\ib [l /
swelling
lntramedullary LJHHU
E J_4_b \ lHfHl
/
-f';.i5#;';H-jj >-]E';El-<
columnsare displacedand thin or absent (subarachnoid
cord swelling may be evident on the orthogonalprojection.C, Intradural-extramedullary.
projection,and
filling defect)on one radiographic
A mass lesion
within the subarachnoidspace causesa filling defect on the orthogonalprolection;cord swelling may be
em\|H$H[2
opacification
tntramedulary
UH$HL4
present. dependingon the size of the mass. 2 Intramedullaryswelling. The spinal cord is swollen,
causingthinningand obliterationof the contrast medium columns on both myelographicprojections.E
Intramedullaryopacification. of the cord parenchymais causedby uptakeof contrastmedium
Opacification
and is consistentwith myelomalacia.Opacificationof the centralcanaldiffersand shouldnot be confused
with myel omal aci(see
a Fi g.10-12).
C a n i n ea n d F el i neIntervertebral
D i scD i sease,Myel ography,
and S pi nalC ordDisease lt 9
:i6
Figurc 1O-11. Myelogramswith artifactsdue to technicalerrors.,4, Air bubbles(arrowheads) create circularor oval filling defects;their locationvariesfrom
r a d i o g r a ptho r a d i o g r a p hu,n iikea fillin gd e fe ctca u se db y a le s i on.A i r bubbl escan be el i mi nated
by attachi ng
a contrastmedi um-fi l l ed
extensi o ns et to the neeote.
l a cem a y occuri f the needl ebevelbri dgesthe subduraland subarachnoispaces.
B , I n j e c t i o no f c o n t ra stm e d iu min to th e su b d u r asp d N ote w av y and i rregul arl y
marginateddorsalcontrastcolumn lopen arrows) and incompletefilling of the ventralsubarachnoidspace (arrowheads). C, Severeepiduralleakagecauseo oy
mproperneedleplacement.Contrastmedium has spilledinto the epiduralspaceof the intervertebral canaland that which surroundsthe sacralnerve roots /b/ack
a r r o w s )D. , M o d e r a tee p id u r ale l a ka g efo llo win glu m b a rm ye lography at L5-6.E pi dural
contrastmedi umcol umnscan be recogni zed ventral l yby the appearancof e
opacifiedvertebralvenous sinuses (largeclosedarrows)and dorsallyby opacificationdorsalto the subarachnoid contrastmedium column /smalicloseoarrows).
OoacifieddeDressions in the centracontainthe basivertebral veins (openblackarrows).
Figure 1O-12. A, Opacificationof the central canal (arrows)occurs when there is communicationbetween the centralcanal and the subarac hnoisdpac e.
B, Myelomalaciais typified by uptake of contrast medium by the cord parenchyma(double-headedarrows).lnlrameduilaryswelling i s al s o pres entand the
subarachnoid
contrastmedium columns are lhin brrowheadd.
I2O AXIALSKELETON
of a normai canalogram should not be confused with cord opacifi- Table 10-2. Myelographic signs of intervertebral disc
disease
cation causedby myelomalacia (Fig. 10-l2B). Large central canals
are associatedwith hydromyelia. The central canai may also become
Extradural D e v i a t i o na n d t h i n n i n g o f s u b a r a c h n o i d
opacified when severetrauma or neoplasiadisrupts the cord paren- pattern contrastcolumn at intervertebraldisc
chpna. space (ventral,dorsal,or lateral)
Forkedsubarachnoidcontrastcolumn
Intervertebral disc protrusion S p i n a lc o r d d i s p l a c e m e n t
Either an extradural or an intramedullary pattern may result from Spinal cord compression(compensatory
22'333s Disc protrusion typical[ displacementflattenscord owing to
disc protrusion (Table 10-21.2t'
.urrsei ut extradural lesion characterized by thinning and dorsal extraduralmass, mimics cord swelling)
"Hourglass"subarachnoidfilling defect
deviation of the ventral aspect of the subarachnoid contrast me-
dium column (lateral radiograph) and comPensatorywidening of Intramedullary U n i f o r m s p i n a l c o r d s w e l l i n g d u e t o e d e m a ;
the cord (ventrodorsalradiograph) (Fig' 10-l3A and 8).'6 On the pattern subarachnoidcontrastcolumns displaced,
lateral radiograph, the cord is compressedand has deviated away thin. or absent
from the site of disc protrusion. The contrast medium column Opacificationof spinal cord parenchyma
adjacent to the protrusion tends to be dome-shaped, and the
opposite side of the contrast medium column is narrowed by the
displaced spinal cord. When disc protrusion is slightly lateral to Frequently, in type I protrusion an intramedullary pattern owing
the ventral midline, a split, or forked, appearanceto the contrast to severecord swelling predominates and masks "classic" extradural
medium column may be seen on the lateral projection (see Fig. signs of extrusion. Cord swelling is caused by edema of one to
10-13C). This finding should not be confusedwith an intradural- three vertebral segmentscranial or caudal to the site of protrusion
extramedullarylesion (seeFig. 10-10).a''z6 Both extruded disc mate- secondary to acute injury, but it is not a feature of chronic disc
rial and a bulging annulus can deviate the subarachnoid contrast protrusion. The subarachnoiddisplacementof intramedullary
medium column and the cord. swelline differs from that of extradural comDression.With intra-
Figure I0-I3. Cervicalmyelogram.There are typicalextradurallesionscausedby tntervertebral disc prolapseat C3-4.A, Lateralradiograph.There is dorsal
contrastmedium column (largearrowd. fhe dorsalcontrastmedium column is thin, owing to displacementof the splnal
deiiation of the ventralsubaiach-noid
cord(smaltarrow).Note mineralizeddisc material(whitearrowheads).B, On the ventrodorsalradrograph, cord swellingis typifiedby thinningand abaxialdeviation
of the contrastcolumnsat C3-4 (arrows).C, Forkedappearanceof the ventralcontrastmedium column is causedby the x-raybeam strikingtwo tangentsof the
ventril subarachnoid space.The extrudeddisc materialis locatedjust lateralto the midline,causingthe ventralcontrastmedium column to appearas a double
/ineon the lateralradiograph(openarrows).The doubleline ls not seen in A, becauseof a slightdifferencein patientpositioning.
C a n i n ea n d F e l i neIntervertebral
D i scD i sease,Myel ography,
and S pi nalC ordDisease l2l
medullary swelling, the contrast medium column is thin and dis- may cause an extradural mass lesion. Whenever there is doubt
placed abaxially (Fig. 10-lM and B). In some instances, severe about the location of disc protrusion on the myelogram, the survey
srvellingmay completely obliterate the subarachnoid space(seeFig. radiographs should be re-evaluatedto be certain nothins has been
10-14C). Evidenceof intramedullary swelling is typically visible on overlooked.
Iateral and ventrodorsal radiographic projections. Compensatory Technical considerations play an important role in the myelo-
erlradural compression of the cord causes focal intramedullary graphic diagnosis of intervertebral disc disease.Radiographs made
sw'elling (shorter length than intramedullary swelling) on a single immediately after rapid injection of contrast medium may enhance
radiographic projection (usually the ventrodorsal), and extradural the extradural component of disc protrusion and the extent of cord
signs of disc protrusion are seenon the orthogonal projection. In swelling.a'" The use of oblique radiographic projections should be
some instances,acutely extruded disc material may dispersearound considered on every myelographic study because they frequently
the cord and cause a subarachnoid filling defect that mimics cord provide useful information. If disc material is located significantly
srvelling.36 lateral to the ventral midline, the lateral and ventrodorsai radio-
If intramedullary swelling is present and there are no obvious graphs will show only cord swelling, whereas in oblique radio-
etradural signs, careful scrutiny of the myelogram may identifii graphic projections (VL-DR and VR-DL) an extradural pattern will
the site of disc protrusion. Slight axial deviation of the contrast be seen(Fig. 10-15). In some instances,both left and rlght lateral
medium column at the site of cord swelling suggeststhe site of an radiographic projections are needed for accurate identification of
ertradural discal mass (see Fig. 10-148). This important clue is an extradural lesion.17
often found on only one radiographic projection, but can help The gradual onset of tlpe II disc protrusion tends to minimize
determine the site for surgical exploration and decompression.It cord swelling, resulting in an extradural myelographic pattern (Fig.
should be kept in mind that hemorrhage from rupture of the 10-16). Chronic changes,including hlpertrophy of the annulus
r-entral vertebral veins is a complication of acute disc diseaseand fibrosus, ligamentum flavum, and ioint capsule of the dorsal inter-
I22 AXIALSKELETON
r o tr u sio nAa. n d B,L a te r aal n dventrodorsamyel ograms.Therearemi l dsi gnsof cordsw eli ngbutthesi teof di s c protrus i on
Figure I O - 1 5 . V e n t r o l ate rdaiscp t
d nni ngand devl ati o ndue to di s c
l esi ontypi fi edby subarachnoithi
e r o le c ti onthere i s an extradural
is not e v i d e n t .c , 1 na v e n tr a l6 s. r ig h td o r sa l,le ft- o b liq u p
to c/, therei s markedcordsw el i ng.The extradural es i onsare bes l
and i ntramedul l ary
prot up r " .a I n a v e n t r a 6 l 5" le ft- d o r sar],ig h t- o b liq uper o je ctio n/o r thogonal
f ec og n i z eodn t h e o b l i q u epr o ie cto n s b e ca u seth e x- r a yb e a mis str kl ngeachl esi ontangental l y'
. Extr a d u r alel slo nca u sedby dsc protrusi on at L3-4(arrow s). The hourgassappearance, a chroni cchange,i s a res ut
F igur e l 0 - 1 6 . T y p e l l disc p r o tr u sio nA,
o f th e ve n tr a lo
l n g itu d r n llg
a ament,the annul fi brosus,and the l i gamentumfl avum.chroni cdegenerati ve
us ch angesot the
of disc p r o t r u s i o n
a n o n y p e r tr o p h y
di sc spaceand fi l i ng defec t i n the dural
a n d sp o n d ya r ih r ltis)B,. Di sc protrusi onat L7-S 1.N ote narrow edi ntervertebral
v ert e b r aa r e a l s o p r e s e ntisp o n o yio sis
sac hrrows).
C a n i n ea n d Fel i neIntervertebral
D i scD i sease,Myel ography,
and S pi nalC ordDlsease 123
vertebral articular processjoint, causecircumferential compression dural space and complete obstruction to cranial flow of contrast
of the spinal cord ("hourglassappearance").Type II protrusion is medium are the most consistentepidurographic findings of lumbo-
part of the cervical vertebral malformation-instability (wobbler) sacral stenosis(compression).a0 However, the normal contour of
and lumbosacral stenosis-instability (caudal equina) syndromes of the epidural space, unlike the subarachnoid space, is undulating
large-breeddogs.''u and subject to misinterpretation. Myelography should always pre-
Diagnosisoflumbosacral disc protrusion presentsa specialprob- cede epidurography because the latter obscures the subarachnoid
1em to the radiologist. Although disc space narrowing, end-plate space.
scierosis,and spondylosisdeformansare associated with L7-Sl disc
protrusion, these changescan also occur in asymptomatic dogs.6In Computed tomography
addition, some dogs with L7-Sl protrusion have no radiographic
changes.ttLateral radiographic projections of the lumbosacrum in Computed tomography (CT) and CT myelography are useful when
both flexion and extension help in the evaluation of the dynamics conventional myelography does not clearly demonstrate a suspected
of lumbosacral instability, but results are often misleading.uRadio- extradural lesion causedby disc protrusion (Fig. 10-17).ar'4,Be-
graphic contrast procedures routinely used to evaluate the lumbo- cause the contrast resolution of CT is suoerior to that of conven-
sacral region include flexion-extension myelographf8 and epidu- tional radiography, extradural compressivelesions causedby lesions
rography.3eMyelography may reveal evidence of disc protrusion, other than disc protrusion (ligamentous hypertrophy, hematoma,
providing the dural sac extends beyond the lumbosacral joint and tumor, etc.) can be identified. Cord swellins and intervertebral
the myelogram is technically adequate. foraminal changesare accurately diagnosed with CT myelography,
Epidurography is performed by placing a spinal needle into the especiallywhen there is minimal subarachnoid distention. In Do-
vertebral canal between 53 and C3 and injecting contrast medium berman pinschers with caudal cervical vertebral malformation-
into the epidural space.n0Dorsal displacement of the ventral epi- instability, CT findings provide prognostic information regarding
t
Figure 1O-17. Myelographyand computed tomography(CT) of a cervicaldisc prolapse.A, ln the lateralcervicalmyelogram,there is a slight hourglass
appearanceof the contrastmedium columnsaI C3-4 (arrows).B, In a transverseCT image,there is ventrolateralcord compressionat C3-4(openarrow) owingto
e x t r u d e dd i s c m a t e r ia l.Do r so la te r a lly, sp acei s thi n. Onl y a smal l margi nof the i ntervertebral
th e su b a r a ch n o id
o b l q u e w i t h r e s p e ctto th e d iscsp a ce .C A co n tig u o u 3 s - m m sl i cecaudalto B ; therei s cordcompressi on
di sc can be seen becauset he i mage pl anei s
(openarrow )and thi nni ngof the do rs ol ateral
as pec tof
the contrastmedium column (closedarrow).D, A slice made at the caudalaspectof C4 is within normallimits.Arror"l subarachnoid spacewith contrastmedium;
black arrowhead,vertebralpedicle;C, centrum of vertebra;Cd, caudalarticularprocess;Cr, cranialarticularprocess,open arrow, epiduralspace;S, spinalcord;
white arrowhead,vertebrallami^a.
I2 4 A X I A LS K E LET O N
paraspinal soft-tissue structures and the cord parenchyma that Cavitaly diseasesof the cord reported in dogs and cats include
iannot be obtained with conventionalradiography'a3 High-resolu- hydromyelia, syringomyelia, and myelomeningocele. Hydromyelia
tion CT provides excellent spatial resolution and image contrast pertains to dilation of the central canal and may be congenital or
and is used to diagnoselesions of the cauda equina of human acquired. Congenital hydromyelia is thought to be associatedwith
beings. A technique using this modality has been proposed for malformations of the ventricular system that cause altered CSF
evaluationof the caninelumbosacralregion'aa flow and increased CSF pressure. In fact, hydrocephalus is often
present when hydromyelia is identified.s' With acquired hydromye-
lia, dilation may occur subsequentto increasedCSFpressureassoci-
I Spinal cord diseases ated with infection, trauma, or neoplasia affecting the ventricular
Selectedconditions of the spinal cord that are amenable to myelo- system.s'Myelographically, hydromyelia is qpified as a wide, con-
graphic evaluation are consideredhere. Although they are im- trast medium-filled central canal (seeFig. 10-l2,4.).Filling usually
portant diseases,conditions such as myelitis, meningitis, and de- results from leakagearound the needle, but in some instances,the
generative myelopathy are not included because they rarely are dilation of the canal is so large that it is accidentally punctured
accompanied by myelographic changes. during a cerebellomedullary tap. Saccular or smoothly marginated
widening of the canal may occur. Clinical signs associatedwith
Spinal cord neoplasia hydromyelia may result from dilation and loss of cord parenchyma
or from the condition causing the hydromyelia (e.g., feline infec-
Tumors affecting the spinal cord may have intramedullary or extra- tious peritonitis). Frequently, hydromyelia is an incidental finding
medullary origtn. Intramedullary tumors are located within the and is not accompaniedby clinical signs.
cord and cause cord swelling and disruption of neural pathways' Syringomyeliarefers to cavitation of the cord parenchyma,which
They are primary, developing from neural elements' or they are may or may not communicate with the central canal.s0When there
metastatic. Extramedullary tumors arise from within the meninges is communication, contrast medium fills the cavitations and can
(intradural) or from any tissue found within the vertebral column be seen on myelography. Howeveg it is difficult to distinguish
(extradural), including the vertebrae. Extradural and intradural- cavitation of the cord parenchyma from hydromyelia becausethe
extramedullary tumors involve the cord secondarily, causing com- cavitations tend to merge with the dilated central canal.'l Because
pression. Discrete cell tumors, like lymphosarcoma' are difficult to the cord parenchyma is directly affected,animals with syringomye-
ilassify because their sites of origin are usually unknown and lia frequently have clinical signs. Syringomyelia is over-represented
becausetheir locations vary. in Weimaraners.
Intramedullary tumors are relatively uncommon in the dog and Myelomeningocelesare associatedwith spina bifida and consist of
cat. Glial cell tumors, including astrocytomasand oligodendroglio- protrusion of the cord and meninges through a defect in the
mas, are the most common primary neoplasmsof the spinal cord vertebral arch.s' Close examination of survey radiographs often
in dogs." Ependymomasand medulloepitheliomashave also been reveals duplication or attenuation of the spinous processesof the
reported and arise from the neuroepithelium.a6'a7 Lymphosarcoma affected vertebra (see Chapter 9). Myelographically, there is dorsal
is the most frequent intramedullary tumor of cats' Intramedullary displacementof the meningealsac and the conus medullaris of the
spinal cord metastasis is seldom diagnosed in dogs and cord. The meningeal sac is dilated and various abnormalities,
cats-lymphosarcoma and hemangiosarcomaare the predominant including hydromyelia and syringomyeiia, may occur cranial to the
cell types.as"Primary" lymphosarcomaof the cord (i'e., no evi- myelomeningocele. Spina bifida frequently affects the lumbar and
dence of extraneural involvement) has been reported in dogs.on sacral vertebrae and is common in the English bulldog and the
Extradural tumors are the tumors most commonly affecting the Manx cat.
soinal cord. These tumors lie within the vertebral canal and include
vertebral-origin osteosarcomas, myelomas,lymphosarcomas,me- Fibrocartilaginous embolism
ningiomas, and metastatictumors. Intradural-extramedullarytu-
mors are locatedwithin the dural sheath,and neurolibrosarcomas' Fibrocartilaginous embolism is a syndrome of acute infarction of
meningiomas,and lymphosarcomasare the predominant cell type. the spinal cord due to the releaseof small fibrocartilaginous emboli
Unfortunately, the clinical presentation of animals with spinal from intervertebral discs, which lodge in the cord parenchyma.
cord tumors often mimics that of disc protrusion and other non- Infarction and ischemia occur, and cord swelling may be present.
malignant causes.Pain and neural dysfunction are usually present. Thus, intramedullary swelling may be seenon myelography.In one
Although gradual onset is expected with intramedullary tumors, report,s2narrowing of the intervertebraldisc spaceassociatedwith
so-. unirnul, may manifestacutesigns.a5'at CSFanalysisperformed fibrocartilaginous embolism is described. However, frequently with
in conjunction with myelography may detect exfoliated tumor cells. fibrocartilaginous embolism, no changesare seenwith radiography
On myelography,intramedullary tumors causecircumferential cord and myelography,and imaging is used to rule out other conditions.
swelling that is characterized by attenuation of the contrast me-
dium column. This cord swelling is easily confused with that Nerve root neoplasia
associatedwith acute disc protrusion' Signs of disc protrusion Neurofibromas,neurofibrosarcomas, meningiomas,and schwanno-
noted on surveyradiographs(narroweddisc space,cloudy interver- mas are the primary neoplasmsthat involve the nerve roots. Neuro-
tebral foramen, etc.) can help with diagnosis.Slow-growing cord fibromas and neurofibrosarcomasarise from the nerve parenchyma,
tumors may causesmoothly marginatedbone loss of the vertebral whereas schwannomasare encapsulatedand distinct from the
canal.However,this sign is inconsistentand is often a retrospective nerve.s3Meningiomas originate from the adjacent meningeal cov-
finding. Extradural tumors causecord compression,attenuationof ering and may compressnerve roots. Nerve root tumors are most
the contrast medium columns, and cord swelling, also similar to commonly associated with the cervicaland thoracic cord segments.
that of disc protrusion. Similarly, intradural-extramedullary tumors Following myelography, an intradural-extramedullary sign is seen
can mimic any other mass within the meninges (see Fig' 10-10 when a tumor lies within the subarachnoid space. However, if
and Table 10-l). invasion of the dura or cord occurs,or if the tumor lies outside of
the dura, a "classic"intradural-extramedullarylesion is absent.In
Intramedullary cavitary disease the latter instance,the tumor mass may causecompressionof the
Conditions typified by cavitation of the cord parenchyma are o{len cord. For paravertebralnerve root tumors, such as brachial plexus
included under the general classification of spinal dysraphism."' tumors, CT or magneticresonanceimaging is necessaryfor identi-
This all-inclusive term relatesto failure of the neural tube to close' fication.
C a n i n ea n d Fel i neIntervertebral
D i scD i sease,Myel ography,
and S pi nalC ordDisease 125
Arachnoid cysts 6. -vVheelerSJ: Lumbosacral disease.Vet Clin North Am Small Anim Pract 22:859-
888. 1992.
Benign, cyst-like areasin the subarachnoid spacemay causeextra- 7. Thatcher CT: Neuroanatomic and pathophysiologic aspectsof intervertebral disc
medullary compression and neural signs. Histologically, these are diseasein the dog. Probl Vet Med Intervert Disc Dis 1:337-357, 1989.
not true cysts becausethey are not lined with epithelial ce1ls.5'' tt
8. Evans HE, Christensen JC: Miller's Anatomy of the Dog, 2nd ed. Philadelphia,
The cause of "arachnoid" cysts is unknown, but becausethey are WB Saunders,1979.
usually seenin young dogs, a congenital etiology is likely. Resistance
9. Toombs lT: Cen'ical intervertebral disc disease in dogs. Compend Contin Edu
to CSF flow, possibly induced by trauma, resulting in backpressure PtactVet l4tl477 1488, 1992.
and dilation of the subarachnoidspace,has also been implicated
10. Shores A: Intervertebral disc slndrome in the dog. Part I. Pathophysiology and
as a cause.With arachnoid cysts, survey radiographic examination management.Compend Contin Edu Pract Vet 7:639-647,1981.
is usually normal. Following myelography, contrast medium fills
11. Simson S: Intenertebral disc disease. Vet Clin North Am Small Anim Pract
the "cystic" area, defining abrupt dilation of the subarachnoid
22:889-897, 1992.
contrast medium column and compression of the adjacent spinal
cord (Fig. 10-18). It is important to recognize the intradural- 12. Morgan JR Atilola M, Bailey CS: Vertebral canal and spinal cord mensuration. A
comparative study and its effect on lumbosacral myelography in the Dachshund and
extramedullary location of arachnoid cysts so they can be differen- German shepherd dog. I Am Vet Med Assoc 19l:951-957, 1987.
tiated from nonsurgical intramedullary lesions such as hydromyelia
13. Pardo AD, Morgan IP: Myelography in the cat: A comparison of cisternal versus
or syringomyelia. The intramedullary-extramedullary sign in this
lumbar puncture, using metrizamide. Vet Radiol 29:89 95, 1988.
instancediffers from that of a mass lesion (e.g.,neurofibroma) in
which a filling defect is present, as well as subarachnoid dilation. 14. Shores A; Spinal trauma: Pathophysiology and management of traunatic spinal
injuries. Vet Clin North Am Small Anim Pract 22:859-888, 1992.
Arachnoid cysts that arise from causesother than previous trauma
or surgery are commonly located in the dorsal aspectof the cervical 15. Prata R: Neurosurgical treatment of thoracolumbar discs: The rationale and value
subarachnoidspace.t*' tt of laminectomy and concomitant disc removal. J Am Anim Hosp Assoc 17:17-26,
1981.
16. Griffiths IR: The extensive myelopathy of intervertebral disc protrusion in dogs
References ("the ascendingslndrome"). I Small Anim Pract 13:425 437,1972.
1. Hoerlein BF: Canine Neurology: Diagnosis and Treatment, 3rd ed. Philadelphia, 17. Morgan JP, Miyabayashi T: Degenerative changes in the vertebral column ofthe
\\rB Saunders,1978,pp 470 560. dog: A review of radiographic findings. Vet RadioI 29:72-77, 1988.
2. DeLahunta A: Veterinary Neuroanatomy and Clinical Neurology, 2nd ed. Philadel- 18. Felts JF, Prata RG: Cervical disc disease in the dog: Intraforaminal and lateral
phia, WB Saunders,1983,pp 186 188. extrusions. I Am Anim Hosp Assoc 19:755 760, 1983.
3. Trotter EJ: Canine intervertebral disc disease.In Kirk RW (ed): Current Veterinary 19. Widmer WR, Blevins WE: Veterinary myelography: A review of contrast media,
Therapy VI. Philadelphia, WB Saunders, 1977, pp 841-848. adverse effects and technique. J Am Anim Hosp Assoc 27:163 177,1991.
.{. Kirberger RM, Roos CL Lubbe AM: The radiological diagnosis of thoracolumbar 20. Olby Nl, Dyce l, Houlton IEF: Correlation of plain radiographic and lumbar
disc diseasein the dachshund. Vet Radiol Ultrasound 33:255 26I, 1992. myelographic findings in thoracolumbar disc disease. J Small Anim Pract 35:345
350, 1994.
5. Seim HB, Withrow SJ: Pathophysiology and diagnosis ofcaudal cervical spondylo-
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I8:24I 251, 1982. Anim Pract 23:307-329. 1993.
126 AXIALSKELETON
22. Burk RL: Problems in the radiographic interpretation ofintervertebral disc disease 51. Kirberger RM, Jacobson LS, Davies lV, Engela l: Hydromyelia in the dog. Vet
in the dog. Probl Vet Med Interyert Disc Dis 1:381-481, 1989. Radiol Ultrasound J8:30-38, 1c97.
23. Sande R: Radiography, myelography, computed tomography and magnetic reso- 52. Cook lR lr: Fibrocartilaginous embolism. Vet Clin North Am Small Anim Pract
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24. Wood AKW: Iohexol and iopamidol: New non-ionic contrast media for myelogra- 53. Oliver JE, Lotenz MD, Kornegay IN (eds): Handbook of Veterinary Neurology,
phy in dogs. Comp Contin Edu Pract Vet 10:32-36, 1988. 3rd ed. Philadelphia, WB Saunders, 1997, p I22.
54. Cambridge AJ, Bagley RS, Britt LG, Silver GM: Radiographic diagnosis: Arachnoid
25. Widmer WR, Blevins WE, Cantwell HD, et al: Iohexol and iopamidol myelography
cyst in a dog. Vet Radiol Ultrasound 38:434-436, 1997.
in the dog: A clinical trial comparing adverse effects and myelographic quality. Vet
R a d i o l33 :3 2 7 -3 3 J,1 s9 2 . 55. Bendey JF, Simpson ST, Hathcock JT: Spinal arachnoid cyst in a dog. J Am Anim
Hosp Assoc 27:549-551, 1991-
26. Lamb CR: Common difficulties with myelographic diagnosis of acute interyerte-
bral disc diseasein the dog. J Small Anim Pract 35:549-558, 1994.
27. Weber WJ, Berry CR: Radiology corner: Determining the location of contrast m Ouestions
medim on the canine lumbar myelogram. Vet Radiol Ultrasound 35:430431' 1994'
28. Tilmant L, Ackerman N, Spencer CP: Mechanical aspects of subarachnoid space l. In non-chondrodystrophic breeds, intervertebral disc diseaseis
puncture in the dog. vet Radiol 25:227-232, 1984. tlpified by
29. Kirberger RM, Wrigley R: Myelography in the dog: A review of patients with A. Chondroid degeneration.
contrast medium in the central canal. Vet Radiol 3:253-258, 1993. B. Fibroid degeneration.
30. Wright JA, Jones DGC: Metrizamide myelography in sixty-eight dogs. J Small C. Severeneurologicsigns.
Anim Pract 22:415 436,198I- D. Disc prolapse atTl2-13 and T13-L1.
31. Adams WM: Myelography. Vet Clin North Am 12i295-3ll' 1971- E. All of the above
F. None ofthe above
32. Suter PR Morgan IR Holliday TA, O'Brien TR: Myelography ofthe dog: Diagnosis
of tumors of the spinal cord and vertebrae Vet Radiol 12:2943' 1971.
2. Which of the following is correct with respect to the canine
33. Funquist B: Thoraco-lumbar myelography with water-soluble contrast medium in spinal cord?
dogs. I. Technique ofmyelography; Side effects and complications. J Small Arim Pract
3:53-66,1962.
A. The conus medullaris ends caudal to L6 in large-breeddogs.
B. In the lumbar region, the cord segmentslie caudal to the
34. Funquist B: Thoraco-lumbar myelography with water-soluble contrast medium in
corresponding vertebral segment.
dogs. IL Appearance of the myelogram in disc protrusion and its relation to functional
disiurbances and pathoanatomic changes in the epidural space. J Small Anim Pract C. The pia is the thinnest meningeal layer and covers the
3 : 6 7 7 3 ,1 9 6 2 . spinal cord.
35. Ticer J, Brown Sl: Water-soluble myelography in canine htenertebral disc protru-
D. The ratio of spinal cord-to-vertebral canal is highest in the
sion. Vet Radiol 15:3-9, 1974- cervical region.
E. None of the above
36. Morgan JR Suter PF, Holliday TA: Myelography with water-soluble contrast me-
dium: Radiographic interpretation of disc herniation in dogs. Acta Radiol F. All of the above
3 I 9 (suppl) :2L7-23 0, 1972.
37. Matteucci ML, Ramirez O 3rd, Thrall DE: Radiographic diagnosis: Effect of right
3. Regarding the pathophysiology of intervertebral disc hernia-
vs. left lateral recumbency on myelographic apPearance of a lateralized erlradural tion, which of the following is correct?
mass. Vet Radiol Ultrasound 40:351-352,1999' A. The cord can better withstand slow deformation than ex-
38. Mattoon JS,Koblik PD: Quantitative survey radiographic evaluation ofthe lumbo- plosive concussion.
sacral spine of normal dogs and dogs with degenerative lumbosacral stenosis' Vet B. Typ" I lesions tend to cause more acute injury than type
Radiol Ultrasound 34:194 206, 1993. II lesions.
39. Lang I: Flexion-extension myelography canine caudal equina. Vet Radtol 29:242- C. Tlpe II lesions are a result of fibroid degeneration.
257, t988. D. Pathologic changesare causedby mechanical disruption of
40. Selcer BA, Chambers JN, Schwensen K, Mahaffey MB: Epidurography as a diag- the cord and by chemical and vascular alterations.
nostic aid in canine lumbosacral compressivedisease:47 cases(1981-1986). Vet Comp E. All of the above
Orthop Tiauma 29:97-103, 1988. F. None ofthe above
41. Stickle RL, Hathcock JT: Interpretation of computed tomographic images. Vet
Clin North Am 214L7-435, 1993. 4. Name three technical considerations that engender good-qual-
42. Feeney DA, Fletcher TF, Hardy RM: Atlas of Correlative Imaging Anatomy of the ity radiographs of the vertebral column.
Normal Dog. Philadelphia, WB Saunders, 1991.
43. Sharp NJ, Cofone M, Robertson ID, et al: Computed tomography in the evaluation 5. What are four suiley radiographic,signs of intervertebral disc
of caudal cenical spondylomyelopathy of the Doberman phscher. Vet Radiol 36:100- disease?
108, 199s.
44. Iones JC, Wilson ME, Bartels JE: A review of high resolution computed tomogra- 6. Which is true regarding disc mineralization?
phy and a proposed technique for regional examination of the lumbosacral spine. Vet A. Disc mineralization begins peripherally and extends cen-
Radiol 35:339-346,1994. trally.
45. Morrison WB: Cancer affecting the nervous system. In Morrison WB (ed): Cancer B . Disc mineralization is a dystrophic change.
in Dogs and Cats-Medical and Surgical Management. Philadelphia, Willims & Disc mineralization and disc prolapse are synonymous,
Wilkins, 1998, pp 6s5-666. D. Only the annulus fibrosus undergoes mineralization.
46. Luttgen PJ, Braund KG, Brawner WR, Vandevelde M: A retrospective study of E, All of the above
twenty-nine spinal tumours in the dog and cat. J Small Anim Ptact2l:2134'16' 1980' F. None of the above
47. Luttgen Pl: Neoplasms of the spinal cord. Vet Clin North Am Small Anim Pract
22:973-984, 1992. 7. Which is true regarding myelographic technique?
48. Waters DJ, Hayden DW: Intramedullary spinal cord metastasis in the dog. I Vet A. Iodinated ionic contrast media like meglumine diatrizoate
Intem Med 4:207 2f5.1990. are safe and efficacious for myelography.
49. Dallman ML Saunders GK: Primary spinal cord lymphosarcoma in a dog. I Am
B. Cervicai myelography is accomplished by puncture of the
Vet Med Assoc 189:1348-1349,1986. ventral subarachnoid space.
C. Lumbar myelography can be most easily accomplished by
50. Oliver IE, Lorenz MD, Kornegay IN (eds): Handbook of Veterinary Neurology,
3rd ed. Philadelphia, WB Saunders, 1997, pp 162-163. puncture ofthe dorsal subarachnoid spaceat L4-5 or L5-6.
The EquineVertebralColumn 127
Figurc 1O-19
D. The normal myelogram is characterized by uniform, thin 9. What is the causeof the opacification iust dorsal to the dorsal
contrast columns and uniform cord width, except at the subarachnoid spacear L5-6 ofFigure l0-7C?
cervicaland lumbar resions.
E. All of the above
F. None of the above 10. Type I disc lesions often causeintramedullary swelling as well
as an extramedullary pattern. Which type of myelographic
8. The myelogram shown in Figure 10-19 was obtained from a pattern is most typical of tlpe II disc herniation?
7-year-oId, female, mixed-breed dog with neck pain. What
type of myelographic pattern is present? Answers begin on page 727.
CHA P T E R
11
The Equine Vertebral Golumn
. RussellL. Tircker I Patrick R. Gavin
High-quality radiographs of the equine cervical spine may be the spine require general anesthesiaand higher output systems.If
obtained using portable x-ray machines and fast intensifying available,computed tomography {CT) can be uery uieful ior evalu-
screens, and many referral centers have equipment capable of ation of the cranial cervical spine in adult horses, and of more
imaging the entire vertebral column. Lateral views of the cervical caudal segmentsin foals. The limitations of CT include the require-
and thoracic spine may be obtained with the patient standing in a ment of generai anesthesiaand the inability to position all spinal
normal position, but if a iong exposure time is required because segments into the imaging gantry. Personnel and patient safety,
of thick body parts, motion blurring often decreasesthe amount radiographic quality, and the likelihood of findine a lesion should
of information obtained from the examination. Diagnostic lateral always be weighed carefully before an examinati6n of a standing
r.iews of the thicker regions and virtually all ventrodorsal views of or anesthetizedhorse is performed.
I28 AXIALSKELETON
Figufe 1I-1. A, Lateralmyelogramof the midcervicalarea in flexed position.Largearrows, Dorsalaspect of contrastmedium column. Smallarrow, Normal
becausethe dorsalas pec tof the
l sp e cto f th e co n tr a stm e d iu mco lu m nd uri ngfl exi on.Therei s no evi denceof spi nalcord compressi on,
t hinn i n go f t h e v e n t r a a
column is wide at the locationof ventralthinning(the vertebraeare C3 through C5). B, Lateralmyelogramof the caudalcervicalarea ln extendedposition.The
ventralaspectof the contrastmedium column dorsalto the intervertebral disc space at C5-6 (arrow)is thinnerthan the ventraland dorsalaspectsat other sites
(arrowheads), but the dorsalaspectis wide, makingthe clinicalsignificanceof the ventralnarrowingunlikely.
The EquineVertebralColumn l2g
I Traumatic lesions
Fractures may occur anl.r,vherealong the vertebral column but
are more common in the cervical area, particularly in foals with
cartilaginous physes.r8Fracture and remodeling of the cervical
spine have been associatedwith forelimb lameness in which no
lesions were suspectedor detected in the distal limbs.te In other
s€gments of the spine, fractures are a diagnostic challenge if the
displacement of bone fragments is minimal, which is common
becauseof the strong paraspinal musculature. The complex shape
of the vertebrae and the excessivethickness of a horse's baik
further reduce the sensitivity of radiography for the detection of
fractures. Fractures of the dorsal spinous Drocessesof the withers
after a backward fall have been iescribed and are usually not
associatedwith neurologic deficitsr8(Fig. l1- ).
If the history and clinical signs suggest a spinal fracture at a
location that could be difflcult to confirm radiographically, bone
s-cintigraphy may be used to support the diagnosis and guide
further radiographic examination. Bone scintigraphy has been ad-
vocated as a screening technique for osseouslesions of the spine
Figure 11-2. A, Lateralradiographof the cranialcervicalsegment in a foal prior to radiographyunder generalanesthesia.20
with ataxiadue to atianto-axial
In selectedregions,
malformation. Thereis a deformedC1 vertebrae.
T h e d e n s ( o d o n t o dp r o ce sso f C2 ) is d isp la ce dve n tr a lto the body of C l ultrasound may be useful to confirm displaced fractures of the
(arrow),and smallosseousfragmentscan be seen betweenthe ventralaspect vertebralspinous processes.
of C1 and the dens (arrowheads).The occipital condyles and the C3-C4
v e r t e b r asl e g m e n t sa p p e a rn o r m a l.B, L a te r am
l ye lo g r a mo f the crani alcervi cal
a r e a i n t h e s a m e f oa l in n e u tr a lp o sitio n T . h e ve n tr a la sp e ctof the contrast
I Acquired lesions and lesions
m e d i u mc o l u m nd o rsa to l th e in te r ve r te b r d a isc
l sp a ceis th n, and the dorsal
aspectof the column is nearlytotallyobliteratedat the C1-C2 lunclton(arrow- I of unknown etiology
h e a d s )T. h e r ei s e n la r g e m e not f th e d o r sa la sp e cto f th e su barachnoispace d
within the body of C'1. Sacroiliac subluxation is reported as a cause of back pain in
horses.13'2t'22The sacroiliacjoint cannot be seenclearly on radio-
graphs because of its obliquity relative to the x-ray beam on
conventional projections. The sensitivity and specificity of radiogra-
of the axis, which may resemble an atlasl5 (Fig. 11-2). Clinical phy for the detection of this condition are low Bone scintigraphy
signs of cranial cervical compressive myelopathy may be recognized provides a more sensitivemethod by which to evaluate the sacroil-
shortly after birth, or later, as acute or progressive ataria and are iac joints in horses,and it does not require generalanesthesia.r3
usually more pronounced than are clinical signs in most horses Thoracolumbar spondylosishas been observed in old horses,
with cervical vertebral malformation s)'ndrome.I6 with or without clinical signs of back pain.r3,22As in dogs and
people, the clinical significance of this finding is difficult to derer-
I Infectious lesions mine radiographically.
Overlappingof the dorsal spinous processesof the thoracolum-
A common infectious lesion of the spine in horses is osteomyelitis bar segmenthas been suggestedas a causeofback pain, particularly
of the dorsal spinous processesof the cranial thoracic vertebrae as in jumpers.r3'" Radiographicsignsinclude narrowing of the inter-
an extension of infectious supraspinousbursitis (fistulous withers). spinousspacewith remodelingof adjacentdorsal spinousprocesses
Often, the infection is limited to the supraspinous bursa and and pseudoarthrosis.Fusion of adjacent dorsal spinous processes
surrounding soft tissues.It is often difficult to determine whether is rare.r3 Although these radiographic signs are easily identified,
osteomyelitis is present becausethe separateossification centers of their clinical significance is difficult to determine because they
the dorsal spinous processesin the affected area are normally are also seen in clinically normal horses.r3, ,, Soft-tissueinjury is
irregular and mottled, which mimics bone inflammation. In addi- undoubtedly the most common cause of back pain in the horse,r,
tion, it is normal for there to be periostealbone proliferation at and there may be a tendency to place too much significance on
the insertion of tendons and ligaments on the spinous processes. radiographically visible osseouschanges.As in most instances,the
Therefore, one should search carefully for lysis of the body of the significance of any radiographic findings should be determined
spinous process or for aggressiveperiosteal reaction to confirm a clinically.
diagnosis of osteomyelitis in that area. If available,bone scintigra-
phy is more sensitive and specific than radiography for the detec-
tion of osteomyelitis(Fig. 11-3). Brucellaspp., possiblezoonoses, I Ataxia
should be ruled out with appropriate tests. The differential diagnosis of ataxia in horses is extensive and
The diarthrodial joints of the spine may become secondarily includes compressiveand noncompressivemyelopathies.I', The
involved during septicemia in foals, and vertebral osteomyelitis cervical vertebral malformation-instability syndrome (wobbler dis-
I3 0 A X I A LS K E L ET ON
ease)is the most common causeof equineataxia,rand antemortem firm spinal cord compression.3'12'18If available, contrast-enhanced
confirmation of the diagnosis is based on radiographic examina- CT yields the most sensitiveevaluation and qualitative information
tion.r e'tt Survey radiographicvertebrai measurementindices have regarding the source,severity,and location of spinal cord compres-
been proposed as sensitiveindicators by which to screenfor cervical sion.lr
vertebral malformation s)'ndrome.24Semiquantitative radiographic In a study including 309 ataxic horses, 587o had myelographic
indicators were reported to be an accurate method of diagnosing evidence of a compressivespinai cord lesion.3 In decreasingorder
and predicting cervical vertebral malformation in Thoroughbred of frequency, the most common sites of compression were C3-C4,
foals up to 1 year of age.2sDefinitive antemortem diagnosisrequires C6-C7, C5-C6, and C4-C5, tn 32o/o,77o/o,74o/o,and 11oloof a1l
myelography to accuratelyidenti$u the actual sitesofcord compres- horses, respectively.Two compressivelesions were seen in 17o/oof
1 1 ,2 6 ,2 7 these 309 ataxic horses, and lo/o had evidence of spinal cord
s i o n .3 ,4 ,
Cranial cervical and caudal cervical radiographs in neutral and compression at threesites.
flexed positions should be included in both survey and myelo- The mechanisms leading to the myelopathy in cervical vertebral
graphic examinations. Myelographic examination should also in- malformation-instability syndrome are not fully understood. In
clude a caudal cervical view in extended position because most many patients, repetitive trauma to the spinal cord appears to be
dorsal compressivelesionsare seenat C6-C7 and C7-T1.' causedby positional narrowing of the vertebral canal, which sup-
Survey ridiographs are examined for the following changes:(1) ports the premise that evaluation of dynamic changesis extremely
remodeling of the caudal aspect of the floor of the vertebral important in myelography. Stretching of the spinal cord against
canal, (2) proliferative responseat the articular processes,and (3) remodeled bone may also be incriminated in the pathogenesis
apparent narrowing of the vertebral canal in neutral, flexed, or of the myelopathy, and absence of myelographic signs of cord
extendedposition3(Figs. ll-5 and 11-6). Significantbone remod- compression may not preclude a diagnosis of cervical vertebral
eling of the vertebrae may occur without myelographic evidence of malformation-instability syndrome.tt,L Although intervertebral
spinal cord compression,and soft-tissue lesions, including synovial disc herniation has been reported in horses,the condition is rare
cysts and hypertrophy of the dorsal longitudinal ligament, may and other causesof extradural compression should be considered.
cause spinal cord compression with no abnormalities visible on Extradural lateral compressivelesions are exceedinglyrare.3They
survey radiographs.' Therefore, myelography is warranted to con- should cause widening of the spinal cord as well as narrowing of
',to t
Figure 114. Lateralradiographof the dorsal midthoracicarea of a horse
fol l ow i nga fal l on the w i thers.The dorsalaspectsof the spi nou sproc es s esof
T4 throughT8 are fractured.
The E qui neV ertebraColum
l n lgl
F i g u r e 1 1 - 5 ' A , L ar e r a lr a d io g r a p h o fth e cr a n ia lce r vicai areaofanataxi cA rabi anfl l y.Theaxi si seasi l yrecogni zedbyi tsl argedors al s pi nous proc es s (a).
There is mild remodelingof the caudalaspect of the floor of the vertebralcanalof C3, apparentlyreducingits dorsoventraldiameter (openarrow). B,
Lateral
m y e l o g r a mo f t h e m i d ce r vicaalr e ao f th e sa m e h o r sed u r n g fl exi onof the neck.B oth dorsaland ventralaspectsof the contrastmedi umcolumnare narrow ed
at the level of the cranialend plate of C4 (smallarrows),indicalingdynamicspinalcord compression(therewas no narrowingof the column on other views).
At
C4-5 (largearrow),rhere is no alterationof the dorsa aspectof the contrastmedium column;thus, the apparentventralcompiessionis likelyinsrgnificant.
24. Moore BR, Reed SM, Biller DS, et al: Assessmentof vertebral canal diameter and
the contrast medium column on the lateral view. They are difficult bony malformations of the cervical part of the spine in horses with cewical myelopa-
to confirm with ventrodorsal views becauseof numerous superim- thy. Am I Vet Res 55:5, 1994.
oositions and increased scattered radiation' both of which reduce
25. Mayhew I, Donawick W, Green S, et al: Diagnosis and prediction of cervical
iadiographic detail.'?8Contrast-enhanced CT has proved useful for vertebral malformation in Thoroughbred foals based on semi-quantitative radio-
docuirenting lateral compressivelesions of the spinal cord caused graphic indicators. Equine Vet J 25:435, 1993.
by malformed articular processes.rr 26. Neuwirth L: Equine myeolography. Comp Contin Educ Pract Vet 14i72, 1992.
A large proportion of ataxic horses do not have radiographic
27. Moore BR, Granstom DE, Reed SM; Diagnosis of equine protozoal myelitis and
signs oiceiviial vertebral malformation-instability syndrome;
ceryical stenotic myelopathy. Comp Contin Educ Pract Yet 17:419, 1995.
th-erefore,the numerous other causesof cervical spinal cord dis-
eases should always be considered in the differential diagnosis' 28. Foss RR, Genetzky RM, RiedeselEA, et al: Cervical intervertebral disc protrusion
in two horses.Can Vet I 24:188,1983.
Equine protozoal myeloencephalitis and herpes virus type 1 mye-
loencephalitis may have clinical signs that partially,mimic cervical 29. Granstrom DE, Dubey JR Davis SW et al: Equine protozoal myeloencephilitis:
antigen analysis of cultured S. neurona merozoites. J Vet Diagn Invest 5:88, 1993.
vertebial malformation but lack radiographic and myelographic
abnormalities. In such patients, analysisofserum and cerebrospinal 30. Wilson WD: Equine herpesvirus 1 myeloencephalopathy.In Reed SM, Bayly WM
fluid provides information about exposure to Sarcocystisneurona (eds): Equine Internal Medicine. Philadelphia, WB Saunders, 1998.
3. PapageorgesM, Gavin PR, Sande RD, et al: Radiographic and myelographic 2, In horses, adverse postmyelographic reactions commonly re-
exa-iratLt if the cewical vertebral column in 306 atuic horses' Vet Radiol 28:53'
1987.
ported with metrizamide include:
A. Seizures.
4. Rantanen NW, Gavin PR, Barbee DD, et al: Atdia and paresis in horses: II'
B. Intensification of preexisting neurologic signs.
Radiographic and myelographic examination of the cervical vertebral column' Comp
Contin Educ Pract Vet 3:161, 1981. C. Prolonged recovery.
D. All of the above.
5. Nyland TG, Bl)the LL, Pool RR, et al: Metrizamide myelography in the horse:
Clinical, radiographic, and pathologic changes Am t Vet Res 41:204, 1980
6. Beech ): Metrizamide myelography in the horse. t Am Vet Radiol Soc 20:22' 1979'
3. True or False.Flexed and extended position views are used in
equine cervical myelography becausemost compressivelesions
7. Nlxon AJ, Stashak TS, Ingram JT: Diagnosis of vertebral malformation in the
horse. proceedings of the Annual convention of the American Association of Equine
in the horse are dynamrc.
V o l 2 8 , 1 9 8 3 'p 253.
Pr a c l i ti o n e rs.
8. Conrad RL: Metrizamide myelography of the equine cervical spine' Vet Radiol 4. Occipitoatlantoaxial malformation is an apparently inherited
25:73, 1984. sl,'ndromein:
9. Foley JR Gatlin SJ, Selcer BA: Standing myelography in sir adult horses Vet A. Arabians.
Radiol 27:54, 1986. B. Quarter horses.
10. Widmer WR, Blevins WE, Jakotevic S, et al: A ProsPectiveclinical trial compar-
C. Thoroughbreds.
ing metrizamide and iohexol for equine myelography. Vet Radiol Ultrasound 39:106' D. Walking horses.
1998. E. Draft horses.
11. Moore BR, Holbrook TC, Stefanacci JD, et al: Contrast-enhanced computed
tomography and myelography in six horses with cervical stenotic myelopathy' Equine 5. Which bacteria must be considered in horses with fistulous
Yet I 24t).97, 1992.
withers becauseof the zoonotic potential?
12. Tomrzawa N, Nishimura R, Sasaki N, et al: Relationship between radiography of A. Staphylococcrsspp.
cervical vertebrae and histopathology of the cervical cord in wobbling 19 foals J Vet
B. Pseudomonasspp.
Med Sci 56:227, 1994.
C. Escherichiacoli
13. Ieffcott LB: Disorders of the thoracolumbar spine of the horse: A survey of 443
cases.Equine VetJ 121197,1980.
14. Mayhew LG, Watson AG, Heissan JA: Congenital occipitoatlantoaxial malforma-
tions in the horse. Equine Vet J 10:103, 1978.
15. Stickles R: The equine skull. In Thrall DE (ed): Textbook ofVeterinary Diagnostic
Radiology, 3rd ed. Philadelphia, WB Saunders, 1998.
16. Delahunta A: Veterinary Neuroanatomy and Clinical Neurology, 2nd ed' Philadel-
p h i a . WB S a u n d e rs.1 9 8 3 .P 215.
17. Adams SB, Stickel R, Blevins W: Diskospondylitis in five horses J Am Vet Med
Assoc 186;270,1985.
18. Nlxon AI: The wobbler slndrome. In Stashak TS (ed): Adams' Lameness in
Horses, 4th ed. Philadelphia, Lea & Febigel 1987.
20. Steckel RR: The role of scintigraphy in the lameness evaluation' Vet Clin North
Am Equine Prcct 7i207, 1991.
21. Jeffcott LB: Pelvic lameness ir the horse Equine Pract 21:L' 1982'
22. Jeffcott LB: Diagnosis of back problems in the horse Comp Contin Educ Pract
vet 4:s134, 1981.
23. Tucker RL, Schneider RK, Ragle CA, et al: Bone scintigraphy in the diagnosis of
sacroiliac injury in 12 horses. Equine Vet J 30:390, 1998.
Figure I 1-7
The E qui neV ertebral
Colum n 133
D. Brucella spp.
E . Streptococcusspp.
--"".
t
--- " .,
,'*;
ll9l,,.lll
liilUll'
APPENDICULARSKELETON-
CANINEAND FELINE
CHA P T ER
12
lnterpretation Paradigms for the
Appendicular Skeleton-Qan ine
and Feline
. Clifford R. Berry . Nancy E. Love . Donald E. Thrall
I Overview osteoblast lays down osteoid, its capability for further osteoid
formation decreases;at this point, the cell is called an osteocyte.
Radiographic evaluation of the small animal appendicular skeleton
Osteocytesare the most plentiful cells found in mature bone, and
is based on the basic four-step process (detection, description,
they are interconnected by a complex system of tunnels called
differentialfor abnormal or deviation from normal, and diagnosis)
canaliculi.t-
outlined in Chapter 5. The purpose of this chapter is to provide
Osteoclastsare multinucleated (n : 6 to 12 nuclei) cells formed
an overview and a framework to build on relative to the other from circulating mononuclear precursors.r',Typically, osteoclasts
chaptersin dealing with evaluation of small animal musculoskeletal
align along a shelf of bone. As the osteoclaststarts the resorption
radiographs. Some information will be redundant but it is critical process,it forms a resorption pit and secreteslysosomal enzyrnes
to understandthesebasic concepts.The reader should be able to
and hydrogen ions into a secondary lysosome along the bone
apply the basic interpretation paradigm or models presentedin this
surface. This initiates the breakdown of the inorganic and organic
chapter to any radiographic study of the small animal appendicular
matrices of bone. Byproducts of this breakdown process, such as
skeleton. A basic concept is the fact that bone is continuously calcium and phosphorus, can be absorbedby the osteoclastand
remodeling throughout the animal's life, and under normal cir- then releasedon the other side of the cell, thereby contributing to
cumstances(appropriatestressesand biomechanics),bone remod- the maintenance and balance of these minerals throughout the
eling provides a balancebetweenproduction and resorption.t''? body. Osteoblastsand osteoclastsact in coordination and are con-
sidered a functional unit known as the basic multicellular unit.
I Bone formation During skeletalgrowth and maturation, bone production predomi-
nates,but as the animal matures and bone growth ceases,a balance
From an embryologic standpoint, all bone is derived from meso- resultswherebybone production equalsbone resorption.a,s
derm.t Initial bone formation is derived from precursor mesenchy- Bone is formed through a processof mesenchymalmodels.',n
mal cells that align themselveswith each other. This results in cell- One model is endochondral ossification, in which mesenchymal
to-cell contact and local humoral interaction, Ieading to cellular progenitor cells first differentiate into a cartilaginous model that
differentiation. The osteoprogenitor cells are pluripotential mesen- forms the framework from which bone is formed. Durine endo-
chymal cells that have the capacity to differentiate into osteoblasts, chondral ossification, cartilage cells (chondrocytes) matureihyper-
chondroblasts,fibroblasts,and other hematopoieticprogenitor trophy, undergo mineralization within the matrix secretedby the
cells; these in turn give rise to monocytes, macrophages, and chondrocytes, and ultimately die. This area of cell death forms
osteociasts.ra the scaffolding for ingrowth of blood vessels(angiogenesis) and
The osteoblast is the primary precursor cell responsible for osteoprogenitor cells that differentiate into osteoblasts.In a long
bone development and the synthesis of osteoid, the proteinaceous bone, the model of endochondral ossification is located in the
organic matrix of the skeletal system. Synthesizedproteins include physis and metaphysis, and this is where active bone formation
type I collagen, which accounts for 90o/oof the organic component takes place. The metaphysis is also called the primary center of
of the normal bone matrix. As bone matures,the organic osteoid ossification.
matrix becomes mineralized. The blend of osteoid (35olo)and In a tlpical long bone, the shaft is called the diaphysis. Pro-
inorganic matrix (65%) accounts for the basis of normal bone gressingaway from the diaphysis is the metaphysis,the physis, and
strengthand hardness.The inorganic matrix is made up of calcium then the epiphysis (Fig. 12-l). The physis is the cartilaginous
hydroryapatite [Ca'o(PO")u(OH),],and the specific details of its model that leads to the development of metaphysealbone. Within
formation are not well understood. The rate of mineralization can each epiphysis, a secondary center of ossification develops from a
vary, but there is normally a 12- Io 15-day lag time between osteoid cartilaginous model. As this secondary center of ossification devel-
formation and mineralization of the matrix. As the immobile ops, the physis is essentially trapped between the epiphysis and
r35
I3 6 S KE L ET ON -C A N INAN
A P P E NDI CU L AR E D FE LIN E
beyond the growth period of the animal and are a primary source
for osteogenesisduring fracture repair.2'a
Another model of bone formation is intramembranousossifica-
tion, whereby mesenchymalprogenitors differentiate into a layer of
fibrous tissue, which then undergoes further differentiation into
a Intramembranous ossification occurs in the skull. It
osteoblasts.'z,
is important to remember that ossification is a process by which
the organic matrix is produced with subsequentmineralization of
the inorganic matrix.
As the primary spongiosa(metaphysis)is replacedby new bone
through the remodeling process,a more organized pattern of colla-
gen and inorganic matrix deposition occurs, and this layered ap-
pearance can be seen histologically. This type of bone is called
iamellar bone. There are four different types of lamellar bone,
including circumferential lamellae (found just beneath the perios-
teum and endosteum), concentric lamellae (around which ha-
versian canalsand systemsare formed), interstitial lame1lae(found
between concentric lamellar and haversiansystems),and trabecular
lamellae. Radiographically, the bone cortex is made up of circum-
ferential (outer and inner layers), concentric, and interstitial lamel-
1ae. Within the cortex, or the intramedullary space, there is a
trabecular lamella that can be seen radiographically. In the young
animal, the trabecular lamella is present in the epiphysis and
metaphysisand extends toward the central diaphysis.As the animal
ages and growth stops, this trabecular pattern recedes from the
diaphysis and metaphysis. The trabecular pattern often thickens
when one reachesthe end ofthe epiphysis,just beneath the articu-
lar cartilage.This thicker area of bone beneaththe articular carti-
lage is called subchondralbone. Thesepatternsof cancellousbone
development are specific to the bone, the species,the age of the
animal, and the individual, depending on the abnormal stresses
Figure 12-3. Folding pathologic
fractures
of the femursecondary to nutri-
applied to the bone. Thesecancellouspatterns continue to change tionalhyperparathyroidism.
Thiscatwas raisedon a rawmeatdiet,andthe
as the animal matures, with a lack of cancellous bone in the calciumphosphorusratiowasabnormal. Therelativeosteopenicappearance
diaphysis of an adult long bone. andthe foldingcorticafractures
aresecondary to lackof normalinorganic
osteoidwthinthe bones. Thefracture
is healedin an abnormalanole:thisis
called
malunion.
I Maintaining healthy bone
Detailed concepts of calcium and phosphorous metabolism are
beyond the scope of this chapter. Recognizethat there exist several should be remembered that after maturity, the skeletal system
hormonal regulatory mechanisms that are responsible for homeo- continues to turn over, but the rates of resorption and production
stasisof calcium and phosphorusmetabolism.3Bone representsthe are equal, so there is no net gain or loss of bone. According to
storehouse for 99o/oof the body's calcium and 850/oof the body's Wolff's law, bone will respond according to the principal stresses
phosphorus. The primary organs and glands involved in regulation and strains placed on it. This inciudes periosteal,cortical, subchon-
of calcium are the kidneys, liver, intestinal tract, and parathyroid dral, endosteal,and cancellousremodeling according to new
glands. There are two pairs of parathyroid glands: An internal stressesand strains placed on the bone.sIn a diseasedbone, the
gland is embedded in the thyroid gland, and an external parathy- response is typically a combination of bone lysis (leading to in-
roid gland is located along the caudal aspect of the thyroid gland. creasedradiolucencyon the radiograph)and bone formation (lead-
The major hormone produced by the parathyroid giands is para- ing to sclerosison the radiograph). Lysis or sclerosisresults from
thormone (PTH), which increasesplasma calcium 1eve1s by: a local imbalancein the ratio of bone production to bone removal.
Becausebone responseto many diseasesis simi-lar,a specificdiag-
. Activating osteoclastsand thereby mobilizing calcium from bone
nosis is usually not possible based strictly on the radiographic
. Increasing renal tubular reabsorption of calcium and renal tubu-
abnormalitiesdetected.
lar secretionof phosphorus
. Increasing conversion of Vitamin D3 to the active dihydrorT form
. Increasing calcium absorption from the gastrointestinal tract.3'a I Interpreting bone radiographs
Enhanced secretion of parathyroid hormone (primary hlper- In reviewing bone radiographs, the first question the interpreter
parathyroidism, nutritional/renal secondary hyperparathyroidism) must answer is whether a particular finding is normal, a projection
or parathyroid-likehormone (lymphoma, anal saccarcinoma)leads artifact based on positioning of the bone rllative to the primary x-
to skeletal demineralization with radiographic visualization of gen- ray beam, a normal variant, or a true abnormality.u,tt
eralized skeletalradiolucency and subsequentpathologic folding or When it is decided that a bone change is abnormal, the next
compressionfracturesro(Fig. 12-3). step should be to assessthe aggressiveness of the iesion. Lesions
Calcitonin, which is basically an antagonist to the effect of that are not aggressivemay represent a window into past events
parathyroid hormone, is secreted by the C cells of the thyroid that are unrelated to the animal's current condition, and invasive
gland. Calcitonin inhibits further calcium resorption from bone procedures aimed at identi$zing the specific cause of the benign
and in the short term Dromotesbone formation. Calcitonin also lesion may not be necessary.Whether a lesion is aggressiveor
stimulates phosphorouJ excretion. 1,25-dihydrory-Vitamin D. is not is based on the specific appearance of the osteolltic and
responsiblefor calcium absorption from the gastrointestinal tract.l osteoproductiveresponses. In a nonaggressive or benign lesion,the
A bone can respond to injury in a limited number of ways. It radiographic changes are chronic or degenerative, or may have
I3 8 S KE L ET ON -C A N INAEN D FE LIN E
A P P E NDI CU L AR
Figure 12-6. Moth-eatenosteoysis in a dog with metastaticneoplasiaof Figure 12-7. Smooth periostealnew bone formationalongthe caudalcor-
the humerus. tex of the humerussecondary
to a previ ousfracture.Overti me,thi s peri os teal
reactionbecame smooth and contiquouswith the cauda cortex of the hu-
merus.
iz). If one is still undecided,it would be a good idea to obtain teoarthrosis are terms used to summarize radiographic changes
thoracic radiographsat this stageand to re-radiographthe lesion involving a joint but are generic with regard to etiology. Primary
in 10 to 14 days.If the lesion has changed,the aggressive character degenerativejoint diseaseis a condition whereby no inciting factor
of the lesion may be more obvious. can be establishedand the etiology is not determined.This is seen
Aside from whether a lesion is aggressive, lesion location and as an age-relatedchangein the shoulderjoints of dogs. Secondary
the number of bones involved become important in establishing degenerativejoint diseaseis a condition whereby an inciting etiol-
the differential diagnoses.Whether a bone diseaseis monostotic ogy is present, such as an osteochondrosislesion or a previous
(one bone) or polyostotic (multiple bones) drasticallyinfluences articular fracture.
the rule-outs. For exampie, a monostotic metaphysealaggressive The radiographic changesaccompanying degenerativejoint dis-
long bone lesion should be considereda primary bone tumor easecan be characterizedby the soft-tissueand bone responsesto
until proven otherwise.But, a primary bone tumor would not be the degenerativeprocess.First, owing either to a biochemical or a
considered for multiple metaphysealaggressivelesions; infection or biomechanical abnormality the hyaline cartilage is damaged and
metastatic neoplasia is more likely. Specific diseaseentities occur joint instabiiity develops. Inflammation and synovitis result in
within specificlocations; it is incumbent on the student or prac- periarticular soft-tissue swelling or intra-articular effusion, which
titioner to memorize these specific sites as key areasto be evaluated may be seenradiographically.The joint attempts to stabilizeitself
on radiographsof a given joint. Thesediseasesare summarizedin by thickening the supporting ligaments and through synovial hy-
Table 12-1. Other sitesofspecific concernare reviewedin Chapters perplasia.Radiographically,bone changesare the most commonly
13 (Diseases of the Immature Skeleton)and 16 (RadiographicSigns identified changesnoted in associationwith degenerativejoint
of Toint Disease). disease.These changesinclude osteophlte formation, enthesophyte
formation, and subchondralbone thickening (Fig. 12-13). Osteo-
I Evaluating radiographs of a phytes occur along periarticular margins and are regions of new
bone formation that develop through a processof subchondral
I specific ioint bone marrow vascularizationat nonpressurepoints of a joint.
Radiographic evaluation of a joint in small animals consistsof two Enthesopathyis periostealnew bone formation from traction at
orthogonal radiographs,usually a mediolateraland a craniocaudal osseousattachmentsof joint capsule,ligaments,and tendons.Sub-
or dorsopalmar (plantar) view. Becausejoint radiographsin small chondral bone sclerosis occurs when the normally thick hyaline
animals are usually obtained in a non-weight-bearing patient, cartilageno longer actsas a buttressand cannot cushion the impact
joint spacewidth is basically impossible to evaluate unless overtly of opposing bones. Progressivethinning of the hyaline cartilage
subluxated, luxated, or collapsed. results in increasedstressto subchondral bone. As subchondral
The synovial joint is made up of the hyaline cartilage covering bone mass increases,there is a correspondingincreasein radio-
the epiphysealsubchondralbone, the joint capsule,and the syno- graphic opacity. In advanced osteoarthritis, narrowing of the joint
vial fluid that bathes the cartilage with nutrients and oxygen. space consistent with loss of normal hyaline cartilage can be seen
Normal hyaline cartilage is a well-organized layer of chondrocytes radiographically.Osteophytosis,enthesophytosis, and subchondral
with surrounding tlpe II collagen fibers that form a meshwork for sclerosisimply chronicity.
proteoglycans,mucopolysaccharides,and water.+6 Over time, the remodeling associatedwith the degenerative
The responseof the joint and surrounding structuresto damage changesbecomes advanced.If articular cartilage becomes frag-
is complex, and this process is oversimplified in the following mented in the joint and embedded in synovium, it can undergo
d iscussio n.De ge ner at iv ejoint dis eas e,os t eoar t h r i t i s ,a n d o s - endochondralossificationand appearradiographicallyas a miner-
Nonaggressive Aggressive
Metaphyseal-primarybone tumor
1. Location
Diaphyseal-metastasis
Smooth,continuous Interrupted,
variable,spiculated,
amorphous
5. Periosteal reaction
C, cat; D, dog; DJD, degenerative joint disease; SLE,sYstemic lupus erythematosus;>>, more common than.
In terpretati on
P aradi gms
for the A ppendi cul ar
S kel eton-cani nean d Feline l4g
alized intra- or juxta-articular fragment (sometimescalled a joint will be formed in responseto the new stressbeing applied to the
mouse). As articular cartilage thins and fissures develop, synovial bone when the cartilage is failing to do its job.
fluid may be forced between the fissuresand causepressureatrophy Finally, evaluation of the extracapsular and intracapsular soft
of subchondrai bone, resulting in syrovial cyst-like lucencies. tissuesis done. This usually requires a "hot" light. Any form of
soft-tissue swelling is a potential site of underlying bone injury.
The area of the bone beneath the soft-tissueswelling should be
I Interpretation paradigm for evaluated critically for subtle periosteal reactions, areas of oste-
I musculoskeletal radiographs olysis, and articular subchondralbone chanqes.One should also
determine whether or not additional radiographs are required to
The interpretation paradigm for reviewing musculoskeletalradio-
better evaluate the areas in question. Review of the radiographs
graphs should be basedupon the mnemonic ABC'S, in which A is may not provide the final answer; additional radiographs may be
alignment, B is bone, C is cartilage, and S is soft tissue. The required for further interpretation.
alignment of the joint or bone in question should be evaluated
Radiographs of the opposite limb serve as a valuable point of
from all availableradiographs. Malalignment can be misinterpreted
referencewhen there is a specific question about whether a possible
if oblique radiographs have been made. An expectedpattern of abnormality is a normal anatomic variant. When an abnormality
joint spacewidening and bone-to-bone congruity is developedby
is detected,a description of the abnormal roentgen signs should
the experiencedreviewer after evaluating a number of radiographs.
Initially, radiographic anatomy textbooks are helpful for compari-
son. Alignment implies an expectedappearanceboth of the way
the bones line up at the joint and of the entire bone itself. Malalign-
ment within a bone due to fracturesor developmentalabnormali-
ties (prematureclosure)can be seenwith abnormal biomechanical
stressesapplied to the bone.
Radiographicevaluation of bones can be very time consuming.
This implies evaiuation from cortex to cortex from the epiphysis
through the diaphysis(Fig. 12-la). It is important to remember
that there is an expectedsize, shape,position (location), opacity,
margin, and number associatedwith each bone. Each roentgen
sign must be assessed with each bone. Also, the bone must be
assessed from cortex to cortex, which includesthe following: peri-
osteum, cortex, endosteum, medullary cavity ( -r cancellous bone
dependingon location), endosteum,cortex,and finally periosteum.
The endosteum and periosteum have a soft-tissue opacity; however,
these margins should be evaluated for new bone formation or for
osteolysis (changein margin and opacity).
The cartilageis of soft-tissueopacity unlessit has becomeminer-
alized. A typical degree of widening should be noted mentally for
each joint and each physis. The pattern of physeal development is
important to keep in mind, particularly when one is assessinga
physealinjury. One of the most common areasof concern is the
proximal tibial physis and the appearanceof the tibial tuberosity.
On a lateral radiograph, the apophysisof the tibial tuberosity fuses
with the epiphysis of the tibial plateau, and then the physis closes
in a caudal-to-cranialdirection, with the cartilageassociatedwith
the tibial tuberositybeing the last to close.This radiolucentregion tlll,:r;l
is commonly misdiagnosedas an al'ulsion fracture. Beneath articu-
lar cartilage is the subchondral bone plate. This thickened area of
bone can give one cluesabout abnormalitiesthat are presentwithin
the joint or in a particular location of the joint. The subchondral
Fi gure l 2-14. Medrol ateral radographof the sti fl ej ont of a normaldog.
bone plate should be of uniform thickness; however, the thickness
E val uati on
of the eachboneneedsto tncl udeal l aspectsof the bone.S eetex t
changesif degenerativechangesare present within the joint. This for detai l s.There i s a normalcancel l ous
and cortl caloatternthat s houl dbe
again would be an attempt by the joint to stabilize itself; new bone notedfor eachbone.
IM A P P E NDI CU L ASRKE L ET ON -C A N INAN
F D FE LIN E
Expected variations
Radiolucent lines are expected as a normal part of the bone,
particularly in young animals.Tn These radiolucenciesinclude the
physis and the nutrient canal and foramina. The physis can be
iomplex and develop superimposed radiolucent lines that are often
confusing. Several examples include the distal femoral and distal
ulnar physes.Thesenormal anatomic radiolucenciesshould not be
mistaken for a fracture. The nutrient canals and foramina are
typically found in the diaphysis and are present along the caudal
cortex.Somevariation may be seen,but thesestructuresare usually a',r.O,''...r,,,:..
bilaterally symmetrical,so the.oppositelimb should provide some ,,):..::::,.a)),.,:.:...,,a).::.:::4..)
anatomic clues as to what is expectedfor the limb in question' irr,l..l.ll
l:,iiillll
Additional radiopacitiesthat are smooth and oval are seenin and .i3::,-,,,i:::ll,.,rri,,.-
w'
e:e
around a number of joints. These sesamoidbones and accessory -
evaluate all aspectsof bones and soft tissues on the radiographs. A. Resorption is greater than production so that by the end of
A-lternate imaging techniques can provide important follow-up the animal'slife, osteopeniais apparent.
information before invasive procedures are performed for further B. Production and resorption are in balance.
diagnostictesting,or before biopsy specimensare obtained. C. A bone will remodel only when new external stressesare
placed on the bone.
References D. Active remodeling occurs in the epiphysis as the bone grows
away from the physis.
1. deKleer VS: Development of bone. In Sumner-Smith G (ed): Bone in Clinical
Orthopedics: A Study in Comparative Osteology. Philadelphia, WB Saunders, 1982. 2, Multinucleated giant cells that are formed from monocyte pre-
t.
2. L)lsson SE:
-- Morphology and physiology of the growth cartilage under normal and culsors ale:
pathologic conditions. In Sumner-Smith G (ed): Bone in Clinical Orthopedics: A A. Osteocytes.
Study in Comparative Osteology. Philadelphia, WB Saunders, 1982.
B. Osteoblasts.
3. Capen CC, Weisbrode SE: Hormonal control of mineral metabolism and bone C. Metabolic bone units.
cell activity. In Sumner-Smith G (ed): Bone in Clinical Orthopedics: A Study in
D. Osteoclasts.
Comparative Osteology. Philadelphia, WB Saunders, 1982.
4. RosenbergA: Bones, joints and soft tissue tumors. In Cotran RS, Kumar V, Collins 3. The physis that is most susceptibleto premature closure second-
T (eds):Robbins PathologicBasisofDiseise,6th ed. Philadelphia.WB Saunders,1999.
ary to compaction is the:
5. Lanyon LE: Mechanical function and bone remodeling. In Sumner-Smith G (ed): A. Proximalradialphysis.
Bone in Clinical Orthopedics: A Study in Comparatiye Osteology. Philadelphia, WB
Saunders,1982.
B. Distal humeral physis.
C. Proximaltibial physis.
6. Pennock PW: Radiologic interpretation of bone. In Sumner-Smith G (ed): Bone
D. Distal ulnar physis.
in Clinical Orthopedics: A Study in Comparative Osteology. Philadelphia, WB Saun-
ders, 1982.
4. The normal anconealprocessof the dog should be fused to the
7. Grandage J: Interpretation of bone radiographs: Some hazards for the unwary.
Aust Vet T 52:305,1976.
olecranonby - months of age.
A. I
8. Campbell lR: Radiology of the epiphysis. j Am Vet Radiol Soc 9:11, 1968.
B.3
9. Riser WH; Radiographic differential diagnosis of skeletal diseasesof young dogs. (-. f
I Am Vet Radiol Soc 5:15. 1964.
D.6
10. Buckley lC: Pathophysiologic considerations of osteopenia. Comp Contin Educ E. 10
Small Anim Pract 6;552, 1984.
11. Losonsly JM, Kaeller SK: Misdiagnosis in normal radiographic anatomy; Eight 5. How is intramembranous ossilication different from endochon-
structural configurations simulating diseaseentities in dogs and cats. J Am Vet Med dral ossification?
Asso c 1 9 1 :1 0 9 1
, 987.
23. Daniel GB, Avenell lS, Young K, et al: Scintigraphic detection of subcutaneous 9. Codman's triangle is a specific radiographic feature of:
metastasisin a dog with appendicular osteosarcoma. Vet Radiol Ultrasound 37:146,
1996.
A. Osteosarcoma
B. Hlpertrophic osteopathy
C. Fungal osteomyelitis
ffi Ouestions D. Tiaumatic periostealhematoma resolution
E. None of the above
l Which of the following statements is true regarding bone re-
modeling? Answers begin on page 727.
CHA P T E R
13
Diseases of the lmmature Skeleton
r Erik R. Wisner . Linda J. Konde
The radiographic aspectsof developmental skeletal diseaseare as mity. Often, the most pronounced radiographicfindings are those
varied as the causesof the disordersthemselves.Table l3-1 lists ofthe secondarydegenerative changes,which can mask the original
some common and uncommon disordersof the immature skeleton. developmental lesion. To reach an accurateradiographic diagnosis,
This table is intended to provide some structure to this chapter and it is therefore important to differentiate the cause (developmental
should not be considered to be a definitive classification scheme. lesion) from the effect (degenerativelesion) whenever possible.
Developmental lesions may be solitary and localized but are
often multifocal or generalized. Localized lesions, such as those primarilv affectins
seenwith osteochondrosis, are often bilateral. Lesion location can
be predicted based on the characteristicanatomic distribution of
I i?i""?t"ttrs
many of these diseases.Although radiographic features of the Osteochondrosis and osteochondritis
various developmental skeletal diseasesvary widely, they generally dissecans
appear nonaggressive.
Osteochondrosisis a common causeof lamenessin young, rapidly
Secondary degenerativejoint diseaseis a common sequel to
growing, large-breed dogs. Clinical signs usually develop between
developmental disorders of the immature skeleton, particularly
when the primary lesion involvesjoints or produces limb defor- 6 and 9 months of age.Osteochondrosis occursowing to epiphyseal
cartilage necrosis and a resulting failure of normal endochondral
ossification.tIf the vascularbed of the adjacentsubchondralbone
can envelopand bypassthe region of cartilagenecrosis,endochon-
Table 13-1. Disorders of the immature appendicular dral ossification may resume without development of a clinical
skeleton lesion. Otherwise, progressivechondromalacialeads to develop-
ment of c1eftsor fissuresextending from the surfaceof the cartilage
Disorders primarily affecting joints
to the subchondralbone. When a chondral or osteochondralfrag-
1. Osteochondrosis, osteochondritisdissecans ment separatesfrom adjacent subchondral bone, the disorder tech-
2. Elb ow dysp las ia
nically should be referred to as osteochondritisdissecans.rHowever,
Unu nite dcor onoid pr oc es s
Fragmentedmedial coronoid process in most patients,it is impossibleto determine from survey radio-
Osteo ch on dr os isof t he m edial hum er alc ondvl e graphs whether a cartilage fragment exists; thus, osteochondrosis
3. Hip d yspla sia is an acceptableterm.
4. Aseptic necrosisof the femoral head (Legg-Calv6-Perthes In dogs, osteochondrosisoccurs in specific anatomic locations
disease) and often involves weight-bearing articular surfaces.It occurs most
Disorders primarily affecting bone frequently in the caudal aspectof the proximal humeral head (Fig.
1. Ma lforma tiono r agenes isof s ingle or m ult iple b o n e s 13-1) but also occurs in the distomedial aspectof the humeral
Ame lia, h em im elia trochlea (Fig. 13-2), the lateral and medial femoral condyles(Fig.
Ectrodactyly,polydactyly 13-3), the femoral trochlea, and the medial and laterai trochlear
Syndactyly ridges of the talus (Fig. 13-4).'?-'g Osteochondrosisis frequently
2. Skeletaldisordersof unknown cause bilateral, but affected animals may have clinical signs in only one
Panosteitis limb. Large subchondrai defects are frequently associated with
Hypertrophic osteodystrophy the presenceof separateosteochondral fragments, which tends to
3. Me tab olican d ot her gener aliz eddis or der s increasethe severityof clinical signs.Io
Nutritionalsecondaryhyperparathyroidism Radiographic signs. Typical radiographic findings of osteo-
Con ge nita hl y pot hy r oidis m chondrosis inciude flattening or concavity of the affected subchon-
Pituitarydwarfism dral bone surface with surroundine subchondral bone sclerosis.
Mucop olysa c c har idos is This may result in nonuniformity and apparentwidening of joint
Osteogenesisimperfecta space.\Arhenmineralized, a cartilage flap is sometimes seen within
Osteopetrosis the subchondral defect,and separateosteochondralfragments
4 . Me tap hyse aland epiphy s ealdy s plas ias (joint mice) may migrate within the joint space.Fragmentsthat
Osteochondrodysplasias have migrated often adhere to the sl.novial lining and may continue
Ch on dro dys plas ia:Alas k anm alam ut e,Nor weg i a n to mineralize and enlarge over time. ]oint effusion, or joint capsule
elkho un d,Coc k ers paniel,Englis hpoint er ,G r e a t
thickening, may appear as a localized region of soft-tissue swelling
Pyrenees
Oculoskeletaldysplasia:Labradorretriever,Samoyed centered on the affected joint. A subchondral bone defect is occa-
Osteochondraldysplasia:ScottishFold cats, Scottish sionally seen involving the articular surface opposite the primary
de erh ou nds ,Bull t er r ier s Iesion.Thesedefectsare called "kissing lesions."Secondarydegen-
Hyp ocho nd r oplas ia: lr is h s et t er s erativejoint diseaseis a common sequelto osteochondrosis.
Multip leep iphy s ealdy s plas ia:Beagles Occasionally,gas is present within the joint space of dogs with
Multip leca rtilaginousex os t os es shoulder osteochondrosis. This findine is referredto as the yacuum
Retainedcartilagecores phenomenonand is due to the intia-articular accumulation of
Incomp leteo ssif ic at ionof t he hum er alc ondy le:S p a n i e l s , nitrogen gas causedby negativepressureinduced by traction on
other breeds
the joint during positioning (seeFig. 13-1).
r4.'.
Diseasesof the lmmatureSkeleton 147
With osteochondrosis of the lateral trochlea of the talus, the Elbow dysplasia
superimposed calcaneusmay obscure the lesion in the dorsoplantar
view. In this instance, a dorsolateral-plantaromedial oblique, or a Elbow dysplasiais a nonspecific term referring to a triad of devel-
flexed dorsoplantar, view can be acquired to provide an unob- opmental lesions that include ununited anconeal process, frag-
structed view of the lesion. In the stifle, the fossa for the origin of mented medial coronoid processof the ulna, and osteochondrosis
the long digital extensor muscle is sometimes mistaken for a lateral of the distomedial aspect of the humeral trochlea. Although osteo-
femoral condyle osteochondrosis lesion becauseit is superimposed chondrosis has previously been implicated as the cause of all three
on the dorsolateral aspect of the condyle on both the lateromedial of these disorders, asynchronous growth of the radius and ulna
and the caudocranial views. and proximal ulnar dysplasia resulting in an elliptically shaped
Cartilage flaps are not visible on survey radiographs unless ulnar notch have more recently been suggested as implicating
calcification or ossification of the fragment has occurred. When a factors.3'tu t0 Elbow joint incongruity may result in nonuniform
nonmineralized cartilage fragment is present, an arthrogram can contact of articulating surfaces,Ieading to nonunion of the anco-
be used to outline the flap, if contrast medium dissectsbetween neal processor separationof the medial coronoid process.re,2r One,
the fragment and the underlying subchondral bone. Arthrography two, or all three of the primary lesions may be present in the same
may also define migrating intra-articular cartilage fragmentsll'12 animal, and both elbow joints are commonly affected.
(seeFig. 13-1C). Newer nonionic and low-osmolar-contrastmedia
provide significantly better arthrographic quality than hyperosmo- Ununited anconeal process
lar, ionic contrast media do becausethe contrast medium is not Large-breed dogs that normally have a separateanconeal ossifica-
diluted as quickly from fluid flux into the joint space.'3However, tion center early in development are at greater risk for ununited
becausearthroscopyhas gained acceptancefor the diagnosisand anconeal process (Fig. 13-5). German shepherd dogs are over-
definitive treatment of osteochondrosis,arthrography is now used represented,although the lesion occurs in other breeds as wel1.The
lesscommoniy.t',tt anconeal processshould normally be fused to the olecranon of the
I4 A SK EL E T O N -C A N INAEN D FE LIN E
A P P E NDI CU L AR
Figure 13-2. Osteochondrosisof the medlal humeralcondyle.A well-de- Figure 13-3. Osteochondrosis of the lateralfemoralcondyle.The subchon-
f inedl u c e n tc o n c a v i t yi n t h e su b ch o n d r ablo n eo f th e m e d ia lh u m eralcondyl e dral bone of the lateralfemoral condyleis flattened.lrregularlucent areas in
brrow) can be visualized. the condvleare surroundedbv sclerosis.
Figure 134. Osteochondritis of the talus. On the dorsoplantar view /A),a small bone flap is presentproxirnalto the medialtrochlearridgeof the lalus (arrow).
r co n to u rwith
A djace nt o t h e f l a p ,t h e b o n e is ir r e g u lain , b o n e lu c encysurrounded by scl erosi s.
Fatteni ngof the trochl earri dgeand concurrent
w ideni ngof the
tarsocruraljoint (blackarrow) are seen on the lateralview /B,. Osteophyteformationis presenton the cranlaland caudalmarginsof the distal tibia and on the
dorsalsurfaceof the talus (whitearrow).
D i seasesof the l mmatureSkelet on l4g
F ig u r e l 3 - 6 . vie
F r a g m e n te d co r o n o id p r o ce ss.A,L a te r awofanormal
l edgeofthemedi alcoronoi dprocess(b/ackarrowhead)has adi s tl nc t
el bow .Thecrani al
(white arrow).The proximalmarginof the
marginthat is supenmposedon the head of the radius.The adjacentthin opaqueline representsthe radialtuberosity
medialcoronoid
ancJnealprocesslblackarrow)is also distinctdespitebeingsuperimposedon the medialand lateralepicondylesof the humerus.B, Fragmented
processwith secondarydegenerativechanges.The marginJof the medialcoronoldand anconealprocessesare indistinctas comparedwith those in Figure13-GA.
Subchondralbone sclerosisis also preseni adjacenttolhe ulnar notch (arrows).Periarticular osteophyteformationls evident on the cranialmarginof the radial
joint. D, A
head. C, Occasionally, visualization of periostealnew bone on the proximalmarginof the anconealprocess(arrow)is facilitatedby flexlngthe elbow
largeosieophytearisesfrom the medialmarginof the ulnaon a craniocaudal view. This osteophyteshouldnot be misinterpretedas the coronoidfragment.
D i seasesof the l mmatureSkelet on l5l
Figure 13-7. Aseptic necrosisof the left femoral head.The femoral head Figure 13-8. llbial agenesisin a young dog. The tibia is not formed, and
containsa largeradiolucentarea with surroundingsclerosis(arrows).There is the fi bul ai s mi sshapen. The proxi mal fi bul arepi physi iss hypopl as tiand
c poorl y
g r fa ceo f th e fe m o r a lh e a d,and the j oi nt
f a t t e n i n g o f t h e w e i gh t- b e a r insu mi neral i zed. l i bi ai agenesi shas l ed to sti fl eand tarsocrural oi
l nt mal formati on
s p a c ei s w i d e n e d .O ste o p h yteas r e p r e se n to n th e fe m o r a ln e c k. as w el l as l i mb shorteni ng and angul ardeformi ty.
I5 2 E D FE LIN E
A P P E NDI CU L ASRKE L ET ON -C A N INAN
ously absent and the limb is usually malformed and shorter than inflammatory response. Microscopically, there is an increase rn
normal. Limb curvature and ioint malformation may also be pres- medullary, endosteal,and periosteal osteoblasticand fibroblastic ac-
ent. tivity.
Radiographic srgns. Very early in the course of the disease'
Polymelia blurring and accentuation of trabecular bone of the affected long
This general term denotes suPernumerary limbs or parts of a limb' bone are noted. Circumscribed nodular opacities similar in opacity
Polydictyly, the presenceof an excessnumber of digits, is the most to cortical bone form within the diaphyseal medullary cavity of
long bones,often near nutrient foramina. As the lesion progresses,
common fot- of polymelia and is most often seen in cats. A few
medullary opacities become more diffuse and homogeneous.
breeds of dogs, su-h as the Great P1'renees'have also been bred to
retain this triit. The anomaly is generally clinically insignificant' Smooth, continuous periosteal new bone formation develops in
Radiographic srgns. Radiographic signs of polymelia vary ac- the diaphysis of affected bones in one third to one half of dogs.
cording to the bone or bones involved. Findings of polydactyly Late in the disease, opacities resolve, leaving coarse, thickened
include a greater-than-normal number of digits, usually arising orr trabecular bone that eventually assumes a normal appearance.
the medial side of the limb. Supernumerary digits may include Cortical thickening may persist as periosteal new bone remodels.
complete or partial metacarpal/metatarsalbones and variable num- Hypertrophic osteodystrophy
bers of phalanges. Hypertrophic osteodystrophy is a systemic illness that usually af-
fects large- and giant-breed dogs that are between the ages of 2
Disorders of unknown etiology and 7 months. The cause is unknown, but oversupplementation
Panosteitis of minerals and vitamins, hlpovitaminosis C, and suppurative
Panosteitis is a self-limiting diseasethat affects the long bones of inflammation without isolation of infectious agents have all been
primarily young, large-breed dogs (Fig. 13-9). Males are affected proposed.tt-t More recently, canine distemper virus has been iso-
iour times more often than femaiesand the lesion is most common lated from metaphysealbone celis in affected animals and has been
in German shepherd dogs. Dogs betrveen the ages of 5 and 12 suggestedas a causative factor.a2aa Clinical signs, including marked
months are most often affected; however, afflicted dogs as young pyrexia, diarrhea, footpad hyperkeratosis,leukocl'tosis,anemia, and
as 2 months of age and as old as 7 yearsof agehave been reported' pneumonia, are occasionally seen with hlpertrophic osteopathy,
Panosteitis lesions may be solitary, may affect multiple sites in a lending credibility to the possibiiity of a systemic infection as a
single bone, or may be multifocal in multiple bones. Although the causefor this disease.at
lesi-onscan affect any part of the diaphysis of a long bone, they Resulting bone lesions are generally bilaterally symmetric and
often originate and are most pronounced near the nutrient fora- involve the metaphysesof long bones, particularly the distal radius,
men. Bone involvement is often sequential and the diseasemay be ulna, and tibia (Fig. 13-10). The costochondral junctions, the
protracted over several months, with lesions resolving in some metacarpal/metatarsalbones, and the craniomandibular region may
areas while developing in others' Severity and location of radio- also be involved. Craniomandibular osteopathy may, in fact, be
graphic lesions do not necessarily correlate with- the severity of a different clinical manifestation of hlpertrophic osteodystrophy.
ili.ri.ul rignt, and the most clinically affected limb may not have Although the diseaseis usually self-limiting and resolvesafter a few
the most pronouncedradiographiclesions.33'3a The term panosteitis weeks, more severeinvolvement can ultimately result in abnormal/
is a misnomer in that histologically there is no evidence of an premature physeal closure and subsequentskeletal deformity. His-
proximaldiaphysis
Figure l3-9. Stages of panosteitis.A, Early stage in a femur. There is circumscribedincreasedopacity in the mid-diaphysisand the
periostealnew bone formationon the diaphysis.C Later
B, Middle stage In a humerus.Thereis diffuse increaiedopacityof the entirediaphysisand a continuous
iiag e i n u r a j i u s - u l n aTh t opaci typri mari l yi n the proxi malradi usand ul na.There i s mi l d peri os tealnew bone
. e r e is le ss in te n seb u t still a p p a r e n increased
formationon the cranialrcdius(arrow)
D i seasesof the l mmatureSkelet on 153
Congenital hypothyroidism
Congenital hypothyroidism is an uncommon developmental disor-
der that has been reportedin Boxers,Scottishdeerhounds,Giant
schnauzers,Affenpinschers, and Great Danes and is due to thyroid
aplasia or hypoplasia*"o (Fig. 13-12). Clinically, the dogs are
disproportionate, short-limbed dwarveswith bowed limbs and long
necksand trunks.
Radiographic srgns. Radiographic findings consist of epiphys-
eal dysplasiathat appears as reduced or delayed ossification of the
epiphysealcartilage model. This is most easily seenin the proximal
tibia and the humeral and femoral condyles. Cuboid bone ossifica-
tion in the carpus and tarsus is also delayed. Vertebral bodies
appear shorter than normal owing to end-plate dysplasia. The
skull may appear shorter and broader than normal. Secondary
degenerativejoint diseasemay be seen.
Mucopolysaccharidosis
The mucopolysaccharidosesrepresent a ioosely related group of
uncommon autosomal recessiveinherited disorders that result in
reduction or absenceofglycosaminoglycancatabolism(Fig. l3-13).
Lysosomal degradation of these mucopolysaccharidesis necessary
for normal growth in developing animals, and the abnormal me-
tabolism leads to chronic, progressivemultisystemic disease.More
than 10 forms are recognized in humans, each produced by a
different enzyrne defect. Many of these have also bein identified in
dogs and cats.sl-s8The most pronounced clinical manifestations
involve the musculoskeletal,ocular, neurologic, hepatic, and cardio-
vascular systems.Affected animals are often stunted and lame and
Figure 13-1O. Hypertrophic osteodystrophy. lrregularradrolucent
regions have visual deficits. Clinical manifestations include disproportion-
arepresent in the distalradial
andulnarmetaphyses, proximal
to the physis
(arrows). Proximalto the lucentzonesareregions of increased
opacity.
Caudal ate dwarfism and facial dysmorphia, which includes a broad max-
uinarmetaphysis thereis a cuff of mineralization
adjacentto the illa, widespread eyes,a flat nose, and short ears.Hyperextension of
HJffifl:l:] the distal extremity joints occurs as a result of ioinf laxity.
Radiographic srgns. Radiographic changes of mucopolysac-
e,+ S ts -i
'
- J- - :- ;;- ": ,
Osteopetrosis
Osteopetrosis is a rare, inherited metabolic bone disease that is
presumedto be due to abnormal osteoclastfunction6'z(Fig. 13-1a).
Affected animals have a generalized increasein bone opacity, spe-
cifically affecting medullary cavities. A resulting decreasein the
Osteogenesis imperfecta
Osteogenesisimperfecta is a rare, generalizedmultisystemic herita-
ble diseasecausedby a structural defect in type I collagen, which
constitutes the majority of the nonmineral bone matrix.se-61Af-
Figure 13-14. Osteopetrosisin a cat. There is a generalizedIncreaseIn
fected animals have stunted growth and generalizedmuscle atrophy bone opaci tyi nvol vi ngthe appendi cul arand the axi al skel e ton.A l os s of
and weaknessand are at risk for pathologic fractures. Teeth may corticomedullary junction definitionis due to increasedmedullaryopacity.In
also appear pink. Affected animals may have a recurring history this example,a small centraldiaphysealregionof the femoralmedullarycavity
of fractures. i s not yet affectedand appearsl essopaquethan surroundi ng b one.
D i seasesof the l mmatureSkelet on 155
curvus. The cuboid bones and the epiphyses are misshapen and compromised, such as the spinal canal and the trachea. Most
larger than normal. Ribs are wider than normal with prominent exostosesremain inert once the dog has matured, but malignant
flaring at the costochondral junction. Hip dysplasia is a common transformation has been reported.80'8lTwo atlpical examples of
sequel of this disorder. The skull and spine appear to be spared. multiple cartilaginous exostoseshave been reported.8'ZOne was a
2-year-oId Great Dane who developed multiple cartilaginous exos-
Multiple epiphyseal dysplasia of Beagles toses after reaching skeletal maturity. The exostosescontinued to
Multiple epiphyseal dysplasia is a rare hereditary disorder of vari- grow, with some bridging of physeal regions and irregular margins.
able expressionthat is characterizedby a failure ofnormal epiphys- The other was a 4-month-old Border collie that had tumors with
eal ossification(Fig. 13-17). Pseudoachondroplasia, reported in
a stippled appearancethat were not contiguous with adjacentbone.
young Miniature Poodles, is also considered by some to be a form The microscopic appearance in both dogs was consistent with
of multiple epiphysealdysplasia.'aAffected individuals have delayed
growth and never reach normal size.
Radiographic signs. Stippling of the epiphyses and irregular
epiphyseal margins are evident by 3 weeks of age, with the most
pronounced changesin the humeral condyles at I to 3 months of
age. Epiphyseal alterations are identified in the humerus, femur,
and metacarpal and metatarsal bones, and occasionally in the
vertebrae. Similar stippling may also be seen in the carpal and
tarsal bones in some dogs. Affected epiphyseseventually mineralize
but are moderately deformed. Aberrant separatecenters of ossifi-
cation that eventually fuse with the normal ossification centers
have also been described.Hip dysplasiaappearsto develop in most
affected dogs, and degenerativejoint diseaseof other joints is a
typical sequel to the primary disease.Tttt
au:,t€ut:rutau:u
rlsl
r,.l13rrr,:iisrir
ilr1r13
:iiioul
9.aa:,:::i
Figure 13-19. Retainedcartilagecore in the distalulna.A triangularradiolu- Figure 13-2O. Incompleteossificationof the humeralcondyle.A vertica
cent region is present in the distal ulnar metaphysis(arrows).A thin rim of radiolucentline is presentin the distalhumeralcondyle(openarrow).Periosteal
b o n e s c l e r o s i si s p r ese n tn e xtto th e r a d iou ce n cy.S ig h t cr a ni albow i ngof the new bone formationls presenton the distal lateralhumerus (curvedarrow),
l r te xa r e d u e to m ild a n g u larl i mb deformi ty
r a d i u sa n d a t h i c k c a u d a rl a d ia co probabl ysecondary to moti onfrom an i ncompl etefractureex tendi ngl ateral l y
r e s ut i n g f r o m d e l a y e du ln a rg r o wth . from the suoracondvl foramen.
ar
I5 8 SK EL E T O N -C A N INAN
A P P E NDI C U L AR E D FE LIN E
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52. Haskins ME, Aguirre GD, lezyk PF, et al: Mucopolysaccharidosis tlpe VII (sly
spdrone). Beta-glucuronidase deficient mucopolysaccharidosis in the dog. Am J 82. Jacobson LS, Kirberger RM: Canine multiple cartilaginous exostoses: Unusual
P a th o l 1 3 8 :1 5 5 3 -1 5 55,
1991. manifestations and a review of the literature. J Am Anim Hosp Assoc j2:45-51, 1996.
53. Haskins ME, Jezyk PF, Desnick Rl, et al: Animal models of mucopolysaccharidosis. 83. lohnson KA: Retardation of endochondral ossification at the distal ulnar srowth
Prog Clin Biol Res94:177-201,1982. plate in dogs. Aust Vet J 571474-478,1981.
54. Haskins ME, Otis El, Hayden lE, et al: Hepatic storage of glycosaminoglycans 84. Riser W, Lincoln J, Rhodes W et al: Genu valgum: A stifle deformity of giant
in feline and canine models of mucopolysaccharidoses I, VI, and VII. Vet Pathol dogs. I Am Vet Radiol Assoc 10:28-37,1969.
29tII2-119, 1992. 85. Marcellin-Little Dl, DeYoung DJ, Ferris KK, Berry CM: Incomplete ossification of
55. Konde L, Thrall M, Gasper P, et al: Radiographic changes associatedwith muco- the humeral condyle in spaniels(seecomments).Vet Surg 23:475-487,1994.
polysaccharidosisin the cat. Vet Radiol 28:223-228, 1987. 86. Rovesti GL, Fluckiger M, Margini A, Marcellin-Little Dl: Fragmented coronoid
56. Shull RM, Helman RG, Spellacy E, et al: Morphologic and biochemical studies of process and incomplete ossification of the humeral condyle in a Rottweiler Vet Surg
canine mucopolysaccharidosisI. Am ) Pathol 114:487-495, 1984. 27:354-3s7,1998.
57. Shull RM, Munger RJ, Spellacy E, et al: Canine alpha-r-iduronidase delicienry A
model of mucopolysaccharidosisI. Am J Pathol 109:244-248,1982.
ffi Ouestions
58. Wilkerson Ml, Lewis DC, Marks SL, Prieur DJ: Clinical and morphologic features
of mucopolysaccharidosis type II in a dog: Naturally occurring model of hunter
l. True or False.Typical radiographic findings of osteochondrosis
slmdrome. Vet Pathol 35:230-233, 1998.
include a flat or concave synchondral bone defect with a sur-
59. Campbell BG, Wootton JA, Krook L, et al: Clinical signs and diagnosis of os- rounding scleroticmargin.
teogenesisimperfecta in three dogs. I Am Vet Med Assoc 2ll,:1,83-187, 1997.
60. Potena A: [On osteogenesisimperfecta. (studies of some casesobserved in dogs).] 2. Tiue or False.Osteochondrosislesions are almost alwaysunilat-
Acta Med Vet (Napoli) 14:79 109,1968.
eral.
61. Schmidt V: fOsteogenesis imperfecta in 2 collie litter siblings.] Wien Tierarztl
Monatsschr 54:92-100, 1967.
3. The anconealprocessis consideredununited if separationof
62. Lees GE, Sautter JH: Anemia and osteopetrosis in a dog. J Am Vet Med Assoc the anconeus from the ulna is present after what age?
175:820-824, 1979.
63. Carrig CB, MacMillan A, Brundage S, et al: Retinal dysplasia associated with 4. Tiue or False.Radiographic diagnosis of fragmented medial
skeletal abnormalities in Labrador retrievers. J Am Vet Med Assoc 170:49 57,1977.
coronoid process is usually made by detection of a well-defined
64. Terpin T, Roach MR: Chondrodysplasia in the Alaskan malamute: Involvement of fracture line and a distinct separatecoronoid fragment.
arteries,as well as bone and blood. Am I Vet Res42:1865-1873,1981.
65. Bingel SA, Sande RD: Chondrodysplasia in the Norwegian elkhound. Am J Pathol 5. A 4-month-old Great Dane has soft-tissueswellingaround the
107:219-229, 1982.
carpi and tarsi, a high fever, and painful forelimbs. In radiographs,
66. Sande RD, Bingel SA: Animal models of dwarfism. Vet Clin North Am Small there are lucent zonesin the metaphysesadjacent to the physeswith
Anim Pract 13:71-89, 1983.
sclerosisadjacent to the lucencies.Periostealnew bone formation is
67. Bingel SA, Sande RD, Wight TN; Chondrodysplasia in the Alaskan malamute. present around the metaphyses.What is the most likely diagnosis?
Characterization of proteoglycans dissociatively extracted from dwarf growth plates.
Lab Invest 53:479-485,1985.
6. Panosteitisis typically located in the:
68. Minor RR, Farnum CE: Animal models with chondrodysplasia/osteochondrodys
A. diaphysis.
plasia. Pathol Immunopathol Res 7:62 67, 1988.
B. metaphysis.
69. Carrig CB, Sponenberg DP, Schmidt GM, Tvedten HW: Inheritance of associated C. epiphysis.
ocular and skeletal dysplasia in Labrador retrievers. J Am Vet Med Assoc 193:1269-
1272,1988.
7. What general group of disorders often result in disproportion-
70. Breur GL Zerbe CA, Slocombe RF, et al: Clinical, radiographic, pathologic, and
genetic features of osteochondrodysplasiain Scottish deerhounds. I Am Vet Med Assoc ate short-legged dwarfism ?
19 5 :6 0 6 -6 1 2 ,1 9 8 9 .
il. Sande RD, Alexander JE, Padgett GA: Dwarfism in the Alaskan malamute: Its 8. This elbow (Figure 13-21) is from an B-month-old German
radiographic pathogenesis.J Am Vet Radiol Soc l5tl0-I7, 1974. shepherd dog with lamenessand pain isolated to the elbow region.
i2. Malik R, Allan GS, Howlett CR, et al: Osteochondrodysplasia in Scottish Fold
Describethe radiographicchanges.
cats. Aust VetI 77:85 92. f999.
;3. A.llan GS: Radiographic features of feline joint diseases.Vet Clin North Am Small
9. These are forelimb radiographsof a S-month-old Irish wolf-
.\nim Pract 30:281-302,2000. hound with an angular limb deformity (Figure t3-22). Describe
i4. Riser WH, Haskins ME, )ezyk PF, Patterson DF: Pseudoachondroplasticdysplasia
the radiographic findings.
in miniature Poodles: Clinical, radiologic, and pathologic features. I Am Vet Med
. \sso c1 7 6 :3 3 53 4 1 , 1 9 80. 10. This elbow is from a 6-month-old Labrador retriever with
, 5. RasmussenPG: Multiple epiphysealdysplasia in a litter of Beagle puppies. J Small Iamenessand pain in the elbow joint (Figure 13-23). What is the
{nim Pract 12:9\-96, I97I. radiographicdiagnosis?
,6. RasmussenPG: Multiple epiphysealdysplasia in Beaglepuppies. Acta Radiol Suppl
319:251-254.I972. Answers begin on page 727.
€z-gl en6!! zz-tL ern6!!
LZ-IL ern6t!
ff Fracture
i 1 4 Healing and Complications
ffi r
ffi RobertL. Toal ' SallyK. Mitchell
I Initial radiographs
If a limb fracture is suspected,at least two radiographs should be sclerotic line or zone where overlapping fragment ends summate.
taken at a 9O-degreeangle to each other (Fig. 1a-1). The joints Alterations in bone size,shape,position, and function are usually
above and below the affected bone should be included in the field presentto some degree.
of view; this allows for the assessmentof both joint involvement Occasionally,a fracture is present, but bone distraction is mini-
and degreeof fragment rotation. The use of sedationor anesthesia mai, making radiographic detection difficult. Reasonsfor fracture
is helpful so that the animal may be positioned properly. A hori- nonvisualization include poor-quality radiographs, a fracture line
zontal-beam craniocaudal radiograph may be obtained when the not tangential to the x-ray beam, early cortical stress fracture,
patient's condition, limb swelling, or decreasedrange of motion minimal displacement, and obscured visualization by overlying
prevents radiographing the limb in extension with a vertically structures. Repeat radiographs, obtained with the use of proper
directedx-ray beam.' Stressed, oblique, and opposite-limbcompar- technique, or oblique projections may help. In some instances, a
ison radiographs are helpful in some patients. more apparent fracture line or early callus formation will be appar-
ent in radiographstaken I or 2 weekslater (Fig. I4-2Aand.B).ln
I Gauses of fracture instancessuch as early cortical stressfracture, nuclear scintigraphy
is indicated becauseof its inherent sensitivity in detecting bone le-
An external force (usually trauma from an automobile accident,
sions.
horse kick, or gunshot) appiied directly to bone is the most com-
Occasionally,normal or variant anatomic structures may slmu-
mon cause of fracture. An external force can be transmitted (indi-
late fracture. This situation occurs with normal or ectopic nutrient
rectly) through bone to another part of that bone where the
foramina,3 normal and accessoryossification centers, inconstant
fracture then occurs. A dog that jumps off a porch and sustains a
and multipartite sesamoidbones, open physes,and syndesmoses.
fracture of the humeral condyle is an example of this type of
fracture. An internal force transmitted to bone by muscle contrac-
tion or ligament tension can also result in fracture.An amlsion of I Fracture evaluation
the proximal ulnar epiphysis in a young dog is an example of this
A radiographic assessmentbegins with a description of the direc-
type of fracture. Repeatedstressto normal bone over a period of
tion and location of fracture line(s) in the bone(s) involved. The
time (metacarpal fracture in a racing Greyhound) and normal
use of a fracture type classification system to describe the fracture
activity on diseasedbone (bone tumor or osteoporosis)can also
is helpfu1 when appropriate.aThe direction of fissure fractures, the
result in fracture.2
presenceof joint involvement, and the presenceof intra-articular
fragments are carefully assessed.Intra-aiticular fragments may be
I Fracture recognition associatedwith luxation, subluxation, or any joint trauma. Next,
Radiographically,a fracture is a disruption in bone continuity. One the positional changes of the major distal fragment relative to
or more radiolucent fracture lines may be seen,or there may be a the proximal fragment should be characterized. The direction of
r6r
162 SK EL E T O N -C A N INAEN D FE LIN E
A P P E NDI CU L AR
Figure I4-2, A, An incompletefractureof the ulnawas suspectedin this young dog, but was not seen in the radiograph.8, The fracturewas confirmedon a
foilow-upradiograph(arrow).C, An obviouscomminutedfemoral fracture in a cat, with severalfissure fracturesradiatinginto the proximalfragment.The full
extent of fissurefracturesis sometimesdifficultto detect radiographically,
displacement and angulation of the fracture fragments should be b. Comminuted fractures have multiple fracture lines that com-
evaluated. Alterations in bone length are described as overriding municate to a single plane or point. A triangular segment of
(bone shortening) or distraction (bone lengthening). Rotational bone that may be present in a comminuted fracture is com-
deformities should be noted, although unstable distal fragments monly referred to as a butterfly segment.
that are fully movable vary markedly in rotational direction. Lastly, c. Multiple or segmental fractures are similar to comminuted
the amount of soft-tissue change should be chatacterizedin terms fractures in that there are three or more fragments, but the
of size (i.e., swelling or atrophy) and opacity (e.g., emphysemaand fracture lines do not meet at a common point.
opaqueforeign objects). d. Incomplete fractures involve a single bone cortex or only a
portion of the bone. Several types of incomplete fractures
Fracture type exist. Flssure fractures are longitudinal or spiral cracks in
the bone cortex without displacement. They are frequently
Various fracture type classification schemeshave been devised that
associatedwith complete or comminuted fractures (see Fig.
describeintegrity of the regional soft tissues,geometry and number
l4-2C).In greenstickfractures, which occur in young animals,
of the fracture lines, degree of physeal-metaphyseal-epiphyseal
one side of the bone is fractured and the other side is bent
involvement, and the other pertinent features of a fracture. Most (plastic deformation). Stressfractures (fatigue fractures) are
fractures may be classifiedaccording to one or more types. Fracture
microfractures in the bone cortex that result from cyclic
tfpe may influence therapeutic plan, rate of fracture healing, aP-
loading.u These are difficult to detect radiographically, al-
p.irance of fracture callus, and possibility of postoperativecompli-
though increased uptake of a radiopharmaceutical may be
cations. Most fractures may be classifiedaccording to one or more
seen scintigraphically. Roentgen signs, when present, include
of these category types.
focal increased bone opacity, faint periosteai reaction, and
1. Integrity of soft tissues:Skin defects in the region of a fracture oblique to dish-shapedfracture lines that involve a single cor-
can communicate with the fracture site. This results in wound tex.
contamination and can lead to bone infection if not treated e. Impacted fractures result from compression forces that
properly. Infected fractures may have delayed healing'' shorten bone length by crushing bone. This results in a
i. Open fractures have a skin defect in the region ofthe fracture. sclerotic appearance. Impacted fractures occur most com-
Ridiographically, the bone may or may not protrude from monly in vertebral bodies or an open physis.
the skin. Occasionally, foreign debris, metallic opacities, or f. Depressionfractures are seen with sinuses or skull fractures.
tissue emphysema is identified deep within the soft tissue; A fragment of bone lies beneath the skull surface and a
this finding servesas a clue that the fracture is open. radiolucent or sclerotic line is seen where fragment gap or
b. Closed fraclures do not have a skin defect in the region of overlap occurs with neighboring bone.
the fracture. g. Avulsion fractures usually occur as a result of excessivetrac-
2. Descriptions of a fracture using geometry and number of frac- tion by muscle, ligament, joint capsule,or tendon. Fragments
ture lines: may be periarticular or intra-articular, or may involve trac-
a. Completefractures have a fracture line that extends through tion epiphyses,which appear as fragments of variable size
the entire bone. The direction of the fracture line relative to with a defect or "fracture bed" in the parent bone the same
the long axis of the bone may be transverse,oblique, ot size as the fragment.
spiral. Displacement of the distal fragment from the proximal h. Chip fractures are small fragments that usually result from
fragment due to muscle contracture is usually present. direct bone trauma or hyperextension with bony impinge-
FractureH eal i ngand C omplicat ions163
/\ /I t\
/t dislocation of the radial head, which is calied Monteggia's
fracture. Shearing injuries are fractures resulting from road
friction that grinds away bone and the collateral ligament of
t:] LJ UU
3. Degree of physeal involvement: Various combinations of
metaphyseal-physeal-epiplryseal fractures in growing bone are
classified according to a Salter-Harris-type scheme (referred to
as Salter fractures).7Five classeswere originally described with
I tl ill a sixth one added later by others (Fig. 1a-3).s Type II injuries
are the most common tipe (Fig. 14-4). Prognosis for Salter
tt
II L-...\
,I
.\t
1t fractures relates Salter type, the degree of initial displacement,
and the exactnessof reduction., Serious comolications of Salter
fractures include clinically evident growth disturbancesand joint
/\\ I abnormalities. These are due to damage to the growth zone
ut-/ IV V
bj VI
layer, or to the transphyseal bony bridges that form during
l-_J
healing and impede longitudinal growth at the physis. Theoreti-
cally, the higher the grade of Salter fracture, the more likely the
physis will close prematurely. This is especiallytrue for Salter V
injuries, in which the physis is crushed. Premature closure of a
physis has more severeconsequencesin very young animals and
Figure 1th3. Sixtypesof Salterfractures. l, physeal;ll, physeal-metaphys- in regions of two bones with different growth
eal;lll, physealepiphyseal;
lV, physeal-epiphyseal-metaphyseal; rates, such as the
V, impacted
physis; physeal
Vl,eccentric impactionresultingin transphyseal bridging. radius and ulna. Damage to the distal radiai or ulnar physis
results in bone shortening and often angular limb deformiiies
and elbow subluxation becausethe bones grow aslmchronousiy
(Fig. 1a-5). Physealgrowth disturbancesmay occur without the
ment. A fracture bed is also present. Periarticular chips presenceof a physeal fracture.Io
should be distinguished from accessoryossificationcentersand
dystrophic soft-tissue mineralization The lack of a fracture 4. Other features: Pathologic fractures are spontaneous fractures
bed in the latter instancesis heloful. that occur without history of overt trauma in abnormal bone
i. Supracondylar,condylar,and bicindylar "7" and "Y" fractures weakenedby a pre-existing lesion. Pathologic fractures are most
indicate that a fracture has occurred in the metaphysis near often seen in bones that are weakenedby tumor. An aggressive
the condyle, through the condyle, or through the condyie bone lesion in conjunction with a fracture is indicative (Fig.
and supracondylar region, respectively. 14-6). Metabolic bone disease,especially hyperparathlroidism,
j. Fracture-Iuxations:Some luxations occur only in association as a cause of pathoiogic fracture is suspect when a fracture
with a nearby fracture. This term is often reservedfor sacroil- occurs in bone that is radiographically less opaque than normal
iac luxations becausesacroiliac displacement is almost always with thin cortices and scant trabeculae.ThesesometimesDresent
accompanied by fracture of the pubis or ischium, or separa- asfolding fractures when the bony cortex is bent at the fracture
tion along the pelvic symphysis. A special tlpe of fracture- site, thereby creating a sclerotic fracture line. Also, in folding
luxation involves fracture of the oroximal ulna with cranial fractures, there is no fragment distraction (Fig. 14-7).
:;
:,4::,
t Fracture healing
Three distinct histologic patterns of bone healing have been identi-
fied: (1) direct healing of bone by osseoustissue,calied primary
bone healing, and (2) secondarybone healing, histologicallyseen
as two patterns: union of fragments by fibrous connective tissue
that is later converted to bone (intramembranous ossification); and
callus formation that matures through a sequenceof granulation
tissue, cartilage, mineralized cartilage, and finally, replacement by
bone (endochondralossification).11
Primary bone healing. Primary bone healingtt,t, may occur
under conditions of rigid fixation, which usually is achieved only
by anatomicreductionand compressionfixation.In areasol-stable
bone contact, direct extension of haversian osteons unites the
fragments. In minute fracture gapsthat are rigidly stabilized,lamel-
lar bone forms after granulation tissue or woven bone deposition.
The process in each instance is bony union through direct bone
formation; callus formation is not involved in the process. Al-
though this repair affectsbone tissue exclusively,initially the repair
is mechanically inferior to normal cortical bone. Normal strenqth
is attained through extensiveremodeling, which may take monihs
to complete.
Primary bone healing is characterized radiographically by lack
of periosteal callus, gradual loss in opacity of the fragment ends,
and progressivedisappearanceofthe fracture line. The re-establish-
ment of cortex and medullary cavity continuity occurs quickly
(Fig. 1a-8).
Secondary bone healing. The process of secondary bone
healing involves fibrous connective tissue or fibrocartilaginous cal-
Figure ltl-6, Lateralradiographin which an expansilelesion of the distal lus that is replaced by bone. This is the most frequently encoun-
t i b i aw i t h c o r t i c atl h i n n in ga n d g e n e r a lizeodste o lysisca n b e seen. N ote the tered form of bone healing. The cells participating in the healing
p a t h o l o g ifcr a c t u r ea t th e ju n ctio no f th e e xp a n silele sio na nd the ti bi alshaft. processare pluripotential mesenchymalelements,which differenti-
Periostealbone is presentadjacentto the fracture.Histologicdiagnosis:fibro-
sarcoma.
Figure 14-7, Pathologicfracture of the proximalfemur from secondary Figure ltI-8. Twelve-weekfollow-upradiographof a healedproximalradial
n u t r i t i o n ahl y p e r p a ra th yr o id ism
M.in e r a l r e so r p tio nwith subsequentbone fracture.The fracturel i ne i s no l ongerevi dent,and there i s c onti nui tyof the
w e a k e n i n gr e s u l t e din th e fr a ctu r eT. h e co r tice sa r e th in , the trabecul aeare cortexand medullarvcavity.Anatomicreductionand stablefixationresultedin
sc a n t ,a n d t h e b o n ei s le sso p a q u eth a n n o r m a l. bone heal i ngw i thoutthe formati onof a peri ostealcal l us.The ul narfrac tures
not heal ed.
I6 6 A P P E NDI CU L AR E D FE LIN E
S KE L ET ON -C A N INAN
Tahle lt -r. Radiographic signs of secondary bone and thus bony union. Callus size is determined by a host of factors:
healing fiacture type, degree of stability, width of the fracture gap, and
vascularity of the regional soft tissues.
5-10 days post-reduction The following radiographic description of uncomplicated sec-
Fracturefragments lose sharp margins ondary bone healing is of a simple long-bone diaphyseal fracture
Demineralization of fracturefragment ends resultsin slight that has been stabilized with an intramedullarv oin (Table 14-1).14
fractureline widening By the first week,fragment ends begin to lose'their sharp margins,
10-20 days post-reduction and the fracture gap increases slightly in width. These changes
Formationof endostealand periostealcallus result from a combination of interfragmentary motion, resorption
Decreasingsize of fracturegaP of necrotic bone ends, and vascular ingrowth. Within the next 2
Variableloss in opacity of free fracturefragments weeks, variable amounts of periosteal, endosteal, and intercortical
After 30 days post-reduction callus appear.Initial periosteal callus is faintly mineralized and has
Fracturelines graduallydisappear irregular margins; it is located subjacent to the cortex on each
Externalcallus increasesin opacity and remodels fragment a slight distance from the fracture gap. By 4 weeks, the
After 3 months post-reduction callus is smoother and more opaque and is visualized as a cuff of
Continuedremodelingof externalcalluses bone beginning to bridge the fiacture gap; the fracture line should
Trabecularpattern may develop within the callus be smaller in size. After 4 weeks, the fracture line is slowly obliter-
Corticalshadow becomesvisible through the callus ated and the bony callus bridges the fracture area. At this point,
MeduIlary cavity continuity re-established g radually
the callus should be as opaque as normal bone. After 12 weeks,
Corticalremodelingalong the lines of stress
the external callus remodels until the continuity of the cortex and
medullary cavity is re-established. This final process may take
severalmonths to years. Healing in individual patients varies from
this description according to severalfactors (Fig. 14-9).
ate into osteoblasts,fibroblasts, or chondroblasts,depending on the Clinical unron. Clinical union refers to that ooint in fracture
soecificmicroenvironment at the time. A local cascadeof molecular healing when the fixation or stabilization device can be removed,
mediators of inflammation, as well as angiogenic factors, growth and the animal returned to some degree of normal activity. A
factors, and electroconductivity potentials, also play an important combination of radiographic, clinical, and historical evidence is
role in the healing process. Bone cannot form in an unfavorable used in making this assessment.Knowledge of the factors that
environment (motion). Therefore, under conditions of instability' modif' fracture healing is important in this regard.
the mesenchymal cells of the periosteum respond by producing a
fibrous to fibrocartilaginous callus. With time, this callus bridges Factors that modify fracture healing
the fragments and increasesstability. The stable environment per- In the evaluation of fracture healing, many factors that influence
mits vascularization of the callus, resulting in callus ossification healing or contribute to complications must be considered.Under-
t:):a::'!))l:.
Follow-up evaluations
Figure 14-16. Lateralradiograph of a pinnedfemoralfracture.Thereis The limb should be remeasured during each radiographic evalua-
in the areaof attachment
mineralization muscle(solidarrow)
of the adductor tion, and appropriate kilovoltage peak (kVp) and milliamperage
Maturecallusis presentat the fracturesite(openarrow). (mA) factors should be selected on the basis of an established
technique chart. Resolution of limb swelling coupled with limb
atrophy postfracture will change the thickness measurement sig-
Fragment alignment and rotation should aiso be assessed.Exact nificantly during fracture-healing evaluations Follow-up studies in
anatomic alignment is desirable but impossible to accomplish in which the same exDosurefactors were used as for the initial fracture
all fractures for al1 fragments. Rotation of the distal fragment radiograph markedly in tissue opacity.
relative to the proximal fragment is an important finding that may Bandages,-uyl'nty
casts,and external fixation rods should be removed if
have serious consequencesif not identified and corrected. The possible before radiography. A clear, unobstructed view of the
accurate assessmentof alignment and rotational deformities, how- fracture area is then ensured. If cast removal is impractical, the
ever, requires the use of good radiographic positioning. Excess following technical alterationsare suggested.For plaster casts,
'measurethe cast limb and increase the normal kVp by 107o. For
fiberglasscastsand healy bandages,measure the cast limb and use
the normal kVp for that measurement.
The protocol for repeat radiographs in fracture healing varies
with the clinician and with the circumstances of each oatient.
Obviously, every follow-up offrce visit of a fracture patient need
not include a radiographic examination. Good clinical judgment
should be exercisedin this regard. In general, a basic radiographic
plan should be followed and modified when appropriate.22Radio-
graphs should be taken immediately after initial fracture reduction
or after any major alteration (removal, adjustment, or addition) of
stabilization devices.Routine follow-up radiographs are taken every
3 or 4 weeks (or less frequently) to assesshealing. If the clinical
signs and history suggestcomplications, immediate re-examination
is indicated. Revision of the routine follow-uo schedule mav be
necessaryif complications are noted that necessitatemore frequent
monitoring.
Follow-up radiographs should be evaluated for progression in
the fracture-heaiing process or for the possible development of
compiications. This evaluation is facilitated by comparing current
radiographs with previous studies, especiallythe immediate post-
operative study and the most recent follow-up examination.
From Brinker WO, Hohn RB, Prieur WD (eds): Manual of Internal Fixation in Small Animals. New
York, Springer-Verlag, 1984; with permission.
pain. Soft-tissueswelling with or without subcutaneousemphysema bone tissue is less exuberant, and clinical signs of osteomyelitis are
may be the only abnormality seen on initial radiographs. In repeat not present.
radiographs 7 to 10 days after the onset of clinical signs, a general- Nerve injury may be associatedwith the initial fracture (e.g., the
ized, irregular periosteal reaction is a common finding. As the bone radial nerve in spiral humeral fractures) or with fracture repair
infection progresses,radiographic signs of an aggressivebone lesion and healing (e.g., the sciatic nerve in femoral fracture pinning).
may develop (see Fig. 14-23). A combination of corticomedullary Fracture-related sciatic palsy may occur with medially displaced
osteosclerosiswith areas of osteolysis surrounding pin metallic caudal ileal shaft fractures or sacroiliac fracture-luxation with cra-
implants is highly suggestiveof motion or pin tract osteomyelitis. nial displacement of the ilium.,e It may also occur secondary to
Pin tract osteomyelitis is frequently associatedwith external fixator surgically induced trauma, scar formation in the region of the
pins (seeFig. 1a-19). Irregular periostealreactionsare often noted nerve, and the proximal placement of the pin in the femur.3oThe
at the pin-cortex junction. more medial the exit of the pin is relative to the greater trochanter
A sequestrum is a dead bone fragment. It may be parosteal, and the longer the exposedproximal portion of the pin, the more
cortical, or intramedullary in location. Classically,an infected se- likely is the occurrence of sciatic entrapment (Fig. 14-25). Thus,
questrum is recognized as a sharply marginated sclerotic fragment postoperative femoral radiographs should be evaluated for proxi-
separatedfrom the parent bone by a zone of radiolucency and an ma[ pin location.
outer rim of sclerotic bone (involucrum) (Fig. 14-24). In some Bone atrophy-demineralization may result from chronic disuse
instances,the draining tract is evident (cloaca). Bone sequestra of the limb or from stressprotection by the orthopedic device. A
may be associatedwith infections or draining tracts. Failure of any generalized decrease in bone opacity with coarse trabeculation
isolated bone segment to be resorbed or revascularizedmay result involving the entire limb signifies disuse atrophy-demineralization.
in sterile sequestra.In these instances,the reaction of surrounding The bone may become hypoplastic. Demineralization may occur
..r,,,.,,,r11tr,,.,1
it!iu,.iitlqtr,.
,a@1,..
giP;1
F i g u r e 1 4 - 2 1 . S e q u e n tiala l te r a lr a d io g r a p hos f a d e la y eduni on, commi nutedmi dshaft,and femoral fracture.A ,4-month fol l ow -upradi ographs how s
m a l a l l g n m e notf f r a g m e n ts,r e a ctiven o n b r id g inca g llu sfo r m a ti on,anda vi si bl efracturegap.B , 5 monthsl ater,therei s an organi zed
cal l us.C l l n i c al l the
y , l i mbw as
s t a b l ea n d n o t p a i n f ul;th e a n im a wa
l s b e a r in gwe ig h t.C, 9 m onthsl ater,a bri dgi ngcal l usob i teratesthe fracturegap.The fracturehas heal ed .
I7 4 SK EL E T O N -C A N INAEN D FE LIN E
A P P E NDI CU L AR
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References
3. Orsini PG, Rendano Vl SackWO: Ectopic nutrient foramina in the third metatar-
sal bone ofthe horse. Equine Vet J 13;132,1981.
7. Salter RB, Harris WR: Injuries involving the epiphyseal plate. J Bone Joint Surg
451587,1963.
Figurc 1/r-26, A, Lateralview of the antebrachiumof a 2-year-olddog 1
year after correctiveosteotomy for radiuscurvus. The dog was moderately 8. Llewellyn HR: Growth plate injuries: Diagnosis, prognosis and treatment. ] Am
lam e a n d e x h i b i t e de l b o w p a in .A la r g eb o n e p la tewith fo u r b o n e screw si s Anim Hosp Assoc12:77,1976.
af f ix e dt o t h e r a d i u s .M e d u lla r yscle r o sissu r r o u n d sth e b o n e scr ew s,and a
9. Marretta SM, Schrader SC: Physeal injuries in the dog: A review of 135 cases.l
focal area of decreasedbone opacity involvesthe radius beneaththe bone
plate and two innermostscrews (arrow).These findingsare compatiblewith Am Vet Med Assoc 182:708,1983.
se
demin e r a l i z a t i o n c o n d a r yto str e ssp r o te ctio nIn . a d d itio nth, e enti redi stal 10. O'Brien TR, Morgan J, Suter P: Epiphyseal plate iniury in the dog: A radiographic
limb e x h i b i t sa g e n e r a l i ze d e cr e a sein b o n e o p a city,co r tica th l inni ng,and study of growth disturbance in the forelimb. J Small Anim Pract l2:I9,1971.
c oars et e x t u r eo f t h e t r a b e cu labr o n e .B, Dista a o f a normaldog.
l n te b r a ch iu m
Com p a r et h e c o r t i c atlh i c k n e ssa n d tr a b e cu labr o n ewith th o se in A. 11. PeacockE, Van Winkle W: Wound Repair Philadelphia, WB Saunders, 1976, p 547.
FractureH eal i ngand C omplicat ions177
12. Perren SM: Primary bone healing. In Bojrab Ml (ed): Pathophysiology in Small B. Is a sign of osteomyelitis
Animal Surgery. Philadelphia, Lea & Febiger, 1981.
C. Retains sharp margins radiographically
13. Rahn B: Bone healing: Histologic and physiologic concepts. In Sumner-Smith G D . I s a s i g no f n o n u n i o n
(ed): Bone in Clinical Orthopedics.Philadelphia,WB Saunders,1982.
E. Indicates excessivemotion of the fragment
14. Braden TD, Brinker WO: Radiologic and gross anatomic evaluation of bone
healing in the dog. I Am Vet Med Assoc 169:1318,1976. 4. Blood supply to the diaphysisof normal bone comesfrom:
15. Dingwall JS:Fractures.In Archibald J (ed): Canine Surgery,2nd ed. SantaBarbara, A. Epiphysealvessels,periosteal vessels,and endostealvessels.
CA, American Veterinary Publications, 1974. B. Telangiectaticvessels,recrudescentvessels,and lacunar ves-
16. Rhinelander FW Wilson IW: Blood to developing, mature, and healing bone. In se1s.
Sumner-Snith G (ed): Bone in Clinical Orthopedics. Philadelphia, WB Saunders, C. Periostealvessels,metaphysealvessels,and nutrient vessels.
1982. D. Articular vessels,joint capsulevessels,and capillaryloops.
17. Lappin MR, Aron DN, Herron HL, et al: Fracture ofthe radius and ulna in the E. None of the above
dog. I Am Anim Hosp Assoc 19:643,1983.
18. Heppenstall RB: Fractures ofthe tibia and hbula. In Heppenstall RB (ed): Fracture 5. Excessiveperiosteal reaction seenat or distant from the fracture
Treatment and Healing. Philadelphia, WB Saunders, 1980. site may be due to:
19. Hulse DH, Abdelbaki YZ, Wilson l: Revascularization of femoral capital physeal A. Rotational instability of the fragments.
fractures following surgical flration. J Vet Orthop 2:50, 1981. B. Periostealstripping at the time of injury or surgery.
20. DeCamp CE, Probst CW, Thomas MW: Internal fixation of femoral capital physeal C. Osteomyelitis/bone infection.
injury in dogs: 40 cases(1979-1987).I Am Vet Med Assoc 194:1750,1989. D. A11of the above
21. Swan KG, Swan RC: Gunshot Wounds: Pathophysiology and Management. Little-
E. None of the above
ton, MA, PSG Publishing,1980.
6, \{trich of the following is a radiographic warning sign that a
22. Morgan lP: Radiographic diagnosis of fractures and liacture repair in the dog.
Small Anim Vet Med Update Series19:1, 1978.
fracture is not healing normally? (Assume that a visible fracture
gap rs present.)
23. Saffar N, Revell PA: Interleukin-l production by activated macrophages sur-
rounding loosened orthopedic implants: A potential role in osteolysis.Br J Rheumatol
A. Demineralization of the fragment that ends at the fracture
33:309,1994. srte
B. Smooth periosteal reaction located a slight distance from
24. Sande R: Radiography of orthopedic trauma and ftacture repair. Vet Clin North
An Small Anim Pract 29:1247, 1999. the fracturegap
C. Linear radiolucency surrounding the shaft of an external
25. DeAngelis M: Causesof delayed union and nonunion of fractures. Vet Clin North
A m S ma l l A n i m P ra ct5:251,1975.
fixator pin
D. Scleroticfragment ends and a closedmarrow cavity
26. Brinker W, Flo G, Braden T, et al: Removal of bone plates in small animals. J Am
E. Minimal callus noted in fracture with rigid fixation
Anim Hosp Assoc 11:577,1975.
27. Rahn B: Bone healing: Histologic and physiologic concepts. In Sumner-Smith G 7. Examine the 3-month follow-up radiographs(Fig. 14-28) of a
(ed): Clinical Orthopedics. Philadelphia, WB Saunders, 1982.
28. Brinker WO, Hohn RB, Prieur WD (eds): Manual of Internal Fixation in Snall
Animals. New York, Springer-Verlag, 1983.
30. Fanton [!, Blass CE, Withrow SJ: Sciatic nerve injury as a complication of
intramedullary pin fixation of femoral ftactures. J Am Anim Hosp Assoc 19:687, 1983.
32. Vasseur R Stevenson S: Osteosarcona at the site of a cortical bone allograft in a ..s',
dog. Vet Surg 16:70, 1987.
,
,1r.
rr9':,,
::.i:::::
ffi Ouestions ll:.,,r
'.Q:,
.')::....
. ,l|:'
l Fractures of the growing physis usually involve what cellular :L'.))):.
l, rrf
layer? 1.U..
A. The reservelayer of chondrocl'tes *.:::
&ut...
B. The zone of proliferating chondrocytes
C. The zone of hlpertrophied chondrocytes
D. The zone of provisional calcification
E. The zone of osseousreplacement
f f i1 5
ffiBon
ffi
e Tumors Versus Bone lnfections
. Donald E. Thrall
Neoplastic and infectious bone lesions typically have an aggressive farction and subsequentosteosarcomaare occasionallysmall breeds
radiographic appearance.The radiographic signs of aggressivebone (shelties and terriers) in comparison with the large breeds that
lesions are discussed in Chapter 12. It is impossible to make a tlpically develop primary bone neoplasia.Bone infarction resulting
definitive distinction between neoplastic and infectious bone le- from a known cause,such as previous physical insult to the bone,
sions by radiographic means alone. However, by consideration of may also result in the development of subsequent osteosarcoma
the radiographic features of the bone lesion along with the sig- (Fig. 1s-6).6
nalment, history, and physical and laboratory findings, one may Rarely, occurrence of a fracture or use of an internal fixation
often rule in or rule out neoolasia versus infection with a hieh device will lead to the development of a primary bone tumor. Case
degree of acutracy. history reports have been published in which the development of
malignant tumors in associationwith previous skeletaltrauma has
been documented.This associationwas discussedin Chapter 14.
I Solitary metaphyseal Primary bone tumors of the appendicular skeleton oiher than
I aggressive lesions osteosarcoma are uncommon. Other than neoolasia, the maior
diagnosisto be ruled out for a monostotic aggressiue bone Iesion
The most common causeof a solitary metaphysealaggressivebone is mycotic osteomyelitis. Occasionally, a mycotic bone lesion is
lesion is a primary bone tumor.r A solitary metaphysealaggressive monostotic and metaphyseal-epiphysealin location. Based strictly
bone lesion in dogs or cats should be consideredto be a primary on radiographic criteria, such lesions may appear identical to a
bone tumor until proven otherwise. Osteosarcomasare the most primary bone tumor (Fig. 15-7). There may be other radiographic
common primary bone tumor in dogs; they originate most com- evidence,such as pulmonary infiltrates or thoracic lymphadenopa-
monly in the metaphysis of long tubular bones in large- and giant-
breed dogs.Common osteosarcoma sitesare the proximal humerus,
the distal radius, the distal femur, and the proximal and distal
tibias. Osteosarcomas may appear primarily lytic (Fig. 15-1), pri-
marily sclerotic (blastic or productive) (Fig. 15-2), or, most com-
monly, mixed, with both iytic and productive featurespresent (Fig.
15-3). It is important to remember that the degreeof lysis versus
sclerosisis not a feature that should be used in deciding whether
or not a lesion is aggressive (seeChapter 12).
Osteosarcomasin dogs may also be characterizedby a range of
periosteal reactions, varying from active or spiculated (Fig. 15-a)
to inactive or smooth (see Figs. 15-1 and 15-2). Although bone
infection may result in an active periosteal reaction, extremely
aggressiveand amorphous types of periosteal reactions are more
commonly associatedwith tumors.
Osteosarcomais also the most commoniy encountered primary
bone tumor in cats, but its prevalencein cats is lower than it is in
dogs. In cats, the hindlimbs are affected more often than the
forelimbs.t* Feline osteosarcomasare also aggressiveradiographi-
cally, but primary osteolytic lesions are more common.n Pulmonary
metastasisfrom feline osteosarcomais lesscommon than that from
canine osteosarcoma.a
In both cats and dogs, most osteosarcomasbegin in the metaph-
ysis but they may readily involve the epiphysis and diaphysis. The
opinion that primary bone tumors do not cross joints or invade
adjacent bones is false because both are possible as the tumor
enlarges.Such invasion, however, occurs late in the diseaseprocess.
Additionally, primary bone tumors may metastasizeto parenchymal
organs and other parts of the skeleton.
There are two specific situations in which the development of
osteosarcomais associatedwith another bone abnormalityt: bone
infarction'?and fracture-associatedosteosarcoma.Idiopathic polyos-
totic bone infarction is uncommon. Radiographically, it is charac-
teriied by multifocal increases in opacity within the medullary Figure 15-1. Lateralview of the distalantebrachium. A primarilylytic lesion
cavity of tubular bones (Fig. 15-5). Dogs with bone infarction are i nvol vi ngthe di stalradi almetaphysi si s present.The corte xi s ex panoeoc au-
dal l y.Margi nsof thi s l esl onare smooth.Thi sl esi onhas not c ros s edthe regl on
prone to the development of bone sarcoma.5The specificcause-
of the physi s,but manyosteosarcomas do. Thi s l esi oni s aggres s i v e,
bec aus e
and-effect relationship between bone infarction and bone sarcoma there i s no sharptransi ti onzone proxi mal l ybetw een no rmaland abnormal
is unknown. Dogs developing idiopathic polyostotic bone in- bone.D i agnosi s: osteosarcoma.
779
Figure 15-2- Lateralview of the femur. A predominantlysclerotic(blastic)
es i o ni s p r e s e n tT. h e p er io ste ar le a ctio nis sm o o th ,a n dth e r eis l i ttl eevi dence
of corticaldestruction.However,the lesionis aggressivebecauseof the lack
of a s h a r p t r a n s i t i o nz on e p r o xim a llyb e twe e n n o r m a la n d a bnormalbone.
Dia g n o s i so:s t e o s a r c o m a .
Figure 15-3. Lateralview of the proximalhumerus.There is a mixed lytic
and producti vel esi on i n the proxi malmetaphysi sand epi phy s i sThere
. is
cortexdestructioncranially,an activeperiostealreaction.and no evidenceof a
transi ti onzone di stal l ybetw eennormaland abnormalbone.Di agnos i sos
: teo-
sarcoma.
t8('
I
I
I
t
T
it
BoneTumorsVersusBone Infections l8l
Figure 15-6. Lateralview of the femur. The stem of the femoralcomponentof a total hip prosthesis
is visible.The prosthesishad been present for 5 years. Focalopacitiesin the medullarycavity of the
femur developedshortlyafter implantinsertionand were interpretedas bone infarcts.The oog oecame
acutelylameand in this radiographa lamellarperiostealreactionis presentcraniallybut an irregular,active
periostealreaction is present caudally.Also noted is soft-tissueswelling, which contains regions of
mineralization;
there is no obviousdistaitransitionbetweennormaland abnormalbone.Theseradiographic
signs are indicativeof an aggressiveprocess.Multiple biopsiesof the femur were obtained;circular
biopsy sites are visible.The histologicdiagnosiswas osteosarcoma,and there is a possibilitythat the
tumor resultedfrom the long-standing infarctsthat resultedfrom the prosthesis.
thy, or clinical signs of systemic debilitation that support the Mycotic osteomyelitisis most commonly identified in geographic
diagnosis of an infectious Process'but a biopsy of the bone lesion regions where predisposing fungi are endemic, for example, the
is necessaryfor a definitive diagnosis.Solitary metaphysealmycotic Southeast (blastomycosis)and the Southwest (coccidioidomycosis)
bone lesions are uncommon, but they do occur; any monostotic regions of the United States.However, infected dogs may relocate
metaphyseal aggressivelesion should be biopsied before a course to nonendemic areaswhere they may be examined by veterinarians
of therapy is selected. who do not have a high index of suspicion for fungal infections.
Bacteiial osteomyelitismay also result in a monostotic aggressive As noted earlier for solitary mycotic bone lesions, there may be
lesion. Bacterial osteomyelitis is most often the result of direct other clinical or radiographic evidence supporting an infectious
contamination of the bone, such as may result from surgery and etiology for polyostotic aggressivebone lesions, but this is not
trauma, rather than being hematogenous' Thus, the location of always true. Mycotic osteomyelitis should be considered in any
bacterial osteomyelitis in the bone is more variable than the loca- dog in which polyostotic aggressivebone lesions are identified
tion of primary tumors, and there is usually a history of previous (Fig. 1s-e).
trauma br surgery. Additionally, the signalment and radiographic With animal cancer patients being treated more aggressivelyand
distribution of the lesion are often sufficient for bacterial infection living longer, it has become apparent that metastatic bone cancer
to be distinguishedfrom neoplasia(Fig. l5-8). is more common than was once thought. Any malignant tumor
has the potential to metastasizeto the skeleton but, in general,
assressivebone bone metastasesfrom epithelial tumors are more common than
I [],t:He bone metastasesfrom mesenchymal tumors.T In dogs, mammary,
lung, liver, thyroid, and prostate cancersare tumors from which it
The major diagnoses to be ruled out for polyostotic aggressive is not uncommon for bone metastasesto develop.s'e Metastatic
bone lesions are metastatic solid tumors and mycotic osteomyelitis. tumor sites in the skeleton arise hematogenously.Therefore, they
Mycotic osteomyelitis is more common in dogs than it is in cats.
tend to have a polyostotic distribution (Fig. 15-10); ribs, vertebrae,
In general, patients with mycotic osteomyelitis tend to be younger
femur, and humerus are common sites.8'eIn long bones, both
than patients with metastatic solid tumors. Mycotic osteomyelitis
diaphysealand metaphyseallocations are common. Metastatic bone
is genirally of hematogenous origin, accounting for its polyostotic
tumors are aggressiveradiographic lesions, and, as with primary
naiure. Another consequenceof the hematogenous origin of my-
bone tumors, they may be sclerotic, mixed, or predominantly
cotic osteomyelitis is a metaphysealdistribution of lesions because
osteolytic. Patientswith metastaticbone tumors are generally older;
of the rich blood supply in this region of bone. Diaphyseal lesions,
they also usually have a history of primary tumor, making the
however, do occur.
index of suspicion higher for tumor than for mycotic infection.
Bacterial osteomyelitis may also cause polyostotic aggressivele-
sions. Hematogenous bacterial osteomyelitis is rare in dogs and
cats. As is the casefor monostotic bacterial osteomyelitis, surgery
and trauma are the most common causesof polyostotic bacterial
bone infection. Thus, bacterial osteomyelitis usually involves only
one limb, but more than one bone may be involved. Polyostotic
bacterial osteomyeiitis affecting one limb may be confused with
neoplasia. However, as has been stated previously, the signalment,
history, and clinical findings are usually sufficient to enable separa-
tion of infectiousfrom neoplasticprocesses(Fig. 15-11).
Hepatozoonosis is a rare protozoal infection that may cause
polyostotic aggressivelesions.lOHepatozoon canis has been diag-
nosed in dogs throughout the world; in the United States, most
infections occur in the South. The primary vector of H. canis is
the brown dog tick, Rhipicephalus sanguineus.Radiographically,
findings are primarily limited to the periosteum and range from
irregular periosteal proliferation to smooth laminar thickening of
the periosteum. Lesions have been reported in the axial and the
appendicular skeleton. The appearanceof the irregular periosteal
reaction is consistent with a polyostotic infection or metastasis.
The smooth periosteal reaction is misleading as this is not typically
associatedwith disseminated bone infection. Dogs with hepato-
zoonosis usually have systemic dysfunction. Common clinical signs
are fever, weight loss, muscle atrophy, ocular discharge,and gener-
alizedpain.lo
Figure 15-9. Lateralradiographsof a rear-limbdistal phalanx/A/ and the distal antebrachium(B) of a S-year-old, mixed-breeddog with a historyof lameness
a n d w e i g h t l o s s .T h e p h a la n xis ch a r a cte r izebdy m u ltifo carlegi onsof bonedestructi on, w i th some evi denceof new boneformati on.The cortexof the phal anxi s
destroyed.The distalradiusis characterized by mottled regionsof increasedand decreasedbone opacity.The cortex is destroyedcraniallyand caudally,and there
n neproxi mal
i s a n a c t i v ep e r i o s t ear le a ctio nT. h e r eis n o sh a r ptr a n sitio zo y betw eennormalandabnormalbone.The phal anxand radi all esi onsare bothaggres s i v e.
T a k e na l o n e ,b o t h a r e co n siste nwith t p r im a r yn e o p la siaT.a kencol l ecti vel a
y,more l i kel ydi agnosi si s mycoti costeomyel i tior
s metastati csol i dtumor.Thi s dog i s
relativelyyoung, lives in a blastomycosisendemic area,and had no identifiableprimarytumor. Blastomycosistiters were high, and Blastomvcesspecieswas
isolatedfrom a bone bioosv.Diaonosis:blastomvcosis.
Figure 15-1O. Lateralview of the proximalhumerus 1Aland ventrodorsalview of the pelvis (B) of a 1O-yearoldBordercolliewith previouslyirradiatednasa
c a r c i n o m aa n d r e c e n to n se t o f la m e n e ss.In th e h u m e r u s,there i s a focal regi onof decreasedbone opaci tythat has i ndi sti nctmargi ns;thus , thi s l es i oni s
th e r e is a ctivep e r io ste arle a ctio no n the caudalhumeralmetaphysi s.
a g g r e s s i v eA. d d i t i o n a lly, In the pel vi s,there i s a regi onof mi xedi ncreas ed
and dec reas ed
o p a c i t yi n t h e r i g h t pr o xim a fe l m u r ,m e d ia lto th e g r e a te rtrochanter.
The femorall esi onal so has i ndi sti nctmargi nsand i s thereforeaggr es s i v e.
P ol y os toti c
a g g r e s s i vlee s i o n si n a n o ld e rd o g with a kn o wnm a lig n a ntu t mor are most l i kel ycausedby metastati cancer.
c A l thoughmal i gnantnasaltumorsrarel ymetas tas i z e
t o b o n e ,s u c ho c c u r r e din th is d o q . Dia g n o sis: m e ta sta ticn a salcarci noma.
I8 4 SK EL E T O N -C A N INAEN D FE LIN E
A P P E NDI CU L AR
Figure IE-11. Lateralview of the antebrachiumof a 2-year-old dog that was bitten by anotherdog 2 months previously.
Th-edog was lame, and the limb was swollen.The radiusis characterized by increasedopacityin the distal diaphysisand
metaph\isis,an activeperiostealreaction,and a fracture.The periosiealreactionhas a palisadeappearancein some areas;
as meniionedpreviousiy(see Fig. 15-8),this is stronglysuggestiveof osteomyelitis.The ulna is characterizedby a relativelt
smooth periostealreaciion,increasedbone opacity,and apparentbendingaround the radialIesion.There are no sharp
transitionzones proximallyor dlstallyin either the radius or ulna. Both the radialand the ulnar lesionsare aggressive.
Although pathologicfracturesoccasionallydevelopthrough primarybone tumors, the historyand signalmentand the fact
that bolh ihe radiusand the ulna are extensivelyinvolvedsuggest infectionas the most likely diagnosis.Diagnosis:radial
fractureand oacterialosteomyelitis
graphic changes in dogs with pododermatitis and digital tumors bone lesions. However, lesions characterizedprimarily by osteolysis
f,avebeen rep;rted.l4 It was found that tumors and pododermatitis were more likely to be due to a malignant neoplasm.t' In another
were fairly evenly distributed between the manus and the pes' Also, study of dogs with digit masses,digit osteolysiswas seen in those
the frequency of bone involvement was similar between subungual with all types of digit masses,but was more commonly associated
tumors and pododermatitis 25148(52.1o/o) for pododermatitisand with squamous cell carcinoma'5 (Figs. 15-12 and 15-13).
33152(63.5%) for digital tumors. Regarding radiographic changes, Digitai tumors typically involve a single digit, but syndromes of
it was concluded thit pododermatitis could not be differentiated multiple-digit tumors have been described in dogst6'tt and catsts-"
from malignant tumors as both conditions resulted in aggressive (Fig. 1s-14).
Figure 15-12. Lateralview of the distal phalanxof the flfth digit of a dog. There is
extensivelysisof the distalphalanx;the lesionis aggressive. appearance
This radiographic
is more consistentwith neoplasiathan with pododermatitis,but histopathologic assess-
subungualme l anoma.(From
ment w i l l be neededfor a defl ni ti vedi agnosi s.D i agnosi s:
VogesAK, NeuwirthL, ThompsonJP,AckermanN: Radiographic changesassociatedwith
digital, metacarpaland metatarsaltumors, and pododermatitisin the dog. Vet Radiol
Ultrasound31.327, 1996.)
BoneTumorsVersusBone Infections 185
Figure 15-13. Lateralview of the swollen third digit of a dog. There is lysis of the
most distal aspect of the distal phalanx(white arrow) and periostealproliferationon the
palmaraspectof the middle phalanx(blackarrowhead).The entire digit is swollen.These
r a d i o g r a p h icch a n g esco u ld r e su ltfr o m e ith e ra tu m o r o r fr om i nfl ammatory di sease.A
b i o p s yi s n e e d e df o r a d e fin itived ia g n o sis.Dr a g n o sis: (FromV ogesA K .
p o d o dermati ti s.
N e u w i r t hL , T h o m p so nJP, Acke r m a nN: Ra d io g r a p h ch ic a ngesassoci ated w i th di gi tal .
m e t a c a r p aaln d m e t a ta r satul m o r s,a n d p o d o d e r m a titis
in th e dog. V et R adi olU l trasound
37:327,1996.1
5. Dubielzig RR, Biery DM, Brodey RS: Bone sarcomas associatedwith multifocal 4. Primary bone tumors in the dog and cat most often originate
medullary bone infarction in dogs. J Am Vet Med Assoc 179:64,1981' in the:
6. Marcellin-Little DJ, DeYoung DJ, Thrall DE, Merrill CL: Osteosarcomaat the site A. Diaphysis.
ofbone infarction associatedwith total hip arthroplasty in a dog. Vet Surg 28:54, 1999' B. Metaphysis.
7. Russell GR, Walker M: Metastatic and invasive tumors of bone in dogs and cats' C. Epiphysis.
Vet Clin North An 13:163,1983. D. Joint surface.
8. Geodegebuure SA: Secondary bone tumors in the dog. Vet Pathol 16:520, 1979' E. Periosteum.
9. Brodey RS, Reid CR Sauer RM: Metastatic bone neoplasms in the dog' J Am Vet
Med Assoc 148:29,1966.
5. Which radiographic appearancebest describesthe most com-
mon appearanceof bone infarcts in the dog?
10. Macintire D, Vincent-Johnson N, Dillon A, et al: Hepatozoonosis in dogs: 22 cases
(1989-1994).I Am Vet Med Assoc210:916'1997
A. Primarily lytic
B. Primarily sclerotic
11. Vail DM, Withrow SJ: Tumors of the skin and subcutaneous tissues ln Withrow
C. Mlxed lysis and sclerosis
SJ, MacEwen EG (eds): Snall Animal Clinical Oncology, 2nd ed Philadelphia, WB
Saunders, 1996, pp 167. D. No bone changes,only soft-tissue swelling
E. Multifocal medullary opacities
i2. O'Brien MG, Berg J, Engler SJ: Treatment by amputation of subungual squamous
cell carcinomasin dogs: 21 cases(1987 1988).I An Vet Med Assoc 201:759,1992'
6. Other than primary bone tumor, what is the next most com-
13. Aronsohn MG, Carpenter JL: Distal extremity melanocltic nevi and nalignant bone ie-
mon diagnosisto be ruled out for a monostotic aggressive
melanomas in dogs. ] Am Anim Hosp Assoc 26:605, 1990
sion?
14. Voges AK, Neuwirth L, Thompson fP, Ackerman N: Radiographic changesassoct A. Bone infarcts
ated with digital, metacarpal and metatarsal tumors, and pododermatitis in the dog'
B. Bacterial osteomyelitis
Vet Radiol Ultrasound 37:327, 1996-
C. Hepatozoonosis
15. Marino DJ, Matthiesen DT, Stefanacci ID, Moroff SD: Evaluation of dogs with D. Metastaticneoplasia
digit masses:117 cases(1981 1991).J Am Vet Med Assoc 2071726'1995'
E. Mycotic osteomyelitis
16. O'Rourke M: MultiPle digital squamous cell carcinomas in 2 dogs' Mod Vet Pract
66:644, 1985. 7. Which of the following tumors would be least likely to metasta-
17. Paradis M, Scott DW Breton L: Squamous cell carcinoma of the nail bed in three size to the skeleton?
Vet Rec 125:322,1989.
relatedgiant schnauzers. A. Mammary adenocarcinoma
18. Brown PJ, Hoare CM, Rochlitz l: MultiPle squamous cell carcinoma of the digits B. Prostaticadenocarclnoma
in two cats. J Small Anirn Pract 26:323, 1985. C. Thyroid adenocarcinoma
19. Pollack M, Martin RA, Diters RW: Metastatic squamous cell carcinoma in multiple D. Acanthomatous epulis
digits of a cat: Case report. J Am Anim Hosp Assoc 20:1984, 1984 E. Nasal adenocarcinoma
20. May C, Newsholme SJ: Metastasis of feline pulmonary carcinoma presentlng as
multiple digital swelling.I Small Anim Pract 30:302,1989. 8. Hematogenousbacterial osteomyelitisis (more, Iess)common
than hematogenous mycotic osteomyelitis in dogs in the United
21. ScottMoncriefJC,ElliottGS,RadovskyA,BlevinsWE: Pulmonarysquamouscell
carcinona with multiple digital metastasesin a cat. I Small Anim Pract 30:696, 1989' States.
16
4
Signs of joint diseasethat may be distinguished radiographically ated with the use of contrast arthrography. This technique has been
are listed in Table 16-l and illustrated in Figure 16-1. Many of used to aid in the identification of chondral flaps and tears in
thesesigns are seenin more than one type of joint disease,that is, dogs with osteochondritis dissecansand of synovial hypertrophy
they are not specific. Animals with joint diseasesthat are progres- in villonodular synovitis.
sive may have different signs when examined during different
phasesof the disease.
Altered thickness of the joint space
The examining clinician must determine whether lameness is The joint space is the region of soft-tissue opacity between the
due to a monoarticular or a multiarticular problem. A hallmark of subchondralbone of opposing weight-bearingsurfacesof a joint.
immune-mediated joint diseasesis their polyarticular distribution. This spaceconsists of two layers of articular cartilage separatedby
The same finding applies to hematogenously disseminated septic a microfilm of synovial fluid. In early joint disease,synovial effu-
arthritis. Most other joint diseasesinvolve one or only a few joints. sion may causewidening of the joint space.As joint diseasepro-
Are there systemic signs of disease?Cats with feline chronic gresses,attrition of articular cartilage results in a thinner appear-
progressivepolyarthropathy or Mycoplasmaarthritis have systemic ance of the joint space. Radiographs made while the patient is
signs of illness, including transient fever, malaise, and stiffness as weight bearing on an affected joint are required if changesin the
well as lameness.Animals with signs of bleeding disorders and thickness of the joint spaceare to be assessed properly. Radiographs
concurrent joint pain should be examined for signs of hemarthro- of the recumbent animal are not adequate for this purpose. The
sis. Systemiclupus erythematosus (SLE) is a multiorgan disease,of one exception to this rule may be when muscle contracture is
which polyarthropathy may be a mild clinical sign. These points present, thereby compressing the joint space. Contracture of the
are mentioned only to underscorethat sound knowledge of joint infraspinatus and quadriceps muscles, for example, reduces the
pathophysiologyis as important in the diagnosisofjoint diseaseas shoulder and stifle joint spaces,respectively.
is the ability to make and interpret radiographs of joints. Decreased subchondral bone opacity
The subchondral bone is separatedfrom the svnovial fluid bv an
I Signs of joint disease intact layer of joint cartilage. Any diseaseprocessthat changesthe
ta7
I8 8 S KE L ET ON -C A N INAEN D FE LIN E
A P P E NDI CU L AR
character of synovial fluid, causing the joint cartilage to erode, Table 16-2, Some common causes of intra-articular
potentially threatens the integrity of subchondral bone. In in- bodies
flammatory joint disease,inflammatory exudates may cause Pro- Joint Etiology
nounced subchondral bone loss. Infectious arthritis may extend
Shoulder Osteochondritisdissecansof the head of the
into subchondral bone. Subchondral bone loss initially appears as
numerus
a ragged margin of subchondral bone, but it may extend to cause Mineralizationof the bicipitaltendon/sheath
marked destruction of bone. When bone loss affects smaller carpal Synovialosteochondroma
and tarsal bones, these small cuboidal bones may be dramatically Elbow U n u n i t e da n c o n e a lo r o c e s s
reduced in mass. Fragmentedcoronoid process
Osteochondritisdissecansof the humeral
lncreased subchondral bone opacity m e d i a lc o n d y l e
Hip Avulsion epiphysealfracturesafter femoral
In benign joint disease,such as degenerativejoint disease,subchon- Iuxation
dral bone may be more opaque than normal. Increasedsubchon- Avascularnecrosisof the femoral head
dral bone opacity appears as a subchondral zone of increased Stifle Osteochondritisdissecansof the femoral
opacity I to 2 mm wide. condyles
Avulsion fracturesof the:
Subchondral bone cyst formation Origin of the long digital extensortendon
Origin or insertionof the crucitate
Subchondral bone cysts, a feature of degenerativejoint diseasein ligaments
humans, are occasionally encountered in young dogs with osteo- Originof m. popliteus
chondrosisl and in mature dogs with advanced degenerativejoint Meniscalcalcification
disease.t Synovial osteochondroma
Tarsus Osteochondritisdissecansof the talus
Altered perichondral bone opacity In all joints, soft-tissue periarticular mineralization may occur secondary
At the chondroslmovial junction, articular cartilage merges with to degenerative joint disease.
the synovial membrane. The highly vascular membrane is sensitive
to inflammation. Synoviai inflammation, or hlpertrophy, may re-
sult in erosion of the bone adjacent to the synovium. Early in- occurred. A good example is the cranial drawer sign in a stifle with
flammation causesthe adjacent bone to appear ragged and spicu- a ruptured cranial cruciate ligament. In this condition, clinically
lated. Long-standing or severe synovial inflammation or detectable displacement is not always easy to demonstrate radio-
hypertrophy may cause pronounced bone erosion. Perichondral graphically, but is best seenwhen stressedmediolateral radiographs
bone erosion is characteristic of some immune-mediated joint of the stifle are made with the tarsal joint held in maximum
diseasesand of villonodular synovitis. flexion.e Joint displacement is usually a consequenceof trauma to
fibrous or ligamentous supporting structures.
Perichondral bone proliferation
In degenerativejoint disease,fibrocartilage elements form at the Joint malformation
chondroslmovial junction. Gradual ossification of this fibrocarti- loint malformation representsthe end product of osseousremodel-
laginous periarticular collar produces osteophytes.Progressiveen- ing and is usually the result of malunion of bones of traumatized
largement of osteophltes may result in their incorporation into the joints, chronic degenerativejoint disease,or congenital joint dis-
adjacentjoint capsule.'z ease.
chondrosynovial junction with resultant fibrocartilage formation. results in increasedloading of the diminished weight-bearing sur-
This fibrocartilage collar gradually ossifies with the formation of face. The combination of increased load, diminished subchondral
perichondral new bone (Fig. 16-5). Enthesophytesdevelop on strength, and loss of shock-absorbing cartilage results in alteration
non-weight-bearing surfaces and are eventually incorporated into in the shape of the subchondral bone table. This remodeling of
adjacent ligamentous or capsular attachments.3s' 3e subchondral bone is complemented by the addition of peripheral
On radiographs obtained during weight bearing, continued attri- new bone in the form of perichondral osteophytes.Altered shape
tion of the articular cartilage may be detected as thinning of the of the osseouscomponents of affected joints is readily identified
radiolucent joint space. Pathologic alteration of the subchondral radiographically.3'g
The gamut of the radiographic changes seen in
bone shelf, including eburnation, compression, and necrosis, may degenerativejoint diseaseis outiined in Table 16-4.
be detected radiographically as increased subchondral opacity of
the weight-bearing surface. Subchondral cyst formation, a feature
of osteoarthritis of the human femoral head, has also been observed
I Hip dysplasia
in joints of small animals.2'3e The term hip dysplasiarneansabnormal development of the coxo-
Affected joints exhibit decreased range of movement, which femoraljoints. Hip dysplasiaoccurs principally in large dogs but
R adi ographiSci gnsof Joi nt Disease l9l
:GG
::a
Figure 16-7. Moderate hip dysplasia.Subluxationof the femoral head is Figure 16-9. A sentinel sign of early degenerativejoint disease is the
a c c o m p a n i ebdy r e mo d e lin o
g f th e a ce ta b u lu mT.h e cr a n iael ffecti veacetabul ar Morganline, representingenthesophyteformationon the caudalaspectof the
margin is rounded isolid arrow), and the acetabuum is shallow. Note the femoralneck, medialto the trochantericIossa brrow).
wedge-shaped joint space (hollowarrow).
Ig 4 R EL E T O N -C A N INAEN D FE LIN E
A P P E NDI C U L ASK
The PennHIP method3a,3s' s0also requiresthe dog to be placed A variant of the PennHIP method has recently been described,
in dorsal recumbency.The femurs are placed in a neutral position, in which the Ortolani maneuver is simulated with the dog in
to duplicate standing. This neutral position avoids spfualtensioning dorsal recumbency.55 This method disclosescraniodorsal and lateral
of the joint capsule, a significant disadvantageof the OFA projec- coxofemoral laxity, which is defined by a subluxation index (SI).
tion. The hindlimbs are held with the femurs neutrally positioned, The SI is essentially similar to the DI derived by the PennHIP
and a radiograph is made while the coxofemoral joints are com- method. This new stresstechnique confirms the findinss of penn-
pressed,to obtain an image of the coxofemoral joints at their most HIP research-thatthe standari OFA method ,,o1 allow for
congruent position. A distraction device is then placed between detectionof coxofemorallaxitv. -uy
the femurs for the second radiograph (Fig. 16-13). When the
femurs are pressedagainst the bars of the distracter, any coxofemo-
ral laxity that is naturally present is visualized radiographically. The
I Trauma that involves the
tlvo views of the hips are compared, and any coxofemoral laxity is
quantified by a unitless measure,the DI. A third (OFA) projection
I osseous components of joints
is made, so that secondarysigns ofhip dysplasia,such as degenera- Any fracture that communicates with a ioint space is an articular
-be
tive joint disease,can be evaluated (Fig. 16-14). fracture (Fig. 16-15). Articular fracturesmust diagnosedaccu-
The PennHIP method has several inherent advantagesover the rately to ensure appropriate surgical reduction and stabilization.
traditional (OFA) method of evaluating the coxofemorai joints Radiographic examinations should include two projections made
(Table 16-5). First, it quantifies joint laxity, which is generally at right angles to one another (Fig. 16-16). To these should be
accepted as the beginning, and probably the cause,of subsequent added oblique views and projections during flexion and stress,
degenerative changes. Second, the examination can be done on when needed. These additional proiections are of most value when
young dogs. The predictive value of the DI is constant after 6 chip or avulsion fractures are suipected or when the osseousstruc-
months of age, thereby providing invaluable information to breed- tures of interestare superimposedon other osseousstructures.
ers when selecting their stock. Third, the technique predicts a DI Articular fractures occur frequentlv in immature animals because
below which degenerativechangesare unlikely to occur. Converseiy, of the incidence of physeal and epiphysealtrauma in these patients.
there appears to be a direct relationship between the DI and the Becausethe proximal femoral physis is intracapsular, all femoral
subsequent development of osteoarthritis when the DI is greater capital physeal fractures are intra-articular fractures (Fig. 16-17).
than 0.3 (for German shepherds) or 0.4 (for Labrador retrievers In other joints, physeal fractures that involve the joint are usually
and Rottweilers). classifiedas Salter type III or IV fractures.s6
I Sprains-capsular,
ligamentous, and tendinous
injury to joints
Supporting soft-tissue structures of joints apPear as soft-tissue
opu.iti.r that positively silhouette with each other and with adja-
cent soft tissuis. Therefore, they are not clearly visualized on a
radiograph. The radiographic features of severesprains include (1)
periarticular soft-tissue swelling; (2) avulsion fractures at points of
attachment of ligaments, tendons, and capsulesto bone; (3) joint
instabiiity or subluxation; and (4) spatial derangement of the osse-
ous componentsof a joint.
It is important that sprains be diagnosed promptly. In many
instances, appropriate medical or surgical therapy ensures return
to normal joint function following moderate to severesprain injur-
ies. Many patients with profound sprains, such as carpal hlperex-
tension inluries, may be effectively treated, thus allowing the af-
fected animal to ambulate satisfactorily instead of surviving with
a disability.
The clinical assessment(palpation and manipulation) of a
sprained joint is usually the best diagnostic tool. Radiographic
eiamination adds information that is useful for treatment planning Figure 76-16, A long,obliquefractureof the ulna penetratesthe humero-
while documenting the presence and magnitude of the sprain ul narj oi ntat the medl alcoronoi dprocess.
R adi ographiSci gnsof Joi nt Disease 197
to which the joint would be subjected in normal daily activity and involves capital physeal fractures of the femoral head. When trac-
are defined as compressive,rotational, traction, shear, and wedge tion is applied to the femur in the extended ventrodorsal position,
forces (Fig. 16-20).Y capital physeal fractures are easyto identiff.
An excellent example of a compressivestressis a radiograph of A technique employing traction stress has been described for
a joint during weight bearing. Ligamentous trauma, as in carpal identi$zing medial scapulohumeral joint instability in small dogs.
hlperextension injuries, is readily detected by this technique. The With the patient in lateral recumbency, nontraction and traction
cranial drawer sign seen in cranial cruciate ligament trauma is a radiographs are made of the shoulder joint. A significant increase
practical example of a shearing stress. It is stress that is used in the shoulder joint spacehas been identified as a sign of medial
routinely in clinical examination of the stifle' The same manipula- shoulder joint instability.s8Traction and wedge stressesare usefu1
tive procedure may be applied to the stifle during radiography. for examining joints for small avulsion fractures and intra-articular
Tlaction stressinvolves pulling the osseouscomponents of the joint joint mice. Unilateral trauma to collateral ligaments of the elbow
away from one another. One useful application of traction stress and stifle may be disclosedwith the use of wedge stresses.Because
Figure I6-2O, Stressradiography of joints involvesthe applicationof traction/Ar,rotational18),and wedge 1C)forcesto demonstratesubluxationthat may not
be-appreciatedon standardradiographicprojections.(Adaptedfrom FarrowCS: Stress radiography: Appltcationsin small animalpractice.J Am Vet Med Assoc
181 7 7 7 .1 9 8 2 . )
R adi ographiSci gnsof Joi nt Disease 199
affected limbs, and affected ioints are swollen and painful. Radio-
graphic examinationin acute hemarthrosisrevealsjoint soft-tissue
swelling, which may be extensive.5eAfter chronic intra-articular
hemorrhage, the joint cartilage may be eroded and thin. The
subchondral bone appearsirregular if it is involved in the destruc-
tive process. Remodeling of bones adjacent to affected stifles was
reported in dogs after repeated intra-articular injections of whole
blood.60 In advanced hemarthrosis, signs similar to osteoarthritis
may be present.
I lnfectious arthritis
Infectious arthritis is a relatively infrequently diagnosed joint dis-
ease in small animals, the incidence being lower than that of
immune-mediated joint disease.Infectious arthritis is difficult to
diagnose radiographically. Initial radiographic changes are similar
to those seen in any effusive, nonerosive joint disease.Irreversible
joint damage has occurred by the time a definitive radiographic
diagnosis can be made. Ideally, the arthritis should be diagnosed
and successfully treated without definitive radiographic changes
becoming apparent.6t
Polyarticuiar infectious arthritis may occur secondary to bacter-
emia associatedwith an isolated focus of infection (endocarditis,
Figure 16-21, An 8-year-old maleAustraliancattledog had neurologlcsigns discospondylitis,or omphalophlebitis) or in conjunction with some
t h a t w e r e r e l a t e dt o th e h in d q u a r te rass we ll a s p a inin th e ri ghtsti fl e.l n the
fat pad i s
t a t th e in fr apatel l ar
l a t e r a vl i e w o f t h e rig h t stifle ,it is a p p a r e n th systemic diseases(as in Mycoplasma arthritis, canine leishmaniasis,
compressed b y s y n oviael ffu sio nNo . teth e b u lg in gca u d aco l mpartment of the or feline caiiciviral lameness).6'?' 63Polyarticular infectious arthritis
stifle joint (arrows).Discospondylitis was identifiedin radiographsof the tho- must be differentiatedfrom immune-mediatedjoint disease.Mo-
racicspine.Laboratorydiagnosis:septicarthritis-basedon isolationof Staphy- noarticular infectious arthritis most likely results from extension
lococcusaureusfrom the synovia fluid.
of focal osteomyelitisinto an adjacentjoint, direct joint trauma, or
foreign body penetration (grass seed awns), or it may occur after
joint surgery or intra-articular therapy.
stress radiography requires that personnel hold the patient during The earliest radiographic changesare synovial effusion and in-
x-ray exposure, utmost care must be taken to ensure that such creasedsprovial mass, which represent an inflammatory response
persons wear appropriate protective clothing. of the synovium (Fig. 16-21). Soft-tissueswelling is usually demar-
cated by the distended joint capsule.foint capsuledistention is best
identified in carpal, tarsal, and stifle joints. A useful landmark in
I Hemarthrosis the stifle is the infrapatellar fat pad. When the fat pad silhouette is
Intra-articular hemorrhage may occur in dogs with coagulopathies displaced cranially, becomes unclear, or is lost, sprovial effusion is
or after joint trauma. Hemarthrosis was reported in a dog with present. In untreated infectious arthritis, joint cartilage destruction
suspected warfarin toxicosis.seOther coagulopathies in the dog follows synovial effusion and is followed by subchondral and peri-
that may cause hemarthrosis include hemophilia A and B; von chondral bone destruction (Figs. 16-22).
Willebrand's disease;deficienciesin factors VII, X, and XI; and liver Specific radiographic featuresof infectious arthritis become con-
disease.Isolated,infrequent episodesof intra-articular bleedingdo spicuous after the articular cartilage is destroyed and subchondral
not significantly alter the articular cartilage. Repeatedhemorrhage osteomyelitis is established.It has been reported that destruction
may lead to severedamage to the cartilage as weli as the subchon- of the femoral head was noted radiographically 4 weeks after the
dral bone. onset of ciinical signs of coxofemoral infectious arthritis.6, The
Affected animals suffer severe non-weight-bearing lameness of width of the radiolucent joint spaceis progressivelyreduced as the
Cll
u:iiieuu,.
illiiii
';::::,.tta:.:
.1.:.:l
11!ill,r,rl!ll,!llll
lr-,ril.:
tgt:!tl
11SU;Utt''',rl
Table 16-6. Progression of radiographic signs of expected in a progressive disease,the magnitude of radiographic
infectious arthritis abnormalities becomes more obvious as the diseaseadvances.
Increasedsynovial mass, indicatingsynovial effusionand The progression of radiographic changesincludes (l) perichon-
widened radiolucentjoint space. dral decreasedbone opacity, (2) subchondral bone destruction and
Diminishedradiolucentjoint space,indicatingdestructionof cyst formation, (3) signs of perichondral osteolysis and erosion
articularcartilage. (Fig. 16-23), (4) narrowing of the joint space, (5) progressive
Loss of the smooth surfaceof the subchondralbone olate- decreasedopacity of epiphysesadjacent to affected joints, (6) de-
an early sign of infectiouspenetrationof subchondralbone. struction ofsubchondral and perichondral bone, (7) mushrooming
Osteolucentsigns of destructionof subchondraland of the ends of the metacarpi and metatarsi (which occurs in
pe rich on dra b
l on e, whic h is us uallyhighlight edby a
advanced arthritis and represents collapse of subchondral bone),
peripheralborder of increasedosseousopacity.
In advancedinfectiousarthritis,weight-bearingsurfacesmay and (8) varying degreesoiloint subluxation and luxation, also in
collapse,causingdistortionof joint architecture. advancedarthritis. Other changesmore characteristic of degenera-
tive joint disease (perichondral osteophytes/enthesophytes,sub-
chondral sclerosis,and calcified periarticular tissues) may also be
present at this stage.6s
articular cartilage is destroyed.Radiographsobtained during weight
bearing are needed to detect this change. Destruction of the sub-
I Systemic lupus
chondral bone plate and subsequent subchondral osteomyelitis
cause the margins of the joint space to appear uneven or ragged. I erythematosus
Continued subchondral bone destruction produces large cystic sub- Systemiclupus erlthematosus (SLE) is a multisystemic diseasethat
chondral radiolucent spaces.Bone sclerosisadjacent to the osteo- affects dogs of all breeds as well as cats. The disorder has a
lytic bone appears as increased osseousopacity, a sign of osseous variety of clinical manifestations, including polyarthritis, anemia,
inflammatory responseto the infection (Table 16-6). nephropathy, skin disease,pericarditis, myocarditis, and lymphade-
Increasingly,septic arthritis is being identified in joints that have nopathy.6q6eThe diagnosis of SLE is complicated, based on the
well-established osteoarthritis. Initial radiographs reveal changes concurrence of clinical manifestations and seroloeic evidence of
consistentwith degenerativejoint disease,often leading to inappro- the disease.
priate therapy for the infection. Radiographs made 2 to 4 weeks The immunopathologic features of SLE should be consistent
later reveal more aggressivesigns of periosteal new bone formation with the clinical involvement (e.g., if arthritis is present, immune
and intra-articular bone destruction.6aSeptic arthritis should be complexesshould be demonstrable in tissue biopsy samples).
suspected when acute lameness and joint pain are identified in The relative frequenry of the different clinicai manilestations
individual animals whose osteoarthritis has previously been well seenin SLE varies according to different authors. In one study, 121
controlled. patients were reviewed, and it was reported that ioint diseasewas
the most frequent clinical sign (6902), followed by hematologic
(53%), renal (507o), cutaneous (33%), and intrathoracic (17o/o)
I Rheumatoid arthritis manifestations.6s
Rheumatoid arthritis is a severe,progressive,erosive polyarthritis Arthritis that occurs in SLE is described as nonerosive and
that has been reported in dogs.6' A similar condition has been effusive. Poiyarthritis (five or more joints affected) is usual, but
identified in cats.66,67 monoarticular and pauciarticular arthritis have been reported.
Radiographic changes usually occur in distal joints of the ex- Clinically, affected animals are reluctant to move becausethey often
tremities. The more proximal large joints (stifle and elbow) are have a shifting lameness.Affected joints may be swollen, painful,
occasionallyaffected.Synovial effusion occurs initially. Radiographs and warm. The joints most commonly affected are the carpus,
made early in the course of the diseaseare typically characterized tarsus, metatarsus,stifle, and elbow.
by nonspecific soft-tissue swelling around affectedjoints. The joint Radiographic signs are usually absent or are minimal. In chronic
capsule may be distended. The first radiographic signs of an osse- SLE, the joint space of affected joints may be narrowed, and the
ous pathologic process may be detected several weeks after the joint capsule is distended. A mild periosteal response has been
onset of clinical signs. Initial changes are mild but, as would be reported at the junction of the joint capsuleand the bone. Contrast
arthrography has been useful in detecting distention of the joint Erosive form
capsule. The synovial margin outlined by arthrography has been
A second, more erosive form of feline noninfectious polvarthritis
reported as being irregular and indistinct.
has been described;it resembleshuman rheumatoid arthritis and
is seenin older cats.66,67
This form of the diseaseis characterized
I Feline noninfectious radiographicallyby severesubchondralbone erosion,perichondral
bone erosion, and subchondral cyst formation. Perichondral en-
t polyarthritis thesophyteformation, bone destruction at points of ligamentous
Feline noninfectious polyarthritis is a diseaseof male cats, aged 1 insertion to bone, and subluxation of small ioints of the extremities
70 The polyarthritis is categorizedas erosive or
to 5 years.66'67' alsooccur.
nonerosive.Tl There are two types of erosive polyarthritis-the A diagnosis of feline rheumatoid arthritis requires a positive
periosteal proliferative form and the erosive form; the latter is
more commonly referred to as feline rheumatoid arthritis. A group
of nonerosive, effusive polyarthropathies that are thought to be
immune mediated also occur in cats and are associatedwith a
variety of conditions.
rheirmatoid factor test, characteristic histologic changesseen on a are not covered with cartilage are roughened, and large perichon-
synovial biopsy, or both. Both of these test results are negative in dral osteophytesform.
cats with feline proliferative polyarthritis."
I Villonodular synovitis
Feline nonerosive polyarthritis
Villonodular sgrovitis is an intracapsular joint disorder character-
Two categoriesof nonerosive polyarthritis have been described in rzed.bynodular synovial hyperplasia,which is thought to represent
cats.7l They are feline SLE and idiopathic polyarthritis (IP), the a responseof the s1'noviumto trauma. Experimentally, villonodular
latter having four subtypes: (1) uncomplicated polyarthritis; (2) synovitis has been reproduced in dogs by repeated intra-articular
reactive polyarthritis, associatedwith a diseaseprocesselsewherein injections of whole blood. Villonodular synovitis is an established,
the body; (3) enteropathic polyarthritis, associatedwith gastrointes- although uncommon, disorder of humans that has also been re-
tinal disease; and (4) malignant-related idiopathic polyarthritis, ported in horses and dogs.z:-zo
associatedwith myeloproliferative disease. The radiographic signs of villonodular synovitis may be nonspe-
Radiography is used to distinguish the erosivefrom the nonero- cific but include articular soft-tissue swelling aione or with erosion
sive form of feline polyarthritis. The latter group is identified as of cortical bone at the chondrosynovial junction. These cortical
having periarticular soft-tissue swelling, joint capsule distention, erosions may appear cyst-like, with slightly opaque borders. In
and synovial fluid accumulation. severe proximal femoral villonodular sgrovitis in humans, the
femoral neck has been described as looking like an apple core. The
I Hypertrophic osteopathy articular cartilage and subchondral bone are not involved in the
diseaseprocess.Arthrography may be used to identifi; the intracap-
Hypertrophic osteopathy (HO) is a generalized'osteoproductive sular nodular massesof hlpertrophied synovium.
disorder of the periosteum that affects the long bones of the The differential diagnosis for perichondral erosive lesions, char-
extremities (Fig. 16-26). HO is usually secondary to cardiopulmo- acteristic of villonodular synovitis, should include s]movial osteo-
nary diseaseor neoplasia.Most neoplasmsare pulmonary (primary chondromatosis,rheumaloid arthritis, and ioint neoplasia.
or secondary), but HO is also reported in animals with primary
intra-abdominal neoplasia without pulmonary involvement. Non-
neoplastic causesof HO include inflammatory lung disease(e.g.,
I Synovial osteochondromas
blastomycosis),intrathoracic foreign bodies, Diroflaria immitis in- Synovial osteochondromashave long been recognizedin the joints
festation, and spirocercosis. of humans. These lesions are described as islands of cartilage that
The pathogenesis of hlpertrophic osteopathy is incompletely are produced by the synovial membrane. Foci of cartilage become
understood. The most consistent pathologic finding in affected pedunculated and may become separated from their pedicles to
animals is increased blood flow to the extremities. This increased form loose bodies within the joint.
flow results in an overgrowth of vascular connective tissue with The radiographic appearanceof mineralized synovial osteochon-
subsequentfibrochondroid metaplasiaand subperiostealnew bone dromas varies. These lesions are usually well-defined, rounded,
formation. New bone formation ty?ically commenceson the digits often multiple intra-articular nodules of calcific opacity (Fig. 16-
and progressivelyextends toward the axial skeleton. 27). Not all chondromas become calcified, in which instance, con-
Periostealnew bone formation results in cortical thickening. The trast arthrography may be necessaryfor their diagnosis.' Synovial
periosteal surface appears nodular or spiculated when visualized osteochondromasmay also arise from extra-articular foci of syno-
radiographically. When joints are involved, the bone surfacesthat vial tissue(Fig. 16-28).
;.-1;:!;T
Figure 16-27, A 5-year-oldfema e {neutered)Burmese cat had brlateral Figure 16-28. A 6-year-oldmale (neutered)Burmesecat had progressive
s t i f l e e n l a r g e m e n tM. in e r a liza tioonf th e in fr a p a te llafar t p a d and w i thi n the l amenessof the ri ghtforel i mbfor 6 w eeks.R adi ographi caltnere
l y , w as a targe,
s t i f l e j o i n t c o m p a r tm e n wa
t s e vid e n t r a d io g r a p h ica lly.Hist ol ogi cdi agnosi s: w el l -defi ned,
ossl fi edmass on the crani omedi al aspecto f the ri ght el bow .
s v n o v i aol s t e o c h o n dr o m a . H i stol ogidi
c agnosi s: extra-arri culsynovi
ar alosteochondroma.
F i g u r c 1 6 - 2 9 . A 1 4 - ye a r - o ld fe m a le in e u -
t e r e d )G o l d e nR e t r i eve hr a d p r o g r e ssivela m e -
n e s so f t h e r i g h tf o r e lim bfo r 4 we e ks. In a d d i-
t o n , t h e e l b o w w a s swo lle n .A a n d 8 , Active
periostealproliferationis present on the distal
h u m e r u sa n d t h e p r oxim aul ln a .Pu n cta tea r e a s
o f r a d i o l u c e n cayr e e vid e n tin th e p r o xim aul ln a
a n d t h e o l e c r a n o nH . isto lo g icd ia g n o sis:syn o -
vt a ls a r c o m a .
E D FE LIN E
2 O4 A P P E NDI CU L ASRKE L ET ON -C A N INAN
rg,
Figure 16-31. A 2-year-old female Great Dane had gradualenlargementof the proximalleft tibia and subsequentacute onsel of non-weight-bearing lameness
of the left hlndlimb.A and B, A focus of osteolysiswithin the medialcondyleof the proximaltibia extendsto involvethe joint space.A small bone fragment is
free within the jolnt space(arrow).Histologicdiagnosis:hemangiosarcoma.{Courtesyof the Universityof Sydney.)
R adi ographiSci gnsof Joi ntDisease 2O 5
Synovial osteochondromashave been reported in the dogtt and 10. McCarthy PH, Wood AKW: Anatomical and radiological studies of the iliopubic
cartilage in adult Greyhounds. Anat Histol Embryol 15:73, 1986.
the cat.a,78Their cause is unknown, but the theory of synovial
metaplasia is generally accepted.These lesions have been reported ll. Pond MJ, Lasonsky JM: Avulsion of the popliteus muscle in the dog: A case
report. J Am Adm Hosp Assoc 12:60,1976.
to causeseverelamenessin some dogs. Surgical removal of synovial
osteochondromas relieves clinical signs of joint pain and lame- 12. Eaton Wells RD, Plummer GV Avulsion of the popliteus muscle in an Afghan
hound. J Small Anim Pract 19:743, 1978.
ness.77
Intrameniscal calcification and ossification have been reported 13. Chaffee VW, Knecht CD: Arulsion of the medial head of the eastrocnemius in the
in the stifle joint of cats.sRadiographically,these lesions appear dog. Ver M ed Sm al l Ani m C l i n 70:c 29.1975.
similar to the reported appearanceof osteochondromaswithin the 14. Robinson A: Atraumatic bilateral arulsion of the origins of the gastrocnemius
feline stifle joint. Other conditions in cats in which intra- and muscle. ) Small Anim Pract 40:498, 1999.
periarticular mineralization may be confused with synovial osteo- 15. Rendano Vl Dueland R: Variation in location of sastrocnemius sesamoid bones
chondromatosis are mild forms of mucopolysaccharidosistype VI r fabel l aeti n a dog. I Am Vet M ed As s oc 173:200.1q78.
(MPS VI)D and hypervitaminosisA.3'? 16. Mahoney PN, Lanb CR: Articular, periarticular and.juxtaarticular calcified bodies
in the dog and cat: A radiologic review. Vet Radiol Ultrasound 37:3, 1996.
I Joint neoplasia 17. Wood AKW, McCarthy PH, Howlett CR: Aratomic and radiographic appearance
of a sesamoid bone in the tendon of origin of the supinator muscle of dogs. Am I Vet
The primary joint neoplasm,synovial sarcoma,arisesfrom primi- Res46:2043,1985.
tive mesenchymal precursor cells outside the synovial membrane 18. Wood AKW, McCarthy PH: Radiologic and anatomic observations of plantar
of joints and bursae.toThese tumors are uncommon in the dog sesamoid bones at the tarsometatarsal articulations of Greyhounds. Am J Vet Res
and are rare in the cat.81They occur most frequently in middle- 45:2158,1984.
aged, medium-sized to large dogs. The most commonly affected 19. Barthez PY, Morgan JP: Bicipital tenosynovitis in the dog-evaluation with posi-
joints are the stifle and the elbow Synovial sarcomasgrow slowly tive contrast arthrography. Vet Radiol Ultrasound 34:325, 1993.
and are first noticeable as a homogeneoussoft-tissuemass that 20. Lowry IE, Carpenter LG, Park RD, et al: Radiographic anatomy and technique for
involves or is near to a joint. Initially, radiographs reveal a mass of arthrography of the cubital joint in clinically normal dogs. J Am Vet Med Assoc
203:72, 1993.
soft tissue. Portions of the tumor may be calcified, with mineral
depositsappearingas hazy and punctate,or as linear streaks(Fig. 21. Muir q Johnson ICA.:Supraspinous and biceps brachii tendinopathy in dogs. J Am
Anim Pract 35:239, 1994.
16-29).
Canine synovial sarcomas are more likely to invade adjacent 22. Rivers B, Wallace L, Johnson GR: Biceps tenosynovitis in the dog: Radiographic
bone than their counterpart in humans. Initial bone involvement and sonographicfindings. Vet Comp Orthop Traumatol 5:51,1992.
appears as a spiculated periosteal response, followed by ragged 23. Muhumnza L, Morgan JP, Miyabayashi T, et al: Positive-contrast arthrography: A
erosion of the cortical bone adjacentto the tumor. Destruction of study ofthe humeral joints in normal Beagle dogs. Vet Radiol 291157.1988.
cancellousbone may be extensiveand most commonly occurs on 24. Cake MA, Read RA; Canine and human sesamoid disease. Vet Como Orthoo
both sidesof the joint (Fig. 16-30). The tumor is locally invasive Tiaumatol 8:70,1995.
with an unpredictable capacity to metastasize,s'? although distant 25. Robins GM, ReadRA: Diseasesof the sesamoidbones.In Bojrab MJ (ed): Disease
metastasis,particularly to the lungs, occurs in as many as one half Mechanisms in Small Animal Surgery, 2nd ed. Philadelphia, Lea and Febiger, 1993,
p 1094.
of reported patients.s0 Radiographicexamination of the thorax is
therefore mandatory in patients with suspectedsynovial sarcoma. 26. Vaughan LC, France C: Abnormalities of the volar and plantar sesamoids in
Many neoplasmsmimic the radiographic appearanceof slmovial Rottweilers.J Small Anim Pract 27:551,1986.
sarcomas(Fig. 16-31). In a recent study of joint neoplasms,syno- 27. Read RA, Black AR Arnstrong Sl, et al: Incidence and clinical significance of
vial sarcomaswere representedin only 8 (27Vo)cases.83 The other sesamoid diseasein Rottweilers. Vet Rec 130:533, 1992.
neoplasms whose radiographic appearancewas similar to that of 28. Davis PE, Bellenger CR, Turner DM: Fractures of the sesamoid bones in the
synovial sarcomas included fibrosarcoma, rhabdomyosarcoma, fi- Greyhound. Aust Vet j 45:15, 1969-
bromyxosarcoma,malignant fibrous histiocytoma, liposarcoma, 29. Ljunggren G, Olsson S-E: Osteoarthrosis of the shoulder and elbow joints in dogs:
and undifferentiated sarcoma.The once "pathognomonic" findings A pathologic and radiographic study of necropsy material. J Am Vet Radiol Soc
16:33,1975.
of an intra-articular tumor with osteodestructivepotential affecting
the bones on either side of the joint cannot be assumedto be 30. Tirgari M, Vaughan LL: Arthritis of the canine stifle joint. Vet Rec 96:394, 1975.
caused by a synovial cell sarcoma. Histologic evaluation of the 31. Marshall JL: Peri-articular osteophltes-initiation and formation in the knees of
lesionis mandatoryto establishits origin. the dog. Clin Orthop 62:37, \969
32. Allan GS: Radiographic features of feline joint diseases.In Watrous BJ (ed):
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I Vet Res4l:55. 1980. 78. Hubler M, Johnson KA, Burling RT, et al: Lesions resembling osteochondromatosis
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46. Morgan lP: Canine hip dysplasia: Significance of early bony spurring. Vet Radiol
2 8 : 2,1 9 8 7 . 79. Crawley AC, Yogalingam G, Muller VJ, et al: Two mutations within a feline
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80. Vail DM, Powers BE, Getzy DM, et al: Evaluation of prognostic factors for dogs
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49. Langenbach A, Grigor U, Green P, et al: Relationship between degenerativejoint 82. McGlennon NJ, Houlton ]EF, Gorman NT; Synovial sarcoma in the dog-a review.
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83. \\.tritelock RG, Dyce J, Houlton JEF,et al: A review of 30 tumours affecting joints.
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Iaxity in the dog. I An Vet Med Assoc 196:59, 1990.
51. Rendano VT, Ryan G: Canine hip dysplasia evaluation. Vet Radiol 26:170,1985.
ffi Ouestions
52. Farrow CS, Back RT: Radiographic evaluation of non-anesthetized and non-
l. Name the tendons in which each of the four sesamoidbones
sedated dogs for hip dysplasia. I Am Vet Med Assoc 194:524,1989.
of the stifle joint are located.
53. Aronson E, Kraus KH, Smith .l: The effect of anesthesia on the radiographic
appearanceof the coxofemoraljoints. Vet Radiol 32;2, 1991.
2. List six radiographicsigns of joint disease.
54. Belkoff SM, Padgett G, Soutas-Little RW: Development of a device to measure
canine coxofernoral ioint laxity. Vet Comp Orthop Traumatol 1:31, 1989.
3. The main causeof compressionof the infrapateilarfat pad is
55. Fluckiger MA, Friedrick GA, Binder H: A Radiographic stress technique for
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56. Salter RB, Harris WR: Injuries involving the epiphyseal plate. I Bone loint Surg
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57. Farrow CS: Stress radiography: Applications in small animal practice. J Am Vet
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58. Puglisi TA, Tangner CH, Green RW, et al: Stress radiography of the canine
humeral joint. J Am Anim Hosp Assoc24:235,1988.
61. Bennett D, Taylor DJ: Bacterial infective arthritis in the dog. ) Small Anim Pract
29:207,\988.
62. Moise NS, Crissman fW, Fairbrother JF, et al: Mycoplasma gateae arthritis and
tenosynovitis in cats; Case report and experimental reproduction of the disease.Am l
Vet Res44:10, 1983.
63. Ernst S, Cogin JM: What is your diagnosis?Mycoplasma arthritis. J Am Vet Med
A s s o c2 1 5 :1 9 ,1 9 9 9 .
64. Schrader SC: Septic arthritis and osteonyelitis of the hip of six mature dogs. J
Am V e t Me d \sso c l 8 l :8 9 4, 1982.
65. Bennett D: Inmune based erosive inflammatory joint diseaseof the dog: Canine
rheumatoid arthritis; L Clinical, radiological and laboratory investigations. J Small
Anim Pract 28:779, 1987.
67. Carro T: Polyarthritis in cats. Comp Cont Educ Pract Vet 16:57, 1994.
68. Grindem CB, Johnston KH: Systemic lupus erythematosus: Literature review and
report of 42 new canine cases.J Am Anim Hosp Assoc 19:489,1983-
70. Moise NS, Crissman JW: Chronic progressive polyarthritis in a cat. t Am Anim
Hoso Assoc 18:965.1982. Figure 16-32
Radiographic
Signsof Joint Disease 2O7
"til:::,.ill'l
"1".;
Figure 16-33
a. joint instability.
b. thickened synovium.
c. synovial effusion.
d. osteochondral fragmentation.
9. An extended ventrodorsal radiograph was made of the pelvis Answers begin on page 727.
APPENDICULAR
SKELETON-EOUINE
ffi CHAPTER
A-,
ffi
The approach to interpretation of large animal radiographs is satisfactory for distal limb radiographs but are problematic for
essentially the same as that for a small animal patient. Primary evaluation of the upper limb, neck, or trunk. Additional safety
differences between large and small animal radiography are dis- considerationsare also important.s Routine use of lead gloves,
cussedin this chapter. However, the reader is encouragedto review aprons, lead thyroid shields, lead-impregnated glasses,and cassette
Chapter 72 for materral presented there on bone formation and holders is a necessaryradiation protection measure. Proper re-
types of bone responseto diseaseamong small animals. These straint of the horse using tranquilization as necessary,to minimize
same responsesare relative to large animals with the exception that the number of people involved, and proper collimation are other
differential diagnostic lists are typically not as extensive.Entities in radiation safety factors to consider. Other technical procedures that
horsescommonly resuiting in skeletalradiographic changesinclude are an important part of patient preparation include the removal
acute injury, chronic repetitive trauma, degenerativejoint disease, of horseshoes, proper foot cleaning,and packing of the lateral sulci
infection, iatrogenic and metabolic derangement, and, rarely, im- of the frog prior to radiographic evaluation of the distal extremity.6
mune-mediatedor neoplasticdisorders.' Labeling of radiographs should be done in a systematic and
Routine radiology is a standard of practice for the evaluation of meticuious fashion. One should place the right/left marker on the
many equine orthopedic conditions.'-nRoutine radiographs are lateral side of the horse's limb for the dorsopalmar (plantar) and
used in evaluation of the skull, larynx/pharprx, thorax, and abdo- oblique radiographs. Also, the right/left marker should be placed
men.1Emphasishas been placedon obtaining correct diagnosesas on the dorsal aspect of the limb for lateromedial radiographs.
well as on identifring how a particular diseaseresponds to therapy. From the midmetacarpus and midmetatarsus distal1y,the lateral
Determining both the extent of a lesion and the involvement of and medial aspectsof the limb are axially symmetrical; therefore,
adjacentsoft tissueand bone is an important aspectof the radio- lateral and medial cannot be differentiated on radiographs that do
graphic examination. Additionally, the call for multiple joint exami- not contain a marking system.As part of the developmentprocess,
nations within a pre-purchaseexamination has increasedin fre- film labeling with proper animal and owner identification as well
quency. These factors, along with the unfortunate litigious nature as the date of the study should be provided.
of our society,emphasizethe importance not only of proper radio- Prior to review of the study for abnormalities, the radiographs
graphic technique but also of accurate methods of evaluation and should be assessedfor quality and positioning. Identification of
interpretation of standard radiographic projections of the equine problems may mean a second or even a third trip to the farm for
musculoskeletalsystem. exposurecompensation,positioning adjustment, or other correc-
tions that need to be made to obtain a diagnostic radiographic
study. A complete set of radiographs is imperative for basic review
I Technical considerations of the joint or area in question.Follow-up radiographicevaluation
Accurate radiographic evaluation of equine skeletal disorders re- of certain joints may require additional radiographs at a slightly
quires precisetechnique,positioning, and development,along with different angle of the limb to ensure that abnormalities have been
a systematicapproach to radiographic review and interpretation.I-6 projected tangent to the primary x-ruy beam. Follow-up radio-
The radiographermust possessexpertisefor proper positioning of graphs may include evaluation of the other limb, as developmental
the standing horse relative to the primary x-ray beam for various variants are typically bilaterally symmetrical.
radiographic projections.TOwing to the complexity of equine Portablefluoroscopicunits should not supplantthe radiographic
joints, routine radiographstypically include a lateromedial,a dor- study of a given joint. A negative fluoroscopic study does not
sopalmar (plantar), and two oblique (dorsolateral-palmarofplan- equate with a normal radiographic evaluation of the particular
taro] medial and dorsomedial-palmaro lplantarol lateral) radio- area in question. The contrast and spatial resolution of routine
graphs of joints distal to and including the carpus and tarsus.l'2 radiographs are superior to images obtained during fluoroscopic
For the best radiographic detail, the radiographer should use the examination. Additionally, the potential radiation burden received
slowest film-screen combination consistent with the capabilities by the operator of the fluoroscopic unit and others involved has
of the x-ray machine. Low-output portable x-ray machines are been shown to be substantial.8
209
2 IO A P P E NDI C U L ASK
R EL E T O N -EOU IN E
I Anatomy/physiology overview
The basics of bone anatomy and physiology were reviewed in
Chapter i2. The primary differences within the equine patient
regarding basicsof anatomy involve the common practice of earlier
Figure 17-1. Microradiographof the medialtrochlearridgeof the distal
imaging of the equine patient as a neonate, foal, and weanling. femurfrom a newbornfoalthat was euthanized reasons.
for unrelated The
Physealblood vesselscross the physis from the metaphysis to the microradiograph
showsthe irregularpatternof incomplete within
ossification
epiphysis in young horses. These transphysealvascular loops form thenormalfemoral
trochlear
ridoe.
complex capillary networks with a high density on the metaphyseal
side of the physis and within the epiphysis beneath the articular
cartilage. This anatomic difference, not Presentin small animals, is sites of osteochondrosisin the ecuine stifle are the medial femoral
important in hematogenous osteomyelitis, wherein bacteria lodge condyle and the lateral or medial trochlear ridge. Thus, in every
in the capillary loops of the physis, metaphysis, and epiphysis. In equine stifle radiograph, these sites should be evaluated for evi-
the neonate, certain epiphyseal structures can be immature with dence of osteochondrosis. Radiographic abnormaiities associated
incomplete endochondral ossification, resulting in a highly irregu- with osteoarthritis or degenerativejoint diseasein the equine are
lar bone margin (Fig. 17-1). This is particularly true for the similar to those described for small animals. Weight-bearing radio-
trochlear ridges of the distal femur and the talus. This incomplete graphs are usually obtained in horses, unless the horse is under
ossification cannot be radiographically differentiated from bacterial anesthesiaor has a non-weight-bearing lameness. Cartilage thin-
osteomyelitis. ning secondary to changesin joint spacethickness is more readily
The nutrient foramina and canalsform diaphyseallines that can
be mistaken for possible incomplete fractures. The position of the
nutrient canal in the proximal phalanx is variable; it can be located
dorsally in a mid-diaphyseal position, and thereby be confused
with a fracture.t The proximal fibula may also be characterized
by transverse radiolucent lines, representing regions of fibrous/
cartilaginous union, that should not be mistaken for fractures (Fig.
l7-2). Other anatomic variations have been described,t and there
are numerous variants of normal equine anatomy that should not
be mistakenfor pathologic processes.l'a' r0'
"
Important anatomic consideration should be given to the radio-
graphic variations within the third metacarpal and metatarsal
bones. These bones have variable cortical thickness within the
diaphysis at different locations, with the thickest portion of the
cortex being at the level of the middle of the diaphysis. The lack
of muscular protection of theselong bones makes them susceptible
to focal avascular injuries and sequestrum formation after blunt
trauma. Anatomic variations of the distal phalanx have also been
teported.a'12'r3
The responseof equine bones to underlying pathologic mecha-
nisms is the same as that described in Chapter 12. Chapters de-
scribing specific abnormalities of various joints include examples
of the common abnormalities. These Patterns and locations of Figure 17-2. Lateralradiographof an equinestiflejoint.The radiolucentline
abnormalities should be memorized and routinely reviewed for a in the proximalfibula is an expectedareaof incompleteossificationand does
particular joint when radiographed. For example, the common not representa fractureline.
l nterpretati on
P aradi gms
for the A ppendi cul ar
S kel eton - Equine 2ll
apparent than in similar small-animal non-weight-bearing radio- reduction in radiographic exposurefactors to avoid overpenetration
graphic studies. of the bone.
The location of the lesion in the bone is as imoortant in horses The chestnut and ergot result in radiopacities superimposedover
as in sma1lanimals.Traumatic injury to bone. periosteum,or soft the metatarsus, the antebrachium, and the metacarpo-/metatarso-
tissues can occur at any location in the bone, so complete evalua- phalangealjoints, respectively.Miscellaneousdebris on the skin can
tion of each radiograph is necessary.Epiphyseal disorders usually also create artifacts superimposed over underlying bone that need
include disorders specific to the growing horse, or to degenerative to be correctly identified as artifactual.
joint disease.Physeal and metaphyseal disorders include angular The normal bone respondsto diseaseby destruction (osteolysis)
limb deformities, growth-related abnormalities (aseptic physitis), or proliferation (osteosclerosis). The normal balancebetweenpro-
septic bacterial emboli with physeal and metaphysealosteomyeiitis, duction and destruction is maintained on a daily basis as osteonal
and trauma (fracture).Diaphysealdisorderstend to be confined to units are removed and replaced. In horses, particularly neonates,
traumatic injuries (e.g.,stressfractures,fractures). osteolysis will supersede osteoproliferation in inflammatory dis-
eases,particularly hematogenousosteomyelitis or septic arthritis. A
moth-eaten or permeative appearanceto the bone may be present
I Interpretation without adjacent areas of osteosclerosis.This helps differentiate
I paradigm-equine benign lesions such as a subchondral cyst with surrounding sclero-
sis from osteolytic lesions of the subchondral bone secondary to
I musculoskeletal radiology septicarthritis (Fig. 17-3). Dramatic osteolyticlesionscan develop
Within each of the chapters related to specific areas of the equine within 24 to 48 hours in foals with hematogenous osteomyelitis
limb, the radiographic abnormalities of commonly encountered (Fig. l7-a).
disorders are described. Use of a standardized evaluation system The bone responsein the neonate has a lamellar appearance,
for hanging and reviewing radiographs is imperative. Once the and in the adult, new bone proliferation (periosteal) appearsmore
radiographs have been placed on the viewbox in a systematic spiculated or smooth. Subperiostealhematomas can mineralize and
fashion, an overview of the radiographs can be made. Each radio- also appear as focal smooth bone exostosesalong a diaphyseal
graph should be removed sequentiallyfrom the viewbox and exam- cortex. It is important to remember that the responseof the bone
ined using a hot light. Soft tissuesshould be evaluatedfor swelling is dependent on many factors and that there is a continuum
or loss of normal/expected soft-tissue/fat planes. Next, the align- betweenthe appearanceofan aggressive lesion and that ofa benign
ment of the bones relative to each other should be reviewed, as lesion. It is also important to remember that bone reactions take
well as the alignment of the bone itsell while note is made of time to develop, even after a penetrating wound has occurred. An
subluxation, luxation, or cortical changes.When alignment is eval- acute bursal infection of the distal sesamoid bone or acute seotic
uated, it is important that the bones themselvesare in their ex- arthritis may not initially have any radiographic evidence of bone
pected location and have a typical shape for the age of the horse. cnange,
The cuboidal bones of the carpus and tarsus often have incomplete For radiographic evaluation, one should remember to use roent-
ossification and an incomplete shapein the neonatal foal compared gen signs as the tools to describe the abnormality. This assumesa
with the adult.'' " Areas of soft-tissueswelling (even if minimal) working knowledge of normal radiographic anatomy and possible
should be critically reviewed for underlying periosteal or endosteal normal anatomic variations. Additionally, the astute equine prac-
reactions or cortical disruption. The intramedullary cavity must be titioner memorizes the specific "go to" areason the radiograph for
scrutinized for areas of osteosclerosisor osteolysis.The overall specific diseaseprocesses.These areas are not meant to limit the
cortical thickness in the foal and weanlins is thinner than in the extent of the radiographic examination. For example, one should
adult, but it alsohas a less"compact" appeirance.More prominent not fall into a false senseof security that there cannot be anything
cancellous trabecular patterns are seen in the epiphyseal and me- else wrong with the tarsus just becausetypicai areas of the tarsus
taphyseal regions of the younger horse when compared with the have been evaluatedfor osteochondrosis.This type of searcherror,
adult. Finally, the joint margins, the articular cartilage-subchondral that is, stopping too soon, is a common mistale and should be
bone interface, and the joint space thickness should be evaluated avoided. Using the hot light for evaluating each radiograph forces
for radiographic evidence of increasedor decreasedwidth. the interpreter to look at each radiograph individually and to focus
Expected variations in normal bone configuration are similar to on specificareas.
those listed in Chapter 12. Anticipated radiolucencies within the Once radiographic abnormalities have been detected and de-
bone include the physis and the nutrient canal. Certain areas, scribed, one can proceed to compile a reasonabledifferential diag-
especially in the distai phalanx and in the proximal and distal nostic list, or a specific diagnosis based on the abnormalities
sesamoidbones, have conspicuous vascular channelsthat represent present, signalment, clinical history, and presentation. When all
normal changeswithin the bone. The pattern of vascularchannel facts are tied togetheq there are several caveats.The first is that a
development in the distal phalanx is variable between breeds of normal radiographic study does not equate with the absence of
horses and even over the life of an individual horse.'' tt These bone abnormalities. Thirty percent to 50o/oof the total bone mass
vascular channels can also change in size and number in various must change before a lesion can be detected radiographically. Sec-
diseasessuch as laminitis or pedal osteitis.l3Radiolucentsprovial ond, radiographic abnormalities may or may not correlate with
invaginationsin the distal border of the distal sesamoidbone are clinical lamenessor the absenceof lameness.Finally,further diag-
anticipatedin all horses.'5Radiolucentchannelsalong the abaxial nostic testing should include nerve blocks and nuclear medicine (if
margin of the proximal sesamoidbones are causedby blood vessels available) if multiple radiographic lesions are identified.
in the area where the suspensoryligament branches attach to the
bone.'6Improper packing of the sole for radiographsof the foot is
a common source of a radiolucencythat is commonly misdiag-
I Alternate imaging
nosed as a fracture.6Re-imagingthe foot after proper packing and Alternate imaging techniques availablefor evaluation of the equine
noting that the radiolucent line extends beyond the edge of the musculoskeletalsystem include computed tomography, ultrasonog-
distal phalanx are ways to know that the radiolucent line is not raphy, magnetic resonanceimaging, and nuclear medicine.
a fracture. Computed tomography requires specialized adaptations to the
When a horse does not bear weight on a limb, a very dramatic patient table so that table motion can still be achieved while the
disuseosteopeniawith decreasedoverali bone opacity occurs within weight of an adult horse is supported.Computed tomography has
severalweeks. The osteopenia may be severeenough to warrant a been useful for evaluation of complex fractures of the equine
I
2 I2 A P P E NDI CU L AR
S KE L ET ON -EOU IN E
Figure 17-3, A, A caudal-lateral to cranial-medial, 45-degreeobliqueradiographof the right stifle joint. There is a focal circulararea of lucency(arrow)within
t he m e d i a lf e m o r a lc o n d ylewith su r r o u n d in su g b ch o n d r ascle
l r o si s.B , l rregul arareasof osteol ysi si n a neonatalfoal w i th hematogenous
osteomy el i ti sFoc
. al
areaso f o s t e o l y s i sr e f l e c tb o n e d e str u ctio nin th e d ista lm e ta p hysi sand physi sw i thout surroundi ngbone producti on,w hi ch i s i ndi cati veof an aggres s i v e
osteomvelitiswithin the bone.
Figure 17-5, Reformatteddorsalplane /A/ and sagittal/B/ computedtomography{CT)imagefrom a horsethat fell over backward.in radiographs there was a
s u s p i c i o u fsr a c t u r eb e twe e nth e b a sio ccip ita a ln d b a sisp h e noibones.
d Thi s fracturei s confi rmedi n both A and B . The fracturew as not vi si bl ei n trans v ers e
im a g e sT . h i s i l l u s t r a t eth
s e va lu eo f CT im a g e s,u sin gm u ltip lanarreformattng i n thi s horse,to cl ari fysuspc ous radi ographil esi
c ons.
limb and for assistance in surgicalplanning and repair. Computed metatarsal imaging) that have been evaluated using ultrasound
tomography has also been used to evaluateequine skull abnormali- include the bicipital tendon, the Achilles tendon, thi tarsal liea-
ties and lesions of the distal extremities and cranial cervical soine ments, and the stifle joint. Ultrasound can be used to evaluite
(Fig. 17-5). Limitation as to what body parts can be imaged is articular cartilage erosions of the tarsus and stifle, particularly in
determinedby the gantry bore size.17 20 the neonatalfoal. SeeChapter 21 for examplesofultiasonographic
Ultrasound has been a mainstay in the evaluation of ligament imaging of tendons.
and tendon injuries in the racing and working equinepopulation.r0 Magnetic resonanceimaging is becoming more available for
Initial lesion localization, description, and architecture are well assessment ofthe horse.Becauseofthe exquisitecontrastresolution
visualized with ultrasound imaging. Evaluation of the pattern of of MR imaging, there is great potential for its use in assessing
fiber replacementand realignmentcan be accomplishedwith ultra- conditions such as navicular syndrome, in which inflammation and
sound imaging. Other areas (aside from palmar metacarpal or hemorrhage of the bone marrow are important features,but are
Figure 17-6. A, Soft trssue static phase images of the right and left fore distal extremity from a b year-old,Thoroughbredsuspectedof havtngnavtcutar
s y n d r o m eT h e i m a g e swe r e o b ta in e d fo r 6 0 se co n d s,e a ch starti ngapproxrmatel y5mi nutesafteri ntravenousi nj ectonof IsomC i (,].2GB q)of nn-Tc -"merny ene
d p h o s p h o n a t e8., B o n ep h a sesta ticim a g e so b tan e d 3 h o u r sp osti nl ecti on of the radi opharmaceuti cal On .the sofi -tl ssue
phasei mages,there s i nc reas eo upraK e
of t h e r a d i o p h a r m a c eu tica l e so ft tissu e so f th e d ista se sa moi dboneon the eft. In the i mageof the ri ghtl i mb,therei s a photopenc vol dtha t i s s eenac ros s
n th
t he i e v e lo f t h e c o r o n ar yb a n dwith o u tth e p r o xim ato l d ista lin creased radi oacti vi tynotedon the l eft. On the bone-phase i mages,i ncreased radioac tl v l ity
s noted
with i nt h e l e f t f r o n t d i s ta lse sa m o db o n e .T h e sescin tig r a p hchanges
ic are consi stentw i th i nfi ammatonof the soft-ti ssue structuresthat are assoc i atedw rn rne
d s t a ls e s a m o i db o n ea n d a ctiveb o n eo ste o b la stic a ctivitya sso c i ated
w i th the l eft di stalsesarnoro
D one.
2 I4 A P P E NDI C U L ASRKE L ET ON -EOU IN E
17. Ramirez O, lorgensen ]S, Thrall DE: Imaging basilar skull fractures in the horse:
not detectablewith other imaging modalities.'o'" A major limita- A review.Vet Radiol Ultrasound 39:391,1998.
tion to the use of MR imaging has been the relatively inaccessible
18. Riggs CM, \ /hitehouse GH, Boyde A: Structural variation of the distal condyles
magnet bore; however, new open magnets are now available that
of the third metacarpal and third metatarsal bones in the horse. Equine Vet I
allow imaging of equine iimbs and head. 3l :130,1999.
Nucleai medicine is an effective method of rapid screening for
19. Crass lR, Genovese RL, Render JA, Bellon EM: Magnetic resonance)ultrasound
areasof increasedor decreasedbone metabolic activity.tt The classic and histopathologic correlation of acute and healing equine tendon injuries. Vet Radiol
injury identified by nuclear medicine is the acute stress fracture- Ultrasound 33:2O6,1992.
related injury, or increased bone activity secondary to repetitive 20. Widmer WR, Buckwalter KA, Fessler )F, et al: Use of radiography, computed
trauma.23Additional soft-tissue inflammatory changescan be im- tomography and magnetic resonanceinaging for evaluation of navicular syndrome in
aged when a soft-tissue phase of the ee'Tc-methylene diphospho- the horse.Vet Radiol Ultrasound 4l:108, 2000.
nate study is used, or when a ee*Tc-pertechnetateor diethylenetria- 21. Koblik PD, Freeman DM; Short echo time magnetic resonanceimaging of tendon.
mine penta-acetate(DTPA) study is undertaken to assessfor Invest Radiol 28:1095, 1993.
inflammatory changes specific to the soft tissues of the area in 22. Hoskinson Jj, Tucker RL, Lillich J, Bertone Jl: Advanced diagnostic imaging
question. One area for which the soft-tissue phase of the nuclear modalities available at the referral center. Vet Clin North Am Equine Pract 13:601,
medicine study has proved to be effective is the evaluation of soft 1997.
tissuessurrounding the distal sesamoidbone (Fig. 17-6). A positive 23. Ruggles A], Moore RM, Bertone AL, et al: Tibial stress Iiactures in racing Stan-
soft-tissue study for this region is consistent with inflammatory dardbreds:13 cases(1989-1993).I Am Vet Med Assoc 209:634,1996.
changeswithin and around the distal sesamoidbone.'o 24. Trout DR, Hornof WH, O'Brien TR: Soft tissue and bone phase scintigraphy for
diagnosis of navicular diseasein horses. I An Vet Med Assoc 198:73, 1991.
I Summary W Ouestions
Equine radiography is challenging owing to the technical limita-
tions of portable equipment, the frequent use of this equipment in 1. The oosition and orientation of the nutrient foramen are most
the field, and the complex anatomy that must be imaged using variable in which bone of the eauine?
multiple radiographs. Routine radiography of the equine limb A. Proximal phalanx
requiies patience and some level of expertise in obtaining and B. Radius
intirpreting the radiographic study. The basic principles laid out C. McIII
in this chapter,along with those found in the other chaptersrelated D. Tibia
to equine joints, provide the initial framework on which to build.
2. Radiation safety features used in equine radiology should in-
References clude:
A. 0.5 mm Pb equivalent aprons, thyroid shields, and gloves.
1. Butler JA, Colles CM, Dyson SJ, et al: Clinical Radiology of the Horse. London, B. Appropriate film-screen combinations for maximizing mAs
Blackwell Scientific Publications, 1993.
techniques.
2. Shelley J, Dyson S: InterPreting radiographs 5: Radiology of the equine hock' C. Use of handheld cassetteextension devices.
Equine Vet l 16;488,1984.
D. Portable cradle systemsfor the portable x-ray equipment.
3. Park RD; Radiographic examination of the equine foot. Vet Clin North Am E. Film badgesand monitoring devicesfor all personnel in-
Equine Pract 5:47, 1989.
volved in making the x-rays.
4. Rendano VT, Grant B: The equine third phalanx Its radiographic appearance J F. All of the above
Am Soc Vet Radiol 19:125,i978.
G. None of the above
5. Koblik PD, Toal R: Portable veterinary x-ray supPort systems for field use J Am
Vet Med Assoc 199:186,1991. 3. Early septic arthritis is difficult to diagnose radiographically
6. Starrak GS: Radiology corner: Equine foot PreParalion. Vet Radiol Ultrasound becauseof:
37:116,1996. A. Incompleteossificationof the subchondralbone.
7. Koblik PD, O'Brien TR, Cope CP: Effect of dorsopalmar proiection obliquity on B. Lack of appropriate radiographic techniquesto capture
radiographic measurement of distal phalangeal rotation in horses with laminitis J Am early changesin the bone.
Vet Med Assoc 192:346,1988.
C. Septic arthritis not involving the bone.
8. Thomas HL, Trout DR, Dobson H, McFadden RC: Radiation exPosureto person- D. None of the above
nel during examination of limbs of horses with a portable hand-held fluoroscopic
unit. I Am Vet Med Assoc 215:372,1999.
4. Normal anatomic variable developmentof the equine carpus
9. Kneller SK, Losonsky JM: Variable locations of nutrient foramina of the proximal includes all of the following except:
phalau in forelimbs ofThoroughbreds. J Am Vet Med Assoc 197:736,1990.
A. Subchondral cysts of the radial carpal bone.
10. Kneller SK, Losonsky JM: Misdiagnosis in normal radiographic anatomy: Nine B. Ulnar remnant along the caudal and lateral aspectsof the
structural configurations simulating disease entities in horses. I Am Vet Med Assoc
195:1272,1989.
distal radius.
C. Incomplete ossification between the distal radius and the
ll. Farrow CS; Critical thinking: Radiographic misdiagnoses in horses. Can Vet I
lateral styloid processof the ulna.
36:442,1995.
D. Remnant of the first carpal bone.
12. Kaneps AJ, O'Brien TR, Redden RR et al: Characterisation of osseous bodies of
the distal phalanx of foals. Equine Vet J 25:285, 1993.
5. An important anatomic difference in the blood vesselsbetween
13. Linford RL, O'Brien TR, Trout DR: Qualitative and morphometric radiographic smal1and large animais is that:
findings in the distal phalanx and digital soft tissues of sound Thoroughbred race-
horses. Am J Vet Res 54;38, 1993.
A. Metaphysealblood vesselsare connected to the diaphyseal
vessels.
14. Laverty S, Stover SM, Belanger D, et al: Radiographic, high detail radiographic,
microangiographic and histological findings of the distal portion of the tarsus in
B. Periostealblood vesselsare the primary blood supply to the
weanling, young and adult horses. Equine Vet J 23:413' 1991. outer one third of the diaphysealcortex.
15. Poulos P: The nature of enlarged "vasculat channels" in the navicular bone of the
C. Metaphysealblood vesselloops cross the physis in the cow
horse.Vet Radiol 29:60, 1988. and horse.
D. Epiphyseal blood vesselsin the dog are derived from the
16. Tiumble TN, Arnoczky SP,Stick JA, Stickle RL: Clinical relevanceofthe microvas-
culature of the ecuine proximal sesamoid bone. Am i Vet Res 56:720' 1995. metaDhvsealarterial arcade.
The Stifle 215
6. Diaphyseal disorders of the equine tend to be primarily re- C. C6-7 articular facet osteochondrosis.
lated to: D. Third tarsal bone fracture.
A. Infectiousetiologies.
B. Traumatic injuries. 9. Ultrasound has been used primarily for the evaluation of:
C. Metabolic disorders. A. Multiple radiographic abnormalities noted on survey radio-
D. Endocrinopathies. grapns.
B. Ligament and tendon injury of the suspensoryligament.
7. Normal radiolucenciesseenin the distal sesamoid(navicular) C. Comminuted tarsal bone fracture of the third tarsal bone.
bone of the horse are called: D. The distal phalanx and dorsal hoof wa1l for laminitis.
A. Vascular channels.
10. Nuclear medicine has allowed for the evaluation of which oart
B. Nutrient foramina.
of the navicular syndrome?
C. Synovial invaginations.
A. Soft-tissue phase for the evaluation of navicular bursitis
D. Incomplete ossification.
B. Acutebone awlsion injuries
C. Proximal border enthesooathv
8. Computed tomography can be used for evaluation of the horse D. Increasedsize and ttr.t-b., of the distal sesamoidbone
for each of the following abnormalities, except: n a v i c u l a ri n v a g i n a t i o n s .
A. Comminuted proximal phalanx fracture.
B. Ethmoid hematoma. Answers begin on page 727.
CHA P T E R
1B
The Stifle
I Mary B. Mahaffev
f The stifle foal (Fig. 18-3). The femoral condyle and femoral diaphysis are
ossification centersin the femur; and the tibial tuberosity, proximal
tibial condyle, and tibial diaphysis are separateossificarion centers
Normal anatomy in the tibia. The cartilaginousjunction betweenthe tibial tuberosity
The stifle is the largestjoint in the body. It consistsofthree separate and the other two ossification centersof the tibia is often irresular.
articulations: the femoropatellar, medial, and lateral femorotibial The distal femoral physis closes radiographically at approximately
articulations. The femoropatellar articulation is formed between 22 months.6 The tibial tuberosity unites with the proximal tibial
the trochlea of the femur and the articular surfaceof the oatella. epiphysis at 9 to 12 months.5'7 Proximal tibial physeal closure
The femoral trochlea consists of two oblique ridges with a deep begins at 20 to 24 months and is usually complete by 30 to 36
groove between them; the medial ridge is much larger than the months, with the distal aspect of the tibial tuberosity physis being
lateral ridge (Fig. 18-1). Becauseof the large size of the medial the last to close.s7 The fibula is incompletelv mineralized at birth
trochlear ridge, the patella lies lateral to the axis of the femur (see and may not be visible radiographicailyin young foals.3,7 The
Fig. 18*18). Besidesthe large medial trochlear ridge, there are femoral trochlea and patella are normally irregularly marginated in
other landmarks that help differentiate the medial and lateral foals younger than 5 months of age (see Fig. 18-38) owing to
aspectsof the femur on a lateromedial view. The extensor fossa for incomplete ossificationof the cartilaginoustemplatesof those
the origin of the long digital extensor muscle is located on the structures.s'e The trochlear ridges are more irregularly marginated
lateral aspect at the junction of the trochlear ridge and condyle proximally than distally. Care must be taken not to misinterpret
(seeFig. 18-1,4); the medial condyle is larger than the lateral onei,2 this change as evidence of septic arthritis. Conversely,the femoral
and has a "hook" that projectsproximally at the junction between and tibial condyles of foals are always smoothly marginated, and
the condyle and the caudal aspectof the distal metaphysis (seeFig. any irregular margination of these structures should be interpreted
18-lA). The transition from the lateral condyle to the metaphysis as abnormal.8'e
is smooth.
The femorotibial articulation is formed between the condyles of Radiographic technique
the femurs and those of the tibiae with the interoosed menisci. For routine evaluation,caudocranialand lateromedialproiections
Between the condyles of the tibiae is a promineni intercondylar of the stifle should be made. Occasionally,craniolateral-caudome-
eminence consisting of medial and lateral tubercles;the medial dial or caudolateral-craniomedial oblique views are useful to pro-
tubercle extends farther proximally than the lateral tubercle. The iect other surfacesof the joint. Raising and extending the hindlimb
large medial tubercle of the intercondylar eminence of the tibia caudally can be a useful technique to improve proximal positioning
is a useful landmark for distinguishing medial from lateral in of the cassettefor the lateromedial view.7 The stifle will tend to
caudocranialradiographsof this joint, particularlyif the patellaand move distally and to be partially flexed when this is done. A
fibula are not visible (see Fig. 18-18). The fibula is incompletely cranioproximal-craniodistal oblique (skyline) view of the patella is
mineralized. Radiolucent gaps between mineralized segments are useful for evaluating the medial and lateral surfaces of that bone
normal (Fig. 18-2) and must not be misinterpretedas fractures.3s (Fig. 1B-a), especiallywhen fracture is suspected.a,s,r0,rr
That view
There are two ossification centers within the distal femur and is taken with the joint held in flexion. Becauseof the thickness of
three in the proximal tibia that are radiographically visible in the the stifle area,the use of a grid considerablyincreasesradiographic
216 S KE L ET ON -EOU IN E
A P P E NDI CU L AR
Figure 18-1. A normal,adult equinestifle, Lateromedial (A) and caudocranial (B) views. a, medialtrochlearridgeof femur; b, iateraltrochlearridge of femur; c,
ex t en s o fro s s ao f f e m u r , d , tib ia ltu b e r o sity;e , in te r co n d ylaerm in enceof ti bi a;f, fi bul a;g, medi altubercl eof ti bi ali ntercondyl ar
emi nence,h, l ater altuberc l eof
t ibialin t e r c o n d y l ae rm i n e ncei,; p a te lla/,j jo in tsp a ceb e twe e nth e medi altrochl earri dgeandthe patel l a;k medi alfemoralcondyl e;1 l ateralfemoralc ondy l e.N ote
t he me d i a fl e m o r a lc o n d yleh a s a slig h t"h o o k" n o t p r e se n to n th e l ateralcondyl e.
detail. Disadvantagesof grid use are the need for alignment of the cartilage appears radiographically as a radiolucent bone defect,
primary beam so that it strikes the grid perpendicularly and the which is usuallv adiacent to an articular surface.
necessityof large exposure factors. In the equine stifle, osteochondrosismay affect the lateral troch-
lear ridge of the femur (Fig. 1B-5), in which instance the periphery
Radiographic abnormalities of the lateral trochlear ridge has an irregular appearanceowing to
multiple areas of cartilage that have not matured into bone.r2
Osteochondrosis and osseous cyst-like lesions. Osteochon- Occasionally, free or partially detached osteochondral fragments
drosis is a relatively common disorder in young horses. It results are observed adjacent to the periphery of the trochlea. Osteochon-
from cartilage maturation failure in which the proliferating carti- drosis is often bilateral; therefore, a radiograph of the opposite
lage model is not completely replaced by bone. The persistent stifle should be taken if osteochondrosisis identified.
r llu,rirtit:rutatii
:-
' :, - - 1 -
-:
e-- * -! *-..
F- .
i- *- r
,:-'"',
elrr,.
,
lt:llrli
tii6lt.,
:
, ' * * , , u'
::lll,::ll9l
11!llrl.iiilisrl
' ,llit,t':ttlll
J::' " l
Figure 18-5, Stifle of a horse with osteochondrosls of the lateraltrochlear Fi gure 18-6. C audocraniradi of an equi nesti fl e.A s mal ls ubc hon-
al ograph
l w.T h e a te r atr o che a r r id g els f attenedand
vie
rid g eo f t h e f e m u r ,l a t e r o m e d ia dra defect is presentin the mediaLfemoralcondyle(arrows).This lesionmay
t he s u b c h o n d r ablo n e is scL e r o tic. Sm al, r o u n d e d m osteochondral
, in e r a lized be consi dered as part of the osseouscyst-l i kel esi onsyndro me.l t c oul dnot
l o ch le arrid g e .
f ra g m e n t sp a r a l l et h e m a r g ino f th e la te r atr be seen i n the l ateravi ew .
The Stifle 219
progresses,sclerosis reflecting new bone formation may be seen, external trauma or wear and tear. Sisns are identical to those seen
and an active periosteal reaction may develop. in degenerative joint diseasein otheijoints. including periarticular
Skin laceration or puncture, with subsequentbacterial contami- osteophyteformation (Fig. 18-10), decreasedsize of articular
nation, is another causeof septicstifle changesin horses.Changes spaces,and subchondral osteolytic defectsdue to s1,novialhyperpla-
may be limited to the soft tissue, in which instance only soft-tissue sia. Care must be taken in the evaluation of articular space size
seen.If bone is involved, typical changesof osteomyelitis becausethis determination is influenced by the geometric relation-
:X."1*:." ship of the x-ray beam, the articular space,and the cassette.
Trauma. Tiaumatic alterations in the ecuine stifle should be Distal patellar changes. Fragmentation, enthesophyte forma-
evaluated in the same manner as in the stifle joint of other ani- tion, subchondrai irregularity, and radiolucency ofthe distal patella
mals.r6Fracturesof the tibial tuberosity,patella (Fig. 18-9), and have all been reported in adult horses with stifle lamenesi (Fig.
lateral trochlear ridge of the femur occur in decreasing order of 18-i1;.'r One of the potential causesfor thesechangesis instability
frequency.tTLigamentous damagecan often be evaluatedultrasono- of and stresson the distal patella causedby medial patellar desmot-
graphically.loDegenerativejoint diseasemay develop as a result of omv.Ie
2 2 O A P P E NDI C U L AR
S KE L ET ON -EOU IN E
t$
119
ii6
References
1. Quick CB, Rendano VT: Equine radiology-the stifle. Mod Vet pract 59i5,I978.
2. Nickles FA, Sande R: Radiographic and arthroscopic findings in the equine stifle.
J Am Vet Med Assoc 181:918,1982.
3. feffcott LB: Interpreting radiographs 3: Radiology of the stifle joint of the horse.
Equine Vet I 16;81,1984.
4. Harrison LJ, Edwards GB: Radiographic investigation of the equine stifle. Equine
Vet Educ 7:161, 1995.
5. Butler JA, Colles CM, Dyson SJ, et al: The stifle and tibia. In Butler JA (ed):
Clinical Radiology of the Horse, 2nd ed. Oxford, England, Blackwell, 2000.
6. Getty R: Sisson and Grossnan's The Anatomy of the Domestic Animals, Vol l,
5th ed.'Philadelphia,WB Saunders,1975.
7. leffcott LB, Kold SE: Radiographic examination of the equine stifle. Equine Vet l
\4:25, 1982.
8. Adams WM, Thilsted lP: Radiographic appearance of the equine stifle from birth
to 6 months. Vet Radiol 26:126, 1985.
9. Crevier N, Denoi-t JM: Normal radiographic appearanceof the equine stifle from
birth to 8 nonths lAbstractl. Vet Radiol Ultrasound 33:122,1992.
10. Latimer FG, Kaneps Al, Pasquini C: Stifle disease in horses. Compend Contin
F duc Pr ac t Vc t 22:J 81,2000.
12. PascoeJR, Pool RR, \\&eat JD, et al; Osteochondral defects of the lateral trochlear
ridge of the distal femur of the horse: Clinical, radiographic and pathologic examina-
Figure 18-11. Close-uplateromedial radiographof the stifle of a horsewith tion and results of surgical treatment. Vet Surg 13:99, 19g4.
fragmentationand radiolucencyof the distal Qatella(arrows)following medral
oatellardesmotomv. 13. Peterson H, Reinland S: Periarticular subchondral bone cysts in horses. proceed
ings of the 14th Annual Meeting of the American Association of Equine practitioners,
D ec em ber9- l l , 1908.Phi l adel phi a.
14. Stewart B, Reid CF: OsseouscystJike lesions ofthe medial femoral condyle in the
horse.J Am Vet Med Assoc 180:254,1982.
15. Steinheimer DN, Mcllwaith CW, park RD, et al: Comparison of radiographic
subchondral bone changes with arthroscopic findings in thi equine femoropatellar
and femorotibial joints: A retrospective study of 72 joints (50 horses). Vet Radiol
Ultrasound 36:478,1995.
17. Dyson SJ: Stifle trauma in the event horse. Equine Vet Educ 6:234, 1994.
18. Mcllwaith CW: Osteochondral fragmentation of the distal aspect of the patella
i n hor s es fqui
. ne Vet | 22:157.l qqO .
19. Squire KRE, Blevins WE, Frederick M, et al: Radiographic changes in an equine
patella following medial patellar desmotomy. Vet Radiol 31:208, 1990.
20. Dodd DC, Raker CW: Tirmoral calcinosis (calcinosis circumscripta) in a horse. I
Am Vet M ed A5s oc157:908,1q70.
21. O'Connor JP, Lucey MP: Tumoral calcinosis (calcinosis circumscripta) in the
hor s e.l r i s h Vet | 3l :173.1977.
22. Goulden BE, O'Callaghan MK: Tlrmoral calcinosis in the horse. N Z Vet J
27:217,1980.
ffi Ouestions
1. The most common location of osseouscyst-like lesions in the
equinestifle is the:
A. Medial femoral condyle.
B. Lateral femoral condyle.
C. Intermediate ridge of the tibia.
D. Patella.
E. None of the above
Figure 18-12. Closeup caudocraniaview of a horsewith tumoralcalcino-
s is. T h e r e s a l a r g emin e r a lize m d a ss o ve r lyin gth e p r o xim alaspectof the
f ib u l a .( C o u r t e s o
y f D r. Ch a r e n eCo o k,Ce n tr a Ge
l o r g iaEq u in eS ervi ces,Fort 2. Approximately _ 7o of radiographically normal horses may
Vallev.GA). have arthroscopic evidenceof abnormal cartilage in the stifle joint.
222 S KE L ET ON -EOU IN E
A P P E NDI CU L AR
A.5 5. The most common location for osteochondrosisin the stifle is:
B. 15 A. The patella.
c. 40 B. The lateral tibial condyle.
D. 75 C. The medial tibial condyle.
E. 90 D. The medial trochlear ridge of the femur.
E. The lateral trochlear ridge of the femur.
3. Stifle joint infection most commonly occurs:
A. Following a kick bY a dam. 6. True or False. Tumoral calcinosis in the stifle usually causes
B. After intra-articular injection. lameness.
C. Secondaryto mastitis.
D. Secondaryto umbilical infection' 7. True or False.On the caudocranial view of the stifle, the patella
E. Secondaryto fistulous withers. is lateral to the axis of the femur, and the medial tubercle of the
tibial intercondylar eminence is larger than the lateral tubercle.
4. On radiographs of the normal foal stifle:
A. The fibula is usuallY identified. 8. True or False.On the lateromedial view of the stifle, the lateral
B. The tibia has two major centers of ossification. trochlear ridge of the femur projects farther cranially than the
C. The margin of the patella is usually smooth and sharp' medial trochlear ridge.
D. The margitt of the femoral trochlea is usually irregular'
E. The marjins of the femoral condyles are normally irregular' Answers begin on prge 727,
CHAPTER
1I
'he Tarsus
r Debra K. Baird
The equine tarsus is complex and reportedly is the most commonly complexity of the joint. The rear limb should be positioned
affected joint in horses with hindlimb lameness.l- The equine squarely beneath the horse so that the metatarsus is perpendicular
tarsus comprises the talus and calcaneus as well as the central, to the ground in both the lateromedial and dorsoplantar directions'
fused first and second, and third and fourth tarsal bones' The A complete radiographic examination of the tarsus includes dor-
calcaneus,the largest bone of the tarsus, includes the tuber calca- soplantar, lateromedial, dorsolateral-plantaromedial oblique, and
neus, which deveLps as a separatecenter of ossification' Ossifica- dorsomedial-plantarolateral oblique views. Additional views to en-
tion of the tuber .ulcat"ns proceedsin a dorsoproximal direction; hance visualization of particular areas or bones are sometimes
it fuses to the main part of the calcaneus between 16 and 24 needed. For example, a dorsoplantar view slightly obliqued in the
months of age.t'u The ialus and the calcaneusform the proximal lateral direction (10 to i5 degrees)is beneficialwhen the medial
row of bonei in the tarsus. The trochlear ridges of the talus are malleolus is evaluatedfor osteochondrosis.Similarly, a flexed later-
distinct features of the bone. The lateral trochlear ridge can easily omedial view allows evaluation of the proximal aspects of the
be identified radiographically owing to the large notch at its distal trochlear ridges of the talus. A flexed plantaroproximal-plantarodis-
aspect. The medial trochlear ridge does not- have this distinctive tal view of the calcaneusallows evaluation of the calcaneusand the
not.h bnt its distal asPect can exhibit variable appearances'The sustentaculum tali without superimposition of other bony struc-
variation in appearancecan range from a small protuberance to tures.lo This view is also called a flexed dorsoplantar viewll and is
separateorr.ooi opacities at its aistal end.t The fitst and second particularly helpful in evaluation of the tarsal groove.
taisal bones .un appeat as separatestructures that fuse after birth'
In some foals, the hrst and iecond tarsal bones fuse before birth'
In one study, approximately 20o/oof 6-month-o1d foals exhibited I Radiographic abnormalities
radiographically separatefirst and second tarsal bones'6The lateral
malle"olusalso ilorms as a separatestructure that fuses to the tibia Osteochondrosis
in most foals by 100 days of age but may take up to 6 months'6 Osteochondrosis(OCD) of the tarsocrural ioint is common in
There are four synovial cavities, or joints, of the tarsus: tarso- the horse.r2't3 Radiographically, osteochondrosismanifests itself in
crural, proximal iniertarsal, distal intertarsal, and tarsometatarsal' several ways. It can appear as a separate osseous fragment, a
The tar-socrural joint is the largest synovial clyity a.nd.the one smooth or irregular radiolucent defect, flattening of the bone con-
involved in "bog spavin." It communicates dorsally with the proxi- tour, or an osseous cyst-like lesion. In the tarsocrural joint, the
mal intertarsal foint. Usually, the distal intertarsal and tarsometa- cranial aspect of the intermediate ridge of the distal tibia is the
tarsal ioints are separate synovial cavities. In some horses, the most commonly affectedsite. A cleavageline within the cranial part
tarsociural and proximal intertarsal joints communicate with the
of the intermediate ridge is visible and indicates an osteochondral
distal intertarsal joint.8 In approximately 9o/oof horses, the distal view best
fragment (Fig. 19-l). The dorsomedial-plantarolateral
intertarsal joint communicatei with the tarsometatarsaljoint' This
demonstrates the abnormaiity. The fragment can usually be seen
percentagecan be increasedro 24o/owith increasedinjection pres-
on the lateromedial view as well. Occasionally,the osteochondral
sure.n
fragment becomes dislodged and is subsequently crushed within
I RadiograPhic technique the tarsocrural joint. In these horses,a radiolucent defect is appar-
Use of a grid is not necessaryto obtain diagnostic radiographs of ent at the intermediate ridge of the distal tibia. Small pieces from
the tarsus. However, accurate positioning is essentialowing to the the crushed osteochondral fragment often gravitate distally and
TheTarsus 223
Figure 19-3. Osteochondrosis of the medialmalleolusof the tibia.Dorsolat- Figure 194, Degenerativejoint diseaseof the tarsus. Lateromedialview
eral-plantaromedial obliquexeroradiograph of the tarsus of a 2-year-oldStan- of the tarsusi n a 5 year-ol d
Thoroughbred
joint effusion.An osteochondral w i th a chroni chi ndl i mbl amenes s .
dardbredwith a tarsocrural fragmentis assocj- Periarticularosteophytosisis evident involvingthe dorsalaspect of the dislal
at ed w i t h t h e m e d i a l m a lle o lu s( a r r o ws) .T h e a xia l b o r d e r o f the medi al i ntertarsal
andtarsometatarsal ,,beak-l i ke,,
m alle o l u sa l s o a p p e a r ss lig h tlyir r e g u la T l oi nts.The protubera ncof e the di s tal
r .h is vie w wa s o b ta in e dby di recti ng medialtrochlearridge is a normalvariation(arrow).
the primarybeam 10 to 15 degreesoff a true dorsoplantarprojection{toward
the lateralside).This projectionallows better visualization of the axial border
of t he m e d i a lm a l l e o l u s .
Fracture and racing accidents. Thrsal bone slab fractures occur in horses
working at racing speed,most frequently in Standardbredhorses.3,
Fractureof the tarsus can be induced by a single,traumatic event, Articular fractures of the dorsal aspectof the proximal third meta-
or by repetitive stress-q?e injuries. Direct trauma to the tarsus has tarsal bone have been reported in Standardbredracehorses.32'33
reportedly resulted in fracture of the distal tibia and of each of the Detection of fractures is sometimes difficult owinq to the complex
tarsal and metatarsal bones.30The traumatic events included falls, anatomyof the tarsus.This is especiallytrue of slab fracturesof
kicks from other horses,polo incidents, automobile encounters, the tarsal bones. Follow-up radiography in 7 to 10 days may be
F ig u r e 1 9 - 7 . O s r e or n ye litis o ' r h e su sr e n r a cu
um t a l i .A , D o r s o m e dia l-apn ta r o la te rviea l w o f th e
. a' s , s . n a 2 O - y e a r - o1
T hdo r o u g h b r e dT.l- e l' o r se
c re s e n t e dw i t h a c h r o n icd r a in in gtr a cta t th e m e -
dial aspect of the tarsus and a hrstoryof a previ-
ou s p u n c t u r ew o u n dt o th issite .Osse o u sp r o life r -
at o n a n d o s t e o l y s i s is e vid e n t in vo lvin g th e
olantaraspectof the sustentaculumtali (arrows).
B, Flexedplantaroproximal-olantarodistal view of
: he t a r s u s T
. h e a r e ao f in vo lve m e nist b e tte re va l-
ua t e di n t h i s v i e w . O s se o u sp r o life r a tiois n p r e s-
en t a o n g t h e m e d i a lp a r t o f th e su ste n ta cu lu m
'.ai (arrows).The tarsa groovedoes not appearto
be l n v o l v e d .
226 A P P E NDI C U L ASRKE L ET ON -EOU IN E
Other conditions
Distention of the tarsal sheath proximal to the joint is referred to
as thoroughpin. It usually is related to trauma, either occurring
directly or by overstretchingofthe sheathand tendinous structures.
Lamenessmay or may not be present. Radiography may be helpful
to determine the presenceor absenceof osseouslesions associated
with the sustentaculum tali and mineralization of soft-tissue struc-
tures. A dorsomedial-plantarolaterai oblique view of the tarsus and
a flexed plantaroproximal-plantarodistal view of the calcaneusare
the best projections for assessmentof this condition. The presence
of radiographic changes warrants a guarded prognosis. Positive-
contrast radiography may provide additional diagnostic informa-
tion concerning possible adhesions or masseswithin the sheath. It
may also allow detection of abnormal communication between
the tarsal sheath and the tarsocrural joint or the intertendinous
calcanealbursa.
Various soft-tissue injuries of the tarsus can occur and usually
are trauma induced. Ligamentous and tendinous injuries may not
Figure 19-8. Osteomyelitis. Dorsal4s-degree radio-
lateral-plantaromedial have associatedradiographic changes for several days or weeks.
graphof the left tarsusfrom a 3-week-old Thoroughbredfoal. Thereare Nuclear scintigraphy may identifi areasof increasedbone turnover
multipleareasof bonelyslswithoutsurrounding reaction.
Thesechanges or blood supply earlier in these horses,before radiographic abnor-
involvethe centralandthirdtarsalbones,the calcaneous, the talus,tfreme- malities become apparent.
taphysis,andthe epiphysis coliwas cultured
of the distaltibia.Escherichia
fromthejoint.
References
1. McDonough j: Hock joint lameness.Am Vet Rev 43:629,1913.
helpful, at which time a fracture line may appear more prominent 2. Manning JP: Bone spavin.Illinois Vet 3:26,1964.
becauseof normal osteoclasticprocesses.When a fracture is sus-
3. Vaughn lT: Analysis of lameness in the pelvic limb and selected cases.Proc Am
pected, additional radiographic views may be beneficial in assess- Assoc Equine Pruct IIt223, 1965.
ment. The flexed lateromedial view of the tarsus is especiallyhelpful
4. Brokken TD: Tarsal lameness in Thoroughbreds: Diagnostic and prognostic aids.
to enhance visualization of the proximal aspect of the trochlear Proc Am Assoc Equine Pract 24:341,1978.
ridges of the talus. In suspectedsustentacuium tali fractures, the
5. Shively Ml, Smallwood lE: Radiographic and xeroradiographic anatomy of the
flexed plantaroproximal-plantarodistal view of the calcaneusis val-
equine tarsus. Equire Pract 4:9, 1980.
uable.
6. Smallwood ]8, Auer lA, Martens RJ, et al: The developing equine tarsus from
birth to six months of age. Equine Pract 6:7, 1984.
Osteomyelitis
7. Butler JA, Colles CM, Dyson S], et al: Clinical Radiology of the Horse. Oxford,
As with any other osseousstructure, osteomyelitis of the tarsus can England, Blackwell Science, 1993.
occur. The calcaneusis the most commonly involved tarsal bone. 8. Brown MR Valko K: A technique for intra-articular injection of the equine
Osteomyelitis of the sustentaculum tali has been associatedwith tarsometatarsal ioint. Vet Med Small Anim Clin 75265, 1980.
unilateral distention of the tarsal sheath.3aThe tuber calcaneusis
9. Sack WO, Orsiai PG: Distal intertarsal and tarsometatarsal johts in the horse:
prone to traumatic injury and subsequent infection. Frequently, Commmication and injection sites. J Am Vet Med Assoc 179:355, 1981.
the horse presents with a draining tract over the plantar aspect of
10. Morgan )P: Techniques of Veterinary Radiography, 5th ed. Ames, Iowa State
the calcaneus.35 Radiographic lesions include soft-tissue swelling, University Press, 1993.
osteolysis,periosteal proliferation, bone fragments, sequestra,and
11. Han CM, Hurd CD: Practical Diagnostic Imaging for the Veterinary Technician,
mineralization of soft-tissue structures. The plantarolateral-dor- 2nd ed. St. Louis, Mosby,2000.
somedial oblique and flexed plantaroproximal-plantarodistal views
12. Stromberg B, Rejno S: Osteochondrosis in the horse. i. A clinical and radiologic
of the calcaneusare particularly helpful in demonstrating involve-
irvestigation of osteochondritic disseens of the knee and hock joint. Acta Radiol
ment of the sustentaculum tali (Fig. 19-7). Sinography of the 358:139,i 978.
draining tract, if present, may also be useful to show osseous
13. Schougaard H, Ronne lF, Phillipson J; A radiographic suwey of tibiotarsal osteo-
involvement. chondrosis in a selected population of trotting horses in Denmark and its possible
genetic significance. Equine Vet J 221288,1990.
Septic arthritis 14. Stephens PR, Richardson DW, Ross MW et al: Osteochondral fragments within
Septic arthritis occurs most commonly in the foal and is often the dorsal pouch or dorsal joint capsule of the proximal intertarsal ioint of the horse.
Vet Surg 18:151,1989.
accompanied by osteomyelitis. Septic arthritis may occur due to
hematogenousspread of microorganisms, from umbilical infection 15. Mcllwaith CW, Foerner )J, Davis DM: Osteochondritis dissecms of the tarso-
crural joint Results oftreatment with arthroscopic surgery. Equine Vet J 23:155,1991-
or pneumonia, or by direct introduction into the joint from trauma
or joint injection, aspiration, or surgery. Hematogenous origin is 16. Tiotter GW, Mcllwraith CW: Osteochondrosis dissecans and subchondral cystic
The EquineCarpus 227
'Iesions and their relationship to osteochondrosis in the horse. J Equine Vet Sci 34. Dik KJ, Merkens HW: Unilateral distension of the tarsal sheath in the horse: A
l :1 5 7 ,1 9 8 1 . report of 11 cases.Equine Yet J l9t3\7 , 1987.
17. Watrous BJ, Hultgren BD, Wagner PC: Osteochondrosis and juvenile spavin in 35. MacDonald MH, Honnas CM, Meagher DM: Osteomyelitis of the calcaneus in
equids.Am J Vet Res 52:607,1991. horses:28 cases(1972-1987).J Am Vet Med Assoc 194:l.]ti. 1989.
18. Obrien T: Radiographic interpretation ofthe equine tarsus. Proc Am Assoc Equine
Pract 19:289, 1973.
ffi Ouestions
19. Eksell R Uhlhorn H, Carlsten J: Evaluation of different projections for radio-
graphic detection of tarsal degenerativejoint diseasein Icelandic horses. Vet Radiol
l. Which of the following is the largest synovial cavity of the tarsus
Ultrasound 40:228, 1999.
and the one involved in "bog spavin"?
20. Hartung K, Munzer B, Keller H: Radiologic evaluation of spavin in young trotters. A. Tarsometatarsal joint
Vet Radiol 24:153,1983.
B. Distal intertarsaljoint
21. White NA, Turner TA: Hock lamenessassociatedwith deseneration ofthe talocal- C. Proximal intertarsal ioint
caneal articulation: Report of two casesin horses. Vet Med Smail Anim Clin 75:678,
D. Tarsocruraljoint
1980.
22. Kraus-Hansen AE, Lamb CR, Wagner von Matthiessen PC, et al: Talocalcaneal 2. Osteochondrosisof the equine tarsus can appear radiographi-
ioint diseasein a Connemara gelding. Equine Pract 14:33, 1992. cally as which of the following?
23. Pool RR: Difficulties in definition of equine osteochondrosis; differentiation of A. A radiolucentdefectwithin the bone
developmental and acquired lesions. Equine Vet I 16(suppl):5, 1993. B. Fiatteningof the bone contour
24. Morgan lP; Necrosis of the third tarsal bone of the horse. I Am Vet Med Assoc C. Osseouscystlike leston
151:1334,1976. D. A separateosseousfragment
E. A1l of the above
25. Shaver IR, Fretz PB, Doige CE, et al: Skeletal manifestations ofsuspected hypothy-
roidism in two foals. J Equine Med Surg3:269,1979.
3. Which of the following is the most commonly affected site of
26. Mclaughlin BG, Doige CE: A study of ossification of carpal and tarsal bones in osteochondrosis in the tarsus?
normal and hlpothyroid foals. Can yetl 23tI64, 1982. A. The cranial part of the intermediate ridge of the tibia
27. Mclllwaith CW: Incomplete or defective ossification of carpal or tarsal bones. In B. Medial malleolus
StashakTS (ed): Adam's Lamenessin Horses,4th ed. Pliiladelphia, Lea & Febiger, 1987. C. Lateral trochlear ridee of the talus
28. Frctz PB: Angular limb deformities in foals. Vet Clin North Am Large Anim Pract D. Medial trochlearridle of the talus
2:125, 1980.
4. There is always good correlation between radiographic lesions
29. Dutton DM, Watkins ]B Walker MA, Honnas CM: Incomplete ossification of the
of degenerativejoint diseasein the tarsus and clinical lamenessin
tarsal bones in foals:22 cases(1988 1996.).J Am Vet Med Assoc 213:1590,1998.
the horse. (True or False)
30. Jakovl.jevicS, Gibbs C, Yeats Jl: Traumatic fractures of the equine hock: A report
of 13 cases.Equine Vet J 14:62, 1982. 5. In addition to the dorsomedial-plantarolateral view, which of
31. Tulamo RM, Bramlage LR, Gabel AA: Fractures of the central and third tarsal the foliowing radiographic views would be most helpful in evaluat-
bones in horses.J Am Vet Med Assoc 182:1234,1983. ing the sustentaculum tali?
32. Ross MW, Martin BB: Dorsomedial articular ftacture of the proximal aspect of
A. Dorsoplantarview
the third metacarpal bone in Standardbred racehorses:Seven cases(1978 1990). J Am B. Flexed proximodistal view of the calcaneus
Vet Med Assoc 201:332, f992. C. Dorsolateral-plantaromedial view
33. Ross MW, SponsellerML, Gill HE, et al: Articular f?acture of the dorsoproximolat- D. Lateromedial view
eral aspect of the third metatarsal bone in five Standardbred racehorses. I An Vet
Med Assoc 203:698, 1993. Answers begin on page 727,
CHA P T E R
20
The Equine Carpus
r Lisa Neuwirth I l. GreggBoring
DL-PaMO DM - PaLO
DL-PalVO DM-PaL0
LM&
FLM
LM&
FLM
A B
Figure ZO-I. Five standardradiographic projections.Diagramsof the proximal14)and distal (B) row oI carpalbones.Directionalterms describingthe point of
entranceto the point of exit of the primaryx+ay beam are designated.The terminologyshown in parenthesesdescribesthe angulationof the x-ray beam.
Angulationof the x-raybeam for the standardobllqueviews may vary from 30 to 40 degrees(D60"L-PaMO to D50'L-PaMO)for the dorsolaterapalmaromedial
obliqu e( D L - P a M Oa) n d f r om 2 0 to 3 0 d e g r e e s( D7 O"M - Pa Lto O D60'M-P aLO) for the dorsomedi al obl i que(D IV I-P aLO).
pal marol ateral C a, access oryc arpal ;C i ,
int erm e d i a tcea r p a lC vi ew ; LM, l ateromedi al
l r p a l;Cu , u ln a rca r p a l;F L M ,fle xe dlateromedi al
; r ,r a d iaca vi ew .
oblique (D60'L-PaMO) and the dorsal 60-degreemedial-Palmaro- skeletal margins should be evaluated with a bright or "hot" light
lateral oblique (D60'M-PaLO). unless computed radiography or xeroradiography is used to in-
In addition to the five standard views, oblique views made creaselatitude and soft-tissue contrast so that subtle chio fractures
tangential to the dorsal surface of the carpus during flexion are or soft-tissue abnormalities are not overlooked.
valuable for complete evaluation of suspectedcarpal disease(Fig.
20-2).a These tangential views are designated dorsoproximal-dor-
sodistal oblique (DPr-DDiO).s The angle of the x-ray beam is
I Normal anatomic variations
varied to project either the dorsal aspectof the distal radius or the The distal radius forms from trvo centersof ossification-the distal
proximal row or distal row of carpal bones6(Fig. 20-3). In general, radial epiphysis and the distal ulnar epiphysis (lateral styloid
the DPr-DDiO views of the dorsal surface of the carpus are ob- process). Fusion of the two epiphysesoccurs as early as 3 months
tained when there is carpal joint effusion and an abnormality to or as late as 9 months of age, depending on the breed (Fig. 20-4).
explain the clinical signs is not apparent or is incompletely evalu- A radiolucent line or cyst-like oval radiolucency is occasionally
ated on the five standard proiections. seen within the distal radial epiphysis secondary to incomplete
fusion of the epiphysis with the lateral styloid process in mature
horses (Fig. 20-5). These defectsare consideredincidental findings.
I Radiographic interpretation Closure of the distal radial physis occurs at betrveen 20 and 36
For standardization, it is recommended that carpal radiographs be months. A vestigeof the distal ulna is occasionallyseenon the DL-
olaced on the illuminator in a routine fashion. The soft tissuesand PaMO view adjacent to the distal radial metaphysis.
Figure 2O-2. Dorsoproximal-dorsodistal oblique(DPr-DD|O) projectionsof the equinecarpus.Theseviews are used to projectthe dorsalaspectsof the equine
caipal bones and the distal aspect of the radius.Angulationof the x-raybeam may vary from 30 to 35 degreesto the cassetteto projectthe distal row, from
50 to bb degreesto the cassetteto projectthe proximalrow, from 65 to 85 degreesto the cassetteto projectthe distal radius.Usually,the greaterangle is
preferred.
The EquineCarpus 229
Figure 20-5. Normal variationin the appearance,with closure of the physis, between the distal radralepiphysisand the styloid process on dorsolateral-
paim a r o m e d i o ab l l i q u ev i e ws.A, Sm a llo va lcystlikelu ce n cya n d smal larti cul arnotch.B , Long ovalcystl i kel ucencyextendi ngto the arti cul arsurfac e.N ote the
l o n e ,wh ich is a n in cid e n tafin
c v s t lik el u c e n c vi n t h e u l n arca r p a b l di ng.
The first carpal bone is more often present in the distal row proliferation, or both, and may result from synovitis, osteoarthritis,
than is the fifth carpal bone (Fig. 20-6). These carpal bones are fracture, or septic arthritis. A radiographic diagnosis of synovitis is
usually small and round or oval in shape.A cystJike lucent defect unusual but should be considered when no bony abnormalities
is sometimes identified in the adjacent aspect of the second carpal 4 fe r h n 4 fe n t
bone and the base of the second metacarpal bone in association Extracapsular swelling on the dorsal aspect of the carpus can
with the first carpal bone, or in the fourth carpal and metacarpal representa hygroma, synovitis of an extensor tendon sheath,bursi-
bones in associationwith the fifth carpal bone. These radiolucent tis, abscessor cellulitis, sgrovial hernia of the antebrachiocarpalor
regions are considered incidental findings and are of no clinical middle carpal joint capsule (ganglion), or carpal joint/extensor
significance. tendon sheath fistula (Fig. 20-10). A hygroma is a subcutaneous
The accessorycarpal bone occasionally develops from two cen- sprovial bursa that forms as a result of trauma. The swelling is
ters of ossification in Thoroughbreds. Incomplete fusion of these tlpically diffuse over the dorsum of the carpus and extends from
centersis radiographically identified in some weanlings (Fig.20-7). the distal radius to the proximal portion oflhe third metacarpus;
Identification of this accessorycenter of ossification is an incidental the ma-ximum degreeof swelling is not at the level of a joint.' The
finding. This physis usuaily fuses at between 5 and 7 months. swelling of a slmovial hernia can be focal or diffuse and similar to
a hygroma. Cellulitis usually results in swelling that is not confined
to the carpus unless there is a penetrating wound or foreign body;
II Disorders of the equine then it may be focal or locally extensive.Tiaumatic tendon sheatfr
I Garpus synovitis, with or without tendinitis, can occur in horses of any
age. Tendon sheath s1-novitisgenerally follows the length of the
tendon, extends from the distal radial metaphysis to the proximal
Soft-tissue swelling
segment of the third metacarpus, and has an indentation at the
Soft-tissue swelling may be intracapsular (within the joint), extra- level of the proximal row due to compression by the extensor
capsular (outside the joint), or both (Fig. 20-8).2 8 Each of the retinaculum. Synovitis of the extensor carpi radialis tendon sheath
three carpal joints has a distinct joint capsule with specific origins occurs secondary to partial or complete rupture of the extensor
and attachments,including the previously mentioned communica- carpi radialis in foals younger than 1 week of age and can be
tion betrveen the middle carpal and carpometacarpal joints (Fig. primary or secondary to flexural deformity.
20-9). The LM and D60'L-PaMO views are best for identifiing Swelling on the palmar aspectof the carpus can representcelluli-
joint distention. Joint distention may represent effusion, slmovial tis or carpal canal svndrome.e'r0 The most common cause of
The E oui neCar ous 231
Ghip fractures
Carpal fractures are usually classified as chip or slab (including
Figure 20-8. Intracapsular and extracapsular soft t;ssue swe ling. intracap- sagittal), and simple or complex. Chip fractures are the most
s ula rs w e l l i n go f t h e a n te b r a ch io ca r p( A) j oi nts
a l ,m id d le ,a n d ca r p o m etacarpal
common type of carpal fracture; these are seenas small periarticu-
/ B / .E x t r a c a p s u lsawr e l l in go ccu r sse co n d a rto
y n o n a r ticu la d rise ases1C l(From
.
O ' B r i e nT R , M o r g a nJ P ,P a r kRD,e t a l: Ra d io g r a p hiny e q u r n eca rpall ameness. Iar bony fragments. Chip fractures of the antebrachiocarpal joint
Cor n e lV l e t 6 1 : 6 6 6 ,1 9 7 1 .) occur at specific sites and predominantly in racing Thoroughbreds
The E oui n eCar ous 233
Figure 2O-1O. Extracapsular soft tissueswelling.Diffuseswellingon the dorsalaspectof the carpuson lateromedial(A/and flexed lateromedial/g/ prolecrrons
consistentwith a hygroma.The diagnosiscan be confirmedby using ultrasonographyor contrastradiography.
F i g u r c 2 0 - 1 4 . Co n tr a str a d io g r a p h y.
Lateromedial14)and dorsopalmar(B) pro-
j e c t i o n so f a h o r s ew ith fo ca lswe llin ga n d
a draining t r a c to n t he d o r saal sp e cto f th e
c a r p u s .O r g a n i ci o d in a te dco n tr a st m e -
dium injectedthrough a ballooncatheter
placed within the tract enters a synovial
hernia (focalaccumulationof contrast)and
t h e m i d d l e a n d c ar p o m e ta ca r p ajo l in ts
(thin line at the level of the jointd. fhe
b a l l o o nc a t h e t e irs a fillin gd e fe ctd o r sa to
l
the antebrachiocarpal joint outlinedproxi-
m a l l y a n d d i s t a l l yby a sm a ll a m o u n t o f
c o n t r a sm t e d i u mw i th inth e d r a in in qtr a ct.
236 SK EL E T O N -EOU IN E
A P P E NDI C U L AR
and Quarter horses. Chip fractures at the level of the antebrachio- lesscommon. Chip fractures of the proximal aspectof the interme-
carpal joint are rare in Standardbreds.Most radial chip fractures diate carpal bone are also common (Fig.20-17). These chip frac-
originate from the dorsolateral aspect of the distal radius, lateral tures may be very small and are best identified on the FLM view,
to the ridge iocated lateral to the midline (Fig. 20-16). Therefore, as are those originating from the proximal aspect of the radial
these chips are best identified on the DM-PaLO and LM views. carpal bone (Fig. 20-18). Complete evaluation of fractures oc-
Chip fractures from the dorsomedial aspectofthe distal radius are curring at the level of the antebrachiocarpal joint requires the
iiG
.',
]] .iii:1],,-.iia!llli,,,i111!lll
. l]:,],
ll1,]]]:i:]]]]
s -&
'.:d :&l
* B;i
Figure 20-17. Acute, nondisplaced chip fractureof the antebrachiocarpal joint. On the close-uplateromedialiAl projection,the exactoriginis uncertain.On the
f l e x e dl a t e r o m e d i a1lBl,two sm a ilch ipfr a ctu r e so r ig in a tefr om the dorsoproxi mal aspectof the rada carpalbone.N otethe proxi mall ocati o nof the i ntermedate
c a r p ab l o n ei l i s h i g h )a n d d ista ld lsp la ce m e notf th e r a d iacarpal
l bonew i th fl exi on.
,iilejl;1olll]iallltYlaii
r!ll::a ;;.ii]lll.'rlgl
lll:r:rlillr,
.,
- - '- , t - - tl
-t
utr iiirrrr:il
Sl
*l
.rlrr.
a .ttll
):,:
:, :L,t
r,,iiillll,.
llllr,,,
,i13
acquisition of DPr-DDiO projections of the distal radius and proxi- plete. Small chip or wedge fractures frequently occur at the proxi-
mar row. mal margins of complete third carpal slab fractures (see Fig. 20-
Chio fractures at the level of the middle carpal ioint are common 21). These chip fractures are seen on the FLM and DPr-DDiO
in Thoroughbreds and Quarter horses and' aie uncommon in views. Slab fractures of the fourth; radial and intermediate carpal
Standardbreds,although most chip fractures in Standardbredsoc- bones are uncommon, and slab fractures of the ulnar and second
cur at this joint.l7-ie Chip fractures of the dorsodistal aspect of the carpal bones ate lare.l3'22'2''28
radial carpal bone (Fig. 20-19) and the proximal aspect of the Sagittal fractures are considered a form of slab fracture; they
third carpal bone are common in Thoroughbreds, Standardbreds, occur primarily in the third carpal bone.20,2e Most occur on the
and Quarter horses (Fig. 20-20). These chip fractures are best seen medial aspect and are minimaliy displaced. These fractures are
on the DL-PaMO and FLM views. Chip fractures originating from usually identified only on the DPi-Onb view. Sagittal fractures in
the distal aspect of the intermediate carpal bone occur less com- the radial or intermediate carpal bones are rare (Fig. 20-22).
monly. Chip fractures from the dorsodistolateral corner of the
radial carpal bone occasionallyoccur and are best identified on the Accessory carpal bone fractures
DM-PaLO view. Complete evaluation of fractures occurring at the Most fractures of the accessorvcaroal bone occur in the dorsal
level of the middle carpal joint requires the use of DPr-DDiO plane and are nonarticular. These fiactures are identified on the
projections of the proximal and distal rows. The DPr-DDiO projec- LM or FLM view Accessory carpal bone fractures can occur in
tion of the distal row is essentialto the diagnosis of third carpal racehorsesor event horses following a fall. Comminuted accessory
bone sclerosisand of nondisplaced slab and sagittal fract:ures.a'2o 22
carpal bone fractures occasionallyoccur.
Chip fractures originating from the palmar aspect of the carpal
bones occur infrequently (seeFig. 20-11). Fracturesof the medial
or lateral aspect of the carpus may represent avulsion fractures of orthoPedic
the collateral ligaments, and radiographs obtained while stress is
applied to enhancevisualization of the laxity of the affected aspect
I 3r:::'""*-ental
of the carpus are useful in identifring instability.'z3Ultrasonography Osteochondrosis
can be used to identifr the extent of ligamentous damage.
Radiolucent cyst-like lesions in the carpal region are common,
Slab fractures and most nonarticular and small articular lesions are considered
Slab fractures extend from one subchondral surfaceto another and developmental and incidental findings.'o These incidental cyst-like
involve two joint spaces.Most slab fractures originate in the dorsal lesions are most common in the ulnar carpal bone (seeFig. 20-58)
plane from the third carpal bone (Fig. 20-21).t?''u26Third' carpal but also occur in the radial, accessory,second, and fourth carpal
bone slab fractures are usually identified on the DL-PaMO and bones. Subchondral cyst-like lesions in the medial aspect of the
DPr-DDiO views. Very large slab fractures and those of the lateral distal radius have been associatedwith lameness (Fig. 20-23).31
corner may be seen on the DM-PaLO and DPI-DDiO views. Slab Tiauma, rather than a developmental anomaly, may be responsible
fractures only identified on the DPr-DDiO view are usually incom- for some cyst-like lesions. Very large or multiple ryst-like lesions
Figure 20-19. Minimallydisplacedchip fractureof the middlecarpaljoint. A, The exact locationof the small chip is uncertainon the lateromedialprojection.B,
On the flexed lateromedialprojection,the chip originatesfrom the dorsodistalaspect of the radialcarpalbone. Most fracturesof the middle carpaljoint originate
from the dorsodistalaspectof the radialcarpalbone.This is the most common bone fracturedin the carpusof Thoroughbreds and Ouarterhorses.
The E qui neCar pus 239
.,'lllillrlll.
.1{lll,
e,ij:,,rii].t -i:.,i:
t,l
ll t.,:;,,,.lllll,.,,lll':,,
',.-:..:::iillrr.i:1i4r,..
.,,
ffi*e r a- *r
:g:"1 :" d-
irillBlrllgrrriil!lrrr,.:11!r:irrrrr,iicrl
q,r - r ' ' r ' ' l
i
::111Qllll:$lll!111@lll:i1$1@ll:i1q
;uuiuu:uu:ul - d:::d :
3 ! * Bs *l
i1@lt,r.,r1@|r,,,r
rlri$jlr:li$i
lllr:
Figure 2O-23. Cystlikelesionof the distal radius.Bilobedcystlikelesionin the medialaspect of the distal radiuswith a small defect in the articularsurfaceon
p aa r o m e d iaolb liq u e1B lproj ecti ons.
t h e d o r s o p a l m a/ rA /a n d d o r so la te r a l-m Thi s l esi oni s usual y cl i ni cal lsi
y gni fi cant.
may result in lameness and degenerativejoint disease or carpal however, other carpal bones may be affected. Radiographs of the
fracture (Fig.20-2a). Bone scintigraphymay be useful for evaluat- carpus and tarsus are recommended in all premature, dysmature,
ing the activity and clinical significance of unusual carpal cyst- and twin foals to enable identification of hypoplastic bones so that
like lesions. proper treatment can be initiated to prevent osteoarthritis.
middle carpal, and carpometacaryaljoints are parallel to each other are not perpendicular. Epiphyseal growth imbalance places the
and perpendicular to the lines bisecting the long bones. Deviation pivot point between the joint spaceand the physis, the distal radial
of metacarpus and foot to the lateral aspect of the limb is called epiphysisis wedge-shaped,and lines through the distal radial physis
carpal valgus and results in knock-kneed conformation. Medial and antebrachiocarpaljoint are not parallel. Ossification defects of
deviation is called carpal ttarusand results in bow-leggedconforma- the cartilaginous precursors of the cuboidal (carpal) bones have a
tion. pivot point corresponding to the area involved, and lines through
Joint instability may be related to flaccid or damaged periarticu- the joint spacesare not parallel. Location of the pivot point is not
lar structures, such as collateral ligaments. foint instability from always reliable as abnormalities may occur in combination; there-
damaged or lax ligaments usually placesthe pivot point of the long fore, all bony and soft-tissue structures should be evaluated.
axis lines at the level of the distal articular cartilage of the radius,
and the cuboidal bones are usually not radiographicaliy abnormal. I Septic arthritis
Imbalanced growth of the distal radial metaphysishas a pivot point
approximately at the level of the physeal growth plate, the physis Acute septic arthritis produces intracapsular distention and severe
is widened on the side of the limb opposite the deviation, and lameness. Septic arthritis is most common in foals and occurs
lines through the long axis of the radius and distal radial physis secondary to extension from osteomyelitis (septic physitis) (Fig.
20-29). Lysis of the metaphysisand epiphysis and indistinct perios- without other signs of osteoarthritis is usually a result of position-
teal reaction are consistent with osteomyelitis originating at the ing artifact. The DPr-DDiO projection of the distal row is required
distal radial physis. If infection enters the antebrachiocarpaljoint, to identify sclerosiswithin the third carpal bone, which is common
intracapsular swelling occurs. The joint space may be widened in racehorses(seeFig. 20-31.20Definitive identification of subchon-
secondaryto effusion, synovitis, and lack of normal weight bearing dral lucency within the third carpal bone also requires the DPr-
on the limb. In subacute or chronic stages, erosion of articular
cartilage results in narrowing of the joint, and lysis of the subchon-
dral bone results in decreasedopacity of joint margins. Poorly
mineralized, indistinctly marginated new bone occurs on the peri-
articular margins.
The signalment, clinical history, and physical examination find-
ings are important when the etiology of septic arthritis is consid-
ered." In foals, extension from osteomyelitis (septic physitis) is
most common and hematogenous origin is less common. Trauma
with penetrating wound or sequestrum and iatrogenic causes(e.g',
surgery or arthrocentesis)are rare, but may occur in horses of any
age. In acute septic arthritis, cytologic evaluation of fluid obtained
by arthrocentesisis necessaryfor prompt diagnosis and treatment.
Traumatic penetrating wounds and iatrogenic infection may result
in septic arthritis of the carpus.3'Osteomyelitis or sequestraof the
radius or carpal bones secondary to trauma are rare.
I Osteoarthritis or degenerative
I joint disease
Osteoarthritis or degenerativejoint diseasemay involve the articu-
lar cartilage, subchondral bone, or both. Osteoarthritis is also
sometimesreferred to as secondaryjoint diseasebecausethe degen-
eration is usually a result of a primary abnormaliry or cause such
as abnormal conformation, developmental orthopedic disease,or
trauma with damage to synovium, articular cartilage, subchondral
bone, or supporting ligaments. Joints with the greatest range of
motion are most commonly involved. Accordingly, the antebrachio-
carpal and middle carpal joints are the most commonly and se-
verely affected.
The radiographic signs of degenerative joint disease include
joint swelling (synovitis), subchondral sclerosis,subchondral bone Figure 20-3O. Mild osteoarthritisor degenerativejoint dlsease.Smallperiar-
lucency or irregularity, periarticular osteophytes (Fig. 20-30), en- ticularosteophytesbrrows)on the dorsalaspectof the antebrachiocarpaljoint.
thesophytes,and narrowing ofjoint spaces.Narrowed joint spacing The degreeof osteophyteformationmay not correlatewith the clinicalsigns.
The EouineCarous 245
DDiO projection of the distal row.'zIA significant amount of pro- of considerablesize (exostosis)sometimes form on the dorsal
ductive or l1tic change must occur before radiographic signs are aspect of the radial or intermediate carpal bones (Fig. 20-31).
visible. Therefore, subtle radiographic abnormalities should be con- Osteoarthritis of the carpometacarpaljoint has been reported in
sidered significant in any horse with lamenessthat is localized to performance horses.arNarrowed joint space, sclerosis,small cyst-
the carpus. Exercise-relatedsclerosisofthe third carpal bone occurs like lucencies,and periarticular osteophltes and enthesophltes have
in horsesduring training and racing.n0 In racehorses, enthesophltes been identified (Frg. 20-32).
30. Butler JA: The carpus. In Butler J (ed): Clinical Radiology ofthe Horse. Boston,
References BlackwellScientificPublications,1993,p 161.
l. Smallwood JE, Shively M: Radiographic and xeroradiographic anatomy of the 31. Specht TE, Nixon AL Colahan PT, et al: Subchondral cyst-like lesions in the distal
equine carpus. Equine Pract 1:22-38, 1979. portion of the radius of four horses. J Am Vet Med Assoc 193:949-952, 1988.
2. Dyce KM, Sack WO, Wensing CJG: Textbook of Veterinary Anatomy. Philadelphia, 32. Gaughan EM: Angular limb deformities in horses. Compend Contin Educ Pract
WB Saunders, 1987, p 551. Vet 20:944-955,1998.
3. Morgan iP, Silverman S, Zontine WJ: Techniques of Veterinary Radiography' 32. Mclaughlin BG, Doige CE: A study of carpal and tarsal bones in normal and
Davis, Calif, Veterinary Radiology Associates,1997, pp 309-316. hlpothyroid foals.Can \tt J 23:164-168,1982.
4. O'Brien TR: Radiographic diagnosis of "hidden" lesions of the third carpal bone. 34. Adams R. Poulos P: A skeletal ossification index for neonatal foals. Vet Radiol
In Proceedings of the 23rd Annual Meeting of the Anerican Association of Equine 29:217-222,1988.
Practice, British Columbia, Canada, 1977, pp 343-354.
35. Auer lA, Marten RJ, Morris EL: Angular limb deformities in foals: Congenital
5. Smallwood lE, Shively MJ, Rendano V! et al: A standardized nomenclature for factors.Compend Contin Educ Pract Vet 4:13-181, 1983.
radiographic projections used in veterinary medicine. Vet Radiol 26:2 9, 1985.
36. Caron lP: Angular limb deformities in foals. Equine Yet ] 20:225-228, 1988.
6. Uhlhorn H, Eksell P: The dorsoproximal dorsodistal projection of the distal
37. Auer jA; Angular limb defornities. In Colahan P! Mayhew IG, Merritt AM,
carpal bones in the horse: An evaluaton of different beam cassetteangles. Vet Radiol
Moore JN (eds): Equine Medicine and Surgery, 5th ed. St Louis, Mosby Inc, 1999,
Ultrasound 40:480-485,1999.
pp 1639- 1640.
7. Dietze AE, Rendano VT: Fat opacities dorsal to the equine antebrachiocaryal.ioint'
38. Morgan JP: Radiographic diagnosis of bone and joint diseases in the horse.
Vet Radiol 25:25-209, 1984.
Cornell Vet 58:28 47, 1968.
8. O'Brien TR, Morgan JP,Park RD, Lebel JL: Radiography in equine carpal lameness'
39. Wisner ER, Young R, Saraydarian T: What is your diagnosis?Wire foreign body
Cornell Vet 6I'.646-660, 1971.
in the joint space between the radial carpal and intermediate carpal bones. J Am Vet
9. Mackey-Smith MP, Cushing LS, Leslie )A: Carpal canal syndrome in horses. I Am Med Assoc 198;895-896,1991.
Vet Med Assoc 160t993-997, 1972.
40. Young A, O'Brien TR, Pool RR, et al: Histologic and microradiographic changes
10. Platt D: Carpal canal slndrome. In Robinson NE (ed): Current Therapy in Equine in the third carpal bone of the racing thoroughbred [Abstract]. Vet Surg 17:27, 1988.
Medicine. Philadelphia,WB Saunders,1997,pp 17-19'
41. Dyson SJ: Proximal metacarpal or metatarsal pain. In Robinson NE (ed): Current
I 1. Barr ARS, Sinnott M]A, Denny HR: Fractures of the accessorycarpal bone in the Therapy in Equine Medicine. Philadelphia, WB Saunders, 1997, p 41.
h orse .fq u i n e V e t I l 2 b :432' lggf.
12. Niron AJ: Carpal canal syndrome. In White NA, Moore lN (eds): Current Practice
of Equine Surgery. Philadelphia, jB Lippincott, 1990, pp 461-464.
ffi Ouestions
13. Dabareiner RM, Sulins KE, Bradley W: Removal of a fracture fragment from the
1. A standard radiographic examination of the carpus should
palmar aspect of the intermediate carpal bone in a horse. J Am Vet Med Assoc
2 03 :5 5 35 5 5 , 1 9 9 3 . consistof how many views?Name them.
14. Held JR Patton CDS, Shores M: Solitary osteochondroma of the radius in three
horses.J Am Vet Med Assoc 193;563-564,1988. 2. What are the two conditions that define the need to make
oblique projectionsof the carpus?
dorsoproximal-dorsodistal
15. Owen RR, Marsh lA, Hallett FR, et al: Intra-articular corticosteroid- and exercise-
induced arthropathy in a horse. I Am Vet Med Assoc 184:302 308, 1984.
3. How does one decide whether to make the dorsoproximal-
16. Moore RM, Schneider RK: Arthroscopic findings in the carpal joints of lame
dorsodistaloblique projection of the distal radius or distal row of
horseswithout radiographicallyvisible abnormalities:41 cases(1986-1991).I Am Vet
Med Assoc 206:1741-1746, 1995. carpal bones?
17. Palmar S: Prevalence of carpal fractures in Thoroughbred and Standardbred
J Am Vet Med Assoc 188;1172-1173,1986.
racehorses. 4. A dorsal 45-degreelateral-palmaromedialoblique compared
with a dorsal 60-degreelateral-palmaromedialoblique rs:
18. Schneider RK, Bramlage LR, Gabel AA, et al: Incidence, location and classification
of 371 third carpal bone fracturesin 313 horses.Equine Vet J Suppl 6;33 42, 1988'
A. Closer to the lateromedialprojection.
B. Closer to the dorsopalmarprojection.
19. Mcllwraith CW: Fractures ofthe carpus. In Nixon AJ (ed): Equine Fracture Repair'
Philadelphia, WB Saunders, L996, pp 208-221.
5. What are the three general types of carpal bone fractures
20. De Haan CE, O'Brien TR, Koblik PD: A radiographic investigation ofthird carpal
identifi ed radiographically?
injury in 42 racing Thoroughbreds. Vet Radiol 28:88 92,1987.
21. Ross MW Richardson DW Beroza GA: Subchondral lucency of the third carpal 6. What bone of the carpushas the highestincidenceof fracture?
bone in Standardbredracehorses:13 cases(1982-1988).J Am Vet Med Assoc 195:789-
794, t989.
7. Why should a carpal radiographic examination be done on a
22. Fischer AI, Stover SM: Sagittal fractures of the third carpal bone in horses: 12
foal with angular limb deformity?
cases(1977-1985).I Am Vet Med Assoc 192:106-108,1987.
23. Bramlage LR: Surgical diseasesof the carpus. Vet Clin North Am (Large Anim
S. Why is a radiographic examination of the metacarpophalangeal
Pract) 5:261-274, 1983.
area needed when there is an angular limb deformity originating
24. Park RD, Morgan JA, O'Brien TR: Chip fractures of the carpus of the horse: A in the distal radius growth plate?
radiographic study of their incidence and location. J Am Vet Med Assoc 157:1305-
13 1 1 ,1 9 7 0 .
9. A horse was referred for surgery of a slab fracture of the
25. Reed WO: Location and incidence of slab fractures of the carpus. In Proceedings
of the 25th Annual Meeting of the Anerican Association of Equine Practice, Miami
third carpal bone, and lateromedialand dorsal 60-degreelateral-
Beach,FL, 1979,p 153. palmaromedial oblique radiographs accompaniedthe horse. You
advise the owner that another radiographic examination is re-
26. StephensPR, Richardson DW, Spencer PA: Slab fractures of the third carpal bone
in Standardbreds and Thoroughbreds: 155 cases (.1977-1984). i An Vet Med Assoc quired. The owner questions the need for another examination
19 3 :3 5 3 -3 5 8 ,1 9 8 8 . only 2 days after the first examination. How would you explain
27. Thrall DE, Lebel JL, O'Brien TR: A five year study of the incidence and location
your need for another examination?
of equine carpal chip fractures.I Am Vet Med Assoc 158:13661368, 1971.
28. Auer JA, Watkins JP,White NA, et al: Slab ftactures of the fourth and intermediate
10. On the flexed lateromedial view how can the intermediate and
carpal bones in five horses.I Am Vet Med Assoc 188:595-601'1986. radial carpal bones be differentiated?
29. Gertsen KE, Dawson HA: Sagittal liacture of the third carpal bone in a horsc J
Am Vet Med Assoc 169:633-635,1976. Answers begin on page727.
ffi CHAPTER
ffi21
ffi The
.
Metacarpusand Metatarsus
K. Kneller
ffi Stephen
I Anatomic considerations There is no visible proximal physis at birth. The distal epiphysis is
within the metacarpophalangeal(metatarsophalangeal)joint and is
Third metacarpus and third metatarsus-the one of the first sites to become abnormal in metabolic bone
cannon bone disease,although its appearancevaries in the normal animal at
different ages.
Radiographically, the third metacarpus and metatarsus (MC nI
On the lateral view, the metacarpus and metatarsus differ at the
and MT III) are basicallythe same (Fig. 21-1). The midportion of
distal end (see Fig. 2l-1). The metacarpusis relatively straight,
the dorsal cortex is thicker than the remaining cortex, and it
whereas the distal end of the metatarsus usually curves slightly,
thins gradually toward the ends of the bone. This variable cortical
giving the dorsal border a slightly convex appearance.
thickness is often mistaken for an abnormality. The palmar/plantar
cortex is more uniform in thickness and is interrupted at the
junction of the proximal and middle one third by the nutrient Second and fourth metacarpi and
foramen. Unlike the nutrient foramina of smaller bones, those in metatarsi-the splint bones
MC III and MT III are like channels, which may be mistaken for
a fracture on lateral and oblique views, especiallyin the rear limb These small bones articulate with the carpus or tarsus and taper
(FiS.21-2). distally. The size and shape are variable between animals and
The palmaroplantar cortex is flattened proximally, often resulting between limbs.] There is a variable degree of natural outward
in visualization of both medial and lateral aspectson a lateral view. curvature. The distal end is usually in the form of a slight bulbous
*
I
I
247
24A S KE L ET ON -EOU IN E
A P P E NDI CU L AR
ataaaLa::lwlil.tllll.
Figure 2 I 4. Dorsomedial-palmaro atera radiographs of the eft metacarpus
:rl19ll:llffillr' (MC )of a 3-year-odS tandardbred gel di ngw i th l amenessof the l eft forel l mb.
;::::ill9lll:-rliiiilr
" *.: The radi ographs are made at sl i ghtl ydi fferentangl es.A , Ther e i s a v erti c al
r riillllll:lllii;ull
:|:i::::
::.::||
radiolucentline in MC ll as lt crossesthe cortexof MC lll (white arrow)\seen
:.:)):...
al so on the i nset).A t the same l evel ,an obl i queradi ol ucent l i n e i s v i s i bl e n
the palmarmedialcortex of MC lll (blackarrow in inset).Both of these lines
are due to the "mach band"effectat the edgesof eachbonea nd s houl dnot
be confusedw i th fractures. Thi si s substanti ated i n B , w herea sl i ghtl ydi fferent
angl eremovesthe overl apas w e I as the superi mposi ti on of the mac h bands
overrne opposrngoone.
I Gharacterization of lesions
Soft-tissue enlargement and mineralization
Abnormal size and shape of the soft tissues in the metacarpal and
metatarsal areas may be evident on radiographs as1enlargements
over the dorsal surface,with early metacarpal periostitis'z;general-
ized enlargements along the palmaroplantar surface, with suspen-
sory desmitis and flexor tendon abnormalities3;and localized areas
along the small metacarpal or metatarsalbones, usuaily proximally,
with interosseousligament damage.Becausethere is normally min-
imal soft tissue in these areas,such soft-tissue abnormalities should
also be evident on visual inspection and palpation of the horse.
The purpose of radiographically evaluating the soft tissues is
threefold. First, in a busy practice, there is a temptation to perform
a quick physical examination and proceedwith radiographic exami-
nation. Finding soft-tissue enlargements radiographically should
:, ::::,..:::':::::
Ir,...:::1
..,,,, r:, stimulate a more thorough physical examination of the area in
.,ri,i.::
llri::::::, :
'lltltiuu:,ut: question. Second,although thorough study of the radiographsis
.,t.,ra!uut,illsut. , ::lillli ,::'
lt,ltr paramount, finding a soft-tissue abnormality should lead to an in-
'.-i
'.:l:):,.,':'::.6:l:::-t1::'at;
::,,..iiiFut::::iarui
depth review of the underlying bony structures to evaluate the
extent of and to further characterizethe lesion. The third purpose
'iil.uut:iii1$]]r"iiiii
'r..ill!lll'ii:ii:,]r"' ';.
is correlation of abnormalities, that is, evaluating the association
,:::lliililiii:.iii or lack of associationof bony lesions with soft-tissue enlargements
in size, shape, and proximity, as well as relative activity. For exam-
ple, in many horses, tendons and ligaments may be delineated
Figure 21-3. Dorsomedial-plantarolateral /A/and dorsoateral-plantaromedial becauseof the loose,fat-1adenadventitiainterposedbetweenthem.
/B) radiographsof the left pelvic limb of a 4-month-oldOuarter horse filly in
which metatarsal(MT) ll 1Aland MT lV (B) can 6e seen. The drstalepiphyses
In such horses, a 1ow degree of inflammation may result in loss of
hav en o t f u s e dt o t h e d i ao h vse s. visualizationof thesemargins on high-quality radiographs.
The Metacarpusand Metatarsus 24!|
'
Soft-tissue mineralization may be identified, especially in the
suspensory ligament and flexor tendon areas. Surface debris and
medication should be removed to avoid confusion. Mineralization
within the soft tissuesis usually dystrophic owing to injury of some
duration. The injury may be from work-related stress,resulting in
damaged or torn structures, or it may be causedby drug injections.
Penetrating foreign objects may also be present in soft tissues.
Therefore, familiarity with the normal appearanceof soft tissue is
important, because only when one is knowledgeable about this
may foreign objects having an opacity similar to adjacent soft tissue
be recognizedas a disturbance of the normal size, shape, and
opacity relationships.
Mineralization in the skin and subcutaneoustissues may result
from surface injuries and must be differentiated from deeper min-
eralization. In the rear limb, the chestnut may contain mineral and
be mistaken for disease.
Mineral opacity between the smali metacarpal or metatarsal
bones and MC or MT III is a common finding as a sequel to
trauma to the interosseousligament ("splint disease").This opacity
may represent actual mineralization of the interosseousligament,
or an associatedperiostealreaction.As in any dystrophic mineral-
ization, this radiographic sign is not evident until some time after
the injury. Accurate positioning is imperative when evaluation of
the mineralization of the interosseous ligament is attempted be-
causeoverlap of the bones may produce a similar appearance(Fig.
21-5). In some horses,becauseof the bone contour, multiple views
at slightly different angles must be made to separate the bones
completely throughout the length of overlap. When this mineraliza-
tion is evident, the animal has had damage in the interosseous
Periosteal response
On high-quality radiographs,periostealsurfacesof the metacarpus
and metatarsusshould be smooth and well defined.Becauseof the
geometryof the bones,the dorsal surfaceof MC III or MT III may
appearindistinct on radiographsunlessa high-intensityilluminator
(hot light) is used.Periostealreaction is a healing responseand its
appearancedepends on the stageof healing. If the inciting causeis
removed, the periosteal responsebecomes mature and smooth
over time.
The dorsal surface of the MC III may develop a periosteal
reaction becauseof microfractures; this is commonly referred to as
metacarpalperiostitis or bucked shins (Fig. 27-6). Care should be
taken to evaluate the cortex for fracture lines (see sectlon on
cortical bone abnormalities).
Another relatively common location for periosteal response is
betweenMC (MT) II and III, with lesionsbetweenMC (MT) III
and IV occurring less frequently. Lesions between MC (MT) II and
III are usually associatedwith the proximal one half of the splint
bones and are secondaryto interosseousligament damage (splint
disease) (Fig. 21-7). The periosteal response is variable in size;
initially, the responseis ill defined and irregular, and it gradually
becomessmooth, opaque, and smaller as it matures, fusing the
small bones to the larger bones. A large, irregular periostealre-
sponsemay mimic a fracture, yet a fracture may be masked by the
callus formation.
Figure 21-5, A, Dorsolateral-palmaromedial radiographof the metacarpal Indistinct margins or small amounts of active periosteal reaction
( M C )r e g i o no f a n 1 ' l- ye a r - o ld
M o r g a nm a r ein wh o m M C lV can be seen.The
sp a c eb e t w e e nM C lll a n d M C lV is n o t cle a r lyse e n ,su g g e sti ng
mi neral i zati on
may be seenon the distal ends of the small metacarpalor metatar-
of the interosseousligament(arrows).B, Sameview at a differentange. There sal bones causedby irritation from suspensoryligament disease
s a c i e a rs e p a r a t i oonf M C lll a n d M C lV,with n o a b n o r m ami
l neral i zati on. (Fig. 21-8).
S KE L ET ON -EOU IN E
2 5 O A P P E NDI CU L AR
:i;t:tl
irll!ill;;l
,-#
s6
or slightly oblique view, and it may be easily missed on underex-
posed radiographs.
.-%] Stressfractures may also be found in the dorsal cortex, especially
-e:' associatedwith metacarpalperiostitis (Fig. 21-ll). Thesefractures
i-
,:,,,uiiallll,:llt' occur most often on the dorsomedialaspectnear the junction of
the middle and distal one third of the bone. Becauseof iheir shape,
these lesions have been called saucerfractures.
Fractures also occur in the palmaroplantar cortex. The most
common site is approximalely 2 to 3 cm from the proximal articu_
'::a.illlr..iil
lar surface, although they may occur in the midportion of the
:),:|lll:: bone. Associatedlesions have been reported as avu-lsionfractures,
"ii9lllr,llil:j stressfractures, and stressresponse,sometimes linked with disease
::::a:::::p)a:a
,:,r',,i1@urr,
of the suspensoryligament.i tl' Some appearradiographicallyonly
rril$t.
,r,,tit:
on the dorsopalmar (dorsoplantar) view as a thin crescent-or
linear-shaped region of decreased opacity.Other appearances in-
..'iiielrr,,,llil
clude an irregular trabecular pattern or slightly increased opacity
llrr. r,,ir,l,,
in the proximal portion of MT or MC III (Fig.21-12). Typically,
-
,.il illl:::,,:tll . iiie]],,,t'
lllll'iiiglr,,.
these abnormalities are medial to the midsagiital plane. In lateral
"t,'::;::)"
"::4a,.::. "iilut,.,t,,
and oblique views, fractures or increased opacity may be seen
.rt
;ir rr'"'li10ll:,
ir:,t:ia!lrt::rir:,
lrr to the palmaroplantar cortex (Fig. 2l-13; see also Fig.
'riiri'i1!llllil"'', ldjacelt
2I-12). Overexposedor underexposedradiographs may lead to
-x misinterpretation of this condition. Additionallv, because of the
large.n^umberof overlying bone margins, fractures in this area may
I
:.:..::.:a:::..:.a.it:,
- be difficult to see. Scintigraphy has aided in proving the presence
r,itlll:rrrl;lll.rrl:
ll:ll::llllll:'liaill, of fractures that are difficult to seeradiographically,i(fig .-2t-14).
.,,a::1,',,:,:!a:::;
Abnormal shape of MC and MT III results from growth distur- the small metacarpal and metatarsalbones, abaxial deviation of the
bance, and is most often seen at the distal end of the bone. This distal ends is often associatedwith suspensorydesmitis, presumably
shape change may be seen as a single, localized problem, or it may from outward pressure exerted by the enlarged ligaments (see Fig.
be seen in conjunction with more proximal limb abnormalities. 21-8). If this outward curving is noted, the suspensoryligaments
Although there is considerable variety in the size and shape of should be evaluatedfor inflammation and enlargement,but appar-
Figure 21-11. Laletal (A) and dorsolateral-palmaromedial/Bi views of the left metacarpal
region of a 6-year-oldThoroughbredgeldingthat became lame immediatelyafter a race 2
weeks before the radiographswere made. The stress ftacture(arrow)evident in B is barely
vi si bl ei n A .
The Metacarpusand lvletatarsus 253
uu,
.iiieutli{!4u:i i:
;::l;
,lill9lll.ii19llll$
aaaaaa::::aaaaa
,ii1191,,:111
!uu::ii19ul
$ll',..,1@1111
'tt1
liiill]iil
l.bl,,l....,
ll:rl, r'.
tr$l
):...
:.,,,,:!.t,,.
rii$11...
iil:
ttt:
1a
1b
2a
2b
3a
3b
Figure 21-18, Z o ne s.Slx zo n e styp ica llyu se dto r d e n tifylocati onof l esi onsi n equi netendonul trasound
Figure 21-2O. A, Equinetendon sonogramimage. Normal tendons are visualized.A hypoechoiclesion is present near the bifurcationof the suspensory
ligam e n tl.n a d d i t i o nb, l o o dve sse lsa p p e a ra s h yp o e ch o icto a n e choi croundstructures.N oti ceacousti cenhancement as w e I as edge refracti onrel atedto the
. , T h e s a m e i m a g ea s th a t in F ig u r e2 1 - 1 9 with str u ctu resl abel ed.The S uspensory
v es s e l s B Li garnent,
contai ni ng the hypoechoilcesi on,i s outl tnedi n w hi te.C ,
y a m e not f th e DDF ) ;DDF .d e e pdi gi talfl exortendon;S D F,superfi ci al
I nf eri ocr h e c kl i g a m e n{t a cce sso rlig di gi talfl exortendon;V vessel s.
hyperechoic to the surrounding structure. Depending on the time 13. Wood AK, Sehgal CM, Polansky M: Sonographic brightness of the flexor tendons
and ligaments in the metacarpal region of horses. Am J Vet Res 54:1969, 1993.
ofsonography relative to an injury, a lesion will vary in appearance
relative to the stage and degree of healing. As with any modality, 14. Cuesta I, Ribar C, et al: Ultrasonographic measurement of palmar metacarpal
tendon and ligament structures in the horse. Vet Radiol Ultrasound 36:131, 1995.
improper use may lead to erroneous diagnosesand conclusions. In
addition to general consideration of the major tendons and liga- 15. Denoit JM, Busoni V Ultrasonographic anatomy of the accessoryligament of the
superficial digital flexor tendon in horses. Equine Vet I 3l:186, 1999.
ments, specific diagnoseshave also been published by authors with
extensive experience with the modality.'z830A word of caution is 16. Gillis CL, Meagher DM, Pool RR, et al: Ultrasonographically detected changes in
equine superficial digital flexor tendons during the first months of racing. Am J Vet
necessaryat this point. A number of parameters that may lead to
Res 54;1797,1993.
misinterpretation have been mentioned earlier, including suitability
of equipment, understanding of imaging physics,and patient varia- 17. Gillis CL, Meagher DM, Cloninger A, et al: Ultrasonographic cross-sectionalarea
and mean echogenicity of the superficial and deep digital flexor tendons in 50 trained
tion. In addition to the patient variation referenced previously, thoroughbred racehorses. Am I Vet Res56:1265,1995.
vascular structures and previous injuries may cause confusion.
18. Gillis CL, Poole RR, Meagher DM, et al: Effect of maturation and aging on the
Thorough knowledge of the local anatomy is imperative. It is
histomorphometric and biochemical characteristicsof equine superficial digital flexor
important that the clinician fully understand the modality and its tendon. Am I Vet Res 58:425. 1997.
use through training and experiencebefore depending on it with
19. Riemersma DJ, De Bruyn P: Variations ia cross-sectionalarea and composition of
client-owned animals. Excellent textbooks are available that deal equine tendons with regard to their mechanical function. Res Vet Sci 4l:7, 1986.
specificallywith sonography.3l'3'
20. Birch HL, Mclaughlin L, Smith RK, Goodship AE: Treadmill exercise-induced
tendon hy'pertrophy: Assessment of tendons with different mechanical functions.
References Equine Vet J Suppl 3Q:222,1999.
1. Getty R: Sisson and Grossman's The Anatomy of the Domestic Animals, 5th ed. 21. Wilson DA, Baker Gl, Pijanowski GJ, et al: Composition and morphologic features
Philadelphia, WB Saunders, 1975. of the interosseous muscle in Standardbreds and Thoroughbreds. Am J Vet Res
52:1,33,1991.
2. Lane EJ, Proto AV, Phillips TW: Mach bands and density perception. Radiology
I2l:9, 1976. 22. Miles CA: Ultrasonic properties of tendon: Velociry attenuation, and backscatter-
ing in equine digital flexor tendons. J Acoust Soc Am 99:3225,1996.
3. Bramlage LE, Gabel AA, Hackett RP: Arulsion of the origin of the suspensory
ligament in the horse.J Am Vet Med Assoc 176:1004,1980. 23. Miles CA, Fursey GA, Birch HL, et al: Factors affecting the ultrasonic properties
4. Lloyd KCK, Koblik P, Reagle C, et al: Incomplete palmar fracture of the proximal of equine digital flexor tendons. Ultrasound Med Biol 22:907, 1996.
extremity of the third metacarpal bone in horses; Ten cases(1981-1986). J Am Vet 24. van Schie ]T, Bakker EM, van Weeren PR: Llltrasonographic evaluation of equine
Med Assoc 192:798,1988. tendons: A quantitative in vitro study of the effects of amplifier gain level, transducer-
5. Dyson S: Proximal suspensory desmitis: Clinical, ultrasonographic, and radio- tilt and transducer-displacement.Vet Radiol Ultrasound 40:151, 1999.
graphic features. Equine Vet J 23:25, 199I. 25. Biller DS, Myer W: Ultrasound scanning of superficial structures using m ultra-
6. Devous MD, Twardock AR: Techniques and applications of nuclear medicine in sound standoffpad. Vet Radiol 29:138,1988.
the diagnosisof equine lameness.J Am Vet Med Assoc 184:318,1984.
26. Wood AK, Newell WH, Borg RP: An ultrasonographic off-set system for examira-
7. Pleasant RS, Baker GH, Muhlbauer MC, et al: Stressreactions and stressfractures tion of equine tendons and ligaments. Am J Vet Res 52:1945, 1991
of the proximal palmar aspect of the third metacarpal bone in horses: 58 cases
27. Prgh CR: A simple method to document the location of ultrasonographically
(1980-1990).J Am Vet Med Assoc 201:19).8,1992.
detected equine tendon lesions. Vet Radiol Ultrasound 34:211,1993.
8, Edwards RB, Ducharme NG, Fubini SL, et al: Scintigraphy for diagnosis of
28. Dyson Sl, Arthur RM, Palmar SE, Richardson D: Suspensory ligament desmitis.
awlsions of the origin of the suspensory ligament in horses; 51 cases(1980-1993). I
Vet Clin North Am Equine Pract II:I77,1995.
Am Vet Med Assoc 207:608,lqq5.
29. Wright IM, McMahon PJ: Tenoslnovitis associatedwith longitudinal tears of the
9. Spaulding K: Ultrasonic anatomy of the tendons and ligaments in the distal
digital flexor tendons in horses: A report of20 cases.Equine yetl 3I:I2, 1999.
metacarpal-metatarsalregion of the equine limb. Vet Radiol 25:155, 1984.
10. Nicholl RG, Wood AK, Martin IC: Ultrasonographic observation of the flexor 30. Lepage OM, Leveille R, et al: Congenital dislocation of the deep digital flexor
tendons and ligaments of the metacarpal region of horses. Am I Vet Res 54:502, 1993. tendon associatedwith hypoplasia of the sustentaculum tali in a thoroughbred colt.
Vet Radiol Ultrasound 36:384, 1995.
ll. Cauvin ER, Munroe GA, Boswell l, Boyd lS: Gross and ultrasonographic anatomy
of the carpal flexor tendon sheath in horses. Vet Rec I4I:489, 1997. 31. Nyland TG, Mattoon JS: Veterinary Diagnostic Ultrasound. Philadelphia, WB
Saunders,1995.
12. Smith RK, Jones R, Webbon PM: The cross-sectional areas of normal equine
digital flexor tendons determined ultrasonographically. Equine Vet I 26t460, 1994. 32. ReefVB: Equine Diagnostic Ultrasound. Philadelphia, WB Saunders, 1998.
The Metacarpophalangeal
(Metatarsophalangeal)
Articulation 25ig
7. Small cortical bone (stress)fractures may be difficult to dem- Answers begin on page 727.
ffi CHAPTER
ffi22
= The Metacarpophalangeal
ffi .(Metatarsophalangeall
.r
Articulation
ffi Russell
RussellL. Tucker
Tucker Ronald
Ronald D
D. Sande
I Anatomy The joint capsule attachments at the proximal end of the proxi-
The anatomic structures of the metacarpophalangeal (MCP) and mal phaianx are immediately periarticular with no redundani cap-
metatarsophalangeal(MTP) articulations are so similar that it is sule or recesses.The capsuleattachesto the distal end of MC III
difficult to differentiate the right from the left or the front from or MT III at the periarticular margins. Dorsally, there is a large
the hind limb on unlabeledradiographs.The MCP or MTP articu- recessthat extends proximally and forms a pouch that allows full
lations are hinge joints formed by the distal end of the metacarpal extension of the joint. There is a bursa interposed between the
(or metatarsal) bone and the proximal end of the proximal pha- extensor tendons and the dorsal joint pouch. The palmar joint
lanx. The articular surface of the proximal phalanx is concaveand capsule extends proximal to the sesamoidsbetween the suspensory
has a sagittal groove opposing the sagittal ridge at the distal end ligament and MC III or MT III.I Ligaments associated*ltn tfr.
of the third metacarpal(MC III) or the third metatarsal(MT III) MCP and MTP articulations have been described, and are illus-
bone. This ridge and groove divide the weight-bearing surfaceinto trated in Chapter 23,The Phalanges.
tlvo unequal parts. The largest surfaceis on the medial (axial) side,
where loading is greatest.The sagittalridge of MC III or MT III is
received into a depressionat the palmar* surface that is createdby I Radiographic examination
the proximal sesamoidsand the intersesamoidean ligament. There
are two radii of articulation of the joint. The dorsal radius serves The intent of the radiographic examination should be to adequately
the weight-bearingportion, and the palmar radius conforms to the visualize the articular and periarticular skeletal structures and the
articulation with the proximal sesamoids.'It is the junction of adjoining soft tissues.The examination should include the proximal
these radii of articulation that may be confused with pathologic interphalangeal joint and the distal ends of the metacirpal or
flattening of the articular surface. metatarsal bones. Identification markers recorded in the emulsion
are essentialin radiographic examination of the MCp or MTp
*"Palmar(o)" is used throughout this chapter with articulation; right versus left and front versus hind should be
the understanding
that "plantar(o)" should be substituted if reference is being made to the clearly designated. If oblique views are obtained, it is crucial to
hindlimb. designate the projection. Markers should be placed to the lateral
2 6o A P P E NDI C U L ASK
R EL E T O N -EOU IN E
surface of all views, with the exception of the lateromedial view to complement radiographic examination. Portable ultrasound ma-
for which markers should be placed dorsally.' chines can be used to image the extensor and flexor tendons, the
Survey radiographic examination of the joint should include a suspensory and distal sesamoidean ligaments, and the s'yrrovial
lateromedial,a dorsopalmaq and two oblique projections (dorsal lining and joint recesses. The normal sonographicfeaturesof the
45-degreelateral-palmaromedialand dorsal 45-degreemedial-pal- MCP and MTP ioints havebeen described.e
marolateral) with the limb bearing weight if possible. The survey In addition to conventional radiography, computed tomography
examination should precede any special radiographic projections (CT) may be useful in selectedpatients to image the MCP or MTP
or contrast studiesof the joint. The lateromedialprojection should joint. Like radiography,CT is basedon x-ray absorptionby tissues;
be made with the primary beam centered at the articulation and however, the system is much more sensitive to attenuation differ-
directed parallel to an imaginary line connecting the collateral encesand has excellent contrast resolution. The CT information is
fossaeat the distal end of MC III or MT III. A true lateromedial displayedin tomographic slicesthat have superb radiographic detail
projection is essentialfor proper assessment of the sagittalridge of and eliminate superimposition of overlying structures. CT excels
distal MC III or MT III.a The dorsoplamar projection warrants in the evaluation of bones and is very useful in imaging complex
thoughtful positioning. Becausethe plane of the joint is at an angle fractures and subchondral lesions in the MCP and MTP ioints.
to the solar surface of the hoof, the primary beam is directed from Unfortunately, general anesthesiais necessary,and few veterinary
dorsoproximal to paimarodistal at approximately 30- to 4O-degree' referral centers currently have accessto CT scannersthat are capa-
(dorsal 35-degreeproximal-palmarodistalview). This should result ble of imaging horses.
in the projection of the proximal sesamoidsover the distal MC III Recently, magnetic resonance (MR) imaging has been used to
6 evaluate the distal limbs in horses including the MCP or MTP
or MT III and the joint space projected with maximum width.l
The dorsal 45-degreelateral-palmaromedialand dorsal 45-degree joints.lo'rt A distinct advantageof MR is the exceptionalanatomic
medial-palmarolateraloblique projectionsshould be a routine part and physiologic detail of both soft tissue and osseousstructures
of the survey examination. These oblique views are necessaryto (Ftg. 22-1A and B). Additionally, MR imaging is multiplanar.
view the abaxial aspectsof the articular surfaces,the periarticular MR examinations are commonly performed using several types
margins, and the proximal sesamoids. of acquisition sequencesto demonstrate different anatomic and
Additional projections of the joint may be indicated according to pathologic features.As with CT scanners,MR systemsare expensive
the information gainedfrom surveyradiographs.'Thelateromedial and require that horses are under general anesthesia,which limits
projection during flexion is performed while the foot is held off the availability to a few large referral centers with MR systems
the ground as if the sole of the hoof were being visually inspected. adapted to equine imaging.
Alternate positions include variations in the degree of flexion and
flexed oblique views. These projections may provide better visual- Radiographic i nterpretation
ization of subarticular surfacesat the dorsal aspect of distal MCIII
or MTIII, the proximal part of the proximal phalanx, and the of diseases of the
articular margins of the proximal sesamoidbones.6 metacarpophalangeal
The dorsodistal-palmaroproximal projection is made while the
limb is not bearing weight. In this study, a tangential view of the
(metatarsopha lan gea I l
articular margin of the distal MC III or MT III bone is created. articulation
The foot is elevated on a block, and the limb is extended. The
primary beam direction is approximately 125 degreesto the axis of ]oint diseasein the horse is often associatedwith repeatedtrauma,
and, as with any species,the pithologic changesmay be characteris-
the metacarpal or metatarsal bone.t The degree of flexion and the
tic of the joint and of the function required of the horse. A
angle of the primary beam determine the tangent of the joint
study of racetrack injuries in horses has provided an overview of
surface that is visualized.
pathologic findings and pathogenesisof MCP or MTP joint dis-
The palmaroproximal-palmarodistal projection is used to visual-
ease.r2Lamenessand distension of a joint are the initial clinical
ize the palmar articular surface of MCIII or MTIII and the proxi-
signs that typically precede the request for radiographic examina-
ma1 sesamoids.Positioning of the patient requires that the x-ray
tion. The earliest signs of joint diseasemay remain obscure on
tube be placed close to the horse's body. The limb should be
radiographs, as wear lines in the articular cartilage or synovial
positioned as far caudal as possible, and the foot is placed on a
hypertrophy are usually not recognized.Radiographsofthe contra-
supporting tunnel containing a cassette.o Some magnification re-
lateraljoint may be obtained for comparison.Although pathologic
sults from the use of this projection owing to the distance betrveen
change is often bilateral, it is usually in different stagesof develop-
the oroximal sesamoidbones and the film cassette.
ment.
The abaxial surfacesof the proximal sesamoidsmay be examined
by placing a cassettemedial or lateral to the joint. The x-ray beam Joint effusion
is then directed in a palmaroproximolateral-dorsodistomedial or
palmaroproximomedial-dorsodistolateral direction, respectively.s foint effusion is usually a result of trauma, with degenerative
Contrast arthrography of the MCP or MTP joint is sometimes changes in the articuiar surfaces and joint capsule. Radiographic
useful. Five to ten milliliters of water-soluble contrast medium signs include soft-tissue swelling and joint distention. With chronic
containing 300 to 400 mg/ml of iodine is adequate.Injection of insults, dystrophic calcification of the periarticular soft tissuesmay
contrast medium should follow arthrocentesis and withdrawal of also be present.13
an equal volume of synovial fluid. Injection is made into the lateral
pouch of the joint, proximal to the lateral sesamoidsand dorsal to Villonodular synovitis
the suspensory ligament. The joint should be vigorously flexed, Villonodular synovitis is characterized by a firm, nonfluctuating
extended, and massagedbefore radiography to distribute the con- swelling at the dorsal aspect of the joint. The villonodular masses
trast medium throughout the joint. arise from enlargement of the synovial vilii of the joint capsule
and are associatedwith repetitive trauma. The condition is usually
Figure 22-1. A, A sagittalmagneticresonanceimage of the metacarpophalangeal and proximalinterphalangeal joints. The deep digitalflexor tendon can be
seen coursingalongthe palmaraspect (largewhite arrow) and the distalsesamoideanligamentsorrginatingon-the distal marginoi thJproximal sesamoid
bone
( s m a l lw h i t e a r r o w d .fh e syn o viaflu
l id in th e ca u d a lp a lm araspectcanbecl earl yvi sual i zedonthi si mage
(bl ackarrow ).Thei ommondi gi tul
locateddorsalto the joint (white asterisk).B, A transversemagneticresonanceimageof the metacarpophalangeal joint. The deep digitalfl-exor
""t"n.orrenoonrs
(white arrow) ano
superficialdigitalflexor (white arrowheadsltendonsare visiblein cross-section alongthe palmaraspect.The originbf the di.tal sesarioideanligamentsis evident
at this level (blackarrowheads). The most distalaspectof the sagittalridgeof the third metacarpuscan be seen within the centralgrooveof th; proximalphalanx
(blackarrow).A cross-section of the common digitalextensortendon is depictedwithin the dorsalsoft tissues lwhite astergK).
Supracondylar lysis
In MC III or MT III, the radiographic features of supracondylar
lysis are similar to the those seen in villonodular synovitis, except
that the former occurs at the palmar surface of the bone' Changes
are caused by chronic proliferative slmovitis. Radiographic signs
are joint distention and lysis of bone at the palmar cortex of MC
III or MT III, distal to the joint capsuleattachment(seeFig. 22-2).
Arthrography may be difficult to perform becauseof the presence
of hlpertrophied synovium and diminished synovial joint space.
Contrast medium permeates an undulating, irregular mass, filling
defect. The erosive concavity formed in the bone is usually readily
apparent (seeFig. 22-3).
Cortisone arthropathy
The changes associatedwith cortisone arthropathy may involve
articular and periarticular structures and have variable degreesof
degeneration and proliferation. Repeated steroid injections result
in localized demineralization of bone and decreased trabecular
detail. Chronic changesinclude mineralization in the periarticular
Figure 22-3. Positive-contrast arthrogram(samehorseas that in Fig 22-2) soft tissues, associated with deposition of steroid within those
Thereare two radiolucent,space-occupyingmassesin the dorsoproximal joint
mass at the palmarsurfacefills the structures. A differential diagnosis of steroid-induced arthritis
space (arrowheadsl.A space-occupying
areaof supracondylarlysis (arrows). should be considered in the presence of degenerative change or
(Metatarsophalangeal)
The Metacarpophalangeal Articulation 263
Osteochondrosis
Osteochondrosis may be found in the distal aspect of MC III or
MT III.'7 'zoThe radiographic findings are well-demarcated,radiolu-
cencies that may extend several centimeters deep to the articular
margin. A lateromedial radiograph of the joint may best demon-
strate the depth of the lesion in the condyle. The shape of the
defect may be a shallow concavity, a deep concavity, crescentic,
oval, or circular.2oThe changes are found at the junction of the
radii of articulation between the MCP or the MTP joint and the
metacarposesamoideanor metatarsosesamoideanarticular surface
(Fig. 22-7). These lesions have been called "traumatic osteo-
chondrosis"-an indication of the controversyregarding their
etiology.L Arthrographically, cavitation of the joint surface may
exist, although advanced degenerative subchondral bony changes
can also be found with the overlying cartilage intact at the articu-
lar surface.
Osteochondral fragments of the palmar aspectof the joint have
been given three classifications.'zlType I fragments occur at the
proximai end of the phalanx, just medial or lateral to the sagittal Figurc 22-7. Lateromedialradiographof a horse with distal metacarpa
groove, and type II fragments have origin from the wing of the osteochondrosiThere
s. i s an opaqueosteochondral
fragmentw i thi n a deec
proximal phalanx. Type III fractures originate from the basiiar concavityof radiolucency(arrows).
2 G , 4 A P P E NDI C U L ASRKE L ET ON -EOU IN E
Septic arthritis
Septic arthritis may be associatedwith hematogenous spread of
microorganisms, as occurs with omphalophlebitis or by direct con-
tamination owing to trauma or nonsterile invasive techniques.
Radiographic signs of early septic arthritis are periarticular soft-
tissue swelling and distention of the joint. Progression of the
disease results in malalignment, subluxation, or collapse of the
joint and bony changes of subchondral bone lysis and periosteal
proliferation at the joint margins (Fig. 22-ll). The cartilage space
may appear increased at areas of subchondral bone lysis. Dimin-
ished joint space is evidence of the loss of articular cartilage that
typically precedessubchondral bony change.
The radiographic sign of an increasein the apparent joint space
must be critically analyzed.Incomplete ossification of the cartilage
model is normally present in young, developing animals. The large Figure 22-9. Lateromedialradlographof an MCP joint with a type lll frac-
soft tissue spaceat articular margins progressivelydiminishes with ture (arrows)originating
from the basilarmarginof a proximalsesamoid.
skeletal maturity. Furthermore, radiographs made in non-weight-
bearing horses will cause joint spacesto be widened compared
with weight-bearing projections. \A/heneverpossible, it is desirable
to have the horse bearing normal weight on the joint at the time
of radiography. Increased thickness of the articular cartilage has have smooth, rounded borders. The latter are usually attached to
not been documented in animals. Excessivefluid or soft tissue in the joint capsuleor to the joint margin as an exostosis(Fig.22-13).
the joint space,as occurs with immune-mediated arthritis, results Free joint bodies may displace or move about within the joint.
in a wider joint space. However, such diseaseshave not been Osteochondral fragments arising from the plantarolateral emi-
documented in the horse. nencesofthe proximal phalanx (seeFig. 22-13) havebeen reported
Nonseptic inflammatory joint diseaseshave varied causesand
may be difficult to classifr. Radiographic signs are distention of the
joint and displacement of periarticular soft tissues.If the condition
is chronic, bone production, at the joint margins or periarticular
osteophytes may be found.
Gondylar fractures
Fractures in the distal condyle of MC III or MT III can be difficult
to visualize radiographically.The radiographic signs include uneven
joint surface,interruption of the metaphysealcortex, and the pres-
ence of a radiolucent fracture line extending from the joint surface
to the cortex. The dorsodistal-palmaroproximal projection, angled
at 125 degreesin a non-weight-bearing position, has been useful
to identifr condylar fractures of the distal MC III or MC III that
were not apparent on standard radiographic series.TThese fractures
usually occur at the lateral side of the joint (Fig. 22-12) and may be
completelydisplaced,completelynondisplaced,or incomplete.36'"
Prognosis following surgical treatment varies.37' 38
Fractures of the proximal phalanx often communicate with the
articular surface.Fracture location and severity must be considered
relative to surgical repair and prognosis."
Figure 22-14, A, A dorsal45-degreemedial-palmarolateral radiograph. Fracturesthroughthe medialsesamoidare apparent.The joint is extended,but separatlon
of a horsew i th fracturesof the medi aland l ateraproxi masl es amoi ds .
oft he f r a g m e n t si s m i n i m al.T h e su lp e n so r ylig a m e n rt e m a in sin ta ct.B , Lateralradi ograph
T he iol n tl s h v p e r e x t e n d e ad n, d th e r eis m a r ke dse p a r a tioonf th e fr agments.The suspensory l i gamenthas separated.
References
1. Getty R: Sisson and Grossman's The Anatomy of the Domestic Arimals, 5th ed.
Philadelphia, WB Saunders, 1975, pp. 357-360.
2. Weaver JC, Stover SM, O'Brien TR: Radiographic anatomy of soft tissue attach-
ments in the equine metacarpophalangealand proximal phalangeal region. Equine Vet
I 24:310, 1992.
3. Rendano VT: Equine radiology: The fetlock. Mod Vet pract 58:871,1977.
4. Butler JA, Colles CM, Dyson SJ, et al; Clinical Radiology of the Horse. London,
Blackwell,1993,pp. 83-99.
5. Allan GS: Radiography of the equine fetlock. Equine pract 1:40, 1979.
6. Morgan JP: Techniques of Veterinary Radiography, 5th ed. Ames, Iowa State
University Press, 1993.
7. Hornof WJ, O'Brien TR: Radiographic evaluation of the palmar aspect of the
equine metacarpal condyles: A new projection. Vet Radiol 21:161, 19g0.
8. Palmer SE: Radiography of the abaxial surface of the proximal sesamoid bones of
Figure 22-17. Lateromedialradiographof the distal metacarpal/metacar- the hor 'e. I Am Vet N l ed As s oc l 8l :2o4, 1982.
p a l p h a l a n g elal ll, t h e M CP jo in t,a n d th e p r o xim apl h a la n xo t a horserecenty
h a v i n ga " w a l k r n gca st" su p p o r tr e m o ve dfr o m th e le g . T h erei s some bone 9. Denolx JM, ]acot S, Perrot P: Ultrasonographic anatomy of the dorsal and abaxial
s c l e r o s i sa r o u n dt r a n sve r sep in tr a cts,b u t th e r e m a in in gb one has advanced a'pec tsof the equi ne [er l oc k .Lqui ne Vet | 28:54, l 9qo.
o s t e o p e n i aT.h e r ei s g e n e r a lizerde m o d e lin o g f b o n e ,a n dth e corti cesare thi n. 10. Martinelli MJ, Baker Gl, Clarkson RB, et al: Magnetic resonance imaging of
O s s e o u st r a b e c u l aea r e co a r sea n d in e g ua r with n o o r g a ni zedpattern.The degenerativejoint diseasein a horse: A comparison to other diagnostic techniques.
s e s a m o i d sh a v ea s po n g e - like a p p e a r a n cea ,n d a vu lsio no f b one has occurred Equine Vet J 28:410, 1996.
a l o n gt h e b a s i l a mr a r g in s.
11._Tucker RL, Sande RD: Magnetic resonance imaging and computed tomography:
Evaluation of equine musculoskeletal conditions. Vet Clin North an
tfq prail
17:145-157,2001.
as fracturesr2'22'23,27,4r
and are considered by some to be manifesta- 12. Pool RR, Meagher DM; Pathologic findings and pathogenesisof racetrack injuries.
tions of osteochondrosis.zr'2+33,42,43 Vet Clin North Am [Eq Prac] 6:l-30, 1990.
13. Gillette EL, Thrall DE, Lebel JL: Carlson's Veterinary Radiology, 3rd ed. philadel-
Fractures of the proximal sesamoids phia, Lea & Febigea1977,p. 435.
14. Barclay WR White KK, Williams A: Equine villonodular synovitis: A case survey.
Proximal sesamoid fractures are consistently of three types: apical, Cornell Vet 70:72, 1979.
mid-body, or basilar.tnSome may be found as osteochondral frag-
15. Nickels FA, Grant BD, Lincoln SD: Villonodular slnovitis of the equtne metacar,
ments separatedfrom the sesamoidapex (apical fractures;seeFig. pophalangealjoint. J Am Vet Med Assoc 168:1043,1976.
22-5) or base (basilar fractures, see Figs. 22-9 and 22-13). Frac-
16. van Veenendaal JC, Moffat RE: Soft-tissue masses in the fetlock joint of horses.
tures through the body of the sesamoidmay have a narrow cleavage Aus Vet J 56:533,1980.
line, indicating that the suspensoryapparatus remains intact (Fig.
17. Petterson H, Reiland S: Periarticular subchondral "bone cvsts,, in horses. Clin
22-IM). Wide separationof sesamoidfragmentsusually indicates
Orthopaedics62:95. I gbg.
bilateral sesamoid fractures and disruption of the fibers of the
suspensoryligament (seeFig. 22-14b. Hyperextensionof the MCP 18. HornofWJ, O'Brien TR, Pool RR; Osteochondritis dissecansofthe distal metacar-
pus in the adult racing thoroughbred horse. Vet Radiology 22:98, l91l.
or MTP joint is apparent if stressis applied to the joint or if the
limb is bearing weight with disruption of the suspensoryligament. 19. Edwards GB: Interpreting radiographs. 2: The fetlock joint and pastern. Equine
Vet T 16:4, 1984.
Abaxial fractures are detectedby using special radiographic pro-
jections. These fractures result from ar,rrlsionof bone by a portion 20. O'Brien TR, Hornof WJ, Meagher DM: Radiographic detection and characteriza-
tion ofpalmar lesions in the equine fetlock joint. I Am Vet Med Assoc 178:231, 1981.
of the attachment of the branches of the suspensoryligament on
the medial or lateral abaxial aspects of the respective proximal 21. Foerner JJ,Barclay WP, Phillips TN, et al: Osteochondral fragments of the palmar/
sesamoid (Fig. 22-15). plantar aspect of the fetlock joint. Proceedings of the 33rd Annual Meeting of the
American Associationof Equine Practitioners,1987,p.739.
The prognosis of sesamoid fractures is correlated to the type of
fracture and damage to the associated structures. A review of 22.
_Birkeland R: Chip fractures of the first phalanx in the meratarsal phalangeal joint
ofthe horse.Acta Radiol (Suppl) 319:73,1972.
the clinical aspects of apicalaaand basilaras sesamoid fractures
is available. 23. Petterson H, Ryden G: Arulsion fractures of the caudoproximal extremity of the
first phalanx. Equine Vet J 14:333, 1982.
Sesamoiditis 24. Saldgren B: Bony fragments in the tarsocrural and metacarpo- or metatarsopha-
langeal joints in the Standardbred horse: A radiographic survey. Equine Vet I (Suppt)
Sesamoiditisis indicated radiographically by bony proliferation on 6:66,1988.
nonarticular surfacesof the proximal sesamoids.a6 Linear or cystic 25. Carlsten l, Sandgren B, Dalin G: Development of osteochondrosis in the tarso
268 A P P E NDI C U L ASRKE L ET ON -EOU IN E
crural joint and osteochondral fragments in the fetlock .ioints of Standardbred trotters' C. Should be centered over the diaphysis of MC III and the
I. A radiological survey. Equine Vet J (Suppl) 16:42,1993. exposuremade with the limb not supporting weight.
26. Grondahl AM, Engeland A: Influence of radiographically detectable orthopedic D. Should be made prior to making special projections or
changes on racing performance in Standardbred trotters. t Am Vet Med Assoc contrast studiesof the joint.
2 0 6 : 1 0 1 3 ,1 9 9 5 .
27. Dalin G, Sandgren B, Carlsten J: Plantar osteochondral fragments in the fetlock 2. Villonodular spovitis of the MCP or MTP joint is usually
joints of Standardbreds: Result of osteochondrosis or trauma? Equine Vet J (Suppl) A. The resultof low-gradeinfection.
16:62, 1993. B. A sequelto osteochondritisdiseccansand some nutritional
28. Grondahl AM, Dolvik NI: Heritability estimations of osteochondrosis in the disturbances.
tibiotarsal joint and of bony fragments in the palmar/plantar portion of the meta- C. The result of repetitive trauma.
carpo and metatarsoPhalangeal joints of horses.I Am Vet Med Assoc203:101' 1993'
D. Occurs with degenerative joint diseaseand cartilagedegra-
29. Philipsson J, Andr6asson E, Sandgren B, et al: Osteochondrosis in the tarsocrural dation.
joint and osteochondral fragnents in the fetlock joints in Standardbred trotters. II.
Heritability. Equine Vet I (Suppl) 16:38,1993. joint
3. Lateromedialprojection of the left metacarpophalangeal
30. Sandgren B, Dalin G, Carlsten J, et al: Development of osteochondrosis in the of a 2-year-old Thoroughbred filly that presented with front limb
tarsocrural joint and osteochondral fragments in the fetlock ioints of Standardbred joints (Fig. 22-
lamenessand swellingat the metacarpophalangeal
trotters. II. Body measurementsand clinical findings. Equine Vet I (Suppl) l6:48, 1993'
18). Give the radiographicfindings, diagnosis,and suggestionsfor
31. Grondahl AM: The incidence of bony fragments and osteochondrosis in the additional radiographicexamination.
metacarpo- and metatarsophalangealjoints of Standardbred trotters; A radiographic
study. Equine Vet Science 12:81. 1992.
4. Fractures that communicate with the MCP or MTP joint
32. Sandgren B, Dalin G, Carlsten J: Osteochondrosis in the tarsocrural .ioint and A. Are most common at the medial condyle of the right
osteochondral fragments in the fetlock joints in Standardbred trotters. I. Epidemiology'
Equine Vet J (Suppl) 16:31,1993.
metacarpusin young, racing Thoroughbreds.
B. May involve any of the bony components of the fetlock
33. Fortier LA, Foerner JJ, Nixon Af: Arthroscopic removal of uial osteochondral joint.
ftagments of the plantar/palmar proximal aspect of the proximal phalanx in horses:
119 cases(1988-1992).J Am Vet Med Assoc 206:7I,1995. C. Are usually exerciselimiting but not prohibiting.
D. Always result in crippling lameness.
34. Copelan RW, Bramlage LR: Surgery of the fetlock joint. Vet Clin North Am llarge
Anim Practl 5:221, 1983.
5. Supracondylar lysis of the metacarpus or metatarsus is
35. Yovich IV. Mcllwraith CW, Stashak TS: Osteochondritis dissecansof the sagittal A. Similar to villonodular synovitis except that it occurs at the
ridge of the third metacarpal and metatarsal bones in horses. J Am Vet Med Assoc
1 8 6 : 1 1 8 6 ,1 9 8 5 .
palmar (plantar) surfaceof the bone.
B. Diagnosedmost easilyusing contrast arthrography.
36. Zekas LJ, Bramlage LR, Embertson RM, et al: Characterization of the type and
C. Is commonly seenas a sequelto cortisoneinjections.
location of fractures of the third metacarpal/metatarsal condyles in 135 horses in
central Kentucky (1986-1994). Equine Vet J 31:304, 1999. D. Is a common sequelto septicarthritis.
37. Rick MC, O'Brien TR, Pool RR, et al: Condylar fractures of the third metacarpal
6. A 6-month-old Appaloosafilly presentedwith an open, drain-
bone and third metatarsal bone in 75 horses: Radiographic features, treatments, and
outcome. I Am Vet Med Assoc 183:287,1983. ing wound dorsal to the fetlock (Fig.22-19). List the radiographic
findings and diagnosis.
38. Zekas Ll, Bramlage LR, Embertson RM, et al: Results oftreatment of 145 ftactures
of the third metacarpal/metatarsal condyles in 135 horses (1986-1994). Equine Vet J
3 1 : 3 0 9 ,1 9 9 9 .
39. Holcombe Si, Schneider RK, Bramlage LR, et al; Lag screw fixation of non-
comminuted sagittal fractures of the proximal phalanx in racehorses:59 cases(1973-
1991).I Am Vet Med Assoc 206:1195,1995.
41. Nixon AJ, Pool RR: Histologic appearanceof axial osteochondral fragments fron
the proximoplantar/proximopalmar aspect of the proximal phalanx in horses. J Am
Vet Med Assoc207:1076,1995.
44. Spurlock GH, Gabel AA: Apical fractures of the proximal sesamoid bones in 109
Standardbredhorses.I An Vet Med Assoc 183:76,1983.
46. Blevins WE, Widmer WR: Radiology in racetrack practice. Vet Clin North Am
l Eq P ra cl 6 :3 1 -6 1 , 1 9 9 0 .
ffi Ouestions
l. Survey radiographic examination of the metacarpophalangeal
joints and the metatarsophalangeal joints
A. Requiresonly left and right markers, becausethe hind limb
and the front limb are distinctly different.
B. Should include four orthogonal projections, flexed lateral
projections,and skyline projections. Figure 22-18.
The Phalanges 269
7. Degenerativejoint diseaseof the MCP or MTP joint of a 2-year-old Standardbred gelding was obtained (Fig. 22-20).
A. Can bestbe diagnosedby radiographicsignsofperiarticular Describe the radiographic findings and give your diagnosis.
bone proliferation and subchondralbone remodeling.
B. Is, most often, a sequelto septicarthritis. 10. Diseaseof the proximal sesamoids,referred to as "sesamoi-
C. Is a nonspecific term for progressivedeterioration of all ditis,"
tissuecomponentsof the joint. A. Acquire the name because,with the exception of fractures,
D. Is a specific joint diseaseresulting from repetitive trauma. most diseasesresult in inflammation and irritation of the
periosteum.
8. Osteochondrosisof the MCP or MTP joint B. Is often associatedwith changesin the suspensoryligament
A. Is diagnosed more frequently in the proximal sesamoids. and tissuessurrounding the fetlock joint.
B. Has clearly defined heritability. C. Is an inflammatory diseaseof the bone that leads to degen-
C. Is often diagnosed in Standardbredsat the proximal erative joint disease.
palmar/plantar margin of the proximal phalanx. D. Results in separation of the bone owing to progressive
D. Has been mistakenly diagnosed as traumatic avulsion of weakeningand avulsion of the supporting ligamentous
apophysesand fractures of the sagittal ridge of MC IIL structures.
CHA P TER
23
The Phalanges
r ElizabethA. Riedesel
Radiographic examination of the equine phalanges is most fre- blocks are used to localize the origin of pain more specifica1ly,
quently performed as part of the diagnosticevaluationof lameness especiallyin the horse with multiple abnormalities identified dur-
or of firm or persistent swellings,or during a pre-purchaseexami- ing the physical examination.r The significance of many of the
nation. History and physical examination findings should indicate radiographic abnormalities of the equine phalanges is difficult to
a high likelihood of lesion in the pasternor foot. Diagnosticnerve ascertain unless pertinent facts obtained from the patient's clinical
2 7 O A P P E NDI C U L ASK
R EL E T O N -EOU IN E
history and physical examination are correlated with the radio- to evaluate them optimally are listed in Table 23-1. Excellent,
graphic findings. complete descriptionsof patient positioningt't are available,and
the reader is referred to these sourcesfor additionai information.
I Technical factors
Patient preparation I Normal radiographic anatomy
Dirt, skin lesions,and iodine-containingmedicationscan all pro-
I (including variations)
duce opacities that complicate radiographic interpretation. Conse-
quently, the patient should be examined ciosely to ensure that all
Osseousstructures
such material has been removed from the hair coat and hoof wall. Normal radiographic anatomy is illustrated in Chapter 50, as well
Shoesand any additional pads should be removed so that optimal as in other published sources.a'sHowever, severalvariations in the
radiographs of the distal phalanx can be obtained. The sole and appearanceof the anatomic structures are worthy of mention.
sulci of the frog should be thoroughly cleaned with a hoof pick. These variations are frequently misinterpreted as abnormal. A nu-
The sulci may then be filled with a material of soft-tissue opacity trient foramen occurs as an inconsistent radiographic finding in
(such as Play-Doh, Rainbow Crafts, Cincinnati, OH) to the level the proximal phalanx of approximately 87o/oof Thoroughbreds and
ofthe solar surface(Fig. 23-IA). Packingthe central and coliateral Standardbredsthat are at least I year of age.u,tWhen present,these
sulci eliminates radiolucent linear shadows created when the air- foramina are sometimes bilaterally symmetrical and can be located
filled sulci become superimposed on the distai phalanx in the in the palmar or dorsal cortex. No horseswere identified in those
dorsal 65-degreeproximal palmarodistal* oblique view (see Fig. surveys to have both a dorsal and a palmar nutrient foramen;
23-18). however, the author has noted both to be present in several foals.
When present in the dorsal cortex, the foramen is typically seen in
Recommended views a lateromedial view as a radiolucent line running obliquely proxi-
The eouine foot is structured such that certain anatomic areascan mal to distal through the mid-diaphysealcortex (Fig. 23-2). In a
be imaged as a group. Thesegroupingsand the projectionsneeded dorsopalmar view, it appears as a thin lucent line within the
medullary region. When in the palmar cortex, the foramen is
*Palmar(o) is used throughout this chapter with the understanding that located in the distal third and courses in a shorter oblique-to-
plantar(o) should be substituted if referenceis being made to the rear digit. transversedirection. Of greatestimportance is that these foramina
Soft tissue
No muscle exists in the phalangeal region of the foot. There are,
however, many tendons and supporting ligaments in addition to
joint capsules.Minimal amounts of fat are present in the phalan-
geal region. Knowledge of the attachment sites of the joint capsules,
tendons, and ligaments of .the foot is imperative for accurate
interpretation of the osseouschanges seen in radiographs of the
phalanges. Figures 23-7 and 23-8 illustrate the attachment sites
of these major structures. Additional information on soft-tissue
attachments is available.t3Most of these soft tissues do not create
independently distinct shadows. However, the deep digital flexor
tendon can often be seen in the lateromedial view as a slightly
Figurc 23-2. Radiolucent linesare visiblein boththe dorsaland palmar more opaque soft-tissue band as it passesbetween the level of the
corticesof Pl of this foal (longarrows).Theseare normalsmallnutrient proximal aspect of the middle phalanx and the proximal margin
foramina. A circular
radiolucencyis alsopresent in the distalpalmarsubchon- of the navicular bone.' The hoof capsule generally is considered to
dralboneof the proximaphalanx (shortarrows).Thisis a cyst-like
osteochon- produce a uniform soft-tissue shadow. However, the junction be-
drosislesion.
tween the stratum medium and the stratum internum of the dorsal
hoof wall can frequently be seenin a properly exposedlateromedial
view.lo The junction of the coronary band and the most proximal
should not be mistaken for fractures. Variability in the location of extent of the hoof wall is not alwavsclearlv distinct in lateromedial
the nutrient foramen of the hindlimb proximal phalanx has not and dorsopalmar views. The ergot .i.rt" a radiopacity when
been reported. Variations have not been reported in other breeds, superimposed on the proximal phalanx -uy in the dorsopalmar view
but they very likely occur. (seeFig. 23-38). In the lateromedial view, the ergot opacity can be
Variations may also occur in the appearanceof trabeculae in the seen along the palmar surface of the skin.
medullary cavity of the proximal phalanx (Fig. 23-3). A prominent
radiolucent center in the medullary cavity surrounded by a ringlike Articular cartilage and collateral cartilages
radiopacity is illustrated in Figure 23-38; this is a normal variation
in trabeculation and does not indicate cyst formation. The properly positioned dorsal 45-degree proximal palmarodistal
If the lateromedial view is slightly oblique, two normal structures view is the best view for evaluation of the width of the metacaroo-
become more prominent and can be misinterpretedas abnormal. phalangeal, proximal interphalangeal, and distal interphalangeal
joints. In the normal foot, the metacarpophalangealjoint is usually
The first is the ridge for the V-shaped attachment of the oblique
sesamoideanligament along the palmar cortex of the proximal the narrowest of these articulations, the proximal interphalangeal
joint is slightly wider, and the distal interphalangeal joint is rhe
phalanx. The second is the eminence for attachment of the collat-
eral ligaments of the distal interphalangeal joint along the dorsum widest (see Frg.23-3A). If the horse is not bearing weight evenly
of the middle phalanx. on the leg, the asymmetrical loading forces can cause the appear-
The radiographic appearanceof the normal distal phalanx varies ance of narrowing of the loaded side and widening of the non-
in severalrespectswhen depicted in the dorsal 65-degreeproximal- Ioaded side of the joint (see Fig. 23-l2B). This artifact can be
palmarodistal oblique view8 10The most obvious differencesare in recognizedbecauseit similarly affectsall three joints. The collateral
the number and distribution of vascular channels. The number of cartilages are not visible as independent shadows in the normal
vascular channels is t1pically greater in the hind- than the forefoot
(rangesof 9 to 19 and 5 to 16, respectively).'All vascularchannels
radiate from the solar canal to the solar border. On their path to
I Radiographicchanges caused
the periphery, some give rise to secondary branches that reach the
solar border. Although this branching pattern is unique to individ-
I by diseasesof the phalanges
ual animals, the major channels identified at the solar margin
should communicate with the solar canal. In Figure 23-4, some
General comments
variations in the number of vascular channels and the distribution The common diseasecategoriesthat affect the phalangesand asso-
and patterns of radiation from the solar canal are illustrated. ciated joints are acute trauma leading to fracture, chronic repetitive
A smoothly rounded concavity in the toe of the distal phalanx trauma leading to enthesopathyand degenerativejoint disease,and
may be seen in the normai horse. This notch is referred to as the infection. Inflammation of the laminae of the hoof wall (laminitis),
crena margins solearisor, more commonly, the crena or toe notch. leading to a disturbanceof the mechanicalsupport of the foot, is
In a radiographic study of the foredigit of the developing Quarter the only common effect initiated by metabolic disease.Neoplasia
horse, a crena was identified in foals between 4 and 22 weeks in of the soft tissuesor phalangesis extremely rare.
272 A P P E NDI CU L ASRKE L ET ON -EOU IN E
iial
Figure 234. Aand B, Two variationsin the patternof vascularchannelformationin the norma distalphalanx.
The Phalanges 273
ia
Figure 23-5. A to C, Normalvariationsin the shape of the extensorprocessof the distal phalanxas might be seen on the lateromedialview. (lllustralonoy
R i c h a r dM . S h o o k .DVM .)
11
13
10
15
9
18
19
B
Figure 23-7. Lateralviews of the tendonand ligamentattachmentsof the digit.A, Superficial
tissues;B, Sagittalsection.illlustrationby RichardA. Shook,DVM.)
9
22
11
i4))
1tcu,,-,,
lli 'li{
'i@lll,.
As there is little soft-tissue volume in the pastern through the ",;
foot, x-ray exposure technique is typically selectedto best define
the bony structures.Still, abnormalitiesdo occur in the soft tissues.
Either the soft tissue must be evaluatedusing a high-intensity light,
or additional images need to be made to optimize soft-tissue
evaluation. Use of a relatively higher kilovoltage peak (kVp) and
lower milliampere seconds(mAs) produces a radiograph with a
longer scaleof contrast and better resolution of soft tissues,
The radiographic signs of abnormal soft tissue include alteration
of thickness, contour, or opacity. Increasedpericapsular soft-tissue
thickness may be seenwith intracapsular fluid accumulation, syno-
vial tissue thickening, extracapsular inflammation (cellulitis), or
fibrosis. If radiographic signs of soft-tissue enlargement are strictly
confinedto the region ofthe joint, intracapsularfluid accumulation
with or without synovial tissue thickening is the likely cause.If the
enlargement extends proximally and distally beyond the sites of
joint capsuleattachment, an extracapsularprocess(fluid and cellu-
lar) is present,which obscuresevaluationof intracapsularchanges.
Isolated enlargement, away from the joint, is most iikely related to
direct local trauma with or without infection. An irregular surface
contour suggests acute laceration or chronic granulation tissue
production. Larger areasof periostealnew bone may persistfor a
long time despiteresolution of the inciting cause.The soft-tissue
contour bulges over such an area of periosteal new bone but may
not be actually thickened.
Increased opacity within pericapsular soft tissue is usually due
to dystrophic mineralization. Lesions that commonly become min-
eralized include chronic sprain or strain of supporting ligaments
and tendons (Fig. 23-9), pericapsulardepositionof corticosteroids, Figure 23-1O, Dystrophiccalcification
in the palmarsoft tissuessecondary
and focal necrosissecondaryto neurectomy(Fig. 23-10). Ossifica- to previousneurectomv.
276 SK EL E T O N -EOU IN E
A P P E NDI C U L AR
tion of the collateral cartilagesof the distal phalanx should not be seen early in its formation at one of the attachment sites will likely
mistaken for dystrophic mineralization of soft tissue. be minimal in volume and have a mildly irregular surface. If the
Decreasedopacity within the soft tissues is associatedwith the strain injury continues, the new bone production enlarges and
presenceof air or gas in the subcutis or the fascial planes of the continues to have a ftrzzy irregular margin. Such a change is
tendons and ligaments. Soft-tissue gas commonly follows diagnos- occasionally seen at the insertion of the lateral digital extensor
tic nerve block and open skin wound but rarely is causedby a gas- tendon, on the dorsolateral proximal surface of the proximal pha-
producing organism. lanx (see Fig. 23-9). In other instances of chronic strain affecting
The radiographic signs of abnormal bone tissue include alter- an attachment site, the thickness of the new bone (enthesophyte)
ation of contour, margination, and opacity. These signs are caused increasesand takes on a smooth, hook or spurlike shape,projecting
by a combination of new bone formation and bone removal. in the direction of tension or traction. Radiographically aging or
Repeatedpatterns of bone change tend to be associatedwith spe- determining the activity ofthese bone changesis diffrcult. Periosteal
cific injury to the phalanges and associatedjoints. Figures 23-11 new bone formation is typically not visible until 5 to 7 days (foal)
and,23-12 depict the variable appearancesof the periosteal surface, or 10 to 14 days (adult) following stimulation. When a prominent
joint space,and subchondral bone that occur in the more common smooth enthesophyteis seen on a first radiographic evaluation of
diseasesof the phalanges. a horse, it should be taken as a signal of strain injury that occurred
at least 5 to 6 weeks oreviouslv.
Strain and sprain iniuries Sprain injury resulis from iu-ug. to the supporting ligaments
of joints induced by movement of the bony components beyond
Projectionsor bumps of bone are commonly seenon the cortical their normal range.' Similar to strain injury, the mild sprain injury
surfaces of the phalanges, especially in the proximal and middle causes inflammation that is not likely to cause visible changes
phalanx. Many of these are caused by strain and sprain injuries. radiographically. Greater degreesof injury result in loss of stability
Strain injury results from damage to muscle or tendon induced by to the joint, allowing complete or partial luxation. Stress views
overuse or overstress.3In its mildest form, strain causes only may be needed to detect subluxation. Laxity in a subluxated joint
inflammation. With chronic repeated strain or more severeacute is often more apparent at physical examination than at radiography,
strain, disruption within the soft-tissue unit or avulsion from its especially if the horse is unwilling to bear full weight on the leg.
bone attachment occurs. Radiographically, the swelling of inflam- Conversely, complete luxation is typically evident and may be
mation in the tendon may not be particularly evident. Soft-tissue accompanied by avulsion fractures at the ligament insertion sites.
changes are best imaged using ultrasound. Although it uncom- Larger fractures of the phalangesmay also be associatedwith joint
monly occurs, dystrophic mineralization can develop in the chroni- luxation. This is commonly seenwith comminuted fractures of the
cally inflamed tendon. Radiography is useful for assessingthe bony middle phalanx and associatedloss of congruency of the proximal
attachment sites of the tendons. Thus knowledge of the attachment interphalangealjoint (seeFig. 23-15). Secondarychangesexpected
sites of the flexor and extensor tendons on the phalangesis needed with subluxation are enthesophlte formation at the ligament inser-
(see Figs. 23-7 and 23-8). Avulsion fracture at the attachment site tion sites and some degreeof degenerativejoint disease.The range
can occur and will be evident as a bone fragment displaced in the of change will depend on the severify of the initial injury and the
direction of traction of the tendon. New bone formation when frequency of recurring subiuxation. Although it is not the result of
overt joint instability, a common site of enthesophyte formation
associatedwith ligament insertion is the palmar or plantar margin
of the proximal phalanx at the insertion of the middle (oblique)
sesamoideanligament. Most enthesophytesdo not regressfollowing
healing of the soft tissues invoived in the inciting sprain or strain
injury.
I Fracture disease
Proximal phalanx
Fractures of the proximal phalanx (P1) occur in different parts of
the bone, depending on the type of stress applied. The common
fracture types are osteochondral edge (chip) fractures at the proxi-
mal dorsal periarticular margin and the palmar or plantar proximal
tuberosity, and longitudinal fractures of the body (diaphysis).'als
By far, the most common fracture invoiving the proximal phalanx
is the osteochondral fracture of the proximal dorsal edge, either at
the medial or at the lateral eminence(seeFig. 23-9). This occurs
as an overextension injury of the metacarpophalangealjoint in
racehorses.This fracture and those of the oalmar eminence are
describedin Chaoter 22.
Various classification schemes have been applied to all other
fractures of the proximal phalanx.'6te By general classification,
the fractures are noncomminuted or comminuted; incomplete or
complete; mono- or biarticular; and in a primarily sagittal or
Figure 23-11- Variableappearanceof contour and opacity of periosteal dorsal plane to the long axis of P1. Figure 23-13 illustratesthese
bone proliferation-andlikely causes:A, Normal cortex. 8, Smooth margin,
mildly opaque-recent subperiosteaihemorrhagefrom direct trauma or exu-
fractures of the proximal phaianx. Several retrospective surveys of
date of infection.C, Smooth margin,opaque-inactive,remodeledtrauma D, Thoroughbred and Standardbred racehorseswith these types of
r a r g i n ,m i l d l yop a q u e - r e ce n to r a ctiver e sp o n seto d ir ecttraumati c
lrre g u l am fractures have been reported with an attempt to correlate fracture
injur y i n c l u d i n gs p r a i n /str a ino r in fe ctive p e r io stitis E, lr r e gul armargi n, configuration to prognosis.l6'17'le 22The most frequently reported
opaque-chronicspraln/strain or infection Note the loss of drstinctionbetween
peri o s t e anl e w b o n e a n d o r ig in aco l d e x in C a n d E. ( lllu str a tiobyn R i chardA fracture configuration in these breeds is the noncomminuted, in-
S ho o k .D V M . ) complete, monoarticular sagittal fracture (see Fig. 23-134). This
The P ha langes277
Figure 23-12. Changesin joint space width, subchondralbone opacity,or both, as seen in the dorsopalmarview of the proximalinterphalangeal joint-and
likelycauses.A, Normaljoint spaceand subchondralbone. B, Widenedjoint spaceon the lateralor medialside, no subchondralbone changes-artf,actbausedby
asymmetricweight distributionon the foot or unbaiancedhoof trimming. C, Widenedjoint space,no subchondralbone changes-non-wJight-bearing at time of
radiography or increasedintra-articular fluid volume. D, Uniformlynarrowedjoint space,no subchondralbone changes-artifaJtcausedby x'+aybeari angutatron
or uniform degenerativewearing and loss of articularcartilage.E, Widened joint space,lysis of the subchondralbone-active septic art'hritis. Nanowed
6 loint
space, irregularopacityand contourof subchondralbone-chronic low-gradeseptic arthritisor chronicosteoarthritisowing to trauma-related instabilityor poor
c on f o r m a t i o n( l.l l u s r r a tiobny Rich a r dA. Sh o o k,DVM .)
fracture is common in 2- and 3-year-olds in race training or active racing times and decreasedperformance indices (order of finish
racing. It occurs in both front- and hindlimbs of these breeds. times purse) regardlessof fracture length or medical versus surgical
However, reported fractures are somewhat more common in the treatment.22This type of fracture is not mentioned in a report of
front limbs of Thoroughbreds and the hindlimbs of Standardbreds. diagnosis and treatment of Quarter horse racehorses.2l
This fracture tl?ically originates at the proximal articular surface
_Noncomminuted, complete sagittal fractures of the proximal
just lateral to or within the midline plane of the sagittal groove phalanx occur with considerablylessfrequency than do incomplete
(Figs. 23-lM; see also Fig. 23-l3A). Very few originate medial to fiactures in racehorses.This type of fracture is, however, reported
the midline plane. to be more common in the Western performance horseJ Two
Two variations of the noncomminuted, incomplete, monoarticu- variations of this fracture occur: one ii biarticular involvine its
lar sagittal fracture occur. The short (<30-mm;xtension into the origin at the metacarpophalangealjoint and its exit at the proximal
diaphysis) variation is slightly more common than the long (>30- interphalangealjoint; the other is monoarticular and exitslypically
mm extension into the diaphysis) variation. Both fractures may through the lateral distal palmar or plantar cortex (see nigs. ZZ-LZA
course in a slightly spiral or oblique manner. This effect is depicted and 23-l4B). These fractures are most readily seen in ihe dorso-
as two parallel or "offset" radiolucent lines representingthe fracture palmar_view. Although these horses have a good prognosis for
plane in the dorsal and palmar cortices. The short fracture may be survival with conservative or surgical treatment, prognosis for
more difficult to identify on an initial radiographic evaluation. rcturn to an equal level of performance is more guarded than with
Both variations of fracture are seenonly on dorsopalmar views. As the noncomminuted, incomplete, monoarticulai sagittal fracture.
there is typically very little gap to the fracture plane, the x-ray Significantly fewer racehorseswith fracture into the proximal inter-
beam must pass parallel to the fracture line to detect the fracture phalangeal joint havereLurnedto racing.ro
gap. Repeatradiographs in 7 to 10 days should allow identification Comminuted fractures of the proximil phalanx (seeFig. 23-l3C)
of the fracture more readily, after lysis of bone along the fracture accounted for approximately 30o/oand 160/oof proximal phalanx
edgeshas occurred during the first stagesof healing. When imaging fractures, not including dorsal proximal chip fractures, in two
occurs several weeks after the onset of lameness, periosteai new surveysof large numbers of horses.r7,2r The maiority of Thoroush-
bone will likely be presenton the dorsal or palmar surface,indica- bredsin one surveywere 2-year-olds.r'Theaverageage ofhoises
tive of bony callus. At this stage, the new bone is visible on the in- another survey was 8.3 years (range,2 to 22 years).ttVariations
Iateromedialview the fracture line on the dorsopalmar view should of this tlpe include comminution throughout the phalanx; only in
be less visible, and sclerosisin the adjoining bone should be seen. the proximal portion; or only in the distal portion. Frequently,
Horses with either the short or the long variation of the non- these fractures have one exit throuqh the lateral rather than the
comminuted, incomplete, monoarticular sagittal fracture have a medial cortex. Thesefractures are typ'ically biarticular and are more
good prognosis for survival and return to athletic performance. likely to be complicated by being open. The multiple fracture
However, in a survey of Standardbreds, these horses had slower planes of the comminuted fracture are visible in both lateromedial
278 A P P E NDI C U L ASRKE L ET ON -EOU IN E
D E
Uru Figurc 23-13. Common fractures
of the phalanges.Proximal phalanx:
,4, S agi ttal pl ane frac tures -non-
commi nuted:(1) Incompl ete,
mm variation);(3) Complete,monoar-
monoar-
ti cul ar(short <30 mm v ari ati on);
Incompl ete,monoarti c ul ar (l ong > 30
(2)
and dorsopalmar views. Oblique views should also be taken to nence (both medial and laterai eminences-common; single
obtain a more thorough depiction of the fracture configuration. sminslsg-uncommon), and osteochondral chip fracture (rare)
Comminuted fractures have the most guarded prognosis for sur- (Fig. 23-15; see also Figs. 23-I3D and E). Physealfracture can
vival and very poor prognosis for return to athletic performance. occur in the skeletally immature horse but is reported very infre-
Much lesscommonly reported are incomplete or complete dorsal quently. The comminuted (complete and typically biarticular) and
plane fractures that originate at the Proximal articular surface eminence fractures (complete monoarticular) are most common in
(see Fig. 23-l3B).w' 20'24These fractures may be detected only on horses whose activity subjects the middle phalanx to an extreme
lateromedial views. The incomplete fracture typically courses dis- combination of simultaneous comoression and torsion forces while
tally toward the dorsal cortex. The complete variation either breaks the foot is fixed to the ground." Thus these types of fractures are
through the dorsal cortex or extends the entire length of the most common in working or performing Western horses, polo
phalanx to exit in the proximal interphalangeal joint. The latter ponies, and jumpers. For both common fractures, the hindlimbs
variation tlpically splits the proximal phalanx into roughly equal are reported to be involved approximately twice as frequently as the
dorsal and palmar or plantar halves. Other sporadically reported front limbs.'zs2eHowever, the front limb is more equally affectedby
fractures of the proximal phalanx include physeal fractures (typi- comminuted fracture. The hindlimb is considerably more fre-
cally Salter-Harris II) and incomplete distal articular fractures.lT
quently reported to have a plantar eminence fracture without
Middle phalanx other comminution. Neither type of fracture is difficult to identify
Fractures of the middle phalanx (P2) include comminuted fracture radiographically. When the eminence is fractured without commi-
(most common), fracture of the plantar or palmar proximal emi- nution, the fragments are variably displaced in a plantar direction.
The P h alanges279
F
p,
. ;,r;.1
,.ultlruuitll
iiuu,:i119u
;"i
""l
::
In the worst cases,the proximal interphalangealjoint is simultane- the middle phalanx, but more commonly, the fracture planes ex-
ously luxated, allowing the distal end of the proximal phalanx to tend into the distal interphalangealjoint. Decision to tre;t and the
descenddistally and override the middle phalanx. As the proximal type of treatment of the comminuted middle phalanx fracture
articular surface of the middle phalanx is involved in this fracture, dependon many factors;however,one of the mosiimportant is the
successfulrepair of this fracture typically includes arthrodesis of degreeof involvement of the distal interphalangealjoint. Additional
the proximal interphalangealjoint. Prognosisfor survival with such oblique views at different angles compared with the standard (see
repair is good and for return to usablesoundnessis fair to good.262s pastern examination, Table 23-l) may be needed to fu1ly identif.
Comminuted fractures can involve only the proximal portion of the planesof comminution. Computed tomography has been used
il-.::..1
.;ii*1i
a;aaa; e;
--J
Fi g u r e 2 3 - 1 5 . A a n d 8 , Co m m i-
nu t e d ,m u l t i p l ef r a c t ur e so f th e m id d le
ph a l a n xI.n t h e l a t e r o me d ia l w /A/,th e
vie
pa l m a rf r a c t u r ee x t e nd sin to th e d ista l
i"l . e r p n s 1 6 n n "j o. 1i . t i n th e a r e a o f tr e
na v r c u l ai lro n e .
2 A O A P P E ND IC U L ASRKE L ET ON -EOU IN E
Distal phalanx
A fracture classification system-types I through VI-is routinely
used to describethe fracturesof the distal phalanx (P3;.'o'" tnt.
classification system is illustrated in Figure 23-13F. Fractures are
typed based on region of the bone affected, articular or nonarticu-
lar involvement, and anatomic plane of the fracture: Figure 23-16. Type ll fracture of the distal phalanx.Dorsa 65-degree-
proximal-45-degree-lateral-palmarodistomedial obliqueview. An obliqueprojec-
I Nonarticular of palmar or plantar process tion such as this is often necessaryto determinewhether the fractureextends
il Articular, extending from distal interphalangeal joint to solar i ntothe di stali nterphaangeaj oi nt,as i t does i n thi s horse.
margin
III Articulat midsagittal, divides into equal parts
IV Articular, extensor process
V Articular, comminuted body fracture (not of type II, III,
or IV) the forelimbs of foals aged 3 to 32 weeks.3sAlthough it has been
VI Solar margin suggestedthat these ossiclesmay be separatecentersof ossification,
the microradiographic and histologic appearancein the majority
Trauma is the most common cause of P3 fractures; however,
of foals studied was consistent with fracture healing.l'z,t' Radio-
they also occur as pathologic fractures secondaryto infective pedal
graphically, these are seen as a triangular fragment at the palmar
osteitis and laminitis. Becausethe hoof wall restricts displacement
aspect of the distal angle of the palmar process, or as an oblong
of any bone fragment, diagnosis of the distal phalanx fracture
fragment separatedby a radiolucent line extending from the inci-
depends on visualization of the fracture line. If the plane of the
sure of the palmar processto the solar margin (Vll-solar border
primary x-ray beam is not parallel to the fracture plane, the
of palmar/plantar processin foals in Figs. 23-l3F and 23-18).35
superimposedparts of the bone obscurethe fracture line, and the
Fractures have been identified at either or both medial and lateral
diagnosis is missed. Therefore, four views of the distal phalanx are
palmar borders. Radiography is an insensitive method for identi-
recommendedwhen a fracture is suspected:(1) lateromedial;(2)
dorsal 65-degreeproximal-palmarodistaloblique; (3) dorsal 65- f ing all foals affected with these fractures. An investigation as to a
causefor these fractures found no significant relationship to exten-
degree proximal, 45-degree lateral-palmarodistal oblique; and (4)
sive trimming of the heels.36Mild, short-duration lameness was
dorsal65-degreeproximal, 45-degreemedial-palmarodistaloblique.
attributed to these fractures in this group of foals. Healing was
Views 2 through 4 are done with the horse standing on the
radiographically complete in an averageof 8 weeks and foals were
reinforced cassetteor cassettetunnel. The type VI fracture requires
sound. Foals through 12 weeks of age have a lucent line between
careful assessmentof the solar margin. Overexposureof the image
the proximal and distal angles of the palmar process.This line is
makes this fracture difficult to see.
normal and should not be mistaken for a fracture.
A wide variety of horses sustain fractures of the distal phalanx.
Quarter horses were most common in a review of a very large
number of horses." Tlpe II fractures were found most often in a
report of 65 horses.3'z Lesions usuaily involved the lateral aspect of
the left front or the medial aspectof the right front (Frg. 23-16).3?'33
In that series of fractures in racehorses,the forelimb that bore
the most weight in turns was at greatest risk (horses were raced
counterclockwise). In another report of 274 horses, type VI was
the most frequently identified type of fracture.3r The type VI
fracture was found in associationwith radiographic signs of lami-
nitis in 42 feet (32o/oof tlpe VI fractures) (see Fig. 23-248).31
The progressionofhealing ofa distal phalanx fracture is difficult
to determine radiographically owing to the minimal amount of
external (periosteal) osseouscallus produced by this bone. Frac-
tures of the extensor processtend to produce the greatestamount
of new bone (Fig. 23-17). The periosteum of the distal phalanx is
poorly developed and does not respond with great proliferation to
the stimulation of direct trauma. Tieatment by corrective shoeing
and stall rest has led to healing in 3 to 19 months, with young
horses and noirarticular fractures showing the most rapid and
complete progression to bone union. Prognosis for return to ath-
letic activity is good for type I and guarded for types II and IV.31'34
Figure 23-17. Long-standing fractureof the extensorprocessof the distal
Solar margin (t1pe VI) fractures have a good prognosis if not phal anx. Thefractureextendsi ntothe arti cul ar
surfaceof the di s tall nterphal an-
associatedwith laminitis or severepedal osteitis. geal j oi nt and has l ed to degenerati ve N ote that peri arti c ul ar
osteoarthrosi s.
Palmar process ossicleshave been identified radiographically in changesare not promi nenton the di sta end of the mi ddl ephai anx .
The P halanges281
.
%.-.--rt,'
11,,,,;::,..ill
,.'lll'lllglll
..-*
'l
signs is fuzzinessat the joint capsuleinsertion or chondro-osseous quence, a smaller region of the joint surface sustains a more
junction on the perimeter of the joint surfaces'As cartilagebegins constant weight-bearingload for a longer period of time in the
to deteriorate,thinning of the joint spaceis seen.As the infection athletic horse.n' This relationship is the basis of an explanation for
invades the deeper regions of the cartilage and reachesthe sub- the characteristic features of progressiveproximal interphalangeal
chondral bone, the subchondral bone margin becomes irregular degenerativejoint diseaseseen in athletic horses,especiallythose
owing to iysis (see Figs. 23-l2E and F and 23-21). Lysis of the active in Western-styleevents.a2The movements of athletic activity
subchondral bone causesthe joint to be unevenly widened'*oAt are proposed to excessivelyconcentrate the load on the articular
this stage,periostealnew bone should be quite evident at the joint cartilage and initiate fibrous thickening of the supporting soft
margins. Septicarthritis alwayscarriesa guardedprognosis. tissues to further restrict joint motion. Continued compression
leads to full-thickness necrosis of the cartilage. Simultaneously,
remodelingof the underlying bone occursin the forms of sclerosis
I Degenerative ioint disease and resorption. The natural attempts to heal the cartilage lesions
Degenerativejoint diseaseis a chronic disorder of slnovial joints are not successfuland gaps are left in the articular cartilage surface.
characterizedby progressivedeterioration of articular cartilage and Osteogenicgranulation tissuefrom the exposedsubchondralbone
by reactivechangesin the joint margin and joint capsule.o'Among bridgesthesejoint gaps,initiating the processof ankylosis.
the multiple causesof degenerativejoint diseaseare acute trauma, Radiographically, typical periarticular osteophytesand entheso-
infection, poor limb conformation, developmentalorthopedic dis- phytes develop. Fibrous thickening of the joint capsule and collat-
ease,and chronic repetitive trauma associatedwith athletic activity eral ligaments,along with compressionremodeling of the articular
such as racing and other styles of competitive performance. These cartilage and subchondralbone, occurs but can be subtle radio-
causestypically produce what is thought of as secondarydegenera- graphically.Focal regions of subchondralbone resorption may be
tive joint disease.Primary degenerativejoint disease,in compari- large enough to be seenas lysis.The osteogenicgranulation tissue
son, is consideredan age-relateddiseaseof slow onset, resultingin in the subchondral sites of bone resorptionarbecomesvisible as
gradual degradationof normal joint structure and function. The bone-to-bone contact. This is the start of bony ankylosisof the
proximal and distal interphalangeal joints can be affected by any joint (see Frg. 23-12F).
of thesecauses.The generalchangesexpressedradiographicallyare If these initial ankylosis sites are sufficiently stable, additional
new bone formation (osteophytes)at the periarticular (chondro- ankylosisprogressesto complete the union of the bone surfaces.
osseous)margin, enthesophytes at the sitesof supporting ligaments However, if activity is continued, the initial ankylosis sites can
and joint capsule,sclerosisand lucency in the subchondralbone, break down and generatemore periarticular new bone (see Fig.
and changesin the joint spacewidth (Figs.23-22 and 23-23). A 23-23). During the ankylosis process,lamenessis likely to persist.
wide spectrum of combination and degree of the above changesis In these horses, the natural ankylosis must be replaced by surgical
seen (see Fig. 23-12). In the situation of secondarydegenerative arthrodesisso that the lamenesscan be resolved.
joint disease,radiographic changesunique enough to reveal the In the standard imagesof the proximal interphalangealjoint, the
primary insult may be present. However, in many horses, the new bone changesare readily seen in all views. The subchondral
primary insult may not be evident. bone sclerosisand resorption changesare most easilyseenon the
The proximal interphalangealjoint is consideredto be a high- dorsopalmar or oblique views. Adequate x-ray beam penetration
load, low-motion joint, meaning that a large range of movement and careful scrutiny of the subchondralbone margin are necessary
does not occur during the stride motion of the 1imb. As a conse- to confirm that subchondral bone resorption is truly presgnt. The
The Phalanges 283
Figurc 23-21, Decreasedwidth of the proximalinterphalangeal jo nt space Figure23-23. Dorsopalmar viewin whichtherearelargeenthesophytes at
w i t h l a r g e ,m u l t i p l ei nd istin ctly
m a r g in e dsu b ch o n d r ablo n ed e fects.The radro- theattachments of the medial collateral
ligaments.ln addition,
collapseof the
g r a p h i cs i g n s i n t h i s fo a l a r e d u e to se p tica r th r itiswith e r osi onof arti cul ar medialportionof theproximal jointwithsubchondral
interphalangeal sclerosis
c a r t i l a g el e a d i n gt o oste o m ye litis o f th e su b ch o n d r ael p ip hysealbone. The of theopposedsurfaces of theproximal andmiddleohalanqes is seen.Osteo-
a b s e n c eo f t h e p e r i o ste arle a ctio nwh , ich u su a llya cco m p a n i es l ysi sow i ng to a'Thr;tis
is secondaryto t..aLria.
L, latera
; M, medial.
o s t e o m y e l i t i s ,u g g estsa fu lm in a tin g in fe ctio n .
I Laminitis
The normal orientation of the distal phalanx to the hoof is main-
tained by the interdigitating leavesof the laminar corium and the
hornlike lamellae of the hoof wall. The laminar corium is attached
to the dorsal surface of the distal phalanx by a modifled perios-
teum, which contains a tightly meshed network of blood vessels.a3, aa
Insult to this unique anatomy can causesufficient damage to result
in the loss of mechanicai support of the distal phalanx within the
hoof capsule.Laminitis is the general clinical term used to refer to
the complex of signs expressedby the horse and its effects on the
Figure 23-22. Osteoarthrosisof the proximal interphalangeal joint. The structural relationships of the hoof wall, distal phalanx, and sole
c o n t o u r so f t h e o p p o sin gsu r fa ce so f th e p r o xim a a l n d m iddl ephal anxare
f l a t t e n e dT. h e a r t i c u l asu
r r fa ce sa r e a lsob r o a d e a
secondary to a variety of insults. Most horses that develop clinical
r s a r e su lto f remodel i ng
and
ne w b o n e f o r m a t i o na t th e p e r ia r ticu lamr a r g in s.T h e se p e ri arti cul ar osteo- laminitis do so secondaryto a systemicillness.Concussiontrauma
ph y t e sa r e o f t e ns h a r p lysp icu la te in d th e m ild lyu n sta b lejo in t. to the feet is a less well defined cause of laminitis. Horses with
284 A P P E NDI CU L ASK
R EL E T O N -EOU IN E
Drotracted, severe unilateral limb lameness have been considered the hoof wall and the coronarv band. The second, a linear marker
io be at risk for developing contralateral limb laminitis.n' preferably of known length, ii placed on the midsagittal plane of
Although there continue to be differences of opinion as to the the dorsal hoof wall (Fig. n-2aC). This should be of sufficient
terminology and categorization of this complex, several clinical Iength to extend approximately half to two-thirds the length of the
phasesor stagesof laminitis are recognized: developmental, acute, dorsal hoof wali. The third is placed at the point of the frog of the
and chronic.'u Developmental laminitis is defined as the period sole. Some place a fourth marker on the white line junction of the
between the initial insult to the first expressionof lameness.It may hoof wall and heel bulb (angle of the wall). These markers not
be as short as 24 hours or as long as 60 hours.a6This is very likely only assist in initial radiographic assessmentbut also assist in
an imperceptible stageto the owner, unless accessto excessivegrain measurement or identification of landmarks needed for planning
is known to have occurred or a systemicdiseaseor other condition corrective shoeing.
is present that warrants concern for initiation of laminitis. This The radiographic signs of distal phalanx displacement are defin-
perlod is a prevention phase for mechanical failure of the foot itive for the presenceof chronic laminitis. The sign seen is either
complex.'u Acute laminitis representsthe phase from the first ex- palmar deviation (rotation) of P3 from the hoof wall, distal (verti-
oression of lameness through 72 hours without evidence of me- cal or sinking) displacement of P3, or a combination of both. A
ihanical collapse, or it ends-at any time that signs of mechanical spectrum of severity is found. In the normal foot, the dorsal cortex
collapseoccur.a6Radiographs may be indicated in either the devel- of P3 should be parallel to the dorsal margin of the hoof wall in
opmental or the acute phase to serve as a baseline for future the lateromedial view. Divergence of these surfaces,with the toe
comparison. Horses may fully recover from either developmental region of P3 deviating or rotating in a palmar direction, is an
or acute laminitis. If, however, radiographic or clinical signs of indication of mechanical separation of the dermal and epidermal
distal phalanx displacement are seen,the phase of chronic laminitis laminae (see Fig. 23-2M). This is the easiestof the P3 displace-
has been entered.a6 ments to detect radiographically. When a straight edge is used to
mark the comparative lines of the hoof wall and dorsal cortex (Fig.
Radiographic evaluation of laminitis 23-25A), these lines should be parallel in the normal foot. In the
horse with palmar deviation of P3, these lines diverge at the toe
Radiographic evaluation of any horse with a clinical impression of
pain and lamenessdue to laminitis is justified. The goals of radiog- region and convergeproximally. The angle at the point of conver-
raphy are to detect changesindicative of mechanical failure and to gence can be measured and is referred to as the degree of rotation
(seeFig. 23-25C).
observe changes that contribute to the formulation of prognosis
and therapy. All four feet should probably be evaluated initially. Vertical displacement of P3 can be more difficult to detect and
Although lameness may be expressedin only one leg, structural is often overlooked.to In the normal foot, the proximal edge of
changesmay be radiographically present in severalfeet. Front feet the extensor processof P3 is positioned roughly at the same plane
are most commonly affected. Optimal lateromedial, dorsopalmar, or just proximal to the junction of the hoof wall and coronary
and dorsal 65-degree proximal-dorsodistal oblique views are rec- band.aa'srThe vertical distance between the proximal limit of the
ommended. Placement of radiopaque markers on the hoof wail dorsal hoof wall and the proximal limit of the extensor process of
has been advocatedto aid in identifying soft-tissue landmarks."-e P3 has been measured to generate a "founder" distance (see Fig.
One marker is placed on the midsagittal plane at the junction of 23-2581.nt\A/hen corrected for magnification, this distance in 25
normal horses was an averageof 4 mm (range, -2 to 11 mm) in than 5.5 degreesof deviation had a favorable prognosis for return
the front feet and an averageof 4.6 mm (range, -2 to 9 mm) in to athletic work, horses with 6.8 to 11.5 degreeshad a guarded
the hind feet.a8 prognosis, and horses with more than 11.5 degreesof deviation
An increase in the thickness of the dorsal soft tissues has been were not useful as performance animals, but some could be sal-
suggestedto be a very early sign of laminar inflammation or edema vaged for breeding.s3In another study, neither the degree of distal
and thus a sign of acute laminitis. The thickness of the dorsal soft phalanx rotation nor distal displacement correlated with outcome,
tissues has been measured on radiographs of clinically normal and lameness severity was a more accurate predictor.saIn a very
horses.to'45' 4s'4e A statistical difference was found in thickness recent study, of those horseswith severeclinical featuresof chronic
among normal ponies, Hanoverians, and Thoroughbreds.nt The laminitis, 54% with a rotation angle greater than 20 degreesand
averagethickness of the front feet for all horses, when corrected B8o/owith a rotation angle less than 2 degreeswere successfully
for magnification,was 16.3 mm (range, 11.1to 20.2 mm).a'When treated and returned to rideable soundness." As a predictor of
only Thoroughbreds were compared between the Cripps and Lin- outcome to riding soundness,founder distance was useful when it
ford studies,to'a8 the averagethicknesswas 16.3mm (range, 13.9to was either in the low range of normal or well beyond the upper
19.7 mm) comparedwith 14.6 mm, respectively(both valuescor- limit. In horses with severe chronic laminitis, no animal with a
rected for magnification). For other specified breeds, from Cripps' founder distance less than 7.9 mm failed to respond to treatment,
study, the measurements(corrected for magnification) were found and only one horse with a founder distancegreaterthan 15.2 mm
for the front feet rangesof ponies (11.1to 16.1mm) and Hanoveri- was a success.ae However, that author found some horses with
ans (17 to 19.1 mm); and for the hind feet rangesof ponies (11.7 palpation findings along the coronary band typical of a sinking P3
to 16.1 mm), Hanoverians(15.9 to 20.4 mm), and Thoroughbreds to have founder distanceswithin the normal range. Using Linford's
(14.3 to 17.9 mm).asA marker of known length must be in the measurement of dorsal soft-tissue thickness (measuredat the distal
image to correct for magnification. If this is not available, an point) calculated as a percentage of the palmar cortex length, a
alternative is to calculate the dorsal soft-tissue thickness as a per- measurementof greaterlhan 2B.Io/oshould be consideredabnormal
centage of the palmar cortex length. In 41 sound Thoroughbreds, for the fore foot of Thorouehbreds.l0Dorsal wall thickness was not
the average was 24.2o/o,and a measurement greater Ihan 28.1o/o found to be an isolated piedictor of outcome with treatment.ae
shouid be considered abnormal for the Thoroughbred (see Fig. Even so, Pelso found increased dorsal soft-tissue thickness to be a
23-258 and D).'0 When not corrected for magnification, a dorsal risk factor for development of clinical laminitis in the contralateral
soft-tissue thickness greater than 20 mm has been suggestedto be limb of horses with unilateral limb lameness.4sIn that series of
abnormal for any breed.t' horses, increased dorsal wa1l thickness and sinking were more
Other radiographic changesthat can be seen with chronic and common than palmar deviation of P3. Some cautions regarding the
progressivelaminitis include a sole that is very thin. The change in use of radiographic measurementsdeservemention. Measurements
the position of the toe of P3 may causea convex bulge in the sole's probably are most valuable when used for serial assessmentof an
contour or the toe may penetrate through the sole. Radiolucency individual horse. Very strict attention to detail must be maintained
at the laminar junction can be seen as a single linear lucency in in the production of images. Positioning of both the horse's foot
the lateral view (see Fig. 23-2M) and as a series of parallel linear and the x-ray beam is critical. An oblique projection angle can
lucencies in the dorsal 65-degree proximal palmarodistal oblique significantiy alter measurement. Likewise, placement of any mark-
view. This linear radioiucency is attributed to air dissectingbetween ers should be standardized.Failure to adhere to strict standardiza-
the hoof wall and the laminar corium when necrosis has eroded tion renders comparative measurementsunreliable.
through to the coronary band or white zone of the sole. Larger
regions of radiolucency are more likely to be associatedwith sec-
ondary infection of the soft tissue (see Fig. 23-24C). An increase
in small circular lucencies is often seen in the central region of P3 I Flexural deformity of the
in the dorsal 65-degree proximal palmarodistal obiique view (see I interphalangealioints
Fig. 23-248). These lucencies represent an increased number of
and wider vascular channels extending from the solar canal to the Distal interphalangeal ioint
dorsal cortex. This is typically seen in combination with new bone
along the dorsal cortex. The new bone also creates a prominent This is the most common of the flexural deformities of the phalan-
domed shape to the dorsal surface of the distal phalanx. The toe ges.The clinical appearanceof this is an almost vertical orientation
of P3 frequently develops a "lipping" shape due to either new of the hoof wall to the ground (Fig. 23-26). Flexural deformity may
bone, resorption of the palmar cortex, or an angular orientation be either congenital or acquired. Genetic influences and teratogenic
of a solar margin fracture (type VI) (see Fig. 23-24A and B). insults during embryonic developmental are factors that may lead
Osteitis of variable severity usually develops. Additionally, disuse to congenital deformities.l ssThe acquired form is most common
of the limbs can further decreasethe bone's opacity. Infectious in rapidly growing foals and has been related to pain that initiates
osteitis can occur in the most severelyaffected horses. A break in a persisting flexion withdrawal response,lack of exercise,or poor
the pastern angle (rotation of P3 about the distal interphalangeal nutritional management in the growing foal. Both overfeeding and
joint) can occur if contraction of the deep digital flexor tendon unbalanced diets have been cited as potentiating factors.56The
occurs, or if the more rapid growth of the hoof wall at the heel is exact manner in which these various influences interact to produce
improperly managed. flexural deformities is unknown, but several theories suggest a
Because of the severe morbidity and protracted treatment re- difference in the rate of bone growth versus tendon and ligament
quired for chronic laminitis, indicators of prognosis for successor lengthening.sqs7A11theories imply a faster rate of lengthening of
failure of treatment are desired. Various radiographic measure- metacarpal III or metatarsal III than for the deep digital flexor
ments have been assessedretrospectively in an effort to define tendon-check ligament unit. Increasing tension on this tendon-
reliable predictors of outcome for horses with chronic lami- ligament unit leads to flexion of the distal interphalangeal joint,
Figure 23-25 illustrates several of these measurements.
nitis.le'53'51 with the foal assuming a "toe dancer" stance.Changesseen in the
Even though none has been completely reliable when used as the distal phalanx of thesefoals range from none to varying irregularity
only indicator, trends have been identified. In general, the more of the solar margin centered at the toe. The irregularity is due to
deviant from normal, the more guarded to worse the prognosis. In widened vascular channels and bone resorption at the solar mar-
a series of 91 horses, the degree of P3 rotation was inverseiy gin.58 If the deformity is corrected early, the bone changes can
correlated with return to athletic performance. Horses with less resolveto a normal appearance.
The P halanges287
I Osteochondrosis
I (subchondral cystlike lesionsl
The phalanges are not affected by classicalosteochondritis dissec-
ans, meaning that osteochondral fragments associatedwith sub-
chondral bone defects are not reported. Single, oval to circular,
radiolucent lesions surrounded by a thin or variably thick sclerotic
rim are sporadically reported in the distal end of the proximal
phalanx, the proximal and distal ends of the middle phalinx, and
the base of the extensor process or body of the distal phalanx.o,
These have been calied subchondral cysts,osseouscysts,or sub-
chondral cyst-like osteochondrosis.There is still considerableques-
tion as to whether any of these lesions in the phalangesrepreients
true defective growth of the articular-epiphyseal complex (abnor-
mal endochondral ossification process).6,Figtre 23-29 illustrates
two examples of the subchondral cystlike lesion.
Clinical expression of lameness is suggested to relate to the
extent of articular surface involvement. Some lesions have no visi-
b1e connection to the articular cartiiage or joint space lucency.
Others have a thin neck or a broader base of connection to the
articular cartilage or joint space lucency. The latter two have a
Figure 23-26. Flexuraldeformty of the d stal interphalangeal joint in a 4- greaterchanceof being associatedwith pain and lameness.These
m o n t h - o l df o a l .T h e d o r sa su r fa ceo f th e d ista lp h a la n xr e m a i nsparal l el
to the
lesions are generally associatedwith joint effusion or lamenessin
dorsal hoof wall (white ltnd. bu| both of these structuresassume an abnor-
m a l l vv e r t i c aol o s i t i o n . horses of training age, that is, younger than 3 years of age. One
report indicated a higher incidence of occurrencein the pelvic limb
in a group of Quarter horses,although either the thoracic or the
pelvic limb may be affected."5Some lesions have been found in
Proximal interphalangeal ioint
Abnormal flexion alignment is uncommon and may be either
congenital or acquired (Frg. 23-27). Visually, there is a bulge in
the dorsal pastern contour that has been referred to as dorsal
subluxation; this representsthe position of distal P1 relative to the
normal pastern axis.se'60 The prorimal interphalangealjoint is,
however, flexed. Thoroughbred race horses have developed this
malalignment following injury to the soft-tissue support structures
of the metacarpophalangeal joint.5' Dorsal subluxation has also
occurred after corrective desmotomy of the suspensoryligament
for treatment of flexural deformities of the metacarpophalangeal
joint.5' A number of young horseshave been observedwith this
deformity in the hindlimb. The flexion is prominent when the
horse is non-weight-bearing, but with full weight the alignment is
reduced,often accompaniedby a clicking sound.60,61 A combination
of deep digital flexor tendon contracture and concomitant superfi-
cial digital flexor tendon la-xityhas been postulated as the causefor
this hindlimb deformity.60 No specific bone changes other than
joint alignment are expected.
Hyperextension alignment
of the interphalangeal joints
Hyperextension ofthe proximal interphalangealjoint is an unusual
appearancethat occurs with rupture of both the straight (superfi-
cial) sesamoideanligament and the superficial digital flexor tendon.
It may also be seenin combination with overextensionof the distal
interphalangeal and metacarpophalangealjoints as a congenital
deformity in foals. No additional bone changesare typically pres-
ent.62
Hyperextension of the distal interphalangeal joint may occur in
Figure 23-27. Flexuraldeformity ("dorsal subluxatron,,) of the proxima
newborn foals as a congenital abnormality affecting al1three joints j oi nt.E nthesophytes
i nterphal angeal of the dorsalj oi ntcaps ul eand s uperfc i a
of the foot. Weakenedflexor tendons may also be seen secondary di gi talfl exortendoni nserti on si tesof the mi dde phal anxi ndic ate the c hronc l ty
to poor nutrition, secondary to slow or incomplete recovery from of thi s i ni urv.
2 AA A P P E NDI CU L ASK
R EL E T O N -EOU IN E
I Gollateral cartilages
Ossification/calcification (sidebonesl
This is a common finding in radiographs of the distal part of the
digit, especiallyin draft breed horses. When the proximal edge of
the ossified collateral cartilage extendsbeyond the proximal margin
of the navicular bone, sidebone formation is considered to be
present (Fig. 23-30).' Even an extensivedegree of ossification may
not be clinically significant, especiallyin older horses, horses with
a broad foot, and horses that have no pain on manipulation of the
heel area.
Asymmetrical calcification of the collateral cartilages may indi-
cate increasedstresson the ossifiedportion (Fig. 23-31). Careful
physical examination is warranted in such an instanceto determine
if localized diseaseis present within the foot. The navicular bone
should also be closely evaluated in the previous example because
collateral cartilage ossification may accompany a more significant
degenerativelesion in the navicular bone.70
A radiolucent linear defect or gap in the ossified cartilage usually
19llll.l"'".ii.,i1: indicates the junction between a separate,peripheral ossification
i,rl9ii:)),,.-.r1:
center and that part of the cartilage that is ossifring from the
rSrr,,.,,,!liilil"'l
ria:lrli.,l
rr"rrl9ll" palmar process of the phalanx (see Fig. 23-31). In a study of
Finnish trotters, almost all radiolucent gaps betrveenseparateossi-
fication centers were located in the middle or distal part of the
ossified cartilage.Tl Fracture of the ossified collateral cartilage is
unusual. Responseto digital pressureapplied to the coronary band,
in the area of suspectedfracture, helps to differentiate a fiacture
from an incomplete pattern of ossification. Occasionally,a fracture
Figure 23-28. Luxationof the distalinterphalangeal joint secondary to at the base or attachment of the cartilage to the palmar process
andpathologic
osteomyelitis of theflexorsurface
fracture of thedistaiphalanx
of thedistalphalanx of thedeepdigital
is dueto avulsion can extend to involve the palmar processand the distal interphalan-
Dorsaldisplacement
flexortendoninsertionand the subsequent unreciprocatedtractionof the geal joint.
commondigitalextensor tendon. Thedistalsesamoidean imparligament is
alsoruptured, proximal
allowing displacement of thenavicularbone Infection (quittor)
Penetrating wounds or lacerations in the coronary band region can
introduce infection into the collateral cartilaees.Necrosis associated
clinically sound older horses presented for pre-purchase evalua-
with infection of this cartilage is called quittor. In acute infections,
tion.63 The subchondral cystlike defects in the distal part of the
radiography should be considered to rule out a metallic foreign
proximal phalanx frequently lead to extensive degenerativejoint
body or deeper lesion in the adjacent bones. In chronic infections,
diseasein the proximal interphalangeal joint (see Fig. 23-298). ln
a draining tract is tlpical. Extension to the distal interphalangeal
such instances,surgical arthrodesis may be needed to allow return
joint is uncommon unless it occurs iatrogenically during aggressive
to useful function.t'' u6'6tIn one seriesof 13 horsesin which solitary
establishment of drainage or dEbridement of the necrotic cartilage.
phalangealsubchondral cystlike lesions were treated by conservative
management, lamenessdisappearedin seven horses over a period
of 1 month to 2.5 years.68In four of these animals, the defect I Hoof balance
could not be identified radiographically 1.5 to 2.5 years after the
initial diagnosis. Unbalanced trimming and improper shoeing of the foot are no
doubt causesof lamenessin horses.TtThey have also been suggested
causesfor development of navicular syndrome and degenerative
I Pedal osteitis joint diseaseofthe interphalangealjoints. Lateromedial and dorso-
Diffuse roughening of the solar border of the distal phalanx, creat- palmar radiographic views of the foot can be used in conjunction
with direct measurementson the foot to assessfoot balance.e'73 7s
ing a ragged, lacy appearancewhen viewed in the lateromedial or
dorsal 65-degree proximal palmarodistal oblique projection' may When radiographic views are used in this manner, particular atten-
be an indication of pedal osteitis.ePedal osteitis is the responseof tion must be paid to positioning of the foot, center of the x-iay
the distal phalanx to inflammation and is manifestedby demineral- beam, and degree of weight bearing on the limb being assessed.
izatron, eiiher focal or more diffuse. The changeis most commonly The measurementsused to assessfoot balance radiographically are
seen secondary to chronic bruising, sole abscesswithout extension shown in Figve 23-32. In the lateromedial view, the dorsal hoof
of infection in the bone, flexural deformities, and other condi- wall should be parallel to the wall at the heel. The pastern axis, as
tions.6eOnce the primary insult and pedal osteitis become inactive, seen in the lateromedial view, is a line that divides the middle
there is frequently little change in the appearanceofthe roughened phalanx into equal dorsal and palmar halves. Ideally, this line
contour of the solar margin. Also, because there is considerable similarly bisects the proximal phalanx and is parallel to the dorsal
variation in the appearanceof the solar surfaceof the normal distal cortex of the distal phalanx. When this line is carried through to
phalanx, a mild degreeof irregularity may be misleading. A positive intercept with a line on the bearing surface of the hoof wall, it
response to hoof testers, an increased number and diameter of should create an angle of 45 to 55 degrees(front foot) or 50 to 55
vascular channels seen concomitantly with demineralization of the degrees (hind foot) with the bony solar margin.3' 73 Significant
bone, and thinning of the sole of the foot increasethe probability differenceswere induced in the anglesof the interphalangealjoints
of pedal osteitis as a current cause of lameness.Thus clinical signs when the hoof angle was altered.T3The greatestdifference in angle
must be consideredin the determination of whether a radiographi- occurred in the distal interphalangeal joint. Clinically, such a
cally irregular margin of the distal phalanx is an indicator of change in the angle of the distal interphalangeal joint is suggested
current or previous pathology. to have an effect on the strain on the deep digital flexor tendon.73
The P h alanges289
r *;
-g -*
u::,,iia!rl
::a]!
,';-;T
-
ru
i
tlpically round as the process of bone change is slow. Differential Mastocytosisis a tumorous swelling of the skin that can some-
diagnoses for this type of bone lesion are septic pedal osteitis times involve the subcutis and adjacent muscle. A recent report
(margin should be more irregular), bone cyst (typically more summarizedthe findings in six horses;three had the lesion in the
centralized in the body of P3), and squamous cell carcinoma, distal limb that created radiographic abnormalities.83The common
fibrosarcoma, or mast cell tumors of the hoof wa1l or sole tissues.e' radiographic lesion was localized soft-tissue swelling, severalcenti-
78,7eHistologic evaluationof soft-tissuemassesof the sole and hoof meters in size, with granular mineralization. A poorly defined
is neededfor definitivediagnosis. periosteal new bone responsewas found in one horse with a
Hypertrophic osteopathyis rare in the equine. The lesions are pastern region lesion. However, this horse had been unsuccessfully
clinically manifested in the iimbs by fairly diffuse soft-tissue swell- treated,and the periostealresponsemay have been a consequence
ing of all four limbs and periosteal new bone formation in the of treatment rather than a result of the mastocytosis. Although
diaphysealregions of the long bones, including the phalanges.The several lesions were close to a joint, no architectural lesions in
amount of new bone is variable. Most of the reported exampleshad the joint were identified. The Arab breed was overrepresentedin
palisade-likenew bone formation. Articular margins or surfacesare this series.
usually not altered. Of horses and donkeys described with these
lesions, the phalangeswere affected in 12 (approximately half).80-8'? References
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S KE L ET ON -EOU IN E
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would provide the best image to determine whether this calcifica-
64. Hurtig MB, Pool RR: Pathogenesisof equine osteochondrosis. In Mcllwraith CW, tion is within the collaterai cartilage of the distal phalanx or the
Trotter GW (eds): Joint Diseasein the Horse. Philadelphia, WB Saunders, 1996. deep digital flexor tendon?
65. Trotter GW, Mcllwaith CW, Norrdin RW, et al: Degenerative joint diseasewith
osteochondrosis of the proximal interphalangeal joint in young horses. I Am Vet Med 3. What are three common radiographic signs seenwith chronic
Assoc 180:1312,1982. laminitis?
66. Trotter GW Mcllwraith CW: Osteochondritis dissecans and subchondral cystic
lesions and their relationship to osteochondrosis in the horse. Equine Vet Sci 5:157, 4, A 10-year-oldArabian cross-breedmare is presentedwith
1 9 81 . lameness and swelling along the lateral aspect of the left front
67. Trotter GW, Mcllwaith CW: Osteochondrosis in horses: Pathogenesisand clinical pastern. The owner reports the duration of both the lamenessand
slndromes. In Proceedings of the 27th Arnual Convention of the American Associa- the swelling to be about 10 days. Radiographs of the region show
tion of Equine Practitioners, 1981, New Orleans, p 141.
a smooth-surfacedperiosteal opacity arising from the lateral cortex
68. Pettersson H, Reiland S; Periarticular subchondral bone cysts in horses. CIin of the proximal phalanx. What factors should be considered in
Orthop 62:95, 1969.
determining the significance of the radiographic findings?
69. ReevesMJ, Yovich fV, Turner AS: Miscellaneous conditions ofthe equine foot. Vet
Clin North Am Equine Pract 5:221, 1989. 5. A 4-year-old Thoroughbred stallion in race training develops
70. Reid CF: Radiography and the purchase examination in the horse. Vet Clin North an acute lameness in the left front foot. On a dorsal 65-degree
Am Large Anim Pract 2:151, 1980. proximal palmarodistal oblique view of the distal phalanx, a linear
71. Ruohoniemi M, Tulamo R-M, Hackzelt M: Radiographic evaluation of ossification radiolucency is noted extending from the solar margin at the lateral
of the collateral cartilages of the third phalanx in Finnhorses. Equine Vet i 25:453, quarter into the body of the bone. What are your rule-outs, and
1993. what additional information (or radiographic projections) would
72. Moyer W, Arderson JP; Sheared heels: Diagnosis and treatment. J Am Vet Med be useful in making the diagnosis?
Assoc 166:53,1975.
73. Bushe T, Turner TA, Poulos P, et al: The effect of hoof angle on coffrn, pastern, 6. What steps should be taken before radiography of the distal
and fetlock joint angles. Proc Am Assoc Equine Pract 33:729, 1987. phalanx to achieve the best-quality images?
74- Caudron I, Grulke S, Farnir R et al: Radiographic assessmentof equine interpha-
langeal joints aslmmetry: Articular impact of phalangeal rotations (part D. J Vet Med 7, A l2-year-old Arabian gelding is presented for a precompeti-
45:319, 1998. tion physical examination (horse does competitive trail riding).
75. Caudron I, Grulke S, Farnir F, et al: Radiographic assessmentof equine interpha-
The horse has not competed for 2 years becauseof problems with
langeal joints asymmetry: Articular impact of asymmetric bearings (part n). t Vet "tytttg-op slmdrome." During the past 2 yearc,the horse has been
Med 45:319,1998. used for riding lessons, with no reported lameness. On physical
76. Colles CM: Interpreting radiographs 1: The foot. Equine Vet I 15:297, 1983. examination, the horse is mildly lame in both front feet at the trot.
The horse is sore through the quarters and toes of both front feet
77. Caudron I, Miesen M, Grulke S, et al: Radiological assessmentof the effects of a
full rolling motion shoe during asymmetrical bearing. Equine Vet J Suppl 23:20, 1997. with hoof testers. Figure 23-33A to C presents the lateral and
dorsal 65-degreeproximal-palmarodistal oblique views of the right
78. Lloyd KCK, Peterson PR, Wheat JD, et al: Keratomas in horses: Seven cases
(1975-1986).I Am Vet Med Assoc 193:967,1988. front foot (radiographs ofthe contralateral foot appearedsimilar).
Identift the abnormal radiographic signs,and make your diagnosis.
79. Ritmeester AM, Denicola DB, Blevins WE, et al: Primary intraosseous mast cell
tumor ofthe third phalanx in a Quarter horse. Equile YelI 291L51,1997.
8. A l7-year-old Quarter horse stallion has been lame for 5 days,
80. Messer NT, Powers BE: Hlpertrophic osteopathy associatedwith pulmonary in with frequent periods of laying down. The horse is not responding
farction in a horse. Comp Contin Educ Vet Pract 5:5636, 1983.
to symptomatic treatment for laminitis. On physical examination,
81. SweeneyCR, Stebbins KE, Schelling CG, et al: Hlpertrophic osteopathy in a pony the horse is lame on both front feet but more on the left. There is
with a pituitary adenona. I Am Vet Med Assoc 195:103, 1989. soft-tissue swelling around the left coronary band. Identifr the
82. Mair TS, Dyson Sj, Frasser lA, et al: Hypertrophic osteopathy (Marie's disease)in radiographic abnormalities in Figure 23-3M and B, and make
Equidae: A review of twenty-four cases.Equine yet J 28:256, 1996. your diagnosis.
83. Samii VR O'Brien TR, Stannard AA: Radiographic features of mastocltosis in the
equine limb. Equine Vet J 29:63, 1997. 9. A 2-month-o1d Belgian/Percheronfilly has a severeright hind
leg lameness of 1 week's duration. She touches only the heels to
the ground, with no weight on the toe. A plantar digital nerve
ffi Ouestions block done to aid working with the foot relieved the lameness.A
sole abscesswas found at the toe. It was opened for drainage and
l. A 7-year-old Quarter horse mare, retired from racing, Pre- appeared to dissect into both medial and lateral sole areas. The
sented with a history of intermittent lameness of the right front foot was soaked and packed. Three days later, the filly was some-
leg when exercised.There is pain in the proximal interphalangeal what better but still lame. Radiographs were made at this time
joint. Radiographs of this region show multiple, small, radiolucent (Fig. 23-35A to C). Describe the radiographic changes,and make
subchondral bone defects in the distal first phalanx, accompanied your diagnosis.
by a narrowed joint space and mature periarticular osteophytes.
The radiographic changesare most likely those of: 10. A 4-month-old Quarter horse colt was presentedfor evaluation
A. Severe,chronic, degenerativejoint disease. of chronic enlargement of the left fore foot distal to the fetlock
B. Osteochondrosis. without lameness.Physically,there was a nonpainful swelling cir-
C. Acute, active septic osteoarthritis. cumferentially around the left front pastern and a firm prominence
along the dorsal surface of the joint. Describe the radiographic
2. A focal area of solid, ovoid calcification is identified in the soft abnormalities in Figure 23-36A and B, and make your diagnosis.
tissuespalmar and slightly proximal to the proximal border of the
navicular bone on the lateromedial view of the foot of a 10-year- Answers begin on page 727.
The Phalanges 293
@ll il@lll
i110u,..,ii:1u
24
The Navicular Bone
I Robert L. Toal
F i g u r e 2 / r - 1 . G r o ssp h o to g r a p hosf th e n a vicu labr o n e .A, E n face vi ew of the di stalborder.N ote: 7, the smal arti cul arsurfacew i th the d stal phal anxand
, Z
t h e p r o j e c t i o no f f t h e d ista lb o r d e rwh e r e th e im p a rlig a m e ntattaches.8, E n face vrew of the proxi malborder.N ote: /, the arti cul arsurfac ew i th the rn oo e
ph a l a n x2, , t h e p r o x i mabl o r d e ritse lfwh e r e th e su sp e n so r ny avi cul ar
l i gamentattaches;and 3, the centralemi nence.The vi ew i n B i s anal oqousto that obtatned
in a o a l m a r o o r o x i m a l- o a lm a r o dr aistad iol o r a o h .
295
296 S KE L ET ON -EOU IN E
A P P E NDI CU L AR
r9url
tl,lrll:,
i(lllli Figure 24-2, Types of positioningaids for navicularradiography.
)::::.:.a:'; A , A w ooden bl ock for angul ardorsoproxi mal -pal m arodivsi ew tal s .
,a::,"'t:',
..irilll: The longitudinallyorientedslot (arrow)is used for lateralviews. The
groovesare of sufficientwidth to allow combinedinselrionof a grid
and cassette.B. A cassettetunnel coveredwlth Plexiglasprotects
the cassette(andgri d)duri ngdorsoproxi mal -pal marodi v isew
tals .
By varying the x-ray beam angulation incident on the navicular upright pedal route.6 Magnification can be minimized on the high
bone in the high coronary route or by altering the position of the coronary stand-on route by using a grooved wooden block. A
hoof in the upright pedal route, an accurate projection of either cassetteand grid are placed in a precut groove behind the hoof as
the proximal or distal navicular border can be obtained. This is it rests on the block. Owing to the position of the cassette,less
becausethe proximal and distal navicular borders are not parallel magnification of the navicular bone occurs when compared with
(they diverge in a palmar direction), and thus a true geometric other stand-on techniques (see Fig. 24-38).
projection of both borders cannot be obtained in a single dorso-
proximal-palmarodistal radiograph. Lateromedial view
An undistorted projection of the proximal navicuiar border is In the lateral view, it is important that both navicular extremities
achieved by using the 45-degree high coronary stand-on route or be projected superimposed. If some degree of angulation occurs,
the 90-degree upright pedal route. The distal navicular border is this factor must be recognized and taken into account during
obscured by these routes becauseit is projected below the level of interpretation. The foot is placed on a wooden block so that the
the distal interphalangealjoint. Becauseonly the proximal navicular x-ray tube can be positioned low enough to center the beam on
border can be accurately evaluated in these two projections, they the lateral axis of the navicular bone. A wooden block also elevates
are used as supplemental views (see Fig. 24-3A and C).
A 65-degreehigh coronary stand-on route or an 80-degreeup-
right pedal route projects the distal navicular border proximal to
the distal interphalangealjoint and superimposesthe entire navicu-
lar bone behind the middle phalanx. The distal navicular border is
well visualized, and although the proximal border is slightly dis-
torted, it is readily identified. Either one of these two positioning
methods is recommended for the angular dorsoproximal-palmaro-
distal projection becausewhen they are done properly, the entire
navicularbone is seen(seeFig.24-38 and D).
Stand-on techniques are technically easier but result in slightly
more magnification of the navicular bone when compared with the
HIGH CORONARYROUTES
Table 24-1. Radiographic views of the navicular bone
Dorsoproximal-palmarodistal views
High coronary stand-onroute
45 degrees-Proiectsproximal border and extremities
65 degrees-Projectsboth bordersand extremities
Upright pedal route
90 degrees-Projectsproximal border and extremities
80 degrees-Proiectsboth bordersand extremities
Lateromedialview
Foreshortenedprojectionalong the axis of the bone
Projectsboth bordersand both surfacesin profile
UPRIGHT PEDAL ROUTES
Extremitiesare superimPosed
Palmaroproximal-palmarodistal oblique view Fi gure 24-3. A ngul ardorsoproxi mal -pal marodi stal vi ew s. H i gh c oronary
Beam is angledtangentialto the flexor surface routes:A , D i rectstand-onmethod;B , Woodenbl ocktechni que;a nd C and D ,
Projectsthe flexor cortex, medulla,and centraleminence Uprightpedalroutes,are illustratedshowing beam or hoof angulatlonrelative
to the hori zontalpl ane.Onl ythe proxi malnavi cul ar in
borderi s w el l v i s ual i z ed
Extiemitiesare obscuredby palmar processesof distal A and C, whereas both proximaland distal bordersare clearlyprojectedin B
oh ala nx and D .
The NavicularBone 297
mately 1.5 times the width of the cone at the base. Size is related
to degree of work, although their shape should remain somewhat
triangular (seeFig. 50-60).
The lateral view offers a clear, unobstructed view of the navicular
bone but presents a foreshortened image. Both extremities should
be superimposed;a well-definedmedulLry cavity is visualized.The
flexor surface is convex palmarly and is imoothly marginated. In
some normal horses, a smoothly marginated dimple of variable
depth is seen in the midportion of the central eminence. The
proximal and distal borders are smooth, as are the articular sur-
faces.Some horses may have a mild elongation of the proximal or
distal border, or both., The ioint spacebetween the navicular bone
and the distal phalanx is usually parallel, but a convergent joint is
sometrmespresent(seeFig. 50-58).
In the palmaroproximal-palmarodistal view, a well-defined med-
ullary cavity of uniform trabecular pattern with four or five small
radiolucent foramina may be r..n. Th" cortex is of homogeneous
opacity and is of uniform thickness centrally, with some thinning
peripherally. The width of the flexor cortex varies from 2.0 to 3.6
mm owing to breed differences and geometric magnification.r, 8
The flexor surfaceis smoothly marginated with a prominent central
eminence.The centrai eminence is usually rounded and prominent,
Figure244. Palmaroproximal-palmarodista vjew.Thedistalrnterphalangeal but in some horses it may appear flattened normally. A small
jointis positioned
in extension,
withthex+aybeamangled tangentially
to the crescent-shapedradiolucency may be seen within the cortex of the
flexorsurfaceof thenavicularbone.
central eminence, representing a normal midsagittal syrrovial fossa.
This fossa is occasionallyseen as a dimple on the flexor surface on
the lateral view. In some horses, a lucent crescent is seen within
the hoof, allowing the cassetteto straddle it proximally and distally. the central eminence even in bones without a dimple. This is due
The entire hoof should be included on the radiograph. to a trabecular bone island interposed between two parallel cortical
bone platesof the centraleminence.lr,LThe endsofboth extremit-
Palmaroproximal-palmarodistal view ies are rounded, being variably superimposedover the palmar
The palmaroproximal-palmarodistalview (Fig. 24-4) projects the processesof the distal phalanx. The articular surfaceis occasionally
flexor cortex, medulla, and central eminence. The concept is to seen in this view (see Fig. 50-62).
isolate most of the bone between the palmar Drocessesof the distal
phalanx. The horse stands on a reinforced cassette or cassette
tunnel. The foot is positioned as far caudal as possible while still I Navicular disease
bearing weight.' Paradoxically,some people prefer that the foot be
more slightly forward than in the normal standing position.qn The term nayicular diseaseis used in this discussion to denote a
Regardless of foot location,the primary beam is positionedtangen- chronic progressive syndrome involving the navicular bone, its
tial to the estimated plane of the flexor cortex and is centered fibrocartilaginous flexor surface, its ligaments and capsular attach-
between the bulbs of the heel. Too steep of a beam angle with the ments, the deep digital flexor tendon, and the navicular bursa. The
foot may result in superimposition of the ergot over the navicular distal interphalangeal joint may be involved to a lesser degree but
bone. Reduced angulation alters the apparent width of the flexor its role in this syndrome is controversial. The precise source of
cortex and results in an indistinct interface between cortical and pain in navicular lameness remains obscure. Variable resDonseto
trabecular bone.8Oblique palmaroproximal-palmarodistalprojec- local analgesiaof the medial and lateral palmar digital nerves, the
tions distort the navicular shape and superimposeit behind the distal interphalangealjoint space,and the naviculaibursa is noted.
paimar processes of the distal phalanx. This variable responsesuggeststhat sensory nerves innervating the
s1'novial membranes of the collateral sesamoideanligament, the
Dorsopalmar view distal sesamoideanimpar ligament, and the navicuiar bone itself
play a separate or combined role in mediating pain in navicular
In the dorsopalmar view, the x-ray beam is directed horizontally
disease.a'13 In addition, it has been shown that pain arising from
toward the hoof, which is in a normal weight-bearing position.
the dorsal margin of the sole can be attenuated by analgesiaof the
The foot should be placed on a wooden block to allow the cassette
distal interphalangealjoint or palmar digital nerve block.raThis
to straddle the hoof and the navicular bone. This view is not done
further complicates the interpretation of nerve block results in
routinely but is useful in evaluating the extremities of the navicular
horses suspectedof having navicular origin pain.
bone, particularly when subtle abnormalitiesare suspected.
Navicular diseaseis primarily a slowly developing, intermittent,
bilateral forelimb lamenessls,16;it is occasionallyrecognized in the
I Normal radiographic hindlimb.l? In general, navicular diseaseis most common between
I 3 and lB years of age, with a peak incidence of 9 years of age at
r appearance presentation. Males are more involved than females, geldings have
In the angular dorsoproximal-palmarodistal views, the navicuiar a greater risk than stallions, and the breed prevalence varies ac-
bone is of uniform radiopacity. Its spindle shape varies somewhat cording to the population characteristicsof the reporting institu-
from horse to horse. The extremities are fairly symmetric and are ti ons .18,Ie
bluntly pointed. The proximal border is smoothly marginated. The There are no pathognomonic clinical testsfor navicular disease.
shapeof the proximal border has been classifiedvariously as con- The diagnosisis basedon a characteristicgait, localizationof pain
cave, undulating, straight, or convex.l0 The distal border has a to the caudal part of the heel, identification of radiographicsigns
variable number (usually no more than seven) of cone-shaped of naviculardegeneration,and elimination of other causesof lame-
radiolucencies.Their sizeis variable, with the height being approxi- ness.tt''0When navicular lamenessis suspected,both feet should
29A SK EL E T O N -EOU IN E
A P P E NDI C U L AR
be radiographed because radiographic changes are often bilateral signs of navicular degeneration is shown in Figure 24-5. Radio-
even if clinical signs are not. graphic manifestations of navicular degeneration and normal vari-
The pathophysiology of navicular syndrome is multifactorial' ants are shown in Figures 24-6 throrgh 24-9.
Classically,it has been characterizedas navicular fibrocartilaginous
degeneration with secondary tendon fibrillation. Palmar cortex Proximal border and navicular bone extremities
bone erosions can develop later.s'rs'20'21
Other bony changesinvolv- The heredity aspectsof the shape of the proximal navicular border
ing the distal border foramina (enlargement) have also been and its relationship to risk for navicular symdrome have been
noted.2l "Abnormalities such as dilated vessels,vascular thrombo- studied in Warmbloods.ro It was concluded that a convex-shaped
sis, granulation tissue, and empty synovium-lined invaginations proximal border showed the least risk for development of severe
2e
have been observed histologically to a variable degree.3'2O It is naviculardisease.
unknown whether these findings represent a continuum of events Dystrophic mineralization at sites of ligamentous or tendon
or are separate,isolated abnormalities. Enthesopathy involving the attachment is termed enthesophytosis.2e, 38 Mineralization of the
ligaments of the proximal and distal borders can occur either with suspensory navicular ligament along the proximal border results
or without distal border foramina changes.Many of the gross and in a roughened or sawtoothed appearance of the bone margin.
histologic features of navicular syndrome suPport the concept of Pronounced enthesophyteson the extremities of the navicular bone
a degenerativearthrosis."'27'2e-3r There is some evidencethat have been termed spurs. When enthesophytosis is excessive,the
chronic passivevenous congestion of the foot is related to navicular overall shape of the bone is altered. This is called remodeling (see
changesof elevatedsubchondral bone pressure and arterial hyper- Figs.24-68 and C, and Fig.2a-7).
32'33 In general, enthesophl'tes are manifestations of a degenerative
emia,27'
Similar confusion exists concerning the significance of radio- process.s'rs'38'3eThey are occasionally seen in non-lame animals,
graphic changes in the navicular bone in horses with lameness particularly in older, heavily worked animals.'&2a'26Enthesophl.tes
attributed to navicular disease.It has been shown that there is a in younger horses and extensiveenthesophltes in others should be
poor correlation of pathologic and radiographic findings with clini- considered significant, particularly if accompanied by lameness.
cal signs and prognosis.t9'24'26'28'3a Horses without radiographic Enthesophytesare best seen in angular dorsoproximal-palmaro-
abnormalities may have clinical navicular lameness, and horses distal views as new bone formation on the extremities or as bone
with pathologic and radiographic changesmay be sound.'& " This proliferations along the proximal border (sawtoothed border) (see
paradox is explained in part by the fact that horses have different Ftg. 2a-7A). In the lateral view excessiveremodeling gives the
pain thresholds, are subjected to wide ranges of physical exercise, bone an elongated appearance(seeFig. 24-78). Caution should be
and are evaluated in variable stagesof disease.sAdditionally, some exercised because improperly positioned lateral views may arti-
pathologic changes may represent insignificant wear lesions or factually distort the bone profile. Similarly, normal variants exist
may be located in tissues of soft-tissue opacity and thus are not that resembie remodeling laterally when angular dorsoproximai-
radiographically discernible.'o''u Sevetal authors agree that radio- palmarodistal images are normal.2e
graphic signs of navicular diseasein an otherwise clinically normal
horse are significant and may warrant a cautious prognosis for Distal border changes
future soundness.8'36 However, there is no universal agreement The radiolucent invaginations along the distal border ofthe navicu-
as to the clinical significance of all radiographic signs seen in lar bone are called synovial invaginations. These are best seenin the
navicular disease. dorsal 65-degree proximal-palmarodistal view. They are normally
inverted cone to popsicle stick in shape.Increasedsize and number
Radiographic signs of navicular degeneration are physiologic changesrelated to type and frequency of work.a'
A change in shape to a lollipop or mushroom shape is considered
Radiographic abnormalities associatedwith navicular degeneration
to signal an abnormal degenerativechange(seeFig.24-7c).2e'3o'40
are varied. Bony abnormalities may occur separately but usually
These abnormal synovial invaginations may be a sign of arthrosis
they occur in combination, unilaterally or bilaterally. Their clinical
of the distal interphalangeal joint, albeit a navicular manifestation.
relevancewith respect to presence,absence,or degree of lameness
The presence of synovial invaginations in the extremities of the
in a given animal is varied.taAdditionally, there is no clear associa- navicular bone has been considered abnormal by some but they
tion betlveen changesin the radiographic appearanceof navicular
do not correlate with lameness.3a
bones and clinical outcome following treatment.3TThus, radio- Horses with clinical navicular diseasehave a high incidence of
graphic changesof navicular degeneration must be interpreted in
abnormal s1'novial invaginations but their clinical specificity re-
context with the presenting clinical signs. This is similar for other mains uncertain. This is because lollipop-shaped qmovial invagi-
musculoskeletalconditions.
nations have been reported rn llo/o of normal horses, and there is
The major radiographic signs of navicular degenerationare no correlation with degree of lameness in confirmed navicular
shown in TabIe 24-2. A diagram depicting various radiographic lameness.3a
Radiolucent changes of the distal border cannot be seen well
in lateromedial views. The palmaroproximal-palmarodistal view,
Table 2tl-2- Roentgen signs of navicular degeneration however, projects them end on within the trabecular portion of
the bone. Increasesin size of visible fossaein this view are abnor-
Proximal border and extremities mal (see Fig.24-9A).8,e The range of normal shape variation of
Enthesophytes fossae for this view, however, has not been established.It is the
Spurs on extremities author's opinion, therefore, that distal border radiolucent changes
Remo de ling
are more consistently evaluated with angular dorsoproximal-pal-
Distal border changes
Synovial invaginations marodistal views, especially when there is only minimal enlarge-
Small osseousfragments ment.
Flexor cortex changes Mineralization associatedwith the distai sesamoideanimpar liga-
Corticalerosions ment is another degenerative change. The significance of this is
Mineralizationof deep digital flexor tendon similar to that of enthesophltes involving the proximal border.
Medullary cavity changes Occasionally, osseous fragments can be seen associatedwith the
Radiolucentcvsts distal border. These can be seen in normal and lame horses alike.
Sclerosis Small osseousfragments occasionallyindicate chip fractures of the
The NavicularBone 299
rt*--*-*-:-:.--]!t
A 'r"-
\*r.rJ*l
,/
#
'w ,fiV
\l
Figure 2tl-5, Radrographic
Remodeling-enthesophyte
b o r d e r ;C L o l i p o p - sh a p ein
changesseen in naviculardegenera-
t i o n . D o r s a l6 5 - d e gr e ep r o xim a l- p a lm a r o d ista l ,4 , No r mal ;B ,
vie w:
on extremity and sawtoothedproximal
d va g ln a tio nosn d ista lb o r d e r ;and D ,
cyst-likelesionformation.Lateromediaview: .4, Norma; B, Elon-
CW r f1,,,,:l
w
g a t e dn a v i c u l apr r o fiiefr o m r e m o d e lin g( e n th e so p h ytefo r mati on);
C F l e x o rc o r t i c ael r o sio na; n d D, Cyst- like Ie sio nfo r m a tio nP . al mar- D fi,.,l
o p r o x i m a l - p a l m a r o d ista
vie wi
l ,4 , No r m a l;B, F le xo rco r tic alero-
s i o n s ;C , E n l a r g e fdossa ea n d fle xo rco r tlcael r o sio n s; a n d D, C yst-
l i k el e s i o nf o r m a t i o n(.M o d ifie dwith p e r m issio frn o m Rich a rdP ark,
F o r tC o l l i n sC . O.)
Figure 24-6. Lateralviews of the navicularbone. A, Normal navicularbone. 8, Proximalelongationdue to remodeling.C Enthesophyte(spur)on proximal
border.D. Flexorcortex lvsis.
S KE L ET ON -EOU IN E
3 OO A P P E NDI CU L AR
Figure 2/t-7. Dorsal proximal-palmarodistal views of the navicularbone. A, Normal navicularbone. B, Remodelingof lateralextremity. C. Lollipop-shaped
synovialinvaginations of the distal navicularborder.D, Cyst-llkecavitationover the planeof the navicularmedullarycavity.Rememberthat flexor cortlcalerosions
ew s.Thus,the pal maroproxi mal -pal marodi
of t en f a l s e l ym i m i c m e d ulla r yca vitycysts o n a n g le dd o r so p r o ximal -pal marodivistal vistal
ew w oul d be n eededi n thi s
situationto accuratelydeterminethe locationof the lesion.
distal border and are discussedfurther under the heading of navic- unusual for large flexor cortical erosions to simulate medullary
ular fractures. Small osseousfragments of the distal border are best cystlike lesions in the dorsopalmar view. It is important to localize
seen in the angular dorsoproximal-palmarodistal views. such cyst-like lesions radiographically. Flexor cortical erosions are
often associatedwith tendinous adhesions,whereasmedullary cysts
Flexor coftex Ghanges are not.30'38This added information mav be imoortant in the
Gross pathologic involvement of the navicular flexor fibrocartilage overail management of the animal. Naviiular va;iants of a flat
is varied. Lesions include yellowish discoloration, cartilage thin- central eminence and a crescent lucency within the cortex of the
ning, focal erosions, and cartilage ulcerations, with or without centrai eminence exist (see Fig. 24-B). These are normal variations
subchondral bone involvement.5'26't0 Some of the abnormalities and should not be misdiagnosed as navicular degeneration. Well-
may be age-relatedphenomena, but all have been seen in navicular positioned lateral radiographs depict the flexor cortex in profile
diseaseto varying degrees.'n''u axially. Minor dimpling of the central eminence in this view may
Bursa, tendon, and cartilage changesare not usually seen radio- be a normal variant or may be the result of geometric distortion.
graphically; only subchondral bone defectsare routinely detectable. Abrupt irregular cavitations are abnormal (see Fig. 24-6D). It is
Early lesions are best seen on the palmaroproximal-palmarodistal recommended that abnormalities of the flexor cortex observedon a
view whereas severe defects may be recognized in other views lateral radiograph be further evaluatedusing the palmaroproximal-
as well. A reliable radiographic sign consists of focal or diffuse palmarodistal view.
subchondral bone corticai lysis (see Fig. 24-9).8 Flexor cortex Dystrophic mineralization of the deep digital flexor tendon may
erosions are rarely seen in sound horses and have a significant be seenin conjunction with flexor erosions.This finding is reported
correlation to the presenceand desree of lameness.''23'3aIt is not rarely and indicates severetendon degeneration, rendering a poor
Figure 24-8. Normalvariationsin the appearanceof the navicularflexorcortexare shown.The flexorcortexshouldbe smoothlymarginatedand havean abrupt
y o n g io saA,
dema r c a t i ofnr o m t h e l e s so p a q u em e d u lla r sp . Pr o m inentcentralemi nence.B , B l untedcentralemi nence.C C rescent-shaped radi ol uc enci n
y c entral
emin e n c e .D . A l t e r e db e a m a n g u la tio na n d p a tie n tm o tio n r e su l t i n i ndi sti ncti nterfacebetw eenthe cortex and the medul l aryspongi osa,
fal se l ys ugges ti ng
nav ic u l asrc l e r o s i s .
The N avi cu lar
Bone 3O l
*4l$i
Figure 2tl-9. Palmaroproximal-palmarodistal views of the navicularflexor cortex and medullashowingvariousabnormalitles. A, En face view of enlargeddistal
b o r d e rs y n o v i ailn v a g in a tio nB,
s. Su b tlefle xo rco r te xe r o sio nsresul ti n a l ossof the normalsmoothfexor contour.C , Largefocalcorti call ysi sc aus i ngi i s rupti on
o f t h e f l e x o rc o r t e xove rth e ce n tr a e
l m ln e n ceD,
. Exte n sive subchondral bonescl erosi s.
Thi sw as al soseenon othervi ew s.
prognosis.rT'a\Faint visualizationof the deep digital flexor tendon ee'Technetium bone scintigraphy
is an extremely valuable ad-
on the lateral view is a frequent normal finding. Diseasedtendons junct when radiographic findings are equivocal, or when the bone
that are sufficiently mineralized may be seen in both lateral and is normal but diseaseof the navicular soft tissuesis susoected.
palmaroproximal-palmarodistal views. This is true because nuclear scintigraphy is more sensitive than
radiography in identifizing early soft-tissue and bone abnormalities,
Medullary cavity changes although a scintigram provides primarily physiologic as opposed
Medullary trabecular disruption in the form of trabecular lysis or to anatomicinformation. Becausephysiologicalterationsassociated
cyst-like cavitations is abnormal. This is rarely seenin sound horses with navicular degeneration are likely to precede gross anatomic
(seeFig. 24-7D). Theseradiolucenciesmay be seenon the angular changes,scintigraphy of the navicular bone should be done when
dorsoproximal-palmarodistal, palmaroprorimal-palmarodistal, and clinical signs are compatible with navicular lameness but radio-
occasionally lateral views. They range in size from 0.5 to 1.5 cm graphs are normal.aa
and are round to oval. They usually are single but may be multiple.
Marginal sclerosisis variable, ranging from complete to none at ail.
Lytic lesions located within the middle or distal phalanx may be
I Fractures
superimposed over the navicular bone. By evaluating other views Navicular fractures are infrequently reported. Therefore, data are
or by repeating the dorsoproximal-palmarodistal view at a different not available from which to draw firm conclusions about their
angle,it is possibleto seeif the suspectlesion changesin position incidence and pathophysiology. Most navicular fractures are trau-
or remains associatedwith the navicular bone. Similarly, lucent matic or pathologic in origin. Both chip and complete fracture
artifacts that result from air trapped in the frog by packing material types have been described. A diaeram of navicular fractures is
may be misinterpreted as radiolucent bone lesions. Air pockets s h o w n i n F i g u r e2 4 - 1 0 .
usually present as linear radiolucent shadows.When there is doubt, Care should be taken to avoid misinterpreting artifacts as navicu-
the frog should be repacked. lar fractures. The sulci of the frog may cast overlying radiolucent
Extensive erosions of the flexor cortex can falsely mimic medul- shadowsin the dorsoproximal-palmarodistal projection that simu-
Iary cavity cysts on angular dorsoproximal-palmarodistal views. On late complete navicular fracture. This situation occurs when the
a palmaroproximal-palmarodistal view, the suspect lesion can be foot is unpacked or when air is trapped in the sulcus by packing
localized as to whether it originates from the flexor cortex or the material. Sulcal lines typically extend beyond the periphery of the
medullary caviry (see Fig. 24-9C and D). navicular bone. Complete fractures are confined to the bone and
Sclerosisof the medullary spongiosais said to be an early finding are seen on dorsoproximal-palmarodistal and palmaroproximal-
in horseslame becauseof navicular disease.', 8'31This is seenas a palmarodistal views. Gravel or debris in the foot, or a foot with
fine trabecular pattern that blends with the flexor cortex, resulting scaly horn may simulate chip fractures. Through proper hoof
in an indistinct interface between the flexor cortex and the medul- preparation (cleaning,paring, and packing), these artifacts can be
lary spongiosa.',8This finding is not reliablebecauseit can often eliminated. Lateral views or dorsoproximal-palmarodistal radio-
be seenin normal horsesas a result of a poorly positioned radio- graphs made at different angles help to localize a suspect opacity.
graph (seeFig. 24-BP1.\ z+'+2, ez When in doubt about navicular fractures, the hoof should be
cleaned and repackedbefore more radiographs are made.
Normal radiographic findings
It should be realized that many horses with clinical navicular Osseous fragments of the distal border
lamenesshave normal radiographs.l'gThese animals may have dis- Small osseousfragments associatedwith the distal border of the
easethat better falls into the category of navicular bursitis. Before navicular bone and impar ligament are occasionallyseen. These
this conclusion is reached, however, an adequate number of high- osseousbodieshavemore than one pathogenesis. They may be due
quality radiographs should be obtained. to chip fractures, damage to the impar ligament with secondarv
3 O2 A P P E NDI CU L ASRKE L ET ON -EOU IN E
Complete fractures
Complete navicular fractures may occur in normal or diseased
navicular bones.t'' 46-52Theyare most frequently seen in the fore-
limb, but hindlimb fractures have been reported.s' Initiating causes
include direct navicular trauma and repeated concussiveforces on
Figure 2tl-11. Chipfractureat the distalnavicular
border,the smallfrag-
a pathologic navicular bone in a neurectomized patient. Lameness menlbrrow).andthe urde'lyingfractLrebedcanbe seen.
associated with complete fracture is usually acute but may be
chronic, and is moderate to severe. In general, the long-term
prognosis for competitive performance is poor.asPostmortem stud-
union becausebony union is not observedradiographically, regard-
ies of limited numbers of fractured navicular bones show fibrous
less of fracture duration. Absence of periosteum and progenitor
unions between the fragments.aTVariable instability is inherent
cells, constant fragment motion, and influx of regional synovial
because of the hingeJike motion allowed by the fibrous compo-
fluid are all thought to play a role in navicular fracture healing
nent.
with fibrousrather than bony union.
Usually, one or two vertical or oblique fracture lines may be
seen within the body or at the body-extremity junction of the
Multipartite navicular bone
navicular bone. A prominent fracture line is usually present. Frac-
What appear to be bilaterally syrnmetric fractures are occasionally
ture fragments have irregular to smooth margins and are minimally
seen in minimally lame animals with otherwise normal navicular
displaced. Occasionally,fragments have mild degenerativechanges
bones. This finding has fostered the belief that the lines represent
of bony resorption and sclerosisadjacent to the fracture line (see
multiple navicular bone ossification centers that have not fused.
Fig.2a-B). Healing is thought to occur from a noncalcified fibrous
Congenital multipartite sesamoidsare occasional, incidental find-
ings in other species,Although the navicular bone develops from
a single ossification center, aberrant formation is theoretically pos-
sible.l Radiographic differentiation between a congenitally multi-
partite navicular bone and a chronic fracture is impossible. Radio-
graphically, multipartite (bipartite or tripartite) sesimoid bones are
often bilateral. Individual fragments have smooth, rounded margins
with wide radiolucent gaps between. In addition, multiple ossifica-
tion centers initially causeno to minimal lameness.If instability is
present, however, degenerativechanges resulting in lamenessmay
occur (Fig. 24-12A).
In some lame horses, a multipartite navicular bone also under-
goes changesthat are compatible with advancednavicular degener-
I Navicular sepsis
Navicuiar sepsismay result from penetrating puncture wounds or
c deep lacerations that involve the bursa or the bone itself. Radio-
graphic signs relative to the navicular bone occurring after a punc-
ture wound to the navicular bursa vary. The length of time between
Figure 2tI-1O, Typesof navicularfractures.A, Chip fracturesof the distal the initial injury and the first radiographic evaluation influences
projection.B and
navicularborder, dorsal 65-degreeproximal-palmarodistal
the findings.s3
C Completenavicularfractures:dorsal65-degreeproximal-palmarodistal and
projections,respectively.
palmaroproximal-palmarodistal If a horse presents within 3 weeks of injury and initial radio-
The NavicularBone 3O3
graphs are negative, a fistulogram or radiograph made following disruption and irregularity of the flexor surface. These lesions are
insertion of a blunt probe should be considered.This examination initially located abaxial to the central eminence. The greater the
aids in establishing if the puncture wound involves the navicular duration of the injury without treatment, the more extensive the
bursa or bone (Fig. 24-13). This is important becausea puncture diseasein terms of depth of the irregularity into the navicular bone
wound that involves a bone or bursa warrants a more cautious and the abaxial extent of it.
prognosis and more vigorous therapy because osteomyelitis may More severechronic findings associatedwith puncture wounds
result. A negative fistulogram does not eliminate the possibility and navicular osteomyelitis include septic arthritis of the distal
that the navicular bone or bursa was involved in the initial injury interphalangeal joint (Fig. 24-14), secondary joint disease,patho-
because partial tract healing in the deeper areas of the wound iogic fracture of the navicular bone, and subluxation of the distal
could prevent passageof contrast medium during fistulography, interphalangeal joint. Rupture of the deep digital flexor tendon or
resulting in a falsely negative study. navicular impar ligament causessubluxation of the distal interpha-
Regardlessof whether a fistulogram is done during the initial langealjoint. In some horses,degenerativechangessimilar to those
evaluation, follow-up radiographs should be taken within the sub- seenin navicular diseasehave been observedas long-term sequelae.
sequent 3 to 12 weeks becauseradiographic evidence of navicular
infection may take 6 weeks or longer to become apparent. Also, it
has been estimated that 50% of horses with navicular sepsisthat I Miscellaneous conditions
have initially negative radiographs subsequently develop radio- Another condition that affects the navicular bone is degenerative
graphic signs of bone infection. Once present, navicular osteomyeli- arthritis. The navicular bone participates in forming the distal
tis may progress and result in serious complications, leading to interphalangeal joint. The articular border of the navicular bone
chronic lamenessthat may eventually necessitateeuthanasia. adjacent to the middle phalanx is normally rounded. Periarticular
Of the standard projections to evaluate the navicular bone, the osteophltes can be seen that result in subtle, pointed, spur-like
iateral and palmaroprorimal-palmarodistal views are more valuable
than the angled dorsoproximal-palmarodistal views in detecting
and staging osteomyelitis of the navicular bone.
Initial radiographic signs of navicular bone infection appear as
focal areas of decreasedopacitv in the flexor cortical bone with
26. Doige CE, Hoffer MA: Pathologic chmges in the navicular bone md associated
Droiections. These have been seen in normal horses as well as in structures of the horse. Can I Comp Med 47"387' 1983.
no.r.s lu-e from naviculardiseaselthus their significanceis uncer-
27. SvalastogaE: Navicular diseasein the horse: A microangiographic investigation'
tain. Reports of significant pathologic processesinvolving the artic- Nord Vet Med 35:131,1983.
ulu, .uriiluge in nivicular diseaseare rate'tu It is believed' however'
".hung", 28. Ostblom L, Lund C, Melsen F: Histologic study of navicular bone disease Equine
that some seen in navicular degeneration are a form of
27'2e Vet I 14:199,1982.
distal interphalangealjoint atthtosis.26'
29. Poulos PW, Smith MF: The nature of enlarged "vascular channels" in the navicular
Congenitat abs"ence'ofthe navicular bone (agenesis)has been
bone ofthe horse. Vet Radiol 2:60, 1988.
reported.sa'ss
30. SvalastogaE, Reimann I, Nielsen K: Changes of the fibrocartilage in navicular
diseasein horses. Nord Vet Med 35:373, 1983.
References
31. SvalastogaE, Neilsen K: Navicular diseasein the horse: The slnovial membrme
Animals' Philadel-
1. Getty R: Sisson and Grossman'sThe Aratomy of the Domestic ofbursa podotrochlearis. Nord Vet Med 35:28, 1983.
phia, WB Saunders, 1975.
32. SvalastogaE, Smith M: Navicular disease in the horse: The subchondral bone
bone in
2. Kder-Hotz B, Ueltschi G: Radiographic aPPearanceof the navicular pressure.Nord Vet Med 35:31, 1983.
sound horses. Vet Radiol Ultrasound 33:9' 1992'
33. Colles CM: Concepts of blood flow in the aetiology and treatment of navicular
and its variations
3. Colles CM, Hickman J: The arterial supply ofthe navicular bone disease.Paper presented at the 29th Arnual Convention of the American Association
ir navicular disease.Equine Yet J 9:150, 1977' of Equine Practjlioners.Decemberl98J' LasVegas,Nevada.
and dye
4. Bowker RM, Ruckershouser SJ, Kelly BV, et al: Immunocytochemical 34. Wright IM: A study of 118 casesof navicular disease:Radiological features Equine
into the distal
distribution studies of nerues potentially desensitized by injections Yet | 25:493. 1993.
Assoc 203:1708'
interphalangeal joint of the navicular bursa of horses J Am Vet Med
1993. 35. Turner T, Kneller S, Badertscher R, et aI; Radiographic changes in the navicular
bones of normal horses. In Proceedingsof the 32nd Annual Meeting of the American
on its pathol-
5. Oxspring GE: The radiology of navicular diseasewith observations Association ofEquine Practitioners, 1986, p 309.
ogy. Vet Rec 15:1$4, f935.
36. Huskamp B, Becker M: Diagnose und prognose der rdntgenologischen Verander-
of navicular disease'
6. Campbell JR, Lee R: Radiological techniques in the diagnosis ungen an den Strahl-beinen der Vordergliedma Ben der Pferde unter besonderer
Equine Vet I 4i135, 1972. Beiucksichtigung der Ankau fsuntersuchung: Ein Versuch zur Schematisierung der
Veterinary Learn- Befunde. Prakische Tierarzt 61:858, 1980.
7. Watrous BJ: A Guide to Equine Field Radiography' Trenton' NJ'
ing Systems,1995, P 13. 37. Wright IM: A study of 118 cases of navicular disease: Tieatment by navicular
Thoroughbred suspensory desmotomy. Equine Vet I 25:50I, 1993.
8. O'Brien TR, Millman TM, Pool RR, et al: Navicular diseasein the
projection' J Am
horse: A morphologic investigation relative to a new radiographic 38. Poulos R Brown A, Brom E, et al: On navicular diseasein the horse: A roentgeno-
Vet Radiol Soc 16:39,1975. logical and patho-anatomic study: II. Osseous bodies associated with the impar
analysis of seventy ligament.Vet Radiol J0:54. 1989.
9. Rose RJ, Taylor BJ, Steel JD: Navicular diseasein the horse: An
2:492' 1978'
casesand assesment of a special radiographic view' J Equine Med Surg 39. Tirrner TA: The anatomic, pathologic, and radiographic aspects of naviculr
the pathogenesis of disease.Comp Contin Educ Pract Vet 4:350, 1982.
10. Dik K, van den Broek J: Role of navicular bone shape in
naviculr disease:A radiological study. Equine Vet I 27:390, 1995' 40. MacGregor C: Radiographic assessmentof navicular bones based on changes in
and the distal nutrient formina. Equine Vet J 18:203' 1986.
11. Poulos P, Brown A: On navicular disease in the horse: A roentgenological
Radiol 30:50'
patho-anatomic study; I. Evaluation of the flexor central eminence Vet 41. Turner TA: Dystrophic calcification of the deep digital flexor tendons resulting
1989. from navicular disease.Vet Med Small Anim Clin 77:571' 1982.
of a
12. Berry C, Pool R, Stover S, et al: A radiographic/morphologic investigation 42. Ruohoniemi M, Teruahartiala P: Computed tomographic evaluation of Finnhorse
bone in the
radiolucent crescent within the flexor central imlnence of the navicular cadaver forefeet with radiographic problematic findings on the flexor aspect of the
ffrr.""gftt*a. In Proceedings of the American College of Veterinary Radiology navicular bone. Vet Radiol Ultrasound 40:275' 1999-
Annual Meeting, Nov 29-Dec 1, 1990, Chicago'
43. Widmer W, Buckwalter K, Fesslerl, et aL Use of radiography, computed tomogra-
tie navicular bursa
13. Dyson S], Kidd L: A comparison of responsesto analgesiaof phy and magnetic resonance imaging for evaluation of navicular slndrome in the
joint in 59 horses' Equine
and intra-ariicular analgesia of the distal interphalangeal horse. Vet Radiol Ultrasound 4l;108, 2000'
Yet I 25: 93, 1993.
of the distal 44. Trout DR, Hornof WL O'Brien TR: Soft-tissue and bone-phase scintigraphy for
14. Schumacher J, Steiger R, Schumacher J, et al: Effects of analgesia diagnosis of navicular diseasein horses. J Am Vet Med Assoc 198:73' 1991'
by solar pain in
irrt rphdung.A joint oi palmar digital nerves on lameness caused
horses. Vet Surg 29:54, 2000. 45. vm De Watering CC, Morgan lP: Chip ftactures as a radiologic finding in
Lea and navicular diseaseof the horse. J Am Vet Radiol Soc 16:206, 1975.
15. Stashak TS (ed): Adam's Lameness in Horses, 4th ed Philadelphia'
Febiger, 1987, p 499. 46. Lillich JD, Ruggles AJ, Gabel AA, et aL Fracture of the distal sesamoid bone in
concePts Paper horses:17 cases(1982-1992).J Am Vet Med Assoc207:924'1995-
16. Rose R]: The treatment ofnavicular disease-a review and current
of Equine 47. Vaughan LC; Fracture of the navicular bone in the horse. Vet Rec 73:895, 1961'
pr.r"nt.d at the zgth Annual Convention of the American Association
Practitioners, Decenber 1983, Las Vegas,Nevada'
48. Arnbjerg J: Spontaneous fracture of the navicular bone in the horse' Nord Vet
of the horse'
17- YaldezH, Adams OR, Pelton LC: Navicular diseasein the hindlimbs Med 3l:429, 1979.
J Am Vet Med Assoc 172t291' 1978.
49. Reeves Ml: Miscellaneous conditions of the equine foot. Vet Clin North Am
Risk factors'
18. Ackerman N, lohnson JH, Dorn CR: Navicular diseasein the horse: Equine Pract 5:221, \989.
170:183' 1977'
radiographic changes,and resPonseto therapy l Am Vet Med Assoc Vet Rec
50. Smlthe RH; Fracture of the navicular bone in the horse-comment'
Equine Vet
19. Wright IM: A study of 118 casesof navicular disease:Clinical features' 73:1009,1961.
I 25:488,1993.
51. Kaser-Hotz B, Ueltshci G, Hess N, et aL Navicular bone fractures in the pelvic
syndrome Vet
20. Pool RR, Meagher DM, Stover SM: Pathophysiology of navicular limb in two horses. Vet Radiol lj.ltrasound 321283'1991.
Clin North Am Equine Pract 5:109, 1989.
52. Rick MC: Navicular bone fractures. In White NA, Moore fN (eds): Current
1953'
21. Wilkinson GT: The pathology of navicular disease'Br Vet J 109:38' Practice of Equine Surgery. Philadelphia, IB Lippincott, 1990' pp 602-605'
242' 1886'
22. Smith F: The pathology of navicular disease'Vet J 23:72' 160' 53. Richardson GL, O'Brien T: Puncture wounds into the navicular bursa of the
fealures of horse: Role of radiographic evaluation. Vet Radiol 26:203, 1985.
23. Wright IM, Kidd l, Thorp BH: Gross histological, histomorPhometric
1998-
the navilular bone and related structures in the horse. Equine Vet J 30:220' 54. Reid CF: Radiology panel-film hterpretation session notes. In Proceedings of the
Vet Rec 22nd Arnual Convention of the American Association of Equine Practitioners, 1976,
24. Colles CM: Ischaemic necrosis of the navicular bone and its treatment'
Dallas. Texas.
1 0 4 : 1 3 3,1 9 7 9 .
arteries: A model for 55. Modransky C, Thatcher C, Welker R et al: Unilateral phalangeal dysgenesisand
25. Fricker CH, Riek W, Hugelshofer l: Occlusion of the digital
yer J I+203' 1982' navicular bone agenesisin a foal. Equine YetJ 19t347' 1987.
pathogenesisof navicular disease.Equine
3 O4 A P P E NDI C U L ASK
R EL E T O N -EOU IN E
26. Doige CE, Hoffer MA: Pathologic changes in the navicular bone and associated
Droiections.These have been seen in normal horsesas well as in structuresof the horse. Can J Comp Med 47:387,1983.
Lorseslame from navicular disease;thus their significanceis uncer-
27. SvalastogaE: Navicular disease in the horse: A microangiographic investigation.
tain. Reports of significant pathologic processesinvolving the artic-
Nord Vet Med 35:131,1983.
ular cartilage in navicular diseaseare rate.26It is believed, however,
that some ihuttg.t seen in navicular degeneration are a form of 28. Ostblom L, Lund C, Melsen F: Histologic study of navicular bone disease.Equine
27'2e Vet J 14:199,1982.
distal interphalangealjoint arthrosis.26'
Congenital absence of the navicular bone (agenesis)has been 29. Poulos PW Smith MF: The nature of enlarged "vascular channels" in the navicular
reDorteo.--'-- bone ofthe horse.Vet Radiol 2:60, 1988.
25. Fricker CH, Riek W, Hugelshofer J: Occlusion of the digital arteries: A model for 55. Modransky C, Thatcher C, Welker F, et al: Unilateral phalangeal dysgenesisand
pathogenesisof navicular disease.Equine Vet J 14:203' 1982. navicular bone agenesisin a foal. Equine yet J 19,347, 1987.
The NavicularBone 3O5
3. Which of the following does not representa normal manifesta- 9. Following a nail puncture wound to the navicular bursa, if
tion of the flexor cortex of the navicular bone? initial radiographs are inconclusive, follow-up radiographs should
A. Blunt-pointed central eminence be done when?
B. Flat central eminence A. Within 3 to 12 weeks
B. Within 12 to 16 weeks
C. Crescent-shapedlucency in central eminence
D. Cortical erosion of the flexor surface C. Within 16 to 20 weeks
E. Flexor cortex width of 3 mm D. No follow-up films are indicated becausea negative initial
study was seen.
4. Which of the following is true about s1'novial invaginations
with respectto the navicular bone? 10. What are proposed pathophysiologic mechanism(s) of navicu-
A. They are most prominent on the distal border. lar diseases1'ndrome?
B. They are seen in sound horses less than 2o/oof the time. A. Infection due to Haemophilus navicularis
C. Their increasedsize but triangular shape suggestsagel B. Progressivenavicularbursitis
work changes. C. Degenerativearthrosis
D. Their lollipop shape is abnormal. D. Osteochondrosis
E. They are suggestiveof navicular sepsis. E. Ischemic necrosis of the navicular
5. Tiue or False.Medullary cysts seen on angular dorsoproximal- Answers begin on page 727.
rl?l
, rl:r,,,1llll'lll!ll::'lll:rllli:1,,:l]lll
S E C TION
:
V '
Irlll iiiilllllliillllllll'ii.rll'''ri,i.,
t:
25
lnterpretation Paradigms for the
Small Animal Thorax
. Clifford R. Berry . Nancy E. Love . Donald E. Thrall
3(J7
3 O8 NE CKA ND TH O R AX -C OMP AN IO N
AN IM ALS
Table 25-1. Inspiratory versus expiratoly thoracic position. The caudal vena cava can be traced to silhouette with the
radiographs6 right crus, usually at a point caudal to the left crus. Food or air
lnspiration within the fundic portion of the stomach can be identified caudal
The diaphragm moves caudally. to the left crus. The apex of the cardiac silhouette tends to become
There is an increaseddistancebetweenthe cardiacsilhouette displaced slightly dorsally from the sternum, giving a circular
and th e dia ph rag m . appearanceto the overall cardiac shape. This should not be mis-
T he lun g lob es a pp ea rt o be "lar ger " and m or e "inf lat e d " ( e . 9 . , taken as a sign of right ventricular enlargement,wherein the cardiac
on the lateralview. the lungs extend to the sternum). apex can rotate dorsally from the sternum, or of pneumothorax,
The lungs appear more "radiolucent."(However,pulmonary in which the cardiac silhouette is elevated away from the sternum.
marking sare still seen. )
Typically, distinguishing between right versus left cranial lobe pul-
Expiration
T he d iap rag man d car diacs ilhouet t ear e in c los e appo s i t i o n . monary vesselsis easier in a left lateral radiograph, and relative
T he lun g lo be s se em "s m aller " and les s "inf lat ed. " vesselsize is easier to evaluate.
The lungs appear more radiopaque(increasedsoft-tissue On a VD radiograph, the right and left diaphragmatic crura
.
opacity).This may cause an artifactualappearanceof an have a convex appearance(thoracic surface) and are superimposed
unstructuredinterstitialpattern. over the larger convex cupola ofthe diaphragm. The cardiac silhou-
ette tends to be more elongated than in a DV radiograph. Changes
From Silverman S, Suter PF: lnfluence of inspiration and expiration on in the descendingaorta and great vesselsare more conspicuous on
canine thoracic radiographs. J Am Vet Med Assoc 166:502,1975.
the VD view and the accessorylung lobe is better aerated,allowing
more accurate assessmentof caudal mediastinal or accessorylobe
pathology.
On a DV radiograph, the cardiac shape is more oval owing to
lobe, as well as separation of the cardiac silhouette from the its upright position (Fig. 25-2). There is better visualization of the
diaphragm. The cranial margin of the left cranial lung lobe should caudal lobar pulmonary vesselsbecausethey are magnified and not
extend to the level of the first rib (Table 25-l). On the VD/DV silhouetting with the collapsed dependent lung, and they are more
radiograph, indicators of inspiration include increased thoracic perpendicular to the primary x-ray beam (see Fig. 25-Z). The
cavity width and thoracic cavity length; the diaphragmatic cupola accessorylobe region is less aerated in DV radiographs becauseof
(dome) is caudal to the mid-T8, and the caudolateral aspectof the cranial displacement of the midportion of the diaphragm. Differ-
caudaliung lobes is caudalto T10. ences between right versus left lateral views and VD versus DV
The effect of positioning on thoracic radiographic appearance vrews are more pronounced in medium-sized and large dogs than
must be understood.s In right lateral radiographs, the cardiac in small dogs and cats.
silhouette is tlpically more oval or egg-shaped (Fig. 25-1). The Other radiographic views of the thorax that can be helpful
diaphragmatic crura are usuaily parallel to each other, with the include oblique radiographs to evaluate rib and pleural abnormali-
right crus being more cranial than the left. The right diaphragmatic ties. Radiographs made using a horizontally directed x-ray beam
crus can usualiy be identified by tracing the dorsal border of the with the patient in lateral recumbency or held in a standing
caudal vena cava to the point at which it becomes confluent with position can take advantageof gravity to move pleural fluid awa|
the right diaphragmatic crus at the caval hiatus. Air within the from areas of interest, such as possible lung masses. Using a
fundus of the stomach may be visible behind the left diaphragmatic horizontal x-ray beam requires an adjustable x-ray tube head. A
crus. Overlap between the right and left cranial lobe pulmonary common application of horizontal beam radiography is evaluation
vesselsis frequent in right lateral radiographs. This may make of cats with severepleural effusion to determine whether a cranial
assessmentof the relative size of the artery and vein difficult in mediastinal mass is also present.
this view. One very important effect of recumbency is the difference in
In the left lateral radiograph, the heart often appearsmore round conspicuityof a lung lesion (nodule, mass,or infiltrate), depending
and the left diaphragmatic crus is usually more cranial than the on whether the lesion is in the dependent or nondependent hemi-
right. The right and left crura typically diverge away from each thorax (Fig. 25-3).In the dependenthemithorax, t[e lung rapidly
other as one traces the diaphragm from a ventral to a dorsal becomes less aerated; thus its radiographic opacity increases.The
Figurc 25-1. Comparisonof a r;ghtand left lateralthoracicradiographfrom an adult dog (Goldenretriever).On the right laterall/A/,the diaphragmatic cruraare
parall ewl i t h t h e r i g h tc r u s,wh ich is cr a n iato
l th e le ft.T h e h e a r tis ovali n shape,and the caudalvena cavasi houettesw i th the most crani alcrus i ri ghtc rus ).On
the left laterairadiograph/B),the diaphragmatic cruraare seen to divergefrom eachother and the left crus is cranialto the rioht crus.The caudalvena cavainserts
into the most caudalcrus.
Interpretati on
P aradi gms
for the S mal lA ni malThor ax 3O g
Figure 25-2. Comparisonof the ventrodorsal(VD)and dorsoventral{DV) radiographsfrom an adult dog. On the VD radiographfAr,the cardiacsilhouetteis
m o r e e l o n g a t e da n d o va lin sh a p e .On th e DV r a d lo g r a p(hB) ,Ihe cardi acsi l houettei s shorterand more upri ghti n the crani ato caucl al and t has oeen
di recti o n,
dr s pa c e di n t o t h e l e f t he m ith o r a bx e ca u seo f cr a n iae xcu r sio n
of the mi dporti onof the di aphragm.
F i g u r e 2 5 - 3 . R i g h t1 Ala n d le ft 1 Blla te r arl a d io g r a p hosf th e thoraxof a dog w th a nodul ei n the rght mi ddl el obe.The nodul el s not seen i n the ri ghtl ateral
v t e w ( A )b e c a u s ei t s i ho u e tte swith th e co l a p se dd e p e n d e nri t ght ung.The nodul ei s cl earl yseen,superi mposed on the heart.i n the l eft l ateralv i ew oec aus e
t he n o n d e p e n d e nr itg h tlu n g s n o w a e r a te da n d p r o vid e sco n trastfor the l ungnodul e.
3I O NE CKA ND T H OR AX -C OMP AN IOA
NN IMA LS
increasedopacity of the dependent lung causesthe lung to silhou- and forelimbs laterally, and the diaphragm caudally. The sternum
ette with any lung lesion that is of soft-tissue opacity. Large lesions consistsof eight sternebrae.The first, which is elongated compared
in the dependent hemithorax may be completely invisible radio- with the other sternebrae, is the manubrium. The last sternebral
graphically. When the opposite view is obtained, the previously segment is the xiphoid process,which extends caudally to a level
dependent lung quickly becomes aerated, providing contrast for ventral to the falciform fat. The intersternebral sDacesare fibrocar-
the lesion and allowing it to be visualized. tilaginous joints similar to the intervertebral disc spaces of the
vertebral column. Costal cartilages from the first eight ribs insert
I Anatomy, physiology, and at the intersternebral disc space. The remaining costal cartilages
insert near the xiphoid process.Degenerativechangesof the sterne-
interpretation paradigm brae and intersternebral disc spacesare common. New bone, simi-
lar in appearanceto the osteophytesthat form secondary to spon-
overview dylosis deformans, and collapse of intersternebral disc space with
The thorax can be subdivided into four basic anatomic regions: (1) end-plate sclerosiscan be seen.These changesare characteristic of
the extrathoracic region, (2) the pleural space,(3) the pulmonary older patients. Costal cartilagesmay mineralize early in life in both
parenchyma, and (4) the mediastinum (including the heart and dogs and cats. The costochondral junction between the body of
great vessels).Evaluation of each of these four areas provides the the rib and the costal cartilage can undergo extensivedegenerative
basis for interpreting thoracic radiographs as expected structures change with heterogeneous amorphous mineralization patterns.
and opacities tlpi!' each region. It is important to memorize basic These degenerativechangesshould not be confused with intrapul-
anatomic boundaries and borders of each region, and to have monary masses,pleural lesions, or aggressiverib lesions (seeChap-
a basic understanding of the physiology of structures within a ter 28).
given region. The cranial aspectof the thorax is bounded by soft-tissue struc-
tures within the ventral neck at the thoracic inlet. The shoulder
The normal thoracic joints and scapula should be evaluated for degenerativechanges.
radiograph-interpretation paradigm Changes in bone opacity within the humerus and scapula should
Recognition of radiographic abnormalities is based on a thorough be noted. Dorsally, the vertebral bodies should be evaluated along
understanding of normal radiographic appearance.Each structure with the scapulafor any changein the expectednormal appearance
has a characteristic size, shape, opacity, margin, contour, number, of these structures.
and location. This interpretation paradigm overview moves in a The diaphragm should be assessedfor normal lung diaphragm
(air-soft tissue) interface and positioning. The crura and dome are
systematic fashion from the extrathoracic region to the intratho-
racic regions. For the most part, thoracic diseasesinvoive only one evaluated for changesin contour or position relative to each other.
of the three intrathoracic regions noted previously. When two or Tracing each ofthe ribs should be a priority on the VD or DV and
more of these regions are involved, a basis for understanding lateral radiographs to ensure the absenceof rib pathology. Based
pathophysiologic mechanismsis important. For example, dogs with on the lateral radiograph, soft tissuesventral to the sternum, soft-
right-sided heart failure (e.g., passive congestion and baclaryard tissue massesor fatty masses,or nipples may result in superim-
failure) have pleural effusion and ascites.These areas (i.e., pleural posed lung opacity. Nipple shadows typically are bilateral and are
and peritoneal cavities) are secondarily involved. Therefore, two of located within one intercostal spaceof each other in opposite lung
the anatomic regions are involved even though a single diseaseis fields on the VD or DV radiograph.
responsible for the radiographic abnormalities. An understanding
of how these two regions are connected is important based on the Pleural space
underlying pathophysiology. The pleural space is the next region to be evaluated. The normal
\A/hen interpreting thoracic radiographs, it is important to keep pleura is composed of two layers-parietal and visceral. The pari-
severalkey factors in mind. The first is that the thoracic radiograph etal pleura lines the thoracic cavity and is fused with the thoracic
is a 1/120th or 1/60th snapshot of the patient's thorax and the wall (intercostal spaces and ribs) and diaphragm. Medially, the
stage of disease. The disease may be more advanced than the parietal pleura reflects dorsally at the level of the sternum; it also
radiographic abnormalities suggest,or changescharacteristicof the reflects ventrally at the level of the vertebrae to form the mediasti-
disease may not yet be present. In other words, radiographic nal pleura. At the pulmonary hilum, the parietal pleura also reflects
changestypically lag behind the stage of the disease;this is true onto the outer pulmonary surface and becomesthe visceral pleura.
for all radiographic examinations, not just those in the thorax. The Normally, the pleural space contains a very small amount of fluid
secondfact to consider is that the radiographic changesare second- that is not visualized on thoracic radiographs. Production of pleu-
ary to alterations in normal anatomy. These anatomic alterations ral fluid is continuous; however, becausethe fluid is also absorbed,
may be a direct result of the disease(e.g., true anatomic abnormal- a net accumulation of fluid does not occur. In older patients,
ity), or they may be a secondary change (e.g., as that described for pleural thickening may be present, particularly between the right
right-sided heart failure). In either instance, an understanding of middle and right caudal lung lobes and is seen best on a left
normal anatomy, the anticipated radiographic anatomy, and possi- lateral radiograph; however, this is not significant unless other
ble radiographic abnormalities based on the underlying pathophys- radiographic abnormalities are present. Knowledge of the localiza-
iology is imperative. Finally, during image interpretation, the focus tion of the normal pulmonary fissures is important as these are
is often on changesin anatomy; however, these anatomic changes sites of fluid or air accumulation and also represent boundaries
may not be related to the patient's clinical signs or disease.For and borders for lung pathology. These boundaries are reviewed ifi
example, increased interstitial lung opacity in a patient who has the next section and also in Chapter 31.
lived in an urban environment may be completely unrelated to the
patient's cough. However, the radiographs must be evaluated for Pulmonary palenchyma
abnormalities that may be associatedwith the cough. The pulmonary parenchyma consists of three structures that are
normally visualized on routine thoracic radiographs: (1) the walls
Extrathoracic region of the airways to the level of the primary and secondary divisions
The extrathoracic region includes the thoracic skeleton and the of the bronchi, (2) the pulmonary arteries and pulmonary veins,
soft tissues of the thoracic wall and diaphragm. These boundaries and (3) the lung interstitium, or the connective tissue framework
include the sternum ventrally, the vertebral bodies and ribs dorsally, of the lung.
the ribs, the intercostal soft tissues, the subcutaneous structures Airway walls. The airway walls appear as thin parallel tissue
Interpretati on
P aradi gms
for the S mal lA ni ma lThor ax 3ll
Iines that taper and branch into the periphery. When a bronchus which the vesselscross the rib. In other words, the summation
is viewed end-on, it will have a circular appearance. As a dog ages, shadowof the intersectingvesseland the 9th rib should be a square.
the tracheal and bronchial walls and cartilage rings may undergo If the vesselis enlarged, the summation shadow is rectangular with
dystrophic mineralization and be more conspicuous.On a right the largestdimension being horizontal; if the vesselis small, the
Iateral radiograph, the first radiolucent oval region superimposed summation shadow is rectangular with the largest dimension being
on the trachea at the heart base area is the bronchus to the right vertical (Fig. 25-a). It is important to realize that relationships,
cranial lung lobe. If the ventral margin of the trachea is traced such as the relative size of the caudal lobe vesselsand the 9th rib,
further caudal, the opening into the left cranial lung lobe can be are only guidelinesand are not accurate 100% of the time (see
seen.It travels approximately 1 cm in a medium-sized to large dog Chapter 33).
and bifurcates into the bronchi to the cranial and caudal segments Lung interstitium. The interstitium is the non-air-containins
of the left cranial lung lobe. At the carina, the trachea terminates part of the lung in which the pulmonary vessels, bronchi, Iymphat-
into the right and 1eftprincipal bronchi. The right middle bronchus ics, and pulmonary parenchyma/connectivetissue (i.e., alveolar
originates at this termination from the right principal bronchus, septum, interlobar septum) are located. The interstitium is the
and is best seen on a left lateral radiograph. The accessorylung sourceof the lacy soft-tissueopacity visible on closeinspectionof
lobe bronchus originatesjust caudalto the cardiacsilhouettefrom normal lung radiographs.There are varying degreesof pulmonary
the right principal bronchus. connectivetissuebetweenspecies.As a result, the lungs of animals
Pulmonary arteries and veins. On lateral radiographs, pulmo- with more connectivetissuenormally appearmore opaque (white).
nary arteries are located dorsal to their corresponding airways, In order of increasingamounts of pulmonary connectivetissueare
which, in turn, are dorsal to their correspondingpulmonary veins. dogs and cats,then the.horses,cattle,pigs. and humans.
On the VD or DV radiograph, the pulmonary artery to a given
lung lobe is lateralto the bronchusto that lobe and the pulmonary Mediastinum
vein is medial. These relationships are extremely important. On an The mediastinum is the spacebetween the right and left pleural
adequatelyexposednormal radiograph,one should be able to trace sacs.In the dog and cat, the mediastinal pleura is incomplete,
the branching pulmonary vesselsto the periphery of the lung field. meaning that nonviscidpleural effusions(e.g.,transudates)tend to
These pulmonary vesselshave their largest overall diameter closest be bilateral. Exudative effusions (e.g., pyothorax, chylothorax, or
to the heart and taper and branch toward the periphery. The hemothorax) tend to be unilateral owing to the plugging of the
branching is linear and is not curved, irregular, or blunted in the fenestrated,incompletemediastinalpleura.
normal dog and cat. The vesselsare of soft-tissue opacity. In The mediastinum, when viewed dorsally, is characterized by
general, the size of any pulmonary artery within the pulmonary reflections wherein certain structures push the mediastinum away
parenchymashould match the sizeof the correspondingpulmonary from its normal midline iocation. These mediastinal reflections
vein at any given level. Although the relative size of pulmonary develop as the lungs grow and cross the ventral aspect of the
arteries and veins is usually sufficient to assesswhether either vessel midline. Three different reflectionsare described(Fig. 25-5). The
is abnormal, absolute size can be quantified. For example, the cranioventral mediastinal reflection forms when the lingula portion
pulmonary artery and vein supplying the right cranial lung lobe of the left cranial lung lobe extends acrossthe midline from left to
should not have a diameter greater than the proximal aspectof the right at the thoracic inlet. The ventral portion of the right cranial
4th rib. Also, the diameter of the caudal lobe pulmonary artery lung lobe aiso extendsacrossmidline in a right to left direction
and vein should equal the thicknessof the 9th rib at the point at just cranial to the cardiac silhouette.ThesetwL ventral extensions
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Figure 2S-5. Reformatteddorsal /A/ and transverse1Blcomputedtomographyimagesof a caninethorax illustrattngth-ocranioventral mediastlnalref -octlon.
Thec a u d o v e n t r a m e d l astin a lr e fle ctio n ca n a lso b e se e n in A.l nA ,therel sextensi veopacfcati oni ntheri ghtcaudal thoraxduetoal ungtumor.S eeC hapter30
o f th e m e d ia stin ar efl ecti ons
f or e x a m p l e so f t h e r a do g r a p h ica p p e a r a n ce
of the cranial lung lobes form the cranioventral mediastinal reflec- Dorsally in the middle mediastinum, the trachea terminates at
tion (Fig. 25-5). The thymus and sternal lymph node are two the carina into the principal bronchi. The descendingaorta is
soft tissue structures found in this reflection' The caudoventral visualizedbecauseof its position along the medial border of the
mediastinal reflection is a result of the growth of the accessory 1eft and right caudal lung lobes. On the VD/DV radiograph, the
lung lobe as it develops and pushes the mediastinum from the aortic arch extends toward the left of midline beyond the vertebral
right to the left. The caval mediastinal reflection, or plica vena cava, bodies. The descendingaorta then convergesin a straight line
is not visible as a distinct structure,but representsthe mediastinum toward the vertebral bodies at the centrally located aortic hiatus of
wrapped around the caudal vena cava in the right hemithora-x. the diaphragm. The esophagusis usually not visible on the lateral
Theie reflections are important anatomic landmarks' For example, or VD/DV radiograph in this portion of the mediastinum. The
the caudoventral mediastinal reflection forms the left lateral extent dorsal portion of the middle mediastinum also contains the tra-
of the accessorylung lobe on the VD or DV radiograph. Within cheobronchiallymph nodes,phrenic nerve,vagosympathetictrunk,
the middle mediastinum, the cardiac silhouette also pushes the and so forth. These structuresare not visualizedon normal tho-
mediastinum apart ventrally. The right convexity of the cardiac racic radiographs(seeChapter 30).
silhouette displaces the right lung lobe in a rightward direction,
and the 1eft convexity of the cardiac siihouette displacesthe ventral Lungs
portion of the left lung lobe in a leftward direction' Dorsally, the There are two lungs, each of which occupies approximately 50o/oof
mediastinum is a midline structure. the thoracic cavity. The right lung is divided into right cranial,
The mediastinum can be divided into cranial, middle, and caudal right middle, right caudal, and accessorylobes. The left lung is
parts, with each having imaginary ventral and dorsal compart- divided into left cranial (further subdivided into cranial and caudal
ments. Surrounding the trachea on the lateral radiograph is a parts) and left caudal lobes. These lobes occupy specificareasof
confluence of soft-tissuestructures that cannot be distinguished the thoracic cavity. Even though interlobar fissuresare not identi-
becauseof silhouetting with each other. These structures include fiable on routine thoracic radiographs,the expectedanatomicloca-
vessels,the esophagus,lymph nodes, and nerves' See Table 30-l tion of thesefissuresmust be understood.
for a complete listing of mediastinal organs. On the VD or DV radiograph,interlobar fissurescurve from the
In the ventral aspectof the cranial mediastinum, the left craniai thoracic wall in a cranial and medial direction toward the pulmo-
lung lobe lingula and the cranial mediastinal reflection are seen. nary hilum (trachea), with the convex side of the curve located
The sternal lymph node is not seen unless enlarged.In a young cranlalty ttrgr. zJ-/ t,
animal, the thymus can occasionally be identified in a lateral . The fissure between the right cranial and right middle lobes is
radiograph between the right cranial lung lobe and the cardiac
located at the 1eve1of the 4th to 5th intercostal space
silhouette. More commonly, the thymus can be seen on the VD or . The fissure between the right middle and right caudal lobes is
DV radiograph extending in the cranioventral mediastinum reflec-
located at the level of the 6th to 7th intercostal space
tion between the left cranial and right cranial lung lobes. The . The fissurebetween the cranial and caudai parts ofthe left cranial
thymus createsan opacity that is usually curved and triangular in
lobe is located at the level of the 4th intercostal space
shape and extends from the midline in a convex fashion, following . The fissure between the 1eftcranial and Ieft caudal lobes is located
the medial border of the left cranial lung lobe into the left hemitho-
at the 1eve1of the 6th to 7th intercostal space
rax. This has been called the "sail sign" (Fig. 25-6). On VD and
DV radiographs, the trachea is normally located slightly to the It should be noted that fluid typically would not extend along
right of midline. The right margin of the cranial mediastinum on an entire fissure.
the VD or DV radiograph is usually formed by the lateral margin
of the cranial vena cava. . Dorsal to the heart, the right cranial lobe contacts the right
-*-H :J
l nterpretati on
P aradi gms
for the S mal lA ni ma lThor ax 313
Figure 25-6' Fight lateraland ventrodorsal(VD) radiographsof a 1O-month-old dog. On the ateral radiograph,there is an increasedsoft-tissueopacttylust
c r a n i atl o t h e c a r d i acsilh o u e tteOn . th e VD r a d io g r a p hth, e r e i s a focaltri angul ar soft ti ssueopaci ty("sai lsi gn")noted to the l eft of the mi dl i nei n the c rantal
l f l e c t i onb e twe e nth e r ig h tcr a n iaal n d le ft cr a n iall ungl obes(arrow s).
m e d i a s t i n ar e Theseopaci ti esare typi calfor the normalthvmusor a thvmi cremnant.
caudal lobe, and the cranial part of the left cranial lobe contacts become filled with fluid and cells. The fluid and cells replace the
the left caudal lobe. Thus, there is opportunity to see an interlo- air within the alveoli and the lung assumesa soft-tissue opacity.
bar fissure on lateral radiographs extending in a dorsal direction Radiographicaliy, this is considered consolidation. Another cause
from the region of the tracheal bifurcation, if there is thickening of air bronchogram formation is collapse of the alveolar air space.
or fluid accumulation within this fissure. This loss of air results in a soft-tissue opacity of the lung at
that site. Radiographically, this is considered atelectasis.rlIn either
Pattern lecognition for assessment instance, the bronchial lumen becomes visible radiographically
One method for assessingradiographic alterationsof the lung is becauseofthe contrastprovided by the increasedsoft-tissueopacity
called pattern recognition.Tr0Pattern recognition is based on the that surrounds it. It may be difficult to determine if an alveolar
theory that diseasesaffecting the alveoli have a different appearance pattern is the result of consolidationor atelectasis. There are some
than those primarily affecting the airways (bronchi). Also, these radiographic findings that may be used to distinguish between the
appearancesare both different from that of diseasethat primarily two causes.An atelectic iung lobe is decreasedin size. As a result,
affects the interstitium or pulmonary vessels. Thus, diagnostic there is often a shift of mediastinal structures, such as the cardiac
considerationscan be restricted to certain groups of diseasesby silhouette, toward the collapsed1ung.Atelectic lung lobes are com-
careful identification of the compartment of the lung that is radio- monly associatedwith pneumothorax or pleural effusion. Alterna-
graphically abnormal. Pattern recognition is a convenient method tively, consolidated lung lobes typically retain their shape and size
by which confidence can be gained in assessingradiographic abnor- so there is no mediastinal shift. However, there are gradations of
malities of the lung. It is important to reaiize that the specific lung change and these findings are not absolute. One cannbt always tell
lobe involved, the distribution of the abnormality in the lung, and with absolute certainty if the alveolar pattern is the result of
the signalment and history are also important in refining the list consolidation or atelectasis,but it is important to try to decide
of differential diagnoses.The four basic pulmonary patterns are: becausethis decision impacts the differeniial diagnosis 1ist.
(1) alveolar,(2) interstitial, (3) vascular,and (4) bronchial (Table In the cat, the right middle lung lobe undergoesatelectasismore
-
25-2). SeeChapter 34 for a more detailed discussionof lung pat- frequently than other lung lobes.rr This fact ii due to a reiatively
terns. larger ratio of pleural space to area of lung volume, a decreasein
Alveolar pattern. The hallmark of the aiveolar pattern is the the effectivenessof the collateral ventilation in this lung lobe, and
air bronchogram (Table 25-3 and Fig.25-8).1There are two gen- a decreasein compliance in this lobe, which worsens when there is
eral causesof an air bronchogram. An air bronchogram may be
createdby air in the bronchial lumen when surrounding alveoli
Figurc ZS-7. Lateral,ventral,and dorsalphotographsof an air-dried,preservedcaninelung specimen.ln fAl, note the right cranlal,middle,and caudallobes
.ni th" fir.ure between the cranialand caudallobes dorsalto the trachealbifurcation.In /BJ,note the segmentedleft craniallobe and the fissure between the
left cranialand caudallobesthat extendsdorsalto the trachealbifurcation.In lcl, note the dorsallylocatedfissuresbetween the cranialand caudallobes. In /D,
note the accessorylobe extendingacrossthe midlineto the left
Interpretati on
P aradi gms
for the S mal lA ni ma lThor ax 315
pulmonary disease.Right middle lung lobe collapseis best identi- tive tissue framework of the lung, between the alveoli and around
fied on the VD or 1eftlateral radiograph. The radiographic findings the vesselsand airways. Interstitial pulmonary pattern must be
include a decreasein the size of the right middle lung lobe, categorizedas structured or unstructured becausethis classification
development of a triangular soft-tissue opacity in the right middle influences the differential diasnosis list.
lung lobe in the VD/DV view and a mediastinalshift to the right The structured interstitial pintt.r,l can be further subdivided into
if the condition is acute. One generallydoes not see air broncho- cavitary and noncavitary types (Table 25-a). A cavitary nodule
grams in chronic stages of fibrosis. The mediastinal shift may contains gas,which can occupy the entire nodule or only a portion
resolveif the atelectasisis chronic as the surrounding lung lobes ofthe nodule (Fig. 25-9)., A noncavitarynodule or massdoesnot
hyperinflate and move the mediastinal structures to a more nor- contain gas, but it may comprise soft tissue, fat, mineral, or a
mal position. combination of theseopacities(Fig. 25-10). For a singlesoft-tissue
With an alveolar pattern, the pulmonary vesselsand outer mar- pulmonary nodule to be visualized on thoracic radiographs,its
gins of the bronchial wa1lsare not seen becausethey silhouette diameter must be 5 to 6 mm. Smaller soft-tissuenodules do not
with the material in the alveoli. Air bronchograms are easy to see absorb sufficient photons to become apparent radiographically.
if there is severealveolar diseasebut they may be difficult to see if Mineralization within the nodule renders visible nodules smaller
the alveolar diseaseis patchy or mild. Importantly, an air broncho- than 5 to 6 mm in diameter.
gram is not alwayspresent with alveolar diseasebecausethe airways Pulmonary vesselsprojectedend on may be confusedwith non-
may be filled with fluid and cells, resulting in total consolidation cavitary pulmonary nodules. Obviously, it is important to attempt
of the luns lobe. to distinguishbetween an end-on vesseland a pulmonary nodule
The distiibution of an alveolar pattern influences the differential becausethis distinction determinesif additional diaenostictestsare
considerations.Therefore, the radiographic anatomy of the lung needed (Table 25-5). Superficial thoracic wall iasses, such as
Iobes must be known. For example, a cranioventral or ventral ectoparasitesor thelia, may be confusedwith noncavitarypuimo-
alveolarpattern is a common consequenceof bronchopneumonia nary nodules (seeChapter 5).
or aspiration.A caudodorsalalveolarpattern is a common conse-
quenceof noncardiogenicpulmonary edema.
lnterstitial pattern. An interstitial pulmonary pattern can be
categorizedas either structured (or nodular) or unstructured.T
Table 25-5. Noncavitary pulmonary nodules versus
Examplesof a structured pattern are pulmonary nodules (<3 cm end-on vessels
in size) and masses(>3 cm in size). An unstructured interstitial
pattern is a collection of fluid, cells,or fibrosiswithin the connec- End-onvessels
Closelyassociatedwith longitudinalvessels
Often follow an organized"pattern"
Very opaque soft-tissueopacity (resultof viewing a "length" of
Table 254. Radiographic criteria for structured vessel)
interstitial pulmonary pattern S a m e d i a m e t e ro r s m a l l e rt h a n t h e a s s o c i a t e dl o n o i tu d i n a l
vessel
SZe; Small (few mm)-large (cm) U s u a l l yo c c u r n e a r l a r g e rv e s s e l s
Sha pe : Rou nd an d well- c ir c um s c r ibed We l l - d e f i n e dm a r g i n s
Number: One to many
Opacity: Cavitary(gas opacity/lucent)and/or noncavitary(soft Pulmonarynodule
tissue,fat, and mineral opacity) Not necessarilyassociatedwith a vessel
Location: In the interstitialspace.May be locatedin any part of G e n e r a l l yd o e s n o t f o l l o w a p a t t e r n( f o u n dt h r o u g h o u tth e l u n g
th e lu ng lob e (e . 9. ,dor s al,v ent r al) without regardfor vesselorientationor position)
Margination:Variesfrom well definedto ill defined {if C a n b e a n y s i z e ( m u s t b e g r e a t e rt h a n b m m f o r v i su a l i za ti o no f
silho ue ttingwith ot her uns t r uc t ur edint er s t it ialc h a n g e ss u c h soft-tissueopacity)
a s ed ema or h em or r hage) M a r g i n s m a y b e w e l l d e f i n e do r i l l d e f i n e d
316 NE CKA ND T H OR AX -C OMP AN IOAN
N IM A LS
Common causesof discrete pulmonary nodules that are small There are technical issues that must be understood so that a
(2 to 4 mm in size) and well defined, and that can be confused false-positive diagnosis of an unstructured interstitial pulmonary
with soft-tissue pulmonary nodules, are subpleural and pulmonary pattern can be prevented. The phase of respiration is very im-
osteomas.r0 These areasof osseousmetaplasiaare found just be- portant. Optimally, thoracic radiographs are made on full inspira-
neath the viscerai pleura along the lung surfacewithin the intersti- tion. This allows the lungs to be well aerated, providing optimal
tium. They appearas well-defined(mineralized)focal noduleswith contrast between intrathoracic structures. When radiographs are
a dependent predilection for a ventral position, but they can be made on expiration, the interstitium appears artifactually opaque,
found throughout the lung fields. Additionally, Sheltie and Collie and accurate evaluation of the lungs is impossible (Frg. 25-I2).lf
breeds are especially prone to this change, which appears to be the radiograph is underexposed (too light), the interstitium also
age-relatedand more common in older dogs. appears artifactually opaque. The opposite happens when the ra-
An unstructured interstitial pattern may result from an increase diograph is overexposed(too dark).
in fluid and cells, or from fibrosis, in the interstitial space (Fig. Vascular pattern. Radiographically detectablechangesin vessel
25-11). The increase in soft-tissue opacity results in decreased sizeequateto a vascularpattern.8Correspondingpulmonary arter-
visualization of the margins of pulmonary vesselsbut may con- ies and veins should be approximately the same size. If there is
versely result in enhancedvisualization of airways (Table 25-6). asymmetry in size between vessels, or if they are larger than
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:a::.::.
r..illl:
))....:::,?:)..,.::::,:))
rill$ll,,,
.il!r,,...:lt:):,,
.':6)::
Figure 25-12. Close-upof the caudodorsallung from right latera radiographsof the same dog during inspiration/A/ and expirationfg. Note the increased
o p a c i t yo f t h e l u n gi n /8 ,/,wh ichwill a lm o sta lwa ysb e m isd iagnosed
as i ntersti ti al
l ung i nfi l trate.
The di stancebetw eenthe heartand draphrag m
(c ompare
A w i th
B ) i s a w a y t o d i s t r n gu ish th e le ve lo f in sp ir a tio n .
318 NE CKA ND T H O R AX -C OMP AN IO AN
N IM ALS
heart score, has been describedwhereby the sum of the heart apex points toward the ieft costodiaphragmatic angle. The shape
length and width on the lateral radiograph is normalized to verte- of the cardiac silhouette tends to be rounder on ih" l"ft lut"iul
bral length.ta'r5This technique can provide objective criteria for view because of rotation of the apex dorsallv from the sternum.
evaluationofthe heart. The vertebralheart scoreshould not reolace The, descendingaorta and main p.,l-otruty aitery extend leftward
subjectiveradiographic evaluation of cardiac size and shape.As of the vertebralbodies on the VD/DV radiograph.
yet, improved accuracyof the vertebral heart scoreversussubjective The opacity of all structures of the cardiac silhouette is that of
evaluation for assessingcardiac abnormalities has not been soft tissue; therefore, differentiation of the various chambers,
proved.r6 valves,blood, surfaces,and vesselscannot be made without admin-
The cardiac silhouette tends to be primariiy located in the 1eft istration of contrast medium or use of echocardiography.
hemithora-xon VD or DV radiographs,much more so on DV In actuality, the accuracy of identification of specific cardiac
radiographsbecauseof cranial excursion of the diaphragm. The abnormalitiesin survey radiographsis very poor. Ao*.uer, .orr-
tc Alternate imaging
Alternate imaging techniques that are useful in evaluating the
thorax include:
Ultrasonography for evaluation of pleural fluid, pleura, and pe-
ripheral pulmonary and mediastinal masses
Echocardiography
Nonselectiveand selectiveangiography
. Computed tomography (mediastinal and high-resolution CT for
evaluation of diffuse pulmonary parenchyma)
. Esophagram for evaluation of the esophagus
Figure 25-16. The clockface analogysuperimposedover the cardiacsilhou- . Pleurography and coeliography for evaluation of the integrity of
ette from the lateral radiograph.Note the posltion of the various cardiac
chambers relativeto the clock face. lt is importantto realizethat there is the diaphragm and the pleural space
suoerimoosition of the atriaand the ventricleswithin the middleof the cardiac . Bronchography
s ilhou e t t eE. n l a r g e m e natl o n gth e m a r g in so f th e a r e a ssp e cificto the cham-
bers noted, however,shouldreflectenlargementwithin that given chamber. These modalities are useful primarily for anatomic imaging.
lnterpretation
Paradigms
for the SmallAnimalThorax ?21
*
il
Roentgenabnormality:
g
Changein size, shape, #*
% I
s# opacity,location,
margination,and number.
&
ls there enlargement Cardiomegaly
in the descendingaorta, present?lf YES, is it
aorticarch, heartbase left sided,right sided,
region,caudalvena cava, or generalized?
or main pulmonary
arterysegment?
ffig
ffi
il *s
Are there radiographic Alterationsin the
featuresof right heartfailure pulmonaryarteriesor
or left heartfailureor both? veins withinthe peripheral
lung fields?
Figure 25-18. Summaryo{ the interpretationparadigmfor evaluatingcardiacdisorders.By answeringthese five questions,one can formulatea reasonable
differentialdiagnosislist for furtherevaluationusingalternateimagingtechniquessuch as echocardiography
or contrastangiography.
3 ,2 2 NE CKA ND T H O R AX -C OMP AN IOA
NN IMA LS
Nuclear medicine techniques for evaluating physiologic processes 13. Tod RL, Losonsky JM, Coulter DB, DeNovellis R: Influence of cardiac cycle on
the radiographic appearmce of the feline heart. Vet Radiol 26:63, 1985.
of the thorax include:
14. Buchman IW, Biicheler H: Vertebral scale system to measure canine heart size in
. Mucociliary clearancestudies radiographs. J Am Vet Med Assoc 206:194, 1995.
.
'ge-Technetiumlabeledmacroaggregatedalbumin for the evalua- 15. Litster AI, Buchanan IW: Measurement of the normal feline cardiac silhouette on
tion of pulmonary thromboembolism thoracic radiographs. J Am Vet Med Assoc 216:210,2000.
. Ventilation scintigraphy
16. Lamb CR, Tyler M: Does the use ofthe vertebral heart score hcrease the accuracy
. First-pass cardiac studies for calculation of cardiac ejection frac- of the radiographic diagnosis of canine cardiac disease?Vet Radiol Ultrasound
tions and pulmonary-to-systemic blood flow (left-to-right 40:675,1999.
shunts)
. Multi-gated acquisitions using ECG-gated blood pool imaging
for the evaluation of diastolic and systolic parameters of cardiac
ffi Ouestions
function
1. List three technical considerationsthat influence the diasnostic
utility of thoracic radiographs of a dog or a cat.
I Summary
2. Give four ways to differentiate an inspiratory thoracic radio-
Based on radiographic abnormalities, one should formulate a dif-
graph from an expiratory radiograph.
ferential diagnosis or arrive at a specific diagnosis, depending on
the specificity of radiographic abnormalities noted. Radiographic
3. If a lung lesion is present in the right middle lung lobe, in
abnormalities should not be interpreted in a vacuum; instead, the
which radiographic view may you not be able to see the lesion
clinical history, signalment, and supporting laboratory data should
and why?
also be considered to prioritize differential diagnostic considera-
tions. As one identifies more specific and sensitive radiographic
4. Give the basic interpretation paradigm for review of the lateral
abnormalities, one should think in terms of how high they are on
and DV or VD radiographs of the small animal thorax.
the cone of certainty. If one is at the base of the cone and only
nonspecific radiographic changesare present, then formulation of
5. Give five expectedroentgen abnormalities that would be pres-
a diagnostic plan should be done to rule in or rule out various
ent in a geriatric thorax of a dog. Give two additional radiographic
disease etiologies that are nearer to the top of the differential
changesexpectedin the thorax of a cat.
diagnosis list. Further assessmentusing alternate imaging tech-
niques can be done. Classification of the diseaseprocess according
6. The expectedlocation of the pleural fissure between the right
to its anatomic location becomes critical for formulating a correct
middle and right caudal lung lobes on the VD or DV radiograph is:
differential diagnosis.
A. At the level of the right +th to 5th intercostal spaces.
B. At the level of the right 6th to 7th intercostal spaces.
References
C. At the level of the Ieft 4th intercostal space
1. Suter PF: Thoracic Radiograph: A Text Atlas of Thoracic Diseasesof the Dog and D. At the level of the left 6th to 7th intercostal space.
Cat. Wettswii, Switzerlmd, Peter F. Suter, 1984.
2. Suter PF: The radiographic diagnosis of cmine and feline heart disease.Compend 7. On a VD radiograph, the main body of the left atrium is
Contin Educ Small Anim Pract 3:441, 1981. located where?
3. Toombs JR Ogburn PN: Evaluating canine cardiovascular silhouettes: Radio-
graphic methods and normal radiographic anatomy. ComPend Contin Educ Small 8. The hallmark radiographic feature of an alveolar lung pattern
Anim Pract 7:579,1985.
is -, and two broad categoriesof alveolar lung disease
4. Spencer CR Ackerman N, Burt JK: The canine lateral thoracic radiograph. Vet include _ and
Radiol 22:262, 1981.
5. Carlisle CH, Thrall DE: A comparison ofnormal feline thoracic radiographs made 9. Describe the location and radiographic appearanceofthe three
in dorsal versus ventral recmbency. Vet Radiol 23:3, 1982. mediastinal reflections caused by the normal development of the
6. Silverman S, Suter PF: Influence of inspiration and expiration on canine thoracic lung lobes.
radiographs. I Am Vet Med Assoc 166:502,1975.
7. Myer CW: Radiography review: The interstitial pattern of pulmondy disease.Vet 10. Which of the following could account for normal widening of
Radiol 21:18, 1980. the cranial mediastinum on the VD or DV radiograph?
8. Myer CW: Radiography review: The vascular and bronchial patterns ofpulmonary A. Fat within the cranial mediastinum in an obeseDatient
disease.vet Radiol 21:156, 1980. B. Normal collection of food within the esophagus
9. Silverman S, Poulos PW, Suter PF: Cavitay pulmonary lesions in animals. I Am C. Secondaryto a thymus or thymic remnant in a young ani-
Vet Radiol Soc XVII:134, 1976. ma_t
10. Reif JS, Rhodes WH: The lungs of aged dogs: A radiographic-morphologic correla- D. Positional hlpoinflation of the left and right cranial lung
tion. I Am Vet Radiol Soc 7:5, 1966. lobes in VD positioning
11. Lord PR Gomez JA: Lung lobe collapse: Pathophysiology and radiologic signfi- E. Branchial cyst involution during the second year of life in
cance.Vet Radiol 26:187,1985. the dog and cat
12. Vmden Broek AM, Darke PG: Cardiac measurements on thoracic radiographs of
cats. I Small Anim Pract 28:125,1987. Answers begin on page 727.
CHA P T ER
26
The Larynx, Pharynx, and Trachea
. StephenK. Kneller
I Larynx and pharynx If the radiograph is made with the head in flexion, the larynx may
be as far caudal as C4. In this position, air flow is compromised,
decreasingthe air-to-tissue ratio. This makes structures more diffi-
Anatomic considerations cult to see,and overlying skin folds are more like1y.
The pharynx, borderedby the baseofthe tongue and the retropha- Dependingon the phaseand depth ofrespiration during radiog-
rprgeal wall, is divided into oropharynx and nasopharynx by the raphy, the tip of the epiglottis may be just dorsal or ventral to the
soft palate, which extends to the level of the epiglottis. On high- soft palate, or it may be on the ventral floor of the pharynx. This
quaiity lateral radiographs, many laryngeal structures can be identi- variation may be seen in normal animals; however, in the presence
fied (Fig. 26-7).1 Laryngeal structures are diflicult to seeon ventro- of swallowing disorders,radiographic and fluoroscopic examina-
dorsalviews becauseof overlyingstructures.In lateral radiographs, tion should be performed during swallowing to determine if the
the transverse basihyoid bone is usually obvious because it is epiglottismovesnormally.
projected on end and may be mistaken for a foreign object. The hyoid bones are relatively well defined and easy to identifr
Radiographs of brachycephalic dogs, as well as those of obese in the dog and cat. The key to diagnostic accuracy is simply
animals, are more difficult to interpret becauseof the larger familiarity with the normal appearance.Hyoid bones have been
amount of soft tissue and fat (Frg. 26-2). This resultsin a lower mistakenly diagnosed as foreign objects. The configuration and
air-to-tissue ratio, providing less contrast as well as opacities that relative position of the hyoid bones are rather uniform among
are more irregular. small animals; however, the position of the head, tongue, and
In very young animals (2 to 3 months of age), laryngealstruc- larynx during radiography causesvariation in the angles between
tures may not be well defined because they are not sufficiently hyoid bones. Oblique views may causesignificantdistortion, lead-
mineralized. Mineralization in laryngeal cartilaginous structures, ing to erroneous diagnosis.Few radiographic abnormalities are
including the epiglottis,is a normal changeof aging.Mineralization evident in the hyoid bones.The most common of theseabnormali-
may be seen in animals as young as 2 to 3 years of age and is ties are fracturesand dislocations.
expected to occur earlier in large and chondrodystrophic dogs. In
one study, 96 of 99 clinically normal dogs of random breeds Radiographic signs of disease
and random age older than 1 year had radiographic laryngeal Space-occupyinglesions
mineralization.': The cricoid cartilage is usually the first laryngeal Masslesions,such as abscesses, polyps, neoplasms,and granulation
cartilage to become mineralized. tissue, may be readily identified with appropriate radiographic
In a routine lateral view with the head in a normal position, the technique and accurate positioning, and with applied knowledge
larlnx is usually ventral to the first two cervical vertebrae. It is of normal anatomy. When small, these lesions appear as variants
usually just slightly more ventral than the main portion of the in the normal shape of structures, and, when large, they may
cervicaltrachea.If the radiographis made with the head extended, obliterate air-filled cavities. Such mass lesions may be found at any
the larynx is pulled slightly cranial and is closer to the spine. location (Fig. 26-3). Variation in radiographic technique may be
Additionally, the hyoid bones are at a lesser angle to one another, necessaryto demonstrate such lesions, owing to the variations in
and the ventrodorsaldiameter of the pharynx may be compressed. overlying tissueopacity betweenportions ofihe skull and cervical
lill]r,:lltllll,,'.irri
llillll9lll:li11.jll::
1er!18lr:::
323
324 NE CKA ND T H O R AX -C OMP AN IO AN
N IM ALS
,-ffirrrJ
The Larynx,Pharynx,and Trachea 325
smallerthan for older dogs.Accuratelateralpositioningis necessary enlargement may result from an obstruction in the trachea or
for accuratemeasurements. larynx. It is often seen as a secondary radiographic sign of laryn-
geai paralysis.5
Tracheitis Confusionmay occur when trachealrings or a partial air column
Airway infections do not usually result in detectablethickening of can be identified dorsal to the upper margin of the tracheal air
the tracheal wall or narrowing of the lumen. Rarely, acute dyspnea column. Although some believe this is caused by overlying struc-
may occur as the result of inflammatory tracheal disease,with tures, tracheography(with injection of contrast medium into the
significantdecreasein diameterof the tracheallumen. If the esoph- trachea) has proved narrowing of the tracheal lumen tn some
agus contains large or small amounts of gas, the esophagealwall instances.An explanation for this pattern is the redundancy of the
may cause a silhouette sign with the dorsal tracheal wall (tracheo- trachealis muscle as it folds into the dorsal trachea, thereby nar-
esophagealstripe sign), presentingan erroneousappearanceof rowing the actual air space.During fluoroscopic examination, the
trachealthickening (Fig. 26-5). soft-tissuetrachealismuscle sometimesmoves into and out of the
lumen during respiration.This radiographic pattern may be seen
Tracheal collapse in large dogs with no evidenceof respiratorydistress;thus, muscle
Most tracheal problems are dynamic in nature, resulting in varia- laxity is difficult to blame for the radiographic phenomenon in all
tion in tracheal size related to the phase of the respiratory cycle, dogs. Becausethe dorsal aspect of the trachea may be flattened
that is, trachealcollapse.nThis variation is most often seenin toy normally, a similar pattern may be seen if the trachea is rotated
dog breeds becauseof weaknessin the structural rigidity of the (Fig. 26-8).
trachea. Tracheal collapse,becauseof its dynamic nature, requires For full evaluation of dvnamic tracheal disease.lateral radio-
special attention for radiographic documentation. graphs should be made during both inspiration and expiration.
Dynamic narrowing of the tracheal lumen due to tracheal insta- Abnormalities in the thoracic trachea are exaggeratedduring
bility occurs in the cervical trachea (especially at the thoracic coughing. Fluoroscopicexamination may be necessaryto demon-
inlet) during inspiration (Fig. 26-6), and in the thoracic trachea strate the dynamic signs.
(especiallyat the carina) during expiration (Fig. 26-7). With severe Narrowing of a region of the tracheahas been reported in cats
loss of rigidity, the site of collapse may not correlate with the secondary to localized obstruction in the cranial aspect of the
phaseof respiration.At times, the area that collapsesmay actually trachea.r0The cause for this localized obstruction may not be
"balioon" during the oppositerespiratoryphase. radiographicallyvisible,suggestingthat discoveryof a narrowed or
Abnormal enlargementof a portion of trachea on inspiration collapsed trachea in cats should prompt further investigation by
should lead to suspicion of obstruction of air flow cranially.This meansof endoscopicexamination.
1*1;---..
lriii6]]:i:i:
::ffir:rJ
The Larynx,Pharvnx,and Trachea 327
F i g u r e 2 6 - 6 . I n s p ir a tio n /A/a n d e xp ir a to n /B) r a d io g r aphsofal 5yearodpoodl ew eremadeduri ngfl uoroscopy.Thecervi cal snarrow edoni ns prrarron
tracheai
a n d i s l a r g e rt h a n t h e th o r a cictr a ch e ao n e xp ir a tio nT. h is findi ngi ndi catesthat i he w eak tracheal i muscl
s ei s bei ngpul l edi nto the l umen by negati v epres s ure
d u r i n gi n s pr a t i o n c, o m p r o m isinagir flo w, a n d is b e in gfo r ce doutw ardby posi ti vepressure duri nqexpi rati on.
i;];#:ii
'avoid
erroneouscompressionof the trachealdiameter,the patient's lapse" tends to occur during inspiration in the cervicalregion and
neck should be flexed. during expiration within the thora-x.
CHA P T E R
27
The Esophagus
r Barbara Iean Watrous
Disorders of the pregastricalimentary tract result in a variety of connectivetissue.IAccumulation of intraluminal gas usually indi-
clinical signs, including regurgitation, dysphagia, abnormal swal- catesesophagealdisease.Occasionally,however,small amounts of
lowing, and gaggingor retching. Other signs include weight loss, swallowedair are seenin the normal esophagus.Common sitesfor
failure to gain weight or grow normally, and chronic or recurrent this on the lateral view include the area immediately caudal to the
respiratory problems. Aspiration pneumonia, tracheitis,and nasal cranial esophagealsphincter (Fig. 27-I), regionsat the level of the
discharge are frequent complications of esophagealdysfunction. thoracic inlet, and those dorsal to the heart base. Aerophagia
In several systemic neuromuscular diseases,the oropharynx, the occurs most often in apprehensive,sedated,and dyspneicanimals.
esophagus,or both may be involved. Indications for evaluationof In subsequent radiographs, it typically is apparent that this focal
the upper alimentary tract, therefore, include dysphagia;regurgita- air accumulation is transient. In the dorsoventralor ventrodorsal
tion; and recurrent, unexplainedrespiratorytract infections. view, this gas is often hidden becauseof superimposition. General
anesthesia may cause marked dilation of a normal esophagus,
I Esophageal anatomy mimicking megaesophagus. The induced pulmonary atelectasis
also mimic aspirationpneumonia. For these reasons,use of anes-
may
The esophagusis a musculomembranoustube bounded at each thesia for thoracic radiographyis not recommended.t
end by a sphincter. The four layers include the mucosa, a keratin- The absenceof abnormal esophagealradiographicfindings does
ized stratified squamous epithelium with infrequent pigmentation not preclude the presenceof esophagealdisease;such is often the
in selectcaninebreeds(e.g.,Chow Chows);the submucosa,a loose casewith acute esophagealdisease.In addition, the presenceof
network of fibrous connective tissue with varying quantities of indirect signs of esophagealdiseaseshould be anticipated. For
smooth muscle and mucous glands; the muscularis, which is com- example,focal or generalizedesophagealdilation may be less ap-
posed of striated muscle in the dog (the terminal one third is parent when the lumen is fluid-filled, creating a positive silhouette
smooth muscle in the cat, with its correspondingmucosa thrown sign with the surrounding mediastinum.
into obliquely directed folds); and the adventitia.
The cranial esophagealsphincter is composed of paired crico-
pharyngeal muscles and paired thyropharyngeusmuscles.These
I Esophageal contrast studies
form an annular band attachedto the dorsal aspectof the larynx Contrast radiographic examination is often necessaryfor accurate
and serveto prevent reflux of esophagealcontents into the pharprx, identification of lesions or for further characterization of survey
thereby minimizing aerophagiaduring respiration. radiographic findings. Differentiation of functional from morpho-
The caudal esophagealsphincter is a complex structure that logic causesof dysphagia may be possible with static contrast
comprises the following: focal thickening of the inner circular layer studies. Specific evaluation of functional abnormalities, however,
of esophagealsmooth musciefrom the muscularis;a confluenceof may be possible only with dynamic fluoroscopic studies, or with
gastricrugal folds that lie transverseto the junction; and a muscu- other imaging modalities such as nuclear scintigraphy. The empha-
lar sling created by the right crus of the diaphragm on the right sis in this chapter is on information provided by static survey and
and the deep oblique smooth muscle layer of the lesser curvature conlrast radiographicfindings.
of the stomach on the left. The complerity of this sphincter can be
attributed to the effect of the oblique implantation of the esopha- Gontrast media
gus into the stomach, as well as to the relatively positive intra- Many contrast media are available for esophagography,and selec-
abdominal pressure that compressesthe short intra-abdominal tion of a specificone should be based on the suspecteddisease.l
segmentof the terminal esophagus. Barium sulfate cream and paste (e.g., Esophotrast,Intropaste,EZ
Paste,and Varibar) have been formulated for extreme radiopacity
sulfate suspensionfollows an esophagramin which paste was used. musculature of the brachium can be reduced by moving one
Aspiration of pastemay lead to asphlxiation; therefore, use of paste thoracic limb cranially and the other caudally. Survey radiographs
is not advised when aspiration is a concern. should include the cranial esophagealsphincter dorsal to the iar-
Liquid barium sulfate suspensions (e.g., e z hd, Liquid Sol-O- ynx, the cervical and thoracic esophagus, and the short intra-
Paqtte, E-Z-Paque, Novopaque, and Flexi-Bar) do not adhere well abdominal esophagealsegment and caudal esophagealsphincter
to the mucosa; however, a high-density contrast medium (45o/oto within the cranial abdomen.
85o/odw) can be used for esophagographybecauseit is relatively A fractious animal may be given a nominal dose of phenothi-
safe when aspirated, mixes well with fluid contents, and readily azine tranquilizer (e.g., acepromazinemaleate, 0.05 mg/lb of body
flows around obstructions. Motility problems in the oropharyngeal weight subcutaneously or intramuscularly). However, the esopha-
and esophagealregions should be evaluated first with liquid bar- gus is affected by most central nervous system depressant drugs;
ium. Barium-coated food may be administered subsequently,par- therefore, their use is disadvantageouswhen motiliry is being evalu-
ticularly in animals with problems in swallowing solids but not ated. Approximately 5 to 20 mL of contrast medium is given to
liquids. Barium-coated food may be the best choice for identifica- induce several complete swallows for coating the pharlnx and
tion of early strictures or regional motility disorders. esoPnagus.
Oral aqueous iodine solutions (e.g., Gastrografin, Oral Hlpaque Oropharyngeal problems are best evaluatedby a series of radio-
Sodium, and MD-Gastroview) are relatively nontoxic in body cavi- graphs made in the midst of a swallow and during a pause after
ties. Therefore, their use is indicated when esophagealperforation the swallow is completed. The esophagealphase can be evaluated
is suspected.These agents are hypertonic; thus, if aspirated, they by an additional radiograph that is made after a sufficient pause to
may induce pulmonary ederna. In addition, because of their os- ensure complete transport of the last bolus to the stomach.
motic effects, a volume-depleted animal may be further compro- The normal appearance of the oropharyngeal region after a
mised by fluid loss through the gastrointestinal tract. If leakage swallow of contrast medium revealscoatins of the mucosa without
occurs into a fluid-filled pleurai spaceor if the leak is minimal, the significant retention of the contrast medirim (Fig.27-3). A small
resulting dilution may make it diffrcult to detect the extravasated amount of contrast medium may occasionallvremain in the esooh-
contrast medium or the site of leakage (Fig. 27-2). Nonionic ageallumen immediatelycaudal to the cranial esophageal sphiniter.
organic iodide agents (e.g., Omnipaque) are isosmolar and are not No contrast medium should persist in the piriform recessesor
associatedwith the complications encountered with ionic contrast nasopharprx, larynx, or trachea unless laryngotracheal aspiration
media, but they are considerably more expensive.Use of a barium inadvertently occurs.
sulfate liquid in the presenceof a perforation is a practice that has The normal canine esophagealmucosa appears as a series of
instigated some controversy becauseof the tendency of barium to longitudinal folds. The lines are close together through most of its
stimulate a granulomatous reaction on pleural surfaces.The use of lengrh but may separateslightly at the thoracic inlet is the esopha-
barium sulfate is indicated, however, when oral iodinated contrast gus passesalong the left lateral side ofthe trachea(Fig.27-a).The
medium fails to define the problem. Aqueous iodine contrast media feline esophagushas a similar appearanceto the leveLof the heart
are not recommended for routine esophagographybecauseof their base, but the caudal esophagushas obliquely directed folds that
poor coating ability. correspond to the smooth muscle segment (Fig. 27-5). Oblique
views eliminate superimposition of the spine and sternum for
Technique better visualizationof the esophagus(Fig. 2l-6).tzt
Survey radiographs should always be made immediately before a
contrast examination is performed. This provides for selection of
a suitable radiographic technique and for assessmentof the status
I Oropharyngeal dysphagia
of the esophagusand surrounding tissues. Superimposition of the Sruallowing disorders related to the oropharl,ngeal phase may be
spine readily obscures even a barium-coated esophageallumen. due to abnormalities of the tongue, the pharynx, and the cranial
Therefore, in addition to the lateral view, an oblique view such as es,ophagealsphincter. Identification of the underlying disorder,
a dorsoright-ventroleft or dorsoleft-ventroright view is recom- when functional, may be difficult, but indirect evidence is often
mended to rotate the esophagus into a more visible location. inferred when oral or pharyngeal retention of contrast medium
On the lateral view, the opacity over the thoracic inlet from the occurs. Mechanical causesof oropharyngeal dysphagia are uncom-
Figure 27-2. Lateralsurveyand contrastradiographs of a 4-year-olddog 2 days after a myotomyat the gastroesophageal
junction.The myotomywas intended
to treat chronic congenitalesophagealhypomotilityand megaesophagus. A, Dehiscenceresultedin esophagealleakage,pneumonia,and pleuriiiswith pleural
ef f u s i o n B
. , F o l l o w i n go r a la d m in istr a tioonf liq u idio d in a te d
co ntrastmedi um,therei s l eakagei ntothe pl euralspace.
3 3 , 2 NE CKA ND T H O R AX -C OMP AN IO AN
N IN /IA LS
F i g u r e 2 7 - 6 . A , N o r m a l e so p h a g r a m( d o r sa l,
right;venlral, left)oI a maturedog after administra-
tion of a barium sulfate cream. The sternum is to
the right of the esophagusand the vertebralcolumn
to the left. B, Same study as in A (dorcal,left,
ventral,rghfview). The sternumis to the left of the
eso p h a g u sa,n dt h e v er te b r aco
l lu m nis to th e r ig h t.
mon but may include foreign bodies, such as fishhooks, and perfo- apparatus (Fig. 27-10). The oral stage is normal, but inadequate
rations of the oral cavity or pharlnx by sticks and infiltrative pharyngeal peristalsis leads to retention of much of the bolus of
lesions. These mechanical causesare often best identified with a contrast medium. Inadequate closure of the pharyngeal egresses
thorough visual examination. Functional abnormalities are usuaily (nasopharynx, oral cavity, and larlrrx) may lead to reflux o?.otr-
characterizedby unremarkable survey radiographic findings. trast medium into theseregions.
Diseases of the oral stage of swallowing usually involve the Cricopharyngeal stage dysphagia may be due to inappropriate
tongue. If an abnormality of the oral stage is present, the effect opening or nonopening of the cranial esophagealsphincter (crico-
may be noted on prehension, during caudal transport through the pharyngeal aslmchrony or achalasia) or failure of closure of that
oral cavity, or by organization of a bolus in the oropharynx by sphincter (chalasia). Chalasia is recognized by the persistenceof a
the tongue. Retention of contrast medium in the oral cavity and patent passagebetween the pharl,nx and cranial esophagus (Fig.
oropharl'nx can be seen radiographically. The subsequentpharyn- 27-11). Reflux of esophagealcontrast medium results in its pres-
geal and cricopharlmgeal stagesare normai (Fig.27-7). ence in the pharynx. Pharyngeal paresis, which is an additional
Pharyngeal stage dysphagia is associated with neuromuscular causefor pharyngeal retention of contrast medium, often accompa-
disease,inflammatory disease (Fig. 27-B), and trauma that may nies cricopharyngealchalasia.Dysfunction of the cranial esophageal
result from perforation (Fig. 27-9) or from fracture of the hyoid sphincter becauseof asynchrony or achaiasiaresults in interference
o.n
tu
.l "
.rll1l:..iiiiilr:;
i!l
r1,,,,:1!ll
ji,,;; :r,
lr:i+ru:: *:li$tl,l:l
{T$T
Table 27-2- Summary of location of retained contrast medium relative to type of oropharyngeal dysphagia
Dysphagia
Site Normal Onat Pnanvuaeat CarcopnnaYueent
Oral cavity +l- +
Nasopharynx J_
Oropharynx T
Pharynx + +
Valleculae +l- + +
Piriform recesses + +
Eso ph ag us +l-
Larynx/trachea + +
+, present; , absent.
segmentally dilated esophagus (Fig. 27-17). Foreign bodies can agealmassesare very uncommon and may be confusedwith foreign
cause complete, partial, or no obstruction, with obstruction oc- bodies. They are usually smooth and round to ovoid and may shift
curring most often at sites of limited esophagealdistention. They position slightly as peristaltic waves attempt to push the mass
may induce esophageallaceration when they are sharp or spiculated aborally (Fig. 27-21). They do not usually cause luminal obstruc-
or when chronic, leading to mural necrosis.In the cervical esopha- tion, possibly becauseof accommodation by the esophagusto the
gus, a tear leads to leakageof luminal contents, which may widen gradual enlargement that occurs with growth of the mass. Contrast
the retrotracheal soft-tissue space and facilitate the escapeof air medium use provides for definition of the mural lesion, with
into tissues.Secondaryabscessmay develop. If the tear is intratho- variable filling defect dependent on the character of the lesion. A
racic, pneumomediastinum (Fig. 27-18) and occasionally axillary pedunculated mass appearsintraluminal (see Fig. 27-21), whereas
air may be seen. Chronic perforation is associatedwith exudation, a broad-based mural lesion often oroduces a more subtle and
producing mediastinitis and pleuritis. irregular filling pattern that suggesti wall irregularity with focal
dilation (Fig.27-22) in the absenceof obstruction.
Esophageal and periesophageal masses Extrinsic masses may cause displacement and partial to total
(neoplastic/i nflammatory) obstruction of the esophagus, depending on location. Cervical
Intrinsic massesof the esophagusare uncommon. They may be masses include thyroid tumors, lymphadenopathy, and cervical
benign or malignant neoplasms or inflammatory masses.The inci- abscesses. Invasion of the esophagusby extension may occur, Iead-
dence is greater in certain geographic regions, specifically areas ing to luminal narrowing or wall stiffness and secondary dysfunc-
endemic for Spirocercalupi. Branchiomas, branchial cleft rysts, tion. Thyroid carcinomas may follow the latter course. Intratho-
papillomas, metastatic tonsillar carcinomas,and squamous cell car- racic massesmay cause significant luminal narrowing because of
cinomas occur rarely. The presenceof a benign leiomyoma may be the restriction of spaceby the spine, sternum, and larger mediasti-
recognized only at necropsy owing to its slow growth rate and lack nal structures (e.g., the heart). Accumulation of intraluminal air
of invasiveness;however,when this tumor is encounteredon survey may be seen cranial to the mass causing the partial or complete
thoracic radiographs, it may be seen as a soft-tissue "stripe" be- obstruction (see Fig. 27-15). Oral administration of contrast me-
tween the descendingaorta and the caudal vena cava in the caudal dium will fill the segmentally dilated esophagusand may demon-
thorax (Fig. 27-19). Mineralization of esophagealmasses is rare strate deviation of the lumen away from the origin of the mass
and appears as amorphous linear mineral opacities usually located (Fig. 27-23). Ultrasonography has proved useful in diagnosing
in the dorsocaudal thorax (Fig. 27-20). Differential causes for compressivestricture by an extramural mass.Periesophageallesions
mineral-like opacities on radiographs include dystrophic mineral- may be aspirated or biopsied with ultrasound guidance when visu-
ization of an inflammatory or neoplastic mass, chronic radiolucent alized on ultrasonography.
foreign body with mineralization, and coating of an eroded esopha-
geal mucosa by an orally administered antacid or enteric-coating Acquired esophageal stricture
agent. These medications contain bismuth and other high-atomic- Esophagealhealing following trauma or severeinflammation may
number elementsthat are radiopaque.' Pedunculatedmural esoph- lead to scarring and contracture of the wall. A recent history of
surgery should trigger a suspicion because reflux during general idiopathic. Segmentalmotility disturbances may affect any portion
anesthesiamay induce focal esophagitiswith secondaryscarring of the esophagus.Reflux esophagitisis probably the most common
and luminal narrowing. Subsequentstenosisproducespartial and form of segmentaldysfunction. It usually involves the caudal
potentiaily completeobstruction with gradual progressionof clini- esophagusand may or may not be associatedwith hiatal herniation.
cal signs.Dependingon the speedof onset,the severityof scarring, These disorders are discussedsubsequently.Diffuse esophagitismay
and the managementof the patient, prestenoticdilation may or produce generalized dilation, but it usualiy causes intermittent
may not be visible on survey radiographs.The diagnosisis usually esophagealspasm,which mimics stricture, as well as focal dilation
made or confirmed using an esophagram(seeFig. 27-14). Persis- (Fig. 27-2a). Fluoroscopicexamination of the esophaguspermits
tent narrowing on sequentialradiographs differentiatesthe stricture evaluation of esophageal function as well as morphology. The
from esophagealspasm. Use of barium-coated food bolusesmay relative strength, rate, and efficiency of contractions can be esti-
be neededto confirm without doubt the diagnosisof stricture. mated. In addition, the coordination and function of the cranial
and caudal esophagealsphincterscan be assessed. The evaluation
Segmental motor disease should include swallows of both liquid and solid boluses, using
Segmentalesophagealdysfunction is uncommonly recognized(in three to six complete swallows of each, to observe the possible
part becauseof the lack of routine availability of fluoroscopy) but differencesin handling of the two consistencies.Nuclear scintigra-
may occur as a result of trauma or inflammation, or it may be phy may also be considered for evaluation of segmental motor
,'r*afu,;:';:1
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Figure 27-24. Lateralcontrastand fluorographic spot radiographs of an adultcat with acute regurgitationduringmeals.A, ln the initialradiograph, the presence
The esophagus
l th e h e a r tb a sewa s su sp e cte d.
of an e s o p h a g e aslt r i c t u red o r sato appeared
di l atedcrani alto thi ssi te.8, In a subsequent
exami nation,
i ntermi ttent
relaxationof the esophaguswas detected at the narrowedsite with normalbolus transportduring these periods.Focalesophagealspasm was the diagnosis.
(Not et h e m u c o s asl e r r a tio no f th e ca u d a el so p h a g u s,
wh ich is typi calof the fel i neesophagus.)
The Esophagus 341
disease.Through administration of a small quantity of radioactive the dorsum of the trachea) and a distinct interface of the dorsal
particles per os, such as water labeled with ee"Tc sulfur colloid, wall of the esophagussilhouettingwith the cranialthoracic hypaxial
esophagealtransit times, sphincter patency, and reflux can be muscleswhen intraluminal air is present.On the ventrodorsalor
observedwith a gamma camera. dorsoventralview, the mediastinumcraniadto the heart is widened
and either relatively lucent owing to air in the esophagus,soft-
Gongenital Gauses of segmental megaesophagus tissueopaqueowing to fluid accumulation,or heterogeneous owrng
Vascular ring anomalies. During fetal development of the to retained food admixed with air (Fig. 27-26). The trachea is
intrathoracic vascular structures,the embryologic arch system is deviatedto the right. The leftward margin of the descendingaortic
initially duplicated on the right and left sides.Segmentsnormally arch is usually absent.In an esophagram,the segmentaldilation of
persistafter birth and segmentsare transient,with eventualregres- the esophaguswith constriction of the lumen fust craniad to
sion of selectduplicate parts during cardiovasculardevelopment. the heart base is apparent. A shallow indentation createdby the
The aorta is normally derived from the left fourth arch and por- contiguous left subclavian artery may be visible craniad to the
tions of the left dorsal aorta. The brachycephalicand right subcla- constriction on the ventrodorsalview
vian arteriesoriginate from the right fourth aortic arch and por- Rarevascularrings include duplication of the aortic arch due to
tions of the right dorsal aorta. persistenceof both the right and left fourth arches (Fjg. 27-27)
The most common malformation leading to entrapment of the and aberrant right subclavianartery (Fig.27-28). A double aortic
esophagusis persistenceof the right fourth aortic arch; this con- arch traps the esophagusbetween the archesand the heart base.
nects to the main or left pulmonary artery (derived from the Occasionally,the trachea may also be constricted, resulting in
ventral root of the right sixth aortic arch) via the ductus arteriosus dyspnea.An aberrant right subclavianartery with a normal aorta
(or ligamentum arteriosusafter birth), which forms from the left traps the esophagusbelow the artery. The artery, normally
sixth arch. Constriction occurs with the esophagusdorsal to the branching rightward off the brachycephalictrunk, may arise di-
heart basebut ventral to the vascularring createdby the aortic arch rectly from the aorta just distal to the left subclavian artery; it
locatedrightward, connectingto the leftward pulmonary artery via then crossesretroesophageally from left to right, constricting the
the ligamentum arteriosum (Fig.27-25). Dilation of the esophagus esophagusdorsally.If a well-definednormal left descendingaortic
occurs orad to the constriction with abrupt tapering seenat about margin is visible on the ventrodorsal/dorsoventral thoracic radio-
the 6th rib. Luminal contents may include air, fluid, and food graph, one of the lesscommon vascularrinq anomaliesshould be
material. Occasionally,foreign debris may be retained within the consideredas the cause.Ultrasound examination or angiography
acquired sacculationsor diverticula (seeFig. 27-I3). Radiographic is needed to characterizethese anomalies.Frequently,additional
signs on the lateral view usually include ventral deviation of the cardiac or vascularanomalies(such as persistentleft cranial vena
thoracic trachea (causedby draping of the dilated esophagusover cava)are presentbut may not be of physiologicsignificance.Rarely,
iiilllll:i1119lll:
iiitlllli:i118lll
;ll'-l@tr,rt$
:rrfrfrut:1tftrl
;]'''iiiuit:i1!
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Figure 27-27. Schematicof doubleaorticarch.Thls view, from the left dorsolateralside, shows persistenceof both right (RAA)and lelt (LAA)aorticarches,
wh i c h w r a p a r o u n dt h e d o r sa la sp e cto f th e e so p h a g u s/E/ a nd the trachea,l eadi ngto constri cton.B C T,brachi ocephaltrunk;
ic C rV C ,crani alvena c av a;C V C ,
c a u d avl e n ac a v a ;L S A,le ft su b cla viaanr te r y;PA,m a inp u lm o nary artery.
with persistentright aortic arch, the ductus arteriosusmay remain causes,including chest trauma, tetanus,organophosphatetoxicity,
patent and can be auscultatedby its characteristicmachinery or lead toxicity, myasthenia gravis, polymyositis/polymyopathy, auto-
continuous murmur. Occasionally,a vascularring anomaly may be immune disease(systemiclupus erythematosus),hypoadrenocorti-
accompaniedby generalizedmegaesophagus(see Fig. 27-13), cism, dermatomyositis,thymoma, dysautonomia(cats),gastrointes-
which may worsen the prognosis for responseto therapy. For tinal disease(gastric dilation/volvulus,pyloric obstruction, hiatal
this reason, contrast examination is recommendedfor complete hernia, esophagitis),central nervoussystem(CNS) disease(menin-
evaluationof vascularring anomaliesprior to surgicalcorrection. gitis, neoplasia,CNS trauma), dyspneausually due to upper airway
Redundant esophagus. Esophagealredundancy is an occa- obstruction, and possiblyhypothyroidism.A defect in the afferent
sional incidental finding; it may be problematicin young brachyce- innervation may be presentin both congenitaland acquiredforms
phalic breeds,especiallyEnglish bulldogs and Shar peis. Regional of idiopathic megaesophagus.
dilation may be presentat the site of deviation in the thoracic inlet Generalizedmegaesophagus with a gas-filledlumen may be visu-
(Fig. 27-29). In survey radiographs, focal gas accumulation may alized along all or part of its length on survey radiographs.In the
occur in the cervicaland cranial thoracic esophagus,or the radio- lateral view, the cervicalportion is apparentbeginning just caudal
graphs may be normal. Contrast examinationhighlights a tortuous to the cranial esophageal sphincter.\Ahen mildly dilated,the esoph-
path, usually at or just caudal to the thoracic inlet. Ventral devia- agus is visible dorsal to the proximal trachea,crossingsomewhat
tion is usually present in redundancy,but occasionally,the lateral lateral to the tracheaat the thoracic inlet. As it dilatesfarther, the
view appearsnormal and leftward or rightward lateral deviation is esophagusdrapes around the trachea and depressesit ventrally
seenon a ventrodorsalor dorsoventralview; therefore,orthogonal (Fig. 27-30).If the esophagusis fluid-filled, the lumen may not be
views are recommendedwhen this problem is suspected.If the visible becauseof silhouetting of the soft tissue and fluid (Fig.
radiograph is exposedin the midst of bolus transport, the peristal- 27*3lA). The thoracic esophagus,when gas-filled,may be inadver-
tic contraction of the esophagusmay mask the redundancyor may tently overlookedbecauseof the relativeradiolucencyof the adja-
mimic a focal diverticulunr. cent lung field. Close scrutiny, however, provides several hallmark
findings characteristicof its presence.
Generalized megaesophagus \{hen the cranial thoracic esophagusdilates, the dorsal wall
Both congenitaland acquiredmegaesophagus occur in the cat and abuts the paired longus colli muscles,which may be seenas a sharp
dog. The congenital form may be hereditary in both the dog interfacefrom the thoracic inlet to the ventral asoectof T5 or T6.
(miniature Schnauzerand Fox terrier breeds) and the cat. The The ventral wall projects lateral and often ventril to the trachea.
underlying causeof acquired megaesophagus is often unidentified The draping of the ventral wall over the dorsal trachealwall results
(idiopathic), although it may be secondaryto one of many possible in summation (silhouetting) of the two walls, which createsthe
=--:
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-=:
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I
N.r' Figure 27-28, Schematc of aberrantrlght subcavian
artery.Thrs vi ew , from the l eft si de, show s the ri ght
subclavianartery (RSA)arising leftward from the aortic
arch (LAA)and coursingover the top of the esophagus
(E/,causlngconstrictlonof the esophagus.BCT,brachio-
cephal l ctrunk;C rV C ,crani alvenacava;C V C ,c audalv ena
cava; LAt, left atrium; LSA, left subclavianartery; PA,
oulmonarvarterv.
The Esophagus 343
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upperai rw ayobstructi on. The enti reesophagus i s v i s i bl ebec aus ei t i s
di l atedand ai rfi l l ed.H ai l marks
of esophagealdi l ati oni nc l udethe s harp
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/A r,the trachealstri pesi gnw i th di spl acement of th e trac heav entral l y
/B /, and the pai red convergi ngsoft ti ssuestri pesin the dors oc audal
thorax /C/.icourtesyof New YorkStateCollegeof VeterinaryMedicine,
Ithaca.N Y )
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Figure 27-31. A, Lateralview of a young dog with megaesophagus. The esophageallumen is not vislblein the cervicalregionowing to its fluid content.Some
hallmarksigns isee legendto Fig.27-30)are apparentin the thoracicregion.B, Deviationof the cervicaland thoracicportionsof the trachea(arrows)by the flu d-
s a y b e se e n .( Co u r te sy
fi l l e dc r a n i ae s o p h a g u m o f Ne w Yo r kS tateC ol l egeof V eteri nary
Medi ci ne,l thaca,N Y )
34 NE CKA ND TH OR AX -C OMP AN IOAN
N IM A LS
may form or cellulitis may extend along the deep fascial planes
through the thoracic inlet to involve the mediastinum and pleural
cavity. Thoracic esophagealperforations result in rapid contimina-
tion of the mediastinum and pleural cavity. Radiographic findings
of esophagealperforation may include variable amounts of intra-
luminal esophagealgas or fluid, deep soft-tissue gas around the
cervicalesophagus,a soft-tissuemasswith or without displacement
of the esophagusand trachea,a widened mediastinumor mediasti-
nal mass, pneumomediastinum (see Fig. 27-I8), pneumothorax,
and pleuritis (seeFig. 27-2A). Extraluminal gas,however,may also
originate from deep skin wounds, trachealrupture, and pulmonary
leakage.When radiographic interpretation is ambiguous,esopha-
gographyis recommended.A water-soluble,organiciodine contrast
medium is recommendedto minimize contamination of the medi-
astinum and pleural cavity with a potentially irritating substance.If
barium sulfate is inadvertently used and leaks from the esophageal
perforation, adequate thoracic lavagewill prevent the granuloma-
tous response caused by the contrast medium and esophageal
contents.Occasionally,the water-solublecontrast medium will fail
to result in detection of a perforation either becausethe medium
did not pass through the hole or becauseof marked dilution in
the thoracic effusion (see Fig. 27-28). In negative studies, barium
sulfate is then recommended.
A fistula between the esophageallumen and the respiratory tract
is uncommon. The site of communication may be esophagotra-
Figure 27-32. Dorsoventralviewof the thoraxof an adultdogwith mega- cheal, esophagobronchial,or esophagopulmonaryin nature. For-
esophagus.Thelateral
wallsof the esophagus areseenas thin,softtissue eign bodies have been recognizedas a causeof fistula, which can
to the spine(arrows).
bandsroughlyparallel Theyconverge in the caudal be induced by graduallocal esophageal necrosisleadingto perfora-
(Courtesy
thorax. of NewYorkStateColegeof VeternaryMedicine, lthaca,
NY) tion and by adhesion formation between the esophagusand the
adjacentrespiratory tract tissue. Potential etiologiesmay also in-
clude malignant esophagealdisease,penetrating trauma to the
tracheal band or tracheal stripe sign. When gas-distended,the esophagus,infectious or neoplasticpulmonary disease,preexisting
caudal thoracic esophagusis seen as a pair of thin, soft-tissue esophagealdiverticula, and periesophageal lymphadenopathy. In
stripes that converge to a point overlying the diaphragm and survey radiographs,bronchopneumoniamay be noted. The loca-
cranial abdomen. Absenceof the ventral stripe may result from tion of the pulmonary infiltrate is dependenton the site of commu-
overlap of the caudal vena cava (see Fig. 27-30). On the dorsoven- nication, which may vary according to whether the speciesaffected
tral or ventrodorsalview, the dilated, gas-filledcervical esophagus is feline (caudal segmentof the left cranial lobe) or canine (right
may be hidden by the spine and trachea,although displacementof middle lobe). If there is a history of coughing and choking, which
the tracheato the right may be seen(seeFig.27-31.8).The dilated are exacerbatedby ingestion of fluids, a barium contrast swallow
cranial thoracic esophagusproduces a wide cranial mediastinum is indicatedto locatethe fistula (Fig. 27-33).If pleural involvement
that is relativelyradiolucent. The lateral rnargins are indented on is noted on the survey radiographs,an isosmotic organic iodide
the left by the descending aorta and on the right by the azygous compound is recommendedfor the esophagramto minimize possi-
vein. The caudalthoracic esophagusconvergesto a V at the hiatus ble contaminationof the pleural spaceby barium. An ionic organic
of the diaphragm (Fig. 27-32). iodide contrast medium may induce pulmonary edemaif commu-
When the esophagusis not identified on survey radiographs, nication with the lung parenchymais present.Esophagealfistulas
contrast radiographsare required.A barium contrast examination should not be mistaken for inadvertentaspiration and subseouent
also better defines the degree of esophagealdilation, the iack of alveolarization of contrastmedium durins a routine swallow.
function, and the extent of involvement. This study helps to rule
out other causesof dilation, such as vascularring anomalies,and
outlines the terminal esophagusto rule out invasiveprocesses that I Diseasesof the hiatus
would causeirregular or asymmetricalnarrowing (seeFig. 27-22).
When the contrast medium fails to enter the stomach on routine The esophagusis tethered to the hiatus of the diaphragm by a
swallows, confirmation of caudal esophagealpatency can often be phrenoesophagealmembrane that normally allows only minor cra-
made by elevating the forequarters and inducing an additional nial movement of the abdominal segment.A congenitalor acquired
swallow, which usually stimulates relaxation through initiation of abnormality of the hiatus may allow for reduced caudal esophageal
the oropharyngealphase.Mild or intermittent motor disturbances sphincter tone and reflux, resulting in the development of a sliding
of the esophagusmay not be identified by standard radiography. hiatal hernia, a periesophageal hiatal hernia, a diaphragmaticher-
Early or segmentaldiseaserequiresdynamic evaluationby fluoros- nia, or a gastroesophageal intussusception(see Chapter 29). The
copy. Differences in esophagealresponseto liquids and solids may differentiation of these disorders may be difficult owing to the
also be assessed. similarity of clinical signs and survey radiographic findings. In
survey radiographs, there may be a variably sized mass-like focus
of increased radiopacity and width near the caudal mediastinum
I Esophageal perforation and that appearscontinuous with the diaphragm. The cranial thoracic
esophagusmay be partly or completely dilated and gas-filled cranial
I esophageal fistulas to the mass.Sizeand visibility of the fundic gasbubble are variable,
Cervical esophagealperforationsresult in leakageof luminal con- but it is often small or not seenat all with herniation and intussus-
tents into the loose periesophagealfascia,leading to chemical irrita- ception. A barium contrast study is required to locate the gastro-
tion with sepsisand secondaryinflammation. Gradually,an abscess esophageal junction and the gastricfundus.
The Esophagus 345
Gastroesophageal reflux the caudal esophagusas barium gradually transits the stomach.
Fluoroscopy and nuclear scintigraphy are more accurate means of
Reflux esophagitisoccurs when acidic gastric contents remain
diagnosinggastroesophageal reflux.
within the esophageallumen for a prolonged period, resulting in
mural inflammation. Reflux may be a normal consequenceof Hiatal hernias
swallowing, but the retrograde flow of gastric acid should be
rapidly clearedby the esophagusby either primary or secondary With hiatal herniation, the caudalesophagealsphincter,recognized
peristaltic contractions. Diagnosis of clinically significant gastro- as a focal narrowing of the barium contrast column, is cranially
esophagealreflux may be difficult using survey radiography. Survey displaced,with no identifiableabdominal esophagealsegment.
radiographs may be negative or may show an esophagealopacity Variable amounts of rugae-lined gastric fundus are seen as an
that varies from subtle in the caudal mediastinum, to visible owing extension of the caudal esophagusin the thoracic cavity (Fig.
to luminal fluid retention. to dilated and air- or fluid-filled when 27-35). A periesophagealhernia causespartial obstruction and
the esophagitisis extensive(seeFig. 27-24). Most often, the survey displacementof the terminal esophaguslaterally away from the
findings are negative or minimal, and they may be overlooked. herniatedgastricfundus. On the ventrodorsalor dorsoventralcon-
Contrast examination with static imaging may also be negative. If trast radiograph,the gastricrugaeare seenlateralto the esophagus
esophagitisis severe,retention of contrastmedium with esophageal within the caudalmediastinum.
mucosalirregularity or ulceration,as well as thickening or diffuse,
nonuniform dilation may be seen (Fig. 27-34). Infiltration by
Gastroesophageal intussusception
inflammatory or granulation tissue usually distorts the mucosal Gastroesophageal intussusceptionis a rare condition of young
surface,obliterating the longitudinal or oblique folds. Most often, puppies in which the stomach invaginatesinto the caudal esopha-
during a gastrointestinalcontrast examination,intermittent reflux geal lumen and may be accompaniedby other abdominal viscera
is seenas recurrenceof the appearanceof contrast medium within (spleen,duodenum, pancreas,and omentum). Pre-existingcongen-
t iilllllt',
illlll.iliil
ital or idiopathic megaesophagusmay be present. With extensive In summary, esophagealdiseasemay be characterizedby focal
hernias,a large soft-tissueor heterogeneousmass may develop in or diffuse involvement. Diffuse diseaseusually results in megaeso-
the caudal mediastinum (Fig. 27-36). A gas-filled,dilated esopha- phaguscharacterizedby generalizeddysfunction,but megaesopha-
gus may or may not abut the mass.Rugal folds are often recognized gus may also occur with obstruction of the terminal esophagus
covering the mass; a stomach silhouette may be absent from the from a few focal causes.Alternatively, focal or segmental disease
cranial abdomen, or when gas-distended,the stomach lumen may may havenumerouscauses.The common locationsof various focal
present with a defined communication with the caudal mediastinal esophageallesions are listed in Table 27-3. The absenceof abnor-
mass.Contrast examinationin thesepatientsconfirms obstruction mal esophagealradiographic findings does not preclude the pres-
of the caudal esophagus by the mass with failure of contrast ence of esophagealdisease;such findings are often encountered
medium to fill the abdominal gastric lumen. Occasionally,gastro- with acute esophagealdisease.In addition, the presenceof indirect
esophagealintussusception may be recognized as an intermittent signsof esophagealdiseaseshould be anticipated.Focal or general-
problem, and only minor invagination occurs (Fig. 27-37). ized esophagealdilation may be less apparent when the lumen is
1 1 1 |.i i ,r l
U l l r i i i r .r l :l i
i:iiltlli:1,r'l
&
fluid-filled, thereby creating a positive silhouette sign with the A. Foreign body.
mediastinum. The enlarged lumen, however, affectsadjacent visible B. Dystrophic mineralization.
structures. The weight of the dilated esophagusmay causeventral C. Both a and b
and right lateral tracheal displacement in the cervical and cranial
thoracic regions. The cranial and caudal mediastinum widens 2. Tr:ue or False.Accumulation of intraluminal gas always indi-
around the dilated esophagus.Pulmonary interstitial or alveolar catesesophagealdisease.
infiltrates occur secondaryto aspiration.Pleuraleffusion,pneumo-
thorax, or pneumomediastinum,and lobar consolidationare occa-
3. Causesfor the presenceof gas surrounding, and therefore
sionally present secondary to esophagealdisease.
making visible, the cervical esophagusinclude:
A. Pneumomediastinum.
References B. Deep fascialgas.
C. Esophagealperforation.
1. O'Brien TR: Esophagus.In O'Brien TR (ed): RadiographicDiagnosisofAbdominal
D. A11of the above
Disorders in the Dog and Cat: Radiographic Interpretation, Clinical Signs, Pathophysi-
ology. Philadelphia,WB Saunders,1978,p l4l.
2. Hall JA, Watrous Bl: Effect of pharmaceuticals on radiographic appearance of 4, This surveyradiographicexaminationis of a 10-year-oldneut-
selected examinations of the abdomen and thorax. Vet Clin North Am Small Anim ered male domestic shorthaired cat (Fig. 27-38). he was presented
Pract 30:349,2000. for sudden onset of dyspnea.What radiographicsigns are present?
3. Kealy JK: The abdomen. In Diagnostic Radiology of the Dog and Cat, 2nd ed. What are the radiographicconclusions?What may causethe com-
Philadelphia,WB Saunders,1987,p 41. bined radiographicfindings?
4. Brawner WR, Bartels JE: Contrast radiography of the digestive tract: Indications,
techniques and complications. Vet Clin North Am Small Anirn Pract l3:599' 1983.
5. Dilation of the esophagusmay cause:
5. Watrous BJ; Clinical presentation and diagnosis of dysphagia. Vet Clin North Am A. leftward and ventral deviation of the intrathoracic trachea.
Small Anim Pract 13:437,1983. B. leftward and dorsal deviation of the intrathoracic trachea.
6. Watrous BJ: Esophagealdisease.In Ettinger Sf (ed): Textbook ofVeterinary Internal C. rightward and ventral deviation of the intrathoracic tra-
Medicine: Diseasesofthe Dog and Cat. Philadelphia,WB Saunders,1983,p 1191. cnea.
7. JonesBD, JergensAE, Guilford WG; Diseaseof the esophagus.In Ettinger SJ (ed): D. rightward and dorsal deviation of the intrathoracictrachea.
Textbook of Veterinary lnternal Medicine: Diseases of the Dog and Cat, 3rd ed
Philadelphia,WB Saunders,1989
6. Focaldilation of the esophagusjust cranial to the heart baseis
often seenwith vascularring anomalies.Name another esophageal
ru Ouestions diseasethat may appearsimilar to vascularring anomalies.
A. nonradiopaqueforeign body lodged at the heart base
l. Increasedradiopacity associatedwith the esophagusmay be B. esophagealstricture locatedat the heart base
due to: C. esophagitis
rfiiiisli:
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ilil
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.ibrllllii;ur9ll
r:,r'tltiill
Figure 27-38
The ThoracicWall 349
\t:L)
Figure 27-39
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' tlirutl
8. A megaesophagusis usually well visualized when filled with 10. \Ahy should survey radiographs of the entire esophagusbe
positive-contrastmedium. In the dorsoventralor ventrodorsalra- obtained before an esophagramis taken?
diograph, the cranial thoracic esophagusis indented by what two
structures? Answers begin on page 727
CHA P T E R
28
The Thoracic Wall
. CharlesR. Root r Robert J. Bahr
The thoracic wall consists of skin, fat, subcutaneousmuscles, ribs Normal radiographic
(or the sternum ventrally), intercostalmuscles,the parietal pleura, Ir appearance
and the associated vasculatureand nerves.Thoracic wall abnormal-
ities are often overiooked when radiographs of the thorax are Other than increasedopacity causedby its osseouscomponents
interpreted. Findings involving the thoracic wall are often critical (i.e.,ribs, sternebrae),the appearanceof the thoracic wall is homo-
in making the correct diagnosis, or in deciding what the next step geneous.In ventrodorsal (VD) or dorsoventral (DV) views, ribs
in patient evaluationshould be. curve in a caudolateral direction from their respectivevertebrae to
35O NE CKA ND T H OR AX -C OMP AN IO AN
N IM A LS
their most lateral extent,then continue caudomedially(Fig. 28-1). or DV radiographs(Fig. 2B-4). Costochondralmineralizationmay
In lateral views, ribs course ventrally or caudoventrally from their also be confused with more aggressiveprocessessuch as infection
vertebralorigins.At the costochondraljunction, the costalcartilage, or tumors, especiallywhen the calcification is extensive.
which may be mineralized, typically changesdirection and courses Pedunculatedthoracic wall soft-tissuenodules, such as nipples,
cranioventrally (Fig. 28-2). papillomas,or ticks, produce a distinct, well-marginatedopacity in
Mineralization of costal cartilagesis common (see Fig. 2B-2); the radiograph (Fig. 28-5). This opacity is very distinct because
this mineralization may occur normally in young dogs. However, of the sharp contrast provided by the surrounding air and the
nearly all old dogs have mineralization of costal cartilages.Move- perpendicularrelationshipbetweenthe nodule and the x-ray beam.
ment at the costochondralor costosternaljunction, which has been When a suspectednodule is seen in VD or DV radiographsin a
stiffened by costal cartilage mineralization, usually results in an location consistentwith a nipple, careful examination of the patient
increasedsize of the junction with exuberant adjacent calcification usually clarifies the significance of the finding. If necessary,posi-
(Fig. 28-3). The opacities createdby normal or enlarged costo- tive-contrastmedium can be placed on the nipple and the radio-
chondral mineralization may be confused with lung nodules in VD graph repeated(Fig. 28-6).
"l,ll,l.rr]llrl
)
l
iiirll:llli
Figure 28-9. VentrodorsaliA) and lateral18)thoracic radiographsof a dog that had been
attacked by another dog. There is subcutaneousgas (white arrows) along the right lateral
thoraci cw al l due to ski n acerati ons.
There i s al so a severel ydi spl acedfractureof the ri ght
eighth rib (open arrows)and adlacentpeural effusion (blackarrows).icourtesy of the Santa
CruzVeterlnaryHospital,SantaCruz.CA.)
3 54 NE CKA ND T H OR AX -C OMP AN IO AN
N IM A LS
Figure 28-1O. Dorsoventral/A) and lateral/B/ thoracicradiographsof a dog with diffuse subcutaneousand intrafascialemphysemasecondaryto a dogfight.lt
wo u l d b e u n u s u aflo r t h is d e g r e eo f su b cu ta n e o uesm p h yse m at o be due to a ski n l acerati on,Moretypi calw oul d be pneumomedi asti num w i th ai r l eak i ngi ntothe
necka n d s u b c u t i so r , a s in th is d o g , lu n g la ce r a tiowith
n p n e u mothorax of pl euralgas throughthe thoraci cw al l defecti nto the su bc uti sThe
and di ssecti on , ri ght
8t h t o 1 O t hr i b s a r e f r a ctu r e dT. h e fr a ctu r e sh a ve r e su lte din severew i deni ngof the ri ght gth i ntercostal pneumothorax
space.B i l ateral i s pres ent.Gas i s al s o
v isi b l ei n t h e f a s c i apl l an e so f th e n e ck.
Fig u r e 2 S - 1 1 , A a n dB,He a lin g fr a ctu r e so ftwo a d ja ce n tri bsontheri ghtsi de(arrow s).Thi sdoghadbeenhi tbyacarseveral w eeksbeforeth es eradi ographs
were made. Noticethe periostealreactionand centralradiolucency on the most cranialrib owing to changesassociatedwith earlyfracturehealingand lysisfrom
m o v e m e n ta t t h e f r a c tu r esite . Ra d io g r a p h ica lly, it is im p o ssibl eto determi nethat the most crani alri b l esi oni s not due to neopl asi a
or i nfecti on.The adj ac ent
, h i c h a p p e a r sm o r e b e n ig n ,a n d th e h isto r yof traumami ght l eadone to concl udethat both l esi onsare l i kel ytraumati c.R e-radi ographithi
hea l i n gf r a c t u r ew ngs
pati e n ti n 2 t o 3 w e e k swo u ld b e a d visa b le to m a kesu r eth e m ost crani al ri b l esi onl s not progressi ng.
The ThoracicWall 355
Figurc 28-12. A and B, Radiographsof a dog with a heaiediraclure (arrows)of the first right rib. lts union is complete,and there is a smooth periosteal
r e a c t i o nb r i d g i n gt h e fr a ctu r esite .
:|tii
::::::.
a d j a c e ntto t h e f i f t h r ib o n th e le ft.No teth e sm o o th lym a r g in ated, broadl ybasedi ndentati on
o f t h e l u n g .C o s t a li n fe ctio no r n e o p la sia a r e o th e rle sio n sth at may producean extrapl eural
l:::lllrii9:li
si g n .l f t h i s o p a c i t yw e r e o f p u lm o n a r yo r ig in ,it wo u ld fo r m e i thera ri ghtor an acuteangl e
w i t h t h e t h o r a c i cw a ll r a th e rth a n h a vin ga ta p e r in gju n ctio n . i!lAll
356 NE CKA ND T H OR AX -C OMP AN IO A
NN IMA L S
uu:.i
.-'..
o
: 'l
l
l
Figure 28-14. Dorsoventral/A/ and left laleral(B)thoracicradiographsof a dog with a mass of the right eighth rib (arrows).The diaphragmis displaced,and
t herei s b o t h e x t e r n aa n d in te r n apl r o tr u sio n o f th e m a ss( a r r o ws).The broadl ybasedi ndentati on j oi nsthe thorac i cw al l
i n the regi onw here the i nternalprotrusi on
in, 4 is c h a r a c t e r i s toi cf e x tr a p le u r alel sio n s.T h e la cko f p le u r ael ffu si onassoci ated
w i th a ri b tumor of thi s si zei s unusual .
i:ltii:.ir!
.,,iil!ll'i.
lr,,.,lial
t1$uu
Figure 28-15. Ventrodorsal radiographof a dog with a largemass in the left caudallung lobe.The
m a sscontactsthe thoraci cw al l . N ote that the j uncti onof the massw i th the thoraci cw al l produc es
a n a c ute angl e;thi s si gn i s evi dencethat the mass i s pul monaryand not ori gi na ti ng from the
th o r a ci cw al l .
The ThoracicWall 357
ihe mass slowly advancesmedially. The extrapleural sign is best The ribs are one of the more common sites in the skeleton to
seenwhen the primary beam strikes the lesion tangentially. Visual- which solid tumors, especiallyepithelial tumors such as mammary
ization of the extrapleural sign may require supplemental oblique and prostatic adenocarcinomas, metastasize.Metastaticrib lesions
projections. are aggressiveand are typically lytic, but productive lesions may
The extrapleural sign can be used to discriminate between lung also be present. The subtle lytic nature of rib metastasesmakes
and thoracic wall as the origin of a peripheral intrathoracic mass. their radiographic detection difficult, and they are often over-
If a peripheral lung mass contactsthe thoracic wall, the junction Iooked. Rib metastasessecondaryto a solid tumor usually arise
between the mass and the thoracic wall forms an angle equal to or hematogenously,but local extension of a tumor into an adjacent
less than 90 degrees (Fig. 28-15). On the other hand, if the rib, as from a mediastinaltumor, may alsobe observed(Fig. 28-19;
peripheral opacity is due to a thoracic wall mass extendingmedi- seealsoFig. 28-18).
ally, the junction of the opacity and the thoracic wall forms an
angle greater than 90 degrees,that is, the concavejunction charac-
teristic of the extrapleuralsign (seeFig. 2B-13).
Rib infection is very uncommon among dogs and cats. Bacterial I Sternal tumors and infection
infection following trauma or surgery is also very rare. Systemic
mycosesmay result in rib lesions as a result of hematogenous Primary sternal tumors are uncommon. Mesenchymaltumors of
spread(Fig.28-16). Mycotic rib osteomyelitisresultsin an aggres- the sternebraedo occur and they result in aggressivelesions of the
sive rib lesion, which may be primarily lytic, primarily productive, sternebrae.Some malignancies within the peritoneal cavity, such as
or mixed. Biopsy is necessaryto differentiatethe lesion from neo- pancreatic adenocarcinoma, may extend along lymphatic channels
plasia. into the ventral mediastinum and eventually invade the sternum.
Primary and secondaryrib tumors are more common than rib Aggressivemammary neoplasmsmay also result in sternal invasion.
infections. Most primary rib tumors are mesenchymaltumors In thesepatients,there is usually voluminous pleural effusion and
(e.g.,chondrosarcoma,osteosarcoma). Primary rib tumors enlarge a soft-tissue mass effect adjacent to the sternum (see Fig. 28-20).
primarily intrathoracically; as a result, they are often very advanced Primary pleural tumors, for example,mesotheliomas,are rare and
at the time of diagnosis.Extensivepleural effusion often accompan- typically do not result in associatedbone changesin the ribs
ies primary rib tumors; when present,this effusion makes radio- or sternum.5
graphic detection and evaluation of the rib lesion difficult (Fig. Sternal infection may result from external trauma, such as a bite
28-17). Rib tumors may be primarily lytic or primarily sclerotic, wound, or it may occur hematogenously.Hematogenousinfection
or they may contain a mixture of lysis and sclerosis.Lytic changes may lodge in the intersternal space,resulting in signs similar to
are typically more common than scleroticchanges(Fig. 28-lB). those of discospondylitiswith lysis of sternebralend plates,widen-
As cancer patients are being treated more aggressiveiy,metastasis ing of the intersternal space,and aggressivelytic or productive
of solid tumors to the skeleton is being diagnosed more frequently. bone changeswithin the sternebrae.
Figure 28-16, Dorsoventral/A/and right lated (B)thoracicradiographs of a dog wlth two rib lesions(arrows).Eachlesionhas resultedin expansionof the rib,
a n d t h e r e i s a c t i v ep e r io ste arle a ctio na n d co r ticalysis
l fu lfill i ngthe cri teri aof an aggressi vel esi on.The appearance
of the l esi onsi s too aggr es s i vto
e be due to
T h u s,tu m o ror i nfecti onare more l i kel y.Thi sdog hadsystemi ccocci di oi domycosi
h e a l i n gf r a c t u r e sa, n dth e r ib sa r e n o t a d ja ce n t. s, theseri b es i onsw ere tl .e
and
r e s u l to f h e m a t o g e n o usp s r e a dT . h e m e d ia le xte n sio no f th e ri b l esi onshas createdtw o extrapeurasi gns.(C ourtesy of D epartmentof V ete ri nary Medc ne a.c
S u r g e r yC, o l l e g eo f Ve te r in a rM y e d icin eUn , ive r sity o f M isso uriC , o umbi a,MO.)
358 NE CKA ND T H OR AX -C OMP AN IOA
NN IMA L S
Figure 28-17, Ventrodorsalradiographof a dog with a rib tumor. Thereis a largeamountof fluid in
the pleuralspace.Lookingclosely,an aggressivelesionat the end of one rib can be seen /anowl.This
is a clu ethat the pl euraleffusi oni s secondary
to a ri btumor,P l euraleffusi oncan makei de nti fi c ati on
of
ri b l esi onsdi ffi cul t.
u n d e r lyi ng
il
ji
f
-i
Figure 28-18. Ventrodorsal1Aland left lateral18)thoracicradiographs of a dog with destruction(arrows)ofIhe left first rib due to a tumor.Thereis displacement
y a cr a n iam
se co n d a r to
of t he t r a c h e at o t h e r i g h ta n d ve n tr a lly, mass.H i stopathol ogidicagnosi w
l e di asti nal s as not obtai ned.The appearance of the ri b l es i oni s
als oc o n s i s t e nwt i t h h e m a to g e n o um s e ta sta sis, massmakesl ocali nvasi onmore l i kel y.(C ourtesy
b u t th e m e d ia stinal of P arkw oodP et C l i ni c,Woodl a ndH i l l s ,C A .)
fi
rl
CHA P TE R
29
The Diaphragm
r Richard D. Park
The diaphragm is the muscuiocutaneous partition between the num and pleural space.Lymph flow from the thorax to the abdo-
thoracic and abdominal cavities. Embryologically, the diaphragm men does not occur.2
is formed by the septum transversum ventrally and by the mesen- The diaphragm consists of a tendinous center and three thin
tery of the foregut and two pleuroperitoneal folds dorsally. peripheral muscles: the pars lumbalis, the pars costalis, and the
The diaphragm provides approximately 50o/oof the mechanical pars sternalis.The pars lumbalis consistsofthe right and left crura,
respiratory force required for inspiration.t The diaphragm also acts which attach to the cranial ventral border of L4 and the body of
as a mechanical partition between the thorax and the abdomen. L3. This attachment results in these vertebrae occasionally having
Lymph vesselsfrom the abdomen penetrate the diaphragm and a concaveindistinct ventral margin that may be mistaken for bone
drain into the thoracic lyrnph nodes and vessels.Thus, inflamma- lysis. The pars costalis attachesin an oblique direction to the 13th
torv or neoplastic abdominal diseasemav spread to the mediasti- through Bth ribs, and the pars sternalis attaches to the xiphoid
360 NE CKA ND T H O R AX -C OMP AN IOAN
N IN /| A LS
or not visualized radiographically if anything of the same opacity, tory cycle, minor changes are difficult to diagnose and in most
such as organs of soft-tissueopacity and fluid, is adjacentto the instancesare not clinically significant. Severepositional changes
surface.Changesin the diaphragm shapeoccur most frequentlyon may be significant and indicative of thoracic or abdominal disease.
the cupula; they are often normal and are causedby contact with Cranial diaphragmatic displacement is usually associatedwith ab-
the heart (Fig. 29-7) or by the position of the animal during dominal disease(see Table 29-1) or generalizeddiaphragmatic
radiographicexamination.The shapeand position may alsoappear paralysis,which should be confirmed with fluoroscopic observa-
altered in some large-breeddogs, with the body appearingmore tion. Caudal diaphragmaticdisplacementis usually associatedwith
convex and extending to a more cranial position in the thorax. severerespiratorydisease(Fig. 29-8). The caudallypositioned dia-
This may be the result of a flaccid tendinous membrane, or it may phragm is an attempt by the animal to increase the level of
be associatedwith a peritoneopleuralhernia, which often produces systemicPOz,which may be low becauseof ventilation or perfusion
no clinical signs. deficienciesin the lungs. Bilateraltension pneumothorax may also
Thoracic masses,or lung disease,adjacent to the diaphragm, cause a caudally displaced diaphragm from increasedpleurai pres-
hiatai and small traumatic diaphragmatichernias,massesoriginat- sure. In most instances of pneumothorax, however, the caudally
ing from the diaphragm, and chronic pleural inflammatory reac- displaceddiaphragm is probably an attempt to increaserespiratory
tions are the most frequentcausesof shapechanges.An asymmetri- ventilation.
cal diaphragmatic shape may occur with unilateral tension Although many of the radiographicsigns of diaphragmaticdis-
pneumothorax or hemiparalysis.Suspectedhemiparalysisshould ease are not specific, they should be observed and their cause
be confirmed by observing diaphragmatic movement during fluo- should be determined. In some instances,additional radiographic
roscopy. studies,such as positional views using a horizontally directedx-ray
Positional changesconsist of cranial and caudal displacement. beam and contrast medium studies, may be indicated to determine
Becausethe position of the diaphragm changesduring the respira- the causeof the radiographicsigns.
rrrlg
iiil!l
tlllll
iou.
Figure 29-8. Lateralviews of the diaphragmaticregion of a norma cat on expiration(A) and on extreme inspiration/B/. The entire diaphragmis displaced
y i t h i n s p i r a t i oannd h a s a fla tte rco n to u rin co m p a r iso with
c auda l l w n the expi ratory
radi ograph.
Figure 29-9. Confirmationof a traumaticdiaphragmatic herniawith a bariumgastrogram.A, Ventrodorsalview of the thorax of a cat. There is increasedsoft-
l o r a xwith o b lite r a tloonf th e e ft di aphragmatioutj
t is s ueo p a c i t yi n t h e l e f t ca u d a th c i ne.P l eurafl ui d di spl aces
the l eft caudall ung l obe aw ay from the thorac i c
wall (arows). The heart is displacedtoward the right thoracicwall, which may be accentuatedby the slightly oblique position of the animal. B, Following
admin i s t r a t i oonf b a r i u ms ulfa teth , e sto m a chis e a silyid e n tifie din the l eft caudalthorax,thus confi rmi nga l eft-si ded di aphragmatiherni
c a.
The D iaphr agm 365
weak or defective areas.Clinical signs that may be observed with (Fig. 29-9). Radiographs made with a horizontal x-ray beam help
diaphragmatic hernias include dyspnea, pain, vomiting, regurgita- identi$' solid organ structures (Fig. 29-10). Thoracocentesisand
tion, muffled heart sounds, and a weak femoral pu1se.lu Some pleural fluid removal followed by another radiographic examinarion
diaphragmatic hernias may not causeclinical signs and are detected provide better radiographic visualization of thoracic structures.Posi-
incidentally. tive-contrast peritoneography can be performed by injecting 2 mL/
Radiology plays an important role in confirming a diagnosis of kg of body weight of an iodinated contrast medium into the perito-
diaphragmatic hernia and may provide information about location, neal cavity. The animal should then be positioned such that gravity
extent, contents, and secondary complications associatedwith the facilitates contrast medium accumulation around the liver and the
hernia.t-tt If a diagnosiscannot be confirmed from survey radio- diaphragm. Contrast medium within the thorax and incomplete
graphs (Table 29-2), additional imaging procedures may be per- visualization of the abdominal surface of the diaphraqm are the
formed to add further diagnostic information. The radiographic most consistent positive-contrast peritoneographic'signi of a dia-
procedures consist of administration of barium suifate per os, phragmatic hernia (Fig. 29-171.,L13Any or all of these procedures
positional radiographic views, removal of pleural fluid and re- may be used, but the most simple proceduresshould be used first.
radiographing the thorax, and peritoneography. Peritoneography should be used after other diagnostic procedures
To ascertain the position of the stomach and proximal small have failed to provide the neededinformation.
bowel, a small amount (20 to 40 mL) of barium sulfate (30% w/v) Other procedures,including positive-contrast pleurography, por-
can be given per os and radiographs obtained after 15 to 20 minutes tography, cholecystography, angiocardiography, angiography, and
Figure 29-1O. Ventrodorsal(A), lateral/8/, and dorsal recumbent,horizontal-beam laleral (C) views of a dog with a traumaticdiaphragmatichernia.,4, An
increased soft-tissue o p a cityin th e ca u d a rl ig h tth o r a xwr th lossof the thoraci cdi aphragmatisurface
c outl i neoverthe cupul ai s show n. B , Th e hearti s di s pl ac ed
dorsally,and a soft-tissueopacityis seen betweenthe heartand the sternum (arrows). The thoracicdiaphragmatic outlineis indistinctover the cupua. C The soft-
ti s s u eo p a c i t y( a r r o ws)r e m a in sin th e sa m e p o sitio nwh , lch indi cates that the opaci tyi s a sol i dstructureand not free pl eurafl ui d.Thl sfi ndi nqi s c ompati bl e
w l tl "
a d i a p h r a g m a thi ce r nia .
366 NE CKA ND T H OR AX -C OMP AN IOA
NN IMA LS
Figure 29-12. Laleral (A) and vsntrodorsa 1Blviews of the thorax of a dog with a traumaticdiaphragmatichernia.Radiographic signs compatiblewith a
diaphragmatic hernia n A are gas-and ingestajilledbowe) (openarrow)withinthe thorax;cranialdrsplacement of abdominalstructures(thatis, small b,owel[small
solid arrowsl),and a craniallydisplaceddiaphragmaticsegment (largesolid arrows).Badiographicsigns in I are the heart displacedaway from the herniated
v i s c e r ag; a s - f ie d s ma llb o we l with n th e th o r a x( a r r o ws)crani
, y di spl acedabdomi nalstructures(thati s, smal lbow el ,stomach,and i ver);and l os s of the l eft
al
d i a o h r a o m a tsi cu r f a ceo u tlin e .
;rrili|]] ,.l
:liiru.r
llilllrtlltlllll,rr
,r ],
rliilllrrillilllir:'
rriltlll'tilril
llr ri
iliirllr''ii1i,r,r:r.
ii! I ,l
trr,,.iiltlll,.
,-ti
r(i:iis:
368 NE CKA ND TH OR AX -C OMP AN IOAN
N IM ALS
occur in an animal of any age after abdominal trauma or transitory mesothelialremnant betweenthe heart and diaphragm is a consis-
increase in intra-abdominal pressure. Defects in diaphragmatic tent radiographic sign of peritoneopericardialhernia in cats (Fig.
development may be present and never result in a hernia. 29-147.'o Additional radiographic studies that may be performed
to confirm a diagnosis include administration of barium sulfate
Peritoneopericardial diaphragmatic hernias per os, nonselective angiography,tt and peritoneography. Barium
With a peritoneopericardialdiaphragmatichernia, abdominal vis- sulfate may be used to demonstrategastrointestinalstructures
cera herniates into the pericardial sac through a congenital hiatus within the pericardial sac or cranial ventral displacement of ab-
formed between the tendinous portion of the diaphragm and the dominal structures(Fig. 29-15).
pericardial sac. This has been reported to occur in litter mates,22 Peritoneographywith negative- or positive-contrast medium may
and it has been suggestedthat this trait is carried on a simple be used to evaluate for the presence of a peritoneopericardial
autosomal recessivegene in cats, with a 1:500 to 1:1500 rate of hernia. For peritoneography, the animal is positioned to allow
incidence.'z3The hernia may have been present from birth or it gravitation of contrast medium from the peritoneum into the
may be acquired.Mild increasesin intra-abdominal pressuremay pericardial sac, or to outline the abdominal surface of the dia-
causeabdominal organs to herniate through a congenital hiatus. phragm. This maneuver may not be successfulbecauseof the
Peritoneopericardial hernias may produce clinical signs, or they inability of contrast medium to flow through a small or obstructed
may be an incidental radiographic finding. These hernias may be hiatus. Nevertheless,a defect in the outline ofthe peritoneal surface
present in old or young animals.s'2428The liver is most frequently of the diaphragmmay be outlined.',
herniated; the stomach, omentum, and small bowel have a less Ultrasonography has also been used to successfully diagnose
frequent occurrence of herniation.'ze peritoneopericardialdiaphragmatichernias.r5t8
Radiographicsigns associatedwith peritoneopericardialhernias
arelisted in Table29-3. Herniatedabdominal organsin the pericar- Hiatal hernias
dial sac are usually caudal, or caudal and lateral, to the heart. Gas- Hiatal hernias are produced when a portion of stomachentersthe
or ingesta-filled hollow visceral organs are not difficult to identify thorax through the esophagealhiatus. Thesehernias are reported to
within the pericardial sac. Radiographically, gas within the bowel occur through a congenitally or traumatically enlarged esophageal
is in abrupt contrast to the adjacentstructuresof soft-tissueopac- hiatus; they also may result from contraction of the longitudinal
ity. Solid parenchymal organs, unless surrounded by omentum, are esophagealmuscle.3t' 33
difficult to distinguish as separate structures within the pericar- There are two recognized types of hiatal hernias.a:sliding and
dium. When abdominal organs are herniated into the pericardial paraesophageal. The gastroesophageal sphincter and a portion of
sac, cranial and ventral organ displacementwithin the abdomen the stomach, usually the cardia, are herniated into the thorax with
may be seen,but this displacementis usually not as pronounced sliding hiatal hernias.35
Sliding hiatal herniasare usually congenital
as that noted with traumatic diaphragmatichernias. and seen in younger animals.3nThey are often associatedwith
A large, round cardiac silhouette and a cardiac silhouettewith esophagitisfrom gastroesophageal reflux. As the name implies, the
an abnormal convex projection on the caudal border are signs caudal esophagusand the cardia slide intermittently from the
consistentwith peritoneopericardialdiaphragmatichernias. These abdomen into the thorax. Becausethe hernia is dynamic, it may
two signs are dependent on the amount of abdominal viscera not be seen on any one radiograph; fluoroscopic examination is
within the pericardial sac. Large amounts of viscera produce a often necessaryto make a diagnosis.Patientswith nonsliding hiatal
large, round cardiac silhouette,whereassmaller amounts, such as hernias have been reported, with the gastroesophagealsphincter
a portion of the liver or stomach, may produce an abnormal and the gastric cardia displacedthrough the esophagealhiatus and
convex caudal cardiac border. A large, round silhouette must be fixed within the thorax.36Only a few sliding hiatal hernias have
differentiated from pericardial effusion, generalizedheart enlarge- been reportedin animals.3T-aa The low incidencemay be a reflection
ment, or both. An abnormally convex caudal cardiac border must of the subtle clinical signs and intermittent manifestations on
be differentiatedfrom neoplasia,pleural granulomas,or localized survey radiographs.
oleural fluid. A paraesophageai hiatal hernia is produced when the cardia or
An indistinguishable outline to the ventral diaphragmatic surface cardia and fundus of the stomach herniate through, or alongside
and the caudal ventral cardiac silhouette is produced by the com- of, the esophagealhiatus and become positioned adjacentto the
munication between the two structures. This finding must be dif-
ferentiated from normal contact between the heart and diaphragm,
pleural fluid, localizedpleuritis, and pleural granulomas.
An apparently confluent silhouette between the heart and dia-
phragm may appear as a wide caudal mediastinum; depending
on the size of the communication, it may or may not be seen
radiographically. This confluent silhouette must also be differenti-
ated from other pathologic conditions that have been listed. On
the lateral view identification of the dorsal peritoneopericardial
ll,llll-.,i1!rll
": ll$):,,.:
Figure 29-15. Lateral(A)andventrodorsal/B/ views of the thoraxof a dog wrth a peritoneopericardial diaphragmatc hernia.A, The pyloricantrumand proxrmal
d u o d e n u ma r e h e r nia te din to th e ca u d a a l sp e cto f th e p e r ic ardi al
sac and are fi l l edw l th bari um(arrow s).
The stomachi s angl edi n an abnormalc rani aldi rec ti on,
a n d t h e r ei s a c o n v exso ft- tissu e p r o tr u sio no n th e ca u d a h
l eartborder.B , The bari umj i l l edpyl ori cantrumand proxi malduodenum(arrow s)arew i thi nthe c auoar
a s p e c to f t h e p e r i c ar d iasa
l c.T h e p ylo r ica n tr u ma n d fu n d u sof the stomachare di spl aced crana l y.
esophagus.They are usually static and do not slide between the an abnormal shape to the cardia and fundus remaining in the
thorax and abdomen, and the gastroesophageal sphincter is in a abdomen. The caudal esophagusmay or may not be distended,
normal position.3r3s'45The herniated stomach may causeesopha- and a soft-tissueopacity (mass) may be seen adjacentto the left
geal obstruction from externalpressureon the caudal esophagus. diaphragmatic crus (Fig. 29-16). The size and visibility of this
Hiatal herniashavebeen reported in both the dog and the cat.36, massdependon the amount of stomachthat has actuallyherniated
3e'4t-44They have been reported associatedwith other esophageal into the thorax. The soft-tissuemassassociatedwith a hiatal hernia
conditions (such as) in Chinese Shar pei dogs.aa Clinical signs must be differentiatedfrom a pulmonary mass or a massoriginat-
reported with hiatal herniasinclude vomiting, regurgitation,exces- ing from the diaphragm. Diaphragmatic neoplasticmasseshave
sivesalivation,dysphagia,and dyspnea.3o' 43'44Hiatal hernia may be been reported,but are rare.a6
suspectedfrom the clinical signsand survey radiographicfindings, A dilated caudalesophagusis usuallybest detectedand evaluated
but it must be confirmed with an esophagram. with an esophagram.An esophagramis alsohelpful for differentiat-
Radiographicsigns of a sliding hiatal hernia are listed in Table ing the type of hiatal hernia. The caudal esophagealsphincter and
29-4. The most consistentsurvey radiographic sign is stomach a portion of the cardia are seen cranial to the diaphragm with a
displacement. The cardia appears to be stretched toward the dia- sliding hiatal hernia.aTThe caudal esophagealsphincter can be
phragm or may extend into the thorax. This displacementproduces identified as a concentric, smooth, l- to 2-cm narrowing in the
caudal esophagus (Fig. 29-17). Displacement and narrowing of
the caudal esophagus by the cardia and fundus are seen with
paraesophageal hiatal hernias, along with barium opacificationof
Tahle 294. Radiographic signs associated with sliding
hiatal hernias the herniated stomach (Fig. 29-18).
lgu
age."O The scallopedmargin noted best on the lateral view should 18. Hodges RD, Tucker RL, Brace l): Radiographic diagnosis (peritoneopericardial
not be confusedwith the normal scallopingobservedon the ven- diaphragmatic herniation in a dog). Vet Radiol Ultrasound 341246,i-993.
trodorsal view in cats on maximum inspiration (see Fig. 29-6). 19. Carb A: Diaphragmatic hernia in the dog and cat. Vet Clin North Am Small Anim
Muscular hypertrophy produced with feline muscular dystrophy Pract 5:477, 1975.
has also been reported to causemegaesophagus from extraluminal 20. Wilson GP, Newton CD, Burt JK: A review of 116 diaphragmatichernias in dogs
hiatal obstruction. Definitive laboratory tests,such as immunoflu- and cats.J Am Vet Med Assoc 159:1142,1971.
orescenceor immunoblot tests,are necessaryto establishthe diag- 21. Iloudrieau RJ, Muir WW: Pathophysiologyof traumatic diaphragmatichernia in
nosis of muscular dystrophy. dogs. Compend Contin Educ Pract Vet 9:379, 19g7.
23. Saperstein G, Harris S, Leipold HW: Congenital defects in domestic cats. Feline
l. Shim C: Motor disturbanccsofthe diaphragnr.Clin Chest Med l:125, 1980. Pract 6:18, 1976.
2. Rivero O, del Castillo H: Lynphatics of the diaphrargmin the dog. Acta Radiol 24. Iljorck GR, Tigerschiold A: Peritoneopericardial diaphragmatic hernia in a dog.
(Diagn) (Stockh) 171663,1976. I
Small Anim Pract 1l:585, 1970.
3. EvansHE: Miller's Anatomy of the l)og,3rd ed. Philadelphia,WB Saunders,1993, 25. Gourley IM, Popp ]A, Park RD: Myelolipomas of the liver in a domestic cat.
p 304. J
Am Vet Med Assoc 158:2053,1971.
4. GrandagcJ;'lhe radiology ofthe dog'sdiaphragm. I Small Anim Pract 15:1,1974. 26. Rendano Vl Parker RB: Polycystic kidneys and peritoneopericardial diaphrag_
5. Schulnan i: Peritoneopericardialdiaphragmatichernia in a dog. Mod Vet Pract matic lrernia in the cat: A case report. J Small Anim hact 17:47t, 1976.
6 0 :3 0 6 ,1 9 7 9 . 27. Wcrtz J, Tilley LR Moldoff D: Pericardiodiaphragmaric hernia in a dog. Am Vet
I
6. Garson HL, Dodman NH, Baker GJ: Diaphragmatic hernia: Analysis of fifty-six Med Assoc 173:1336, 1978.
casesin dogs and cats.J Small Anim Pract 2l:469, 1980. 28. Evans SM, Biery DN: Congenital peritoneopericardial diaphragnatic hernia in the
7. Farrow CS: Radiographic diagnosis of diaphragmatic hernia. Mod Vet Pract dog and cat. Vet Radiol 21;108,1980.
64:979, 1983. 29.. Neiger R: Peritoneopericardial diaphragmatic hernia in cats. Compend Contin
8. Silvernan S, Ackerman N: Radiographicevaluation of abdominal hernias. Mod Educ Pract Vet l8:461, 1996.
V e t P ra ct 5 8 :7 8 1 ,1 9 7 7 .
30. Berry CR, Koblik PD, Ticer JW: Dorsal peritoneopericardial mesothelial remnant
9. Wilson CP III, HayesHM Jr: Diaphragmatichernia in the dog and cat: A 25 year as an aid to the diagnosis of feline congenital peritoneopericardial diaphragmatic
overview.Senrin Vet Med Surg 1;318,1986. hernia. Vet Radiol 3l:239, 1990.
10. Levine SH: Diaphragnatic hernia. Vet Clin North Am Snall Anim Pract 17:411, 31. Willard MD, Aronson E: Peritoneopericardial diaphragmatic hernia in a cat. An
)
I 987. Vet Med Assoc 178:481,1981.
11. Stokhof AA, Wolvekamp WTC, Hellebrekers Ll, et al: Traumatic diaphragmatic 32. Edwards MH: Selective vagotomy of the canine oesophagus: A model for the
hernia in the dog and cat. Tijdschr Diergeneeskd1I I (suppl t):625, 1986. treatment of hiatal hernia. Thorax 31:185,1976.
12. Rendano VT: Positive contrast peritoneography: An aid in the radiographic diag- 33. TeunissenGHB, Happ RP, Van Toorenburg J, et al: Esophagealhiatal hernia: Case
nosis of diaphragmatic hernia. J Am Vet Radiol Soc 20:67, 1979. report of a dog and a cheetah. Tijdschr Diergeneeskd 103:742, 1978.
13. Stickle RL: Positive-contrast celiography (peritoneography) for the diagnosis of 34. Ellison GW, Lewis DD, Phillips L, et al: Esophagealhiatal hernia in small animals:
diaphragmatichernia in dogs and cats.J An Vet Med Assoc 185:295,1984. Literature review. I Am Anim Hosp Assoc 20;783, 19g4.
14. Willians JLR, Myer CW: Imaging modalities used to confirm diaphragmatic 35. Ellis FH Jr: Controversies regarding the management of hiatus hernia. Am Surg
J
hernia in snall aninals. Compend Small Anim 20:1199,1998. 139:782,1980.
15. Lamb CR, Mason GD, Wallace MK: Ultrasonographic diagnosis of peritoneoperi- 36. Prymak C, Saunders HM, Washabau RJ: Hiatal hernia repair by restoration and
cardial diaphragmatichernia in a Persiancat. Vet Record 125;186,1989. stabilization of normal anatomy. An evaluation in four dogs and one cat. Vet Surg
18:386,1989.
16. Hay WH, Woodfield JA, Moon MA: Clinical, echocardiographic, and radiographic
findings of peritoneopericardial diaphragmatic hernia in two dogs. J Am Vet Med 37. Rogers WA, Donovan EF: Peptic esophagitis in a dog. J Am Vet lvled .\ssoc
A s s o c1 9 5 :1 2 4 51, 9 8 9 . 163:462,1973.
17. Hashimoto A, Kudo T, Sawashima I: Diagnostic ultrasonography of noncardiac 38. Gaskell Cl, Gibbs C, Pearson H: Sliding hiatus hernia with reflex oesophaeitis in
intrathoracic disordersin small animals.ResBull 55;235,1990. two dogs. I Small Anim Pract l5:503, 1974.
374 NE CKA ND T H OR AX -C OMP AN IOAN
N IM ALS
Figure 29-22
rl|rlliill;
rrlrrrr,l
nriirllrll$lliil ill1,rii
i',1,,'iilllil
..,t" 'i,
glllr.liiluu
Figure 29-23
The Diaphragm 37!5
39. Alexander JW, Hoffer RE, MacDonald ,M, et al; Hiatal hernia in the dog: A case
report and review of the literature. J Am Anim Hosp Assoc 11.:793,1975.
40. Iwasaki M, DeMartin Bw' DeAlvarenga J, et al: Congenital hiatal hernia in a dog.
Mod Vet Pract 58tI0I8, 1977.
43. Bright RM, Sackman JE, NeNovo D, Toal C: Hiatal hernia in the dog and cat: A
retrospectivestudy of 16 cases.J Small Anim Pract 3l:244,199O.
45. Miles KG, Pope ER, JergensAE; Paraesophagealhiatal hernia and pyloric obstruc-
tion in a dog. J Am Vet Med Assoc 193:1437,1988.
46. Anderson GM, Miller DA, Miller SW: Peripheral nerve sheath tumor of the
diaphragm with osseousdifferentiation in a one-year-old dog. J Am Anim Hosp Assoc
35:319, 1999.
47. Steiner GM: Gastro-oesophagealreflux, hiatus hernia, and the radiologist with
special referenceto children. Br J Radiol 50:1.64,1977.
49. Leib MS, Blass CE; Gastroesophagealintussusception in the dog: A review of the
literature and a casereport. J Am Anim Hosp Assoc 20:783,1984.
50. Bath GF: Congenital diaphragmatic hiatus in a dog: Case report. i S Afr Vet Assoc
47:55, \976.
51. Nicholson C: Defective diaphragm associated with umbilical hernia. Vet Rec
98:433, 1976.
52. Sawyer SL: Defective diaphragm associatedwith umbilical hernia. Vet Rec 98:490,
r976.
Figure 29-24
53. Swift BJ: Defectivediaphragm associatedwith umbilical hernia. Vet Rec 98:511,
1976.
54. Valentine BA, Dietze CB, Noden AE: Canine congenital diaphragmatic hernia. J
Vet lntern Med 2:109, 1988. 4. Identif ing abdominal structureswithin the thorax is patho-
55. WolffG: Familial congenitaldiaphragmaticdefect:Reviewand conclusions.Hum gnomonic for diagnosinga diaphragmatichernia. What two other
Ge n e t 5 4 :1 ,1 9 8 0 . radiographicsigns are most crediblefor identif,iing diaphragmatic
56. Voges AK, Hill RC, Neuwirth L, Schaer M: True diaphragmatic hernia in a cat. hernias?
Vet Radiol Ultrasound 38:116,1997.
57. GreeneCE, BasingerRR, Whitlield JB: Surgicalmanagementofbilateral diaphrag- 5. You observea mass in the caudal dorsal thorax on a lateral
matic paralysisin a dog. I Am Vet Med Assoc 193:1542,1988. view What is your differential diagnosis?
58. Mainwaring CJ: Post-traumatic contraction of the diaphragm slnchronous with
the heartbeat in a dog. I Small Anim Pract 29:299, 1988.
6. What contrast examination procedure would provide addi-
59. Cooper Bl, Winand NJ, Stedman H, et al: The homologue of the Duchenne locus tional information to help differentiatea hiatal hernia from other
is defectivein X-linked muscular dystrophyof dogs. Nature 334:154,1988.
possiblemassesin this region?
60. Berry CR, Gaschen FR Ackerman H: Radiographic and ultrasonographic features
of hypertrophic feline muscular dystrophy in two cats. Vet Radiol Ultrasound 33:357,
19 9 2 . 7. What radiographicsign is a consistentfinding with muscular
dystrophyin cats?
61. Gaschen FP, SwendrowskeMA: Hypertrophic feline muscular dystrophy. A unique
clinical expression of dystrophin deficiency. Feline Pract 22:23, 1994.
8. What radiographic signs can be identified on the lateral and
ventrodorsalthoracic radiographs (see Figs. 29-22A and B), and
K Ouestions what is your specific or differential diagnosis?
l What two factors relating to physical alignment during the
9. What other diagnosticimaging modalitiesor techniquescould
radiographic examination affect the appearanceof the diaphragm
be usedto help determinea specificdiagnosis(referringto Fig.29-
on a dorsoventralor ventrodorsalradiograph? ?r\
2. On a recumbent lateral radiograph of the thorax, which dia-
phragmatic crus is displaced cranially? 10. What radiographic signs are present on the lateral decubitus
views (Fig. 29-23A and B) and the upper GI study (Fig. 29-2a)
3. The thoracic surface of the diaphragm is easily visualized that would confirm the diagnosis of a traumatic diaphragmatic
radiographically becauseof the adjacent air-filled lungs. What con- hernia in the right caudal thorax?
ditions obliterate or cause the diaphragmatic surface not to be
visible radiographically? Answers begin on page 727,
CHA P T E R
30
The Mediastinum
. Donald E. Thrall
M E D I A S TI N UM
COSTAL PARIETAL PLEU R A
M EDIASTINAL PARIET AL PLEU R A
VrErol body
potielol plero
to body woll)
A PARIET ALP LE U R A
DIAPHRAGM AT IC
ARY PL EUR A-
MEDIASTINUM ADHERENT T O L U N G
PL EURALSPA C E
B DIAST INALPARIETA LP LE U R A
Slsrnum
Figure 30-1. Drawingsof the thoraxin dorsal/A/ and transverse/B/ planes Figure 30-2, Cross-sectionof the canine thorax in a transverseplane.
o f th e p le u r a la
illu s t r a t i ntgh e r e l a t i o n sh ip l ye r s.A, No te th e co nti nui tyof the The mediastinumdividesthe thorax into right and left halves.Note that the
costal,mediastinal, and diaphragmatic partsof the parietalpleura.(Lungshave medi asti num(medi asti nalspacel does not communi catewi th the p/eural
not been includedin .4.)B, Note how the mediastinalpleurais reflectedonto space.(FromThral lD E , LosonskyJM: D yspneai n the cat: l l . R adi ographi c
t he l u n ga s p u l m o n a r py le u r aNo . tea lsoth a tth e p le u r aspl a ceis not conti nuous aspectsof i ntrathoracicauses
c i nvol vi ngthe medi asti num.
Fe l i neP rac t& 47,
wit h t h e m e d i a s t i n u m. H, h e a r t;L , lu n g ;I tr a ch e a . 1978)
376
The Mediastinum 377
sufficient number of x-rays, (2) there is insufficient fat in the In ventrodorsal or dorsoventral thoracic radiosraphs, most of
mediastinum to provide contrast, or (3) they are in contact with the cranial mediastinum is superimposedon the"spine, and the
other mediastinalstructuresof the sameradiopacityand cannot be width of the mediastinum is usually less than approximately two
seenbecauseof the silhouettesign. An example of silhouetting of times the width of the vertebrae(Fig. 30-5). In obesepatients,the
mediastinalstructuresis the appearanceof the cranial mediastinum cranial mediastinum may be widened by fat accumulation, and
in a lateral thoracic radiograph.A distinct opacity is usuallyvisible the resultant opacity can be confused with a mediastinal mass
in the cranial mediastinum ventral to the trachea,but individual (Fig. 30-6).
organs cannot be discerned(Fig. 30-3). This opacity is due to the There are three mediastinal reflections, onlv the first two of
absorption of x-rays by cranial mediastinal organs, that is, the which are frequently identified in normal thoracic radiographs:
left subclavian artery, brachiocephalic trunk, cranial vena cava, (1) the cranioventral mediastinal reflection, (2) the caudoventral
mediastinallymph nodes, and possibly thymus. These organs are mediastinalreflection,and (3) the vena cavalmediastinalreflection,
not seen individually becausethey are in contact with each other, or the plica vena cava.
and typically there is insufficient fat interspersed between these On a ventrodorsal or dorsoventral radiograph, the cranioventral
organs.Thus, the margin of thesevesselsin the cranial mediasti- mediastinal reflection appears as a curving radiopaque line, with
num is obliterated.On the lateral projection, the cranial mediasti- the concavesurface on the patient's right, extending from approxi-
num is more radiopaquejust ventral to the tracheathan just dorsal mately T1 or T2 to the region of the main pulmonary artery (see
to the sternum becauseof the greaterthicknessof the mediastinum Figs. 30-4 and 30-5). This reflection is causedby extensionof the
ventrally (Fig. 30-4; seealso Fig. 30-3). right cranial lobe acrossthe midline, pushing the mediastinum to
the left (seeFig. 30- ). The thicknessofthe cranioventralmediasti- graphs of young animals. The thymus is not as readily seen on
nal reflection is affected by the amount of fat it contains. On the lateral thoracic radiographs (Fig. 30-7). In lateral projections of
lateral view, the cranioventral mediastinal reflection and the margin the thorax made before the thvmus involutes, however, the thvmus
of the right cranial lobe may frequently be identified immediately may silhouettewith and obscurethe cranial margin of the heart.
cranial to the heart (seeFig. 30-3). The cranioventralmediastinal The caudoventral mediastinal reflection is seen only on ventro-
reflection is not visible in every thoracic radiograph. The thymus dorsal or dorsoventral radiographs; it cannot be seen in lateral
lies in the cranioventral mediastinal reflection, and the thymus can projections. It is created by extension of the accessorylobe (a
sometimes be identified in ventrodorsai or dorsoventral radio- lobe of the right lung) across the midline, thereby pushing the
1l::;]r,,.t.'Q
itll:rrlet,...
'l:illiirl.llll
iiliut. ::ir:11..
lrr.i.q
'':it*.
"]];:iilllll
i':iliiiilll
but its presenceas an extension of the mediastinum to the right mediastinal position may be evaluated by noting the position of
should be understood (seeFig. 30-2). visible mediastinal organs, such as the trachea, heart, aorta, and
caudal vena cava, or by analyzing the cranioventral or caudoventral
mediastinalreflections(Fig. 30-10). Improper patient positioning
I Pathologic mediastinal with rotation of the sternum to the right or left may create the
I conditions false impression of a mediastinal shift.
'l
j
"r ' .
-r I
;' 6 -"ll
_
can often be distinguishedfrom mediastinalmassesbecausethey pleural fluid obscuresthe mediastinum and a mediastinal mass is
are usually positioned lateral to the mediastinum (Fig. 30-12). being considered,removing the fluid and repeating the radiographs
There are instances, however, when mediastinal massesprotrude may be helpful. Additional radiographs made with a horizontally
Iaterally and are surrounded by sufficient lung (which provides directed x-ray beam may also be helpful. These horizontal-beam
contrast) to be mistakenfor a lung mass. radiographs take advantage of gravity, which causespleural fluid
Cranial mediastinalmassesoften causeelevationof the trachea. to migrate away from the area of the suspectedmediastinal mass.
Elevation of the trachea may also result from a large volume of Ultrasonographic examination is also of value in assessingthe
fluid in the pleural space(Fig. 30-13). With a large-volumepleural cranioventralmediastinum for the presenceof a mass,and ultra-
effusion, tracheal elevation results from displacement of lungs as sound-guided aspiration or biopsy facilitatesmaking a definitive
they float in the pleural fluid.' Tiacheal elevation does not occur diagnosis.6,?The specific location of a mass lesion within the
when only a small volume of fluid is present in the pleural space mediastinum also provides helpful information in the formulation
unless a mediastinal mass is also present. If pleural effusion is of a differential diagnosis.Causesof mediastinalmassesare listed
present, definitive identification of a concurrent mediastinal mass in Table 30-2.
is usually not possible unless the mass compressesthe trachea; Mediastinallymphadenopathyis one of the most common causes
pleural fluid alone does not result in tracheal compression.If of a mediastinal mass, and lymphadenopathy can be associated
with a variety of diseases(Table 30-3). Alternatively, there are enlarged mediastinal lymph nodes in dogs with lymphosarcoma
neoplastic and inflammatory diseasesthat would seem to logically has been identified as a negative prognostic factor.ro
involve the mediastinal lymph nodes, but do not typically do so The sternal lymph node is usually represented by a single node
(Table30- ). The major groupingsof lymph nodesin the mediasti- on each side in the dog, and a single node in the cat. In the dog,
num are discussedin the following paragraphs.8'e there is occasionally only a single median node. The sternal node
The cranial mediastinal lymph nodes vary in number and size. Iies in the ventral mediastinum, immediately cranial to the
Most of them lie along the cranial vena cava and brachiocephalic, transversusthoracis muscle and medial to the secondcostal carti-
1eft subclavian, and costocervicalarteries and are therefore located lage or second interchondral space;it is cranioventral to the inter-
in the cranial mediastinum, just ventral to the trachea. Afferent nal thoracic blood vessels.The afferent lvmphatics of the sternal
lymphatics come from the muscles of the neck, thorax and abdo- node lie under the transversus thoracis in the fat between this
men, scapula,last six cervical vertebrae,thoracic vertebrae,ribs, muscle and the dorsal surfacesof the sternal ends of the costal
trachea,esophagus,thyroid, thymus, mediastinum, costal pleura, cartilages. They arise in the abdominal wall and perforate the
heart, and aorta. The cranial mediastinal lymph nodes also receive diaphragm near the middle of the costal arch. Afierent vessels
efferent lymphatics from the intercostal, sternal, middle, and caudal receivetributaries from the ribs, sternum, serous membranes, thy-
deep cervical, tracheobronchial, and pulmonary lymph nodes. Ef- mus, adjacent muscles,and mammary glands. Sternal lymphade-
ferent channels from the tracheobronchial lymph nodes drain into nopathy appearsas an isolated soft-tissueopacity dorsal to the
either the thoracic duct or the left tracheal trunk, or both. Enlarge- region of the second sternebra and is best seen on the lateral
ment of the cranial mediastinal lymph nodes results in a visible projection, although occasionally there is a sufficiently large mass
mass in the cranial mediastinum that often createsa mass effect in for the enlargement to be seen on the ventrodorsal view (Figs.
the cranioventral thorax characterizedby elevation of the trachea 30-15 and 30-16).
on the lateral view and widening of the cranial mediastinum on The tracheobronchiallymph nodes are known as the right, left,
the ventrodorsalview (Fig. 30-1a). Radiographicidentification of and middle tracheobronchialivmoh nodes. The right and left
Table 30-2. Causes of mediastinal masses Table 30-3. Gauses of mediastinal lymphadenopathy
Cause of mass Mediastinal location Causes of mediastinal
lymphadenopathy Nodes typically involved
Media stin allymp ha denopat hy Cranioventral
Sternal lymphadenopathy Cranioventral L y m p h o s a r c o m a( f e l i n e ) .L u n g C r a n i a lm e d i a s ti n a l .ste r n a l ,
H ilar lymp ha de no pa t hy Per ihilar infiltratesnot reported.Pleural possiblythymus
V ascula rring an oma ly Craniodorsal* effusion may be present
(esophagomega ly) L y m p h o s a r c o m a( c a n i n e ) M . ay be C r a n i a lm e d i a s ti n a lste
, rnal,
Neuro ge nictumo r Dor s al accompaniedbyinterstitiallung tracheobronchial
P ar a so inatumo
l r Dor s al infi ltrate
Mediastinalabscess-usually Cranioventra l. Pulmonarymycoses.May be Tracheobronchial
secondaryto esophagealperforation caudoventral,caudal a c c o m p a n i e db y m i x e d l u n g
Generalizedmegaesophagus Dorsal infiltrates
Spirocerca lupi Caudodor s a l L y m p h o m a t o i dg r a n u l o m a t o s i s . C r a n i a lm e d i a s ti n a l ,ste r n a l ,
Media stin ald iap hra gm at icher nia Caudoventral U s u a l l y a c c o m p a n i e db y m i x e d tracheobronchial
Ectopicthyroid or parathyroidtumor Cr aniov ent r a lp, e r i h i l a r lung infiltrates
Thymoma Cranioventral Malignanthistiocytosis.Usually C r a n i a l m e d i a s ti n a l ,ste r n a l ,
Heart-basetumor Cr aniodor s a lp, e r i h i l a r a c c o m p a n i e db y m i x e d l u n g t r a c h e o b r o n ch i a l
H ia ta lhe rnia Caudodorsal i nfi ltrates
Diaphragmaticeventration Caudodorsal Spread of peritonealinflammation Sternal;pleuraleffusion
H emato ma Variable or neoplasiainto thorax may be present
Primarylungtumor. Pulmonary Tracheobronchial
*Severe esophagomegaly may appear cranioventrallY. mass will be oresent
The Mediast inum 383
nodes lie on the lateral side of their respectivebronchus and also Mediastinal fluid
contact the trachea.The right node is ventral to the azygousvein,
Free mediastinal fluid is usually of soft-tissue opacity; therefore, it
the left ventral to the aorta. The middle tracheobronchial lymph
may appear radiographicallyas a mediastinalmass, or as cardio-
node is the largestof the group. It is in the form of a V and lies
megaly if it collects around the heart, or both (Fig. 30-19). If
in the angle formed by the origin of the primary bronchi from the
mediastinalfluid is a radiographicconsideration,its presencemay
trachea.Afferent vesselsto the tracheobronchiallymph nodescome
be detectedby horizontal-beamradiography (unlessit is trapped
from the lungs and bronchi primarily, but they also come from
or loculated) or ultrasonography.The more common causesof
the thoracic parts of the aorta, esophagus,trachea,heart, mediasti-
mediastinalfluid include feline infectious peritonitis, trauma, co-
num, and diaphragm. Enlargement of the tracheobronchial lymph
agulopathy, and esophagealperforation. Mediastinal fluid may also
nodes resultsin visualizationof a soft-tissueopacity in the region
accumulatesecondaryto an underlying mass.
of the tracheal bifurcation on the lateral view (see Fig. 30-15).
Enlargementof the tracheobronchiallymph nodes is usually more
Pneumomediastinum
apparent on the lateral than on the ventrodorsalor dorsoventral
projection.Lateraldivergenceor separationof the principal bronchi Pneumomediastinumis free gas in the mediastinum. Mediastinal
may be apparent on the ventrodorsalview (Fig.30-17; see also gas provides excellent radiographic contrast, thereby resulting in
Fig. 30-15). The easewith which enlargedtracheobronchiallymph enhancedvisualizationof mediastinalorgans (Fig. 30-20). If only
nodes are seen on the lateral view deoends on their size and a small amount of mediastinal gas is present, the only apparent
the amount of adjacent lung opacity. In instancesin which the abnormality may be patchy regions of radiolucency in the cranial
lymphadenopathy exists with lung disease,the opacity from the mediastinum (seeFigs.30-13 and 30-16). The sizeof the mediasti-
lung diseasemay make the enlarged tracheobronchial lymph nodes num is not greatly increasedwhen pneumomediastinum is present.
more difficult to identi0' becauseof the silhouettesign (Fig. 30-18). Therefore, pneumomediastinum is not readily seenon ventrodorsal
On the lateral view, enlarged tracheobronchial lymph nodes may or dorsoventral radiographs (Fig. 30-21). Pneumomediastinum
result in elevation or depression of the tracheal bifurcation; in may progress to pneumothorax if mediastinal pressure results in
some dogs,no changein position of the trachealbifurcation results tearing of mediastinal pleura, thus establishing communication
from tracheobronchial lymphadenopathy. Enlarged tracheobron- between the mediastinum and the pleural space.Dyspnea is usually
chial lymph nodes that result in elevation of the tracheal bifurca- not seen with pneumomediastinum unless it progressesto pneu-
tion may be confused radiographically with an enlargedleft atrium. mothorax. Pneumothorax does not progressto pneumomediasti-
num. Becauseof the communication of the mediastinum with the
neck and retroperitoneal space,pneumomediastinum may result in
subcutaneousemphysemaor pneumoretroperitoneum (Fig. 30-22;
Table 3O4. Diseases not typically associated with see Fig. 30-2I). Alternatively, gas in the retroperitoneal space or
mediastinal lymphadenopathy fascial planes of the neck may diffuse into the mediastinum.
Mam m ar y adenoc ar c inom a There are six causes of pneumomediastinum, listed here in
Metastaticlung neoplasia decreasingorder of likelihood:
Bact er ialpneum onia l. Air escapinginto the lung interstitium from sites of alveolar
Pyothorax
rupture can diffuse in a retrograde direction in loose connecti\-e
Th or ac icwall t um or s , e. 9. ,r ib t um or s
tissueadiacentto bronchi and vesselsinto the mediastinum.tlThis
384 NE CKA ND TH O R AX -C OMP AN IOA
NN IMA LS
Figurc 3O-15, Lateral/A/ and ventrodorsal/B/ thoracicradiographsof a 9-year-o1d Dalmatianwith a historyof generaltzedperipherallymphadenopathy. In the
lat e r arl a d i o g r a p ht h, e r eis a r e g io no f so ft- tissu o e p a cityju st d o r salto the secondand thi rdsternebrae ow i ngto enl argement of the sternall vmphnode,Therei s
als oa n i l l - d e f i n e rde g i o no f in cr e a se do p a citya r o u n dth e tr a ch e albi furcati on
causedby tracheobronchil al ymphadenopathy. The enl argedtracheobronc hil aly mph
node sh a v ea l s oc a u s e de le va tio n o f th e tr a ch e alu st cr a n iato
l th e bi furcati on.
In the ventrodorsal
vi ew ,the enl argedsternall ymphnodeshaveresul tedi n w i deni ng
of t h e c r a n i o v e n t r m a l e dia stin ar le fle ctio na, n d th e e n la r g e dtr a cheobronchinodes
al haveproducedl ateraldi spl acement of the pri nci palbronchi(s eeFi g,30-17).
Diag n o s iw s a s l y m p h o s a r co m a .
situation occurs commonly after trauma and also occurs after trauma or, less likely, erosion from neoplasiaor inflammation. If
iatrogenicpulmonary hyperinflation during anesthesiaor resuscita- the hole is intrathoracic,air entersthe mediastinum directly.If the
tion.12Pneumothorax is not present when pneumomediastinum hole is in the neck, air may dissectalong the tracheathrough the
resultsfrom this mechanismunlessthe pulmonary pleura becomes thoracic inlet into the mediastinum. Pneumomediastinum may
torn or the mediastinalair accumulation resultsin perforation of occur following jugular venipuncture if the needle inadvertently
mediastinalpleura. punctures the trachea.In cattle and horses,pneumomediastinum
2. Caudal extension of gas in neck fascialplanes into the medias- is frequently seen following transtrachealaspiration procedures.
tinum may occur. Gas in the neck is a common sequel to neck or Tlacheal rupture in anesthetizedcats associatedwith overdistention
oral cavity trauma; it also may result from tracheal or esophageal of the endotrachealtube cuff is a noteworthy cause of pneu-
rupture. momediastinum.r3, raThere may be a tendencyfor cuff overdisten-
3. A hole in the wall of the trachea may occur as a result of tion during procedures such as dental prophylaxis wherein aspira-
tion is considered likely. Cuff overdistention may result in rupture 2. Evans HE: The respiratory system. In Evans HE (ed): Miller's Anatomy of the
Dog, 3rd ed. Philadelphia, WB Saunders, 1993.
of the trachealis muscle at the point of attachment to the tracheal
cartilages. Tiacheal rupture may occur at a modest cuff volume 3. Kern DA, Carrig CB, Martin RA: Radiographic evaluation ofinduced pneumotho-
and may not be immediately apparent to the anesthetist.Develop- rax in the dog. Vet Radiol Ultrasound 35:411,1994.
ment of subcutaneousemphysemais concurrent with pneumome- 4. Burk RL: Radiographic definition of the phrenicopericardiac ligament. J Am Vet
diastinum and if observed should alert the anesthetist to this Radiol Soc 17:216,1976.
potentially fatal complication of anesthesia. 5. Snyder PS, Sato T, Atkins CE: The utility of thoracic radiographic measurement
4. Trauma, neoplasia, or inflammation may lead to esophageal for the detection of cardiomegaly in cats with pleural effusion. Vet Radiol 3l:89, 1990.
perforation. 6. Konde LJ, Spaulding KA; Sonographic evaluation of the cranial mediastinum in
5. Retroperitoneal gas may extend cranially into the mediasti- small animals. Vet Radiol 32:178, 1991.
num. 7. Reichle JK, Wisner ER; Non-cardiac thoracic ultrasound in 75 feline and canine
6. A gas-producingorganism in the mediastinum is a very un- patients.Vet Radiol Ultrasound 41:154,2000.
likely cause. 8. Bezuidenhout AJ: The lymphatic system. In Evans HE (ed): Miller's Anatomy of
the Dog, 3rd ed. Philadelphia, WB Saunders, 1993.
References
9. Tompkins MB: Lymphoid system. In Husdon LC, Hamilton WP (eds): Atlas of
Feline Anatomy for Veterinarians. Philadelphia, WB Saunders, 1993.
1. Schummer A, Nickel R, Sack W: The Viscera of the Domestic Mammals, 2nd ed.
New York, Springer-Verlag, 1979. 10. Starrak GS, Berry CR, Page RL, et al: Correlation between thoracic radiographic
Figure 30-23
The Mediastinum 389
Figurc 30-24
changes and remission/survival in 270 dogs with lymphosarcoma. Vet Radiol Ultra- 4. Based on the following lateral and ventrodorsal feline thoracic
sound 38:411,1997.
radiographs (Fig. 30-23), list as many roentgen signs as you can
11. Macklin CC: Transport ofair along sheathsofpulmonic blood vesselsfrom alveoli indicating that the opacity seen in the cranial thorax is a mediasti-
to mediastinum:Clinical implications.Arch Intern Med 64:913,1939.
nal mass.
12. Brown DC, Holt D: Subcutaneous emphysema, pneumothorax, pneumomediasti-
num, and pneumopericardium associatedwith positive-pressureventilation in a cat. J
Am Vet Med Assoc206:997,1995. 5. Basedon the following lateral canine thoracic radiograph (Fig.
30-24), the most likely diagnosisis:
13. Mitchell SL, McCarthy R, Rudloff E, Pernell RT: Tiacheal rupture associatedwith
intubation in cats:20 cases(1996-1998).J Am Vet Med Assoc 216:1592,2000.
A. Diaphragmatichernra.
B. Pleural effusion.
14. Hardie EM, Spodnick GJ, Gilson SD, et al: Tracheal rupture in cats: 16 cases
(1983-1998).J Am Vet Med Assoc 214:508,1999. C. Pneumomediastinum.
D. Cranial mediastinal lymphadenopathy.
ffi31 space
ffiIi:,1,,',:ural
I Pleural anatomy Opaque, thin pleural lines are sometimesnoted betweenlobes.
Thickenedpleura may assumethis appearance.Occasionally,how-
There are two typesof pleura-pulmonary and parietal.Pulmonary
ever,the x-ray beam strikesnormal pleura in an interlobar fissure
pleura, also called visceral pleura, covers the lung parenchyma.
exactly tangentially, resulting in absorption of a sufficient number
Parietalpleura is subdividedinto three parts: costalparietal pleura
of x-rays for the pleura to be seen.It is impossibleto determine
lines the inside of the thoracic cage,diaphragmaticparietal pleura
radiographicallywhether isolated,thin pleural lines are normal or
coversthe diaphragm, and mediastinal parietal pleura forms the
whether they representevidence of slight pleural thickening. In
boundariesof the mediastinalspace.
either instance,such a finding is usually of no clinical significance.
The 1eft and right pleural sacsare distinct entities,each having
When pleural thickeningis advanced,wider pleural lines may be
continuous costal,diaphragmatic,mediastinal,and pulmonary
seenbetweenlung lobes (Fig. 3l-2). In pleural thickeningand with
parts (Fig.31-l). The pleural spaceis a potentialspacebetween
pleural effusion, the specificinterlobar fissuresseen radiographi-
parietal and pulmonary pleural layers and between pulmonary
cally depend on to which fissuresare struck tangentiallyby the x-
pleural layers in interlobar fissures;it normally contains only a
ray beam. This varieswith changesin positioning of the patient.
small volume of fluid, which servesas a lubricant.
N4ED]AST NUIV
COSTAL PARIEIAL PLEURA
[,IEDIASTINALPARIETAL PLEURA
PLEURA -
PULt\,4ONARY
MEDI AST ADHEREN-I TO LUNG
PLEURAL SPACE
390
The P l eur alSoace 391
Table 37-7. Causes of pleural fluid Table 31-2. Roentgen signs of free pleural fluid
Cause Fluid type Visualizationof widened interlobarfissures;fissure is of
soft-tissueopacity
Congestiveheart failure M
Retractionof pleuralsurfaceof lung away from pleuralsurface
Pyothorax E
Malig nanc y of thoracicwall; space between lung and thoracicwall is of
M
soft-tissueopacity
Pne um onia M, E
Increasedsoft-tissueopacity dorsal to sternum on lateral
Trauma M
radiographs;opacityfrequentlyhas scallopedmargins
Coagulationdefect M
B l u n t i n go f c o s t o p h r e n i cs u l c i i n v e n t r o d o r s a rl a di o g r a p h s
Hypoproteinemia T
Decreasedvisualizationof the heart in dorsoventralradiographs
Me dia s t init is M, E
Obscureddiaphragmaticoutline in dorsoventraland lateral
Chylothorax M
radiographs
Dia ph r agm at icher nia M
c D
F i g u r e 3 l - 3 . D r a win g so f th e th o r a xillu str a tinth g e lo ca t i onof i nterl obar fi ssures.The exactfi ssuresvi si bl ew hen pl euraleffusi oni s pres entdependon the
p o s i t i o no f t h e p a t i en t,th e vo lu m eo f flu id ,a n d wh e th e rth e x-raybeam stri kesthe fi ssuretangenti al l y. Onl y fl ui d{i l l edfi ssuresthat are struc ktangenti al lare
y
s e e n .A , F i s s u r e so f th e la te r aal sp e cto f th e le ft lu n g( lo o kingmedi alto l ateral ). Thesefi ssuresare more l i kel yto be seenw hen the pati enti s i n l eft rec umbenc y .
8 , F i s s u r e so f t h e l a te r aal sp e cto f th e r ig h tlu n g ( lo o kin gm e d al to l ateral ).
Thesefi ssuresare more i kel yto be seenw hen the pati enti s i n ri ghtrec umbenc yC
F i s s u r e so n t h e d o r sa al sp e cto f th e u n g s.T h e sef ssu r e sa r e more l i kel yto be seenw hen the pati enti s i n dorsalrecumbencv. N otethat the co s tophrenrc
s u c us
b e c o m e sr o u n d e dw he n p a tie n tswith p le u r ael ffu sio na r e in dorsalrecumbency. D , Fi ssureson the ventralaspectof the l ungs.Thesefi ssure sare more l i k el yto
b e s e e nw h e n t h e p a tie n tis in ve n tr a rl e cu m b e n cy. A, a cce ssory l obe;C d, caudall obe;C dC r,caudalpartof l eft crani all obe;C r,ri ghtcrani a obe ;C rC r,c rani alpar-t
o f l e f t c r a n i allo b e ;C s, co sto p h r e n ic
su lcu s;F , in te r lo b afissure;
r F', medi asti nal refl ecti onbetw eenthe l eft caudall obeand the accessorvl obe (o eura fl urdmav
accumulata e d j a c e nto
t th is r e fle ctio n L) ;, le ft; M , m e d ia stin arefl ecti on;Md, ri ghtmi ddl el obe;R , ri ght.
392 A N IMA LS
NE CKA ND T H O R AX -C ON /IPA N ION
.tr ,ttr l
,
, ll ,rliirlll'
rlrr,i:,tllf4llri'i
- .1
h- r r
Figurc 314, Ventrodorsal(A/ and left lateral (B) thoracicradiographsof a dog with a moderatepleuraleffusion.A, Numerousinterlobarfissures are seen
(doubleopen arrows);some containmore fluid than do others.The costophrenicsulcusis blunl (dottedblackarrow).B, Fewer interlobarfissuresare also visible
in the lateralradiograph(small double arrows).The cranialpart of the left craniallobe has been displaceddorsally(largedouble arrow) by sunoundingfluid.
(Courtesyof the Universityof Georgia.)
The PleuralSoace 393
I il'il1ll"'
''.:lt::
::':'.'
B 'l"lll'll
,r',,,,,1,1r,,,.,,1
Figurc 31-7. Right lateral/A/ and horizontal-beam lateral(dog in dorsalrecumbency)/B) views of a dog with pleuraleffusion.A, There is an opacitydorsalto
t he s t e r n u m w , h i c h i s c on siste nwitht flu idb u t m a y a lsob e a m a ss.In the ventrodorsal vi ew i not show n),therew as onl ymi ni malevi denceof pl eu raleffus i on.To
clarifythe significanceof the opacity,the horizontal-beam view was made. B, The fluid has gravitateddorsallyand can be seen adjacentto the spine as a soft-
g e lu n gfr o m th e th o r a cicwa ll. Also ,there i s no l ongeran opaci tyadj acentto the sternum.Thus,the opaci tyseen i n A, dors alto the
t is s u eo p a c i t ys e p a r a t i nth
s t er n u m w , a s f l u i d .N o t eth a t th e r eis n o t a sh a r ph o r izo n taflu fl ui d l i nesare seen i n hori zontal -beam
l id l i ne.H ori zontal radi ographs onl yw hen therei s a gas -fl ui d
int e r f a c eI.n B , t h e c o n t ou ro f th e flu idis co n fo r m in gto th e sh a peof the parti al l coly l apsed l ung.
The PleuralSpace 395
* *
,-j:JJ*,:i-;-,'*i-
I appearance
gravi tates
of pl euraleffusi on.A , The pati enti s i n ventralrecumb enc yand
ventral l y.
, fl ui d
The fl ui d i s l n contactw th the heart,thus obscuri ngthe heart
from vi ew .When the pati entis pl acedi n dorsalrecumbencyIB i ,the fl ui d grav tates
dorsal l yand i s not i n contactw i th the heart;thus, the cardi acsi l houettei s v i s i bl e.
The absol utedepthof the fl ui di s greaterw hen the patl entl s i n vent ralrec umbenc y
/A/ becausethe ventralpart of the thoraciccavityis narrower,and the fluid risesto
a hi gherl evel .Thus, overal L thoraci cradi opactyi s greaterw hen th e pati ent s i n
venl ra recumoency.
The PleuralSpace 397
I Pneumothorax
Gas in the pleural space is called pneumothorax. Air can enter the
pleural space from the outside or from the lung or mediastinum
(Table 31-3). The characterof the changesresriiting from gas in
the pleural space depends on the volume of gas and the relative
position of the patient and the x-ray beam. Roentgen signs of
pneumothorax are listed in Table 31-4.
Retraction of the lung from the thoracic wail can be seen on
Iateral, ventrodorsal,and dorsoventralradiographs.In a small
pneumothorax, this separation is small and may appear as a fine
radiolucent line (Fig. 3I-12). As in pleural effusion, air surrounds
the lung but is most apparent radiographically when the air is
struck tangentiallyby the x-ray beam (seeFig. 31-12). Visualization
of gas-containinginterlobar fissuresis not common with pneumo-
Figure 31-11. Ventrodorsalvtew of the thorax of a normal Bassethound.
T h e s t e r n u mi s d i s p la ce dslig h tlyto th e le ft. T h e r e is a n a rea of soft-ti ssue
thorax becausegas usually does enter the fissures of the iollapsed
opacity adjacentto the thoracicwall on the dog's /eft slde and an area of lung.
radiolucency adjacentto the thoracicwall on the rrghtside.Theseare artifacts Pneumothorax results in lung collapse becauseof the elasticity
c r e a t e db y t h e i r r e gu lath r o r a cicwa ll co n fig u r a tioin n th is chondrodystrophi c of- the lung and the increasedpleural
d o g .T h e o p a c i t yo n th e le ft sid eis d u e to th e p r o m in e nco t st ochondral
space pressure.As lung
regi on;
rotationof the patient resulted in its being located at the peripheryof the volume decreases,the lung contains less air and Decomesmore
t h o r a x .T h e l o c a t i o na n d a p p e a r a n ceo f th is o p a citym a y r esul t i n i ts bei ng radiopaque(Fig. 31-13). The degreeof increasedopacity is directly
c o n f u s e dw i t h p l e u r a e
l ffu sio n h; o we ve r in, te r lo b afissu
r r e sare not seen.On related to the degree of collapse, and the increased opacity may
l"l,eight slde, the opacitycreatedby the costochondraldeformity is located interfere with evaluation of the lung. The pulmonary collapse is
c l o s e rt o t h e m i d l i n eb e ca u seo f p a tie n tr o ta tio n .L a te r a to l thi s opaci tyi s
n o r m a l u n g ,w h i c ha p p e a r sr a d iou ce n tb e ca u seo f th e sh a r pcontrastprovi ded also responsible for the lack of visible lung markings extending to
by the costochondra o lp a city.T h e r a d io lu ce n cy
o f th is lu n g may be confused the periphery of the thoracic cavity, which is u .ommon ruJio-
w i t h p n e u m o t h o r a x. A h o r izo n ta l- b e arm a d io g r a p o
h f th e th orax i n thi s dog graphic sign of pneumothorax.
w a s n o r m a l( i . e . ,n o p le u r ael ffu sio no r p n e u m o th o r a x) . If the pneumothorax is open, that is, with no valve at the site of
gas entrance, gas may continue to enter the pleural space until
pleural pressureequals atmospheric pressure.At this point, the
Significance of pleural fluid lung is maximally collapsed but still maintains roughly the shape
of a normal lung becauseof its elasticity.
Pleural fluid may result from a primary pleural disorder, such as Separationof the heart from the sternum is commonly seenin
pleural neoplasm,but most often it is a sign of diseaseelsewhere. lateral
radiographs ofpatients with pneumothorax (seeFig. 3l-12).
It is usually impossible to determine the cause of pleural effusion The heart appears elevated from the floor of the thorax, but
from radiographs. When pleural fluid is present, structures are actually it is displaced into the dependent hemithorax owing to
obscured, and extremely large lesions can go unidentified. lack of underlying inflated lung to support the heart in its normal
Vy'hen pleural fluid is identified, careful scrutiny of the radio- midline position. As the heart falls into the dependent hemithorax,
graph is necessary.Occasionally,subtie radiographic findings such it slides dorsally creating the appearanceof elevation when seenon
as a rib lesion or asymmetrical distribution of free fluid are noted, a lateral radiograph (Fig. 31-1a). Although pneumothorax is the
which can be of great help in the evaluation of the patient. In most common causeof the appearanceof elevationof the cardiac
patients with a large pleural effusion, the indiscriminate approach silhouette on the lateral view, this radiographic sign has also been
of using a horizontaliy directed x-ray beam with various patient
positions to searchfor other lesions is unrewarding and should not
be done. Making additional radiographs after some of the fluid has
been removed may provide important information. Table 314. Radiographic signs of pneumothorax
AJI pleural effusions are clinically significant, and it is important Retractionof pleuralsurfaceof lung away from pleuralsurface
to attempt to reach a definitive diagnosis. In small effusions, there of thoracicwall; space between lung and thoracicwall is
may be no abnormal clinical signs, whereas large effusions usually radiolucent
result in dyspnea. It should not be assumed, however, that small Lung markingsdo not extend all the way to thoracicwall
effirsions are less significant than large ones. Thoracocentesiswith Lung has increasedopacity becauseof collapse
appropriate fluid anaiysis should be done when pleural fluid is Appearanceof dorsal displacementof the heart on the lateral
view
identified.3
398 NE CKA ND TH OR AX -C OMP AN IO AN
N IM ALS
c
F igu r e g l - 1 2 . V e n t r od o r sa( A)
l ,le Itla | e r a /8
l /,a n d r ig h tla te r arecumbenthori zontal -beaml C /radi ographsof adogw i thpneumothorax.4,Thehearti s s hi fted
x n o t se e n b e ca u seth e ai r has ri senand accumul ated
t o t he l e f t . b u t e v i d e n c eof o n e u m o th o r ais ventralto the sternumw here i t i s not strucktang enti al lby y the
x -rayb e a m .T h e r ei s a l i n e a r e g io no f g a s m e d ia to l th e r ig h tsca pul aandan areaof hemorrhage i n the l eft caudall obe.B , Therei s a thi n,radi ol ucent l i nebetw een
t he di a p h r a g m a n d a c a u da lol b eca u se db y g a s in th e p le u r asp l a c e.The heartl s separated from the sternum,andtherei s a radol ucentareabetw eenthe s ternum
and t h e h e a r t .T h e r ea r e op a q u ein te r lo b afissu r r e se xte n d in gca udoventralfrom l y the cari naand superi mposed on the cardi acapex regi onow i ng to c onc urrent
pleur ael f f u s i o n C . T h e e x te n to f p n e u m o th o r ais x r e a d ilya p p a r e nt.B y pl aci ng the pati ent
i n ri ghtrecumbency and by usi nga hori zontal di l y rectedx -raybeam,ai r
in t he l e f t h e m i t h o r a w x a s str u ckta n g e n tia lly b y th e x- r a yb e a m .The mi l i amperesecond (mA s)w as decreasedby 50% to faci l i tateai r vi sual i zati on by renderi ng
t he lu n g m o r e r a d i o p a q ue .
The PleuralSpace 399
Tension pneumothorax
Tensionpneumothorax occurswhen pleural spacepressureexceeds
atmospheric pressureduring both phasesof respiration. Tension
pneumothorax results from a check-valvemechanism at the orisin
of pleural spacegas.In tension pneumothorax,the increasedpleu-
ral pressure causesthe lung to collapseto a greater degree than its
maximal collapse in an open pneumothorax. Thus, it may no
longer maintain the shapeof a lung but may assumethe appear-
ance of an amorphous opacity compressedagainst the midline.
With unilateral tension pneumothorax, the increasedpleural space
pressure tends to cause a contralateral mediastinal shift. Tension
pneumothorax may also result in caudal displacementof the dia-
phragm to the degree that its costal attachments become visible
(Fig. 31-16). It is important to recognizetension pneumothorax
because it is a potentially fatal condition requiring immediate
thoracocentesis.
bacterial pneumonia in the dog-two case reports. I Am Arim Hosp Assoc 17:783,
1981.
7. Kern DA, Carrig CB, Martin RA: Radiographic evaluation of induced pneumotho-
rax in the dog. Vet Radiol Ultrasound 35:411, 1995.
W Ouestions
l. For interlobar fissures to be visualized radiographically when
pleural effusion is present, the x-ray beam must strike the fissures:
A. Tangentially.
B. Perpendicularly.
C. At maximal inspiration.
D. At maximal expiration.
References
1. Groves TF, Ticer IW: Pleural fluid movement: Its effect on appearanceofventrodor-
sal and dorsoventral radiographic proiections. Vet Radiol 24:99, 1983.
2. Lord PR Suter PF, Chan KR et al: Pleural, extrapleural and pulmonary lesions in
small animals: A radiographic approach to differential diagnosis. J Am Vet Radiol Soc
l3:4,1972.
4. Steyn PF, Wittum TE: Radiographic, epidemiologic, and clinical aspectsof simulta-
neous pleural and peritoneal effusionsin dogs and cats:48 cases(1982-1991).] Am
Vet Med Assoc 202:307,1993.
8, list three radiographic signs that would suggestthat a pneu_ 10. Describehow costalcartilagecan be distinguished
mothorax is a tension pneumothorax from a fluid_
containing interlobar fissure.
9. List two reasonsfor a falseradiographicdiagnosisof pneumo_
thorax. Answers begin on page 727.
CHA P T E R
32
The Heart and Great Vessels
. CharlesR. Root r Robert I. Bahr
I Normal radiographic anatomy the left and a more oval appearanceof the heart.r,2
Thesechanees
The external and internal boundaries of the individual chambers are more pronounced in large dogs than in small dogs or
."tr, 6ut
are presentto some degreein all animals.Thus, a
of the heart are not visible radiographically.External chamber mental note as
marglns merge with adjacentchambersbecauseall are of the same should be made before the radiograph is
lo lut].l,,Oortji""ilg
evaluated (seeFig. 32-ll).
opacrty,containedwithin the pericardialsac and surrounded by a
small amount of fluid. Coronary arteriescannot be seen,although
pulmonary vesselssuperimposedon the cardiac silhouette in tle I Radiographic signs
lateralprojection are sometimesmistakenfor them (seeFig. 5_14).
Similarly,the junction of the ieft atrium and left ventricle,"andthat Individual cardiac chamber enlargement
of
_the right atrium and right ventricle, may only be inferred The.reis probably more variation in the normal appearance
radiographically. of the
Internal featuresof the cardiac chamberscannot be visualized h:"r,.than in any^other organ. The t"urt L inherently
radiographicallyunless contrastedby an opaque medium during -lilll.,
vanaDlern srze becauseof contractionduring the
cardiaccycle.
angiocardiography. Echocardiography is the mithod of choice foi Additionally, there is considerabrebreed variati"onin
normal heart
assessment of cardiacanatomic and pathologic features. size and shape (seeFig. 32-l). As a starting point, it is
reasonable
Unlesscardiacabnormalitiesare pronounied, it is common for to consider that with compressedor-muscjar body stature
.dogs
havea heart that looks biggerthan would be expected.Misdiagnosis
strrdentsof radiology to spend coniiderabletime trying to decide
whether there is mild cardiac enlargementor mild chamber dila_ ot cardromegalyin chondrodystrophoiddogs, and in athletiJdogs,
tion. Similarly, the normal heart is often misdiagnosedas mildly is common. One solution for thii is to c;;ider the heart
radio_
enlarged,especiallyin breeds in which the heari normallv has a
round appearance(chondrodystrophoidbreeds, sporting treeds)
(Fig. 32-1). Thus, it is critical to realizethat radiogiaphic-examina_
tion is an insensitiveand nonspecificmodality to use in evaluation
of the heart. Pronouncedabnormalitiescan be assessed radiograph_
ically, and some congenital defects diagnosed with a fair deiree of
certainty. However, for accurate assessmentof cardiac morpiology,
with the added benefit of being able to evaluate function, echoca*i_
diography is the procedureof choice.
Cardiac.radiography should be reserved(l) as a screeningtool
-
for assessingmarked cardiac abnormalities, (2) as a means of
evaluatingthe pulmonary circulation in concert with cardiacfunc_
tion, and (3) to gain some insight as to whether cardiacdecompen_
sation has occurred.Additionally, any suspectedcardiacabnormal_
ity must be interpreted in combination with signalment and
physical findings relative to the cardiovascuiarsysteri. The purpose
of this chapter is to provide an appreciation for moderate to
marked chamberenlargement,information on the featuresof some
common congenitalabnormalities,and a descriptionof the radio_
graphicfealuresof heart failure.
The effect of radiographicpositioning on the appearanceof the
cardiac silhouette must also be recognized.In ihe ventrodorsal
projection,-.the_heart appearsmore elongatedand is aligned in a " ,1 ")
more parallel direction with the spine. However, cardiac magnifi_ idrl;rail
t r: l
cation will be marked in ventrodorsalradiography becauseo? the . .*;,' 'r,.,
1
greater distance from the heart to the x-ranfilm. In dorsoventral Figure 32-1. Ventrodorsal radographof a normalDachshund.
Chondrodys_
radiographs,the,diaphragm is displacedcranially, thus reducing sporrrns
dogshavea hearrtharnor...ty appearsrarge.
Xlll^!: l$:-f ,lnd
Lorsc,oJs dentt'rcattoF
the volume of the thoracic cavity. Cranial dispiacement of the of breedmust oe a parl of .ddi ograpn
c Inrerpretat,on
of the thorax.Fai l ure
to correl ate
breedand r.uOi ogr"p;;
diaphragm also resultsin displacementof the apex of the heart to i n the mrsdi agnosiofs cardi omegali n '- - u";pl
"""- arancewr, res ul t
y manydog!
The Heartand GreatVessels 4O3
graphicaliy normal unless there is an obvious alteration in size or Also, when the left atrium is dilated, a slight concavity is typically
shape;it is also important to considerthe patient'sbreed whenever seen in the approximate location where the left atrium meets the
the heart is evaluated. If uncertainty about the radiographic ap- left ventricle, on the caudal aspect of the cardiac silhouette. In the
pearanceof the heart remains,the next step should be echocardiog- ventrodorsal or dorsoventral projection, left atrial dilation causes
raphy rather than spending time anguishing about normality versus the left and right main stem bronchi ro diverge (see Fig. 32-3).
diseasein the radiograph.There are, however,certain radiographic Superimposition of the dilated left atrium on the cardiac apex
signs that correlate with specific cardiac lesions, especially when occasionallyresults in a summation effect causing a double opacity
these are considered in light of clinical history, physical findings, (seeFig. 32-3). The dilated left atrium may also causesignificant
and other radiographicobservations;thesesigns will be discussed compressionof the left main stem bronchus.
nere. Dilation of the left atrial appendage(auricle) is recognizedless
As a result of the uncertainties of cardiac radiography, a system often than dilation of the left atrium. In the ventrodorsal or
of cardiac measurement was designed to take into account the dorsoventral projection, dilation of the left auricle produces focal
inherent breedvariation in cardiacsize.The systemis called"verte- bulging of the 1eft cardiac border between the main pulmonary
bral heart scale."' To quantify heart size, the lengths of the long artery and the apex of the heart in the 2 o'clock to 3 o'clock
and short axes of the heart are measuredand scaledagainstthe position (Fig.32-a).
length of vertebraedorsal to the heart, beginning with T4. Based Left ventricle. The left ventricle is relatively thick-walled; there-
on examinationof 100 clinically normal dogs,the normal vertebral fore, hypertrophy causeslittle distortion of its conrour.Also, hyper-
heart scale is 9.7 + 0.5 vertebrae. Because95o/oof a normal trophy of the left ventricle occurs at the expenseof lumen volume,
population resideswithin 2 standard deviationsof the mean, the rather than causing heart size to increase.Thus, a heart with
normal scalerangesfrom 8.7 to 10.7.This a relativelywide range considerable left ventricular wall hypertrophy may appear radio-
and it resultsfrom inherent breed variation in cardiacsize,as was graphically normal. With severe left ventricuiar hypertrophy, the
noted earlier.The vertebralheart scalemay be useful for beginning heart may elongate,causingdorsaldisplacementof the trachea(Fig.
interpreters,but it has not been proven superior to subjectiveheart 32-58). This dorsal displacement involves the entire intrathoracic
assessment. portion of the trachea, from the thoracic inlet to the carina,
To facilitate recognition of certain cardiac abnormalitiesin the resulting in a decreasein the angle between the trachea and the
dorsoventralor ventrodorsalradiograph,the cardiacsilhouettecan thoracic vertebrae (see Fig. 32-5A). Pleural effusion may cause
be thought of in terms of a "clock face."Bulgesand bumps on the similar tracheal displacement,at least in cats, even in the absence
cardiac silhouette,causedby dilation of parts of the heart, can be of significant cardiomegaly.aTherefore, when the cardiac silhouette
Iocatedby a clock analogy-that is, in the 1 o'clock to 2 o'clock is obscuredby pleural fluid, the tracheovertebralangle is not a
position (Fig. 32-2). This system can assistone in remembering reliable sign of left ventricular elongation. In the ventrodorsal
the causesfor some alterationsin shaoeof the cardiacsilhouette. or dorsoventralprojection, there are no dependablesigns of left
Left atrium. The left atrium is to the right main stem ventricular hypertrophy other than the previously mentioned in-
bronchus,and medial and ventral to -.dirl
the left main stem bronchus. creasein heart length.With severehypertrophy and increasedheart
The only left atrial abnormality that can be detectedradiographi- iength, the cardiac apex may be displaced into the left hemithorax.
cally is left atrial dilation. In the lateral view, left atrial dilation In reality, left ventricular hypertrophy is very difficult to assess
causesdorsal deviation of the left main stem bronchus (Fig. 32-3) radiographically,and suspectedhypertrophy should be confirmed
and an increasein heisht of the caudodorsalborder of the heart. echocardiographically.
Left ventricular dilation developsin conjunction with right ven-
tricular dilation in patients with myocardial disease,and as a
secondary change to mitral insufficiency. Ventricular dilation con-
tributes to a heart that is "generallyenlarged";this is discussedin
the following section.
Right atrium. As with the left atrium, the only abnormality
resulting in right atrial enlargement is dilation, and right atrial
dilation is very uncommon. The right atrium may dilate secondary
to tricuspid insufficiencycausedby tricuspid dysplasiaor severe
pulmonic stenosis.In the ventrodorsal or dorsoventralview the
enlargedright atrium appearsas a bulge on the cardiac silhouette
in the 9:30 to 11:30 o'clock position. The caudal extent of the
dilation (in the 9:30 direction) is typically farther than anticipated
(Fig. 32-6). In the lateral view, a dilated right atrrum causesa
bulge on the cranial aspectof the cardiacsilhouettejust ventral to
the trachea(seeFig. 32-6).
Right ventricle. Right ventricular hypertrophy occurs most
commonly as a result of pulmonic stenosisor heartworm infection.
Hypertrophy of the right ventricle causesincreased cardiosternal
contactin the lateralprojection and bulging ofthe right ventricular
component of the cardiacsilhouettein the ventrodorsalor dorso-
ventral view (Ftg. 32-7). The latter lesion has been describedas
the "reverseD" appearance.In some instances,hlpertrophy causes
the apex of the heart to be elevated from the sternum, especially
in the left lateral projection (Fig. 32-8). Right ventricular dilation
rarely occurs as an isolated event, but may coexist with left ventric-
ular dilation in patientswith myocardialdisease.
Figure 32-2. Diagramof the heart in a ventrodorsa(or dorsoventral) view Generalized cardiomegaly. There are no specific radiographic
I ustratingthe clockfaceanalogy.Locationsof dilationof the left auricle(LAu),
main pulmonaryartery(MPA),aorticarch (AA),and rightatr um 1FAlare shown:
signsof generalizedcardiomegalybecausegeneralizedcardiomegaly
L A u ,b u l g ea t 2 : 0 0t o 3 :0 0 ;M PA,b u lg ea t 1 :0 0to 2 :0 0 ;AA, b u ge at I 1:30to results in an overall increasein heart size without soecific chamber
1 2 : 3 0 ;R A ,b u g e a t 9 :3 0to 11 :3 0 . enlargement(Fig. 32-9). A common causeof generalizedcardio-
4 O 4 NE CKA ND TH OR AX -C OMP AN IOA
NN IN / A LS
Figure 32-3- Right lateral(A/ and dorsoventral/8/ thoracicradiographsot a dog with left atrialenlargementdue to mitral insufficiency..4, The enlargedleft
atrium is clearlyseen (solrdarrow),and there is dorsaldeviationof the left main stem bronchus(openarrows).Compressionof the left mainstembronchusmay
be t h e s o u r c eo f a c o u g hin p a tie n tswh o h a veye t to p r o g r e ssto l eft heartfai l ureand pul monaryedema.8, D i vergence
of the l eft and ri ghtcaud all obarbronc hi .
Both caudallobar bronchi(openarrowheads)are bowed aroundthe enlargedleft atrium (smallopen arrows),and the caudalportionof the base of the heart is
increasedin opacity(smallopen arrows)Irom superimposition of the enlargedatrium summatingwith the left ventricle.(Courtesyof GrandAvenuePet Hospital,
S an t aA n a . )
Figure 32-5- Right lateral/A/ and dorsoventral/B/ thoracicradiographs of an 8-month-oldfemale miniaturelonghairDachshundwith patent ductus arteriosus.
ln the dorsoventralprolection1Bl,dilationof the proximaldescendingaofta (largesolid arrowsJis makingthe cariiac silhouetteappearelongated
and createsa
distinctbulge.A seconddistinctbulge (smallthin arrows)iustcraniolateral to the descendingaortais cauied by dilationof the main pulmonar!..tery segment.A
third distinct bulge (largeopen arrows)along the left cardiacborder is causedby dilationand protrusionof the left auricle.Note the enlarg;d right caudaltobe
pulmonaryvein (curvedarrowsland its adjacentartery,causedby pulmonaryovercirculation. In the lateralprojection1Al,the hugelydilatedlJft atrlumfurge open
arr o w s )a n d t h e f i l l i n g o fth e r e g io n o f th e ju n ctio n o fth e r ig h tventri cl eandthecrani al
venacava(smal sol l i d'arrow sl causedby-aorti candma i npul monary artery
segmentdilationmake the heart baseappearwider and the entirecardiacsilhouetteappearelongated.In a selectiveleft ventricularangiocardiogiam (different
patient),the dilatedmain pulmonaryarterysegment (smallthin arrows)and the ascendingaorta(solidarrowheads)areaccentuated /C)
bypositive-iontrastmedrum,
and the patent ductus arteriosus(curvedarrows), opacifiedbecauseof the left-to-rightshunting of blood, lies between the descendinqaorta and the main
oul ' n o n a r a
y r t e r ys e g m en t.
406 NE CKA ND T H OR AX -C OMP AN IO A
NN IMA LS
megaly is myocardial dysfunction. The vertebral heart scale, de- Changes in great vessels
scribed earlier,was designedto allow a more accurateassessment
of overallheart size;problemswith this techniquewere mentioned. Caudal vena cava. The caudal vena cava is variable in diameter
Others have suggestedthat the heart should occupy between 2.5 depending on the stage of the cardiac cycle and the degree of
and 3.5 intercostalspaceson the lateral view. This, too, is subjec- hydration. It is a very insensitiveindicator of central venous pres-
tive, and assessment of the overall size of the cardiac silhouetteis sure, and firm conclusionsabout hydration or venous pressure
best accomplishedusing subjectivecriteria developedby repeated should not be basedon the radiographicappearanceof the caudal
viewing of thoracic radiographswith echocardiographicconfirma- vena cava. A quantitative assessmentof caudal vena cava size,
tion of suspicions.Generalizedcardiomegalymay also result from comparedwith aortic diameter,was undertakenin dogs with right
poor ventilation,with the thoracic cavity being small as a result of heart failure. The diameter of the caudal vena cava as measured on
incomplete aeration of the lung (Fig. 32-10). Making a radio- a left lateral thoracic radiograph was comparedwith the diameter
graphic diagnosisof mild cardiomegalyis inaccurate;if more accu- of the descending aorta, the length of the thoracic vertebra above
rate information is desired,echocardiography should be performed. the trachealbifurcation, and the width of the risht 4th rib in 35
i .r 'iiiulr,ri
, ,. |tr,rrill
ul
Figure 32-7. Left lateralA/ and ventrodorsal/8, thoracicradiographs of a dog with pu monic stenosis.Thereis rightventricularenlargementin both projections,
and t h e r e i s b u l g i n go f th e m a in p u lm o n a r ya r te ( yb r r o w) in the ventrodorsaprol ectl on. The l atterradi ographisic gn i s due to poststenoti dic l ati onc aus edby
t urb u l e nftl o w . N o t et h e e le va tio no f th e ca r d ia ca p e xfr o m th e sternumi n A ; thi s i s a typi calsi gnof ri ghtventri cul ar
hypertrophy.In B , the bul gi ngri ghtv entri c l e
has r e s u l t e di n a h e a r tsh a p eth a t h a s b e e nca lle dth e "r e ve r seD " si gn.
The Heartand GreatVessels 4O7
.iilfil
iiitll,l
rlllrll:
dogs with right-sided heart diseaseand 35 control dogs. The ratio part of the arch is most commonly associated with turbulencefrom
of the caudal vena cava to each of the three structures was signifi- a patent ductus arteriosus (see Fig. 32-5). Dilation of the entire
cantly larger in dogs with right-sided heart disease.A caudalvena aortic arch resultsin widening of the caudal portion of the cranial
cava-to-aorta ratio of 1.5 was found to be strongly suggestiveofa mediastinum or a bulge on the cranial aspectof the heart on the
right-sided heart abnormality. There was, however, considerable lateralview (seeFig. 32-ll). Dilation of tlie descendingportion of
overlap in the caudal vena cava-to-aorta ratio between normal the arch is usually seen only on the dorsoventralor ventrodorsal
dogs and dogs with right-sided heart disease.Therefore,the ratio view as a widening of the aorta as the lateral aortic margin is
of caudalvena cavaldiameterto aortic diameterhas no clinical use followed cranially from the caudal thoracic area.
in most patientswith right-sidedheart disease.' In aged cats, the aortic arch may be elongated and thereby
Aorta. Either the entire aortic arch or only the descendingpart appear somewhat redundant; this is often accompaniedbv an
of the arch may becomedilated.Dilation of the entire arch is most exaggerated"horizontal" alignment of the heart (inireased sternal
commonly associatedwith turbulence resulting from valvular or contact), occurring in 2\o/oto 40o/oof cats that are 10 to 15 years
subvalvularaortic stenosis(Fig.32*11).Dilation ofthe descending of age and older.6The abnormally shapedaortic arch may appear
K-. $
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iiiuut:iiiiiutrl
rr rl;q]|r,,iiiigil!
Fig u r c g Z - 1 O , V e n tr o d o r sathl o r a cicr a d lo g r a p hosf a d o g made dur ng i nspi ratron /A / and exhaati on /B /. N ote the dramati cdi fferencei n ap pearancof
e the
c a r d i a cs i l h o u e t t el.n ( B) ,th e th o r a cicca vityis sm a lle rb e ca u seof crani alexcursi onof the di aphragm. The heartappearsmuch l argeri n (8) and w ou d be eas i l y
m i s d i a g n o s eads s i g n i fica n tly n ust be takeni nto consl derati on
. g r e eo f ve n tila tio m
e n la r g e dDe w hen heartsi zei s bei ngeval uated.
to be tortuous on the lateral view, or it may appearas a lung mass ceedstissue oncotic presslrre.Interstitial edema results in overall
on the ventrodorsalor dorsoventralview (Fig. 32-12)' The exact increasedunstructured opacity of the lung and blurring of vessel
causefor these changesof aging has not been conclusivelydocu- margins; this is difficult to identifii radiographicallybecausethese
mented." findings also occur with underexposedradiographs,with radio-
Main pulmonary artery. Dilation of the main pulmonary ar- graphs made on exhalation, and in aged lungs with increased
tery appearsin the ventrodorsal or dorsoventralview as a bulge interstitial connectivetissue.Progressivepulmonary edema results
on the left cranial part of the cardiacsilhouettein the 1 o'clock to in fluid spilling into the alveoli and the developmentof air bron-
2 o'clock position (Fig. 32-13; seealso Figs.32-2, 32-5' and 32-7 ). chograms(seeChapter 34). Cardiogenicpulmonary edemamay be
Main pulmonary afiery dilation is typically not seenin the lateral patchy in distribution, especiallyin cats (Fig. 32-16). Cardiogenic
view. In cats,dilation of the main pulmonary artery is usually not pulmonary edema typically resultsin coughing in dogs but not in
seen on either view becauseof the more medial position of the cats.In dogs with left-sidedheart failure secondaryto cardiomyop-
artery, which leads the enlargedartery to be superimposedover athy, lung edema is often concentratedin the peribronchial and
the cardiac silhouette. Dilation of the main pulmonary artery interstitial compartments (Frg. 32*17). This radiographic appear-
results from increasedturbulence (pulmonic stenosis),increased ance is actually more typical of inflammatory lung diseasethan of
pressure(heartworm disease),or a combination of both (patent cardiogenicedema, but the typical coexistingclinical and radio-
ductus arteriosus). graphic signs (cough fin dogs], dyspnea,fatigue, heart murmur,
and cardiomegaly) usually point the clinician to the diagnosis of
Heart failure peribronchial and interstitial edema rather than inflammatory lung
disease.Echocardiographyis necessaryfor a definitive diagnosisof
Left-sided heart failure. Left-sided heart failure is most com- myocardial dysfunction.
monly associatedwith incompetenceof the mitral valve (Fig. 32- Right-sided heart failure. Except for right-sided heart failure
14) and with mvocardialdisorders.With establishedieft-sidedheart resultingfrom heartworm disease,pulmonic stenosis,and tricuspid
failure, the left atrium is usually dilated and pulmonary veins are dysplasia, the right ventricle rarely fails without pre-existing left
usually larger than their correspondingarteries.Venous enlarge- ventricular failure. The appearanceof the heart in patients with
ment without pulmonary edema is not a sign of heart failure right-sided heart failure depends on the inciting cause of the
(Fig. 32-15). Venous enlargementis a sign of pulmonary venous failure. Physiologically,right-sided heart failure results in increased
hypertension, and this hypertension may not have reached the central venous pressure, which may cause the vena cava to be
point of fluid transudation into the lung. Compressionof the left dilated. However, as mentioned previously, caudal vena cava en-
main stem bronchus by an enlarged left atrium may be sufficient largement is an insensitive radiographic sign of elevated central
to elicit a cough. In left-sided heart failure, the left ventricle may venouspressure.
be elongated,causingdorsal displacementof the baseof the heart. Increasedcentralvenous pressureresultsin chronic passivecon-
With sudden left-sided heart failure, the left atrium and pulmonary gestion of the liver with hepatomegalyand ascites.Pleural effusion
veins may not have had time to dilate and can appear normal; may also develop secondaryto the elevatedcentral venous pressure
thus, pulmonary edema may develop before veins have had suffi- (which obscures the heart and diaphragm owing to silhouette
cient time to dilate. sign) (Fig. 32-18). Pleural effusion resulting from right-sided heart
Pulmonary edema is a natural consequenceof left-sided heart failure is more common in the cat than in the dog. In the dog,
failure. Pulmonary edema begins as transudation of fluid from the right-sided heart failure resulting in pleural effusion usually stems
capillaries into the interstitium as venous hydrostatic pressure ex- from cardiomvooathv.
The Heartand GreatVessels 4O9
ii:i$]lllrrldlllr.:11gn]ll.,':gl
]1,..,lll-@9.ffi ; "d
Figure 32-11. Right lateral/A/ and dorsoventral/B/ thoracicradiographsof an I1-month-oldfemale Rottweilerwith aortic stenosis.The left ventricleis not
e n l a r g e di n e i t h e rp r oje ctio nin
, co n tr a stwith so m e o th e rp a ti entsw i th thi s defect.N ote the shi ft of the cardi acapexto the l eft i n i B l ; thi s i s due to the pati ent
b e i n gi n s t e r n a r e c u m b e n cy,with cr a n iadl isp la ce m e notf th e di aphragm pushi ngthe apexto the l eft.Thi si s a commonsourceof mi sdi agnos iof s c ardi omegal y .
T h e c a u d a lp o r t i o no f th e cr a n iam
l e d ia stin u mis wid e n e din the dorsoventral proj ecti on(arrow s),and there i s a bul gei n the regi onof tFe j unc ti onof the i i ght
ventriclewith the cranialvena cava in the lateralview (curvedarrow).These radiographic signs are producedby poststenoticdilationof the root of the aorta. C,
N o t e t h e n a r r o ws u bva lvu larre g io na n d d ila tio no f th e a o r tadi stalto the aorti csi nus i n the angi ocardi ogram. The aortashoul dbe no w i der than the s i nus ;
e n l a r g e m e notf t h e a o r tad ista tol th e sin u sis d u e to tu r b u le ntfl ow .
'. : l r l
,::: a
:tlil;l
liil]]'
Figure 32-12. Ventrodorsal/A/ and laterall,8)thoracicradiographs of an aged cat. In A, the end-onvrew of the aorticarch (arraw)crealesthe appearanceof a
y a s s .T h e s ec h a n g e sa r eco m m o n lyse e nin th o r a cicr adi ographs
pulm o n a r m of agedcats.In B , the hearti s moreparal l el
w i th the sternum,andthe ao rtal s tortuous .
Figure 32-14. Rightlateral/A)and dorsoventral/B/ thoracicradiographs of an 11-year-old Chihuahuawith severeleft heartenlargementand advancedleft heart
fa i i u r e T
. h e c a u d aa l n d le ft h e a r tb o r d e r sa r e la r g e lyo b scu redby si l houettesi gn causedby al veoi arpul monaryedemai n the peri hi l arand mi ddl e-l ung regi ons ,
evidentby the fluid opacityin these lung fields with air bronchogramsigns (largerarowsl. Silhouettesign also obscuresportionsof the cupulaof the diaphragm
a n d m a k e sa l l p u l m o n a r yva scu la tu rin e th e se r e g io n sin visibl e. The eft ventri cul arenl argementi s evi dentow i ng to the trachealel evati on,
and di v ergenc e
of the
caudallobe stem bronchi(small,thin anows) in the dorsoventralview indicatesleft atrialdilation,which is also responsiblefor the riqhtwarddisolacementof the
tr a c h e aN . o t et h e a bse n ceo f r a d io g r a p hsig r c n so f r ig h th e a rtfai l ure.
Figure 32-15. Right ateral/.4/and dorsoventral/B/ thoracicradiographs of a dog with mitral insufficiency.There is left atrialdilation(/argesolid arrowheadsin
Aand BJ,and the left auricle(smallsalid arrows in 8) protrudesalongthe left borderof the cardi acsi l houette.
A n enl arqedand tori uousri qh tc audaltooarv etn
mav be seen (openarrow, 8/. Pulmonaryedema is not present.
4 I2 NE CKA ND T H OR AX -C OMP AN IOA
NN IMA LS
Figure 32-16. Lateral (A), ventrodorsal /8/, and close-uo laleral (C) of a
cat w l th decompensatedhypertrophi ccardi omyopathy and p ul monary
edemafrom left heartfailure.Note the oatchvdistributionof the increased
l ung opaci tyand the l ackof di screteai r bronchogram
formati on In . C the
sharpcrani almargi nof the l ung opaci tyi n the dorsall ung i s a l obars i gn
causedby the junctionof the diseasedcauda lobe with the better aerated
crani all obe.
Figure 32-18, Left lateraliAl and ventrodorsal/B/ thoracicradiographsof a 6-year-oldneuteredmale Samoyedthat had been treated 4 years previouslyfor
of the visible portionsof the pulmonaryarteries(white arrows),and pleuraleffusion (blackarrows)can be seen. These radiographicsigns are compatiblewith
progressive c a r d i o va scu la eadi ngto ri ght heartfai l ure.(C ourtesyof A ni mal Medi c alC l i ni cof B othel l ,
r a sese co n d a r y1 0 le sio n sin iti atedby di rofi l ari asils,
d ise
B o t h e l lW
. A.)
also occur. Increasedresistanceto blood ejection through the valve Ventricular septal defect
region resultsin elevatedright ventricular pressureand turbulent Abnormal development of the heart results in a communication
blood flow distal to the narrowing. between the left and right ventricles. Most of the time, the commu-
Commonly affected breeds are Basset hound, Beagle, Boxer, nication is located dorsally in the septum, just ventral to the aortic
Boykin spaniel, Chihuahua, Chow Chow, Cocker spaniel, Labrador valve. Becausesystolic pressureis higher in the left ventricle, blood
retriever,Newfoundland, Samoyed,Schnauzer,West Highland flows into the right ventricle during systole. Little flow is present
White terrier, and other terrier breeds.T during diastole becauseof the similar diastolic pressurein the two
Radiographic signs of pulmonic stenosisare these (see Fig. ventricles.Owing to the upper location of the defect,most shunted
32-7): blood immediately enters the pulmonary artery and not the right
ventricle. The volume of blood shunted with each contraction
1. Dilated main pulmonary artery (causedby turbulence) dependson the size of the defect,but the magnitude of shunting
2. Enlargement of the right ventricle (causedby hypertrophy) is typically less than with patent ductus arteriosus.
3. Normal pulmonary vessels(if right-sided heart failure devel- Commonly affected breeds are the English bulldog and the
ops, vesselsmay be small owing to undercirculation and reduced English Springer spaniel.7
cardiacoutput) The magnitude of the radiographic signs seen with ventricular
septal defect dependson the amount of blood shunting through
Aortic stenosis the defect (Fig. 32-19).
Narrowing of the subvalvular region of the left ventricle is more
common than primary valvular stenosis.As in pulmonic stenosis, 1. Mild right ventricular enlargement may be present when
the narrowing results in increased resistance to left ventricular shunting is large (due to increased pressure and flow during sys-
ejection. Increasedleft ventricular pressure and turbulent flow tole).
develop in the aortic arch distal to the obstruction. Mitral valve 2. Normal to slight increase in pulmonary artery and vein size
dysfunction and regurgitation may occur secondary to the mitral may occur (due to mild to moderate increasedpulmonary blood
annulus becoming misshapen. flow; enlargement is typically less than with patent ductus arterio-
Commonly affected breeds are Boxer, Bull terrier, German shep- sus).
herd, German shorthaired pointer, Golden retriever, Great Dane,
Newfoundland, Rottweiler, and Samoyed.T
Tetralogy of Fallot
Radiographicsigns of aortic stenosisinclude (seeFig. 32-77):
Tetralogy of Fallot consists of pulmonic stenosis,right ventricular
l Enlargement of the aortic arch (due to turbulent flow) hypertrophy, ventricular septal defect, and overriding aorta (Fig.
2. Elongation of the left ventricle (due to hypertrophy) 32-20). Thus, during systole, the increased resistanceto flow out
3. Left atrial dilation if secondary mitral dysfunction develops of the right ventricle causesunoxygenatedblood to flow acrossthe
4. Normal pulmonary vesselsunless secondary mitral dysfunc- ventricular septal defect into the 1eftventricular outflow tract. The
tion develops,then pulmonary veins may become enlarged overriding aorta also allows blood to flow directly into the systemic
4 I4 NE CKA ND T H OR AX -C OMP AN IO A
NN IMA LS
d
,q{t,,.
,lrnllll
l'lliri:1rl
circuiation from the right ventricle. Thus, systemicarterial blood is as mirror imagesof their normal location. It is usually associated
poorly oxygenatedand cyanosisis a ciinical feature ofthis anomaly. with sinusitis and bronchitis, in which instance the condition is
Commonly affected breeds are the English bulldog and the known as Kartagener'ssyndrome.',n Radiographically (Fig. 32-21),
Keeshond.t the cardiac apex is on the right, the caudal vena cava is on the left,
Radiographic signs of tetralogy of Fallot include: the pylorus and fundus of the stomach are reversed, the right
kidney is more caudal than the left, the liver lobes are reversed,
l. Right ventricular enlargement (due to hypertrophy)
and so forth. Other than the associatedrespiratoryproblems, this
2. A more angular appearanceof the cardiacsilhouettebecause
conditionhas little clinicalsignificance.
ofshifting ofthe apexto the right in responseto the right ventricu-
lar hypertrophy
3. Small pulmonary arteries and veins (due to pulmonic stenosis Acquired cardiovascular lesions
and ventricular septal defect; blood flows from the right ventricle
into the aorta rather than into the lungs) Mitral insufficiency
Chronic mitral valve insufficiency is the most common heart dis-
Tricuspid dysplasia easein dogs.roIt results from primary degeneration of the mitral
Commonly affectedbreeds are German shepherd,Golden retriever, valve leaflets, with possible dysfunction or malformation of the
Great Dane, Labrador retriever, and Weimaraner.T chordae tendineae or papillary muscles. Valve dysfunction results
Radiographic signs of tricuspid dysplasia include the following in incomplete left ventricular emptying on systole, and reflux of
(seeFig. 32-6): blood into the left atrium during systole. Left atrial pressure and
1. Right atrial enlargement blood volume are elevated. Radiographic signs of mitral insuffi-
2. Small pulmonary vesselsif the insufficient valve results in ciency are the following (seeFigs.32-3 and 32-4):
decreasedcardiac output
1. Left atrial enlargement (due to regurgitant flow)
Situs inversus 2. Possible left ventricular dilatation. (Actually, echocardio-
Situs inversus is an extremely rare congenital malformation in graphic evidence of Ieft ventricular dilatation is common, but in
which the thoracic and abdominal viscera are reversed,and appear radiographs this alteration may not be detectable.)
The H eartand GreatVessels 415
Figure 32-2o- Right lateral1Aland dorsoventral/B/ thoracicradiographs of a dog with tetralogyof Fallot.There is right ventricularenlargementwith increased
s t e r n acl o n t a c ta n d d isp la ce m e notf th e a p e xto th e le ft.T h e pul monary
arteri esand vei nsare smarr.
3. Distendedpulmonary veins (due to pulmonary venoushyper- the vascularintima becomesroughened,irregular, and hypertro-
tension) phic, further compromising laminar flow. The pulmonary irteries
4. Pulmonary edema (due to left heart failure) dilate and become tortuous. Perivascularfibroiis followi oulmo-
nary hypertension,and the diseasebecomesself-perpetuaiingto
Heartworm disease. Heartworm diseaseis probably the most
common cause of acquired cor pulmonale in dogs. The adult the extent that progressivecardiovascular changesmay occur even
parasitesusually reside in the right ventricle or in the pulmonary after the parasitesare no longer present.
arteries,occupying spacein the lumina, causingphysicalobstruc- Typical radiographicsigns of heartworm diseaseare the follow-
tion of the outflow tract, and destroying normal laminar blood ing (seeFig. 32-13):
flow in the pulmonary arteries.Typically,as the diseaseprogresses, 1. Right ventricular hypertrophy (due to pulmonary hyperten-
sion)
2. Dilation of the main pulmonary artery (due to turbulent flow
and pulmonary hypertension)
3. Parenchymalpulmonary artery enlargementand truncation
4. Interstitial and alveolar infiltrates (due to allergic reaction or
secondaryto thromboembolism).
5. Hepatomegalyand ascites(due to right-sided heart failure)
Gardiomyopathy
Dilated cardiomyopathy describesany primary myocardial disease
that is characterizedby cardiac chamber dilation and systolic ven-
tricuiar dysfunction caused by impaired myocardial contractility.ll
Dilated cardiomyopathy in cats is rare now that the role of taurine
has been definedr2(Fig. 32-22). Commonly affected canine breeds
include Scottishdeerhound,Doberman pinscher,Irish wolfhound,
Great Dane, Boxeq St. Bernard, Afghan hound, and Newfound-
land.r3In dogs,dilated cardiomyopathy(FiS.32-23) has the follow-
ing radiographicsigns:
1. Generalizedcardiomegaly
2. Left atrium may be dilated
3. Possiblepulmonary vein enlargement from mitrai dysfunction
4. Possible enlargement of both pulmonary arteries and veins
-
from fluid retention (hypervolemia)
5. Possiblepleural effusion from right-sided heart failure
6. In dogs, especiallyDoberman pinschers,development of
mixed alveolar/interstitial/bronchial lung opacification as a result
of atypical pulmonary edema; this lung pattern is similar to that
produced by inflammatory lung disease,but it occurs in dogs with
dilated cardiomyopathy
Figure 32-21. Ventrodorsalthoracc radiographof a dog with Kartagener's Hypertrophic cardiomyopathy is characterized by a hypertro-
_
sy n d r o m eT. h e r a d i o g r a pis h p o sitio n e co
d r r e ctlywith r e sp e ctto ri ghtand l eft. phied, nondilatedleft ventricle and absenceof other cardiacdisease
T h e r ei s c o m p l e t em ir r o rim a g ep o sitio n inogf th e th o r a cica n d the abdomi nal or systemicor metabolic abnormalities capableof producing hyper-
v i s c e r aT. h e a p e xo f th e h e a r tis o n th e r ig h t,th e ca u d a ve l n a cavai s on the
le f t ,t h e t r a c h e ai s o n th e r ig h t,th e ve n tr a lp o r tio no f th e ca u daimedi asti num trophy.l'?Hypertrophic cardiomyopathy occurs in dogs, but is more
is o n t h e r i g h t ,a n d s o fo r th .No ticeth e b r o n ch ialu l n gp a tte r n.P recrsel abel i ng common in the cat, in which the following radiographic signs are
of r a d i o g r a p hi s n e e d e dif th is co n d itio nis to b e d ia g n o se d . common (Fig. 32-24):
416 NE CKA ND TH OR AX -C OMP AN IO AN
N IM A LS
Figure 32-22. Left lateral /A/ and dorsoventralf8, thoracic radiographsot a cat
w i t h d i a t e d c a r d io m yo p a thTy.h e r e is g e n e r a lizeca
d r d io megay i n both prol ecti ons.
T h e h e a r t s s h i f t edto th e r g h t. Pu lm o n a ray r te r e sa n d ve insare enl arged,and there
is p eura effusion(arrows).
l. Extremeleft atrial enlargement,resultingin the characteristic presenceof a small amount of free fluid in the pericardialsac.This
"valentine" heart shape.The left atrium becomesso large that it fluid, between the pericardial sac and the epicardium, silhouettes
extendsto the right beyond the margin of the right atrium. Often the inside of the pericardiai sac and the outside of the heart.
this appearanceis misinterpretedas biatrial enlargement. Distention of the pericardialsacwith large amounts of fluid causes
2. Enlargedpulmonaryveins the cardiac silhouette to be enlarged anJ globoid lPig. 32-25). ln
3. Pulmonary edema the ventrodorsalor dorsoventralprojection,the edgeofthe pericar-
4. Pleural effusion as a late development dial sac may touch the costalmargins bilaterally.Furthermore,the
edge of the distended pericardial sac is often distinct becauseit
Pericardial effusion. As has been described earlier, the epicar- undergoeslittle, if any, motion during systoleand diastole.If the
dial edgesof the heart are normally not visualizedbecauseof the efficiencyof the cardiacpump function is disruptedby the pericar-
l,lll.rll
.1.
lPiilBlr,.-
:::llt:)'::,;
letrt;li:li
i!jl,,,,ttt'
fllrel '.itl
tfrj,))..:
Figurc 32-25' Lare'al (A) and ventrodorsaliBl thoracic radiographsof a S-year-oldmale mixed breed dog with pericardialeffusion owng to a rgft a:ra
n e o pa s m . I n t h e v e ntr o d o r saplr o je ctio nth
, e ca r d ia csilh o u e ttei s markedl yenl argedand gl oboi d.
4 I8 NE CKA ND TH O R AX -C OMP AN IOAN
N IM ALS
dial fluid, radiographic signs of congestiveheart failure may also ffi Ouestions
be present. The causesof hydropericardium may be neoplastic,
inflammatory,congenital,hemorrhagic,or idiopathic.raAmong the l. Why is it not possibleto accuratelyassesscardiovasculardisease
possibie neoplastic causesfor hydropericardium are heart base by physically measuring structures seen on thoracic radiographs?
tumors (chemodectomas)and metastaticor primary hemangiosar-
comas. Not all neoplasms at the base of the heart invoive the 2, \A4rich of the following are generally acceptedas reliable radio-
pericardial sac. Pericardiocentesisand pneumopericardiography graphic signs of left atrial enlargement?
have been recommendedfor the purpose of differential diagnosis A. Dorsal deviation of the Ieft main stem bronchus in the
of pericardial diseases.Diagnostic ultrasonographyis now the lateral projection
method of choicefor imaging such lesions. B. Ventral displacement of the caudal vena cava in the lateral
Microcardia. The decreasein size of the cardiac silhouette may projection
be absolute or relative. If relative, the thorax has been overinflated C. Divergence of the left and right main stem bronchi in the
by one of severalpossibieconditions such as emphysemaor simple dorsoventralor ventrodorsalproiection
hyperventilation. If absolute, the causesinclude hypovolemia (due D. Widening of the arch of the aorta in either projection
to blood 1oss,shock, or severedehydration),atrophic myopathies, E. Medial displacement of the right main stem bronchus in
and hypoadrenocorticism(due to Addison's disease).The patho- the ventrodorsal or dorsoventral projection
genesisof hypovolemia in Addison's diseaseis apparently equivocal.
Microcardia causedby hypoadrenocorticismhas been induced ex- 3. Under which circumstancesis a decreasein the angle between
perimentally in dogs.'sHypovolemia appearsto be the major rea- the vertebral column and the trachea (in the lateral iadiograph)
son for the decreasedsize of the heart in the more acute form of an unreliable radiographic sign of left ventricular enlargement?
the disease.In the ihronically afflicted patient, however, decreased
cardiac size appears to be caused, at least in part, by electrolyte 4. True or False.Enlargedpulmonaryveins are a sign ofheart fail-
imbalance, which theoretically results in decreasedmyocardial mass ure.
resulting from chronicallyweak contractions(disuseatrophy). The
radiographic sign associatedwith microcardia (Fig. 32-26) is, as
5. Which of the following radiographicsigns is generallyassoci-
the term suggests, the appearanceof a smallerthan normal cardiac
ated with left-sided heart failure?
silhouette relative to the size of the thoracic cavitv. No obiective
A. Increasedcardiosternalcontact in the lateral proiection
measurementscan be made for assistance in borderline or eouivo-
B. Elevation of the left main stem bronchus in the lateral
cal situations.
projection
C. Hepatomegaly
References D. Ascites
E. Alveolar pulmonary infiltrate
l. Carlisle CH, Thrall DE: A comparison of normal feline thoracic radiographs made
in dorsal versus ventral recumbency. Vet Radiol 23:3, 1982. F. Elevationof the axis of the tracheain the lateral proiection
G. Free pleural fluid
2. Ruehl \{W, Thrall DE: The effect of dorsal versus ventral recumbency on the
radiographicappearanceofthe canine thorax. Vet Radiol 22:10, 1981.
6. \{4rich of the following radiographicsigns is generallyassoci-
3. Buchanan ]W, Bucheler J: Vertebral scale system to measure canine heart size in
radiographs.J Am Vet Med Assoc 206:194,1995.
ated with right-sidedheart failure?
A. Increasedcardiosternalcontact in the lateral Droiection
4. Snydcr PS, Sato T, Atkins CE: The utility of thoracic radiographic measurement
for the detectionof cardiomegalyin cats with pleural effusion.Vet Radiol 31:89,1990.
B. Elevation of the left main stem bronchus in the lateral
projection
5. Lehmkuhl LB, Bonagura lD, Biller DS, Hartman WM: Radiographic evaluation of
caudal vena cava size in dogs. Vet Radiol Ultrasound 38:94,1997.
C. Hepatomegaly
D. Ascites
6. Moon ML, Keene BW, Lessard P, et al: Age related changes in the feline cardiac
E. Alveolar pulmonary infiltrate in the hilar and intermediate
silhouette.Vet Radiol Ultrasound 34:5, 1993.
zonesof the lung fields
7. Sisson DD, Thomas WP, Bonagura jD: Congenital heart disease.ln Ettinger Sj,
F. Elevationof the axis of the tracheain the lateral proiection
Feldman ED (eds): Textbook of Veterinary Internal Medicine, 5th ed. Philadelphia,
WB Saunders,2000. G. Free pleural fluid
8. Carrig CB, Suter PF, Ewing GO, et al: Primary dextrocardia with situs inversus,
associatedwith sinusitis and bronchitis in a dog. I Am Vet Med Assoc 164:1127, 1974- 7. List the survey radiographic signs generally associatedwith
patent ductus arteriosus;with aortic stenosislwith pulmonic steno-
9. Stowater lL; Kartagener's syndrome in a dog. I Am Vet Radiol Soc 171174,1976.
sis.
10. Kvart C, Hiiggstrdm J: Acquired valyular heart disease.In Ettinger SJ, Feldman
ED (eds): Textbook ofVeterinary Internal Medicine, 5th ed. Philadelphia, WB Saun-
ders, 2000. 8. List the survey radiographic signs generally associatedwith
heartworm disease;with mitral insufficiency.
11. Richardson R McKenna W Bristow M, et al: Report of the 1995 World Health
Organization/lnternational Society and Federation of Cardiology Task Force on the
Definition and Classification of Cardiomyopathies. Circulation 93:841, 1996. 9. Provide an accurate radiographic interpretation for Figure 32-
12. Fox PR: Feline cardiomyopathies. In Ettinger SJ, Feldman ED (eds): Textbook of
27,left iateral and ventrodorsalthoracic radiographsof a 9-year-
Veterinary Internal Medicine, 5th ed. Philadelphia, WB Saunders,2000. old neutered male Golden retriever dog with progressivelethargy
13. Sisson DD, Thomas WR Keene BW: Primary myocardial disease in the dog. In
and exerciseintolerance. List the major radiographic signs.
Ettinger SJ, Feldman ED (eds): Textbook of Veterinary Internal Medicine, 5th ed.
Philadelphia, WB Saunders, 2000 10. Tiue or False.The heart often appears faisely enlarged in the
14. Miller MW Sisson DD: Pericardial disorders. In Ettinger SJ, Feldman ED (eds): dorsoventral view becausethe diaphragm is displaced cranially and
Textbook of Veterinary Internal Medicine, 5th ed. Philadelphia, WB Saunders,2000. the cardiac apex is displaced into the left hemithorax.
15. Rendano VT, Alexander JE: Heart size changes in experimentally-induced adrenal
insufficiency in the dog: A radiographic study. J Am Vet Radiol Soc 17:57,1976. Answers begin on page727,
CHA P T E R
33
The Pulmonary Vasculature
. TohnM. Losonsky
42|,
The PulmonaryVasculature 421
HEART
A
Figurc 33-2' A, lllustrationof a lateralcaninethoracicradiograph, The locationof the right craniallobar artery(a),vein /y/,and bronchus/B/ is specified,g, Left
la t e r arl e c u m b e nvt i ew o f th e th o r a xo f a n o r m a l6 - m o n th - o lmal
d e S t. B ernard.N ote the ri ghtcrani all obarartery/a/and vei n /v/.The ri ghtci a ni ail obarbronc hus
is l o c a t e db e t w e e nt he a r te r ya n dth e ve in .( F r o mT h r a llDE,L osonsky JM: A methodfor eval uati ng cani nepul monary ci rcul atory
dynami cJfroms urv eyradrographs .
J Am Anim Hosp Assoc 12:457,1976.)
Figure 33-3. Lateralviews of the thoraxof a 12-year-old male Beagle.A, With the dog in left lateralrecumbencyon inspiration.B, With the dog in right lateral
re c u m b e n c o
y n e x p i r a tio nNo
. teth e b e tte rvisu a liza tioonf th e ri qhtcrani all obarvessel si n A .
422 ANIN/ALS
NECKAND THORAX-CON/IPANION
dorta
Heart
Figure 334. A, lllustrationof a dorsoventralcanine thoracic radiograph.The locationof pulmonaryarteriesand pulmonaryveins to caudal lung lobes is
female Dachshundare shown. Note that the caudallobararteriesand veins are better seen
illustrated.Dorsoventral/B/ and ventrodorsal/C/views of a 12-year-old
in I isternalrecumbencv)than in C. a, artery;cc, caudalvena cava;v vetn.
The PulmonaryVasculature 423
Table 33-1. Gonditions that may increase the size of enced by medication or administeredtherapies.Sequentialradio-
both pulmonary arteries and pulmonary veins graphs provide more meaningful information on underlying circu-
Left-to-rightshunts latory dynamics, especiallyif therapeutic interventions are changed.
Patentductus arteriosus
Ventricularseotal defect Geometric changes
Perip her alar t er iov enousf is t ula Sr2e. On the left lateral recumbent radiograph, the right cranial
latro ge nicf luid ov er load lobar artery and vein should be approximately equal in size. The
Cardiomyopathy(volume overload) relative size of these two vesselsshould be compared, and the size
Mitral insufficiencvand heartworm disease
of each should be compared with the right 4th rib just ventral to
the spine.s The diameter of each vessel should not exceedthe
smallest diameter of the right 4th rib.
On the dorsoventralradiograph,the sizesofcaudal lobar arteries
more fully aerated(lesslung silhouettingwith the vessels),and the
and veins should be compared with each other and with the
oncoming x-ray beam strikes the vesselsin a more perpendicular
diameter of the 9th rib at the point of intersectionof the 9th rib
manner (lessdistortion).
and correspondingvessel.The artery and vein of each caudallobe
Although the lobar bronchus lies between the artery and vein, it
should be similar in size. The diameter of the artery and vein
is important to realizethat the entire spacebetweenthe artery and
caudal to the 9th rib should not exceedthe diameter of that rib.
vein is not taken up by the bronchus. The exact position of the
Table 33-l provides a list of some common diseasesin which
bronchus can be determinedonly if the wall is mineralized.
there can be an increasein sizeof both the pulmonary arteriesand
veins.a History, physical examination, electrocardiography, survey
I Radiographicsigns of the thoracic radiographs, angiocardiographS echocardiography,and
I pulmonary vasculature clinical pathology resultscan be used to differentiatethese condi-
tions. The radiographicchangesdepend on the severityand dura-
The pulmonary vesselsare dynamic, their size being mainly a tion of the disease(Fig. 33-5).
function of intraluminal pressureand volume. Pressureand volume Pulmonary arterial enlargement without venous enlargement
can change quickly, such as in dehydration from diuretic overuse may occur with the diseaseslisted in Table 33-2. Heartworm
or in overhydration from overzealousfluid administration; there- diseasein the dog is the most common causeof pulmonary arterial
fore, the appearanceof pulmonary vesselsin a given radiograph enlargement.In heartworm disease,vesselenlargementoccurs be-
must be interpreted with the knowledge that they may be influ- causeof lesionsin the tunica intima and tunica media.or thrombo-
#w
Figure 33-5. Latera view of the thorax /A/ of a 6-month-oldmale
C o c k e rs p a n i e w l i t h a co n tln u o u sh e a r tm u r m u r .No te th e in creasei n
s i z e o f t h e r i g h t c r ana lo b a r a r te r y a n d ve in o win g to p ul monary
overcircuation associatedwith a left-to-rightshunt.There ls also heart
er r l a r g e m e nN t .o t e t h e in cr e a se d
o p a cityin th e ca u d a lol b e sow i ng to
hy p e r v a s caur i t y .D i a g n o sis:p a te n t d u ctu s a r te r io su s.B, A c l ose-up
v i e w i n w h i c h t h e r i g h t cr a n ia llo b a ra fte r yb ) a n d r ig h t cr a ni all obar
vein (v)are visible.The vein appearsargerthan the artery.More severe
pu m o n a r yv e i n e n l a r g e m e n t,in r e fe r e n ceto p u lm o n a r ya r teri es,i s
c o m m o ni n p a t e n td u c tu sa r te r io su s, b e ca u seth e th in - wale d vei nsare
m o r e e a s i l yd i s t e n d ed(.F r o mT h r a llDE, L o so n skyJM : A m e thodfor
ev a l u a t i n gc a n i n ep u l m o n a r ycir cu la lo r yd yn a m icsfr o m su r veyradi o-
graphs.J Am Anim Hosp Assoc 12:451,1916.)
424 A N IMA LS
NE CKA NDT H OR AX -C OMP AN IO N
Tdhle 33-2. Conditions that may increase the size of the diameter of the caudal lobar artery at the seventh intercostal
pulmonary arteries spacewas 5 mm or larger, or 4 mm or larger at the ninth intercostal
Tunica intimal proliferation or tunica media hypertrophy space,as seenon the ventrodorsalview, this was consideredconsis-
Dirofilariasis tent with feline heartworm disease.eIn experimental infection of
An gio stro ng ylia s is cats with third-stage heartworm larvae, most cats had peripheral
Aelu rostron gylus( f eline) caudalpulmonary arterial enlargementby 5 months post infection,
Thromboembolic disease or primary thromboses but at 9 months post infection, there was resolution of the periph-
Dirofilariasis eral pulmonary arterial enlargementin more than 50oloof cats.ll
Dissemin ate dintr av as c ular
c oagulat ion Another important aspect of that study was persistent bronchial-
Trauma interstitial lung opacification,appearing similar to feline allergic
Secondaryto cardiacdiseases
lung disease,after vascular changeshad resolved.tlThus, heart-
An gio stro ng ylia s is
Ren ald ise ase-a m y loidos isglom
, er ulonephr it is worm diseaseshould be consideredin cats with radiographicevi
Septicemia denceof bronchial-interstitiallung opacification,even though car-
Pancreatitis diovascularevidenceof heartworm diseaseis not oresent.rr
Hyperadrenocorticism Other changesassociatedwith canine heartworm diseasethat
Severe chronic lung disease may be used to differentiate it from other diseasesare pulmonary
artery tortuosity (Fig. 33-9; see also Fig. 33*7), loss of normal
tapering (pruning) (see Figs. 33-7 through 33*9), and foci of
increasedlung opacity along the courseof the caudallobar arteries
embolic disease,or both. Thoracic radiographicabnormalitiesseen on the lateral view (Fig. 33-10;.s'oThe foci ofincreasedopacity in
in spontaneousdirofilariasisare well documented.s-8 The percent- the caudallobeswere present6 months after experimentalinfection
age of dogs with right-sided heart enlargement,main pulmonary with L. larvae and were still evident 12 months after treatment
artery enlargement, and right cranial lobar pulmonary artery en- (Fig. 33-11). Theselesionsrepresentperipheralpulmonary arteries
largementhas been reported.TThe percentageof right cranial lobar with dilation and tortuosity.uFibrous connectivetissueand chronic
pulmonary artery enlargementwas only 47o/o(Fig. 33-6). In that inflammatory cellsmay also persistin the arterial wall and perivas-
study, caudal lobar pulmonary arteries were not measuredbecause cular tissue.
the animals were radiographed in dorsal as opposed to sternal Heartworm diseaseis also the most common causeof thrombo-
recumbency. In the author's experience, the lobar arteries that embolic diseasein that there is arterial occlusionby worm emboli,
enlargemost frequently in spontaneousheartworm diseaseare the or clots.sPulmonary thromboembolism typically resultsin an in-
caudal lobar arteries,with a predilection for enlargementof the crease in lung opacity, which has mixed interstitial and alveolar
right more than the left (Fig. 33-7). Experrmentally, the right characteristics. In later stages,or when there is an associated
allergic
caudal lobar artery was the first to enlarge and did so most responseto the worms, the alveolar component predominates.
frequently. The left caudal lobar artery was the next most frequently Pulmonary infarction in heartworm diseaseis rare.'t
enlargedvessel.6'8 It is common in canineheartworm diseaseto see Pulmonary thrombosisor thromboembolismdue to causesother
main pulmonary artery enlargement in associationwith peripheral than dirofilariasismay be associatedwith normal to reducedlung
pulmonary arterial enlargement(Fig. 33-7).? volume with lobar hyperlucency,and possibly reduced size of
In feline heartworm disease,it is unusualto seemain pulmonary peripherallung vesselsin affectedareas.Radiographicchangesmay
artery enlargementon survey radiographs.'With angiography, also inciude alveolardisease,hyperlucencyof a lung lobe or lung
howeveg it is possibleto see that the main pulmonary artery is region (hypovascular),and pleural effusion, especiallywith in-
enlarged in most cats with heartworm disease;the main pulmonary farction or cardiac disease.'tIt is important to remember that
artery is positioned such that it is not visible in survey radio- many patients with pulmonary thromboembolism do not have
graphs.tuParenchymalpulmonary arteries are also enlarged and radiographic changeshighly suggestiveof arterial occlusion, and
become tortuous in feline heartworm disease(Fig. 33-B). It has definitive diagnosis may require nuclear perfusion scintigraphy or
been reported that enlargementof the central and peripheralpor- pulmonary angiography.
tions of caudal lobar arterieson the ventrodorsalview with nor- Table 33-3 outlines the differential diagnosesfor pulmonary vein
mal-sized caudal pulmonary veins, representsthe earliest radio- enlargement occurring without arterial enlargement (Fig. 33-12)."
graphic change seen in spontaneousfeline heartworm disease.If Most causesare associatedwith cardiac disease.Pulmonarv vein
i1111''
.rr,
elll'1,,...
],,,1$l1l.1l11i116llfr
l]:.
1[1f
Figure 33-6- Lateralview of the thorax (A)ot a7-year-oldmale Englishsetter.Note the en argedright craniallobarartery felativeto the right craniallobarvein.
Diagnosis:heartwormdisease.8, A close-upview illustratesthe size differentialbetweenthe artery /al and the vein iyl.
The PulmonarvVasculature 425
Figure 33-7. Dorsoventral/A/ and ventrodorsaliBl radiographsof a 4-year-oldmale Germanshepherdwith heartwormdisease.The right and left caudallobar
pulmonaryarteriesare extremelyenlarged(arrows),lackthe normaluniformtapering{pruning),and are blunted(truncated)at their most distalasoect.Born vrews
show main pulmonaryarteryenlargement.There is severetortuosityof the right caudallobarartery.Note the better visualization
of the caudallobe vesselsin the
dorsoventralview (A).
enlargement without arterial enlargement is seen most commonly on survey thoracic radiographs, but they are best documented by
in mitral insufficiency in dogs. Table 33-4 lists diseasesassociated pulmonary angiography.On survey radiographsof 200 dogs with
with decreasedsizeof both the pulmonary arteriesand veins.The spontaneous heartworm disease, only 76.50/owere identified as
lung field appearshyperlucent, which results from the contribution having tortuous arteries (author's unpublished data). In that study,
of less soft-tissue opacity by pulmonary arteries and veins to the radiographsof dogs in left lateral recumbencyand dorsal recum-
lung parenchymabecauseof their reduction in size (Fig. 33-13). bency were evaluated. In radiographs made with the animal in
Shape. Shape changesare most commonly seen in dogs with ventral recumbency, the caudal lobar arteries are better visualized
heartworm disease.With dirofilariasis, in addition to an increase (see Fig. 33-7).3 Shapechangeswith heartworm diseaseare seen
in size of the pulmonary arteries, there may be vascular tortuosity early in the diseaseand often involve caudal lobar arteries,although
(see Figs. 33-7, 33-9, and 33-11), nonuniform tapering from the they may also be seen in the remaining peripheral arteries. Rapid
midportion of the artery distally (see Figs. 33*7 and 33-8), and peripheral arterial tapering and focal saccular dilations may occur
dilation of smaller arterial branches. These changes may be seen with any diseasethat produces pulmonary arterial thrombosis or
thromboembolism, but the incidence of occurrenceis sreater in
heartworm disease.
Margination. Loss of pulmonary vessel margins can be focal,
Table 33-3. Gonditions that may increase the size of
pulmonary veins multifocal, diffuse, symmetrical, or asymmetrical (Fig. 33-14).
Soft-tissue opaque material (fluid, cells, or debris) in the intersti-
Cardiac tium or alveoli adjacent to a pulmonary vesselsilhouettes with the
Volume overload vesseland obscuresits margins.
Mitral insufficiency
Early left-to-rightshunts-thinner wall of vein dilated more
easilY
Patentductus arteriosus Table 334, Gonditions that may decrease the size of
Ventricularseptal defect pulmonary arteries and veins
Prim ary myoca rd ia I d i sease
Myocardialfailure Right-to-leftshunts
Dilatorycardiomyopathy Tetralogyof Fallot
Hypertrophiccardiomyopathy Ventricularseptal defectwith pulmonic stenosis
Restrictivecardiomyopathy Severepulmonic stenosis
Noncardiac Hypovolemia
Left atrial obstruction Shock
Ne op lasm Dehydration
Th romb osis Adrenocortica I hypofunction
426 NE CKA ND TH OR AX -C OMP AN IOAN
N IM ALS
:.: i:),
"
I
I iillfu*u l
; ,,,11!1,,.
.iiilt
t::):l{j::::t:)
6. Rawlings CA, Losonsky JM, Lewis RE, et al: Development and resolution of D. Enlargement of right craniai lobar pulmonary artery and
radiographic lesions in canine heartworm disease.J Am Vet Med Assoc 178:1172,1981,. vein.
7. Losonsky JM, Thrall DE, Lewis R.E;Thoracic radiographic abnormalities in 200
dogs with spontaneous heartworm infestation. Vet Radiol 24:120,1983.
3. This 6-month-old, male Bloodhound tires easily and has a
8. Thrall DE, Badertscher RR, Lewis RE, et al: Radiographic changes associatedwith holosystolic heart murmur most prominent in the cranioventral
developing dirofilariasis in experimentally infected dogs. Am J Vet Res 4l:81, 1980. right thorax. The most accurate assessmentof this dorsoventral
9. Schafer M, Berry CR: Cardiac and pulmonary mensuration in feline heartworm thoracic radiograph (Fig. 33-17) is:
disease.Vet Radiol Ultrasound 36:499,1995. A. Enlargedcaudallobar pulmonary arteries.
10. Donahoe JM, Kneller SK, Lewis RE: In vivo pulmonary arteriography in cats B. Enlarged caudal lobar pulmonary veins.
infected with Diroflaria immitis. I Am Vet Radiol Soc 17:147, 1976. C. Enlargedcaudallobar pulmonary arteriesand veins.
11 . S e l ce r B A , N e well SM , M ensour AE, M cCall lW : Radiogr aphi c and 2- D
echocardiographic findings in 18 cats experimentally exposed to D. immitis via mos-
4. The most common causeof pulmonary arterial enlargementis:
quito bites. Vet Radiol Ultrasound 37:37, 1996.
A. Mitral insufficiency.
12. Thrall DE, Badertscher RR, Lewis RE, et al: Collateral pulmonary circulation in
B. Pulmonic stenosis.
dogsexperimentallyinfectedwithDirofilariaiffimitis.Vet Radiol2l;131,1980.
C. Heartworm disease.
13. Norris CR, Griffey SM, Samii VF: Pulmonary thromboembolism in cats: 29 cases D. Patent ductus arteriosus.
(1987-1997). J Am Vet Med Assoc 215:1650, 1999.
Figure 33-15
43O NE CKA ND TH OR AX -C OMP AN IOA
NN IMA LS
llililfilrr:ll
ri$l
!taut:iliisul
Figure 33-16
B. On the lateral thoracic view, the large right pulmonary 9. The right cranial lobar pulmonary artery and right cranial
artery is dorsal to the trachea. lobar pulmonary vein are best visualized and most frequently
visualizedwhen the dog or cat is positioned in:
7. On the dorsoventralthoracic view which statementis correct? A. Left lateral recumbency.
A. Pulmonary arteriesare lateral to pulmonary veins. B. Right lateral recumbency.
B. Pulmonary veins are lateral to pulmonary arteries.
10. Which one of the following diseaseentities could result in a
8. The caudal lobar pulmonary arteries are best visualized on right cranial lobar pulmonary vein larger in size than the right
which one thoracic radiographicview? cranial lobar pulmonary artery?
A. Ventrodorsalthoracic view (patient in dorsal recumbency) A. Pulmonic valvular stenosis
B. Dorsoven tral t hor ac ic v iew ( pat ient in s t er n a l r e c u m - B. Pulmonic valvular insufficiency
bency) C. Mitral valvular insufficiencv
Figure 33-17
CHA P T E R
34
The Ganine and Feline Lung
r ChristopherR. Lamb
The radiology of pulmonary diseaseis describedin four sections, Table 34-1. Differential diagnosis of the bronchial
including puimonary diseasesthat cause (1) increased opacity, pattern
(2) hlperlucency, (3) pulmonary mass lesions, and (4) calcified
Bronchialcalcification
pulmonary lesions.
Chronic bronchitis
Allergic
I lncreased opacity Irritant
Parasitic,e.9., aelurostrongylosis
It is customary to describethe radiographic signs of pulmonary Peribronchialcuffing
diseasesthat cause increasedopacity in terms of the anatomic Edema
divisions of the lung. The three categoriesof radiographic signs P u l m o n a r ye o s i n o p h i l i ci n f i l t r a t es
(patterns)describedhere are bronchial, interstitial,and alveolar. Bronchopneumonia
Bronchial pattern
Increasedvisualizationof bronchial walls constitutesthe bronchial or vessels.These alternatives may be distinguished by tracing the
pattern of pulmonary disease.This may result from calcificationof linear structures peripherally-adjacent arteries and veins diverge
the bronchial cartilage (which is a normal age-relatedchange) or in the periphery of the lung, whereas bronchial walls converge is
thickening of the bronchial wall or peribronchial tissues. the bronchi become progressively smaller., Also, as is shown in
Caicification of the bronchial wall causesan increase in opacity Figure 34-3, the pattern of branching appears different-vessels
but not in thickness(Fig. 3a-l). It is common among middle-aged produce solitary branchesand bronchi produce paired branches.
and old dogs and is not significant.In catswith bronchial disease, Thickening of the bronchus is most often associatedwith chronic
multifocal pulmonary calcificationmay be observedas a result of inflammation or hypersensitivity; hence, the principal differentiai
calcification of the peribronchial mucous glands or broncholithi- diagnosesfor a diffuse bronchial pattern ar. ihronic bronchitis3,a
asis.r Opaque foci compatible with calcification of peribronchial (Fig. 34-4), pulmonary eosinophilicinfiitrates,5-7 and parasiticin-
mucous glands in cats may also be observed in cats without festation, such as aelurostrongylosis.sIn some instanceslinfiltration
respiratory signs; hence, this too can be an incidental finding of the peribronchial tissuesby edemaeor by inflammatory cells mav
$ig.3a-2). produce the appearanceof bronchial thickening on radiographi;
The key radiographicsign ofbronchial diseaseis a changein the therefore,peribronchial edema (e.g.,as a result bf cardiacitrsufn-
cross-sectional appearanceof the bronchus from a thin circle to a ciency, lymphatic obstruction, or acute allergic or inflammatory
thick circle of the samediameter (Fig. 3 -3). This appearancemay pulmonary conditions) and bronchopneumoniamust also be con-
occur as a result of bronchial mucosal thickening, debris in the sideredas differentialdiagnosesof the bronchial pattern (Table34-
lumen, hyperplasia of the peribronchial glands, or peribronchial
infiltration by fluid or cells.Increaseddiameterof the lumen (with '
Bronchialdilation and lossof the normal taperingand branching
or without thickening of the wall) indicates bronchiectasis. It is space between pulmonary vesselpairs are signs ol bronchiectasii
frequently easier to recognize bronchial thickening when the af- (Fig. 34*5).10Bronchiectasisis not easily recognizedon survey
fected bronchus is seen end on rather than side on becauseoarallel radiographs; hence, this diagnosis may require bronchography for
linear structureson a thoracic radiograph could representbronchi confirmation.lr-r3
4:ll
432 NE CKA ND T H OR AX -C OMP AN IO A
NN IMA LS
\
oa
4-
Ar/
€o
B
ooo
c
Figure 34-3. Variatlonsin the radrographic appearance of the bronchialwall. In the normaldog /A/,
th e bronchi aLw al l may be seen end on as a thi n,ci rcul arstructurebetw eenpai redvess el sbut i s not
visibl ew hen vi ew edsi de on. In many oi d dogs,cal ci fi cati onof the bronchi al carti l ag ei s v i s i bl eas a
.O
th in opaquel i ne paral l el i ng
the vessel s/R . When the bronchi al w al l i s thi ckened1C r,i t appearsas a
4 th ick ri ng seen end on and as a pai redbranchi ngstructureseen si de on. The accompany i ng
ve ss el sare normal l yl ess apparentradi ographi calwl hen
y si gni fl cant bronchi al
bl ood
thi cken i ngi s pres ent.
Figure 3/t-5. A, Detailof a lateralthoracicradiographof a Huskywith a historyof chroniccoughthat improvedwhen antibioticswere administeredbut recuned
when medicatiow n a s d isco n tin u e dEn . d o sco p ica lly,th e r ewas excessi vemucus i n the bronchiand evi denceof bronchi ectasithi s; s i s vi si bl eradi ographi c alas
ly
loss of the normaltaperingof the bronchialwal)s (arrows).B, Exampleof markedsaccularbronchiectasis in anotherdog in which the bronchialwallsire markedly
t h i c k e n e da n d m i s s ha p e np,r o d u cin g
a b u b b ly- a p p e a r inbgr a, nchi ng
structurethat i s superi mposed
on the cardi acsi l houette.
4 34 NE CKA ND T H OR AX -C OMP AN IO AN
N IM A LS
Tahle 3th2. Differential diagnosis of nodular interstitial Tahle 3tl-3. Differential diagnosis of unstructured (hazy)
patterns interstitial patterns
Noncavitarynodule Diffuse
Thoracicwall structure,e.9., nipple,tick Artifact
Prima r ylung t um or U nderexposedradiograph
Pulmonarymetastasis Underinflatedlung, e.9., end-expiratoryexposure,obesity
Gra nu lom a "Old dog lung"
Mycotic Lymphosarcoma
Heartworm-associated Diffusepulmonary metastasis
Foreignbody Pneumonitis
Eos inophilic( idiopat hic ) Viral-distemoer
Fluid - f illedbulla Parasitic-e.9.,dirofilariasis,aelurostrongylosis
Hematoma Metabolic-e.9., uremia, pancreatitis,septicemia
Abscess Inhalant-allergy,smoke
Cyst Toxic-e.9.. paraquat
Mucus-filledbronchus Diseasein transition
Cavitarynodule Edema
Prima r ylung t um or Bronchopneumonia
Pulmonarymetastasis Hemorrhage
Mycotic granuloma,e.9., blastomycosis Localized
Pa rag onim ias is P a r t i a ll u n g c o l l a p s e
Abscess Hemorrhage
Pa rtiallyf luid- f illedbulla P u l m o n a r ye m b o l i s m
Cyst Bronchialforeign body
Bronchiectasis Diseasein transition
Edema
B r o n c h o o n em u o ni a
Hemorrhage
Pulmonaryparasites
Figurc 34-7. A, Lateralthoracicradiographof a dog with multicentriclymphosarcoma in which diffuse, moderateto severeinterstitialinfiltrate,which includes
a small nodularcomponent,can be seen. The caudaltracheaappearsnarrow,probablybecauseof compressionby adjacentlymphadenopathy (arrow).B, Larctal
th o r a c i cr a d i o g r a pohf a ca t with p r im a r yp u lm o n a r ca (*) and pul monarymetastasi s.
y r cin o ma S everalof the metasi aseiare cavi tarV
(mostci ea rl vv i s i bl ec ranrat
to
the heart).
. Have a similar opacity to a side on vesselof the same diameter tasis, is to obtain three thoracic radiographs (e.g., both left and
. May be small or large regardlessof their location within the lung; right lateral and dorsoventral or ventrodorsal views) whenever
hence, pulmonary nodules may be recognizedwith certainty malignant neoplasia is suspectedclinically.
when they are larger than adjacent blood vessels Distinguishingthe various causesof pulmonary nodules can be
Foci of pulmonary heterotopicbone: challenging because there is considera-bleoverlap in the radio-
graphic appearanceof tumors (Fig. 34-7),r'. te 21'-24 2s granulomas
. Are usually small with a speckledopacity (Fig. 34-8),"-3' and abscesses(Fig.34-9).,, Also, a fluid- or mucus-
. Are irregularly shapedon closeinspection filled bronchus could be confusedwith a nodule in some instances
(Fig. 3a-10). The pulmonary lesions of acute paragonimiasisap-
Pulmonary nodulesmay be solitary or multiple, solid or cavitary
(see Thble 34-2). Pulmonary nodules may have distinct, smooth pear radiographicallyas multiple, poorly circumscribed nodules
that range from I to 4 cm in diameter; subpleural air-filled cavities
margins or may have indistinct margins and tend to coalesce,
and bullae (often septated)developin chronic infection.3a
which makes individual nodules more difficult to recognize. The
most common solitary nodules in dogs are primary pulmonary
tumors, and the most common multiple nodules are pulmonary Unstructured (hazyl interstitial patterns
metastases. The sensitivityof radiographyfor pulmonary metastasis This categoryincludesa large number of radiographrcappearances
detectionhas been estimatedat 650/oto 97o/o.t7-22
There is evidence that share two features: increased lung opacity and obscured, but
that a standard two-projection thoracic radiographic study (e.g., not obliterated,puimonary vasculature.laUnstructured (hazy) in-
right lateral and dorsoventral views) is adequate for detection of terstitialpatternsmay include linear (reticular)3'and reticulonodu-
pulmonary metastasis";however,depending on their position in lar comPonents.
the lung, lesions can be missed using this approach.,3Another A wide variety of causesmust be consideredwhen a diffuse, hazy
recommendation,which reflectsthe importanceof detectingmetas- interstitial pattern is interpreted (see Table 34-3). These include
Figure 34-1O. A, Detailof a lateralthoracicradiographof a dyspneiccat. Thereare multiplesmall nodules(aaows).On the basisof examinationof the entire
radio g r a p ht h, e l u n g sw e r e co n sid e r e dh yp e r lu ce n p t.o ssib lyr e flecti ngai r trappi ng.The cat w as treatedfor suspectedfel i neasthma.In a repeatradi ograph 18
day sl a t e r/ B r ,t h e n o d u l esa r e n o lo n g e re vid e n t,a n d th e h yp e r lu cencyhas resol ved.Mucuspl uggi ngof bronchii n catsor dogsw i th bronchi al
di sea s emay mi mi c
( Ra d io g r a p hussedby courtesyof A ni taS . Mai tra,MR C V S .)
oulm o n a r yi n t e r s t i t i anlo du le so f o th e re tio lo g ie s.
The C ani neand Fel i n eLunq 497
,sl
Figure 3tl-15. A S-year-old Standardpoodlehad clinicalsigns and transtracheal aspiratefindingsconsistentwith bronchopneumonra; however,treatmentwith
antibioticsproducedno sustainedimprovement.Lateralthoracicradiographswere made with the dog in right lateralrecumbency
A) and standing/B/ with a
horizontalx+ay beam. in the recumbentlateralradiograph(A),an extensiveventralalveolarpatternand;ir bronchogramsare visible;this appearance'is typicalof
c o n s o l i d a t ebdr o n c h o p n e u m o n T l b a rb r o n chus(l argearrow )appearsto taperand branchnormal l y,but other bronchiappeardi l atedand bl unt
iah. e le ft cr a n ia lo
ended (small arrowd. fhis appearanceis enhanced in the standing lateralview. Radiographicdiagnosis:bronihopneumoniaand bronchiectasis.Note the
accumulationof mucus in the tracheain the standinolateralview ilaraewhite arrow).
Figure 34-16. A, Lateralthoracicradiographof a cat with dyspnea,tachycardia, and murmur.rApatchyalveolbrpulmonaryinfiltrateis present,which otrscures
t h e c a r d i a cs i l h o u e t t e.
T h isa p p e a r a n ce
is n o t sp e cificfo r a n y di sease;how ever,the cl i ni calsi gnssuggestthe possi bi l i ty of cardi acdi sease;henc e,the i nfl l trate
m i g h t r e f l e c tp u l m o n a r ye d e m a .B, Re p e a tla te r a rl a d io g r a pafter
h l 2 hoursof di uresi sshow s resol ul i onof the i nfi l trateand more cl eary show s ev i denc eoj
cardiomegaly. Echocardiography confirmed cardiomyopathy.
4 4 O NE CKA ND T H OR AX -C OMP AN IOAN
N IM A LS
Figure 34-17. A, Lateralthoracicradiographof a young dog that bit an eectric cord. An alveolarpatternwith air bronchogramsaffectingthe caudallobes can
be s e e n .I n t h e s ei n s t an ce s, e le ctr icastim
l u la tioonf th e b r a incausesa burstof sympathetinerve c di scharges, w hi ch i n turn causesacutepul mon aryhy pertens i on
an d p u l m o n a r ye d e m a.4B, 6 L a le ( ath o r a cicr a d io g r a pohf a ca t w i th pul monaryedemasecondary to cardi omyopathy. The dstri buti onof the rnfi l trate
i s mai nl y n
l n d v e n t r a rl e g io n so f th e lu n g ;th e ca u d a lo
t he c e n t r a a l b a rtip s are not affected.Thi s di stri buti on
i s typi calof pul monary edemai n catsw i th cardi omy opathy .
rhage (Fig. 34-18). Lesscommon causesof diffusealveolarpatterns thoracic wall and lung, respectively.Pathologic causes of diffuse
include upper airway obstruction,aeeosinophilicgranulomatosis,3' pulmonary hyperlucencn such as air trapping or emphysema,
uremic pneumonitis,s0 acute respiratorydistresssyndrome,sr's2 and might be suspectedif inspiratory and expiratory radiographsap-
paraquat toxicity.s3,s4 pear similar.
Localized alveolar patterns that correspond to the position of Hyperlucencymay be classifiedas diffuse or focal (Table 34*5).
individual lung lobes may occur secondaryto various diseases that Diffuse pulmonary hyperlucencyand increasedlung volume are
causelobar consolidation.Depending on the cause,consolidation observedin some cats as a result of air trapping associatedwith
of a lung lobe may be accompanied by a change in its volume, bronchial asthmaa,or or emphysema,which can occur as a congeni-
which may be recognizedif there is a mediastinal shift (Fig. 34-19). tal anomalf'?' 63(Fig. 34-23), or as a sequel to chronic bronchitiso
For example,neoplasticinfiltration may result in increasedlobar or aspiration of mineral oi1.6a Emphysemaassociatedwith chronic
volume and mediastinal shift to the contralateral side, whereas bronchitis may also produce foial'lucent lesions (Fig. 34-24).
lobar collapse may result in a mediastinal shift to the ipsilateral Other causesof focal pulmonary hyperlucency include congenital
side. Consolidation as a result of bronchopneumonia or hemor- bronchogeniccyst, traumatic bulla,6spneumatocele,2e'66 and pul-
rhage usually results in no recognizable change in volume of the monary thromboembolism.6TBronchogenic cysts and bullae are
affected lobes. In animals in which pleural fluid collects around usually recognizedradiographically as cavitary lesions becausethey
the collapsedlobe, a mediastinalshift may not be observed." Of contain gas; however, a fluid-filled cyst or bulla might be mistaken
the lung lobes of the dog, the right middle lobe is most prone to for a solid nodule (Fig. 34-25).
collapse.suThis also appearsto be true of cats, becauseapproxi-
mately 10% of cats with bronchial diseasehave a collapsedright
middle lobe,' probably as a result of bronchial obstruction by
mucus or exudate(Fig. 34-20). Lung lobe torsion is an uncommon
causeof lobar consolidationin dogs.'''"' " Typically,the affected Table 3tI-5. Differential diagnosis of pulmonary
lobe (usually the right middle lobe) is not visible radiographically hyperlucency
becausesurrounding pleural fluid masksits borders.Ultrasonogra- Diffuse
phy is a potentially useful method for examining animals with N o n p u l m o n a r yf a c t o r s
consolidatedlung lobes (Fig. 3a-21) or pleural fluid.se'60 OverexDosu re
Mixed radiographic patterns composed of two or more of the Hypovolemia
patterns described in this section may be encountered when a Hyperinflation
diseaseaffects different components of the lung simultaneously or I n c r e a s e dt i d a l v o l u m e , e . 9 . ,m e t a b o l i ca c i d o si s
latrogenic(positive-pressure ventilationunder anesthesia)
is at different stagesof development in different locations in the
Air trapping
lung. Pulmonary conditions that often produce mixed radiographic Emphysema
patterns include neoplasia,hemorrhage, parasitism, eosinophilic Focal
infiltrates,and smoke inhalation (Fig. 3a-22). C o n g e n i t a lb r o n c h i a lc y s r
Localizedbreakdownof pulmonary parenchyma
Emphysema
I Hyperlucency Pneumatocele
Bulla
Hyperlucency implies that the lung appearsless opaque than nor- S u b p l e u r a lb l e b
mal in technically adequateradiographs. In addition to the finding Bronchiectasis
of reduced pulmonary opacity, the cardiac silhouette, aortic Cavitarysoft-tissuemass
shadow, and ventral aspects of the thoracic vertebrae may be Neoolasm
sharply defined. ]ust as an interstitial infiltrate may be mimicked Granuloma
by underexposure or expiratory exposure, artifactual hyperlucency Paragonimuscyst
may be produced by overexposure or overinflation of the lung Abscess
R e d u c e db l o o d s u p p l y
during anesthesia.Weight loss and hlpovolemia also may produce
P u l m o n a r yt h r o m b o e m b o l i s m
apparent lung hyperlucency by reducing x-ray attenuation in the
The C ani neand FelineLung 441
F i g u r e 3 4 - 1 8 . A 3 - ye a r - o ld fe m a leJa ck Ru sse l te r r ie rh ad a cough for 2 days and then devel opedpal l or,dyspnea,hemoptysi s,and m el ena.In rnorac rc
r a d i o g r a p h(sl a t e r aAl , d o r so ve n tr aB)
l ,th e r eis a m ixe dp u lm onarypatternthat obscuresthe cardi acsi l houette. The l eft crani all obe'appears cons ol i dated and the
r e m a i n d eor f t h e l u n g h a s a m a r ke din te r stitiatol a lve o lapr a ttern;the pul monaryvessel sare most vi si bl ei n the l eft caudall obe,i ndi cati ng
that thi s i s the l eas t
a f f e c t e dl o b e .T h e t r a ch e a lul m e n is n a r r o we da s a r e su ito f extensi vemucosalhemorrhage. A l so,the crani almedi asti numl arge arrow i ) and pl euralfi s s ures
(smallwhite arrow) appearwidened compatiblewith pleuralfluid. The dog died despitetreatment,The pathologicdiagnosis
was pieural,pulmonary,and intestinal
h e m o r r h a gceo m p a tibe with a n tico a g u la rnot d e n ticidto e xicity.
Figure 3/t-2O. Exampleof collapseof the right middlelobe in a cat with bronchial
h th e co lla p se dlo b e i s vi si bl eonl y as a ti ssue
d i s e a s e .I n t h e l a te r a rl a d io g r a p /A/,
edge (arrow)superimposedon the cardiacsilhouette.ln the ventrodorsalradiograph
/8/, it appearsas a smalltriangularopacilYbrrow)adjacentto the cardiacsilhouette.
Figure g/I-21. A 3-yearold female Retrieverwas hit by a car and had a ruptureddiaphragm.After surgeryto repairthis injury,there was persistent
pneumothoraxand consolidationof the right middle lung lobe. In thoracicradiographsmade after referral(ventrodorsalview A/, there was an opaqueright
middlelobe without apparentloss of volume,compatiblewith consolidation. To better definethe changesin this lobe,ultrasonography was performedthrough
an in t e r c o s t awl i n d o w / B J.T h e p r im a r yb r o n ch u swa s flu idfille d,appeari ng "fl ui d bronchogram").
as an anechoi cbranchi ngstructure{so-cal l ed Th orac otomy
revealedinfarctionof the right middlelobe.Althoughtorsionwas not present at surgery,torsionsecondaryto the diaphragmatlc rupturewas consideredto be
a lik e l yc a u s eo f t h e i n fa r ctio n(.F r o mSto wa te rJL , L a m b CR: U l trasonography of non-cardi ac
thoraci cdi seasesi n smal l ani mal s.J A m V et Med A s s oc
195: 5 1 41. 9 8 9 . )
The C ani neand Fel ineLuno 44?
I
i
Figure 34-25. A, Lateralthoracicradiographof a terrier-crossdog hit by a car about t hour previously.The lucent space between the heartand the sternum
ind i c a t e sp n e u m o t h o ra x, a n d th e r eis a m o d e r a ted, iffu sein te r sti ti apatternconsi stentw i th l ungcontusi on, parti alcol l apse,
or both.C l osei nspec ti on al s orev eal s
s m a l l ,g a s - f i l l e dt r a u ma ticlu n g b u lla e( a r r o ws) .8 ,Re p e a tr a d iograph 24 hours l atershow s resol uti onof pneumothorax patter n.The bul l aeare
and i ntersti ti al
pa r t i a l lfVi l l e dw i t h f l u i d ( p r o b a b ly
b lo o d )a n d n o w a p p e a ra s sh a rpl ydefi ned,roundnodul es.A t thi s stage,they may be mi si nterpreted as othertypesof pul monary
no d u l e ;h o w e v e r t, h e histo r yo f r e ce n tth o r a cictr a u m a ,th e p r ogressi on from gas to gas and f ui dj i l l edstate,and the peri pheral l ocati onare typi c a of traumati c
lun gb u l l a e .
The C ani neand Fel i neLunq 445
I Pulmonary mass lesions massesis as stated for nodules in Thble 34-2. primarv neoDlasiais
the most common causeof a pulmonary massin the dog or cat.
Although the pulmonary nodule is described in the section on
interstitial patterns, some additional discussionof mass lesions is
required. Lesions that are usefully classifiedas "masses" are larger I Galcified pulmonary lesions
than "nodules" and, becauseof their size, often produce a "mass A variety of pulmonary lesionsmay calcifu.un,70 Thesecalcifications
effect" such as displacementof adjacentorgans.Unilateral pulmo- may be classifiedas focal or diffuse (Table34-6). Many instancesof
nary massesoften causea mediastinal shift toward the contralateral focal pulmonary calcification in the dog or cat represent incidental
side (seeFig. 3a-19). When there is no mass effect and the shape findings; however, calcification is a notable featuie of Histoplasma
and location of the lesion correspond to a specific lung lobe, granulomas in dogs3eand is observedin a small proportion of
consolidationor lobar collapsewith local pleural fluid accumula- primary pulmonary neoplasmsr'(Fig. 3a-27). Barium sulfate sus-
tion must alsobe considered.When thesethree possibilitiescannot pension, which may be deposited in the lung during bronchogra-
be distinguishedradiographically,some alternaiiveimaging mod- phy or when an upper gastrointestinal contralt study is attempied,
ality such as ultrasonography'n,un(Fig. 3a-26) or computed tomog- may be confusedwith calcificationbut is more opaquetFig.:+-
raphf'8 may be useful. The differential diagnosis of pulmonary 28).
Figure 3tt-28. A, Lateralthoracicradiographof an old lrish setter presentedfor lamenessevaluation.This radiographwas made as a routinepre-anesthetic
check,and, unexpectedly, bariumwas seen in the caudoventrallung.The dog had an uppergastrointestlnal contraststudy severalyears previously;there was no
his t o r yo f r e s p i r a t o rsyi g n s.T h e lo ca tio no f th e b a r iu min th is r a di ographi s compati bl w
e i th aspi rati on
and subsequent to the tracheobronc hil yalmph
transl ocati on
nodes(arrows).Most aspiratedbariumis coughedup within a few minutes;bariumuptakeby macrophages and migrationto regionallymph nodesaccountsfor a
relativelysmall part of total lung clearancein these patients.B, Dorsoventralradiographof anotherdog made during an attemptedupper gastrointestinal series.
A s p i r a t i o no f b a r i u ms ulfa tesu sp e n sio n h a s o u tlin e dth e tr a ch eaand l obarbronchiThe . greatestopaci fi cati on bronchii s i n the ri gh tmi ddl el obe,a
of i ntral obar
c om m o ns i t e f o r a s p i ra tio p n n e u m o n iaAcc,
. a cce sso r lo y b e ;L C d,l eft caudall obe;LC r, eft crani all obe;FC d, ri ghtcaudall obe;R C r,ri ghtcraniall obe;R M, ri ght
m i d d l el o b e .
The C ani neand FelineLunq r yn
References 31. Calvert CA, Mahaffey MB, Lappin MR, et al: pulmonary and disseminated eosino-
philic granulomatosisin dogs. J Am Anim Hosp Assoc 24:311,198g.
1. Allan GS, Howlett CR: Miliary bronchiolithiasis in a cat. T Am Vet Med Assoc 32. Walker MA: Thoracic blastomycosis: A review of its radiographic manifestations
162:214, 1973. in 40 dogs. Vet Radiol 22:22,1981.
2. Myer CW: Radiography review: The vascular and bronchial patterns ofpulnonary 33. Suter PF, Lord PF: Thoracic Radiography: A Text Atlas of Thoracic Diseasesof
disease.Vet Radiol 21:156,1980. the Dog and Cat. Wettswil, Switzerland, pF Surer, 1984, p 595.
3. Mantis R Lamb CR, Boswood A: Assessmentof the accuracy of thoracic radiogra- 34.- Pechman RD: The radiographic features of pulmonary paragonimiasis in the dog
phy in the diagnosis of canine chronic bronchitis. J Small Anim Pract 39:518, 1998. and cat. J Am Vet Radiol Soc 17:182, 1976.
4. Moise SN, Wiedenkeller D, YeagerAE, et al: Clinical radiographic, and bronchial 35. Reif JS, Rhodes WH: Linear opacities in canine thoracic radiographs. An Vet
J
cytologic features of cats with bronchial disease:65 cases( 1980-1986). J Am Vet Med Radiol Soc 9:57, 1968.
Assoc 194;1467,1989.
36. Farrow CS: Near-drowning in the dog. ) Am Vet Radiol Soc 18:6,1977.
5. Suter PR Lord PF: Thoracic Radiography; A Text Atlas of Thoracic Diseasesof 37. Tams TR, Sherding RG: Smoke inhalation injury. Comp Contin Educ pract Vet
the Dog and Cat. Wettswil, Switzerland, PF Sutea 1984, p 570. 3:986,1981.
6. Corcoran BM, Thoday KL, Henfrey JI, et al: Pulmonary infiltration with eosino- 38. Dobbie GR, Darke PGG, Head KW: Intrabronchial foreign bodies in dogs. J Small
phils in 14 dogs. J Small Anim Pract 32:494,1991. Anim Pract 27:227, 1986.
7. Moon M: Pulmonary infiltrates with eosinophilia. J Small Anim Pract 33:19, 1992. 39. Burk RL, Corley EA, Corwin LA: The radiographic appearance of pulmonary
8. Losonsky JM, Thrall DE, Prestwood AK: Radiographic evaluation of pulmonary histoplasmosis in the dog and cat: A review of 37 .ur. histoii.r. J Am Vet Radiol Soc
abnormalities after Aelurostrongylus abstrusus inoculation in cats. Am J Vet Res l9:2. 1978.
44:478, 1983. 40. Wolf AM, Green RW: The radiographic appearance of pulmonary histoplasmosis
9. Staub NC, Nagano H, Pearce NL: Pulmonary edema in dogs: Especially the in the cat. Vet Radiol 28:34,1987.
sequenceof fluid accumulation in the lungs. J Appl Physiol 22:227, 1967. 41. Millman TM, O'Brien TR, Suter pF, et al: Coccidioidomycosis in the dog: Its
10. Myer CW, Burt lK: Bronchiectasis in the dog; Its radiographic appearance.J Am radiographic diagnosis. J Am Vet Radiol Soc 2O:50, 1979.
Vet Radiol Soc l4:3, 1973. 42. Forrest LJ, Graybush CA: Radiographic patterns of pulmonary metastasis in 25
11. Douglas SW: The interpretation of canine bronchograms. J Am Vet Radiol Soc cats.Vet Radiol Ultrasound 39:4, 1998.
15:18,1974. 43. Ackerman N: Radiographic aspects of heartworm disease.Semin Vet Med Surs
12. Webbon PM, Clarke KW: Bronchography h normal dogs. J Small Anim Pracl 2:15, 1987.
18t327,1977. 44. CarlisleCH: Canine dirofilariasis:Its radiographicappearance.Vet Radiol 2l:123,
1980.
13. Walter PA: Non-neoplastic surgical diseasesof the lung and pleura. Vet Clin North
Am Small Anim Pract 17:359,1987. My:, W: Radiography review: The alveolar pattern of pulmonary disease.I Am
15.
Vet Radiol Soc 20:10, 1979.
14. Myer W; Radiography review: The interstitial pattern of pulnonary disease.Vet
Ra d i o l 2 1 :1 8 ,1 9 8 0 . 46. Lord PF: Neurogenic pulmonary edema in the dog. J Am Anin Hosp Assoc
l l :778,1975.
15. Biller DS, Myer CW: Case examplesillustrating the clinical utility of obtaining
both right and left lateral thoracic radiographsin small animals. I Am Anim Hosp 47. Kolata RJ, Burrows CF: The clinical features of injury by chewing electrical cords
A sso c2 3 :3 8 1 ,1 9 8 7 . in dogs and cats.J Am Anim Hosp Assoc l7:219, 1981.
16. Reif JS,RhodesWH: The lungs of ageddogs:A radiographic-morphologiccorrela- 48. Berry CR, Gallaway A, Thrall DE, et al: Thoracic radiographic features of anticoag-
tion. I Am Vet Radiol Soc 7:5. 1966. ulant rodenticide toxicity in fourteen dogs. Vet Radiol Ultiasound 34:391, 1993.
17. Suter PF, Carrig C, O'Brien TR, et al: Radiographicrecognition ofprimary and 49. Kerr LY: Pulmonary edema secondary to upper airway obstruction in the dog: A
metastaticpulmonary neoplasiaof dogs and cats.J Am Vet Radiol Soc 15:3, 1974. reyiew of nine cases.I Am Anin Hosp Assoc 25:207,19g9.
18. Lang J, Wortnan JA, Glickman LT, et al: Sensitivity of radiographic detection of 50. Moon ML, Greenlee PG, Burk RL: Uremic pneumonitis-like syndrome in ten
lung metastasesin the dog. Vet Radiol 27:74,1986. dogs. J Am Anim Hosp Assoc 22;687,1986.
19,'fiemessen I: Thoracic metastasesof canine mammary gland tumors: A radio- 5l._Parent C, King LG, Walker LM, van Winkle TI: Clinical and clinicopathologic
graphic studl Vet Radiol 3A249,1989. findings in dogs with acute respiratorydistresssyndrome: t9 cases(1985-1993).J Am
Vet Med Assoc 208:1419,1996.
20. Holt D, Van Winkle ! Sclielling C, et al: Correlation between thoracic radiographs
and postmortem findings in dogs with hemangiosarcoma: 77 cases( I 984-1989) ) An 52. Suter PF, Lord PF; Thoracic Radiography: A Text Atlas of Thoracic Diseasesof
Vet Med Assoc 200:1535,1992. the Dog and Cat. Wettswil, Switzerland, pF Suter, 1984, p 564.
21. Hammer AS, Bailey MQ, Sagartz JE: Retrospective assessmentof thoracic radio- 53. Darke PGG, Gibbs C, Kelly DF, et al; Acute respiratory distress in the dog
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34:235,1993.
54. Gee BR, Farrow CS, White RL Orr l: paraquat toxicity resulting in respiratory
22. Barthez PY, Hornof WJ, Theon AP, et al: Receiver operating characteristic curve distress syndrome in a dog. I Am Anin Hosp Assoc 14:256, l9jg.
analysis of the performance of various radiographic protocols when screening dogs
55. Lord PR Gomez JA: Lung lobe collapse: pathophysiology and radiologic signifi-
for pulmonary metastasis.J Am Vet Med Assoc 204:237, 1994.
cance.Vet Radiol 26:187,1985.
23. DeHaan CE, PapageorgesM, Kraft SL; Radiographic diagnosis. Vet Radiol Ultra-
56. Robinson NE, Milar R: Lobar variations in collateral ventilation in excised dos
s o u n d 3 2 :7 5 ,1 9 9 1 .
lungs. Am Rev Respir Dis 121:827,1980.
24. Barr FJ, Gibbs C, Brown PJ: The radiological features of prinary lung tumours 57. lohnston GR, Feeney DA, O'Brien TD, et al: Recurring lung lobe torsion in three
in the dog: A review of thirty-six cases.j Small Anim Prcct 271493,1986. Afghan Hounds. .l Am Vet Med Assoc 184:842,1984.
25. Koblik PD: Radiographic appearanceof primary lung tumors in cats. A review of 58. Lord PR Greiner TP, Greene RW, et al: Lung lobe torsion in the dog. J Am Anim
41 cases.Vet Radiol 27:66, 1986. Hosp Assoc 9:473, t973-
26. Barr F, Gruffydd-Jones TJ, Brown Pl, Gibbs C: Primary lung tumours in the cat. 59. Stowater JL, Lamb CR: Ultrasonography of non-cardiac thoracic diseasesin small
J Small Anim Pract 28:1115,1987. animals.) Am Vet Med Assoc 195:514,1989.
27. Miles KG, Lattimer JC, Jergens AE, et al: A retrospective eyaluation of the 60. Reichle JK, Wisner ER: Non-cardiac thoracic ultrasound in 75 feline and canine
radiographic evidence of pulmonary metastatic diseaseon initial presentation in the patients.Vet Radiol Ultrasound 41:154,2000.
dog. Vet Radiol 3l:79,1990.
61. Moise SN, Spaulding GL: Feline bronchial asthma: pathogenesis,pathophysiology,
28. Shaiken LC, Evans SM, Goldschmidt MH: Radiographic findings in canine nalig- diagnostics, and therapeutic considerations. Comp Contin Educ pract Vet 3:1091,
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29. Silverman S, Poulos PW, Suter PF: Cavitary pulmonary lesions in animals. J Am 62. Herrtage ME, Clarke DD: Congenital lobar emphysema in two dogs. ] Small Anim
Vet Radiol Soc 17: 134. 1976. Pract 26:453,1985.
30. Ackerman N, Spencer CP: Radiologic aspectsof mycotic diseases.Vet Clin North 63. Tennant BJ, Halwood S: Congenital bullous emphysema in a dog: A case reporr.
An Small Anim Pract 12:174, 1982. I Small Anim Pract 28:109,1987.
448 NECKAND THORAX-COMPANIONANIMALS
65. Aron DN, Kornegay lN: The clinical significance of traumatic lung cysts and
associated pulmonary abnormalities in the dog and cat. J Am Anim Hosp Assoc
19:903,1983.
66. Lamb CR, Neiger R: Differential diagnosis of pulmonary cavitary lesions. Vet
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67. FliiLckigerMA, Gomez IA: Radiographic findings in dogs with spontaneous pulmo-
nary thrombosis or embolism. Vet Radiol 25:124,1984.
68. Tidwell AS: Diagnostic pulmonary imaging. Probl Vet Med 4i239, 1992.
69. Thrall DE, Goldschmidt MH, Clement RJ, et al: Generalized extensive idiopathic
pulmonary ossification in a dog; A casereport. Vet Radiol 21;104, i980.
70. Berry CR, Ackerman N, Monce K: Pulmonary mineralization in four dogs with
Cushing's slmdrome. Vet Radiol Ultrasound 35:10, 1994.
X Questions
l. A large dog has a nodule in the right middle lung lobe. In a
left lateral recumbent radiograph, the nodule is likely to:
A. Be invisible.
B. Appear smaller than on a right lateral view
C. Be similar in appearanceto a right lateral view
4. It is normally recommended that thoracic radiographs be ex- 9. Match the following pulmonary lesions with the most appro-
posed at peak inspiration. State an exception to this rule. priate description:
A. Tiaumatic pulmonary hemorrhage
B. Bronchopneumonia
5. List three predictable differences in the radiographic appear-
C. Cardiogenic pulmonary edema
anc€ of pulmonary nodules and pulmonary blood vessels seen
D. Smoke inhalation
eno on.
1. Often produces a mixed radiographic pattern that re-
flects damage to the bronchi and alveoli.
6. How might repeating thoracic radiographs within 24 hours aid
2. Usually has a bilaterally symmetrical distribution in the
diagnosisof a pulmonary lesion?
caudal lobes.
3. Usually affectsthe ventral lung.
7. True or False.Aspiration bronchopneumonia in a dog is likely
4. Is often localized and asymmetrical.
to be less visible on a dorsoventral thoracic radiograph than on a
ventrodorsal thoracic radiograph. 10. List five differential diagnosesfor pulmonary calcification.
8. A 9-year-old female German shepherd had a chronic cough Answers begin on page 727,
The C ani neand Fel ineLunq 445
Figure 3/t-3O
'11trtl
ffi35
ffi Larynx,Pharynx,
Airway
ffi ."J,l,Proximal
The laryngeal/pharyngeal region is commonly evaluated radio- disorders.This procedure, performed by placing barium in the
graphicallyby checkingthe size,shape,and position of each of its mouth with a dose syringe followed immediately by radiography,
parts against the norm (Figs. 35-1 and 35-2). However, more than usually allows differentiation of pharyngeal from laryngeal maises;
structural analysis is required for complete assessmentof this it also enablesevaluation of the ability of the epiglottis to keep
anatomic region. Endoscopyhas provided valuable functional in- ingestedmaterial out of the trachea(Fig. 35-3).
formation. Further, the pharynx, larynx, guttural pouches, and
trachea must be conceived of as a functional unit, not merely as
so many individual, unrelatedparts. Anatomic abnormalitiesmust
be sought and explainedin light of observeddysfunction,particu- I The appearanceof
larly that which has been witnessedendoscopically.
It is the correla- I laryngeal disease
tion between radiographic abnormalities and endoscopicallyob-
served malfunctions that forms the basis for diasnosis in this In terms of what may be specificallyidentified in a radiographic
complex region. 1mage,the larynx consistsof the epiglottis, the arytenoepiglottic
foids, the corniculateprocessof the arytenoid cartilage,ttre lateral
ventricles,and the body of the larynx (seeFig. 35-l). Architectural
I Complementary examinations or spatialalterationsto thesestructuresconstitutethe basisfor the
radiographic signs of laryngeal disease.These signs include (1)
Pharyngography and esophagography
abnormalepiglotticpositionrelativeto the soft palate,(2) epiglottic
Pharyngographyand esophagography are performed to assesssus- thickening or marginal irregularity, (3) decreasedepigloitii size
pected soft-palate and epiglottic dysfunction, as weli as swallowing (includeslength if measurable),(4) displaced,deformed,indistinct
.,4
ro;r:l,i
Figure 35-1. A, Rig h tla te r apl r o je ctio nT. h e n o r m a e
l q ui nel arynx,pharynx,and gutturalpouches.B , C ompani onl i nedraw i ng
451
452 NECKANDTHORAX-EOUIDAE
arytenoepiglotticfolds or corniculateprocesses,and (5) laryngeal one of the arytenoepiglotticfolds, causingthe proximal part of the
or paralaryngealmineralizationor gas.r larynx to be nearly formless and greatly increasedin opacity (Fig.
Acute epiglottiditis resulting from inflammation or infection 35-7). Likewise,a paraepiglotticmass or mass effect may distort
typically resultsin uniform enlargementas observedendoscopically or obscurethe rostral part of the larynx (Fig. 35-8). Paralaryngeal
Nasotrachealintubation injury may causesim-
or radiographically.'? abscessation may occur secondaryto laryngealinfection. If fistu-
ilar changes.3 lation develops,the abscessmay drain into the larynx, its support-
Medium to large subepiglottic,epiglottic, and paraepiglottic ive content being replacedby air; this can produce a variety of
massescan alsobe radiographicallyidentified.Theselesions,partic- distinctivegas accumulations(Fig. 35-9).s
ularly if of the subepiglottictype, may displacethe epiglottis in a Epiglotticentrapmentmay or may not be detectableradiographi-
dorsocaudaldirection, effectivelyincreasingthe distancebetween caily. Decreasedepiglottic size and altered shape and positioning
the epiglottis and the soft palate. Unfortunately, it is often not relativeto the soft palatesuggestentrapment;invariablesequential
possibleto establishthe etioiogy of such lesionsbecauseof their imagesof the epiglottisdo likewise.6Epiglottic blunting and dorsal
radiographicsimilarity. Differential considerationsinclude subepi- displacementhave also been observedin associationwith entrap-
glottic cyst, granuloma,abscess, and rarely,tumor (Fig. 35-4). m ent.7,8
Inflammation (especiallyif chronic), postsurgicalscarring, and Laryngealmineralization may occur as a function of aging, or,
congenitaldisordersmay distort or otherwisealter the appearance alternatively, may develop following laryngeal surgery or chronic
of the epiglottic and arytenoid tissues(Figs.35-5 and 35-6).' laryngealinflammation, arytenoid chrondritis, or arytenoid chon-
Occasionally,a primary lesion such as a tumor may occur in drosis (Fig. 35-10;.'0," Such dystrophic calcificationmay signify
Soft
; '' p o l o t e- '
F "
. a:
r:iiiiltli:riii;
iil$ll].iilllllt
*i
.iilut lluu,iiiu:rriii:
.-:
. si
t, ii rt,,,i'rt,t.,iit9ll;
Subepiglotticobscess
A B
Figure 354, A, Exampleof a subepiglotticmass,latera projection D ragnosi s:
subepi gl ottiabscess.
c B , C ompani on
l i nedraw i ng
Larynx,Pharynx,and ProximalAirwav 453
'. :
l
-
i
l __Jr*4
Tooth rools
B
Figure 35'5. A , L a te r apl r o je ctio nCh
. r o n icla r yn g e ainfl
l ammati on
has resui tedi n epi gl otti cdeformi tyand restri ctedmoti on.B , C ompani on
l i nedraw i nq
t.'liiilir,,ir:l
liilll 'i,,,
tiliul
ltrlr
,
"lr
F i g u r e 3 5 - 6 . A , De fo r m ityo f a r yte n o idca r tila g ea n d a s soci atedl aryngealmi neral i zati on g, C ompani on
resuti ngfrom surgi calfa ure {ateralproj ect i on).
l i n ed r a w i n g .
454 NE CKA ND TH OR AX -EOU ID A E
fl.,,,l.,ll'l.',,
ll ' ,,,,,1
lll
Sofl polole
(l I
$,
$'i
Epiglottis 'Poroepiglollic
mosS
A B
Figure 35-8. mass resultingin secondaryepiglotticimmobiization(lateralprojection).8, Companionline drawing
A, Paraepiglottic
Larynx,Pharynx,and ProximalAirway 455
]w1[
Compressed
_.nosopnorynx
A B
F igu r e 3 5 - 1 1 . , 4 ,G u ttu r ap o u chin fe ctio nr e su ltin gin e xtr e m ecompressi on
of the pharynx,l arynx,and trachea:l ateralproi ecti on.
B , C omoanon l i nedraw rnq
4 56 NE CKA ND T H OR AX -EOU ID A E
b
; ""H-lS
'* iw:
. iillutau:'ii$uullf
.ll:'rar. iiai
'::lFlll
.iiiiiilu,iu]iiiiiiuu,,iii',
- 't d
ffillili'iilll...lll3rr.
the soft palate, without associatedlarlmgeal disorder, may be linked One or both guttural pouches may be distended with gas, fluid,
to airway disease." or a combination (Fig. 35-15). With unilateral disease,the abnor-
mal pouch often compressesthe adjacent normal pouch to the
I The guttural pouches extent that it becomes invisible radiographically.rOSeveregaseous
distention, also known as tympany, is most frequently seenin foals
The guttural pouches are large, thin-walled, air-filled extensionsof and young horses;its causeis speculative.The degreeof swelling is
the pharynx. Although readily visible becauseof their air content, often so great that the enlarged pouch compressesthe pharynx and
their superimposition and relative proximity afford minimal op- displacesthe larynx and proximal tracheaventrally. This dislocation
portunity for radiographicseparation.Oblique projectionsmay be of the proximal part of the upper airway may severelyhamper
of some use in partially separating the pouches, but only the breathing (Fig. 35-16A and B). Subtotal fluid accumulationin ihe
ventrodorsalview completelyeliminatessuperimposition.Accord- guttural pouch is usually associatedwith a distinctive fluid level in
ingly, assessment of the guttural pouches is usually based on one radiographs made with a horizontally directed x-ray beam (Fig.
or more lateral projections.'e 35-L7). It is not possible,however, to distinguish the nature of the
The radiographic signs of guttural pouch diseaseinclude in- fluid. Fortunately, the possibilities are few in number, with the two
creasedor decreasedair content, increasedfluid, deformity, intra- primary considerationsbeing exudate(empyema)and hemorrhage.
luminal mass, extraluminal gas, pharyngealcompression,and la- Hemorrhage can result from erosion of the internal carotid
ryngotrachealdisplacement. artery secondary to guttural pouch mycosis,2t although it may
A
Figure 35-13, A, LocalizedadenopathyproducingalteredcontoursIn the gutturalpouches(l ateral
proj ecti on).
B , C ompani on
l i nedraw i ng
Larynx,Pharynx,and ProximalAirway 457
,. .rrlu,lriiitllllrll
,,trlrl,iiiillll"'ii,r]l
.l 1
*i
Figure 35-14. A, Dorsaldisplacementof the soft pa ate secondaryto palatalhypoplasia(lateralprojectlon).B, Companionline draw ng
f,
tn)
Moss in'veirircilosoect
of gutlurol pouch
, llii
A iidlll
B Trocheo
Fig u r e 3 5 - 1 8 ' A , E xtr a lu m ln ag a s a ccu m u la tio nasn d flu id level sdevel opedsecondaryto chroni cgutturalpouch i nfecton,fi stul ati on,
and ex tens i onof
lnf e c t i o ni n t ot h e p r o x im ace
l r vicar e g io n ,a te r a p
l r o le ctio nB,
. Compani oni ne draw i ng.
occur secondaryto bacterialinfection, regionaltrauma, penetrating Fistulas and sinusessometimesform and often are amenableto
foreign body, or gunshot.22 Exudatemay accumulatein the guttural sinography. Bacterial gas formation occurs rarely.
pouch secondaryto a ruptured retropharyngealabscess, a regional Intraluminal massesare identified occasionallyif they are of
streptococcalinfection, or outflow obstruction secondaryto steno- sufficient size and are surrounded by air (Fig. 35*19). possible
sis of the pharyngealopening.'zr The pouch may also be infectedby causesof such massesinclude chondroids, inflammatory tissue
contaminatedinstruments,needles,or irrigating solutions.Mycotic masses,and blood clots. Tumors may appear similarly; however,
infection may extend to the adjacent stylohyoid bone, causing they are rare.
bone deposition,destruction,and in severeinstances,a pathologic Large volumes of luminal fluid may somewhat or entirely ob-
fracture.2a Most infectionsare unilateral.25 scure one or both guttural pouches.It may be especiallydifficult
Occasionally, gas or fluid levels are noted in proximity, but to establishthe laterality of such lesions becausethey frequently
external,to the guttural pouches(Fig. 35-18). Inferentially,a gut- compressthe uninvolved pouch as well as the pharynx, larynx, and
tural pouch origin should be considered,although other gas-con- proximal trachea(Fig. 35-20).
taining structures,such as the pharynx, larynx, and trachea,may
also leak air after perforation.With regardto the guttural pouches, I Tracheal disease
it is usually an infection that results in necrosisof the guttural The normal equine cervical trachea may be imaged sufficiently to
pouch wall and subsequentescapeof its gasand infectiouscontent. detect the following structures: the caudal aspectof the larynx, the
Gullurol
pouch
A B
Figure 35-19, l a sse s( chondroi ds)
A, M u ltip lelu m in am (l ateralproj ecti on).
B , C ompani on
l i nedraw i ng
460 NE CKA ND T H OR AX -EOU ID A E
A
and cervicalgas is secondaryto associatednecrosisand gas
Figure 35-2O, A, Reducedgas content secondaryto chronicexudatereplacement.Extraluminal
es c ap e( l a t e r apl r o j e c t i o n)B,
. Co m p a n io n
lin ed r a wn g .
tracheal lumen, the inner tracheal surface (mucosa),the tracheal Primary trachealdisordersare only occasionallydetectedradio-
rings, and the annular ligaments (by inference, the space between graphically. Tiacheal displacement, however, is common, usually
tracheal rings) (Fig. 35-2i; see also Fig. 35-2). The absenceot resulting from enlargementof the guttural pouch or the cervical
alterationsof these normally visible shadowsform the radiologic part ofthe esophagus,and may be readily appreciatedradiographi-
basisfor a diaenosisof trachealdisease. c a l l y( s e eF i g s .3 5 - l l a n d 3 5 - 1 5 ) .
The most common indirect indicator of trachealdiseaseis extra-
tracheal gas. Causesof extraluminal gas include (1) transtracheal
aspiration, (2) tracheal fracture after blunt trauma, (3) tracheal
perforation causedby penetratingtrauma, and (4) trachealnecrosis
secondaryto trachealor paratrachealinfection or abscess formation
(Figs. 35-22 and 35-23); the latter may result in fistula forma-
tion.2628 Gas may also be seen along the outer margin of the
trachea after laryngeal or tracheal surgery, and as a complication
of wound dehiscence. It is highly unusual for air to reach the
tracheal perimeter as a result of a laceration. In the event such
a finding is made under this iatter circumstance, it is strongly
recommended that upper airway leakagebe sought.
Pneumomediastinum is usually the result of tracheal fracture or
perforation, the escapinggas dissecting caudally into the mediasti-
num along the deep fascial planes of the neck (see Fig. 3I-21).
The origin may, however, be the thoracic trachea or bronchi.
Occasionally, air may arise from ruptured alveoli, dissecting in a
fashion along the vascular adventitia into the mediasti-
;.Jil:*U.
Decreaseddefinition of the normally visible tracheal soft tissues
may occasionally be seen with infection or trauma; however, the
change is subtle. Paratracheal disease or duplication cysts may
visually blend with the adjacent trachea, effectively mimicking
tracheal disease.'nThe absenceof a ventrodorsal view often makes
it impossible to make the necessarydistinction.
Luminal alterations in the form of tracheal stenosis,collapse,or
Figure 35-21. Extraluminal gas escapingthe cranialcervicaltrachea3 hours massesoccur occasionally.Most stenotic lesions are the result of
aspiration(lateralprojection).
after transtracheal tracheotomy-induced scarring related to incorrect surgical tech-
Larynx,Pharynx,and ProximalAirway 461
nique (see Fig.35-23).30 Deep cervical lacerations,penetrating able, unless they are sufficiently large and convex. The same may
foreign bodies, and gunshot wounds may also lead to tracheal be said for other pharyngeal masses,such as abscesses and granulo-
scarringand stenosis.Luminal massesare rare, most being tumors mas. Free pharyngeal fluid cannot be detected radiographically.
or foreign bodies.Trachealcollapsemay be congenitalor acquired,
and is often regional in nature. Based on the small number of Larynx
published reports, it is rare.''' " Trachealhypoplasiain the horse, In the horse, there frequently are no radiographic abnormalities
as in other domesticanimals,is associated with a uniformly dimin- associated with epiglotticentrapment.Subsequentserialendoscopic
ished size, but unlike in other animals, laryngeal hypoplasia may examinations of affected horses have shown varying degrees of
also be present.t' entrapment or, more usually,restrictedor limited epiglottic move-
ment (Fig. 35-24). These findings have usually been attributed to
I Diseases often associated a slight inward folding of the arytenoepiglottic folds. Thus, as
with any radiographic examination designed to evaluate altered
I with a normal-appearing anatomy, the alteration must be of sufficient magnitude to be
I radiograph recognizable; subtle changes or slight variations from normal are
likely to go undetected.For this reason, not only should endoscopy
be performed in all horseswith suspectedepiglottic entrapment,
Pharynx
but also it should precedethe radiographic examination; the
Pharyngeal lymphoid hyperplasia is radiographically recognizable chancesof finding a radiographic abnormality are thereby greatly
if the lymphoid plaques are very large and project into the pharyn- enhanced.
geal cavity; otherwise, they are indiscernible from the rest of the Laryngeal hemiplegia cannot be diagnosed radiographically, nor
pharyngealsoft tissues.t'Likewise,pharyngealcysts are undetect- can all but the most extreme epiglottic inflammations. Even this
, :,,,
rrrrrllll,tt,,,
$lil:,'.,:'t,'.,l.,
Figurc 35-24,
A
A, Lateralprojectionof a normal-appearing
fl
larynx, which on subsequentendoscopyshowed restricted epiglottic motion, B, Companion
linedra w i n g .
severetype of inflammation may not result in detectable change. 7. Butler JA, Colles CM, Dyson SJ, et al: Clinical Radiology of the Horse. London,
Blackwell Scientific Publications, 1993, p 347.
All but the largest thyroid tumors are radiographically invisible.3s
Noisy breathing, with or without distress,is one of the features 8. Dik KJ, Gunsser I: Atlas of Diagnostic Radiology of the Horse. philadelphia, WB
Saunders,1990,p 102.
of hyperkalemic periodic paralysis, a genetic disease of Quarter
horses, including young foals. Although endoscopic examination 9. Orsini PG: Xerographic examination. In Beech j (ed): Equine Respiratory Disor-
may reveal laryngeal spasm or paralysis, radiographs are likely to ders. Philadelphia, Lea & Febiger, 1991 p 12ir
appear normal.36'3t However, extreme muscular hypertrophy has 10. Haynes PF, Snider TG, McClure JR, McClure JJ: Chronic chondritis ofthe equine
been known to cause external compression of guttural pouches, arytenoid cartilage.J Am Vet Med Assoc 177:1135,1980.
with the resulting radiographic appearanceof a pharyngeal 1 l. Cahill JI, Goulden BE: Diseasesof the larynx. In Colahan PT, Mayhew JG, Merritt
m a s s . 38 '3 e AM, Moore JN (eds): Equine Medicine and Surgery, 4th ed. Goleta, California,
American VeterinaryPublications,Inc, 1991,p 411.
Trachea 12. Dik Kl, Gunsser I: Atlas of Diagnostic Radiology of the Horse. philadelphia, WB
Saunders,1990,p 104.
Tracheitis has not been described radiographicallS with or without
13. PascoeJR. Pathophysiology of upper aimay obstruction. In White NA, Moore JN
the use of contrast medium. Tracheal fluid, even in large volumes, (eds): Equine Surgery. Philadelphia, WB Saunders, 1990, p 213.
is usually not detectable radiographically. Small luminal masses
14. Honnus CM, Kemper T, Linford RL: What is your diagnosis?J Am Vet Med Assoc
(lessthan I cm) typically remain unidentified. Tiacheograms show
194:1769, 1989.
only major lesions and rarely identifr perforations, including those
15. Bllthe LL, Cardinet GH 3rd, Meagher DM, et al: Palatal myositis in horses with
that produce large volumes of extratracheal air.
dorsal displacement of the so{l palate. } Am Vet Med Assoc 183:781, 1983.
16. Haynes PF: Persistent dorsal displacement of the soft palate associated with
References epiglottic shortening in two horses. I Am Vet Med Assoc l:g:6i7, 1981.
l. Linford RL, O'Brien TR, Wheat JD, Meagher DM, et al: Radiographic assessment 17. Freeman DE: Dorsal displacement of the soft palate. In \ /hite NA, Moore JN
of epiglottic length and pharlngeal and larlngeal diameter in the Thoroughbred. Am (eds): Equine Surgery. Philadelphia, WB Saunders, 1990, p 230.
I Vet Res44:1660,1983.
18. Robertson JT: Pharlnx and larlmx. In Beech I (ed): Equine Respiratory Disorders.
2. Barclay WR Phillips TN, Foerner lJ: Acute epiglottidis in a horse. J Am Vet Med Philadelphia,Lea & Febiger,199i, p 331.
Assoc 181:925,1982.
19. Cook WR: The auditory tube diverticulum (guttural pouch) in the horse; Its
3. Holland M, Snyder JR, Steffey ER Heath RB: Laryngotracheal irjury associated radiographic examination. J Am Vet Radiol Soc 2:51, 1923.
with nasotracheal intubation in the horse. J Am Vet Med Assoc 189:1447, 1986.
20. Barber SM: Diseasesof the guttural pouches. In Colahan PT, Mayhew JG, Merritt
4. Dixon PM, Railton DI, McGorum BC: Ventral glottic stenosisin 3 horses. Equine AM, Moore JN (eds): Equine Medicine and Surgery, 4th ed. Goleta, California,
Yet I 26:166, 1994. American Veterinary Publications, Inc, 1991.
5. Farrow CS, Barber SM: Pharlngeal abscesswith larlngeal fistulation in a horse 2I. Lingard. DR, Gosser HS, Monfart TN: Acute epistaxis associated with guttural
(What is your diagnosis?).J Am Vet Med Assoc 179:830, 1981. pouch mycosis in two horses. J Am Vet Med Assoc 164:1038,1974.
6. Ferraro GI: Epiglottic entrapment. In White NA, Moore fN (eds): Equine Surgery. 22. Bayley WM, Robertson lT: Epistxis caused by foreign body penetration of a
Philadelphia, WB Saunders, 1990, p 236. guttural pouch. I Am Vet Med Assoc 180:L232,1982.
The E quineLung 463
23. Freeman DE: Guttural pouches.In Beech J (ed): Equine RespiratoryDisorders. 37. Naylor J: Equine hlperkalemic periodic paralysis. Can Vet J 35:279,1994.
Philadelphia, Lea & Febiger, 1991
38. Berry CR: ACVR Film Reading Session; Case 5. Vet Radiol Ultrasound 36:332,
24. Cook WR: The clinical features of guttural pouch mycosis in the horse. Vet Rec 1995.
8 3 :3 3 6 ,1 9 6 8 .
39. Berry CR: Answers for Film Reading Session; Case 5. Vet Radiol Ultraosund
25. Freeman DE: Guttural pouch empyema. In White NA, Moore IN (eds); Equine 36:449, 1995.
Surgery.Philadelphia,WB Saunders,1990,p 240.
28. Fubini SL, Todhunter RJ, Vivrette SL, Hackett RP: Tracheal rupture in two horses. 2. Which of the following radiographic features characterizephar-
J Am Vet Med Assoc 187:69,1985.
yngitis?
29. Peek SR De LaHunta A, Hackett RP: Combined esophagealduplication cyst in an A. Increasedpharyngealopacity
Arabian filly. Equine Vct J 27:475, 1995.
B. Decreasedpharyngealopacity
30. FreemanDE: Tracirea.In BeechJ (ed): Equine RespiratoryDisorders.Philadelphia, C. Irregular pharyngealcontours
Lea & Febiger,1991. D. Reducedpharyngealvolume
31. Carig CR, GroenendykS, SeawrightAA: l)orsoventralflattening ofthe tracheaof E. Increasedpharyngealvolume
a horse and its attempted surgical correction: A case report. ] Am Vet Radiol Soc F. Patchy pharyngeal opacities
14:32,1973.
G. None of the above
32. Simmons TR, Peterson M, Parker J, et al: Tracheal collapse due to chondrodysplasia
in a miniature horse foal. Equine Pract l0:39, 1988. 3. What is epiglottiditis,and how might it appearradiographically?
33. Dik KJ, GunsserI: Atlas of DiagnosticRadiology of the Horse. Philadelphia,WB
Saunders,1990,p 106. 4. What are the two most common causesof laryngeal calcification
34. Koch C: Diseasesof the larynx and pharynx of the horse. Comp Contin Educ in order of likelihood?
Pract Vet 5:S73,1980.
35. Hillidge CJ, SaneckiRK, Theodorakis MC: Thyroid carcinoma in a horse. J Am 5. What is the major limitation to lateral or oblique projectionsin
Ve t Me d A sso c1 8 1 :7 1 1,1982. attemptingto confirm the presenceof unilateralguttural pouch dis-
36. Traub-DargatzJL, Ingram JT, StashakTS, et al: Respiratorystridor associated
with
ease?
polymyopathy suspected to be hyperkinetic periodic paralysis in four Quarter Horse
foals. J Anr Vet Med Assoc 201:85, 1992. Answers begin on page 727.
CHA P T E R
36
The Equine Lung
I C. S. Farrow
The thorax of a foal may be completelyimaged with a 14 X 17- and one or both humeri usually are visible cranially.The lung is
inch x-ray film (Fig. 36-14 and B). By comparison,four lilms of typically overexposed and difficult to see clearly because of the
this size are neededto image the thorax of an adult horse (Figs. high kilovoltage required to penetrate the thick cardiovascular
36-2 through 36-5). tissuesand the musculature of the partially superimposedproximal
forelimbs.
I Normal appearance
A standard radiographic examination of the thorax of an adult
Caudodorsal proiection
horse comprises four projections, including (1) craniodorsai,(2) This projection providesthe largestunobstructedview of the lung.
cranioventral,(3) caudodorsal,and (4) caudoventral.Each requires It is important to recognize that normal interstitial lung opacities
a different radiographic technique. Cardiovascularassessmentis in the horse are particularly outstanding, especiallywhen compared
optimized by centering the heart on a single 14 X l7-inch film. with dogs and cats. The vascular size and pathways are relatively
Refer to Figures36-2 through 36-5. constantin this region of the lung, making it the ideal location for
assessingpulmonary circulation. The diaphragm usually appears
Craniodorsal proiection flattened, or the thoracic side may be slightly convex.
The dorsal part of the heart, the cranial aorta, and the large
pulmonary arteries and veins are evident in this view. Also seen Caudoventral projection
are the trachea, the tracheal bifurcation, and the continuing bron- This view provides visualization of the caudal part of the heart,
chi. The lung is visible, but it is difficult to evaluate because of the left atrium, and associatedpulmonarv veins. A radiolucent
superimpositionby the heart and vessels.An accurateassessment triangle of lung, bounded by the iaudal vena cavaithe ventral part
of heart size is impossible from this view. of the diaphragm, and the caudalmargin of the heart, is a conve-
nient location for evaluating the lung parenchyma.
Cranioventral projection Of the four describedprojections,the caudodorsaland caudo-
Most of the heart, the aortic origin, the cranial mediastinum,and ventral views are most apt to reveal any pathologic processesln
the thoracic part of the trachea are visible in this view. The scapulae the lung.
Text continuedon Dage168
4G,4 NECKAND THORAX-EOUIDAE
w/ry
Coudolveno covo
Principol bronchi
'Diophrogm
End-on view ol ,/
illltll,,,rllll
-'llll"llll
'rl,r'li
,:W r - S- { l
qqg&l
i, SJ
' '1ffi
' ql
t:l
!6
r.!
,, r,"ri:lrrrrrr
rilClr,.'.111{1lll
. .: r,.ttt,rrrrltrtiilBut,ril
,l.,,;.,.:..tll.lgl,1
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. . , , i. t . , , , t i ; t r , l s r r . 'l l 1 F
.;.::i
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' Sl
- -4::
:,A;9.;iP|ari9ll$i
-.. :,.,,,:,,,, ::,,,,,iiir, ii6|iii
r,,lll,,;,
rilillllr
Multi-comportmentedlung moss
seen with righl side neorestto film
A
c
F ig u r e 3 6 - 6 . A , C o s e u p r ig h t la te r ath o r a cicr a d io g r a p oh f centrall ung regi on(ri ghtsi de of horse nearestcassette). Therei s a arge,vaguel ymargi nated
p r o xim ato
c av i t a r yl u n gl e s i o ni m me d ia te ly l th e h e a r tb a se .B, Compani oni ne draw i ng.C C ose-upeft ateralthoraci cradi ograph of centrall ungregi on(l efts i de
of h o r s en e a r e s ct a s s ette )T. h e sa m e lu n g e sio na s th a t se e n in A i s vi si bl e,but l t i s more sharpymargl nated.
The rel ati vei mprovement i n esi onc l ari tvi ndi c ates
t he c a v i t aot n i s n t h e l e ft sid eo f th e lu n g .D, Co m p a n io nin e d raw i ng.
The E qui n eLung 469
Owing to the enormous size of the horse'sthorax (often ex- massessuch as abscesses, granulomas,or metastases(Figs. 36-9
ceeding 1 meter in width), vascular superimposition is marked, to 36-11).
especiallyin the lateral projection. Body fat further degradesthe Fungal pneumonia also has a range of appearances, a common
radiographicimage through scatterand resultantloss of structural one being widespread,relatively indistinct spherical opacification
definition. (Fig. 36-12). Mixed peribronchial-interstitialpatterns have also
An inability to make postural radiographs,such as decubitaland been observed.Histoplasmacapsulatum and Coccidioidesimmitis
erect projections, prevents detection of the movement of pleural are reported most frequently in the southwesternUnited States,the
fluid awayfrom potentialmassesin the ventral aspectof the thorax, latter sometimesappearingas a large solitary lung mass.tChronic
particularly those in the cranial mediastinum. mycotic pneumonia may appear as diffuse ventral consolidation
(Fig.36-13).
Viral pneumonia usually does not alter the lung enough to be
I Specific lung diseases -
detected radiographically.
Pulmonary abscessation
Pneumonia
In young horses,and less commonly in adults, pleuropneumonia
Equine bacterial pneumonia usually occurs in the ventral half may lead to abscessation,
although abscesses
may developindepen-
of the lung, often appearing initially as a localized or regional
consolidation superimposedon the caudal heart margin (Fig.
36-7).1 If therapeutically unchecked, many equine pneumonias
result in abscessation and pleuritis'?'3 (Fig. 36-8).
Interstitialpneumonia (alveolitis)occursin foalsas well as adults
and is currently theorized to be a distinct diseaseof unknown
cause,occurring in at leasttwo forms.aIn the foal, the radiographic
alterations are often subtle, initially revealing a mild increase in
overall lung opacification,sometimesaccompaniedby prominent
bronchi (probablyrepresentingperibronchialinflammation). As an
aside,the radiographsof pneumonic neonatesoften appearto have
been made during expiration. Although such an appearancemay
in part be due to expiration, it may also be associatedwith an
elevatedrespiratoryrate or low tidal volume. Further volume loss
probably results from luminal obstruction due to inflammatory
secretions.
When thoracic radiographsare made in recumbent foals, pos-
tural atelectasisdevelops almost immediately (assuming the animal
was standing previously) and is well advanced if the foal has
been recumbent for longer than a few hours. Thus, apparent lung
opacification in such animals must-at least in part-be attributed
to a combination of factors other than disease,including postural
atelectasis,hypostatic pulmonary congestion, and reduced ventila-
tion associatedwith recumbent positioning.
In adult horses(i.e., those 2 years of age and older), interstitial
Figure 36-8. Latera thoracicradiograph.There s patchyconsoliclation be-
pneumonia may result in a generalizedmild to moderate opacifi- grnnrngat the l evelof the aortaand extendi ngventral l yw he re i t ob i terates
cation or a diffuse patchiness;the latter may be confused with lung the caudalpartof the heart.D i agnosi s:
regi onalpneumona w ith abs c es s at on.
4 7 O NE CKA ND T H O R AX -EOU ID A E
Lung hemorrhage
Injury-inducedhemorrhage
Blunt or penetrating injury to the lung often produces bleeding,
which may be identified in conjunction with other thoracic abnor-
malities such as pneumothorax, hemothorax, and rib fracture. The
resultant lung consolidation usually resolves within 1 week; this
enables the differentiation of pulmonary hemorrhage from other
forms of consolidation such as pneumonia, which take longer to
disappear.
Exercise-induced hemorrhage
Exercise-inducedpulmonary hemorrhage may cause localized, re-
gional, or diffuse parenchymal bleeding, in some instancesresulting
in sudden death.' Often, however, the disorder is not fatal but
results in weakness,epistaxis, and radiographically identifiable le-
sions in the dorsal aspect of the caudal lung lobes. Observed
changesrange from totally opacified, wedge-shapedregional lesions
to nearly transparent, oval-shaped entities, usually located in the
caudodorsalpart of the lung (Fig. 36-17).10Radiologic-pathologic
correlation indicates a direct relationship between degree of lesion
opacification and severity of the disorder.lr Curtent research is
focusing on the relationship between the large cardiac output
generatedduring racing and the inability of pulmonary capillaries
in some horses to withstand the resultant pressure-relatedstress.r2
Figure 36-1O. Lateralthoracic radiographin which there is a moderate
and reducedvascularclarity.Diagnosis:moderate,
Diffuse bleeding disorders such as disseminatedintravascular coag-
increasein lung opacification
diffuse interstitialpneumonia. ulation (DIC) may resemblepneumonia.'r
The E qui neLung 471
r,lll:.,,l9lilS
..'iltSut.,tlrll;
I '::illllt:illlrui
iilliut,
illlut,-tut
:.:1.:W
,,lll,,,lilll,ll
ii:illl
L$lt),,. ' '..,r.
,ir
&li:iir3rl, .t
@li:iiiir;'r.
,
lr:11@tt'rr.,
::':
:):.:.
))..;.
lllllirilllll.
li llll.lt:tr,,.,t,r,
lil',,,
lll9lr
:a:,)l:
,,;,ll""ll'
Pulmonary edema
There are three potential distributions of pulmonary edema: (1)
vascular, (2) interstitial, and (3) alveolar; these distributions reflect
changesto the lung with increasingpulmonary capillary hydrostatic
pressure.Which distribution is present varies with the severity and
duration of the inciting condition. Combined patternsare common
with pulmonary edema because the excessivecirculating blood
Figure 36-15. Lateralthoracicradiograph. Thereis a weli-marginated region volume initially enlarges the pulmonary veins, later resulting in
of c o n s o l i d a t i oi n t h e c e n tr a lu p n e u m o n iawi
l n gfie ld .Dia g n o sis: , th extensl ve accumulationof fluid in the interstitium (i.e., perivascularintersti-
ou m o n a r vc o n s oi d a t l o n. tial tissues)and subsequentlyin the alveoli.'u'ttAlveolar edema is
almost always acute and usually (but not always) is bilateral. In the
early stages,edema often collects about the hilus-an extremely
Lung rupture and the accumulation of difficult radiographic determination to make in animals with left
extrapulmonary air atrial enlargement and pulmonary hyperemia, and especiallydiffi-
cult in horses becauseonly lateral projections are usually available.
Rupture of the lung usually producespneumothorax,often associ- The causesof pulmonary edema are broadly divided into those
ated with pulmonary contusion. Occasionally, there also may be due to circulatory causes,such as heart failure or fluid overload,
hemothorax. Most such iniuries are causedby blunt trauma, but and those that are unrelated to heart disease,in which increased
they may be incurred by a penetratingthoracicwound (Fig. 36-18). capillary permeability is the fundamental diseasemechanism. Ex-
amplesof the latter include aspirationof stomachcontents,smoke
Pulmonary hyperemia, oligemia, and inhalation, near-drowning,and strangulation.One way of separat-
vascular deficit ing cardiac from noncardiac pulmonary edema is the rapidity with
Heart disease,whether congenitaior acquired,is the most common which the former may resolve-often in as little as 24 hours with
causeof altered pulmonary vasculaturein the horse' In neonates effective theraov.
i:.' :l
: ::::i.Jjl
ry_*rjli*t
A
Figure 36-16. A, Close-uplatera thoracicradiographcenteredon the heart.There is a gas-cappedfluid line superimposedon the heart base. B, Companion
co m m u n lca tinlu
lined r a w i n g .D i a g n o s i s: g n ga b sce ss.
The E quineLung 473
Noncardiac pulmonary edema has been reported recently in such bronchi or bronchiolesmay appearas lung nodules,or in the
horses immediately following inhalation anesthesia.Proposed caseof larger airways,as lung masses.
causesincluded severe alveolar hypoxia related to anesthesiaand
acute upper airway obstruction during recovery.ls
Chronic obstructive lung disease
Chronic bronchitis and bronchiectasis Chronic obstructivelung diseaseis the most common pulmonary
Chronic bronchial diseaseis capableof causingenough structural disorder of mature horsesthroughout most parts of the world. The
alteration in the bronchi and surrounding connectivetissueto be majority of these disorders are associatedwith a normal radio-
recognized radiographically.When present, bronchial diseaseis graph; the minority have abnormal-appearinglungs. In this latter
characterized by an outlining or accentuation of the large and regard, there are no consistentfindings, although the lung and
middle airways, enhancing their radiographic visibility. Seen on airways are usually diffusely affected-often by linear and ring-
end, the diseasedbronchus resemblesa ring; in profile, the affected shaped opacities,or by very small, poorly defined lung nodules.
airway appearsas a pair of parallel lines'' (Fig. 36-19). Functionaily, especially in the advanced stagesof these disorders,
Bronchiectasis,generallyconsideredto be an end stageof chronic chronic obstructive lung diseasemay be inferred from the radio-
bronchitis, is characterizedby a pronounced accentuationof the graphic triad of (1) hyperinflation, (2) hyperlucency,and (3) pul-
large and medium-sized airways,at times accompaniedby cylindri- monary oligemia, particularly if present on both inspiratory and
cal or saccular enlargement of one or more bronchi. Because expiratory radiographs.Some of thesehorsesalso show a uniform
bronchiectatic airways often contain fluid, end-on projections of tracheobronchialdilation (seeFig. 36-19).
References 19. Farrow CS: Radiographic aspects of inflammatory lung diseasein the horse. Vet
Radiol 22:107,1989.
1. Kangstrom LE: The radiological diagnosis of equine pneumonia. Vet Radiol 20. Dik KL Gunser I: Atlas of diagnostic radiology of the horse. part 3: Diseasesof
9:8 0 ,1 9 6 8 .
the head, neck, and thorax. Philadelphia, WB Saunders, 1990,pp 160, 162, 164.
2. Raphel CF, tseech lB: Pleuritis secondary to pneumonia or lung abscessationin 21. Mair TS, Hillyer MH, Brown PJ: Mesothelioma of the pleural cavity in a horse:
90 horses.J Am Vet Med Assoc 181:808,1982. Diagnostic features. Equine Vet Educ 4:59, 1992.
3. Mair TS, Lane JG: Pneumonia, lung abscessesand pleuritis in adult horses: A
review of 51 cases.Equine Vet J 2l:175, 1989.
7. SweeneyCR: Causesof pleural effusion in the horse. Equine Vet 4175,1992. 2. Of what use is vascularassessment
in the radiographicevalua-
tion of lung disease?
8. Farrow CS: Radiographic examination and interpretation. In Beech J (ed): Equine
RespiratoryDisorders.Philadelphia,WB Saunders,1991,p 89.
3.- A mass with a gas-fluid interface is seen in the dorsal lung field
9. Gunson DE, SweeneyCR, Soma LR: Sudden death attributable to exercise-induced
pulmonary hemorrhagein racehorses:Nine cases(1981-1983).I Am Vet Med Assoc
of a 6-year-oldhorse.What is the most likely diagnosis?
1 9 3 :1 0 2 ,1 9 8 8 .
4. What are two significanttechnicallimitations of equine thoracic
10. PascoeJR, et al: Radiographicaspectsof exercise-induced
pulmonary henorrhage
in racing horses.Vet Radiol 17:134,1983.
radiographyin relation to canine thoracic radiography?
11. O'Callaghan MW et al: Exercise-inducedpulnonary henorrhage in the horse:
5. Tlue or False:Multiple pulmonary nodules in a horse are less
Results of a detailed clinical, post mortem and inaging stucly. VI. Radiological/
pathologicalcorrelations.Equine Vet J 19:419,1987. likely to be neoplasticthan a similar radiographicfinding in a dog.
12. WesatJB, Mathiew-CostelkrO: Stressfailure of pulmonary capillariesas a mecha-
nism for exerciseinduced pulmonary hcmorrhage in the horse. Equine Vet J 26:441,
6. Why is a mediastinal shift difficult to identi$' in equine thoracic
1994. radiographs?
13. Morris DD, Beechl: Dissenrinatedintravascularcoagulationin six horses.J Am
Vet Med Assoc 183:1067,1983.
7. In which portion ofthe lung are radiographicchangesassociated
with equine exercise-inducedpulmonary hemorrhag- most likely
14. Cottrill CM, et al: Persistenceof fetal circulatory pathways in a newborn foal.
Equine Vet | 19:252,1987.
to be seen?
15. Dik Kl, Gunser I: Atlas of diagnosticradiology of the horsc. Part 3: Diseasesof 8. In which portion ofthe lung are radiographicchangesassociated
the head, neck, and thorax. Philadelphia,WB Saunders,1990,p 156.
with equine bacterialpneumonia most likely to be seen?
16. Morgan PW, Goodman LR: Pulmonary edcma and adult respiratory distress
syndrome.Radiol Clin North Am 29:943,1991.
9. Even though it is not possible to obtain ventrodorsal radio-
17. Staub NC, Nagara H, Pearce ML: Pulmonary edema in dogs, especiallythe graphs of the equine thorax, how might one determine if a lung
sequenceoffluid accumulationin the lungs. J Appl Physiol22:227,1967. massis in the right or left lung?
18. Ball MA, liim CM: Post anesthesiapulmonary edema in 2 horses. Equine Vet
8 :1 3 ,1 9 9 6 . Answers begin on page 727.
CHA P T E R
37
The Pleural Space
. RussellL. Tircker . Ronald D. Sande
I Anatomy the thorax and the abdomen. The anatomic limits of the costo-
diaphragmatic recessmay be estimated on the surface of the horse
Pleural anatomy should be taken into consideration when the
by piacement of a line connectingthe following points: the lTth
equine thorax is evaiuated.Horses have minimal external lung lobe
intercostalspaceat the level ofthe tuber coxae;the 15th intercostal
separationand lack prominent interlobar fissures.The mediasti-
spaceat the level of the tuber ischii; the l3th intercostalspaceat
num is partially fenestrated.The parietal pleura is reflected along the dorsoventralmidpoint; the 11th intercostalspaceat the level
three major boundaries,which serve as important landmarks in of the point of the shoulder; and a gradually descendingline
diagnostic imaging.t At the sternal line of reflection, the costal to the point of the elbow. Radiographically, this line is located
pleura reflects dorsaliy to become the visceral pleura of the ventral a?proximatelyat the level of the costochondraljunctions caudalto
mediastinum. At the vertebral line of reflection, the costal pleura the ninth rib, where it courses caudally and dorsally at a gradually
turns ventrally to form the dorsal mediastinal pleura. Perhapsthe increasing distance from the sternal ends of the ribs to the level of
most important pleural reflection in diagnostic imaging is the the midshaft of the last rib. It then reflects slightly cranially and
diaphragmatic reflection, at which the parietal pleura of the costal dorsally to terminate at the vertebral end of ihe last intercostal
surface extends to the surface of the diaphragm and forms the space.
costodiaphragmaticrecess.This line is the demarcation between Radiographic examination of the thorax for the purpose of
476 NE CKA ND T H OR AX -EOU ID A E
I Ultrasonography
Ultrasonography may be used for primary examination of the Figure 37-1. Left-right of an equinethoraxwith a small
lateralradiograph
thorax or to augment radiographic findings. Portable ultrasound Theventralmarginof the lungis visl'le (anows).
pleuraleffusion. Noticethe
silhouettesignof the ventral
heartanddaphragm andlossof detailof the
machines often provide the initial method of imaging the pleural peripheralrightmiddlepulmonary vasculature.
space.Ultrasonographyis consideredthe diagnostictechnique_of
choicefor assessing pleuropneumoniaor pleural effusion.tIn addi-
tion, the presenceof loculatedfluid, pleural thickening,pulmonary
abscess,and concurrent pericarditis can be accurately detected thorax. This normal finding is often misinterpretedas the accumu-
with ultrasonography.'Ultrasonography is alsoextremelyuseful for lation of fluid.
locating and determining the boundariesof fluid-filled spaces.This A common error in radiographic interpretation is made when
provides an inexpensivemethod by which the responseof pleural one expects to always find a fluid line with pleural effusion. The
diseaseto treatment can be monitored. Ultrasonographicexamina- characteristic fluid line (horizontal fluid-air interface) is createdby
tion is used to study tissue texture or fluid composition and may the interface of the pleural effusion ventrally and the free gas
provide an etiologic diagnosisin horses with pleuropneumonia'' dorsally.Becauseof the capillarity and surfacetension, a straight
Ultrasonography,which can be used to guide catheterplacement (horizontal) fluid line is not presentunlessthere is also free gas in
for targetedthoracentesis, ensuresproductiveyields.tThe literature the pleural space.In the absenceof free gas within the pleural
should be consulted for a more complete understandingof this space,a straight fluid line will not be seen even though pleural
valuable imaging modality.n n effusion may be present.
The pathogenesisof pleural effusion is complex, and the causes
are many.3''0Pleural effusion may be primary or secondaryand
I Diseasesof the pleura may be associatedwith coexistingdisease.Reportedcausesinclude
r-'aprimary neoplasia,lsabdominal neoplasia,'u
I and pleural space thoracic metastasis,r
inhaled foreign bodies,'t''* and primaryre-22and systemic infec-
tion'z3;it may also occur secondary to pneumonia, pulmonary
Pleural effusion abscess, trauma,2aand pulmonary infarction.'?s Our experiencealso
Accumulation of fluid within the pleural spaceis often a nonspe- includes pleural effusion associatedwith esophagealperforation
cific finding. Differentiation of transudate, exudate' or blood is and descendingcellulitis and as a sequelto respiratory infection
impossible without a thoracentesis.Many folds and pockets exist compoundedby stress.
within the mediastinum and pleural cavities. Horses are usually in Pleural effusion,regardlessofcause, is usually detectedon physi-
a standingposition and, as expected,accumulationof fluid is most cal examination, including auscultation and percussion. Radio-
often dependent. The earliest radiographic sign of fluid in the graphic examination may be used to substantiatethe clinical diag-
pleural space is loss of detail in the ventral aspect of the thora-'r nosis. Radiographic signs vary according to the volume of fluid
caudal to the heart (Fig. 37-1). The area cranial to the heart is present; howeveq negative findings do not preclude the presence
more difficult to evaluate. Loss of vascular detail within any pafi of significant fluid."' Small volumes of fluid result in increased
of the lung nearestthe ventral margin of the thorax is an indication opacity and loss of detail in the ventrocaudal thorax. Increased
of pleural effusion. The volume of fluid required for radiographic volumes of fluid result in progressivesilhouettingof the border of
detection varies with the size of the patient and the quality of the the diaphragm, the heart, and the vena cava (Fig. 37-2). These
study. Perhaps no less than 1 or 2 L in any compartment can be signs are compounded by concomitant collapse of the lungs with
detected in a 450-kg patient. Greater volumes of fluid result in loss increasedpulmonary opacity and loss of detail due to reduction of
of detail, which progressesdorsally in the thorax, causing silhouet- air from the pulmonary parenchyma.
ting of the fluid with the borders of the diaphragm and the heart. The prognosis and treatment of pleural effusion are not often
Deipite the opinion that fluid moves freely between the right and determined or altered by the radiographic findings. Radiographic
left pleural spaces,it is common to find compartmentalizationof evidence of fluid in the pleural space or mediastinum does not
the fluid or unilateral fluid; the latter is most often associated provide definitive information as to the cause. To determine the
with inflammatory conditions and is best studied by the use of etiology of pleural effusion, thoracentesisis necessary.
ultrasonography. Fat adjacent to the heart in the mediastinum Ultrasonography is very useful for locating and characterizing
causesaccentuation of the costal border of the lungs in the caudal pleural effusions. Its echogenic characteristicscan reveal details of
The P l eur alSpace 477
the fluid's cellularity and inflammatory nature. The amount and the scalloped borders characteristic of restrictive pleuritis in other
Ievel of the fluid can be accurately visualized and followed over species are not typically seen. Accumulation oi fibrin may be
time. In addition, the condition of the surface and subpleural tissue detected when pleural adhesions and fibrin sheets form and the
of the adjacent lung can be evaluated (Fig. 37-3). The detection of pleural fluid regresses.The fibrin tags tend to orient vertically
free gas echoes associated with anaerobic bacterial infection, exten- within the pleural spaceor are at least more easily identified when
sive fibrinous tags, or areas of loculation within the pleural fluid their axesare orthogonal to the vesselsand airways within the lung
is associated with a poor prognosis, requiring a more extensive (Fig.37-4).
therapeutic regimen.3 Ultrasonography is invaluable for performing Severechronic fibrinous pleuritis mav become compartmental-
g u i d e d t h o r a c o c e n te sis, e sp e cia lly in co n d itio n s w i th l ocul ated ized, resulting in cavitary pieural disease,which is difhcult if not
fluid. Ultrasonographic examination may be difficult or impossible impossible to distinguish from cavitary lung disease.Compartmen-
when a large volume of free air is present in the pleural space.a talization of pleural fluid often results in confusing imiges (Fig.
37-5). The inability to perform a dorsoventral or ventrodorsal
Pleuritis projection of the equine thorax often limits the clinician to specula-
tion regardingthe location of many lesions.Ultrasonography
Radiographic signs of acute or subacute pleuritis are often not prove helpful for identifying cavitary pleural disease. -ry
differentiated from those of effusion. The presence of fibrin re- Ultrasonographicexamination can allow for detection of subtle
mains undetectedunlessit causesrestriction of the lung margins. pleural thickening and inflammatory changes in the early phases
Becausethe equine lung is not divided by deep interlobar fissures, of pleuritis and pleuropnemonia.The normal, uniformly'smooth,
Figure 37-3- Two-dimensional B-modetransverseultrasoundimagesof the right and left thorax of an adult horse wlth bilateraloleuraleffusion.A. Lett-sided
s o n o g r a mi n t h e e i g hthin te r co stasp a cea t th e e ve o f th e chondrocostalj uncti on.Therei s anechoi cpl euraleffusi on(pE )betw eeni he thoraci cw al l (TW )and the
ventral dome of the diaphragm(D) that measures5 cm in width. The ventral lung iL) margin is collapsedowing to atelectesis(arrowheads).g, Rightsided
j uncti on.On thi s si de,therei s l essanechoi cpl euraleffusi on(pE );how ev er,the v entral
s o n o g r a mi n t h e e i g h thin te r co stasp a cea t th e le ve lo f th e chondrocostal
lung (L) marginis more severelycollapsedand containspocketsof hyperechoicaeratediung (arrows)mixedwith hypoechoicconsolidatedlunqtissue hrrowneaosr
478 NE CKA ND T H O R AX -EOU ID A E
- ;,r;,:_-,;i:
and reflective pleural surface of the lung becomes patchy and finding of large volumes of gas in the pleural space as a result of
irregular in the early phasesof the disease.With progression,Iarger gas-producing bacteria is very rare. However, it is common to find
subpleuralconsolidationsand abscessation of peripherallung tissue entrappedgas within an abscess(seeFig. 37-5).
may become evident with ultrasonography(Fig' 37-6). The hallmark radiographicsign of pneumothoraxis clearvisual-
ization of the margins of the lungs. Air in the pleural spacerises
Pleural and extrapleural masses dorsally and compartmentalizes according to the availabie space.
In the standing horse, free air quickly moves dorsally, adjacent to
In the absence of excessivefree fluid, a pleural mass may be the spine. The mass of pulmonary and cardiactissuein the horse
visualized radiographically. The location of the mass may be deter- results in dependent displacementof tissue in relation to air. Sharp
mined by the use ofopposing projections(Fig.37-7). Radiography visualizationof the dorsal lung margins is a reliable sign of air in
is likely to be informative when the lung surface is normal and the pleural space(Fig. 37-8). Right and left lateral projectionsmay
changesoccur more deeply within lung tissue or are confined to be necessaryfor accurateidentification of the pulmonary margins
the mediastinum." and for determination of the location of the pneumothorax. The
Tissue massesextending from the pleural surface or in contact detection of pneumothorax does not enable identification of the
with the costal pleura may be best examined with the use of precise location of air within the thorax, nor does it define the
ultrasonography. cause. The use of ultrasonography to detect pneumothorax is
difficult becausethe free air in the dorsal thorax and that in the
Pneumothorax aeratedventral lung appear sonographically similar.'
Pneumothoraxhas multiple causes,although the sourcesof air are Pneumomediastinumcan result whenever a significant volume
limited to the lung, esophagus, and external body surface. The of free gas is introduced into, or is produced within, the mediasti-
F i g u r e 3 7 - 6 . A , T wo - d im e n sio nB- a l m o d etr a n sve r se u tr a soundi mageof the ri ghtthoraxof an adul thorsew rth sonographisi c gnsof earl ypleuri ti sThere
. is a
s m a l la m o u n to f a n e ch o icp le u r ael ffu sio n( PE)b e twe e nth e thoraci cw al l (TW)and the l ung (L).The pl euralsurfaceof the l ung i s i rregul ar and h as s ev erals mal l
foci castinglinearreverberations indicatingplewitis (arrows). The normallung surfaceshouldbe smooth and uniformlyhvperechoic.The thoracicpleuralsurface
ap p e a r sn o r m a la t t h is tim e . B, T wo - d im e n sio nB- a l m o d etr a nsverseu trasoundi mage of the l eft thoraxof an adul t horsew i th a subpl eur al ;bs c es s of the
s u p e r f i c i a l l u n g . A l a rg e h yp o e ch o icle sio n isp r e se n ta lo n gthepl eural sur{aceofthel ungparenchyma (anow s).Thethoraci cpl eurai sal soi hic k enedandi rregul ar
an d a s m a l la m o u n to f p le u r ael ffu sio n ( PE)is p r e se n t.( lm a g e s
compl i ments
of N ormanR antanen, D V M, S anLui sR ey E qurneH osoi talB, onsal l.CA .)
Fig u r e 3 7 - 7 . A , R i gh t- le ftla te r raal d io g r a p h oaf n e q u in e th orax.Therei samassl esi onw thw el l -defi nedmargi ns.D of etai
thecaudalvenacavaanddi apnragm
is a d e q u a t eT. h e r ei s l osso f d e ta ilin th e lu n gcr a n iaal n d ve n tr alto the mass.8, Left-ri ghtl ateralradi ograph
of the same horse.Therei s sl i qhtl os sof detai li n the
ow e r l e f t c o r n e ro f t h e im a g e .T h e m a ssle sio nis m a g n tfie d a nd superi mposed i n that area.
9. RantanenNW: Diseasesofthe thorax. Vet Clin North Am Equine Pract 2:49, 1986. 3. In this left lateral radiograph of the dorsal,caudal thorax of a
7-year-old Quarter horse gelding with respiratory difficulty after
10. Smith BP: Pleuritis and pleural effusion in the horse: A study of 37 cases.I Am
Vet Med Assoc 170:208,1977.
being used as a rodeo horse (Fig. 37-9), what are the significant
findings and what is the radiographicdiagnosis?
ll. Foreman JH, Weidner JR Parry BW, et al: Pleural effusion secondaryto thoracic
metastatic mammary adenocarcinoma in a mare. J Am Vet Med Assoc 197:1193, 1990.
4. Radiographicsignsof pleural diseasein the horse:
12. Morris DD, Acland HM, Hodge TG: Pleural effusion secondary to metastasis of
A. Are first seenas loss of detail in the ventral thorax, craniai
an ovarian adenocarcinoma in a horse. i Am Vet Med Assoc 187:272' 1985.
to the heart.
13. RossierY, SweeneyCR, Heyer G, et al: Pleuroscopicdiagnosisof disseminated B. Result in loss of detail and obscurity of the aorta, dia-
hemangiosarcomain a horse. J Am Vet Med Assoc 196:1639,1990.
phragm,and cardiacmargins.
14. Mueller PO, Morris DD, Carmichael KR et al: Antemortem diagnosis of cholangio- C. Result in a fluid line, indicating the fluid level in the thorax,
cellular carcinoma in a horse. I Am Vet Med Assoc 201:899, 1992.
on horizontal-beamlateral projections.
15. Mair TS, Lane JG, Lucke VM: Clinicopathological features of lymphosarcoma D. May require a fluid or air volume in excessof 2 L for
involving the thoracic cavity in the horse. Equine Vet J 17:428, 1985. detectionby radiographyof the thorax.
16. Harvey KA, Morris DD, Saik JE, et al: Omental fibrosarcoma in a horse. ] Am Vet
Med Assoc l9l:335, 1987. 5. Pneumothorax in the horse is usually recognizedby the follow-
17. Hultgren BD, Pearson EG, Lassen ED, et al: Pleuritis and pneumonia attributed rng
to a conifer twig in a bronchus of a horse. J Am Vet Med Assoc 189:797, 1986. A. Elevation of the heart and lung margins from the sternum
18. O'Brien JK: Septic pleuritis associatedwith an inhaled foreign body in a pony. Vet B. Clear definition of cardiacmargins
R e c l l9 :2 7 4 ,1 9 8 6 . C. Clear definition of the diaphragmaticcrura
D. Clear definition of the dorsal lung margins and aorta
19. Benson CE, SweeneyCR: Isolation ofSrreptococcuspneumoniae type 3 from equine
species.J CIin Microbiol 20:1028, 1984.
20. SweeneyCR, Divers TJ, Benson CE: Anaerobic bacteria in 21 horses with pleuro-
6. In this right lateral projection of the cranial dorsal thorax of a
pneumonia. J Am Vet Med Assoc 187:721,1985. 3-year-old Thoroughbred filly with respiratory distress,elevated
temperature is noted following transport between racetracks (Fig.
21. Rosendal S, Blackwell TE, Lumsden JH, et al: Detection of antibodies to MTco-
plasma felis in horses. J Am Vet Med Assoc 188:292, 1986. 37-10). What are the significantfindings and radiographicassess-
ment?
22. Hoffman AM, Baird JD, Kloeze HJ, et al: Mycoplasmafelis pleurtis in two show-
jumper horses. Cornell Vet 82:155, 1992.
7. Pleural effusion in the horse:
23. Mair TS, Lane JG: Pneumonia, lung abscess,and pleuritis in adult horses: A
A. Results in retraction of lung margins and scalloped lung
review of 5l cases.Equine Yet I 21:175, 1989.
borders on radiographicimages.
24. Collins MB, Hodgson DR, Hutchins DR: Pleural effusion associatedwith acute B. Results in progressive obscurity of margins of the heart,
and chronic pleuropneumonia and pleuritis secondary to thoracic wounds in horses:
43 cases(1982-1992). I Am Vet Med Assoc 205:1753, 1994.
diaphragm, and vena cavaon radiographicimages.
C. Is characterizedby cavitary changesand fluid-air interfaces
25. Carr EA, Carlson GR Wilson WD, et al: Acute hemorrhagic pulmonary infarction
on radiographicimages.
and necrotizing pneumonia in horses: 21 cases (1967 1993). J Am Vet Med Assoc
210:1774, 1997. D. Does not occur as a primary diseaseand is often associated
with radiographic signs of coexisting disease.
26. Pruter PE, Patton CS, Held JP: Pleural effusion resulting from malignant hepa-
toblastoma in a horse. I Am Vet Med Assoc 194:383, 1989
8. Which of the following statementsregarding the use of ultraso-
27. ReefVB, Boy MG, Reid CF, Elser A: Comparison between diagnostic ultrasonogra-
phy and radiography in the evaluation of horses and cattle with thoracic disease:55
nography in the detection and evaluation ofpleural diseaseis false?
cases(1984 1985). I Am Vet Med Assoc 198:2112, 1991. A. The echogeniccharacteristicsof fluid may provide informa-
The PleuralSpace 481
Figure 37-9
Figurc 37-1O
4 A2 NE CKA ND T H OR AX -EOU ID A E
Figure 37-l I
tion that helps in the determination of the etiology of A. When the diseaseis in the mediastinum or occurs deep to
oleural effusions. lung tissue.
B. illtrasonography can yield information about the pleural B. When lesions extend from lung margins into the lung
lining and pericardium. parenchyma.
C. Ultrisonography is useful for evaluation of the lung surface C. For differentiation of causes of pleural and mediastinal
when a lirge volume of free air is present within the masses.
pleural space. D. For detectionof fibrinous, restrictivepleuritis.
D. Ultrasonographyis helpful for detectingthe irregular sur-
face of the normally smooth visceralpleura of the lung in 10. In this left lateral radiograph of the thorax of a l2-year-old
the early phasesof pleuritis and pleuropneumonia' Thoroughbred mare being treated for chronic pleuritis (Fig. 37-
11), what are the significantfindings and radiographicassessment?
9. Diagnostic radiology of the equine thorax, for the study of
pleural disease,is better than ultrasonography: Answers begin on page 727,
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ABDOMEN-GOMPANION
ANIMALS
CHA P T E R
3B
Interpretation Paradigms for the
Abdomen-Ganine and Feline
r Nancy E. Love . Clifford R. Berry
I Objectives to the diaphragm and cranial to the stomach (lateral and ventro-
dorsal zones 1 and 2). The cranial margin of the liver follows the
At the completion of this chapter,the readershould be able to:
contours of the diaphragm ("dome" shaped).The caudal margin
1. Identift each abdominal zone and know which organs are is sharply marginated and may be difficult to visualize on the VD
within eachzone. view. There is silhouetting between the lobes of the liver, the liver
2. Describenormal radiographicsignsfor various abdominal or- and the diaphragm, and sometimesthe liver and the stomach,If
gans. the patient is exceptionally fat, individual liver lobes may be identi-
3. Describe the protocol for making a survey radiograph of a fied. The liver of both the doe and the cat is divided into four
small animal abdomen. -quadrate.
lobes: left, right, caudate,and The left and right lobes
4. Follow or develop an interpretation paradigm for the small are further divided into medial and lateral sublobes.
animal abdomen. Normal liver size is empirical; therefore, both views must be
5. Understand the indications for the use of ultrasound, CT, used to make a determination.All indicators neededto assess liver
MRI, and nuclear scintigraphy when evaluating the small animal size may not be present;however,the observermust still decide if
abdomen.
483
484 A N IMA L S
A B DO M E N-C OMP AN IO N
Lateral Lateral
Gallbladder Medial iliac lymph nodes
Stomach Ureters
Body Colon/rectum
Pylorus Ventrodorsal
Pancreas Medial iliac lymph nodes
Mesenteric lymPh node Ureters
Ventrodorsal Colon/rectum
Liver U r i n a r yb l a d d e r
Left lobes Uterus
Stomach Prostategland
Fundus Rectal lymph node
Body
SPleen Structures listed in italics are not normallv visualized.
Head
Left adrenal gland
Structures tisted in italics are not normallY visualized Structures listed in italics are not normallv visualized.
Interpretati on
P aradi gms
for the A bdomen-cani nean d Feline 4g5
Stomach Stomach,
pancreas& duodenum
Spleen& L KidneY
Stomach, Kidneys
Colon
Golon
The kidneys (see Figs. 38-1, 38-3, 38-4, and 38-5) are of soft- Ovaries
tissue opacity and are located in the retroperitoneal space. The
cranial pole of the right kidney is often difficult to visualize because The ovaries, which lie in the retroperitoneal space caudal to the
it is embedded in the renal fossa of the caudate lobe of the liver kidneys, are not normally identified on survey radiographs. Abnor-
and thus silhouetteswith the liver. The left kidney is caudal to the malities of the ovariesare not common, but they should be consid-
right kidney, and its location is more variable. In the dog, normal ered on the differential list for dorsal to midabdominal massesin
kidney sizeis 2.5 to 3.5 times the length of L2 (using the ventrodor- intact females.
sal view); in the cat, the normal kidney sizeis 2.4 to 3.0 times the
length of L2 (using the ventrodorsalview). Testicles
The testiclesare not typically evaluated using conventional radiog-
Ureter raphy. Consider a retained testicle as the cause of an abdominal
mass in a cryptorchid male dog. Feminization may be associated
The ureters (seeFigs. 38-3, 38-4, and 38-5) lie in the retroperito-
with malignant transformation of retained testicles; radiographic
neal spaceand are not normally visualized on survey radiographs.
signs may include nipple enlargement (gynecomastia)and prostatic
If visualized following intravenous contrast medium administra-
enlargement.
tion, they should be no larger than 2 to 3 mm.
Stomach
Urethra
The stomach (see Figs. 38-1 to 38-4) lies immediately caudal to
The male urethra comprises three parts: prostatic (narrowest part), the liver and cranial to the transverse colon. The axis of the
membranous, and penile. The prostatic urethra is confined to the stomach should be parallel to the ribs on the lateral view The
prostate gland, the membranous urethra extends from the prostate pylorus of the dog is generallyto the right of midline, and the
to the os penis, and the peniie urethra is dorsai to the os penis. pylorus of the cat is generally on midline or slightly to the left of
The penile urethra is considerably shorter in the cat than in the midline. The size of the stomach is extremeiy variable, as is the
dog. In females,the urethra is shorter and wider than in males. opacity,dependingon gastriccontents.
48A A N IMA L S
A B DO M E N -C O MP AN IO N
The gas/fluid pattern within the stomach may be influenced by the small animal abdomen includes two views-the lateral and
patient positioning. The gas rises to the highest point within ventrodorsal views.
the patient. Whether to routinely make a right or left lateral view of ttr,e
abdomen depends on viewer preference. It is important that the
Left lateral-gas in pylorus positioning of the lateralview be consistent.If you chooseto make
Right lateral-gas in body and fundus a right iateral projection as part of the standard examination, then
Ventrodorsal-gas in body and pyloric antrum the right lateral view should always be made (unless there is a
Dorsoventral-gas in fundus medical reasonnot to).
Other views might also be useful. The opposite lateral view
On the right lateral view, the pylorus may appear as a round
might be made to allow gas to shift into previousiy fluid-filled
soft-tissue opacity, which may be misidentified as a mass or foreign
portions of the GI tract (seeFig. 38-6). A dorsoventralview might
body. A comparison with the left lateral view allows a redistribution
also be made to allow gas to shift, as in gastric diiation. A hori-
of fluid and gas, and gas may collect in the pylorus, making it
zontal-beam radiograph with the animal in Ieft recumbency could
easierto identify (Fig. 38-6).
Small intestines
The small intestine (seeFigs. 38-2 and 38-3) occupiesthe midab-
domen. In the dog, the normal small bowel should be no wider
than the central portion of the body of a lumbar vertebra, and it
should not exceed the diameter of twice the width of a rib. The
diameter should not exceed 12 mm, and it should be no wider
than the central portion of the body of L4. The normal bowel may
contain variable amounts of fluid or gas.In cats, gas accumulations
are typically less than in normal dogs.
Large intestines
The cecum is generally to the right of midline on the ventrodorsal
view (see Fig. 3S-a). It is located in the central abdomen on the
Iateral view. It has a C-shaped appearancein the dog. In the cat,
the cecum is very small and is usually not seen.
The ascending colon is to the right of midline. At the hepatic
flexure, the ascending colon turns to the left and continues across
the midline to the left. At the splenic flexure, the colon turns
caudally and continues into the pelvic canal, where the name
changesto rectum.
T Radiographic technique/
positioning
Radiography of the small animal abdomen requires an animal that
Figure 38-7. Lateraland ventrodorsalradiographsof the abdomenof a large
is tractable. Images may be made in the awake or sedatedpatient; dog using a total of four cassettesto includethe entire abdomen. lf this
general anesthesiais not tlpically required for a routine abdominal techni quei s empl oyed,rememberto overl apabdomi nalanatomyon both
radiographic examination. A standard radiographic examination of vtews.
Interpretation
Paradigms
for the Abdomen-Canineand Feline 489
Figure 38-1O, Lateralradiographo{ the abdomenof a dog with an enlargeduterus due to pyometra/A/, sonogramof the same uterus /8,. The contentsof the
ut eru sa r e c l e a r l yf l u d with fle ckso f e ch o g e n icm a te r ia(l co n slstent
w i th an exudate)and supportthe di agnosi sof pyometra.Fromthe radi ograph,
the ty pe of
m at e r i ailn t h e u t e r u sc o uldn o t b e d e te r m in e d .
method that either may provide the reader with the necessary the ventral soft tissues(evaluatethe ventral abdominal body wall,
foundation to develophis or her own approach,or may help one prepuce,os penis, and urethra). On the ventrodorsalview, evaluate
to become more organizedin approachingthe task of evaluating the body wall and the soft tissuessurrounding the abdomen.
radiographicexaminationsof the small animal abdomen. 3. Critically assessskeletalstructures(spine, ribs, pelvis, coxo-
Do not try to evaluateall structureson the lateral radiograph' femoral joints, femurs, and stifles).
and then all structureson the VD radiograph.There are too many 4. Evaluatethe portion of the thorax that can be seen.Incidental
structuresto allow consistentrememberingof all the changesto be thoracic findings are often critical to making the correct diagnosis.
evaluatedbetween views. Go back and forth, comparing structures 5. Evaluatethe diaphragm.
on the ventrodorsal and lateral views. (Italicized structuresare not 6. Evaluateserosalmargin detail. Rememberthat loss of detail
normallv visualized.) may be generalizedor focal dependingon the cause.
7. Evaluate the mesentericlymph nodes,Iiver, gallbladder, and
1. Evaluateradiographsfor technique,positioning, and phase
spleen.
of respiration.Make sure that the radiographsare of high diagnos-
8. Evaluate the retroperitoneal spacefor adrenal or renal alter-
tic quality before proceeding.
ations, or for masses involving the medial iliac lymph nodes.
2. Evaluate soft tissues. Progressing clockwise, begin with the
Comparethe detail in the retroperitonealversusthe intraperitoneal
dorsal soft tissues,move to the perineum (evaiuatescrotum) and
space.Often slight detail differencesare the only radiographic sign
inguinal region (evaluateinguinal lymph nodes), and finish with
of peritonealor retroperitonealfluid.
9. Evaluate the region of the ureters.
10. Assessthe urinary biadder.
11. Evaluate for the uterus in the female. Evaluate the prostate
in the male.
12. Assessthe stomach(evaluatethe fundus, body, and pylorus),
panteas, small intestine, and large intestine, including the cecum.
Remember that the cecum is not normally seen in the cat.
I Alternate imaging
Ultrasound
Ultrasound is an excellentmodality for evaluating the small animal
abdomen (Fig. 3B-10). Changesnoted in the parenchymacan be
used to further refine a radiographic differentiai list. Ultrasound
may also be used to visualize structures not seen on radiographs,
or when peritoneal effusion is present. Ultrasound is useful for
performing guided aspiratesor biopsiesof abdominal organs.
Computed tomography
Figure 38-11. Transversecomputed tomography image of a dog with a
The use of computed tomography in the evaluation of small animal
oartiallvmineralizedadrenallumot (arrowheads). abdominal diseaseis growing. The increasedavailability of conven-
Interpretation
Paradigms
for the Abdomen-Canlneand Feline 4gl
. !l
'l
l
I
Figure 38-12. Lateralscintlgramof a normaidog /A) and a dog with a portosystemicshunt /8/. The procedureinvolvesdepositionof a small amount of es.Tcin
t h e c o l o n ,w h i c h i s su b se q u e n tly a b so r b e din to th e p o r ta lclrcul ati on.
In A , the l i vercontai nsconsi derablradi
e oacti vi ty
due to normalportalfl ow . In B , tnere rs
ra d i o a c t i v i it ny t h e h e a r tb u t n o n ein th e live r T. h isis d u e to a portosystemishunt c l eadl ngto absorbedradi oacti vi bvoassi
tv nq
the l i ver.
492 ANIN/IALS
ABDOMEN-CON/IPANION
Nuclear scintigraphy
Nuclear scintigraphy may provide physiologic information to com-
plement morphologic information revealedby conventional radio-
graphs. Specific examinationsof selectedorgans of the abdomen
include liver function studies and glomerular filtration determina-
tions. Another commonly performed examination is perirectal por-
tal scintigraphy, a screening examination for portosystemic shunts
(Fig.38-12).
ffi Questions
l. Identifr the following structures(Fig. 38-13): Liver, (fundus of)
stomach, (left) kidney, spleen,urinary bladdea and (descend-
ing) colon.
2. List as true or false the ability to normally see the following
structuresin the abdominal radiograph of a dog or cat: Liver,
gallbladder, pancreas,prostate, kidneys, and ovarres.
3. Identifr the following alternate imaging examinations (Fig. 38-
l4): Ultrasound, nuclear scintigraphy,and computed tomogra-
phv.
4. What are the normal guidelines for size of the kidney and small
intestinein the normal dog?
5. What are the normal guidelines for size of the kidney and small
intestinein the normal cat?
Figure 38-13
Figure 3t14
CHA P T E R
39
Abdominal Masses
. CharlesR. Root
Stomach
Enlargementof the stomach (Fig. 39-l), whether postprandial or
pathologic, causes caudal displacement of the small bowel, the
transversecolon, and the spleen.
Uterus
Uterine enlargement is usually not detected radiographically until
it exceedsthe diameter of adjacent small bowe1. Further enlarge-
ment of the uterine body and horns causescraniodorsaldisplace-
ment of the small bowel in the lateral projection, and cranial and Fi gure 39-1. The radi ographisic gnsof gastri cenl argement
and ts effec :
possibly medial displacementof the small bowel in the ventrodorsal on adl acentvtscera.
493
494 A B DO N/ I E N -C O MP AN IOAN
N IMA L S
Figure 39-3. La\e"al(A)and ventrodorsal/8/ abdominaL radiographs of a dog with a historyof incontinence.The atonicurinarybladderis distended,displacing
t h e s m a l l b o w e l c r a n ia llya n d th e co lo nd o r sa lly.C T h e lin e di agramsshow the typi calvi sceraldi spl acement.
i A and I courtesyof the S antaC ruzV eteri nary
H o s p i t a lS, a n t aC r u z,CA.)
Liver gastric axis can still be identified if gastric contents can be seen.
Occasionally, gastrography may be necessaryto fully characterrze
Diffuse hepatomegaly hepatomegaly.
Generalized enlargement of the liver produces characteristic dis-
placement of the pylorus and pyloric antrum caudally, dorsally,
and to the left (Fig. 39-5). In the lateralprojection, the gastricaxis Focal lobar hepatic masses
(an imaginary line conirecting the fundus, body, and pylorus of Massesdeveloping in the right lateral or dght middle lobe of the
the stomach) should be either parallel to the ribs or perpendicular liver, in the absenceof diffuse hepatomegaly,often produce rather
to the spine, or somewhere between those two extremes. In the specific visceral displacements(Fig. 39-6). There is dorsomedial
ventrodorsal projection, the gastric axis should be perpendicular to displacement of the pyloric antrum, pylorus, proximai descending
the spine in the dog. Becausethe pylorus may normally be more duodenum, and ascendingcolon. Furthermore, there is caudodor-
caudal in the cat, it can be approximately 30 degreesfrom perpen- sal displacement of the adjacent small bowel loops and, if the
dicular to the spine in that species,especially in the ventrodorsal hepatic mass is pedunculated and sufficiently large, craniodorsal
projection. In many instances,the enlarged caudoventral edge of displacement of the body of the stomach. Left lateral or left middle
the abnormal liver can be seen as it projects beyond the costal lobar hepatic massescause dorsomedial displacement of the head
margin. However, when poor abdominal visceral detail prevents (proximal extremity) of the spleen, the adjacent small intestine,
direct visualization of the edse of the liver, disturbances in the and the gastric fundus (Fig. 39-7). The tail (distal extremiry) of
496 AN IN /IA L S
A B DO M E N -C O MP AN IO N
Splenic torsion
Splenic torsion may be either secondary to gastric volvulus or
independent of other abdominal lesions.' In animals in which
splenic torsion has existed for several days, only a poorly margin-
ated, generalized,pronounced splenomegalymay be seen (Fig.
39-12).t In patients with more recent splenic torsion, it may be
possible to identify caudal displacement of the gastric fundus, and
the spleen is often dramatically and diffusely enlarged and may be
drawn into a "C" shape as a result of rotation about its own
pedicle. If the tail of the spleen is located between the body wall
and the right lateral aspectof the enteric viscera,there is often
medial displacementof the descendingduodenum and ascending
colon. Signs of splenic torsion are difficult to identifo if ascitesis
Jumbar vertebral
radlograph of a dog Notlcethat arsopresent.
Figure 394. Ventrodorsal
the caudalpartof the descending colonis on the rightside.Thisfindingis
common, especiallywhenthe urinary bladderls full,whenthecolonis redun- Mesenteric or enteric masses
dant,andwhentheanimal recumbency
wasin rightlateral immediateLy before
beingplaced on itsbackfortheventrodorsal radiographicprojection. (Courtesy Circumscribedmassesoriginating in the mesenteryand those origi-
Veterinary
of the Seattle Hospital
for Surgery,Lynnwood, WA) nating from the bowel wall often produce similar radiographic
signs of visceraldisplacement.Location of such massesis variable
and often unstable in serial or positionai radiographs.Therefore,
visceraldisplacementis rarely predictable.Massesoriginating from
the spleen is variably displaced,but the fundus of the stomach may the root of the mesentery,however,generally produce characteristic
be markedly displacedcraniodorsallyif entrappedby a peduncu- peripheral enteric displacementin the ventrodorsalprojection and
lated hepatic mass of sufficient size lying to the left. It is important dorsal, cranial, and caudal displacementof the intestine in the
to realizethat focal hepatic massescan appear radiographicallyto lateral projection (Fig. 39-13). They are easilyconfusedwith some
be caudal to the stomach,a position not typically associatedwith splenic masses,especiallythose originating from the tail or body
a liver mass (seeFig. 39-7). of the spleen.Massesderived from enlargementof the colic lymph
Central lobar liver massesare rare but usually causethe body node causeventral and dextrolateral displacement of the ascending
of the stomach to be displacedcaudodorsally,creating extrinsic colon. Such ventral colonic displacementis best seen with the
indentation of its lessercurvature (Fig. 39-8). Contrast gastrogra- patient in left lateral recumbency(Fig. 39-1a).
phy may be necessaryfor this sign to be fully appreciated.
Pancreas
Spleen Pancreatic massesproduce radiographic signs that vary with the
Diffuse splenomegaly location of the mass within the pancreas.If the mass originates in
Generalized enlargement of the spleen, if miid, is difficult to verify the left limb of the pancreas(Fig. 39-15), there is almost always
radiographically.The spleenundergoesconsiderablenonpathologic lateral displacement of the descending duodenum and extrinsic
variation in size.Radiographicassessment of splenicsize is subjec- displacementof the right caudal aspectof the pyloric antrum of
tive, at best. The most acceptable criterion appears to be that a the stomach in the ventrodorsal projection. In the lateral projec-
spleenshould be consideredenlargedif its edgesare rounded and tion, the duodenum is usually displaced ventrally. If the mass
ifit obviouslydisplaces adjacentviscera(Fig. 39-9). originates from the right limb of the pancreas,there is usually no
extrinsic distortion of the gastricwall, but the adjacentportion of
the descending duodenum is displaced ventrally and to the right.
Splenic masses Identification of these radiographic signs depends on visualization
Massesoriginating in the head (proximal extremity) of the spleen
of the duodenum, sometimesrequiring administration of contrast
cause caudodorsal displacement of the adjacent small intestine in
medium.
the lateral projection. In the ventrodorsal projection, proximal
splenic massescause the small bowei to be displaced caudaliy and Kidneys
to the right. Also, becausethe gastrosplenic ligament renders the
head of the spleen relatively immobile, massesof the head of the Visualization of the entire contour of the right kidney is rarely
spleen may compressand causecranial displacement of the greater possible in survey radiographs becausethe cranial pole is embed-
AbdominalMasses 457
t&tillt4l
ls{Sf
[ *-'
Figure 39-5. Laleral(A) and ventrodorsal{8) abdomina radiographsof a dog with generalizedhepaticenlargement.There is displacementof the booy ano
pyl o r l ca n t r u mo f t h e s to m a chca u d a lly, a n d to th e e ft (C ).l A and B from R ootC R :A bdomi namasses:The radi ographidi
d o r sa lly, c fferenti al
di a gnos i sJ. A m V et
RadiolSoc 15:26.1974.)
49A AN IM AL S
A B DO M E N- C OMP AN IO N
ded in the renal fossa of the caudate lobe of the liver. However, if colon. Furthermore, there is ventral deviation of the caudal pole
the caudal pole is not visible, and if there is a homogeneoussoft- of the right kidney if the ovarian massis large enough.
tissueopacity on the right side of the craniodorsalportion of the Left ovarian masses,in addition to producing a space-occupying
abdomen, enlargementof the right kidney should be suspected, soft-tissuemass caudal to the left kidney, usually produce medial
and adjacentvisceraldisplacementshould be assessed. Enlargement (but not ventral) displacementof the descendingcolon and adja-
of the right kidney produces medial and ventral displacementof cent small bowel (Fig. 39-20). The caudal pole of the left kidney
the descending duodenum and ascending colon. There is also may be tipped ventrally, depending on the size and location of
usually left ventral displacementof the adjacent portion of the the mass.
small intestine (Fig. 39-16). At first consideration,massesoriginating in the ovarieswould
Visualizationof the left kidney is more reliablethan that of the seemto be capableof producing visceraldisplacementidentical to
right. Inability to visualizethe normal left kidney in either projec- that produced by kidney masses.They do not, however, because
tion may be the first radiographic sign associated with a left ovaries are not retroperitoneal. Therefore, as an ovarian mass
renal mass. Left renal masses often produce ventrai and medial enlarges, its ovarian ligament stretches,permitting it to gravitate
displacementof the descendingcolon and adjacent small bowel ventrally either between the body wall and the descending colon
(Fig. 39-17). (left ovarian mass),or betweenthe body wall and the descending
Renal masses,even those of considerablesize, remain dorsal duodenum and ascendingcolon (right ovarian mass).As a result,
in the abdomen. The kidneys are retroperitoneal and, like all ovarian masses usually displace adjacent structures medially but
retroperitoneal structures, are prevented from migrating ventrally not ventraily. Consequently,visceral displacementis best seen in
by the retroperitoneal fascia. Enlargement of retroperitoneal struc- the ventrodorsal view (seeFig. 39-20C and D) and is rarely appar-
tures other than the kidneys is rare. In instancesof retroperitoneal ent in the lateral projection. Becausethe ovarian ligament is
massesother than renal origin, visualizationof the ipsilateralkid- attached to the caudal pole of the kidney, a sufficiently pendulous
ney should not be impaired. Renal displacementin such instances ovary producesventral deviation of the caudal pole of the ipsilat-
varieswith the location of the mass.Adrenal masses,massesorigi- eral kidney in lateral projections.
nating from the epaxial spinal musculature, and massesoriginating
from one of the caudal ribs or one of the lumbar transverse Prostate gland
processes(Fig. 39-18) are examplesof extrarenalretroperitoneal
Generalizedor symmetricalenlargementof the prostategland pro-
space-occupying lesions.One note of caution is appropriate:Adre-
duces cranial displacement of the urinary bladder and, possibly,
nal pheochromocytoma may invade and replace ipsilateral kidney
dorsal displacementof the rectum (Fig. 39-21). The ventrodorsal
tissue (Fig. 39-19).3 Inasmuch as renal massestend to remain
projection is often of little value in assessmentof the prostate
dorsal,progressiveenlargementcausesventral displacementof the
gland. It should be noted that prostatomegaly(in the absenceof
adjacent mobile visceral structures. Becausethe kidneys are lateral
distention of the urinary bladder) can displacethe colon to either
to the root of the mesentery,renal massesproduce medial visceral
side of the midline. If the prostate gland is painful, the coion may
displacement as they enlarge.
be full of fecal material, as the animal may be obstipated.
Eccentric enlargement of the prostate gland, as produced by
Ovaries prostatic cysts or some neoplastic infiltrates, has a variable effect
Right ovarian massesare associatedwith a well-circumscribedho- on the adjacent caudal abdominal visceral structures (Fig.39-22).
mogeneousopacity chudal to the right kidney, separateand distinct Depending on the location or site of origin of the prostatic cyst,
from the caudal pole of the kidney. They produce medial, but not the urinary bladder may be displaced either cranioventrally or
ventral, displacement of the descendingduodenum and ascending craniodorsally. Contrast radiography or ultrasonography may be
Text continuedon page 513
AbdominalMasses 499
irll..' l
r. rl ,l
ii tr' 'i
, 'l i i l l l
,,
1,]]]'
F i g u r e S 9 - 7 . L a l e r a l( A) a n d ve n tr o d o r sa
/8 /a b d o m in ar a di ographsof adogw i thal ocal i zedmassi nthel eftl ateral l obeof thel i ver.There i s c rani al
andmedi al
d i s p l a c e m e notf t h e g a str c fu n d u sa n d m e d ia d
l isp la ce m e nt
of the descendi ng col on.The hepati cmassi s seento be conti nuous w i th the l i veraroundthe l atera
a n d c r a n i aa s p e c t sof th e sto m a ch .C, T h r sm a ssis d e p icte di n the l l nedi agramsas w el l . (A and B from R ootC R :A bdomi nalmasses:The radi ographidic fferenti a
d i a g n o s i sJ. A m V e t Ra d ioSo l c 1 5 2 6 , 1 9 1 4 .)
AN IM AL S
5 OO A B DO M E N-C OMP AN IO N
Figure 39-8. Latercl(A)abdominalradiographof a dog with a largecentralhepaticmass that displacesthe stomachcaudallyand dorsally.On the ventrodorsal
view (B),the mass displacesthe stomachto the left. Extrinsicindentationof the cranialborder of the stomach is best seen in the lateralprojection.The line
drawings(Cl illustratethe same effects. (A and B courtesyof AuburnValleyAnimalClinic,Auburn,WA.)
AbdominalMasses 5Ol
Figure 39-9. Lareral(A)and ventrodorsal/B/ abdominalradiographsof a dog with diffuse splenomegaly. The spleen is generallyenlarged,displacingadjacent
m o b i l ev i s c e r a a, n d its b o r d e r sa r e r o u n d e dT. h e ser a d io g r aphiscgns are seen i n the accompanyi ng
l i ne draw i ngs(C ).Therei s al sodi ffusehepatomegal ythe
;
s a s y m p h o sa r co m a( A
d i a g n o s iw . a n d B fr o m F o o t CR:Ab d omi naimasses:The radi ographidic fferenti al di agnosi s.
J A m V et R adi olS oc 15:26,1974.)
AN IN /A L S
5O 2 A B DO M E N -C O MP AN IO N
r,
\-/
Figurc 39r-1O, Latercl (A) and ventrodorsal/8/ abdominalradographsof a dog with a mass in the head of the spleen.The adjacentsma I bowel loops are
c a u d a l Lbvv th e m a ss ( C) .lA a n dB fr o m Ro o tCR:Abdomi nalmasses:The radi ographrc
disolaced J A m V et R adi olS oc 15: 26,1974.)
di fferenta di agnosi s.
A bdomi nalM asses 5O 3
. . 1 - ll* * ;
1,
"'rl;tl'r.iriicua];l
l..iiil'rlll,,,l
l:lllr.:ri[!]
:'
.'.a::,)):.:):
iiil,lliirl
ill$Ut.l
,iililll::i
..,iil!l
itu .iiwu
.i
;
tt)):.,..:
( 8 /a
F i g u r e S 9 - 1 1 . L ate r a l( A) a n d ve n tr o d o r sa l b d o m in arladi ographsofadogw i thahematomai nthetaiofthespl l een.Thesmalbow
l elpr i mariy i s di s pl ac ed
c a u d a l l yC. a n d D V i sce r adl isp la ce m e nist va r ia b led, e p e n d i ngon the l ocati onof the massw i thi nthe spl een.
A N IN /AL S
5 O4 A B DO M E N-C OMP AN IO N
Figure 39-13. Late-al(A) and ventrodorsal18l abdomina radiographsof a dog with a large cyst in the root of the mesentery.Noticethat the smal c,owe ts
, u d a lly,a n d d o r sa llyin th e a te r a lp r o j ecti on(si miar to the drspl acement
d i s p l a c e dc r a n i a l l yca that may occur w i th a spl eni cmass),but there i s per pnera
d i s p l a c e m e notf t h e b o we lin th e ve n tr o d o r saplr o je ctio nC, . D i agrammatirepresentati
c on
of the typi calradi ographisicgnsof a mesenteri mass
c .(A and B c ourres y
o f t h e A n i m a lM e d i c a Ce l n te r Ne
, w Yo r k.NY)
506 AN IM AL S
A B DO M E N -C O MP AN IO N
i-r.;tti,-i11!
F igur e 3 9 - 1 6 - l a t e r a l (A) a n d ve n tr o d o r sa 1 8l la b d o m in ar al d io graphsofadogw i thal argeri ghtki dneyneopl asm.Therei sventral di spl acement oftheadj ac ent
mobil ev i s c e r aa n d c o l o n l n th e ve n tr o d o r saplr o ie ctio nth , e d u o d enumi s not seen,but most of the adj acentsmal lbow eli s di spl aced
medi al l y.
Thes eradi ographi c
s ignsa r e s p e c f l cf o r t h e p r e se n ce
o f a cr a n iarl ig h tr e tr o p e r ito n eal
massand,togetherw i th the abserceof a normalri ghtki dneyoutl i ne,are hi ghl ys ugges ti v e of
a righ tr e n a lm a s s C D i a g r a m m a tic ch a r a cte r iza tio o fnth e r a d io graphisicgns.(A and I from R ootC R :A bdomi nalmasi es:The l adi ographiui c tt"ereni i i i i ragnos i s .
J Am Vet RadiolSoc 15:26,1974.1
A N IMA L S
5 O8 A B DO M E N -C O MP AN IO N
! - ' - :: #
a d - - *l
t:;
:!rl:;ll,
iilt9lil
'111!l .',
illlllr
. iiiii!
iillt.
',::l':)
'ltl;,
rliillu.'
,lt lr:ii
tllir;
Figure 39-19, Laleral (A) and ventrodorsal/B/ abdominalradiographsof a dog with a large
m a s s i n t h e e f t s u b lu m b a r e g io n ;n o ticeth e typ ica lvisce r aldi spl acement. The eft ki dneyi s
n o t s e e n , a n d t h e r e is ve n tr a la n d ca u d a ld isp la ce m e not f the metal l i csuturespl acedduri ng
y.is le sio np r o ve dto b e a n a d r e n a p
ov a r i o h y s t e r e c t o mTh l h eochromocytoma that had i nvaded
an d r e p l a c e dt h e l e f t kid n e yb y va scu la re xte n sio n (. F r o m Root C R : A bdomi nalmasses:The
radiographic dlfferentialdiagnosis.J Am Vet RadiolSoc 15:26,1974.)
5 IO A B DO M E N -C ON /IPA N ION
A N IMA L S
W.3le.'
rl,,,rr,iiirll
.,,',,lllfl
1i.:'l',''',
rlll
Figwe 3!r-21. Lateralabdominalradograph (A) of a dog with symmetric prostatomegaly. The ventrodorsalprojectronis generallynoncontributoryin this
c o n d i t i o nT. h e u r i n a r yb la d d e ris d isp la ce d a n d th e p r ostategl andmay be seen at the bri m of the pel vi s.Often,therei s mi i d dorsaldi s ol ac ement
cr a n ia lly, ot the
pe l v i cp o r t i o no f t h e d esce n d inco ( A
g o n , a s se e n in B. f r o m Ro otC R :A bdomi nalmasses:The radi ographidicfferenti al J A m V et R adi olS oc j S :26,1974.)
di agnosi s.
5I2 AN IN /IA L S
A B DO M E N -C O MP AN IO N
Figure 39-22. Lateralabdominalradiograph1,4/and cystogram(B)oI a dog with a prostaticcyst. ln this animal,the prostaticcyst is betweenthe colon and the
urinarybladder,whereas in other dogs the prostaticcyst nnaybe between the urinarybladderand the ventralbody wall (C and D). Cystographyor sonography
p r o sta ticcystsfr o m th e uri narybl adder.
u s u a l l ym u s t b e d o n eto d iffe r e n tia te The descendi ng coi oni s usual l ydrspl aced
dorsal l y.
The ventrod ors al (C
proj ec ti ons
of th s l esi on.(A and B from R ootC R :A bdomi namasses:The radi ographtc
y o n o t co n tr ib u tesig n tfca n tlyto th e e va lu a ti on
a n d D ) g e n e r a l ld di agnos i s .
di fferenti al
J A m V e t R a d i oS l o c 15 2 6 , 1 9 7 4 .\
A bdomi nalM asses 513
':'
:
ffiffihjlltl0l
,'_Rl
"iiiitt' i.tl*llu:,1
:::i]ttt
rq
ll*ri.lr
,:'
" 41
s-t
'. ! ' s!.ti-
: &l
illl
Figure 39-23- Lateralabdominalsurveyradiograph(A) oI a dog with medialilraclymphadenopathy due to Lymphosarcoma. Noticethe ventraldisplacementof
t h e d e s c e n d i n cg o l o n .T h e sp le e na n d live ra r e a lsoe n la r g e d.
The l i nedraw i ngs/8/ representtypi calventralvi sceraldi spl acement
i n such l esi o ns{. A c ourtes y01
Colorado S t a t eU n i v e r sitv. F o r l Co llin s.CO.)
necessary to differentiate between the urinary bladder and the 2. Root CR: Abdominal masses: The radiographic differential diagnosis. J Am Vet
prostate gland in such instances. Radiol Soc 15:26, 1974.
muscular masses,inflammatory granulomas,and abscessforma- 5. Ferron RR: Low-cost pocket-sized CO, dispenser for medical use. J Am Vet Radiol
tion. Sublumbarmassescausethe descendingcolon to be displaced Soc 17:18,1976.
ventrally in the lateral projection. There is usually a broadly based 6. Ticer lW (ed): Radiographic Technique in Small Animal practice, 2nd ed. philadel
homogeneousmassin the caudalretroperitonealspace.The ventro- phia, WB Saunders, 1984.
dorsal projection is usuaily noncontributory. Z Root CR: The urinary system. In Ticer JW (ed); Radiographic Technique in
Veterinary Practice, 2nd ed. Philadelphia, WB Saunders, 1984.
References 8. Root CR: The gastrointestinal tract. In Ticer I\{ (ed): Radiographic Technique in
1. O'Brien TR: Radiographic Diagnosis of Abdominal Disorders in the Dog and Cat. Veterinary Practice, 2nd ed. Philadelphia, WB Saunders, 1984.
Philadelphia, WB Saunders, 1978. 9. Morgan lP: Celiographywith iothalamic acid. J Am Vet Med Assoc 145:1095,1961.
|5 I4 A N IMA L S
A B DO M E N- C O MP AN IO N
Figure 39-24
Figure 39-25
A bdomi nalM asses 515
2. Which lateral projection of the abdomen routinely provides 7. Ventral and medial displacementof the descendingcolon and
better visualization of the spleen?Why? small bowel is a radiographic sign that may be produced by a mass
originating from the:
3. In instancesin which differential diagnostic featuresare lacking A. Left kidney.
in routine radiography, which of the following procedures should B. Left 13th rib.
be consideredas the next step? C. Left sublumbar muscles.
A. Contrast radiography D. All of the above
B. Positionalradiography
C. Exploratory surgery 8. The patient is a 7-year-oldfemale German shepherddog with
D. Referral progressively severe depression, anorexia, icterus, and vomiting.
E. Ultrasonography There is a palpable firm right cranial abdominal mass. Right lateral
(A) and,ventrodorsal (B) abdominal radiographs (Fig. 39-24) were
4. Which of the following contrast radiographic procedures may made approximately 30 minutes after oral administration of bar-
be helpful in further assessmentof a right cranioventral abdomi- ium sulfatesuspension.List the radiographicsignsof this disorder.
nal mass?
A. Excretory urography 9. Right lateral (A) and ventrodorsal (B) abdominal radiographs
B. Cystography were made of a 4-year-old female Doberman pinscher with a
C. Upper gastrointestinal series history ofacute vaginalhemorrhage(Fig. 39-25). ihe owner stated
D. Sonography that the dog had been bred approximately 30 days prior to onset
E. Urethrography of clinical signs, which began after recent vigorous exercise.List
the radiographic signs to be expected.
5. Name three abdominal structures that may undergo consider-
able normal variation in srze. 10. Figure 39-26 shows right lateral (A) and. ventrodorsal (B)
abdominal radiographs of a 6-year-old male Weimaraner with a
6. Caudal, dorsal, and left displacement of the small bowel com- history of anorexia and depressionand a large palpable abdominal
bined with dorsomedial displacement of the descendingduodenum mass.List the radiographicsigns.
and caudal displacement of the transversecolon is suggestiveof a
massoriginating from the: Answers begin on page 727,
CHA P T E R
40
The Peritoneal Space
r Mary B. Mahaffey . Don L. Barber
The peritoneum is a thin, serous membrane that is divided into broad and includes transudates,exudates,blood, urine, bile, and
parieial, visceral, and connecting layers,which are a1l continuous.t chyle.sIn practice, all abdominal fluids are of water or soft-tissue
The parietal peritoneum, which covers the inner surface of the opacity comparableto the visceralorgans.
abdominal cavity and is closely adhered to abdominal musculature, Peritonitis with edema and inflammation of serosalsurfacesand
separatesextraperitonealand intraperitoneal spaces.The visceral adjacent fat may also cause loss of intra-abdominal contrast. In
peritoneum covers the organs of the abdominal cavity either in addition, abdominal effusion is usually present with peritonitis.
whole or in part. The connectingperitoneum includesmesenteries, Peritonealseedingof neoplasticfoci can also causea loss of intra-
omenta, and intra-abdominal ligaments.The peritoneaispace,be- abdominal contrastbecauseofthe soft-tissueopacity ofthe nodules
tween the parietal and visceral peritoneal layers, normally contains and possiblecoexistenteFfusion.
only a small amount of fluid for lubrication. The radiographic appearanceof the aforementioned conditions
The spacebetween the dorsal margin of the parietal peritoneum varies with the cause,the severity of the disease,and the relative
and the abdominal wall is the retroperitonealspace.The retroperi- amount of fluid versusfat Dresent.It is a common misconceotion
toneal spaceis extraperitoneal and contains adrenal glands, kidneys, that accumulationof any amount of intraperitonealfluid resuitsin
ureters,major blood vessels,and lymph nodes.The retroperitoneal complete obliteration of serosal margins. The degree to which
spacecommunicates with the mediastinum cranially and the pelvic serosal margin detail is obscured by fluid is determined by the
canal caudally.2 relative amounts of fat and fluid present: the more fat present, the
Fat is usually deposited throughout the abdominal cavity, pri- more fluid is neededto causecompleteobliteration of organs and
marily in the falciform ligament,the greateromentum, the mesen- serosalmargins. Thus, organ margins may still be visible when free
tery, and the retroperitonealspace.The presenceof intra-abdomi- fluid is presentin the intraperitonealspace.
na1 fat is important for visceral organ visualization because fat A large volume of abdominal fluid appearsas a homogeneous
provides an interposedopacity betweenviscera(Fig. 40-1). fluid opacity uniformly distributed throughout the abdominal cav-
ity (Fig. 40-2). The homogeneousappearanceis due to total silhou-
etting of all soft-tissue structures within the abdomen. A large
I Abnormal radiographic voiume of fluid often causesabdominal distention, with outward
I findings protrusion of the contour of the abdominal wall. Care must be
taken because radiographs of normal immature animals may ex-
Increased fluid opacity hibit similar findings. A large volume of fluid may also displace
the diaphragm cranially. If relatively mobile segments of bowel
Increasedamounts of fluid within the peritoneal cavity causea loss contain gas, they often float to the highest or uppermost area
of the differential opacity interface between soft tissue and fat. within the abdominal cavity. The presenceor absenceof coexistent
Phrasescommonly used to describe the loss of differential opacity peritonitis cannot be ascertainedradiographically.
include Smalleramounts of abdominal fluid or oeritonitis mav produce
. Loss of intra-abdominal contrast a mottled, hazy, or irregular fluid opacity on survey radibgraphs
. (Fig. a0-3). Individual viscera may be visualized, but there is
Decreasedvisualizationof serosalsurfaces
. Increasedintra-abdominal soft-tissueopacity indistinctnessor blurring of the margins of soft-tissuestructures.
. Increasedintra-abdominal fluid opacity. With small amounts of fluid, this appearancemay be the result of
interdigitation of fluid with folds in the greater omentum and
Causesfor loss of intra-abdominal contrast include lack of fat, small bowel but without a total silhouette effect.aInflammation of
peritoneal effusion, peritonitis, and peritoneal neoplasia.A wet hair the peritoneum or fat may produce a similar effect. Smaller
coat, or hair coated with ultrasound gel, superimposedover the amounts of effusion may be causedby early fluid accumulation of
abdomen may also create irregular opacities that appear to be a generalizedprocessor by more localizeddisease.
rvithin the abdomen. Manipulation of viscera during iaparotomy produces physiologic
Lack of intra-abdominal fat may be the result of the age of the changeswithin the abdomen that may appear comparable to peri-
animal, or it may be caused by emaciation. Immature dogs and tonitis on radiographs, and these changesmay be modified by the
kittens younger than a few months of age lack sufficient fat to amount of induced tissue trauma.a Solutions containing water,
provide intra-abdominal contrast; thus, the abdomen appearsas electrolytes, and relatively low-molecular-weight components are
relatively uniform and homogeneous with soft-tissue oPacity. The absorbedby the peritoneal membrane within 24 hours.sProtein-
abdomen may also be somewhat pendulous in normal immature aceousfluids such as serum, blood, and lymph are absorbedmore
patients.Emaciation causesa similar homogeneoussoft-tissue siowly and may be present for 1 to 2 weeks. These changescan be
opacity throughout the abdomen becauseof a lack of fat (seeFig. visualized after laparotomy, and they should not be mistaken for
40-lC). In emaciatedpatients, the abdomen is often tucked up, more significant complications. Static or progressivefluid accumu-
which can be visualized on radiographs; however, the possibility of Iation during this period is abnormal.
coexistent peritonitis cannot be excluded. One convenient method of assessingthe intraperitoneal space
Abdominal effirsion refers to increased fluid within the perito- for fluid accumulation is to comoare the detail and contrast in
neal cavity. Fluid between abdominal viscera provides added overall the intraperitonealversusthe retroperitonealspace.Becausemany
opacity, and it silhouettes with viscera, thereby causing a loss of diseasesresulting in intraperitoneal fluid accumulation do not
intra-abdominal contrast. Classificationof abdominal effusion is affect the retroperitoneal space,retroperitoneal detail is often pre-
5t6
The Peritoneal
Soace 517
served when intraperitoneal fluid has altered the serosalmargin of described.Foci of mineralization may occur in areasof fat necro-
bowel and other intraperitonealorgans (seeFig. 40-3). Normally, sis.ro
detail and contrastin the intraperitonealand retroperitonealspaces The shapeor contour of the abdomen should also be evaluated.
should be identical. However, large volumes of intra-abdominal Large amounts of abdominal effusion result in a pendulous abdo-
fluid obscurethe retroperitonealspace,even if the fluid is confined men. However, the abdomen may also be pendulous from other
to the intraperitonealspace.This phenomenon is due to superim- causes,such as obesity and the muscle weaknessof Cushing's
position by the large fluid volume. Loss of contrast and detail in syndrome. Emaciation usually causesthe abdomen to appear
the retroperitonealspaceis an indication of fluid accumulationor, tucked up. Trauma to the abdominal wall or localizedabdominal
lesscommonly,inflammation. Fluid accumulationmay be confined pain may produce asymmetricalcontraction of abdominal mus-
to the retroperitoneal space,with a normal appearanceof the cles.a
intraperitoneil space (Fig. aO- ). The most common causesof
isolaGd retroperitoneal fluid are hemorrhage and urine leakage'
Sonography of the peritoneal space
Inflammation and abscessation of the retroperitonealspacemay be
Ultrasound is extremelyuseful for evaluatingthe peritonealspace,
causedby migrating grassawns,penetratingwounds, foreign bod-
especiallywhen increasedfluid opacity is detectedradiographically.
ies, ligatures from ovariohysterectomy,and perforation of the ure-
7 Small volumes of fluid can be readily detectedand sample collec-
thra during catheterization.6'
tion via fine-needleaspiration facilitatedby ultrasound guidance.
An ill-defined nodular or granular pattern (Fig. 0-5) may be
Fluid can be characterized by its echogenicity. Fluid with low
caused by seeding of the peritoneum with multiple, metastatic
celluiar content such as urine or a transudate is anechoic (Fig.
neoplasticfoci, or it may result from proteolytic enzymesescaping
40-8); fluid with moderate to high cellular content such as exudate,
from an inflamed pancreas,causingsaponificationof omental and
blood, or chyle is more echoic (Figs. 40-9 and 40-10). Peritoneal
mesentericfat. Examples of tumors associatedwith such spread
massescan be characterized as solid or cavitary (see Fig. 40-98),
include hemangiosarcomaof the spleenand carcinoma of various
may be usedto describe and samplescan be obtainedvia fine-needleaspirationfor cytologic
abdominal organs.The term carcinomatosis
evaluation.Although uncommon, peritonealmetastasiscan be de-
any cancerdisseminatedthroughout the abdomen; it may be lim-
tectedand appearsas fingerJike projectionsof hypoechoicmaterial
ited to carcinomaswith this distributiont or it can be used as a
generalterm to describeloss of serosaldetail with nodularity. scatteredthroughout the mesentery(Fig. 0-11). Samplescan be
Localized radiographic changesof peritoneal diseaseare most obtained via fine-needle aspiration for confirmation.
often causedby a small amount of fluid or by localizedperitonitis Sonographic evaluation of the pancreashas become standard
(Fig. 40-6). One of the more common causesof localizedperitoni- practice for evaiuating patients suspectedof having pancreatitis or
tis ls acute pancreatitis.The frequency and appearanceof radio- pancreaticmassesas the pancreasis better evaluatedsonographi-
tt cally than on radiographs. The normal pancreas is difficult to
graphic changescausedby acute pancreatitis are variable.e
Changescan usually be iocalized to the right cranial abdomen, identifi' because of its small size, echogenicity similar to that of
where the right lobe of the pancreasis closely associatedwith the surrounding fat, and lack ofa well-definedcapsule.ts'tu In addition,
proximal duodenum and pyloric antrum, or to the midline just gas in adjacent bowel segments often obscures the pancreatic re-
iaudal to the stomach, where the left lobe of the pancreasis gion. Therefore, identifiable adjacent landmarks are used to scan
located. The major radiographic abnormality is usually an in- the pancreatic area. Patients can be scanned in dorsaltt-20or lateral
creased, irregular soft-tissue opacity in the right mid- to cranial recumbencyr6using the highest frequency transducer that will pro-
abdomen, indicating localized peritonitis (Fig. a0-7A). Abscesses, vide sufficient depth penetration. The body and right limb of the
inflammatory masses,and pseudocystsmay be sequelaeto pancre- pancreascan be found by scanning the stomach in a longitudinal
atitis.r2la The proximal descendingduodenum may be displaced plane and sliding the transducer to the right until the duodenum
ventrally or toward the right to produce a broad curvature, and can be identified. The right limb lies just dorsal to the duodenum,
the pylorus of the stomach may be displaced toward the left (see medial to the right kidney, and lateral to the portal vein. Another
Fig. a0-78). Lessfrequently, the transversecolon may be displaced approach is to scan the cranial pole of the right kidney in a
caudally.Bowel loops adjacentto the pancreas,such as the proximal longitudinal plane and move the transducer medially until the
descending duodenum, may contain gas; they may also have loss descendingduodenum is found. The left limb of the pancreaslies
of tone and be dilated. Soasticitv of the duodenum has also been between the greater curvature of the stomach and the transverse
The Peritoneal
Space 519
:rrril:,;,,
,,-
ir,|tli.,f.u;il : lldiii,
Figure 40-9. Sagittalsonogramsof a 6-year-olddog with an abdominalmass and peritonealeffusion.A, Free peritonealfluid(arrows)withlowlevel echoes is
compatiblewith highlycellularfluid, 8, The contentsof the abdominalmass /cursorslare uniformlyhypoechoicand similarin appearanceto the peritonealfluid.
Diagnosis:peritonealabscessand purulentperitonealexudate.
colon and extends to the level of the spleen. The pancreatic area echoicareas(Fig. 40-14)."'17'le Other findings may include cavitary
should be examined in both longitudinal and transverseplanes. lesions,thickened duodenum, biliary obstruction,localizedperito-
As has been stated earlier, the normal Pancreas is routinely neal fluid, and dilation of the pancreaticduct.'6,2127 Hypoechoic
difficult to identifu; when seen, it has indistinct margins (Fig. areas within the pancreasare likely due to inflammation, hemor-
40-12). The normal pancreas is somewhat hypoechoic, being less rhage, necrosis,and edema.l7,2s,28 Hyperechoicareasmay be due
echogenicthan the spleenr6but more echogenicthan the liver.l6'tt to fibrosis.28
The surrounding tissuemay be increasedin echogeni-
Occasionally,the pancreaticoduodenal vein, which lies within the city owing to acoustic enhancement through hypoechoic areas or
pancreasand runs parallelto the duodenum, can be identified'tt'" to saponificationof mesentericfat.r2't6'2sPancreaticpseudocysts
The pancreasis more likely to be identified in puppies, thin dogs, and abscessesmay occur secondary to pancreatitis3's' A' 2e-32ithey
and dogs with peritoneal fluid.'6 In people, fatty infiltration of the appear as large, mostly anechoic massesin the pancreatic area with
pancreas is associated with obesity, and age is associated with distal acoustic enhancement and low-level internal echoes (Fig.
increased pancreatic echogenicity, making the pancreas similar in 40-15). They may be difficult to differentiate ultrasonographically;
echogenicity to surrounding fat and, therefore, difficult to iden- ultrasound-guided aspirates are helpful in differentiating between
tifr." Perhapsa similar change occurs in dogs and cats. the two.5
Combined with history and clinical findings, ultrasound has Pancreaticneoplasmsare uncommon, but may be detectedsono-
become a useful diagnostic aid for patients with pancre- graphically. Exocrine pancreatic carcinomas tend to invade the
In patientswith mild pancreatitis,the pancreasmay
atitis.r6'2r'23-26 duodenum and often metastasizeto regional lymph nodes, liver,
be uniformly hypoechoic surrounded by more echogenic fat (Fig. and the peritoneum.33Functional islet cell tumors may be benign
40-13;.te':nIn more severeinflammation, the pancreasmay be or malignant and should be suspected in dogs with persistent
enlarged and contain irregularly shaped hypoechoic and hyper- hypogiycemia. Both types of tumors may appear as discrete hypo-
echoic nodules or massesin the pancreatic region.Il t6'23'34 A cant.3s'36Although not common, they are seenmore often in cats
potential source of error is misinterpretation of enlarged hypo- than dogs. Metastatic calcification of the abdominal vasculature is
echoic lymph nodes as pancreatic masses.3a Islet cell tumors can be rare (Fig. 40-17) and is associatedwith abnormal calcium metabo-
quite small and difficult to detect sonographically; therefore, a lism, primarily in animals with chronic uremia,35,37 or in those
normal examinationdoesnot rule out neoplasia.r6 Both pancreatitis with hypothyroidism.
and pancreatic neoplasms may cause biliary dilation, lymphade-
nopathy, and peritoneal fluid. Hyperechoic or heterogeneous Free abdominal gas
massesare more often found in pancreatitis, and discrete hypo- Although there are many causesof free intraperitoneal gas,the two
echoic nodules are more characteristic of neoplasia. The main most common are penetration of the abdominal wall, either by
sonographic features that distinguish between inflammation and surgery or by penetrating wounds, and perforation of the bowel.
neoplasia are findings of a diffusely hypoechoic pancreas in dogs However, not all bowel perforations produce free abdominal gas.38
with pancreatitis and of discrete hypoechoic nodules in dogs with Laparotomy is the most common causeof free abdominal gas, and
neoplasms.23 the history is usually known in this instance. Following laparotomy,
a moderate amount of gasmay persist for days to weeks.3e Penetrat-
lntra-abdominal calcification ing abdominal wounds are usually diagnosed by physical findings.
Increased mineral opacity, not associatedwith the gastrointestinal In patients with a penetrating wound, differentiating whether free
tract, can be seen in various sites within the abdomen. Focal abdominal gas is due solely to penetration of the abdomen or is the
calcifiedbodies may be found in the peritonealspace(Fig. a0-16). result of concurrent organ rupture is impossible from radiographs.
These are thought to be the result of dystrophic calcification of A small volume of free abdominal gas is difficult to recognize
necrotic mesenteric fat, and are not considered clinically signifi- on conventional radiographs made with a vertically directed x-ray
Figure 40-12. Sagittal(A) and transverse(8) sonogramsof the pancreaticregionsof two normaldogs.The pancreas(arrows),which lies dorsaland media to
t h e d u o d e n u mi,s n ot se e na s a d istin ctstr u ctu r eb e ca u seo f i ts smal lsi zeand i ts echogeni ci ty,
w hi chi s si mi l arto the surroundi ng c (FromMahaffey
mesenterifat.
M B : T h e P a n c r e a sI .n Ca r te eRE { e d ) :Pr a cticaVe
l te r in a rUltrasound.
y a, l i ams& Wi l ki ns,1995,p. 56.)
P hi l adel phiWi
i-
524 AN IM AL S
A B DO M E N -C ON /PA N ION
"t"-',";l
:1-." :
beam becauseresulting bubbles are small and irregular in shape.' 40-194).s A commonly used projection for documenting free gas
Larger gas volumes may coalesceinto a larger bubble. This larger is a ventrodorsalview obtainedwith the patient in left recumbency
bubble may still be difficult to recognizeon a radiograph made with the use of a horizontally directed x-ray beam. Gas usually
with a vertical x-ray beam becauseit is superimposedover other localizesunder the highestportion of the right abdominalwall (see
viscera. In addition, this larger bubble may simulate a gas-con- Fig. a0-198), which is usually under the caudal ribs. With larger
taining organ,such as the stomach.Suchfree abdominalgasusually volumes of gas, the bubble may extend under the diaphragm
floats to the highest point within the abdomen. In lateral recum- or along the abdominal wall caudally. Raising or lowering eitler
bency,this point is usually under the caudal ribs or in the midab- end of the animal shifts the point of gas accumulation.Eiposure
domen. The concurrent presenceof abdominal effusion may make factors should be lowered to underexpose the abdomen, utrd the
recognition of the gas bubble easierbecausethe fluid provides a right abdominal wall should be centeredin the x-ray beam to avoid
more uniform, homogeneoussoft-tissuebackground opacity (Fig. superimpositionof abdominal organs createdby divergenceof the
40-1BA). A large volume of free abdominal gas is readily detected beam at its periphery.A view with the animal in right recumbency
on survey radiographsbecausethe gas providescontrast to outline rs not recommendedbecausethe gas bubble rises to the ieft side
serosalsurfacesof viscera,such as bowel loops, the stomach,and and may be confusedwith gas within the fundus of the stomach.
the diaphragm (seeFig. 40-188). Gasmay alsoaccumulatein the retroperitonealspace.T Retroperi-
Becausefree gas risesto the highestportion within the abdomi- toneal gasis most often the result of extensionof the pneumomedi-
nal cavity, free gas may be isolated from superimposed structures astinum (see Chapter 30) or penetration of the abdominal wall.
by means of a horizontally directed x-ray beam. With a small Retroperitonealgas is confined to the retroperitoneal space in
volume of gas,it may be preferableto position the patient for l0 the dorsal abdomen and is best seen on i lateral radiograph
minutes before exposureto allow most of the gas to migrate and (Fig.a0*20).
coalesceat the uppermost portion of the abdomen. The most
sensitive projection for detecting small volumes of gas is a lateral Abdominal wall abnormalities
view made with a horizontally directed x-ray beam, with the
patient in dorsal recumbencyand with the cranial portion of the Mineralization may occasionallybe visualized in the soft tissues
abdomen slightly elevated,so small amounts of gaswill accumulate surrounding the abdomen. As an example, calcinosisassociated
between the liver, diaphragm, and ventral abdominal wall (Fig. with Cushing'ssyndrome may produce nodulut or linear calcifica-
P,lrr.iil!Ul"'
: t*:'':::::
,,rlrr.rll9ll
: ::l:a::'
,:::a
tion of soft tissuesthat may be visualizedradiographically,most may be contained within herniated bowel loops (Fig. 40-22; see
often dorsally and in the ventral abdominal wa11.''Gas from a also Fig. 40-2lB). Gas that dissects along fascial planes is most
variety of causesmay be seen in the soft tissuessurrounding the often due to large open wounds or to upper airway perforation or
abdomen. Abrasions with lacerations often produce a mottled, pneumomediastinum. These patterns, however, are not pathogno-
irregular gas pattern (Fig. 0-21A). Tubular or round gas pockets monic for the causeof the gas accumulation.
ryie*W* b*PSYe"?.
-wrc*u,*Wle:tw .'wwryWW
The colon may be normally positioned more ventral than usual I The adrenal glands
without being displaced by a mass. The most common cause of
medial iliac lymphadenopathy is neoplasia;however, inflammatory The adrenal glands are located in the retroperitoneal space near
the craniomedial border of the kidneys. The left adrenal gland is
diseasesmay also cause node enlargement. Neoplastic lymph node
located more cranially with respect to its corresponding-kidney
involvement may be primary (e.g., lymphosarcoma) or metastatic
(i.e., from caudal abdominal or pelvic neoplasms).u' than is the right adrenal gland, which is located near the hilus of
the right kidney. The right adrenal gland is bordered dorsally by
Visceral abdominal lymph nodes are not usually seen on radio-
the psoas minor muscle and the crus of the diaphragm, medially
graphs. They rarely eniarge enough to be seen radiographically,
by the caudal vena cava, ventrolaterally by the right kidney, and
they tend to silhouette with surrounding organs, and they are
cranioventrally by the right lateral liver lobe. The left adrenal gland
infrequently specifically recognized. However, cranial mesenteric
is bordered dorsally by the psoas minor muscle, ventrally by the
lymph nodes may occasionally enlarge sufficiently so as to be seen
spleen, laterally by the left kidney, and medially by the aorta.r
as an ill-defined central abdominal mass displacing the intestine
Because of their small size and soft-tissue opacitv, the adrenal
peripherally(Frg. a0-27).
glandsare not usually seenradiographically.
Figurc 40-28. Sagittal(A) and transverse(B) sonogramsof a normal medial iliac lymph node. On the sagittalview, the lymph node (arrows)is seen as an
elongatedstructureiust ventralto the aorta near the aortic bifurcation.The lymph node is nearlyisoechoicto surroundingstructuresand has a thin echogenic
capsule.On the transverseimage,the lymph node (arrows)is seen as a curvedstructurejust ventrolateralto the aorta.Ventralis to the top (A and B), and the
head is to lhe left (N.
532 AN IM AL S
A B DO M E N -C OMP AN IO N
Figurc 40-29. Sonographicappearanceof abnormalIymph nodes.A, Enlarged,hypoechoicmedial iliac lymph nodes (arrows)surroundingthe aorta in a dog
with lymphosarconra. The anechoictriangular-shaped structurein the upper left corner is the urinarybladder.B, Enlargedjejunallymph node (cursors)in a dog
wi t h l y m p h o s a r c o mT a.h is lym p hn o d e is h yp o e ch o ic ti ssuesand has a hypoechoi ri
to su r r o undi ng c m surroundl ng a more echogeni ccenter.C , E nl arged j ej unal
lymph nodes (arrows)in a dog with inflammatorybowel disease.Lymphoidhyperplasiawas found on evaluationof lymph node aspirates.Both nodes are
hy p o e c h o i ac n d a p p e arsim ila rto th o se se e n in a d o g with ly mphosarcoma (A ). D , E nl argedi eocol i cl ymph nodes i n a cat w i th l ymphosarc oma.The i l eum
(arrowhead)is seen in cross-sectionsurroundedby enlargedhypoechoiclymph nodes (arrows).E, Sonogramof a large (6 cm) mixed echogenicmass in the
mi d a b d o m e no f a d o g. T h e m a ss in co r p o r a tein l g ments.Gas (arrow )w i thi n one bow el segmenti s seen as an echogeni cfocus pr oduc i ngac ous ti c
d te stin ase
s h a d o w i n gT. h e h y p o ech o ic to n e a r lya n e ch o ica r e a swe r e p r esumedto be enl argedmesenteri cl ymphnodesas l ymphosarcoma w as di agnos ed
from as pi rates
o f th e m a sswas si mi l arto that i n Fi gure4O-27.
of t h e s es t r u c t u r e sT. h e r a d io g r a p haicp p e a r a n ce
The Peritoneal
Space 533
origin of the primary masslesion.In such an instance,the metasta- sis, Addison'sdisease,tumors (benign and malignant), cysts,Nie-
sesmay be the major radiographicfinding, although there may be mann-Pick disease,60 and Wolman'sdisease.o'
an ill-defined soft-tissuemassin the craniodorsalabdomen. It appears that calcification of the adrenal glands in cats is
Mineralization may occur in non-neoplasticadrenalglands (Fig. relativelycommon, but calcificationin most animals is not suffi-
40-31). Radiographicallyvisible adrenal mineralization of un- cient to be seenradiographically.A normal-sizedmineralizedadre-
known etiology has been reported in cats.52'5rHistologic detection nal gland in cats and dogs is likely to have no clinical significance.
of adrenalcalcificationwas reported rn 3.5o/oof dogs, 30o/oof cats, Adrenal gland dysfunctionusuallycausessecondarychangesthat
and 50oloof monkeys in one study,sTand in 25o/oof catss8and, lo/o are visible radiographicaliy.Radiographic findings of Cushing's
of dogssein two other studies.Calcificationoccurred in the zona syndrome include hepatomegaly,bronchopulmonary mineraliza-
reticularis of the adrenal cortex in the dogs, monkeys, and cats; tion, dystrophic mineralization of the skin and other soft tissues,
however, in some cats. calcification affected the entire adrenal and adrenal gland enlargementwith mineralization, when func-
cortex and extended into the medulla.uuAdrenal calcification was tronal tumors are present.a6's2'5r
Pulmonary arterial thrombosis has
not correlatedwith clinical findings. The causeand pathogenesis also been reported in dogs with Cushing'ssyndrome.62 Decreased
of adrenalcalcificationare unknown. In humans, adrenalcalcifica- size of the heart,63os peripheral pulmonary arteries,caudal vena
tion has been associated with intra-adrenalhemorrhage,tuberculo- cava, and liver65has been associatedwith Addison's disease.Al-
;1 1
ellriiirl9rl
i:"
.,- .1
v4 '
. ::atl:::
""1:
**F*
.-".;:.-j
Figure 4042. Sagittalsonogramsof the left adrenalglandof a normaldog /A/ and the right adrenalglandof a normal cat (B).A, The left adrenalgland has a
dumbbellshapeand is seen just ventralto the aorta (arrowheads). lt is less echogenicthan the surroundingfat; however,the medullaryportionof the adrenal
gl a n di s s l i g h t l ym o r e ech o g e n icth a n th e co r te x.T h e a d r e n agl
l andmeasured15.9mm i n l engthand 5.4 mm i n thi ckness.8, The ri ghtadrenagll andi s s een as
an e l o n g a t e dh y p o e c ho ic str u ctu r eju st d o r sa lto th e ca u d a vena
l cava.The adrenalgl andi s surrounded by a hyperechoicapsul
c e.The adrenagll andmeas ured
10 . 3m m i n l e n q t ha n d 3 .0 m m in th ickn e ss. T h e h e a dis to th e l eft and ventralto the top.
though esophagealdilation has been thought to be a feature of The shape of the right adrenal gland of the dog is different from
Addisons disease,s2it is probably a rare finding as no evidence of that of the left. The right has been described as having a "comma-
esophagealdilation was found in a recent study of 22 affected shaped"z+or "bent-arrow" conformation.TTIn cats, both adrenal
dogs.us glands are oblong and oval to bean-shaped(see Fig.40-328).7t'"
Overlying bowel gas obscuring the adrenal glands is a major prob-
Ultrasonography of adrenal glands lem, especiallyon the right side. If this happens,the patient or
transducer can be repositioned in an attempt to move the overlying
Ultrasound is the most useful imaging modality for evaluating the
bowel. Sedationmay be helpful in somepatientsthat resistabdomi-
adrenal glands. It has been used to evaluate normal dog adrenal
nal compression by the transducer. Imaging the adrenal glands in
glands,6e70 normal cat adrenal glands,Tt'72 and dogs with hyper-
66'6t'6ehypoadrenocorticism,T3 the dorsal plane is an alternate method of avoiding the overlying
adrenocorticism,4T' and adrenal
bowel gasproblem, and is preferredby some sonographers.8. Both
masses.Tn'7s However, the ability to image the glands accurately is
adrenalglandscan be imaged in a dorsal plane with the patient in
highly dependenton the quality ofthe equipment,operatorexperi-
Iateral recumbency. An intercostal approach may be necessaryto
ence, and size of the patient. The highest frequency transducer that
image the right gland.
will produce adequate penetration is recommended. If possible,
Ultrasonographicdeterminationof adrenalsizehas been used as
7.5- to 10.0-MHz transducersshould be used,but 5.0-MHz trans-
an aid for evaluating dogs suspectedof having hyperadrenocorti-
ducers may be necessaryto obtain adequate penetration in larger
cism and hypoadrenocorticism. Adrenal size may be dependent on
dogs. The adrenal glands are more easily imaged in smaller patients
in which higher resolution probes can be used to obtain quality the age of the dog,68with middle-aged and older dogs having larger
glands. The thickness (ventrodorsal dimension) of the gland is
images with adequate penetration. Overlying bowel gas often ob-
scuresthe adrenal glands. more accurate than adrenal length (craniocaudaldimension) or
Most patients are scanned in dorsal recumbency.To find the left adrenal width (mediolateral dimension) in estimating gross adrenal
adrenal gland, scan the cranial pole of the left kidney in a longitu- size.67Adrenal gland length is proportional to body weight, but the
dinal plane, then slide the transducer medially to the aorta. The diameter (thicknessor width) is not.66Therefore, cross-sectional
left adrenal gland lies iust ventrolaterai to the aorta between the measurements are more valuable than length in assessmentof
cranial mesenteric and renal arteries. To obtain a full longitudinal adrenal giand size. Adrenal gland thickness greater than 6 mm in
view of the adrenal gland, it may be necessaryto rotate the probe small-breedand 7 mm in middle-agedto older large-breeddogs
so that the aorta will be imaged obliquely. The left adrenal gland may be used as the criterion for maximum normal adrenal gland
of the normal dog is usually described as a "peanut shell"76or size.68However, adrenal gland measurementsalone should not be
"dumbbell"" shaped structure (Fig. 40-32A). Both adrenal glands used to diagnose abnormalities as there is considerable overlap of
of dogs and cats are hypoechoic to the surrounding fat and hypo- adrenal size in normal and abnormal dogs.
echoic or isoechoic when compared with the renal cortex. Occa- Ultrasound is considered useful in differentiating pituitary-de-
sionally, the adrenal gland has a layered appearance, with the pendent hyperadrenocorticism(PDH) and functional adrenocorti-
medulla being more echogenic than the cortex. This layered ap- cal neoplasia.66'67 In dogs with PDH, the adrenal glands have
pearancehas been ascribedto both normalt2'78and hyperplastic a "plump" appearance; they are bilaterally enlarged, uniformly
glands.T'A hlperechoic capsule can often be identified (see Fig. hypoechoic,and normally shaped(Fig. 40-331.0e'0',u' Normal adre-
80The right adrenal gland is more difficult to image,
40-328).?'1' nal gland size does not rule out PDH.68 Adrenal gland tumors
especiallyin larger dogs.8'After the cranial pole of the right kidney cause gland enlargement with loss of normal shape and a change
is scanned in a sagittal plane, the transducer is moved medially to in echotexture(Figs.40-34,40-35, and 40-36). Tumors may occur
find the caudal vena cava.The right adrenal gland lies dorsolateral bilaterally, but are most often uni1ateral.74'7s
In dogs with functional
to the caudal vena cava and cranial to the renal vein. The phrenico- adrenocortical tumors, the contralateral adrenal gland is often of
abdominal veins cross the ventral surfacesof both adrenal glands normal srzeT',75 and can be imaged with ultrasound. This is con-
and can occasionallybe identified with high-resolution transducers. trary to previous suggestionsthat the contralateral adrenal gland
The Peritoneal
Space 535
Figure 40-33. Sagittalsonogramof the left adrenalgland (cursors)ol a Figure 40-34. Sagittalsonogramof the left adrenalgland (cursors)ol a 13-
Dachshund w i t h p i t u ita r y- d e p e n d ehnyp
t e r a d r e n o co r ticism.
T he adrenalgl and year-oldYorkshireterrier with a history of systemic arterialhypertension.A
h a s a " p l u m p " a p p ea r a n ceb,u t is n o r m a llysh a p e d .T h e g l and i s enl arged hyperechoi cnodul e i s seen i n the crani alpol e of the a drenalgl and.The
m e a s u r i n g2 5 . 9 m m in le n g th a n d 9 .7 m m in th ickn e ss.The hypoechoi c nodulewas presumedto be a pheochromocytoma, and the dog was treated
c o r t e xc a n b e d i f f e re n tia tefrd o m th e m o r e e ch o g e n icm e d ul l a.Thi s l ayered successful lwyi th phenoxybenzami ne. The ul trasonographi c
a ppearanc of
e thi s
a p p e a r a n chea sb e e nd e scr ib e din n o r m a ld o g sa n d in d o g swi th hyperadreno- nodul ei s not speci fi cand coul d be due to other tumor tv oes or nodul ar
corticism,The arow pointsto the aorta. hyperplasia.The aortacan be seen as an anechoicelonqatedstructuredorsal
to the adrenalgl and.
would atrophy.2aUltrasound is not useful in differentiating between 12. Edwards DF, Bauer MS, Walker MA, et al: Pancreatic masses in seven doqs
following acute pancreatitis. J Am Anim Hosp Assoc 26t189,1990.
benign and malignant lesions as there is no consistent appearance
for a tumor type.TaMineralization may be seenin both benign and 13. Salisbury SK, Lantz GC, Nelson RW, et al: Pancreatic abscessesin dogs: Six cases
(1978-1986).I Am Vet Med Assoc 193:1004,1988.
malignant neoplasmsas well as in adrenocorticalhyperplasia.68'ta
In one report, pheochromocytomas and adenocarcinomastended 14. Wolfsheimer KJ, Hedlund CS, Pechman RD: Pancreatic pseudocyst in a dog with
chronic pancreatitis.Canine Pract 16:6, 1991.
to be rounded masses;adenomas,hyperplasia,and adrenal metasta-
sis tended to appear as nodules.Tn BecausePDH-induced nodular 15. Lamb CR: Abdominal ultrasonography in small animals: Examination ofthe liver,
spleen,and pancreas.J Small Anim Pract 31:6, 1990.
cortical hyperplasia may appear similar to small functional adreno-
cortical tumors, ultrasound is not useful in differentiating the 16. Saunders HM: Ultrasonography of the pancreas. Probl Vet Med 3:583, 1991.
two.68Ultrasound is helpful in evaluating extension of tumors into 17. Nyland TG, Mulvany MH, Strombeck DR: Ulirasonic features of experimentally
surrounding tissues, especially the caudal vena cava. Ultrasound- induced, acute pancreatitis in the dog. Vet Radiol 24:260, 1983.
guided biopsy and fine-needle aspiration of the adrenal gland are 18. Nyland TG, Mattoon JS, Wisner ER: Ultrasonography of the Pancreas.In Nyland
not commonly performed in veterinary medicine, but they have TG, Mattoon JS (eds): Veterinary Diagnostic Ultrasound. Philadelphia, WB Saunders,
been reported without complication in 2 dogs and 2 cals.'o'82'e3 1995.
In six dogs with hypoadrenocorticism, the adrenal glands were 19. Murtaugh RJ, Herring DS, Jacobs RM, et al: Pancreatic ultrasonography in dogs
measurablysmallerthan the adrenalglands of normal dogs.'3This with experimentally induced acute pancreatitis. Vet Radiol 26:27,1985.
was a significant change in the left adrenal gland in which the 20. Mahaffey MB: The pancreas. In Cartee RE (ed): Practical Veterinary Ultrasound.
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81. Grooters AM, Biller DS, Merryman J: Ultrasonographic parametersof normal
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52. Ticer JW: Ro€ntgen signs of endocrine disease.Vet Clin North Am 7:465, 1977.
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5a. lubb KVB Kennedy PC: Pathology of Domestic Animals, 2nd ed. New York, l. SeeFigure 40-37, which presentslateraland ventrodorsalviews
Academic Press,1970,p 427. of the abdomen of a l-year-old Rottweiler with a history of lethargy
55. Kelly DF, Darke PGG: Cushing's syndrome in the dog. Vet Rec 98:28, 1976. and inappetence.Abdominal distention had been present for 2
weeks.What is the radiographicdiagnosis?
56. Siegel ET: Endocrine Disorders of the Dog. Philadelphia, Lea & Febiger, 1977,
p 166.
2. SeeFigure 40-38, which presentsthe lateral abdominal radio-
57. Ross MA, Gainer JH, Innes IRM: Dystrophic calcification in the adrenal glands of
monkeys,cats,and dogs. Arch Pathol Lab Med 60:655,1955.
graph of a l3-year-old Poodle. The owner noticed a mass in
the inguinal region and another near one shoulder. What is the
58. Marine D: Calcification of the suprarenal glands of cats. J Exp Med 43:495, 1926.
radiographicdiagnosis?
59. Rajan A, Mohiyuddeen S: Pathology of the adrenal gland in canines (Caris
familiark). Indian ) Anim Sci 44:123, 1974. 3. What is the best radiographic view for detecting small quanti-
60. Bergman SM, Scouras GC: Incidental bilateral adrenal calcification. Urology ties of free peritoneal gas using a horizontally directed x-ray beam?
22:665,1983.
A. Lateral view, patient standing
61. Raafat R Hashemian MR Abrishami MA: Wolman's disease:Report of two new B. Lateral view patient in dorsal recumbency
caseswith a review of the literature. Am T Clin Pathol 59;490. 1973 C. Ventrodorsal view, patient in left lateral recumbency
62. Burns MG, Kelly AB, Hornof WJ, et al: Pulmonary artery thrombosis in three D. Ventrodorsal view, patient in right lateral recumbency
dogs with hlperadrenocorticism. J Am Vet Med Assoc 178:388, 1981.
63. Rendano VT, Alexander JE: Heart size changes in experimentally induced adrenal 4. Which of the following is least likely to result in decreased
insufficiency in the dog: A radiographic study. J Am Vet Radiol Soc 17:57,1976. intra-abdominal contrast?
64. Scott DW: Hlperadrenocorticism (hlperadrenocorticoidism, hlperadrenocortical- A. Peritonitis
ism, Cushing's disease,Cushing's slndrome). Vet Clin North Am 9:3, 1979. B. Normal puppy
65. Melian C, Stefanacci J, Peterson ME, et al: Radiographic findings in dogs with C. Abdominal mass
naturally-occurring primary hlpoadrenocorticism. J Am Anim Hosp Assoc 35:208, D. Peritonealmetastasis
1999.
66. Barthez Pl Nyland TG, Feldman EC: Ultrasonographic evaluation of the adrenal 5. List three rule-outs for a diffuse increasein soft-tissueopacin'
glands in dogs. J Am Vet Med Assoc 207:1180,1995. in the retroperitonealspace.
538 A N IMA L S
A B DO M E N- C O MP AN IO N
Figure 40-37
,'rliiirlil
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rilirlll
:
,lll'lllirr,
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,
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.:
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lpll'r:i,irr
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:r'
61!!41:l"rrititl:
Figure 4O-38
Thc P eri fnne:l S n:r.c 539
iidllri,ili!rll
111tu....',ig
iilsut:il!ridqlitl, ff s !* ',S+.'* c eql
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. , 4 , 'r : l i
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-iiii
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., illll
Figure 40-39
6. The retroperitoneal space communicateswith which of the 10. Radiographsare more or less sensitivethan ultrasound for
following? evaluationof suspectedadrenalgland tumors?
A. Mediastinum
B. Pelvic canal
ll. Which of the following sonographic findings is (are) more
C. Pieural space
characteristicof pancreaticneoplasiathan of pancreatitis?
D. Peritonealspace
A. Biliary dilation
7. Which of the foilowing structures are not normally identified B. Diil-uselyhypoechoicpancreas
on survey abdominal radiographs? C. Discretehypoechoicnodules
A. Adrenal giands D. Peritoneal fluid
B. Sublumbarlymph nodes
C. Falciform ligament fat 12. What sonographiccharacteristics
are seenin abnormal abdom-
D. Caudal surface of the diaphragm inal lymph nodes?
8. In Figure 40-39, examine the (A) lateral and (B) ventrodorsal
abdominal radiographs of a 2-year-old cat with vomiting and 13. True or False.In dogs with functional adrenocorticaltumors,
depression. The owner had seen the cat eat a string 1 week pre- the contralateral adrenal gland is usually atrophied and difficult to
viously. What are the radiographic findings? imaee with ultrasound.
9. What is the clinical significanceof a normal-sized,mineralized
adrenalgland on the abdominal radiographsof a cat? Answers begin on page 727.
CHA P T E R
41
The Liver and Spleen
. SusanM. Newell . Iohn P. Graham
Radiography and ultrasonography are commonly employed to as- ablessuch as chestconformation, age,respiratoryphase,and body
sessthe liver and spleen.Radiographsprovide information about position may affect the radiographic appearanceof the normal
the size, shape, margination, location, and opacity of these or- liver. The liver appears enlarged if the thoracic cavity is overex-
gans.l-3Ultrasonography may also yield data about size, shape, panded for any reason (e.g.,respiratorydistress,pleural effusion),
and location but its principal use is in assessingdiffuse or focal and it appearssmall in animals with diaphragmatichernias and
parenchymalchangeswithin these organs.a-t5 In evaluating a pa- subsequentcranial displacementof the liver into the thorax. The
tient with suspectedhepatic and splenic disease,radiography and conformation of the patient has a marked effect on the apparent
sonographyare usuallycomplementary.Under somecircumstances, size and shapeof the liver. In general,deep-chesteddogs such as
one techniquemay be more valuableor preferred.In the presence Doberman pinschers,Greyhounds,and Great Danes have the ma-
of moderate to large volumes of abdominal fluid and in cachectic jority of the liver beneath the ribs, and thus appear to have
or immature patients, ultrasound is the preferred modality. In microhepatia. Older dogs and cats may have stretching of the
such patients, abdominal detail is reduced or obliterated,making coronary ligaments, which attach the liver adjacent to the dia-
radiographicassessment of abnormalitiesof size,shape,and mar- phragm, causing the liver to slide caudoventrally, thus resulting in
gination difficult. Conversely,large volumes of gastrointestinal gas the appearanceof hepatomegaly.Young animals in generai have
and food or free peritoneal gas significantly hamper ultrasono- larger livers for the size of the abdominal cavity versus adults.3In
graphic evaiuation,but they affect radiographic organ assessment the cat, the majority of the liver is on the right side of the body,
to a lesserextent.With free peritonealgas,serosalmargin visualiza- and in most dogs, the hepatic parenchymais more symmetrically
tion may be enhanced radiographically,depending on whether distributed.
peritonealfluid is also present.In addition to providing data about The normai sonographicappearanceof the liver has been thor-
the internal architectureof the liver and spleen,ultrasonography oughly described.l'I2'I8'reThe canine liver has a uniform echogeni-
may be used for guidance in obtaining a fine-needleaspirateor city, being less echoic than the adjacent spleen (Fig. 41-3) and
biopsy of a lesion. Although ultrasonographicand radiographic slightly hyperechoicor isoechoicto the renal cortex. In the normal
abnormalitiesare frequentlynonspecific,the ability to obtain accu- cat, the echogenicityrelationshipsbetweenliver, spleen,and kidney
rate tissue sampleswith their guidanceoften leads to a definitive
diagnosis.Even if radiographsand ultrasound imagesare normal,
fine-needleaspiratesor biopsies sl-rouldbe obtained if there is a
well-founded suspicionof hepatic or splenic disease.
I Liver
The liver is the largestorgan within the abdomen of the dog and
cat. It is located caudal to the diaphragm, cranial to the stomach
and spleenon the left side,and cranial to the right kidney, duode-
num, and pylorus on the right side.The cranial margin of the liver
silhouetteswith the diaphragm, and the left and right edgesblend
with the abdominal wall unlessabundant peritonealfat is present.
The ventral border of the liver is usually visible, outlined by the
adfacent falcifonn fat. The caudal aspect of the liver is difficult to
visualizeowing to summation with, and superimpositionof, adja-
cent organs,including the right kidney, stomach,and cranial duo-
denal flexure.
In both dogs and cats, the liver is divided by deep running
fissuresinto four lobes and four sublobes;in the cat, the right
medial and quadratelobes may be fused at their cranial aspect.16'r7
Individual liver lobesare generallynot visible radiographically,with
the exceptionofthat portion ofthe left lateral (dog) or right lateral
(cat) lobe creating the caudoventral angle of the liver on the
lateral projection. Individual liver lobes can often be discerned
sonographically,particularly if abdominal fluid is present.
The normal radiographic appearanceof the liver is that of a
uniform soft-tissue structure that extends from the edge of the
lungs to the costal arch on the lateral view (Figs. 4I-l and 4l-2);
it is further defined by the location of the stomach, or what is
calledthe gastric axis. The gastric axis is defined as a straight line
drawn on a lateral radiograph from the fundus to the pylorus of Fi gure 41-1. Lateralradi ograph of the crani alabdomenof a norma dog.
the stomach (seeFig. 41-1) and is normally locatedbetweena line The gastri caxi s i s defi nedas a strai ghtl i ne draw n from the fundusto the
drawn paral1e1 with the ribs and perpendicularto the spine. Vari- pyl orusand has been i l l ustrated
by a bl ack/i nepl acedon thi s rad i ograph.
540
The Liverand Spleen 541
are not consistent, and comparisons with adjacent falciform and isoechoic with the hepatic parenchyma and the anechoic luminal
mesenteric fat are used.'?0The normal feline liver is usually less contents. The common bile duct can often be traced to the duode-
echoic than the surrounding fat, although in some clinically normal num in cats, and the normal width of the common bile duct is
obese cats, the opposite relationship has been found.2l less than 3 to 5 mm in cats. In normal dogs, the common bile
Within the liver, two venous systemsare readily identified-the duct is not usually apparent sonographically.r,
portal venous system and the hepatic venous system. The walls of
the portal veins are hyperechoic owing to fat and fibrous connective
Hepatomegaly
tissue; however, the walls of the hepatic veins are isoechoic with
the Iiver parench).rna,and thus difficult to discern, with the excep- Radiographic evaluation of the liver should be based on radio-
tion of the larger veins near the caudal vena cava (Fig. al-a). graphic signs, or alterations of normal size, shape,margination,
These venous structures add a general "coarseness"to the overall opacity, and location. Enlargement of the liver is called hepatomeg-
echotexture of the normal liver when comDared with the fine aly, which is an objective diagnosis when made from survey radio-
granular echotexture of the spleen, and disruption of this coarse graphs. The diagnosis of hepatomegaly is made by evaluation of
echotexture is often seen with hepatic disease.The intrahepatic both_the gastric axis and the degreethat the caudoventral angie of
arteries and the biliary tree ur" noi normally visible sonogriphi- the liver extends beyond the caudal aspect of the ribs ai the
cally. costochondral junction. Generalized enlargement of the liver usu-
The gallbladder is readily visible in normal dogs and cats (Fig. ally causes caudal and dorsal displacement of the pvlorus and
41-5), with thin walls (less than 1 to 2 mm)'e that are often caudal displacementoF the gastric axis (Fig. 4l-6) on'the lateral
F ig u r e 4 1 - 5 . S o n o g r a p h ic im a g eo f th e n o r m a g
l a llb la d d einr a dog.
Th e i m a g ew a s a c q u i r e din th e r ig h ttr a n sve r sep a n e .T h e g a ll bl adder
ha s a n e c h o i cl u m i n aco l n te n ts,with a co u stice n h a n ce m e notf the l i ver
beyond the gallbladder(blackarrowheads).The gallbladderwalls are
diff i c u l t o d i s c e r nb, l e n d in gwith th e n o r m a lh e p a ticp a r e n ch yma. The
hvperechoiccurvedline at the bottom of the image is the diaphragm-
lun oi n t e r f a c e .
Table 41-1. Differential diagnoses for generalized Table 41-2. Differential diagnoses for focal
hepatomegaly hepatomegaly
cranial tilting ofthe stomach axis (Fig. 41-12). There is a subjective Acquired shunts are t1pically seen as multiple abnormal vessels
impression of less soft tissue between the gastrointestinal tract and (varices) in the areasofthe kidneys and caudal vena cava.Reported
the diaphragm. Focal reductions in hepatic volume result in cranial sensitivity rates are variable, and reliable detection of shunts is
displacement of the adjacent portion of the stomach and duode- dependent on patient preparation and cooperation, operator skill,
num. In some deep-chestedbreeds, the normal liver may be in a and equipment quality.
reiatively cranial and ventral location, and there may be mild Tianscolonic scintigraphy has been used to confirm the presence
cranial tilting of the stomach. of a shunt(s) but offers little anatomic information.3s,16 This tech-
The ultrasonographic diagnosis ofmicrohepatia is subjectiveand nique involves depositing a small volume of a radionuclide in the
difficult.'z3-'?s
Microhepatia may be suspectedif the liver cannot be terminal descendingcolon, where it is absorbed acrossthe mucosa
seen because of interposition of the stomach when imaged from and into the portal venous system. Serial scintigraphic images
the ventral abdomen, or of the lungs when imaged via an intercos- are rapidly made and evaiuated to determine if the radionuclide
tal approach. subsequently appears first in the liver (normal) or in the heart
A common cause of microhepatia is a portosystemicshunt.3r (shunt). Definitive diagnosis of a portosystemic shunt may be
With a shunt, portal venous blood flow from the gastrointestinal obtained by selectiveangiography.37,38 The most common technique
tract bypassesthe liver and is diverted to the caudal vena cava or is operative mesenteric portography. A jejunal vein is catheterized
azygousvein. Portosystemicshunts may be congenital or acquired. at laparotomy and the abdomen temporarily closed. Water-soluble
Acquired portosystemic shunts deveiop as a consequenceof pro- iodinated contrast medium is iniected into the catheter, and flow
longed portal hypertension,resulting from conditions such as is observed either fluoroscopicily or by obtaining serial radio-
chronic hepatocellular diseaseor arteriovenous fistula.32With ac- graphs. The normal intrahepatic portal circulation has a character-
quired portosystemic shunts, the liver size is variable, and the istic arborizing pattern, which is usually attenuated or absent in
radiographic findings range from severemicrohepatia to general- the presenceof a shunt. Opacification of the caudal vena cava or
ized hepatomegaly,depending on the primary cause. Unlike with azygousvein before or at the same time as the liver indicates that
congenital shunts, ascitesmay be present. With congenital shunts, a shunt is present (Figs. 4i-13 and 41-14). Shunt vesselslying
the reduced intrahepatic blood flow and the absenceof trophic cranial to T-13 are more likely to be intrahepatic; those caudal to
factors causethe liver to fail to develop normally; thus microhepa- this level are usually extrahepatic.3eAlternative methods include
tia is common. Bilateral, smoothly marginated mild to moderate selectivecatheterization of the cranial mesenteric artery, percutane-
renomegaly may be seen with congenital shunts, in part due to ous injection into the splenic pulp, and percutaneous catheteriza-
exposure of the kidneys to these trophic factors. tion of a splenic vein with ultrasound guidance.
Shunt vesselsmay be detectedby ultrasonography.tt'to The portal
vein and caudal vena cava are best imaged in the right cranial Hepatic gas and mineralization
abdominal quadrant, either just caudal to the ribs or using an Gas may enter the liver via the portal or systemic circulation or by
intercostal approach. The shunt vesselsmay be identified by careful ascending the biiiary tract. When there is gas within the vascula-
assessment of these two large veins. Color Doppler evaluation of ture, branching radiolucentlines that closel/ resembleair broncho-
the caudal vena cava for evidenceof turbulence at the junction of grams may be seenwithin the liver parenchyma.Portal gasaccumu-
the shuntine vesselwith the caudal vena cava mav focus the search. lation usually occurs as a sequel to necrosis of the mucosa of the
stomach or small intestine, such as occurs with eastric dilation
and volvulus. Emphysematouscholecystitis, a rare iondition often
associatedwith diabetesmellitus, results in a focal accumulation of
gas in the right cranioventral portion ofthe liver. Hepatic abscesses
may also contain gas.'g'40Hepatic abscesses are usually ill-defined,
or irregularly marginated, accumulations of multiple bubbles
within the liver (Fig. 41-15). Biliary gas can result from surgical
procedures such as cholecystoduodenostomyor cholecystojejunos-
tomy.
Hepatic mineralization is an uncommon finding. Focal or
multifocal hepatic parenchymal mineralization may be associated
with parasiticgranulomas,abscesses, or neoplasia.Biliary tree min-
eralization results in a branching linear mineral opaque pattern
within the liver parenchyma (Figs. 41-16 and 4l-17). Mineral
opaque choleliths are occasionally noted in companion animals
and infrequently causebiliary obsiruction.
Liver ultrasonography
Ultrasonographic evaluation of the liver should be performed if
liver disease is suspected even if no radiographic abnormalities
are detected. Numerous diseasessuch as biliary obstruction or
cholecystitis,hepaticabscessation (Fig. l-1 8), necrosis,cholangio-
hepatitis, primary or metastatic hepatic neoplasia, toxic hepatopa-
thies, or hepatic lipidosis can causeminimal to no alteration in the
radiographicappearanceof the liver (Tables4l-4 and 41-5).
Text continued on page 549
Figwe 41-11. Ventrodorsalradiographof the same dog as that in Figure Figure 41-12. Lateralradiographof a dog with microhepatia.The pylorus
41- 10 , T h e s t o m a c h\ b l acksta r sin lu m e n )co n ta in sg a s a n d h a sbeenseverel y of the stomachhas shiftedcranially,and the axis of the stomach(blackline)is
c au d a l l d
y isplaceb d y t h e e n la r g e dlive r No
. r m a llyo n th e ve n tr o dorsal vi ew ,the displaced.The tail of the spleen is presentjust caudalto the pylorusof the
s t om a c hl o c a t i o ni s o v e rth e 1 o tha n d 11 th th o r a cicve r te b r a eIn, thi s dog,the stomach;i t i s normal .
stomachis over the first lumbarvertebra.
Figure 4l-14. Ventrodorsalradiographof the same dog as that in Figure Figure 41-15. Lateralradiographof the cranialabdomenof a dog with gas
4 1 - 1 3 , N u m e r o u sc oile dsh u n tin gve sse ls/wh ltea r r o ws)a r e presentmedi al w i thi nthe l i versecondary to a hepati cabscessand gas-formi ng The
bac teri a.
t o t h e l e f t k i d n e ya n d ca u d ato
l th e sto m a ch . l i veri s moderatel general
y i enl
y arged,
and the gas appear sas s mal l ,darkfoc i
in the cranialand ventralaspect lblackarrowheads).The correctidentification
of hepati cgas i s vi tal ,as most ani mal sw i th hepati cgas,re gardl esof
s c aus e,
havea poorprognosi s.
Tabte 47-5. Ultrasonographic liver abnormalities- Table 47-6. Differential diagnoses for generalized
focal/multifocal lesions splenomegaly
Mixed echoic/ Smooth margins !rregularmargins
Hyperechoic Hypoechoic complex
Neoplasia,e.9., LSA, MCT, Neoplasia-HSA, LSA, etc.
Neo pla sia e, .9..H CA Cyst (anechoic) Neoplasia h istiocytosis Hematoma
Nod ula r h yp erp las ia Hem at om a Abscess l m m u n e - m e d i a t e dh e m o l y t i c Abscess
Extramedullaryhematopoiesis Neoplas ia,e. 9. , Hematoma anemia Infarcts
Abscess LSA Necrosis Venouscongestion(RHF,portal) N o d u l a r h yp e r p l a si a
Gran ulo ma Abscess Sedationor anesthesia S p l e n i ct o r si o n
Hema toma(matur e) Splenitis
N o d u l a rh y p e r p l a s i a
HCA, hepatocellular carcinoma; LSA, lymphosarcoma.
HSA, hemangiosarcoma; LSA, lymphosarcoma; MCT, mast cell tumor;
RHE right heart failure.
.tilii
llllii
without internal cavities.t''L The appearanceof lymphosarcoma is 15. Wrigley RH, Konde LJ, Park RD, et al: Clinical features and diagnosis of splenic
hematomasin dogs: 10 cases(1980 to 1987).J Am Anim Hosp Assoc 25:371,19g9.
highly variable, including a diffusely hypoechoic parenchyma and
focal or multifocal hypoechoic nodules (Fig. a1-23), or the spleen 16. Evans HE: Miller's Anatomy of the Dog, 3rd ed. philadelphia, WB Saunders, 1993.
may appear sonographicallynormal.t'''?8Hyperechoicsplenic nod- 17._Rosenzweig LJ: Anatomy of the Cat: Text and Dissection Guide. Dubuque, IA,
ules are frequently seen in older dogs near splenic veins; these William C Brown, 1993.
nodules are usually of limited clinical significance, often resulting 18. Burk RL, Ackerman N: Small Animal Radiology and Ultrasonography, 2nd ed.
from hemosidetosis or mvelolipoma.aT Philadelphia,WB Saunders,1990.
19. Kealy JK, McAllister H: Diagnostic Radiology and Ultrasonography of the Dog
Splenic torsion and cat, 3rd ed. Philadelphia, wB Saunders, 2000.
Torsion of the spleen occurs in large and giant deep-chested 20. YeagerAI, Mohammed H: Accuracy of ultrasonography in the detection of severe
hepatic lipidosis in cats. Am I Vet Res 53:597, 1992.
dogs.assaThe spleentwists on its pedicle, which results in complete
occlusion of the venous drainage and eventual occlusion of the 21. Nicoll RG, O'Brien RT, fackson MW: Qualitative ultrasound of the liver in obese
cats. Vet Radiol Ultrasound 39:47, 1998.
arterial perfusion. Severesplenomegalydevelops following torsion.
The spleen may have a characteristic C-shaped appearanceon the 22. Spaulding KA: Gallbladder wall thickness. Vet Radiol Ultrasound 34(4):270,1993.
lateral view (Fig. 41-24).53Splenic torsion may be accompaniedby 23. Godshalk CP, Badertscher RI, Rippy MK, et al: euantitative ultrasonic assessment
a small to moderate volume of peritoneal fluid; this characteristic of liver size in the dog. Vet Radiol 29:162,1988.
splenic shape may be obscured by the abdominal fluid. Instead, a 24. Barc F: Ultrasonographic assessmentof liver size in the dog. I Small Anim pract
large homogeneous mass may occupy the midabdomen. The fun- 33:359, 1992.
dus of the stomach may be displaced caudally and medially owing 25. Barr F: Normal hepatic measurements in mature dogs. I Small Anim pract
to tension on the gastrosplenicligament, and the normal triangular 331367,1992.
soft-tissue opacity of the head of the spleen in the left cranial 26. Newell SM, Selcer BA, Girard E, et al: Correlation between sonographic findings
quadrant on the ventrodorsal view is absent. In some instances, and specific hepatic diseasesin the cat-72 cases(1985-1997). I Am Vet Med Assoc
anaerobic bacteria may proliferate within the spleen and causegas 213:94,1998.
accumulation with the appearance of numerous small bubbles. 27. Nyland TG: Ultrasonic patterns of canine hepatic lymphosarcoma. Vet Radiol
Torsion of the spleen may also occur as a consequenceof gastric 25:167,1984.
volvulus. 28. Lamb CR, Hartzband LE, Tidwell AS, et al: Ultrasonic findings in hepatic and
Ultrasound is the diagnostic tool of choice to confirm a splenic spleniclymphosarcomain dogs and cats.Vet Radiol 32:117,1991.
torsion. The spleen is typically severely enlarged and the paren- 29. Whitely MB, Feeney DA, Whitely LO, et al: Ultrasonographic appearance of
chyma often has a coarse hypoechoic lace-like appearance (Fig. primary and metastatic canine hepatic tumors: A review of 4g .ar.r. J Ultrasound
4l-25).t'z,aeA similar pattern may be occasionally seen with lym- M ed 8:621,1989.
phoma, but with lymphoma, there is normal blood flow in the 30. Stowater JL, Lamb CR, Rhodes WH: Ultrasonographic features of canine nodular
splenic veins. With splenic torsion, venous blood flow is absent, hyperplasia. Vet Radiol 3l:268, 1990.
which usually can be seen on B-mode images and confirmed by 31. Martin R: Portosystemic shunts. Semin Vet Med Surg Small Anim Sl5, 1990.
spectral, color, or power Doppler evaluation. In some instances,
32. Rogers WA, Suter PF, Breznock EM, et al: Intrahepatic arteriovenous fistulae in a
the veins are filled with echogenicthrombi rather than the expected dog resulting in portal hypertension, portacaval shunis, and reversal of portal blood
anechoicblood (Fig. 4I-26). flow. I Am Anim Hosp Assoc 13:470, 1927.
33. Wrigley RH, Konde LJ, Park RD, et al: Ultrasonographic diagnosis of portacaval
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1. Gibbs C: Radiological features of liver disorders in dogs and cats. Vet Annu 34. Lamb CR: Ultrasonographic diagnosis of congenital portosystemic shunts in dogs:
2l:239, I98L Results of a prospective study. Vet Radiol Ultrasound 37:281, 1996.
2. O'Brien T; Liver, spleen and pancreas. In O'Brien T (ed): Radiographic Diagnosis 35. Meyer HR Rothuizen f, van den Brom WE, et al: euantitation of portosystemic
ofAbdominal Disorders in the Dog and Cat. Philadelphia, WB Saunders, 1978. shunting in dogs by ultrasound-guided injection of 99MTc-macroaggregates into a
splenic vein. Res Vet Sci 57:58, 1994.
3. Suter PF: Radiographic diagnosis of liver diseasein dogs and cats. Vet Clin North
Am Small Anim Pract 12:153,1982. 36. Koblik PD, Komtebedde J, Yen CK, et al: Use of transcolonic 99m technetium-
pertechnetate as a screening test for portosystemic shunts in dogs. I Am Vet Med
4. Nyland TG, Hager DA, Herring DS: Sonography of the liver, gallbladder, and Assoc 196:925,1990.
spleen.Semin Vet Med Surg Small Anim 4:13, 1989.
37. Suter PF: Portal vein anomalies in the dog: Their angiographic diagnosis. J Am
5. Lamb CR: Abdominal ultrasonography in small animals: Examination of the liver, Vet Radiol Soc 16:84,1975.
spleen and pancreas.J Small Anim Pract 31:5, 1990.
38. Schmidt S, Suter PF: Angiography of the hepatic and portal venous system in the
6. Biller DS, Kantrowitz B, Miyabayashi T; Ultrasonography of diffuse liver disease: dog and cat: An investigative method. Vet Radiol 2l:57, 1980.
A review. I Vet Intern Med 6:71.1992.
39. Birchard SL Biller DS, Johnson SE: Differentiation of intraheoatic versus extrahe-
7. England G: Renal and hepatic ultrasonography in the neonatal dog. Vet Radiol patic portosystemic shunts in dogs using positive-contrast portography. J Am Anim
Ultrasound 37:374, 1996. Hosp Assoc 25:13,1989.
8. Evans SM: The radiographic appearance of primary liver neoplasia in dogs. Vet 40. Lord PF, Carb A, Halliwell WH, et al; Emphysematous hepatic abscessassociated
Radiol 28:193,1987. with trauma, necrotic hepatic nodular hlperplasia and adenoma in a dog: A case
history report. Vet Radiol 23:46, 1982.
9. Farrar ET, Washabau RJ, Saunders HM: Hepatic abscessesin dogs: 14 cases
(1982-1994). J Am Vet Med Assoc 208:243, 1996. 41. TG, Gillett NA: Sonographic evaluation of experimental bile duct ligation
-Nyland
in the dog. Vet Radiol 23(6):252, 1982.
10. Hanson IA, Penninck DG: Ultrasonographic evaluation of a traumatic splenic
hematoma and literature review. Vet Radiol Ultrasound 35:463, 1994. 42. Rivers BJ, Walter PA, lohnston GR, et al: Acalculous cholecystitis in four canine
cases: Ultrasonographic findings and use of ultrasonographic-guided percutaneous
11. Lamb CR: Ultrasonography of the liver and biliary tract. Probl Vet Med 3:555, cholecystocentesisin diagnosis. J Am Arim Hosp Assoc a3:407,1997.
199r.
43. Newell SM, Selcer BA, Mahaffey MB, et al: Gallbladder mucocele causing biliary
12. Nyland TG, Mattoon JS: Veterinary Diagnostic Ultrasound. Philadelphia, WB obstruction in two dogs: Ultrasonographic, scintigraphic and pathologic n"aings. )
Saunders,1995. Am Anim Hosp Assoc 3I:467,1995.
13. Wrigley RH, Park RD, Konde LJ, et al: llltrasonographic features of splenic 44. Besso JG, Wigley RH, Gliatto JM, et al tlltrasonographic and clinical findings in
hemangiosarcoma in dogs: l8 cases(1980-1986).J Am Vet Med Assoc 192:1113,1988. 14 dogs with gallbladder mucocele. Vet Radiol Ultrasound 41:26I,2000.
14. Wrigley RH, Konde Ll, Park RD, et al: Ultrasonographic features of splenic 45. Walter PA, lohnston GR, Feeney DA, O'Brien TD: Renal ultrasonography in
lymphosarcomain dogs: 12 cases(1980-1986).I Am Vet Med Assoc 193:1565,1988. healthy cats. Am J Vet Res 48:600, 1987.
554 AN IM AL S
A B DO M E N- C O MP AN IO N
46. Root CR: Abdominal masses:The radiographic differential diagnosis. J Am Vet argy. Which of the following statementsis most correct regarding
Radiol Soc 15:26, 1974. the radiographic diagnosis?
47. Walzer C, Hittmair K, Walzerwagner C: Ultrasonographic identification and char- A. The large mass in the center of the abdomen is most likely
acterization of splenic nodular lipomatosis or myelolipomas in cheetahs (Acinonyx associatedwith the GI tract.
jubatus). Yet Radiol Ultrasound 37(4):289, 1996.
B. The large mass in the center of the abdomen is most likely
48. Hurley RE, Stone MS: Isolated torsion ofthe splenic pedicle in a dog. I Am Anim associatedwith the left kidney.
Hosp Assoc 30:119, 1994.
C. The large mass in the center of the abdomen is most likely
49. Konde LJ, Wrigley RH, Lebel JL, et al: Sonographic and radiographic changes associatedwith the soleen.
associatedwith splenic torsion in the dog. Vet Radiol 30:41, 1989.
D. The large mass in thi center of the abdomen is most likely
50. Nagel ML, Tellhelm B, Haasper A: Splenic emphysema and torsion in a dog. associatedwith the liver.
Kleintierpraxis33:135, 1988.
51. Neath PL Brockman DJ, Saunders HM: Retrospective analysis of 19 cases of 4. Sonographicimage (Fig. 41-30) of the liver of an 8-year-old
isolated torsion ofthe splenic pedicle in dogs. J Small Anim Pract 38:387,1997.
Cocker spaniel with a history of vomiting and anorexia. Which of
52. Stead AC, Frankland AL, Borthwick R: Splenic torsion in dogs. ) Small Anim the following is most correct regarding the sonographic appearance
Pract 24:549, 1983. and sonographicdiagnosis?
53. Stickle RL: Radiographic signs of isolated splenic torsion in dogs: Eight cases A. The liver is sonographically normal. If hepatic disease is
(1980-1987).J Am Vet Med Assoc 194:103,1989.
suspected,a biopsy or aspirate of the liver is recommended.
54. Wrigley RH:.Ultrasonography of the spleen. Life-threatening splenic disorders. B. The liver contains multiple target lesions (hyperechoic center
P r o b l Ve t Me d 3 :5 7 4 , 1 9 9 1 . with a hypoechoic rim).
C. The liver parenchyma is normal, but the gallbladder is dis-
K Ouestions tended and the intrahepatic bile ducts are enlarged. The
sonographicdiagnosisis biliary obstruction.
l. Normal sonogram(Fig. a1-27) of the centralportion of the iiver D. The liver is diffusely hyperechoic. Evaluation for canine
of a dog. Identifr the structure indicated by the black arrowhead. Cushing's diseaseor hepatic lipidosis should be performed.
A. Hepatic vein
B. Hepatic artery 5. Focal enlargement of the caudate lobe of the liver results in
C. Intrahepatic bile duct caudal displacement of which organ(s)?
D. Portal vein A. Gastric fundus
B. Head of the spleen
2. Lateral radiograph (Fig. a1-28) of an 8-year-old mixed-breed C. Left kidney
dog with a clinicai history of polfrria and polydipsia. 'vVhich of D. Pylorus
the following answers is most correct regarding the radiographic E. Right kidney
diagnosis?
A. The liver is normal. 6. The use of as a Dremeclrcatronor
B. The liver is mildly enlarged, with rounded irregular caudo- as an anesthesiainduction agent may result in gener-
ventral margins. Differential diagnoses should include he- alizedsplenomegalyin dogs.
patic neoplasiaand nodular hyperplasia.
C. The liver is moderately enlargedwith smooth, sharp margins' 7. Exogenous steroid administration may cause which of the fol-
Differential diagnosesshould include diseasessuch as canine lowing?
Cushing'sdiseaseand hepaticlipidosis. A. Diffusely increasedhepatic parenchymal echogenicity
D. The liver is small. Differential diagnosesshould include he- B. Diffusely reduced hepatic parenchymal echogenicity
patic atrophy secondary to a Portosystemic shunt or hePatic C. Hepatic venous congestion
cirrhosis. D. Mild/moderate generalizedhepatomegaly
E. Mild microhepatia
3. Lateral and ventrodorsalradiographs(Fig. 41-29) of a l3-year-
old domestic shorthaired cat with a history of anorexia and leth- Answers begin on page 727.
Figure 41-27
Figure 41-28
Figure 41-29
Figure 41-3O
555
CHA P T E R
42
The Kidneys and Ureters
. Daniel A. Feeney r Gary R. Johnston
I The kidneys
Surveyradiographicprocedureswith contrast medium and sonog- the unlikely occurrenceof contrast medium-induced renal disease
raphy can contribute much information toward the diagnosis of or failure, readersare directedto textbookson renal disease.t'2
renal and ureteral diseases.The external boundaries of the kidneys The technique of excretory urography is described in detail in
can usuallybe identified on surveyradiographs.This identification TabIe 42-I. The patient should be prepared as for survey radio-
permits assessment of the size,shape,and radiographicopacity of graphs:Food is withheld, and cleansingenemasare administered.'u
the kidneys, which may aid in the diagnosisof diseaseprocesses. Generally,ionic iodinated contrast media are used and are given by
However, when the kidneys cannot be assessedby survey radio- bolus intravenous injection. However, if previous systemicreactions
graphs, or when qualitative functional information is needed,ultra- (e.g., shock) have occurred in the patient, or if the patient is
sonography or excretory urography may provide the ciinician with severelycompromised medically, nonionic contrast media, such
imoortant information. as iopamidol and iohexol, or an alternative procedure such as
ihe general goals of this chapter are to specifu the radiographic ultrasonographyshouid be considered.The dose of contrast me-
and ultiasonographicimaging proceduresapplicableto the kidneys dium for excretoryurography is 400 mg iodine per pound ofbody
and ureters and to place each of theseproceduresinto perspective weight injected via a preplacedcephalicvenous or jugular venous
regarding indications, limitations, contraindications,and pitfalls catheter.a-7 Catheter placement should be maintained for at least
when applicable. Subsequently,the normal radiographic findings 15 to 20 minutes after administration of the contrast medium
basedon roentgen signs are described.In addition, the abnormal becauseit provides a readily accessibleroute in the event of a
radiographic findings are described,and at least a partial list of hypotensive reaction to the contrast medium. There are many
gamutsthat should be consideredin associationwith certain roent- suggestedfilming sequences; however,radiographsobtained imme-
gen signs is presented. diately and 5, 20, and 40 minutes after injection of contrast me-
dium generallyyield the most information.l' s'7
lmaging procedures The interpretative phasesof the excretory urogram are the
nephrographicand pyelographicphases.Opacificationof the func-
Survey radiographs provide information on the external anatomy
of the kidneys when contrast is adequateto permit their visualiza- tional renal parenchymais the nephrogram, and opacification of
the renal pelvis, pelvic recesses,and ureters is the pyelogram.
tion. In addition, it is possibleto assessany abnormal opacities
Each phase should be evaluatedseparately(based on subsequent
near the kidneys, such as air and mineral, that may suggest a
pathophysiologicmechanism for the clinical signs of renal disease.''' information in this chapter).Although proceduresin which radio-
graphic contrast media are used provide considerableinformation
Becausethe right lateral view permits greaterlongitudinal separa-
relativeto urinary tract disease,they may complicatesome subse-
tion of the radiographic images of the right and left kidneys' it
quent determinations for as long as 24 hours. For example, in-
is the projection most applicable to radiography of the upper
urinary tract.3
Survey radiographsmay not provide adequatemorphologic in-
Table 42-1. Technique for excretory urography
formation when the patient is emaciated or has peritoneal or
retroperitoneal fluid. Excretory urography is useful for defining Provideroutine patient preparation
anatomic structuresand for assessing qualitativelythe function of Allow 24 hourswithout food; water ad libitum
the kidneys. It is a relatively simple means of verifring and localiz- Performcleansingenema at least 2 hours before radiography
ing upper urinary tract disease,and it may be used to assessthe Assesshydrationstatus;proceedonly if normal
Obtain survey radiographs
reversibility of renal disease.Although excretory urography is not
I n f u s ec o n t r a s tm e d i u m i n t r a v e n o u s l yv i a t h e c e p h a l i co r
a quantitative measurement of renal function, it may be used to j u g u l a r v e i n a s r a p i d l ya s p o s s i b l e( b o l u s i n j e c t i on )
assiss the relative function of the kidneys and may be loosely Dose:400 mg iodine/lbbody weight
interpreted to assessthe pathophysiologic mechanismsof renal fail- U s e c o n t r a s tm e d i u m : u s u a l l ys o d i u m i o t h a l a m a t eor so d i u m
ure.n d i a t r i z o a t eb, u t c o n s i d e rn o n i o n i ca g e n t ss u c h a s i o p a m i d o l
Excretory urography may be used in both azotemic and nonazo- o r i o h e x o l i n h i g h - r i s kp a t i e n t s
temic patients, provided hydration is adequate. As the degree of O b t a i n a b d o m i n a lr a d i o g r a p h si n t h e f o l l o w i n g s e q u e n ce :
renal failure progresses,however, it may be necessaryto increase Ventrodorsalviews at 5 to 20 seconds,5 minutes,20 minutes,
the dose of contrast medium to provide adequatevisualizationof and 40 minutes post injectionfor generalassessment
Lateralview at 5 minutes post injectionfor general
the kidneys. In any instance, patient hydration should be assessed
ASSESSMENI
and determined to be normal before any contrast medium is Oblique views at 3 to 5 minutes post injectionfor ureteral
administered.' It is possible that there may be a temporary decrease t e r m i n a t i o ni n u r i n a r y b l a d d e r
in kidney function after excretory urography; an in-depth discus- Lateraland ventrodorsalviews at 30 to 40 minutes post
sion of this is beyond the scope of this text. The clinical significance injectionto observe urinary bladder if retrograde
of this decreasedfunction is considered minimal in the presence cystographyis contraindicatedor impossible
of adequateurinary output and patient hydration.
Azotemia is not a contraindication in excretory urography' pro- Modified from Feenev DA, Barber DL, Johnston GR, et al: The excretorY
urogram: Techniques, normal radiographic appearance and misinterpreta-
vided the patient is adequatelyhydrated. For information concern- tion. Comp Contin Ed Vet Pract 4:233, 1982.
ing the specific pathophysiotogy and management of patients with
556
The Kidneysand Ureters 557
creased urine specific gravity due to intravenously administered Table 42-2. Ouantitative appearance of normal canine
contrast medium may be erroneously interpreted as adequaterenal and feline excretory urograms
concentrating ability.' In addition, although detailed in vivo studies
Structure Measurement* Valuet
are not available for all types of urinary pathogens, contrast me-
dium inhibition of growth of some urinary tract organismscannot Kidney Length Dog
be ignored.' It is recommended,therefore,that samplesfor culture 3.00 (0.25 yl (L-2l
and renal concentrating ability studies,as well as for urine sediment 2.50to 3.50 (L-2)
cytologic analysis, be performed before or at least 24 hours after
(including severalvoidings) excretory urography. 2.4 to 3.0 (L-21
4.0 to 4.5 cm
Renal ultrasonography is a noninvasive technique in which width Dog
sound is directed into the tissue and the reflected echoes are 2.00 (0.201(L-2r,
reconstructedinto two-dimensional images.lors With the use of Cat
sonography, information on renal architecture may be provided 3 . 0 t o 3 . 5 cm
without the use of contrast medium. R e n a lp e l v i s width Dog
Two-dimensional ultrasonography is based on the concept of 0 . 0 3 ( 0 . 0 1 7 )( L - 2 )
tissue reflectivity. Sound exiting the transducer (handheld part of ( g e n e r a l l y2 .0 m m )
the instrument) traversesthe tissueinto which it is directed.Vari- Cat
ances in tissue fat and connective tissue content as well as vascu- Not reported
Pelvicrecesses width Dog
larity influence how much of the sound is reflected back to the
0.02 (0.005)(L-2)
transduceras it passesthrough tissues.The degreeof sound reflec- ( g e n e r a l l y1 .0 m m )
tion that occurs at a given tissue interface determines how echo-
genic (bright comparedwith the scan background) specifictissues Not reported
or organs will be. Reflection dominates to the point of nothing Proximal width Dog
visible (so-cailed "shadowing") beyond materials that are very dif- ureter 0 . 0 7 ( 0 . 0 1 8 )( L - 2 )
ferent from soft tissue (e.g.,bone, air, metal). Simple fluids (e.g., ( g e n e r a l l y(2 .5 m m )
transudatesor normal urine) usually have no echoesand appear Cat
black. It must be rememberedthat the image representsa "slide" Not reported
Distal ureter width Not reportedin dogs
of tissueusuallybetween5 and 15 mm thick. The appearanceof the
or cats
kidney will vary dependingon the location (e.g.,medial, cranial) of
the slide in the kidney, and the whole kidney should be scanned *Measurements apply
onty to the ventrodorsal view.
in a smooth slow motion using standard imaging planes (i.e., tL-2, the length of the body of the second lumbar vertebral bodv as
visualized on the ventrodorsal view.
sagittal, transverse,dorsal). The expectednormal appearancesof
canine and feline kidneys are shown in the section on normal _From Feeney DA, Barber DL, Johnston GR,et al: The excrerory urogram:
T:chliq!gs:.nolmal radiographic appearance and misinterpretation. bomp
imaging findings. Contin Ed Vet Pract 4:233, 1982; modified with permission.
Figure 42-I. Ventrodorsal views of a normaldog after intravenousadministration of 400 mg iodineper pound body weight in the form of sodium iothalamate
; , 5 m i n ute s;C,2 0 m in u te s;a n d D,4 0 m in u te sa fteri nj ecti on,
A, 10 s e c o n d s B
However, if high-resolution equipment (e.g.,7.5 to 10.0 MHz) is Normal size and shape
used, the pelvis may be visible as an anechoic (black) slit. Similarly, . Amyloidosis
the ureter is usually not seen excePt where it enters the urinary . Glomerulonephritis
bladder where a jet of urine expelled from the ureter into the . Acute pyelonephritis
bladder can sometimesbe seen.Aggressivefluid therapy may cause . Familial renal disease
the renal pelvis, the pelvic recesses,and the ureter to dilate physio- Normal size, irregular shape and margin
logically, but the normal pelvis will still be less than I to 2 mm . Focal
wide and the ureter less than 3 mm in diameter. Typically' the . Infarct
renal cortex in dogs appearseither a little less or a little more . Abscess
bright than the liver background and should always be less bright . Diffuse
than the spleen. Renal cortical echotexture in cats can be quite . Chronic pyelonephritis
variable and is often greater than the liver and may approach that . Polycystic renal disease
of the spleen. The renal medulla in dogs and cats is less echogenic Small size, regular shape and margin
than the cortex. The echotexture consideration is important for . Hypoplasia
trying to assessdiseasesthat do not alter the kidney architecture . Glomerulonephritis
(e.g., tubular necrosis, feline infectious peritonitis). Architectural . Amyloidosis
disruptions of the kidney or ureter are interpreted similarly to the . Familial renal disease*(Fig. a2-5)
radiographicmethods defined below"'u Small size, irregular shape and margin
. End-stagerenal disease
Abnormal imaging findings . Dysplasia
Figure 42-2, Ventrodorsal views of a normalcat after intravenousadministration of 400 mg iodineper poundof body weight in the form of sodium iothalamate.
/, 1 0 s e c o n d s 8; , 5 m in u te s;C 2 0 m in u te s;a n dD,4 0 m in u tesafter i ntravenous
i ni ecti on.
=i-,
560 A N IMA L S
A B DO M E N- C O MP AN IO N
Figuro 42-5. Ventrodorsal views 10 seconds/AJand 5 minutes (BJafter intravenouscontrastmedium injectionfor excretoryurographyin a 1-year-old Shihtzu.
The k id n e y sa r e s m a l, n e ph r o g r a p hoicp a cityis p o o r ,a n d p ye lo g r aphiopaci
c tyi s mi ni mal Mi
. croscopidi
c agnoss:S hi htzu fami l i alrenaldi sease.
Table 42-3. Possible structural nephrographic the filtration of the contrast medium from the blood and the
opacification patterns associated with certain renal concentrationof the contrast medium within the tubules. Loss of
diseases* either of these capabilities within the kidneys (assuming adequate
Opacification pattern Renaldisease dosageand proper route of administration of contrastmedium are
performed) may result in a lessthan optimal pyelogram.
Unifo rm Nor m al
Compensatoryhypertrophy
Ac ut e glom er ularor I The ureters
t ubuloint er s t it ial
dis eas e
Perirenalpseudocysts Normal radiographic findings
Hypoplasia
F oca l,n on un iform Neoplas m The normal ureters are not visible on survey radiographs. As can
Hem at ur ia be visualized at excretory urography, the diameter of each ureter is
Cyst usuallylessthan 2 or 3 mm at the hilus.i t The shapeof the ureters
Single inf ar c t is tubular, with segmentationsecondaryto peristalsis.a'sThe ureters
Hy dr onephr os is are primarily retroperitonealbut become intraperitoneal as they
Abscess approachtheir termination at the bladder trigone.so,0 Care should
Multifo ca l.n on un ifor m Polycysticdisease be exercisedin the interpretation of the end-on view of the deep
M ult iple inf ar c t s circumflex iliac artery as a survey radiographic abnormality related
Acute pyelonephritis to the ureter.6The normal findings for excretory urography relative
Chr onicgener aliz edglom e r u l a ro r to the ureter have been described(seeFigs.42-l and 42-21.+z
dis eas e
t ubuloint er s t it ial
Felineinf ec t iousper it onit i s
Infiltrativeneoplasia Abnormal radiographic findings
No nopacificatio
n Aplasia/agenesist Number. As was describedpreviouslS agenesisand aplasiaof
Renalartery obstructiont the kidneys and their associatedureters have been reported. Ure-
Nephr ec t om yor nonf unc t i o n a rl e n a l teral duplication in the presenceof renal duplication in dogs has
par enc hy m at also been described.2t
Insufficientor extravascularcontrast Size, shape, and marginafion. Information pertaining to the
m edium injec t ion
sizeof the ureteg its overallshape,and the mucosalmargin charac-
*Best identified on radiographs exposed 5 to 20 seconds or 5 minutes teristicsmay be combined to assistin the differential diagnosisof
after contrast medium injection. Do not overinterpret corticomedullary
7,I0 r8,28,8s,87-r0r
ureteral disease.a In the following list, this triad of
separation on early postinjection radiographs. roentgen signs is used and, if possible,differential considerations
f Only unilateral conditions compatible with life. of diseaseprocessesare listed.
Diffuse enlargement,regular shape,smooth mucosa
. Obstruction at trigone
Figure 42-11, Lateral(A)and ventrodorsal/B/ radiographsin which there are smoothlymarginated,oval,white calcificopacitiesin the areaof the right kidney
and ureter.C Ventrodorsal view 5 minutesafter intravenousinjectionof contrastmediumfor excretoryurography.Peripheralopacification of the right nephrogram
is i d e n t i f i e dw i t h o u tacco m p a n yince l r p ye lo g r a p h o
g n tr a o icp aci fi cati on.
S urgi caldi agnosi s:
ri ghtrenaland ureteralcal culw
i i th ureteralobstructi onand ri ghtrenal
hvdroneoh rosis.
564 A N IMA L S
A B DO M E N-C OMP AN IO N
Figure 42-14. Ventrodorsal views immediatelybefore A/, 10 secondsalter (B),5 minutes after (C),and 40 minutes aflet (D) intravenousinjectionof contrasr
medium for excretoryurography.The size of the kidneysis normal,but nephrographic
opacificationis poor and does not fade with time. Microscopicdragnosrs:
glomerulonephritis
secondaryto systemiclupus erythematosus.
566 AN IM AL S
A B DO M E N -C OMP AN IO N
. Ectopic ureter (Fig. 42-15) enter the vagina. The advantageof this procedure is the definitive
. Atony from infection or periureteral inflammation (rare) identification of ureters that terminate in the vagina (Ftg. aZaT).
. Chronic vesicoureteralreflux (rare) The disadvantageof this procedure is that it requires either deep
Focal enlargement,smooth mucosa sedation or general anesthesia,and it will not predictably allow for
. Ureterocoele(Fig. a2-16) identification of ureters that do not terminate in the vagina. The
. Diverticuium excretory urogram not only provides insight on ectopic ureters,
Diffuse enlargement, irregular mucosa regardlessof where they terminate, but it also provides a physio-
. Fibrosis logic means to filI the urinary bladder with positive-contrast me-
Focal enlargement, irregular mucosa dium to assessurethral sphincter continence.
Radiopacity. Air in the ureters is most likely associatedwith
' Neoplasia
Focal enlargement,smooth mucosa vesicoureteralreflux secondary to pneumocystography.Mineraliza-
. Focal obstruction tion of the ureter is rare; most mineral opacities in the area of the
Focal lumen narrowing, smooth mucosa ureter represent calculi (see Fig. 42-77).4'u Loss of retroperitoneal
. Extrinsic compression contrast in survey abdominal radiographs may be an indirect
. Stricture indication of the accumulation of blood or urine or both, one
Focal lumen narrowing, irreguiar mucosa causeof which is ureteralrupture (Fig. 2-1S)' This loss of retro-
. Stricture peritoneal contrast must be interpreted in light of the body fat
status in the remainder of the patient.
Location. The abnormal location of the ureter that is most During excretory urography, a reproducible filling defect in the
often encountered is ectopic ureter, in which the distal portion of contrast medium column in the ureter may be causedby a calculus,
the ureter terminates at a point other than the bladder ttigone'tLe0 a neoplasm, infiltrative disease,or a stricture secondary to disease
The most common site of abnormal ureteral termination is the or extirnal compression.a'6' e2-es
Assessmentof the margination and
vagina, followed in relative frequency by the urethra, bladder neck' opacity of these structures on suney radiographs in combination
an-cluterus. As mentioned in the preceding section' the affected with the size, shape, and margination of the ureter at excretory
ureter is usually dilated throughout its length (see Fig' 42-14)'
urographic examination may help differentiate these considera-
Another possiblecauseof abnormal location of the distal portion
tions. Nonvisualization of a ureteral segment is usually normal
of the ureter is trauma, usually due to avulsion of the ureter from
because of peristalsis.''t' 7 Howevet, this segment of the ureter
the bladder neck. In ureteral avulsion, retroperitoneal effusion may
should be visualized at some time in the sequenceof radiographs.
also occur.
If the segment is not seen during the sequence,especially in the
In addition to excretory urography (which is the authors' prefer-
presenceof contrast medium accumulation in the retroperitoneal
ence) for diagnosisof ectopic ureter, retrogradepositive-contrast
In this technique, sterile, iodinated spaceot loss of retroperitonealcontrast, ureteral rupture should
vaginography"canbe used.io'z
is placed in the vestibule and vagina via a balloon be considered (see Fig. 42-18).4 r0's6Another consideration in
.oittui
of suitable size to limit contrast medium extravasatlon segmental nonvisualization of the ureter is stricture, but there will
catheter -.dirr-
around the balloon. The balloon is placed just inside the vulvar be proximal dilation to provide Perspectiveon the nonvisualized
lips and contrast medium is infused until mild resistanceis met' segment.
T'he goal of this procedure is to identify the ectopic ureters that Function, Ureteral atony or hypotonia may be induced second-
Figure 42-15, Lateral /AJ and ventrodorsal(8/ views of a patient 40 minutes after
is ex-
iniavenous injectionof contrastmedium for excretoryurography.The right ureter
extends
tremetydilated,as are the right renal pelvisand pelvicrecesses The right ureter
d o r s ailo t h e b l a d detrr ig o n ea n dve n tr atol th e ve stib u lea n dtermi natesi n the di stalurethra
va g in o g r a mo u tlin e dth e te r m ln a tionof thi s ureteras w el l as the
A p r e v i o u sr e t r o gr a d e
urethralorifice,tlie cervix,and the uterinehorns.Radiologicdiagnosis:ectopicureter'
The Kidnevsand Ureters 5,67
Figure 42-16. Lateral(A) and ventrodorsal/B,)views of a patient 40 minutes after intravenousinjectionof contrast medjum for excretoryurography,The
t e r m i n apl o r t i o no f t h e le ft u r e te ris d ila te din its in tr a m u r aaln d submucosal
pathi n the uri narybl adderandtermi natesi n the proxi malurethra.R adi ol ogidi
i agnos i s :
ectopacureterwith ureterocele.fhe radtolucentline in the caudalaspectof the bladderin B is the wall of the ureterocele.lt is visiblebecauseof adjaient contrast
m e d i u mi n t h e u r e t e r alu l m e na n d in th e b la d d e rlu m e n .
ary to intraluminal infection, periureteral inflammation, trauma, urethrography. The major significance of vesicoureteral reflux lies
or ureteral obstruction (see Figs. 42-12 and 42-15).4'6'85'86'e2'e3 in the potential of retrograde flow of urine contaminated with
Differentiation among these possible causesrequires complete as- pathologic organisms from the urinary bladder toward the kidney.
sessment of the size, shape, and margination of the opacified The normal ureter is not visible sonographically as a tubular
ureter as well as observation of the site and character of ureteral entity except as it enters the urinary bladder.'qt3,14,23' 2s This is
termination. Comparison with the results of urine rytologic and most easily recognizedby the characteristic "flow jet" produced in
culture studies is also of value. the bladder lumen when the peristaltic ureter ejectsurine. However,
Vesicoureteral reflux is the retrograde flow of urine from the when the ureter is either focally or diffusely enlarged, it can be
bladder into the ureter either as a low-pressurephenomenon in recognized as a fluid-containing tube that may or may not have
the presence of incompletely filled bladder or as a high-pressure evidence of peristalsis during real-time ultrasonography. As the
phenomenon in the presenceof a filled bladder or during voiding.nu ureter exits the kidney, it can create a circular black void in the
Vesicoureteralreflux may be encountered in immature small ani- otherwise uniformly bright renal sinus fat in the renal hilus when
mals and may be induced during retrograde radiographic proce- viewed in the sagittal plane. The dilated renal pelvis can be seen to
dures. Reflux may also be induced secondary to manual compres- make a "funnel-shaped" transition into a dilated ureter at the
sion of the urinary bladder in an attempt to perform voiding ureteropelvic junction when viewed on the transverseplane
The Kidneysand Ureters 569
il'
AN IM AL S
5 7O A B DO M E N -C O MP AN IO N
62. Minkus G, Breuer W, Wanke R, et al: Familial nephropathy in BerneseMountain 95. Moroff SD, Brown BA, Matthiesen DT, Scott RC: Infiltrative ureteral diseasein
Dogs. Vet Pathol 3l:421, 1994. female dogs;41 cases(1980-1987).I Am Vet Med Assoc 1991247,1991.
63. Morton LD: Familial nephropathy in Miniature Schnauzers Can Vet J 32:389, 96. Klausner JS, Feeney DA: Vesicoureteral reflu. In Kirk RW (ed): Current Veteri-
1 99 1 . nary Therapy VIII. Philadelphia, WB Saunders, 1983.
64. Noonan CHB, Kay lM: Prevalence and geographic distribution of Fanconi syn- 97. Ross LA, Lamb CR: Reduction of hydronephrosis and hydroureter associated
drome in Basenjis in the United States.J Am Vet Med Assoc \97:345,1990' with ectopic ureters in two dogs after ureterovesicalanastomosis.J Am Vet Med Assoc
196:1497,1990.
65. O'Brien TD, Osborne CA, Yano BC' et al: Clinicopathologic manifestations of
progressive renal disease in Lhasa Apso and Shih Tzu dogs. J Am Vet Med Assoc 98. Scott CW Greene RW, Patnaik AK: Unilateral ureterocele associatedwith hydro-
1 80 :6 5 8 1
, 982. nephrosis in a dog. I Am Anim Hosp Assoc 101126,1974.
66. Perry W: Generalized nodular dermatofibrosis and renal cystadenoma in a series 99. Takiguchi M, Uasuda J, Ochiari K, et al: Ultrasonographic appearance of or-
of 10 closely related German Shepherd dogs. Aust Vet Pract 25:90' 1995' thotopic ureterocele in a dog. Vet Radiol Ultrasound 38:398, 1997.
67. Reusch C, HoeraufA, Lechner J, et al: A new familial glomerulonephroPathy in 100. Smith CW, Park RD: Bilateral ectopic ureteroceles in a dog. Canine Pract
BerneseMountain dogs.Vet Rec 134:4ll' 1994. l:28, 1974.
68. Robinson WF, Huxtable CR, Gooding IP: Familiar nephropat\ in Cocker Span- 101. Stowater JL, Springer AL: Ureterocele in a dog. Vet Med Small Anim Pract
iels. Aust Vet I 62:109, 1'985. 74:1753,1979.
69. Schulze C, Meyer HR Blok Al, et al: Renal dysplasia in 3 Dutch Kooiker dogs' 102. Johnston GR, Osborne CA, Wilson JW, Yano BL: Familial ureteral ectopia in th€
Vet Q 20:146,1998. dog. J Am Anim Hosp Assoc l3:168, 1977.
7I. Zullen CD, Nickel RR VanDiik TH, et al: Xanthinuria in a family of Cavalier
K Ouestions
King CharlesSpaniels.Vet Q l9:I72,1'997.
l. Which of the following diagnostic proceduresprovides qualita-
72. Chew DJ, DiBartola SP, Boyce JT, Basper PW: Renal amyloidosis in related
tive information on relative renal function?
Abyssiniancats.J Am Vet Med Assoc 181:139,1982.
A. Survey radiography
73. Tarr ML DiBartola SP: Familial amyloidosis in Abyssinian cats: A possible model B. Intravenous urography
for familial Mediterranean fever and pathogenesisof secondary amyloidosis. Lab Invest
52:67a,1985. C. Gray-scaleultrasonography
D. Renalbiopsy (tissuecore)
74. Morrow KL, Salman MD, Lappin MR, Wrigley R: Comparison of the resistive
index to clinical parameters in dogs with renal disease.Vet Radiol Ultrasound
E. None ofthe above
37:193,1996.
75. Nyland TG, Fisher PE, Doverspike M, et al: Diagnosis ofurinary tract obstruction
2. Which of the following must be consideredbefore an excretory
in dogs using duplex Doppler ultrasonography. Vet Radiol Ultrasound 34:348' 1993' urogram is performed?
76. Allworth MS, Hoffman KL: Crossed renal ectopia with fusion in a cat' Vet Radiol
A. Is there adequateurine production?
Ultrasound 40:357, 1999. B. Is the patient adequatelyhydrated?
C. Is the urinary bladder catheterized?
77. Wells CA, Coyne JA, Prince JL: Ectopic kidney in a cat. Mod Vet Pract 61:693'
19 8 0 . D. Is the patient sedated?
E. AandB
78. Johnson CA: Renal ectoPia in a cat. I Am Anim Hosp Assoc 15:599, 1979'
79. Osborne CA, Klausner JS, Clinton CW; Analysis of canine and feline uroliths ln
3. Which of the following tests is potentially influenced by the
Kirk RW (ed): Current Veterinary Therapy VIII. Philadelphia, WB Saunders, 1983'
presenceof radiographiccontrast medium in urine?
80. Ling GV, Ruby AL, fohnson DL, et al: Renal calculi in dogs & cats: Prevalence' A. Sediment cytology
mineral t]pe, breed, age, and gender interrelationships. J Vet Intern Med 12:11' 1998'
B. Specific gravity
81. Barber DL, Rowland GN: Radiographically detectable soft-tissue calcification in C. Some bacterial cultures
chronic renal failure. Vet Radiol 20:117,1979.
D. Some protein analyses
82. Hall MA, Osborne CA, Stevens JB: Hydronephrosis with heteroplastic bone E. Ali of the above
formation in a cat. J Am Vet Med Assoc 160;857, 1972.
83. Miller JB, Sande RD: Osseous metaplasia in the renal pelvis of a dog with 4. Which of the following can obscurevisualization of the kidneys
hydronephrosis. Vet Radiol 21:146, 1980.
on either the lateral or the ventrodorsal view?
84. Fuller WJ: Subacute pyelonephritis with a unilaterally non-visualized pyelogram' A. Retroperitoneal fluid
I Am Anim Hosp Assoc 12:509,1976. B. Lack of retroperitoneal fat
85. Barber DL, Finco DR: Radiographic findings in induced bacterial pyelonephritis C. Infiltrative retroperitoneal mass
in dogs. ) Am Vet Med Assoc 175:1183'1979. D. Peritoneal fluid
86. Selcer BA; Urinary tract trauma associatedwith pelvic trauma' J Am Anim Hosp E. A. B. and C
Assoc l8:785, 1982.
87. Faulkner RT, Osborne CA, Feeney DA: Canine and feline ureteral ectopia' In 5. Basedon multifocal inhomogeneity of the nephrogram, which
Kirk RW (ed): Current Veterinary Therapy VIII. Philadelphia, WB Saunders' 1983' of the following conditions would be consideredas possiblediagno-
88. Hagar DA, Blevins WE: Ectopic ureter in a dog: Extension from the kidney to ses?
the urinary bladder and to the urethra. I Am Vet Med Assoc 189:309, 1986 A. Glomerulonephritis (glomerulotubular imbalance)
89. Hayes HM: Breed associations of canine ectopic ureter: A study of 217 female B. Multifocai metastatic cancer
cases.J Small Anim Pract 25:501,1984 C. Perinephric fluid accumulation (pseudoryst)
90. Owen RR: Canine ureteral ectopia. I Small Anim Pract 14:407' 1983' D. Polyrystic renal drsease
E. BandD
91. Jakovljevic S, VanAlstine WG' Adams LG: Ureteral diverticula in two dogs Vet
Radiol Ultrasound ,r'425, t998.
92. Rose IG, Gillenwater JY: Effects of obstruction on ureteral function' Invest Urol
6. Unilateral failure of (or unilateral delay in) renal parenchymal
12:139,1975. opacification during an excretory urogram may be causedby which
of the following?
93. Rose IG, Gillenwater lY Effects of obstruction and infection upon ureteral
function. Invest Urol 11:471,1974. A. Poor renal function (e.g., chronic renal diseasewith azote-
mia)
94. Burton CA, Day MJ, Hotston-Moore A, Holt PE: Ureteric fibroepithelial pollps
in 2 dogs. J Small Animal Pract 35:593, 1994.
B. Inadequate dose of radiographic contrast medium
The UrinaryBladder 571
CHA P T E R
43
The Urinary Bladder
I Richard D. Park r Robert H. Wrislev
I Radiographicsigns of urinary
I bladder disease
Signs of urinary bladder diseaseon survey radiographs are some-
what limited. In many instances, the signs indicate disease in
adjacent structures. Signs that indicate diseaseof the urinary blad-
der or of adjacent structures are poor or nonexistent bladder
visualization and abnormal bladder position, shape,size,and opac-
ity (Table43-l).
Inadequate or nonexistent radiographic visualization of the uri-
nary bladder may occur with good or poor serosal detail in the
caudal abdomen. If the serosal detail is good and the bladder is
not seen,the bladder either is empty or has been displaced caudally
or ventrally. If poor serosaldetail is present and the bladder surface
is not distinctly seen,free peritoneal fluid or inadequate peritoneal
fat may be the cause(Fig. a3- ).
The bladder may be abnormally displaced in various directions.T
The cause of the displacement may often be determined radio-
graphically through observation of surrounding structures (Fig.
Figure 472. Lateralradiograph of the caudalabdomenin a normaldog
because of fatwithinthe bladder llgaments. 43-5). With severe bladder displacement, such as occurs with
Thebladder neckiswellvisualized
Therectusbbdominis muscle/shortarrows) is ventralto the bladder'Bowelis hernias, the bladder may not be seen on survey radiographs but
superimposed (longarrows)overthe cranialanddorsalborders of the bladder' may be identified by cystography or ultraosonography. Bladder
retroflexion was found on examination in 12 (20o/o)of 61 dogs
with a perineal hernia.8 A urinary bladder partially within the
der may extend to the umbilicus. Severedistention may occur in a pelvic canal (Fig. a3-6) may be associatedwith congenital urinary
normal bladder if the animal has not had an opportunity to void tract anomalies.' A minimally distended bladder may be pelvic in
or will not void because of a strange or unfamiliar environment. position and displaced more cranially when distended; pelvic blad-
The urinary bladder in the dog is usually oval, but with distention ders have been reported as a normal variation.a's Incontinent
it becomesmore ellipsoid (Fig. a3-3A). The feline urinary bladder female dogs with a pelvic bladder usually have shorter urethras
is almost always ellipsoid (see Fig. 43-38). than do continent dogs.lo Becausepelvic bladders do not always
The bladder is cranial to the pubis, dorsal to the rectus abdomi- indicate a clinical problem, a pelvic bladder should be coordinated
nis muscle, caudal to the small bowel and omentum, and ventral with clinical signs and tests to determine its clinical significance.
to the large bowel. In females, the uterus lies between the bladder It is uncommon to observe a change in shape of the urinary
and the rectum. The normal urinary bladder may be partially bladder on survey radiographs. Abdominal masses adjacent to
within the pelvic canal or cranial to the pubis (external to the the serosal surface of the bladder may distort the bladder shape.
pelvic canal).a'sThe distendedurinary bladder is more often lo- Occasionally, tumors originating from the bladder wall protrude
cated cranial to the pubis but may be within the pelvic canal'n'' from the serosal surface and produce a discernible change in
The normal urinary bladder in the cat is always intra-abdominal bladder shape (Fig. 43-7).tt A pointed vertex with the bladder
and is located 2 or 3 cm cranial to the pubis. This positioning appearing elongated may occur with a persistent urachal ligament
results from the long bladder neck in the cat,6which is not always in the cat.t'?
visible on survey radiographs. An abnormally small or large urinary bladder is difficult to
The urinary bladder is a soft-tissue opaque structure' Any opac- diagnose radiographically becauseof the wide normal variation in
ity greater or less than that of soft tissue detected within the bladder size.In most instances,a consistentlysmall or large bladder
bladder on surveyradiographsis abnormal. with associatedclinical signs is an indication that a contrast study
Figure 43-3, A, Bladderin a normalfemale dog. The bladderis adjacentto the pubis and is oval. Brokenline,The peritonealreflectionaroundthe bladder.8,
Bladderin a normalcat. The bladderis ellipsoidand has a long neck,which makesthe bladderappearto be displacedcraniallyaway from the pultis.Brokenline,
The p e r i t o n e ar le f l e c t i o n of the uri narybl adderand urethra.In O'B ri enTR {edl :R adi ographiDci agnos iof
. r o mPa r kRD: Ra d i ol ogy
a r o u n dth e b la d d e riF s A bdomi nal
Dis o r d e r isn t h e D o g a n d Ca t.Da vis,CA, Co ve llPa r kVe te r in a Company, ry 1981)
The UrinaryBladder 5Zo
Gamut of condition(s)
-----"'""'-' or
Radiosraphic sisn disease(s) "' condition(sl or
Radiosraphic sisn dGiSg::;l
Visualization r.
Bradder
notseen; postvoidins 3:ffijix1:ffi:t';:* perinear
abdominal serosal DisplacedbJadoer hernia
o utlin esa re clea r per inealher nia L a r g ea b d o m i n a lm a ss( e s)
c o n g e n i t a la n o m a l i e s
I nguinalher nia
pelvic bladder Short urethra
EctoPicureters
Short urethra
Ec t opic ur et er C o n g e n i t a l f i s t u | a s
consenitalristutas Dorsat
disptacement
t,:fl1il;r;li::,1.., Abnormar
shape
^.HHli:ifl'.:.fJ:io"'
Mesenchymar
F#ftnX{..,Jlliuoliiio"J," neoprasia
outlines are not clearly Adjacent abdominal mass(es)
Transudate
seen NeoPlasia
Exudate
Hem or r hageAb s c e s s o r g r a n u | o m a
Persistenturachalligament
Emaciatedaiimat Abnormal size
Young animal <4 months of age Increasedsize
Abnormal position Distal urinary obstruction
VentralAisptacement Urethralobstruction
Abdominal wall hernia
Bladderneck obstruction
craniardispracement [::i:fi:i::::Xe Decreased
size
Neoplas ia
]il""'""Fjlff#l[f:
prostatitis ureters
_Eglopi.
prostaticcyst rlstulas
disease
cranioventrar
dispracement ."TJ'!"#:|fl, :'3;fi.lJ"oo"'walr
NeoPlasia
Pyometra
Hemorrhage
Pregnancy
Sublum barm as s ( e s ) Opacity changes
Large bowel distention Increased Calculi
Ut er ines t um p gr an u l o m ao r
B l a d d e rw a l l m i n e r a l i za ti o n
aoscess
Neoplasia
Persistentpatent urachusor Decreased Inflammation
ur ac halligam en t
Gas
latrogenic
Emphysematouscystitis
or ultrasound examination should be performed to determine the bent lateral view. Gas in the bladder lumen, bladder
causeof the small or large bladder. wall, and
occasionally the bladder ligaments occurs with emphysernatous
Any change in radiographic opacity in the urinary bladder is cy,stitis(Fig. 43-8). Emphysematouscystitisis produced
. by glucose_
abnormal and is usually easy to detect. Gas in the bladder mav be termenting organisms and may be seenin association
iatrogenically introduced from catheterization or cystocentesis. ra witir liabetes
mellitus.l3' Occurrenceof emphysematouscystitiswithout
Small gas bubbles from iatrogenic causesare usually found within diabe_
tes mellitus also has been reported.rs,16
Most radiopacitiesassoci_
the bladder lumen and in the center of the bladder on the recum_ ated with the bladder are calculi. Not all calculi jre
radiopaque
(Table43-2), however,and thus the absenceofradiopacitieswithin All cathetersand equipment should be sterilized,and the genita-
the bladder does not rule out the presenceof cystic calculi. A lia should be cleanedbefore the bladder is catheterized.The equip-
horizontal-beam radiograph can be made to diagnose sandlike ment necessaryfor bladder catheterization is illustrated in Figure
materiai within the bladder. This is particulariy helpfui in cats with 43-9. To reduce bladder pain and spasm during cystography, 2 to
feline urologic syndrome.'t 5 mL of 2% lidocaine (Xylocaine) without epinephrine may be
injected into the bladder before cystographyis performed.
Complications resulting from catheterizationand cystographic
I Contrast cystography proceduresoccur infrequently and are usually not detrimental to
Retrograde contrast cystography is a fast, simple, and inexpensive t h e a n i m a l . I a t r o g e n i c t r a u m a , b a c t e r i a l c o n t a mi n a ti o n ,2 ro r
technique that may provide valuable prognostic and diagnostic kinked'z*and knotted urethral cathetersmay occur from improper
information about bladder disease.Clinical indications justifiing catheterizationtechniques.Intramural and subserosalaccumulation
cystographyinclude dysuria,pollakiuria,and intermittent or persis- of contrast medium in the bladder (Fig. 43*10) has been reported
tent chronic hematuria.Radiographicsignsthat justifu cystography after maximal bladder distention with a Foley catheter.25-r8 This
include identilication of increasedor decreasedopacity that may be complication occurs more frequently in the cat. often with a non-
associated with the urinary bladder,evaluationof caudalabdominai distendedbladder and minimal intravesicularDressure.It usuallv
massesthat may be associatedwith the urinary bladder, nonvisual- does not result in a clinicalproblem. Mucosalulceration,inflam'-
ization of the bladder after abdominal trauma, and evaluation of mation, and granulomatous reactions may occur, but the changes
the urinary bladder with an abnormal shapeor location. are usuallytransitoryand produceno seriousclinicalproblemi.r"
Voiding cystographyis not discussedin this chapter.For more The most seriouscomplication from negative-contrastcystography
information, the reader is referredto other publications.l8t2Void- is gas embolization into the circulatory system, which may result
in death.3o 3'?Fortunately, such complications
ing cystography, coupled with cystometry and urethral pressure occur rarely. Also,
profiles, is the technique of choice for investigating dynamic blad- death from gas embolism may be prevented by the use of nitrous
der diseases such as urinary incontinenceand other voiding abnor- oxide or carbondioxideinsteadof room air.
malities. _Both negative-and positive-contrastmedia are usedfor cystogra-
phy. Negative-contrastmedia include room air, carbon dioxide,
and nitrous oxide. Positive-contrastmedia are orsanic iodides in a
Cystography technique 20o/oiodine solution (Table 43-3). Barium shou'id never be used
If possible,food should be withheld for 24 hours and an enema for cystography.2s' 33The volume of positive-contrastmedium used
given before a cystographic examination is begun. Fecal material for cystography varies with body weight, the species, and the
superimposed over the urinary bladder may obliterate important pathologic processpresent in the bladder. An approximation of 10
radiographic information. mL, or a range of 3.5 to 13.1mL of contrastmedium per kilogram
body weight, may be used.33The injection should be terminated
before the estimatedvolume has been administeredif the bladder
feels adequately distended by external palpation, if reflux occurs
Table 43-2. Radiopacity of cystic calculi on survey around the catheteE or if back pressure is felt on the syringe
abdominal radiographs plunger. Moderate bladder distention is recommended as complete
Calculus composition distention may obliterate subtle mucosal and bladder wall
Opacity
changes.3a Four radiographic views of the caudal abdomen (one
Calciumoxalate Radiopaque recumbent lateral, one ventrodorsal,and two recumbent oblique)
S ilica Radiopaque should be made to adequatelv examine the contrast medium-
Triple phosphate Radiopaque- s m allc alc u l im a y b e llled bladder.
nonr adiopaque
Cystine Nonr adiopaque,but m ay h a v e Cystographic procedures
r adiopaques t ippling
Retrogradepositive- and double-contrastproceduresare best for
U rate Nonr adiopaque
study of the bladder. Positive-contrastcystography is performed by
,$l$
I'7 6 AN IM AL S
A B DO M E N -C OMP AN IO N
injecting a 20% solution of an organic iodide compound into an acter of aspirate obtained with bladder catheterization (Fig. a3-
evacuated bladder via a urethral catheter. The procedure is the 12).
method of choice for identifying bladder location and demonstra-
ting bladder tears or ruptures or communications with structures Radiographic signs with contrast cystography
adjacent to the bladder.
A double-contrast cystogram may be performed by injecting a Radiographic signs observed with urinary bladder diseaseinclude
small volume of undiluted positive-contrast medium into an emPty an irregular mucosal bordet intramural thickening, filling defects,
bladder. The recommended dose of positive-contrast medium is and extravasationpatterns3s(Table 43-4). These radiographic
0.5 to 1 mL for a cat, 1 to 3 mL for a dog weighing less than 25 changes must be differentiated from artifacts produced by factors
lb, and 3 to 6 mL for animals weighing more than 25 lb. Contrast such as air bubbles and inadequate bladder distention. By noting
medium injection is followed by bladder distention with negative- the number, severity, and distribution of radiographic signs, one
contrast medium (Fig. a3-11). Double-contrastcystographyis su- can usually postulate a specific diagnosis. If a specific diagnosis
perior for assessingthe bladder wall and intraluminal filling defects. cannot be made, the bladder condition, whether normal or abnor-
The selection of positive- or double-contrast cystography is based mal, can be demonstrated. If nonspecific radiographic signs are
present or further confirmation is necessary,additional diagnostic
on clinical history, clinical signs, radiographic signs, and the char-
tests may be performed.
Mucosal changes. The urinary bladder has a transitional epi-
thelium, which appears smooth on a normal-contrast cystogram.
Table 43-3. Organic iodides available for contrast The transitional bladder epithelium is capable of metaplastic, neo-
cystography plastic, and non-neoplastic proliferation.s6 Mucosal proliferation
appears as an irregular outline along the inside bladder surface
Brand name Genericname Manufacturer
and may be accentuatedwith inadequate bladder distention. The
Hypaquesodium 20% 20ok Diatrizoale Nycomedt distribution of mucosal irregularity is usually focal, but it may be
Na diffuse; it may vary in severity from a slightly irregular "brush-
Hypaquesodium 25% 25o/oDiatrizoale Nycomed type" surface to a severe "cobblestone" appearance (Fig. a3-13),
Na Ulcers may be present with mucosal proliferation. On a double-
Hypaquesodium 50% 50% Diatrizoate Nycomed
contrast cystogram, ulcers can be identified if contrast medium
Na
H y p aq ueme glu mine 60% Diatrizoate Nycomed adheresto the ulcerated surface. Mild mucosal irregularity may be
60% m eglum ine obliterated on a cystogram if the bladder is completely distended.'n
Omnip aq ue * lohexol Nycomed lntramural changes (bladder wall thickening). A normal
R eno -DlP 30% Diatrizoate Bracco* bladder has a wall approximately 1 mm thick regardlessof the
m eglum ine degree of distention.'zeIntramural changes are demonstrated best
RenoCal-76 66% Diatrizoate Bracco wiih double-contrast cystography and lnclude increased bladder
m eglum ine& wall thickness that is usually focal but may be diffrrse (Fig. 43-14).
10% Diatrizoate Mild bladder wall thickening may be missed if the bladder is
Na
Bracco completely distended.3aBladder wall thickening may be caused by
Reno-30 & 60 30% & 60%
Diatrizoate cellular infiltration or fibrous tissue proliferation. Cellular infiltra-
m eglum ine tion may result from inflammation, hemorrhage from trauma, or
Renovist 35% Diatrizoate Bracco neoplasia. Intramural bladder thickening causesdecreasedbladder
Na & 10% distinsibility, which may be symmetricil with diffuse intramural
DiatrizoateNa bladder diseaseor asymmetrical with focal intramural bladder dis-
lsovuet 200,250, 41%,51%,61%,& Bracco ease.
300, & 370 76% lopamidol Filling defects. A bladder filling defect is anything occupying
* Nonionic contrast med i um. space within the bladder lumen that alters normal filling; such a
tNycomed Inc, 90 Park Avenue, New York, NY defect occupies space normally filled with contrast medium on a
tBracco Diagnostics, Princeton, NJ 08543. cystogram. AJI filling defects appear radiolucent when surrounded
The UrinaryBladder 577
BladderCatheterization
_
.,-'
urine-
Aspiratenormal-appearing Historyof abdominal -No historyof abdominaltrauma
/ rrauma. Unablero
trauma.unaote to Asptrare
Asplrateotoooy
bloodyunne
urine
/ urineor
asPirate I
/ bladdernotidentified I
/ on survey I
/ radiograohs I
/l l
/ll
cystogram
Double-contrast Positive-contrast Flushbladderwithsterilesaline
/ \ cystogram to
bladder
identlfY
/
Normal
/ \
\
Bladderwall /
/ t\ | \ Double-contrast
lestonsor
lum inalf illing Normalbladder
defects ,/u..on'".\
Normal Bladder-wall lesion
or fillingdefects
of
Extravasation Bladderin abnormal
contrastmaterial location
ruPture
indicates
Figure 43-12. Selectionof cystographicprocedure.(Modifiedfrom Park RD:Radiology of the urinary
bladder
andurethra.
In O'Brien
TR [ed]:Radiographic
Diagnosisof AbdominalDisordersin the Dog and Cat, Davis,CA, CovellParkVeterinary
Company, 1981.)
ffifi-
Fig u r e 4 3 - 1 6 . A , Do u b le - co n r r a sr
c y s t o g r a m . A l a r g e n e o p la stic m a ss
(arrows)prolrudes into the bladder lu-
me n .T h e r ei s m i n i m a lb la d d e wa r ll in fil
t ra t i o n .C o n t r a s tm e d i u m co a ts th e u l-
c er a t e d s u r f a c e o f t h e n e o p la sm . 8 ,
Po s i t i v e - c o n t r a sct y s r o g r a m .A la r g e
neo p l a s t i cl e s i o n( t r a n sitio n ace l ll ca r ci-
nom a )i s p r e s e n to n t h e r ig h tsid eo f th e
bladder (arrows).The neoplasm causes
a la r g ef i l l i n gd e f e c tw i t h a n ir r e g u lasu
r r-
face.
Contrast extravasationinto the peritoneal cavitv and sur- 5 to l0 minutes after contrast medium injection to obtain
rounding soft tissueshas an irregulai outline and usually occurs positive diagnosis.
simultaneously with injection of contrast medium into the blad-
der (Fig. 43-19). With small bladder neck tears, extravasation of Pitfalls with cystographic interpretation
contrast medium may be slow, with only a small volume extrava- Interpretation pitfalls are changes noted on the radiograph that
sated.6'a3
In theseinstances,a secondradiograph may be required mimic actual pathologic changes.These changes ur. ariifu.ts that
Figure 43-18. Positive-contrast cystogramwith a small, irregularurachaldiverticulum(arrows).The air-filledballoonon the Foley cathetercausesthe filling
i s i denti fi ed(arrow s).l mmedi atel after
defe c tw i t h i nt h e b l a d d e rn e ck.8 , A tr a u m a ticb la d d e rd ive r ticul um y trauma,traumati cdi verti cul must
a b e di fferenti ated
. n tu sio nus su a llyh e a lwith in4 8 h o urs,and the bl adderdi stendssymmetri cal l y.
f rom a b l a d d e cr o n t u s i o nCo
adjacentcolon can give rise to an erroneousdisplay of echogenic (2 mg/kg), the mean wall thicknesswas 1.6 mm, but this thickness
material in the bladder lumen, and the curved bladder wall can does increasewith body weight.tt Normal urine is anechoic.The
create additional echoesadjacent to the dorsal bladder wall (Fig. turbulence createdby dischargeof urine through the ureteral open-
43-22). Transducer rotation of 90 degrees over such suspicious ings may generatetransientechojets in the bladder lumen adjacent
areas is often helpful to enable recognition of the proximity of to the trigone.56
the colon and determination of the nature of the artifact. Free
intraluminal abnormalities(i.e., calcuii, sediment,and blood clots) lntraluminal changes
gravitate to the most dependent side of the bladder. In lateral
recumbency,careful examination of the most dependent area of Urinary calculi, cellular and crystallinedebris, gas,and blood clots
the bladder is requiredso that small calculi are not missed.Ballotte- are readily detectedby sonography.Considerationof the gravita-
ment is useful for initiating sedimentswirling acrossthe real-time tional alignment is especiallyhelpful in differentiating calculi and
display.Additional imaging after the animal has been positioned in blood clots that fall downward from gas bubbles that rise upward.
the opposite lateral recumbent or standing position allows detec- The location of cellularand crystallinedebris and freshhemorrhage
tion of gravitation of free intraluminal objects to a dependent is more variable.Sedimentationtends to occur, and vigorous bal-
oosition within the bladder. lottement will generateswirling echo patternson real-time display.
The normal filled bladder is ovoid in shape,with a slight elonga- Calculi. The urine/calculus interface is intensely hyperechoic and
tion caudally at the trigone. The ureters and urethra are not usually appears convex. Multiple calculi often aggregatetogether
visualizedunless they become distended with urine. With high- and give rise to an irregular,somewhatcontinuous surface,which
resolution transducers,the normal bladder wall can be seento be makes it difficult for one to distinguish and measure individual
divided into three distinct layers.The mucosais a thin hyperechoic calculi. Distinct acousticshadowswill be observeddeep to calculi
surface outlined against the urine, the middle muscle layer is that exceedthe diameter of the sound beam (Fig. 43-23).5?Smaller
hypoechoic,and the outer serosallayer is hyperechoic.ttThe cra- calculi may not generatethe characteristic shadows until the beam
nioventral wall is slightly thinner than other regions. In normal focus is optimized at the depth of the calculi. Echogenicity and
adult cats,the mean bladder wall thicknessdid not exceed1.7 mm acousticshadow generationare independentof chemicalcomposi-
+ 0.56 mm.s5In normal adult doss with mild bladder distention tion, and so radiopaqueand nonradiopaquecalculi can be detected
Mural Ghanges
Sonography is especiallyusefirl for detecting changesdue to chronic
cystitis and neoplasia. Contrast radiographic techniques are supe-
rior to sonography in diagnosing congenital abnormalities of the
urachus and ureters, as well as ruptured bladders.
Cystitis. Chronic cystitis results in diffuse thickening of the
bladder wall and is readily detected by sonography. The bladder Figure 43-25. Transverse sonogramof the urinarybladderrevealsan abnor-
mal l ythi ckenedbl adderw al l .S essi l enodul armassesprotru defrom the v eni ral
wall becomes abnormally hypoechoic, and the normal layering
bl adderw al l i nto the bl adderl umen,H i stol ogyof the bl adderw al l rev eal eda
becomeslessparallel. Measurementsreveal abnormal wall thickness transitionalcell carcinomathat had obstructedthe right ureter,causing hy-
Gig. a3-2q, and hypoechoic cellular debris frequently accumulates droureter{U )and l ^vdronephrosi s.
586 A B DO M E N -C O MP AN IO N
A N IMA L S
blood clots are common and can falsely contribute to the size and 25. FeeneyDA, lohnston GR, Tomlinson MJ, et al: Effects ofsterilized micropulverized
barium sulfate suspension and meglumine iothalamate solution on the genitourinary
echo texture of the mass. An abrupt transition is observed com- tract of healthy male dogs after retrograde urethrocystography. Am J Vet Res 45:730,
monly between the neoplastic mass and the adjacent bladder wall.'o 1984.
Some highly aggressivecarcinomas and mesenchymal tumors also
26. Johnston GR, StevensJB, JessenCR, et al: Complications of retrograde contrast
tend to spread through the bladder wall. If a small intraluminal urethrography in dogs and cats. Am J Vet Res 44:1248, 1983.
mass occurs, the bladder wall takes on the appearanceof severe
27. Barsanti JA, Crowell W, Losonsky J, et al: Complications of bladder distention
cystitis. Unfortunately, the sonographic appearance of polypoid during retrogradeurethrography.Am I Vet Res42:81d, 1981.
cystitis, adherent blood clots, and mural hematomas is similar to
28. Farrow CS: Exercisesin diagnostic radiology. Can Vet I 22:260, 1981.
that of bladder neoplasia. The observation of ureter dilation adja-
cent to the bladder wall mass (see Fig. 43-25) and of focal medial 29. Mahaffey MB, Barber DL, Barsanti JA, et al: Simultaneous double-contrast cystog-
raphy and custometry in dogs. Vet Radiol 25:254, 1984.
iliac lyrnphadenopathy tends to support the diagnosis of neoplasia.
Cytology or histology or both are necessaryto confirm the presence 30. Ackerman N, Wingfield WE, Corley EA: Fatal air embolism associated with
of bladder neoplasia.Ultrasound-guided thin-needle aspiration has pneumourethrography and pneumocystography in a dog. J Am Vet Med Assoc
160:1616, 1972.
been shown to be an accurate technique for obtaining diagnostic
samplesfrom bladder neoplasia.s0 31. Zontine WJ, Andrews LK: Fatal air embolization as a complication of pneumocys-
tography in two cats. J Am Vet Radiol Soc l9:8, 1978.
References 32. Thayer GW, Carrig CB, Evans AT: Fatal venous air embolism associated with
pneumocystography in a cat. I Am Vet Med Assoc 176:643, 1980.
1. Fletcher TF: Anatomy of pelvic viscera. Vet Clin North Am 4:471, 1974.
33. Brodeur AE, Goyer RA, Melick W: A potential hazard of barium cystography.
2. International Committee on Veterinary Anatomical Nomenclature: Nomina Ana- Radiology85:1080,1965.
tomica Veterinaria. Vienna, World Association of Veterinary Anatomists, 1973.
34. Mahaffey MB, Barsanti JA, Browell WA, et al: Cystography; Effect oftechnique on
3. Evans HE: Miller's Anatomy of the Dog, 3rd ed. Philadelphia, WB Saunders, 1993. diagnosis of cystitis in dogs. Vet Radiol 30:261, 1989.
4. Mahaffey MB, Barsanti JA, Barber DL, et al: Pelvic bladders in dogs without 35. Johnston GR, Feeney DA: Radiographic Evaluation of the Urinary Tract in Dogs
urinary incontinence. ] Am Vet Med Assoc 184:1477, 1984. and Cats: Contemporary Issues in Small Animal Practice. Vol 4: Nephrology and
Urology. New York, Churchill Livingstone, 1986, p 203.
5. ]ohnston GR, Osborne CA, JessenCR, et al: Effects of urinary bladder distension
on location ofthe urinary bladder and urethra ofhealthy dogs and cats. Am ) Vet Res 36. Mostofi FK: Potentialities ofbladder epithelium. J Urol 7l:705, 1954.
47:404,1986.
37. Weichselbaum RC, Feeney DA, JessenCR, et al: In vitro evaluation of contrast
6. Nickel R, Schummer A, Seiferle E, et al: The Viscera of the Domestic Mammals. medium concentration and depth effects on the radiographic appearance of specific
Berlin, Paul Parey, 1973. canine urolith mineral t1pes. Vet Radiol Ultrasound 39:396,1998.
7. Park RD: Radiology of the urinary bladder and urethra. In O'Brien TR (ed): 38. Weichselbaum RC, Feeney DA, JessenCR, et al: Urocystolith detection: Compari-
Radiographic Diagnosis of Abdominal Disorders in the Dog and Cat. Davis, CA, son of survey contrast radiographic and ultrasonographic techniques in an in vitro
Covell Park Veterinary Company, 1981, p 543. bladder phantom. Vet Radiol Ultrasound 40:386,1999.
8. White RAS, Herrtage ME; Bladder retroflexion in the dog. J Small Anim Pract 39. Stowater JL, Springer AL: Ureterocele in a dog: A case report. vet Med Small
27:735,1986. Anim Clin 74:1753, 1979.
9. Adams WM, DiBartola SP: Radiographic and clinical features of pelvic bladder in
40. Scrivani PV Leveille R, Collins RL: The effect of patient positioning on mural
the dog. J Am Vet Med Assoc 182:1212,1983. filling defects during double contrast cystography.Vet Radiol Ultrasound 38t355,1997.
10. Holt PE: Urinary incontinence in the bitch due to sphincter mechanism incompe-
41. Archibald J: Urinary system. In Archibald J (ed): Canine Surgery. Santa Barbara,
tence: Surgical treatment. J Small Anim Pract 26:237, 1985.
American Veterinary Publications, 1965.
ll. Patnaik AK, Greene RW: Intravenous leiomyoma of the bladder in a cat. ) Am
42. Green RW, Bohning RH Jr: Patent persistent urachus associatedwith urolithiasis
Vet Med Assoc 175:381, 1979.
in a cat. J Am Vet Med Assoc 158:489,1971.
12. Hansen JS: Persistent urachal ligament in the cat. Vet Med Small Anim Clin
43. Osborne CA, Johnston GR, Kruger JM, et al: Etiopathogenesis and biological
67:1090,1972.
behavior of feline vesicourethral diverticula. Vet Clin North Am Small Anim Pract
13. Root CR, Scott RC: Emphysematous cystitis and other radiographic manifestations 3:697, 1987.
of diabetes mellitus in dogs and cats. J Am Vet Med Assoc 158:72I, 1971.
44. Hansen JS: Patent urachus in a cat. Vet Med Small Anim CIin 67:379, 1972.
14. Ellenbogen PH, Talner LB: Uroradiology ofdiabetes mellitus. Urology 81413,1967.
45. Osborne CA, Rhoades )D, Hanlon GF: Patent urachus in the dog. Anim Hosp
l5. Middleton DJ, Lomas GR: Emphysematous cystitis dueto Clostridium perfringens 2:245, 1966.
in a non-diabetic dog. J Small Anim Pract 20:433,1979.
46. Scherzo CS: Cystic liver and persistent urachus in a cat. ) Am Vet Med Assoc
16. Sherding RG, Chew D): Nondiabetic emphysematous cystitis in two dogs. J Am 151:1329, 1967.
Vet Med Assoc 174:1105, 1979.
47. Park RD; Radiographic contrast studies of the lower urinary tract. Vet Clin North
17. Steyn PF, Lowry J: Positional radiography as an aid to diagnose sandJike uroliths Am 4:863, 1974.
in the urinary bladder of feline urologic qmdrome cats. Feline Pract 19:21, 199I.
48. Osuna Dl, Stone EA, MetcalfMR: A urethrorectal fistula with concurrent urolithi-
18. Moreau PM, Lees GE, Gross DR: Simultaneous cystometry and uroflowmetry asis in a dog. ) Am Anim Hosp Assoc 25:35,1989.
(micturition study) for evaluation of the caudal part of the urinary tract in dogs:
Studies ofthe technique. Am J Vet Res 44:1769, 1983. 49. Biller D, Kantrowitz B, Partinton R, Miyabayshi T: Diagnostic ultrasound of the
urinary bladder. J Am Anim Hosp Assoc 26:397, 1990.
19. Moreau PM, Lees GE, Gross DR: Simultaneous cystometry and uroflowmetry
(nicturition study) for evaluation of the caudal part of the urinary tract function in 50. L6vell6 R, Biller D, Partington B, Miyabayashi T: Sonographic investigation of
dogs: Reference values for healthy animals sedated with rylazine. Am J Vet Res transitional carcinoma of the urinary bladder in small animals. Vet Radiol 33:103,
44:1774, 1983. 1992.
20. Moreau PM, Lees GE, Hobson HP: Simultaneous cystometry and uroflowmetry 51. Berry CR: Differentiating cystic calculi from colon: Vet Radiol 33:282,1992.
for evaluation of micturition in two dogs. J Am Vet Med Assoc 183:1083, 1983.
52. GeisseAL, Lowry JE, SchaefferDJ, Smith CW: Sonographic evaluation of urinary
21. Rosin AE, Barsanti JA: Diagnosis of urinary incontinence in dogs: Role of the bladder wall thickness in normal dogs. Vet Radiol Ultrasound 38:132,1997.
urethral pressure profile. J Am Vet Med Assoc 178:814, 1981.
53. Douglas JP, Kremkan FW: Ultrasound corner: The urinary bladder wall hlpo
22. Oliver JE Jr, Young WO: Afu cystometry in dogs under rylazine-induced restraint. echoic pseudolesion. Vet Radiol Ultrasound 34:45, 1993.
Am J Vet Res 34:1433,1973.
54. Barthez PY, L6vell6 R, Scrivani PV: Side lobes and grating lobes artifacts in
23. Mooney IK Jr, Cox EC, Heniman F: Vesical contamination fiom insertions of ultrasound imaging. Vet Radiol Ultrasound 38:387, 1997.
everting cot or catheter in inoculated canine urethra. Invest Urol lI:248, 1973.
55. Finn-Bodner ST, et al: Sonographic architecture and morphometric evaluation of
24. Buchman IW: Kinked catheter: A complication of pneumocystography. I Am Vet the nornal feline urinary bladder wall. In Proceedings of the Annual Meeting of the
Radiol Soc 8154,1967. American College of Veterinary Radiology, 1992, Orlando.
The UrinarvBladder 5A7
Figure 43-26
56. Spaulding KA, Stone E: Color Doppler evaluation of ureteral flow dpamics in
7.
the dog as influenced by relative specific gravity. In Proceedings of the Annual Eo* would you differentiate a pseudofilling defect from a
Scientific Meeting of the American College of Veterinary Radiology, 1993, Chicago. pathologic filling defect?
57. Vords K, Wadir S: Ultrasound of urinary bladder calculi in dogs. Canine pract
18t29, 1993. 8. Is vesicoureteralreflux an abnormal finding when cystography
is performed?
58. FeeneyDA, Walter PA: Ultrasonography ofthe kidneys, adrenal glands and urinary
bladder. In Proceedings of the American Institute of Ultrasound in Medicine Animal
Ultrasound Course, 1989, Phoenix, Arizona. 9. Figure 43-26 is a lateral caudal abdominal view of a oositive-
contrast cystogram in a dog. What type of filling defect ii present
59. Ackerman N: Radiology and Ultrasound of Urogenital Diseasein Dogs and Cats.
Ames, Iowa State University Press, 1991, p l. in the urinary bladder,and what is the most likeiy diagnosii(es)?
60. Finn-Bodner ST: The urinary bladder. In Cartee RE (ed): Practical Veterinary
Ultrasound. Philadelphia, Lea & Febiger, 1995, p 219. 10. Figure 43-27 is a caudalabdominal view of a Dositive-contrast
cystogram in a cat. What contrast pattern is present on the radio-
61. Finn-Bodner ST, et al: Transabdominal sonographic evaluation of experimentally
induced cystitis of the feline urinary bladder. In Proceedings of the Annual Scientific
graphic study, and what does it indicate? B, bladder.
Meeting of the American College of Veterinary Radiology, 1993, Chicago.
Answers begin on page727.
I Ouestions
l. You observe the caudal aspect of the urinarv bladder to be
within the pelvic canal on a lateial abdominal radiograph of a dog.
Is this abnormal?
44
The Urethra
. Robert D. Pechman,Jr.
584
The Urethra 589
A, A retrogradeurethrogramin a
rlieuy
e m a t ed!n-2-
o g . I h e s m o o th ,sh a r pm u co sa lsu r fa ce
(arrowheads)ofthe normalfemale is aooarent.A
balloon catheter was inserted into the urethral
orifice (arrows)and inflated;a positive contrast
m e d i u m w a s i n j e cte d r e tr o g r a d e .g , A va g i_
nourethrogram rn a femaledog. Fefluxof contrast
m e d i u mi n t o t h e u r e th r aa n d b la d d e ris a p o a r e n t.
C o n t r a sm
t e d i u mf i l l sth e va g in aT. h e u r e th r am
l u-
cosa (arrows)in this dog is rough and irregular
o w t n gt o m u r a lm a s se se xte n d in gin toth e lu m e n .
Diagnosis:transitionalcell carcinoma.(B courtesv
of DavidBiller,DVM, KansasState Universitv.)
tipped catheter is placed into the vagina and the balloon inflated Filling defects
to occlude the outflow from the vaginal cavity. positive-contrast
medium is injected (10 to 15 mL in dogs and 5 to 10 mL in cats) defectsmay be intraluminal, intramural, or extramural. Intra_
filling
through the catheter. The vagina wiil htt preferentially; with ex_ Ium-lnatfllhng detectsmay be causedby air bubbles
in the contrast
treme filling, and sometimes what seemslike firm resistance to medium column, mineralized or nonmineralized urethral calculi,
or
injection, the contrast medium will reflux into the urethra and blood-clots (Fig. a+-a). Air bubbles are round ro oval
and have
into the bladder, yielding an excellent contrast urethrogram (see smooth margins and a distinct, sharpiy defined border.
Urethral
Fig. Aa-2). It is important that patients be given general inesthesia variable in shape,^haveirregular margins, and usually are
for vaginography and that extreme injectio=npr.ir,rr., be avoided i3*li.*:
craractenzedby a poorly.defined or blurred margin. If
large enough,
to prevent rupture. urethral calculi may produce widening of the urJthral lurien.
nlo-od
Urethrography should be performed in any patient with abnor_ clots are rrregular in shapeand have poorly defined margins.
mal urination or hematuria that is thought to be of urethral origin. filling defectsmay be due to'neoplasia,indammatory
Pelvic fractures, especially in male dogs, are an indication "for ,,_t-1,*-r.ul
drsease, or scar tissue from previous urethral surgery, or they
may
contrast urethrography if urinary tract injury is suspected.4,e-u result from carelessinstrumentation. Intramurai urethral
lesions
usually result in marked irregularity of the mucosal surface
of the
urethra a.nd may cause widining or narrowing of
I Urethral ultrasonography lumen. l he transitional zone from normal to abnormal
the urethral
urethra is
Ultrasonographic examination of the urethra is a relatively easv usually abrupt and is sharply defined with intramural lesions.
and noninvasive way to evaluatepatients for urethral disease. Extramural filling defects result from compression
by masses
Tlansabdominal ultrasonography can be used to examine the proxi- -,
that surround the urethra. prostatic hyperphsL or neopLsia may
mal urethra in females and at least a portion of the prostatic result in extraluminal filling defects.T'tre mucosal surfaie
remaini
urethra in males (Fig. aa-j). However,the pubic bones limit the smooth, and the margins of the extraluminal filling
defect are
caudal extent ofthe urethra that can be examined with sonography. smooth and tapered.,
Tiansrectal sonography allows evaluation of the caudal ureihri in
females, and the caudal portion of the prostatic urethra and the Extravasation of contrast medium
membranous urethra in males.Ultrasonography permits evaluation
of the thickness of the wall of the urethia i, ,"ill Extravasation of contrast medium indicates a disruption
the mucosal in the
"s
surface. The information acquired from ultrasonography is com- of the urethra a -5). Contrast medium may enrer
ilteSritl .(Fig.
the peritoneal cavity if the urethral rent is near the
plementary to that gained from urethrography.'2 braddei neck.
Contrast medium may also enter the systemicvenous circulation
if
urethrocavernousreflux of contrast medium occurs (Fig.
sisnsof urethral Pelvic fractures or fractures of the os penis may produce
44_61.t,u
urethral
I Ll*""Taphic lacerations.e-llAbdominal trauma maabe u.ro.iut.d
rupture at the vesicourethraljunction.rO,11
with urethral
Urethrographic signs of urethral diseasemay be classifiedas filling Iatrogenicurethral dis_
may result.from poor catheter manipulaiion or as a sequel
defects in the contrast medium column, extravasation of contrasi :lplio:.
to urethral surgery.r
medium from the urethral lumen,t or both. Extravasation of urethral contrast medium may also
be seen
59O A B DO I M E N -C OMP AN IOAN
N IM AL S
I
I
Ii
,it
when there is communication through fistulous tracts between the GR, Feeney DA, Osborne_CA: Urethrography and cystography
.8..Johnston in cats:
urethral lumen and the extraurinary organs. Urethrorectal and II. Abno-mal radiographic anatomy and complication"s.
io.p Contin Educ pract Vet
urethrovaginalfistulashavebeen reportedr,r:; thesefistulasmay be 4:931, 1982.
,,
j;
T.. ,.",
Figure 4tI-7
592 A N IMA L S
A B DO M E N- C O MP AN IO N
4. Positive-contrasturethrographyshould be performed using urethrogram can be caused by air bubbles, calculi, and prostatic
A. Room air. hyperplasia.
B. 30o/obarium suspenslon.
C. Oil-basedcontrast medium. 8. List three possible causes of intramural fiiling defects in a
D. Water-solubleorganic iodide contrast medium. positive-contrasturethrogram.
E. Carbon dioxide.
9. True or False. Diagnostic information available from contrast
5. Tlue or False. Urethral distention and overall quality of a urethrography and from urethral ultrasonography is the same for
urethrogram are improved if the bladder is ful1y distended when both examinations, so utilization of both imaging techniques in
the examination is performed. the samepatient is contraindicated.
6. True or False. Vaginourethrography is an old and outdated 10. True or False.Extravasationof contrast medium in a positive-
technique for evaluatingthe urethra in female dogs and does not contrast urethrogram indicatesdisruption of the integrity of the
differentiate the normal mucosal surface from the abnormal. urethra.
CHA P T E R
45
The Prostate Gland
r Jimmy C. Lattimer
Prostaticadenocarcinomais relativelyuncommon.'','s When it tric, as often occurs with cysts and abscesses,the direction of
occurs, this tumor is often advancedat presentation, with metasta- bladder displacement may be different. Dorsal prostatomegalyby a
sis to regional lymph nodes, the pelvis, and distant sites such as cyst or abscessmay extend dorsal to the bladder, compressing it
the liver and lungs.l618In some dogs, the prostate is massively against the floor of the abdomen (see Fig. 45-2). Alternatively,
enlarged by the tumor, and in others the degree of enlargement is with ventral prostatomegaly, the bladder may be elevated (Fig.
minimal. Small in situ prostatic carcinomasare unusual,but they 45-3). A large prostatic cyst or abscessmay extend ventral to the
do occur; they are usuallydiscoveredas a result of metastasisrather bladder,also resulting in craniodorsaldisplacementof the bladder.
than as local effects. Prostatic neoplasms are often secondariiy This latter appearanceof elevationof the bladder may also be seen
infected or necrotic, and affected dogs may therefore have clinical with severebenign prostatic hypertrophy (seeFig. 45-3).
signs of prostatitis.Thesepatients are difficult to diagnose,unless The other major radiographic sign of prostatomegalyis dorsal
signsof metastasisare present,becauseof the tendencyof prostati- displacementof the colon (see Figs. 45-1 and 45-2). The colon
tis to overshadowneoplasia.le 21 normally lies in contact with the dorsal or dorsolateralsurfaceof
the bladder. As prostatomegalydisplacesthe colon dorsally, contact
Clinical signs with the bladder is lost. Radiographicaliy,rhere is separationof the
ventral border of the colon and the dorsal border of the bladder.
The clinical signs of prostatediseaseare usually referableto either
In a male dog, such a finding is virtually confirmatory of prostato-
urinary or rectal problems. Stranguria, hematuria, and pyuria are
megaly.5
commonly seen.5'8' ro'13Complete urethral obstruction is unus-
Prostaticenlargementmay causenarrowing of the colon lumen.
ua l.3'2 2Ano the r c om m on c om plaint wit h pr ost a t i c d i s e a s ei s
Radiographically,this compressionmay be visible, or the colon
dyschezia,with small or ribbon-like stools.s'" As the enlarging
may simply become confluent with the prostatemassat the pelvic
prostate displacesthe colon dorsally,it compressesit againstthe
inlet (Fig. 45-4). The latter appearancedoes not usually occur
sacrum and pelvis, resulting in a decreasein stool diameter (Fig.
unless the prostate is very enlarged.The colon is often displaced
45-1). Extreme straining to defecatemay result in small amounts
laterallywithin the pelvic canal by a prostatic mass.
of fresh blood in the stool. Severe rectal compression by the
The urethra, although not really displacedrelative to the pros-
prostatemay causeclinical and radiographicsigns of constipation
tate, may be elevatedfrom the pelvic floor or displaced laterally by
or obstipation. The problem is then critical and immediate, and
an enlargedprostate.Urethral displacementis most often seenwith
definitive treatment must be instituted. Another lesscommon but
asymmetrical prostatic disease,such as tumor and abscess.The
important complaint is a pelvic limb gait abnormality.The animal
urethra is also often elongatedby its passagethrough an enlarged
may refuse to climb stairs and jump. Owners often believe the
prostate. The position of the urethra is impossible to ascertain
animal has developeddegenerativejoint diseasein the hips. Such
unlesscontrast medium is used to outline it (seeFig.45-2).
animalsmay havesevere,activesepticprostatitis.s'8 The pain caused
A tremendously enlarged prostate displacesother abdominal
by the prostatic infection is markedly exacerbated by walking,
organs cranially.Huge prostatic lesions usually lie on the floor of
climbing, and jumping. Both pelvic limbs are usually affected
the abdomen, so there is some dorsal displacementof the remain-
uniformly becausethe pain is central. These animals are also
der of the abdominal contents. Prostatii and paraprostaticcysts
usually sensitiveto palpation of the caudal abdomen. There may
may become so large that they reach almost to the costal arch.rl
also be some erythema of the skin due to inflammation in this
With massesof this magnitude, organ displacementis so severe
area. Gait abnormalitiesare seen rarely in uncomplicatedbenign
that the actual source of the mass may be difficult to determine
prostatic hypertrophy.
without the use of specialradiographicproceduresor sonography.
All common prostate diseasescauseenlargement.As is the in-
Radiographic changes
stance with most organs, the enlargement may be symmetrical
Although ultrasonographyhas enhancedvisualizationof the pros- (diffusein origin), asymmetrical(focal in origin), or a combination
tatic parenchyma,retrograde urethrography is still an important of the two. Hypertrophy and prostatitisare examplesof symmetri-
and useful imaging procedurethat should be performed in patients cal enlargement,whereasneoplasiaand cystsare examplesof asym-
with suspected prostaticdisease. metrical enlargement.Large prostatic and paraprostaticcysts and
Becauseof the intimate relationship between the prostate and abscesses are generallycombination lesionsthat involve the entire
the urinary bladder,prostatomegalydisplacesthe bladder cranially prostate, but a single lobe predominates as the source of the
(Fig. 5-2). If prostatomegalyis uniform, bladder displacementis radiographic lesion.8Becauseit is difficult to preciselydefine the
cranial along the floor of the abdomen.If prostatomegalyis eccen- shape of the normal prostate, it may be difficult to determine
,r,igF
594 A N IMA L S
A B DO M E N-C OMP AN IO N
whether the enlarged prostate is symmetrical or asymmetrical when the rectum and are therefore recognized as an intrapelvic mass.
enlargement is mild. If the enlarged prostate is relatively symmetri- The lack of regional peritonitis associatedwith the large abscess
cal in its relationship to the bladder, the enlargement is probably may be due in part to the thickness of the capsule and to the low
symmetrical; if not, the enlargement is asymmetrical (Fig. 45-5; virulence of the organism. It is seldom possibleto distinguish a cyst
see also Fig. a5-2). from an abscesson the basis of radiographic examination alone.
Prostatic size that exceeds90% of the distance from the pubis to Any change in the opacity of the prostate from its normal
the sacral promontory is suggestiveof a mass lesion (cyst, abscess, soft-tissue opacity indicates severe or chronic disease.Areas of
or neoplasm).23 The actual degreeof prostatic enlargementvaries calcification within the gland are a sign either of long-standing
tremendously, however. For instance, prostatic size may vary from prostatitis or of neoplasia(Eig. 45-7).13,2r,23 Most prostatecalcifi-
slight enlargement to 10 times normal size for benign prostatic cation is a result of neoplasia. Therefore, calcification should be
hlpertrophy, and the prostate may actually decrease in size in considered a serious finding that warrants biopsy.,a
chronic prostatitis. If prostatic cysts or abscessesare present, the The presence of gas within the prostate is also an important
prostate shadow may be as great as 20 or more times normal size, sign. Becausethe prostate does not normally communicate with
or the degree of enlargement may be minimal. Acute prostatitis any air-containing organ, there is no reason for it to contain gas.
and neoplasia do not usually cause huge enlargement, as is seen Such a finding is considered evidence of a gas-forming bacterial
with hypertrophy and cyst formation. Some small in situ prostatic cystitis unless the gas opacity can be attributed to an overlying gas-
tumors are not recognizeduntil the animal is examined for another filled bowel loop. Coliform or clostridial prostatitis results in severe
problem, such as cough and lamenesscausedby metastasis,or they hemorrhagic necrosisofthe gland, potentially causing a generalized
may be discoveredas an incidental finding at postmortem. peritonitis. Becauseof the rapidly fatal course of these infections,
It is important where possible to evaluate the margination of identification of non-iatrogenic gas within the prostate should be
the prostate. The presenceof adequate amounts of abdominal fat viewed as an unfavorable prognostic sign. Even if the animal
is essentialto enable visualization of the prostatic margin, In the survives,severepermanent scarring ofthe prostate is likely. Sterility
presence of emaciation, normally thin animals (such as sight- and urinary retention or incontinence may become long-term se-
hounds), pelvic trauma, or abdominal effusion, the prostatic mar- quelae to such scarring.
gin and even the entire prostate itself may be indistinctly seen. If The prostate may contain air becauseof reflux from the bladder
the prostate has a smooth margin that is easily seen, the disease during a negative- or double-contrast cystogram (Fig. a5-8). A
involving the gland is likely to be benign or is slowly progressing small amount of reflux into prostatic ducts is a normal but not
(see Fig. 45-l), such as benign hypertrophy and low-grade or consistent occurrence. Simple filling of the ducts with air does not
chronic prostatitis. A rough or indistinct margin in the presenceof necessarilyindicate prostatic disease.Filling ofair in pockets within
adequate abdominal fat is more likely to be due to an acute or the prostate is abnormal, however, and is most often associated
aggressiveprocess,such as neoplasiaor prostatitis (Fig. 45-6).':0' with cyst formation secondary to benign hypertrophy.
24'2s \!hen the margin is indistinct or is not discernible, the Palisade-type periosteal proliferation is sometimes seen on the
impression is that of alocalized peritonitis in the caudal abdomen. ventral aspect of the caudal lumbar vertebrae and pelvis. Such
Except for prostatic rupture with hemorrhage, this assessmentis proliferation is suggestive of regional metastasis from prostatic
probably accurate. There is usually some secondary inflammation neoPlasia.20-23'27'28
in the surrounding tissuesin most aggressive prostatic diseases.
Paraprostatic cysts and abscesses usually have well-defined mar-
gins that are easily seen (see Fig. a54). An occasional abscessis I Special radiographic
poorly marginated, although this occurrence is the exception rather
I procedures for evaluating
than the rule. Occasionally,a cyst or abscessmay form in the pelvic
canal; such lesions may not be readily visible on survey radiographs
I the prostate
nor produce the usual displacement of the bladder.26These lesions The only special radiographic technique that has been found to be
do, however, produce marked displacement and compression of uniformly useful in evaluation of the prostate is the positive-
.:'"', l$]l
.:. . ..ll$:ii
... l:i6llj
caudally to see the caudal pole of the prostate where it lies just b. inferred sonographically and must be confirmed by ur_
dorsal to the pubic brim (Fig. 45-11). Mensuration of the prosiate :-l-tl
ernrography.
and lesions within the prostate is easily performed with thi use of Benign pro^statichypertrophy usually presents a sonographic
ultrasonography and has been found to be accurate,33 appearance of a uniformly enlarged gland that is mildly"hyper_
The normal prostate is uniformly echogenicwith an echogenicity echoic (bright) and has a_smootli maigin. The dorsal portion
. of
that is very similar to that of the surrounding fat. The urithra is the gland
usually seen as a small echolucencyin the center of the eland with Tay q. enlarged to a greater iegree than the ventral, or
yt..,::rr1, but the changesare symmetrical from right to left (Fig.
a very narrow band of slightly hyperechoic tissue adjicent to it 45-lJ)..lhrs symmetry may be lost as the hypertrophy
(Fig. 45-12). Although the position of the urethra can usually be increasJs
rn severlty ancl enters the cystic stageof the disorder. As cysts
ascertained, involvement of the urethra by a diseaseprocess can form,
some invariably becom.elarger thin others and distort ihe
shape
ot,the prostate as-they increasein size. Differentiation between
tle
solro and cystrc forms of hypertrophy was generallynot possible
prior to the advent of ultrasonic examination.
The sonographic changes seen in prostatitis vary from very
mild hyperechogenicityand enlargementof the prosrateto
severe
enlargementwith a very mottled hyperechoicto hypoechoic(dark)
pattern (Fig. 5-l ). The shapeof the prostate is usually
normal,
but in,severe prostatitis, it may be somewhat distorted. This
is
especiallytrue if there is abscessformation within the
sland. some
a hypoechoicband of edema i" rh" j,il;;"pr;i;
1o-t; i"t g*n'bit
outtrrung the prostate.Other dogs, in which the inflammation has
extended into the surrounding fat, may exhibit hyperechoic
fat
surrounding the gland. In seveie necrotizing prosratitis, the
delin_
eation of the gland from the surrounding fit'may be lost and
the
prostate may appear as a very dark structure with an irregular
and
indistinct margin along the jurrounding hyperechoic fat. -
Cysts and abscesseswithin and attaclhed^tothe prostate appear
as thin-walled structures with echolucent centers.Tiley vary
widely
in size from a couple of millimeters to several centimeteis.
Theii
contents completely echolucent, or they may exhibit the
presenceof -!.-
-ly cellular debris within the lumen.raAs
a'general rule,
the presence of septation or large amounts of debris within
the
lumen is more indicative of abscessand a very clean interior
is
s,Tqqesliveof a cyst; however, this is not a universally accurate
drstrnction. Occasionally,both cysts and abscesses may occur in
conlunction with neoplasia.As with urethrography, caviiary lesions
wrtn rough or shaggyinternal margins or solid tissue masses
within
them are highly suggestiveof neoplasia( Fig. 45_15).
The presenceof calcification within the
. irostate, as indicated by
bright echoes that cast shadows, is generaily corrsid.red a
sign of
malignancy; however, in some instanies, chrlnic inflammation
can
cause slight calcification of the prostate, which is detectable with
ultrasonograpl.ry. Thus a diagnoiis of malignancy on the basis of
Figure 45-12, Transverse sonographicimageof normalprostate.The organ
catclhcatton aloneshould not be made.
marginsare distinct,and the echogenicityis very close io that of the iur_ Malignant neoplasia of the prostate in the dog is usually ad_
roun d i n gf a t . T h e u r e t h rais a sm a ll e ch o lu ce n cy
in th e ce n te rof the gl and vanced at the time of presentition. These are hlghly aggressive
(whitearrowheadsl.Mild artifactualstreakingof the prostateis present.
clrseaseprocessesthat destroy the architecture oflhe gl-"-rrd,.._
600 AN IM AL S
A B DO M E N-C O MP AN IO N
sulting in a mixed echogenic pattern that causes asymmetrical A definitive diagnosis of any given prostatic diseaseshould not
enlargement ofthe prostate. This is the typical sonographic pattern .
be made on the basis of sonographicfindings alone.35 An ultraso_
of advancedsolid tumors that is seenin many organs (Fig. 4S:q. nographically.guidedbiopsy should be performed to support the
When seen early, prostatic neoplasia may cause a single bright sonographicdiagnosis.In dogs with suqpectedneoplasia,biopsies
focus within one area of the gland, and the gland may or may nor should be taken of the primaiy lesion of interest urrd of th. oth",
be distorted (Fig. a5-17). quadrants of the gland.
27. Christensen GC: In Evans HE, Christensen GC, Miller ME (eds): Miller's Anatomy
References ofthe Dog, 2nd ed. Philadelphia, WB Saunders, 1979, p 565.
l. Finco DR: Diseasesofthe prostate gland ofthe dog. In Morrow DA (ed): Current 28. Franks LM: The spread of prostatic carcinoma to the bones. ] Pathol 65:91, 1953.
Therapy in Theriogenology. Philadelphia, WB Saunders, 1980.
29. Root CA: Urethrography. In Ticer IW (ed): Radiographic Techniques in Veterinary
2. O'Shea ]D: Studies on the cmine prostate gland: 1. Factors influencing its size Practice, 2nd ed. Philadelphia, WB Saunders, 1984, p 387.
and weight. J Comp Pathol 73:321, 1962.
30. Johnston GR, Feeney DA, Osborne CA, et al: Effects of intravesical hydrostatic
3. Metten S; A morphologic study of benign prostatic hlpertrophy in the dog pressure and volume on the distensibility of the canine prostatic portion of the
ldoctoral dissertationl. Fort Collins, Colo, Department of Anatomy, Colorado State urethra. Am I Vet Res 46:748. 1985.
University, 1978.
31. Ackerman N: Prostatic reflux during positive contrast retrograde urethrography
4. Barsanti IA, Shotts EB Jr, Prasse K, et al: Evaluation of diagnostic techniques for in the dog. Vet Radiol 241251,1983.
cmine prostate disease.J Am Vet Med Assoc 177:160, 1980.
32. O'Brien T: Normal radiographic anatomy of the abdomen. In O'Brien I Biery
5. Gricne TP, Johnson RG: Diseases of the prostate gland. In Ettinger SI (ed): DN (eds): Radiographic Diagnosis of Abdominal Disorders in the Dog and Cat:
Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat, 2nd ed. Radiographic Interpretation, Clinical Signs, Pathophysiology. Philadelphia, WB Saun-
Philadelphia, WB Saunders, 1983. ders, 1978,p 9.
6, Rogers KS, Wanrschek L, Lees GE: Diagnostic evaluation of the canine prostate. 33. Cartee RE, Rowles T: Transabdominal sonographic evaluation of the canine pros-
Comp Small Anim 8:799, 1986. tate. Vet Radiol 24:156,1983.
7. Zollron GM, Gricner TP: Prostatic abscess:Surgical approach J Am Anim Hosp 34. Stowater JL, Lamb CR: Ultrasonographic features of paraprostatic cysts in 9 dogs.
Assoc 14:698,1978. Vet Radiol 30:232, 1989.
8. Barsanti JA, Finco DR: Canine bacterial Prostatitis Vet Clin North Am 9:679' 1979. 35. Hager DA, Nyland TG, Fisher P: Ultrasound-guided biopsy of the canine liver,
9. Kornegay J: Canine prostatic disease.SW Ver 26:257, 1973. kidney and prostate. Vet Radiol 26:82, 1985.
10. Zolton GM: Surgical techniques for the prostate. Vet Clin North Am (Small Anim
Pract) 91:349, 1979. n Questions
11. Price D: Comparative aspectsofdevelopment and structure in the prostate lmono-
graphl. Nad Cancer Inst I2:I, 1962, l. Does the prostatebecomemore or lessprominent radiographi-
12. Rife J, Thornburg LP: Osteocollagenous prostatic retention cyst in the canine' cally with age?
Canine Pract 7:44. 1980,
13. Weaver AD: Discrete prostatic (Paraprostatic) cysts in the dog. Vet Rec 102:435' 2. Enlargement of the prostate due to benign prostatic hypertro-
1978. phy usually results in cranial displacement of the bladder. What is
14. O'Shea JD: Studies on the canine prostate gland: 11. Prostatic neoplasms J Comp the usual displacement seenwith paraprostatic cysts?
Pathol 73:244, 1963.
15. WeaverAD: Fifteencasesofprostatic carcinomain the dog Vet Rec 109:71,1991. 3. Acute prostatitis classically results in a loss of distinction of
,i
16. Gill CW: Prostatic adenocarcinoma with concurrent Sertoli tumor in a dog. Can
the prostate silhouette. Why?
Vet I 221230,198]'.
4. How can the route that the urethra takes while passingthrough
17. Grant CA: Carcinoma of the canine prostate. Acta Pathol Scand 40:197' 1957-
the prostate help in establishingthe most likely diagnosis?
18. Rabaut SM, Kelch WJ: Undifferentiated carcinoma in the canine Prostate' Mod
Vet Pract 60:401, 1979.
5. When the prostate gland is examined sonographically, what
19. Jameson RM: Prostatic abscessand carcinoma of the prostate. Br J Urol 40:288,
other two organs should also be examined?
r 9 6 8.
20. Leav E, Ling GV Adenocarcinoma ofthe canine prostate. Cancet 22:1329' 1968.
6. The echogenicity of the normal prostate is similar to that of
21. Rendano VT Ir, Slauson DO: Hypertrophic osteopathy in a dog with Prostate what adjacent tissue?
adenocarcinoma and without thoracic metastasis. J Am Anim Hosp Assoc 18:905,
1982.
7. In benign prostatic hypertrophy, the echogenicity of the pros-
22. Bortwiek R, Mackenzie CP: The signs and results of treatment of prostatic disease tate is (increased/decreased/unchanged).
in dogs. Vet Rec 89:374,1971.
23. Feeney DA, Johnston GR' Klausner JS, et al: Canine prostatic 8. What is the significance of fine linear air lucencies in the
disease-Comparison of radiographic appearance with morphologic and microbio-
logic findings: 30 cases(1981-1985).I Am Vet Med Assoc 190:1018,1987.
prostate when a double-contrast cystogram is performed?
24. Zontine Wl: Radiographic interpretation: The prostate gland. Mod Vet Pract
56:341, 1975.
9. What is the significance of a stricture of the prostatic urethra?
46
The Uterus, Ovaries, and Testes
. Daniel A. Feeney . Gary R. Johnston
603
6 (t 4 AN IM AL S
A B DO M E N -C OMP AN IO N
The size, shape, and opacity of the feline uterus are similar to gestational sacs can be found around 20 days gestational age, a
those ofthe dog. The feline uterus during gestationis describedin true gestational sac is easily identified in the 25- to 30-day range
considerabledetail elsewhere,2lbut a brief summary follows. In the (Fig. a6* ). In the 30- to 40-day range of gestationalage, the
pregnant cat, radiographically detectable uterine enlargement oc- conceptus begins to take on shape (e.g., not just a disc or a
curs at approximately 25 to 35 days of gestation. Fetal mineraliza- rounded aggregate).After 40 or so days, evidence of mineralization
tion is identified at approximately 36 to 45 days of gestation and can be found and identification of the stomach, urinary bladder,
progressesbeyond this time. heart, and great vesselsbecomesprogressivelyeasierwith time (Fig.
The location of the pregnant uterus in both the dog and the cat 46-5). In our experience,the radiographic assessmentof distal
is in the mid- to caudal ventral abdomen at mid- to late gestation. limb bone development is still the best predictor of late-term
The enlargement of the uterus at this site causes cranial and gestationalage.u,tt However,the ultrasonographicassessment is the
somewhat dorsal displacement of the small intestine, with dorsal best for assessingfetal viability and well-being.ra We use the rule
and lateral displacement of the descending colon and some degree of thumb that the fetal heart rate should be 1.5 to 2.0 times that
of ventral compressionof the urinary bladder.8 of the bitch or queen. Slow heart rate raises concern about fetal
i' A normal pregnancy can be detected sonographically in dogs distress.A searchfor feti must be made in an organized fashion by
and cats at gestational age slightly less than 20 days. However, in checking both horns and the body. As for late-term gestational
our hands, the confidencehas been limited, particularly in bitches aging, survey radiographs have been more accurate in our hands
or queens presented for follow-up to breeding intervention from for counting feti than has ultrasound.
past infertility problems, or in those with unknown breeding or
heat dates. Although details are availableelsewhere,'o'rr' 13'ra the
Abnormal imaging findings
following is a working assessmentof pregnancy focused on the
dog. The earliesttime we suggestultrasonographicassessment of Number, Absenceof one of the horns in a normally bicornuate
pregnancy is between 25 and 30 days gestational age. The closer to uterus has been reported,22 but this is rare.
30 days gestational age, the more likely a clearly defined heartbeat Sr2e. Generalized uterine enlargement in the absence of fetal
will be detected.A common problem is assessment too early in the mineralization may be suggestiveradiographically of a number of
gestation (particularly when the breeding dates are uncertain), diseasesin addition to the early phasesof normal pregnancy before
which usually yields equivocal results. Although small cyst-like fetal mineralization. Differential diasnosesthat should be consid-
ered under these circumstancesinclude early pregnancy and possi- indicative of either fetal deathl 5' 6 or ischemia due to uterine
bly pseudopregnanct'{' "; pyometra, hydrometra, and mucome- torsion.2 In both instances, the qas is due to devitalization and
uterine torsion38,2s'26'
tra3-8,23,24' uterine entrapment2T; and uterine breakdown of the tissues.An exairple of an emphysematousfetus
adenoinyosis.'z8,'zeRepresentativeexamples of diffuse uterine en- is shown in Figure 46-10. Be careful that there have been no
largement are shown in Figures 46-6 and 46-7. traumatic attempts at catheterization of the cervix wherein gas
Generalizeduterine enlargement in the presenceof fetal mineral- could have artifactually been introduced and overinterpreted as
ization is suggestiveof pregnancy,but the possibility of torsion of evidence of intrauterine disease.The other possibility is that a gas-
the pregnant uterus should not be excluded. Clinical signs and forming organism within an abscessof the uterine stump inlhe
history must then be used to differentiate these possibilities. neutered patient may cause focal accumulation of air, bu1 this is
Localized uterine enlargement may be suggestiveof a number of highly unlikely.8
diseases, including neoplasia3,30; cystic endometrial hyperplasiaz3o; Mineralization within the uterus is usually indicative of fetal
localized or loculated pyometra, hydrometra, or mucometra2a;uter- skeletons,but it is imperative that the alignment of the structures,
ine stump granuloma or abscessT,8'3t; cystic uterine remnant32;and such as vertebrae, ribs, and limbs, and the shape and alignment of
uterine adenomyosis.28' 2e Focal uterine body enlargement con- skull bones be assessedto differentiat. a tudiostaphicillv viable
firmed as a uterine stump granuloma with urinary bladder invasion fetus, a dead fetus, and a mummified fetus.i u in eenerai, radio-
and a fistulous tract draining into the flank are shown in Figure graphic evidenceof axial or appendicularskeletalmilalignment or
46-8. collapseof the skull bones is suggestiveof fetal death. Overlap and
Location. The normal location of the uterus in the caudal apparent compression of the structures into a smaller than expected
ventral midabdomen has been discussed,and its detection as well spaceis more suggestiveof mummification than of a recent liistory
as location and effect on adjacent organs is highly dependent on of fetal death. An example of a mummified fetus is shown in
its size.3,8Herniation of the uterus through discontinuitiesin the Figure 46-1 1.
abdominal wall, including the inguinal ring, may occur and may If the fetal skeleton appearsto be tightly curled, is more obvious
be congenitalor acquired.'''z7 It is also possiblethat thesehernia- than expectedwhen surrounded by uterus, or is not associated
tions may occur during pregnancy. An example of uterine hernia- with a tubular uterine radiopacity or its expectedlocation, the
tion into the subcutaneoustissuesvia the inguinal canal is shown possibility of ectopic pregnancy should be considered.3.-.s perito-
in Figure 46-9. This uterus was in the stagesof gestation prior to neal effusion may complicate the assessmentof the uterine bound-
fetal mineralization. ar.i9s
!n these patients and may further confuse the diagnosis
Radiopacity. The normal nonpregnant and early pregnant with the possibility of acute uterine rupture rather than eitopic
uterus is of soft-tissue or fluid radiopacity.3t Other uterine condi- pregnancy.'3'3a Ultrasonographyis of value in this situation.T,rs
tions that also have soft-tissue radiographic characteristicsare pyo- Function. Dystocia may be due to both maternal and fetal
metra, hydrometra,mucometra, and uterine torsion.3-8,2s,26 As was factors.36Radiographs are of minimal value in determining the
previously mentioned, history and clinical signs are necessaryto maternal factors, such as uterine contractilitv, other than for assess-
differentiate these possibilities. Gas within the uterus is generally ment of the size relationship between the ietus and the maternal
tiirltl
pelvic canal. Radiographymay be helpful in assessingone of the massesby assistingin identification of and distinction from the
fetal factors-positioning relative to the maternal peivic ipsilateral kidney. Excretory urography may also be helpful to
canal-thus providing additional evidencefor the necessityof ce- determine the degreeof renal displacementand to separaterenal
sareansection (Fig. 46-12). If there is no fetus lodged in the birth parenchyma from that of the ovary if the mass has not resulted in
canal, another considerationis uterine inertia. Survey radiographs ventral migration of the ovary ventrally into the abdomen away
may also be of value in the postpartum bitch to determine the from the kidney.
possibility of a retained fetus, but routine follow-up radiography Another techniquethat is extremelyvaluablein assessing intra-
of every pregnancyis not indicated. abdominal masses,including ovarian masses,is that of ultrasonog-
raphy.T''15 Ultrasonographic techniques are useful in assessing
general and follicular ovarian architecture, which facilitates deter,
I Ovaries mination of ovarian activity and staging of ovarian masses.The
anestrousovary in the bitch and the queen has folliclesin the early
lmaging procedures
stagesof development (Fig. 46-13). It may also contain complex
Survey radiographshave limited applicability to the ovaries.Be- or echogenicareasindicative of corpora hemorrhagicaor corpora
cause ovaries are the basis of reproduction, exposureto ionizing lutea. As estrus approaches,selectedfollicles become dispropor-
radiation should be minimized. The major applicatior.rof survey tionatelyiarger.The use of ultrasound to determineprime breeding
radiographsto the ovary is that of identifying a massnot palpable time has not become a routine procedurein the bitch and queen
at physical examination, or further localizing an abdominal mass as it has in the large domesticspecies,however.For further details,
to the ovary. On the basis of location, displacementof adjacent readersare directedto References12 and 13.
organs,and radiographic opacity,the organ of origin of the mass
may be determined.nSurveyradiographsare of considerablevalue Normal imaging findings
in differentiatingovarian,splenic,and renal masses.The limitations The normal ovaries,located just caudal to the kidneys, are not
are that normal ovaries cannot be visualized and the internal (' The
seen radiographically.'z' ovaries are not, however, functionaliy
architectureof ovarian massescannot be assessed by radiography retroperitoneal as are the kidneys, and ovarian massesgravitate
unlessmineralizationis present;such mineralizationis uncommon. ventrally without extensiveventral displacement of other abdomi-
Excretory urograp\ may be of assistancein assessingovarian nal viscera,such as that causedbv a renal mass.37
iw
608 A N IN /IAL S
A B DO M E N- C OMP AN IO N
tr,iiitl
rlclll]..i
it{l
tf
:' ,'
,;
lilltitl''rll
Sonographically,the normal ovary can be diffrcult to find unless cyst,38'3etumors of gonadostromalorigin,3qa0tumors of epithelial
the bitch or queen is cooperative or sedated.At sonography, the origin,38,a0germ cell tumors (see section on Radiopacity),3& 4t
ovary is often slightly ventral and slightly lateral to the caudal pole tumors of mesodermalorigin,38'a'and hydrovarium.2a An example
of the ipsilateral kidney. Visuaiization of the multiple anechoic of a well-circumscribedovarian massis shown in Figure 46-14.
follicles facilitates identification of the ovary and differentiation of Location. The normal ovaries lie caudal to their resoective
it from other intraperitonealstructures.Further descriptionof the kidneys.As ovariesenlarge,they may displacethe ipsilateraltidney
normal ovary is provided under Imaging Proceduresin the section cranially or laterally and may pull it ventrally. The degree and
on Ovaries. direction of adjacent organ displacement and the extent of ovarian
mass migration depend on ovarian size and the position of the
Abnormal imaging findings patient during radiography.Abdominal viscera other than those
described specifically in the previous section may be displaced.
Number. Usually only one ovary, but occasionallyboth, may be
The role of ultrasonographyin detectingovarian masslesionsis
radiographicallyabnormal.In the authors' opinion, the ovary must
fourfold. The first role is identification of the mass, particularly if
increasein size to at least the diameter of two bowel loops to be
it is not visible (but clinically suspected)on suney radiographs.
identifiable on survey radiographs.The shape of the abnormal
ovary may be variable, but ovarian massesare usually well circum-
scribed.'If the ovarian massis neoplastic,peritonealfluid may also
be present.
Size, A radiographically detectablemass in the appropriate ana-
tomic region for the ovary, which is usually caudal to the respective
kidney and originating from the dorsal abdominal wall, should
have certain differential considerations: follicular cvst, 38't' luteal
Second,the determination must be made that the mass is ovary, likely to be a benign follicular cyst ifthe clinical signs are consisrenr
often by exclusion of association with other regional structures. with this.
Locating some small follicular structureson the perimeter is useful Radiopacity. Ovarian cysts and most ovarian neoplasms are of
because the anestrous ovary can be difficult to locate (see Fig. soft-tissueopacity.tt'a0Occasionally,ovarian neoplasmsmay con-
46-13).In that circumstance,what the mass is not attachedto or tain mineralizedareas,including those with the opacity of bone or
an extensionof must be determined,with ovarian mass being the tooth enamel.Such massesare usually benign teratomas(dermoid
rule-out based on location. Third, becausemany ovarian masses cysts),38'a0but malignant teratocarcinomashave also been reported
are malignant,4o-43 the concern is whether or not local or regional to contain mineralization.a2 On the basis of this assessmentand
spreadhas occurred.The searchfor peritonealseeding,abdominal the vast difference in prognosis for these two types of tumors, it is
fluid collections, and noduies in any other abdominal organs is the ill-advisedto baseprognosison the presenceof mineralization.
goal to appropriately stage this potential malignancy. Fourth, be- Consideration. It is important to be aware of the possibility of
cause malignant versus benign ovarian masseshave no specific intersex conditions, including the true and pseudoiermaphro-
sonographic architecture to differentiate between them, about the dite.44'4sComplex anomaliesencompassing
the entire genital tract
only architectural characteristic that can be comfortably assessed and involving the urinary tract should be considered in patients
are follicular cysts. A fluid-filled cavity with no internal echoes; with other intra-abdominal abnormalities or combined urinary
smooth, thin walls; and good echo enhancement beyond it is most and reproductivesigns.Although contrastradiographicprocedures
Figure 46-14' Lareral(A) and ventrodorsal/B/ views of a patientwith a soft-tissueabdominalmass approximatelyfour times the size of the left kidneyand
lo c a t e dc a u d a a l n d v e n tr a to
l it. T h e m a ss is n o t se e n cle a rl yi n the l ateralvi ew but i s causi ngdeformati on
of the dorsaland crani alaspectsof the bl adderby
compression,Kidneysare opacifiedsecondaryto the injectionof contrastmedium.The locationof the soft-tissuemass is consistentwith a mass arisinqfrom the
o v a r y .D i a g r o s i so: v a r ia ncysria t sJr g e r y) .
6 IO A B DO M E N -C OMP AN IO N
AN IM AL S
Figure 46-17- Lateralview of a male dog in which only one testiclewas intrascrotai.
There is an ovoid soft-tissuemass (arrowheads)in the peri-inguinal soft tissues in the
regi o no f t h e o s p e n i s .Su r g icadl ia g n o sis:m a iig n a ntr
t a n sfo r mati on
of an i ncompl etel v
des c e n d e dr e s t i c J e .
612 A N IMA L S
A B DO M E N- C O MP AN IO N
ated mass,and, if the testicle is the site of enlargement,the internal Peritoneal effusion, which may occur from a wide variety of
architecture of the mass. An example of a focal testicular mass is causes,may result from peritoneal seeding and diffuse metastasis
shown in Figure 46-18. of malignant ovarian tumors or hemorrhage due to rupture of an
ovarian tumor.a3Although ovarian tumors are less often the cause
of malignant effusion, abdominal hemorrhage, or both, these Ie-
I Abnormal intra-abdominal sions should at least be considered as differential possibilities in an
I findings related to the uterus, intact bitch.
Medial iliac lymphadenopathy may be identified in patients with
I ovaries, and testes testicular diseaseand is most suggestiveof metastasiss6,sT or exten-
Unexplained intra-abdominal calcific opacities may be related to sion of an inflammatory process. Lumbar vertebral osteomyelitis
previous uterine rupture or ectopic pregnancy and subsequent and discospondylitis have been reported in patients with inflam-
mummification of the involved fetuses.Careful radiographic scru- matory diseasesof the testicle, including, specifically,infection due
tiny of the character of the calcified intra-abdominal massesand to Brucella canis.s8
the possibleuse of serial radiographsto assessreproducibility of One final consideration of genital imaging is the vagina. A1-
the location are indicated. Occasionally,ingestion of an intact body though this organ is usually accessiblevia direct visualization facili-
of a puppy or other small mammal by the patient may complicate tated by various endoscopic devices,there are times when contrast
the diagnosis of intrauterine fetal calcification, intra-abdominal radiographic imaging is the only method of viewing the area cranial
ectopic pregnancy, or fetal mummification. to the vestibule. Positive-contrast vaginography is the retrograde
Variations in abdominal contrast may be somewhat nonspecific filling of the vestibule and vagina.seVaginography is performed
in that there are numerous causesof accumulationof abdominal using sterile, iodinated contrast medium diluted to about 150 to
fluid and free intraperitoneal air. The presenceof abdominal fluid, 200 mg of iodine/ml. The contrast medium is injected through a
however, especiallyif the patient has intestinal displacement (based balloon catheter that has been placed just inside of the vulvar lips
on the intestinecontaining gas,so it can be recognized)consistent using appropriate sedation. Retrograde injection is performed until
with an enlarged uterus, may be suggestiveof uterine rupture with mild resistance to injection is met. A lateral view is made to
subsequenthemorrhage,ruptured pyometra, or hemorrhagefrom determine the degree of filling. Retrograde injection is continued
uterine torsion. Free intraperitoneal air in such patients, especially if the vagina is not well distended. Overdistention may result in
in the presenceof intrauterine (perifetal) or intrafetal air, is highly expulsion of the contrast medium as a result of an abdominal
suggestiveof uterine rupture and fetal death. press. Vaginography may be used to localize vaginal or vestibular
masses,ciefts, and stenosesor strictures.T, 6062Ajf example of a 24. McAfee CT: Hydrouterus and hydroovarium in
a Beagle bitch. Canine pract
vaginal stricture is shown in Figure 46-19. Vaginographymay also 4:48, 1977.
be useful in the clarification of morphology in the inconiinent 25. Shull RM, Johnston SD, lohnston GR, et al: Bilateral
torsion of the uterine horns
bitch.53Vaginal pooling of urine mimickine incontinence due to rn a nongravid bjtch. J Am Vet Med Assoc 172:60I,197g.
ectopic ureter or sphincter-relatedincontin.-r.. .u., be assessed by 26. FreemanLf: Feline utcrine torsion. Comp Contin
Educ pract Vet 10:107g,l9gg.
the combination of postvoiding radiographs after an excretory
27. Munro E, Stead C: Ultrasonographic diagnosis
urogram (looking for vaginal staining/pooling) and a retrograde inguinal hernia. J SnrallAnim pract 34;139,199J.
of uterine entrapment 1n an
positive-contrastvaginogram (looking for striitures, masses,etc.)
28. Pack FD: Feline uterine adenomyosis.Feline pract
that could alter the normal relationship among the external ure_ l0:45, 19g0.
thral orifice, the vagina, and the vesti6ule. Wlien ectopic ureters 29.
_PottcrK, Hancock DH, Gallina AM: Clinical and pathologic featuresof endome_
trial hypcrplasia,pyometra and endometritis in cats:79.ur.r'1l9gtt-tlSS;.,
connect to the vagina, vaginography can also further ciari{, this in Am Vet
Med Assoc 198:1427,1991.
addition to that possible via excretory urography.63
3O. RS. Roszel IF: Ncoplasms of the canine utems, vagina
.Brodcy and vulva; A
c i l nr c opJ l hotogtc
,ur v r 1. I Am Vet M ed As ,r r c l 5l :12q4, l qb7.
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1. England G: Infertility in the bitch and queen. In Arthur GH, Noakes DE, pearson ovarlan sturnps:A casereport. I Am Anirn Hosp Assoc
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H, et al (eds): Veterinary Reproduction and Obstetrics, 7th ed. philadelDhia, WB
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from a cystic uterine remnant.
Vct Radiol 24:139,\983.
2. Morrow DA: Current Therapy in Theriogenology. philadelphia, WB Saunders,
1986. al-'t. IM-, philbrick AL: primary abclominal pregnancy 1n a cat
].1;-
\uD s equent9U:9_:":l"I
r o ( ) H E. I Am Vc r M ed A\s o( l bU :J 09,1e72.
3. Ackerman N: Radiographic evaluation of the uterus: A review. Vet Radiol 22:252,
1 981 . 34. fbmlinson l, lackson ML, pharr
JW: Extrauterinepregnancyin a cat. Feline pract
10:18,1980.
4. Kenney KJ, Matthiesen D! Brown NO, Bradley RL: pyometra in cats; 183 cases
( 1 97 9 1 9 8 4 ).I A n V e t Med Assoc 191:1130,1987. 35,. DeNooy PP: Extr.rutcrtncprcgnancy and sevcre
ascitesin a cat Vct Med Small
Ani nr C l i n 7+349. 1979.
5. Farrow CS, Morgan JP, Story EC: Late term fetal death in the dos: Earlv radio
graphic diagnosis.J tun Vet Radiol Soc 17:11,1976. D: Canine dystocia_a review of the literature. Smalt Anim pract
]!..IJ:rt::!, )
I5:101,1974.
Rendano Vl: Radiographic evaluation of fetal development in the bitch and fetal
.6. 37. Iloot CN: Abdominal masses:The radiographic
death in bitch and queen. ln Kirk RW (ed): Current Veterinary Therapy VllI. differential diagnosis.J Am Vet
_the RacliolSoc 15:26, 1974.
l'hiladelphia,WB Saunders,1983,p 947.
7. Ilivcrs ll, Johnston GR: Imaging of the reproductivc organs of the bitch: Methods 3u. Dow C: Ovarian abnormalitiesin the bitch. Conp patliol
) 70:59, 1960.
and linritations.Vet Clin North Am Small Anim pract 2lt[3i, l9gI. 39. Silva LDM, Onclin K, VerstegenJp: Asscssmentof
ovarian changesaround ovula_
8. Root CN: Interpretation of abdominal survey radiographs.Vet Clin North Am tion in bitches by ultrasonography,lapirroscopy,,n.t
hor-o,rui chinges. Vet Racliol
41763,1974. Uftrasound 37:313, 1996.
9. Allen WE, England GCW, White KB: Hydrops fetalis cliagnosedby real_time 40. Barrett IlE, 'I'hcilcr LH: Neoplasntsof thc canine
ancl felinc rcproqucuyc rracts.
ultrasonographyin a Bichon frise lritch. .l Smali Anini pract 30:4;5, 1989. In Kirk llW (cd): Currcnr Vcrerinary .I.hcrapyVI. philaclelphia,
WII Saunders,1977,
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10. England GCW, Allen WE: Studiesof canine pregnancyusing B-mode ultrasourd:
Diagnosis of early pregnancy and the nunber of ionceptuses.I Small Anin pract 41. lliscr WH, Marcus lF, Gajbor EC, et al: Dcnloid
cyst of thc canine ovary. I Am
3 l : 3 2 1 ,1 9 9 0 . Vct Med Assoc 134:27,1959.
I 1. England GCW, Allen WE: Studiesof canine pregnancyusing I3_modeultrasound: 42. Patnail(AK, Shaer M, Parks JL, ct al: Mctastasizing
ovarian teratocarcinomirin
Development of the conceptusand determination of gestationil age. Snall Aninr dogs. J Snrall Anirr pract 17:235,t976.
I
P r a ct 3 l :3 2 4 , 1 9 9 0 . 43. Crcenc JA, RichardsonRR Thorrrhill
JA, et al: Ovarian papillary cystaclenonra
in
12. England GCW Allen WE: Real-time ultrasonic imaging of the ovary and uterus a bi tc h. I Am Ani r r H os p As s oc l 5:35t, 1979.
ofthe dog. J Reprod Fertil 39:91, 1989.
Mllti GS, Gilbert Dl,, Bougrrann Ap: Caninc intersexstatcs.
11;. J Am Vet Med Assoc
13. Ingland GCW, YeagerAW: Ultrasonographic appearanceof the ovary and uterus 149:l183, 1966.
of the bitch during oestrus, ovulation and early pi.grnn.y.
J Reprod Fertil Suppl 45 -Iodorcff R|: Canine urogenital anomalics.Comp
Contin Ecluc pract Vct l:780,
4 7 : 1 O7 ,1 9 9 3 . t979.
14. JohnstonSD, Smith FO, Bailie NC, et al: prenatal indicators of puppy viability 46. Pugh CR, Konde LJ,park RD:'ltsticular ultrasound
at
term. Conp Contin Educ Pract Vet 5:1013,19g3. in the normal dog. Vet Radiol
31:195,1990.
15. Poffenbarger EM, Feeney DA; Use of gray-scale ultrasonograp\ in the cliagnosis 47 ParkinsonTI:. Fertility and infertility in male animals.
of reproductive diseasein the bitch: 18 cases(1981_1984).J irn Vet Med Assoc In Arthur GH, NoakesDE,
rearson ft. et .l (eds): VererinaryReproduction and
I 8 9 ;9 0 ,1 9 8 6 . C)bstetrics,7th ed. philadelphia,
WB Saunders,1996,p 572.
16. Noakes DE: Pregnancy and its diagnosis. In Arthur GH, Noakes DE, pearson H, 48. GR, FeeneyDA, JohnstonSD, O'Brien TD: Ultrasonographicfeatures
et al (eds): Vcterinary Reproduction and Obstetrics,7th ed. philadelphia.WB Saun- .Johnston of
testicular neoplasmsin dogs: l6 cases(19g0_198g).
d e r s , I9 9 6 . p 6 J. J Am Vet Med Assoc lggtl77l,
1991.
17. Rendano VT, Lein DH, Concannon pW: Radiographic evaluation of prenatal 49. JohnstonGR, FeeneyDA, Rivers B, ct rl: Diagnostic
development in the Beagle: Correlation with the time of breeding, LH releise, and ioraging of the male canine
reproductrveorgans:Methods and lirritations. vet clin
parturition. Vet Radiol 25:132, 1984. North am Small Anim pract
21:553,1991.
18. Tsutsui. T:.Prorcessof development of uterus, fetus, and fetal appendices during 50.-Peanon H, Kelly DF: Testiculartorsion in the dog:
pregnancyin the dog. Bull Nippon Vet Zootech Coll 30:175,1981. A review of 13 cases.Vet Rec
97:200,1975.
19. Pharr JW, Post K: Ultrasonography and radiography of the canrne posr pa[um 5,1 Pugh..CR. Konde LI: Sonographic evaluation
uterus.Vet Radiol Ultrasound 33:35,1992. of cani'e testicular and scrotal
aDnormalrtres:
A review of 2b casehistories.Vet Radiol Ultrasound 32:243,1991.
20. Reberg SR, Peter AT, Blevins WE: Subinvolution of placental sites in dogs. Comp 52. CL: Developmenralanomaliesincluding cryptorchidism. In Morrow
Contin Educ Pract Vet 14:789.1992. .W-ensing DA
leq): Lurrent therapy n Theriogenology.philadelphia,WB Saunders,
19g0,p 583.
21. Boyd JS: Radiographic identification of the various stages of pregnancy in the 53..Bauran V, Dijkstra F, Wensing CJ: Testicular
domestic cat. I Small Anim Pract 12:501,1971. clescent in the dog. Acta Histol
Em br y ol 10:97,1981.
22. Robinson GW: Uterus unicornis and unilateral renal agenesisin a cat. Am Vet
I 54. Navlor RW, Thompson SMA: Intra abdoninal testicular
Med Assoc I47:516, 1965. torsion_a report ot 2
cases.J Am Anim Hosp Assoc 15:763,1979.
23. Stein BS: Obstetrics,surgical procedures and anesthesia.In Morrow DA (ed):
55. Leio DH: Canine orchitis. Tn Kirk RA (ed):
Current Therapy in Theriogenology. philadelphia, WB Saunders, 1986, p 865. Current \tterinary Therapy VI.
Philadelphia,WB Saunders,1977,p 1.255.
614 A B DO N/ I E N -C O MP AN IOAN
N IM AL S
56. McNeil PE, Weaver AD: Massive scrotal swelling in two unusual casesof canine D. Fetus in a position such that it is blocking the entrance to
sertoli cell tumor. Vet Rec 106:144, 1980.
(or unlikely to pass through) the maternal pelvic canal
57. Simon J, Rubin SB: Metastatic seminoma in a dog. Vet Med Small Anim Clin E. B, C. and D
74:941,1979.
58. Henderson RA, Hoerline BF, Kramer TT, et al: Diskospondylitis in three dogs 6. An ovarian mass can:
infected with Brucella canis. J Am Vet Med Assoc 165:451, 1974. A. Displace the bowel, particularly the colon, ventrally as can
59. Allen WE, France C: A contrast radiographic study of the vagina and uterus of be seen with retroperitoneal massesoriginating in the kid-
the normal bitch. I Small Anim Pract 26:153, 1985. ney.
60. Gibbs PEC, Latham l: An evaluation of positive contrast vaginography as a B. Migrate ventraliy among the small intestinal loops, if en-
diagnostic aid in the bitch. J Small Anim Pract 24:531,1984. larged.
61. Kyles AX, Vaden S, Hardie EM, Stone EA: Vestibulovaginal stenosis in dogs: 18 C. Induce peritoneal fluid, if malignant and there has been
cases(1987-1995).J Am Vet Med Assoc209:1189,1996. "peritoneal seeding."
62. Root MV Johnston SD, Johnston GR: Vaginal septa in dogs: 15 cases(1983-1992). D. A, B, and C
I Am Vet Med Assoc206:50,1995. E. BandC
63. Johnston GR, Osborne CA, Wilson JW, Yane BL: Familial ureteral ectopia in the
dog. J Am Anim Hosp Assoc 13:168,1977. 7. Mineralization of an ovarian mass as detected bv survev radi-
ography:
A. Is useful to differentiate malignant from benign masses
K Ouestions becauseonly benign massesundergo mineralization.
B. Is useful to differentiate malignant from benign masses
l. The normal uterine body in a nulliparousbitch: becauseonly malignant massesundergo mineralization.
A. Is easily detectableon routine survey radiographs. C. Eliminates consideration of an ovarian cyst becausebenign
B. Is difficult or impossible to detect on routine survey radio- ovarian cysts never undergo mineralization.
grapns. D. AandC
C. Usually lies between the distal colon and the urinary blad- E. None of the above
der near the midline.
D. Usually lies between the urinary bladder and the rectus 8. Intra-abdominal testes:
abdominis muscle on the midline. A. Are readily detected on survey radiographs, even if not en-
E. Ban dC larged.
B. Are difficult to impossible to detect on survey radiographs,
2. The uterine horns in a bitch may: unless quite enlarged.
A. Be indistinguishable from the small intestine, if normal, C. Have a radiographically specific appearancewhen enlarged
B. Sometimes be distinguishable from the small intestine if and can be easily differentiated from massesoriginating in
only mildly enlarged, provided the small intestine contains the bowel, mesentery,or abdominal wall.
gas. D. AandC
C. Displace the kidneys cranially because both the uterine E. BandC
horns and the kidneys are retroperitoneal.
D. Aa nd B 9, Acute testicular torsion:
E. A, B, and C A. Is readily diagnosedon survey radiographsbecauseof gas
in the scrotum.
3. Gas in the uterus can be the result of: B. Is readily diagnosedon surveyradiographsbecauseof min-
A. Fetal demise. eralizationin the scrotum.
B. Uterine ischemia. C. Is readily differentiated from other intrascrotal problems
C. Vaginitis. such as hydrocele or mass using survey radiographs.
D. Intrauterine fetal growth retardation. D. Cannot be diagnosed by survey radiographs and is best
E. Aan dB defined using a combination of acute history of pain, sym-
metrical testicular enlargement at palpation, and, if avail-
4. Which of the following survey radiographic findings are indica- able,Doppier ultrasonographyto assess blood flow.
tions of late-term fetal death? E. AandC
A. Malalignment of fetal structures
B. Collapse of the fetal skull 10, The normal ovary:
C. Tightly curled fetus A. Can have survey radiographically detectablemineralization.
D. Emphysematousfetus B. Can be determinedas to its phasein the estrouscycleusing
E. All of the above survey radiographic techniques.
C. Can be easily identified on survey radiographs and can be
5. Which of the causesof dystocia listed below can be diagnosed readily differentiated from the small intestine.
from survey radiographs? D. A, B, and C
A. Uterine inertia E. None of the above
B. Fetus too large for maternal pelvic canal
C. Fetus lodged in the maternal pelvic canal Answers begin on page 727.
CHA P T E R
47
The Stomach
. Mary B. Mahaffev . Don L. Barber
615
.-=-''---.
616 A N IMA L S
A B DO M E N- C OMP AN IO N
Ittt9u
ltgt,..l
Figurc 47-2. Gastrogramsillustratingnormalpositionsof the stomach.A, Laterclview of a cat. The gastricaxis is parallelwith the ribs. B, Ventrodorsalview
of a d o g .T h e g a s t r i ca x i so f th is d o g is p e r p e n d icu la
tor th e sp in e.C V entrodorsal and the pyl ori csphi nc terand fundus
vi ew of a dog.The stomachi s U -shaped,
are normallylocated.D, Ventrodorsal view of a cat. The stomachis acute{yangled,with the pyloruslocatedat midline.
The long axis of the stomach may be perpendicular to the One of the most important factors in the appearance of the
spine, with the stomach appearing to run transversely across the stomach is the position of the patient during radiography." The
abdomen, making the angular notch difficult to identifr (see Fig. relationship between the position of the patient and the radio-
47-28). The stomach may also have a U-shaped appearancewith graphic appearanceof the stomach is an important concept that
a more obvious angular notch and still be within its normal must be understood for accurate interpretation of radiographs and
location (see Fig. 47-2C). On the ventrodorsal view of the cat, the for demonstration of some gastric lesions. Variation in appearance
stomach is more acutely angled with the pylorus located at or near of the stomach with different patient positions is caused by shifts
the midline (see Fig. 47-2D). Variations in the appearanceof the in fluid and gas distribution within the lumen of the stomach. The
stomach in the dog based on the shape of the thorax and cranial stomach usually contains both fluid and gas, with the fluid being
abdomen, that is, breed conformation, have been described.t The either of water opacity or positive-contrast medium opacity. This
actual shape of the stomach also varies with the degree of gastric fluid and gas distribution varies with the position of the patient
distention becausedifferent portions of the stomach vary in their becausefluid settlesdependently owing to gravity, and gas rises to
distensibility. the highest part of the lumen. Gas and positive-contrast medium
The Stomach 617
are relatively easyto visualize on radiographs, whereasfluid within the fundus and body (see Fig. 47-58) and may not stand out as
the stomach may be more difficult to seebecauseit may silhouette discretely as on the left recumbent lateral view. In addition, fluid
with other structures of similar opacity. settlesdepend€ntly to fill the pyloric portions and part of the body
To explain the radiographic appearance of the stomach, the of the stomach. In this position, the pyloric portion is well visuall
stomach can be described as J-shaped and positioned in a trans- ized with positive-contrast medium. Occasionallx the pyloric an_
verse plane in the cranial abdomen. Thus, as an example, with a trum and distal part ofthe body may appear in survey radiographs
patient positioned in dorsal recumbency for a ventrodorsal view, as a soft-tissue mass in the right recumbent lateral view (see
fluid within the lumen settlesdependently to the fundus and body Fig. a7-sB).
of the stomach. If enough fluid is present, the pyloric portion of The radiographic appearanceof the normal stomach is variable.
the stomach also fills. Gas rises to the uppermost portion, which It is thus_important to recognizevariations that exist in the appear-
is in the pyloric antrum and the body near midline (Fig. a7-3). ance of the normal stomach and to understand how the appeaiance
Frgwe 47-3 is a computed tomographic cross-sectionalview of the of the stomach may be altered by factors such as the position of
cranial abdomen at the level of the stomach acquired with the dos the patient and the volume and ratio of fluid to gas within the
in dorsal recumbency.Note rhe fluid opacity hlling most of thI stomach. It is also important to be able to take advintage of fluid
stomach, with the gas bubble floating near midline. With this and gas shifts within the stomach to visualize certain portions of
image as an example, it is possible to predict how the fluid and the stomach more clearly.
gas would be distributed if the animal were rotated in 9O-degree Rugal folds are not seenwell on survey radiographs. With posi-
increments for a left recumbent lateral view, a dorsoventral view .
tive-contrast gastrography,rugal folds are best seen at the p.iipt _
in sternal recumbency, a right recumbent lateral view, and back to eral portions of the stomach, where they may be visualized endon
a ventrodorsal view in dorsal recumbency. These variations in as regular, small, filling defects at the mucosal surface (Fig. 47-6).
appearanceof the stomach are further altered by the volume and If projected en face, rugal folds are not visible with -positive-
ratio of fluid to gas within the stomach. Examples of the appear- contrast gastrography unless the barium is well penetrated by the
ance of the stomach with various views are illustrated in Figure x-ray beam, or the stomach has emptied much ofthe original dose.
47-4; theseviews were made with a vertically directed x-ray beam. Rugal folds then appear as relatively radiolucent, linear, filling
On the ventrodorsalview (seeFig. a7-M), gas is located in the defects separatedby barium in the inierrugal spaces(Fig. a7-78i.
pyloric antrum and the body near midline. Fluid settlesto fill the Double-contrast gastrography provides the moJt detailed evalua_
fundus, body, and pyloric portions of the stomach. Less fluid with tion of the gastric mucosa and rugal folds.
a larger volume of gas would fill additional areas of the stomach Radiographic assessmentof rugal folds is usually subjective.
with gas. If completely empty, the fundus and body may appear as _
Rugal folds vary in size and number,t 2r and the appearance of
a soft-tissue mass on the ventrodorsal view. On a dorsoventral rugal folds is dependent on the degree of gastric distintion. Rugal
view (seeFig.47-aB), gas risesto the cardia and fundus, and fluid folds are more tortuous in the nondistendJd stomach and becoire
settlesdependently to fiil the pyloric portions and part ofthe body. more uniform and parallel to the gastric curvature with increasing
On the left recumbent lateral view (see Fig. a7-aC), gas rises to distention.s't2Rugal folds are smallir and more spiral in the pvlorii
the pyloric portion of the stomach, which is on the patient's right antrum.2oRugal folds may not be visible if the siomach is overdis-
side and is thus the uppermost point of the stomach. Fluid settles tended.r3Rugal folds are smaller and fewer in number in cats than
dependently to the fundus and body. Occasionally, a gas pocket in dogs.'zAreference-range for normal rugal fold thicknessin dogs
may be trapped in the fundic region. In this position, the fundus weighing 2 to 50 kg has been reported to be 1 to g mm.2s
and body are well visualized with positive-contrast medium but Gastricperistalsisand gastricemptying may be observeddirectly
are more difficult to visualize if fiiled with fluid (Fig. a7-5A). On ,
clunng fluoroscopy with the use of positive-contrast medium. Ul_
the right recumbent lateral view (seeFig. 47-4D), gas rises to the trasound examination can also be used to assessmotility. Although
fundus and body, which are on the patient's left side and thus are a peristaltic contraction may be seen on a conventional radiografh
uppermost. With this view, the gas ii often more spread out to fill during gastrography,visualization of peristalsis is a chance event
dependent on when the radiograph wis made during the contrac-
tile cycle of the stomach. A peristaltic contraction appears as an
indentation of the wall of the stomach with slisht diiaiion of the
lumen immediately preceding the contraction. Feristaltic contrac-
trons are stronger and more obvious in the pvloric portion of
the stomach.
Following administration of barium, gastric emptying should
start within 15 minutes in most normal patients.2, ,t, ,d Durinq
gastrographywith barium sulfate,the stomach generallvemptiel
within I to 4 hours in dogs.e,7 Minimal signidcance .t o,rli Ue
applied. to emptying of the sromach; delayed emptying is
-rapid
more significant.
The rate of gastric emptying is a complex phenomenon that is
-
altered by a variety of factors, such as volume of contents, chemical
and physical properties of chyme entering the duodenum, various
reflex mechanisms, certain medications, ind the t11re of contrast
medium used.Thus a standardapproachmust be usedto evaluate
the rate of gastric emptying radiographically. Becausethe stomach
starts to empty faster with an increasedintraluminal volume,rn the
dose of contrast medium should be standardized. Low doses may
result in delayed gastric emptFing, which in turn may lead to a
false-positivediagnosis of pyloric obstruction. The type of contrast
medium used, the volume administered, and the Dresenceor ab-
Figure 47-3, Computedtomographicimage of a normal dog in dorsalre-
c u m b e n c ya t t h e l e v e lo f th e sto m a ch .F lu id( f) fills m o st o f th e stomach,and senceof medications that affect gastric emptying are all factors that
t he g a s b u b b l e( g )f l o atsn e a r th em id lin e(. F r o mBa r b e rDL : lm agi ng:R adi ogra- must be considered and standardized. If these factors can be ex-
ph y l l . V e t R a d i o l 2 2 : 1 4 91,9 8 1.) cluded as a causeof delayedgastric emptying, then such delaysare
618 A B DO M E N -C O MP AN IO N
A N IMA L S
, t'l
I
Figurc 474. Normal variationsin fluid {barium)and gas distributionwithin the stomach with different patient positions.A, Ventrodorsalview, in dorsal
rec u m b e n c yG. a s i s l o c a te din th e b o d y a n d p ylo r ica n tr u m .F lui dsettl esdependentlto y fi l l the fundus,body,and pyl ori cporti ons(comparew i th Fi g. 47-3],.B ,
Dorsoventralview, in ventralrecumbency.Gas rises to the cardiaand fundus, and fluid settles dependentlyto fill pyloricportlonsand part of the body. C Left
rec u m b e nlta t e r avl i e w .Ga sr ise sto th e p ylo r icp o r tio na, n d flu idsettl esdependentlto y fi l the fundusand body.D , R i ghtrecumbentl ateralvi ew . Gasri s esto the
f und u sa n d b o d y ,w h i c ha r e co a te dwith b a r iu m .F lu idse ttle sd e pendentlto y fi l l the pyl ori cporti onand partof the bodv.
most often caused by psychological influences or actual disease ing times for dogs and cats varied from 4 hours for high-moisture
at the pylorus. Emotional stress and noise may inhibit gastric food to 16 hours for dry food.s An alternative technique for
movement.2eAnxiety, fear, rage, or pain induced by physical ma- evaluating gastric emptying of solids in dogs and cats has been
nipulation of the patient, gastric intubation, and physical restraint developed using barium-impregnated, polyethylene radiopaque
may contribute to delayed gastric emptying. Thus, patients with spheres (BIPS)* mixed with food.20-23The number and size of
delayed gastric emptying must be allowed to calm down in a quiet radiopaque spheres,type and amount of food, and fasting period
environment before diagnostic significance is placed on delayed must follow a standardizedprotocol. An advantageof the technique
gastric emptying. Also for these reasons, minimal significance is is that it can be performed in most veterinary practices; however,
usually placed on slight or minor delays in gastric emptying if study times may be long (up to 10 hours). Some controversy
the stomach proceeds to empty in a normal manner after an exists about the usefulnessof BIPS for gastric emptying analysis.
initial delay. Scintigraphic evaluation of gastric emptying of food may be con-
Studies using barium-food mixtures have been performed in an sidered the "gold standard" technique. The study can be completed
attempt to further evaluate gastric function.l5'16 Emptying times in 4 to 5 hours, but availability is limited to teachins hospitals and
for individual dogs were repeatable;however, the range of normal large institutiolls.e' 30,rl
gastric emptying times was so wide (7 to 15 hours) that the
procedure is not useful for evaluation of gastric emptying unless
gross abnormalities are present.lsIn another study, gastric empty- *BIPS, Chemstock Animal Health Ltd,
Christchurch. New Zealand
The St om ach 619
.-,,,lrW'-eFreFql
i,t,:*and
portron partortheilff':"ff
{ri'.itiilff bodv. andi',:: ;ililx'j,il iT::xj::ri?:Ti::
a sasHi*.n?:ffxj;::i,HJu,i[:
pockei
remains
nearthe ii,io i :,"11recumbent,arera,view Gas rises
rorhepy,oric
"u'oiu. ."ii;;;;;:l,i:;i'itl?ii^';?;.i"jl:?JTfftf;if'."/::,,f:;,,'';""'":o,jnr;:;
}x!,l';.il*:l.Z*l:ii;rmifrui::vjnrl::*
ruryl,l{11'.i?"JiJ:: se*,es
#"ll$l;:ql;"iiir.""oi#'uiddependen,y
tothe
py,orc
til"'j[::ili:Jxltfi:
il[f;::,fi.?r;:r:T-*:t;ll,l,,l,:"tm:t*n';i;xj;#.J?;iil r;;,:m:l
?]_Bii.Ty;?fr',t:"ffi'J::iTffj,:l
620 AN IM AL S
A B DO M E N- C O MP AN IO N
I Normal ultrasonographic
I findings
The appearanceof the stomach varies with the amount of disten-
tion and the extent of luminal contents. When empty, the stomach
Figure 47-6. Dorsoventralgastrogram.Rugalfolds at the peripheryot the may have a "wagon wheel" appearancedue to infolding of rugal
s t om a c ha r e v i e w e d e n d on a n d cr e a tesm a ll fillin gd e fe ctsa t th e mucosal folds (see Fig. a7-88). This is especiallynoticeable in the cat. With
s urf ac e .R a d i o l u c e nlti n e arfillin g d e fe cts a r e d u e to r u g a l fo ld s proj ected increasing distention, rugal folds become less prominent. Stomach
en f ace ,
wall thickness in dogs has been reported to be 3 to 5 mm, de-
pending on the location measured and the size of the dog, with
larger dogs having larger measurements.33, s2In cats,normal gastric
I
I Ultrasonographic examination wall thickness averaged2.0 mm for the fundus and 2.7 mm for the
I pylorus.s3Measurementswere made between rugal folds. Five wali
Ultrasound examination is a useful addition to abdominal radiog-
raphy for evaluation of the gastrointestinal tract. It may eliminate layers corresponding to the mucosal surface, mucosa, submucosa,
ri the need for contrast studies in many patients as gastric motility'
wall thickness and architecture, and to a lesser extent, luminal
muscularispropria, and subserosa/serosa can be identified.33
Iayers have alternating hyperechoic and hypoechoic layers with
These
contents may be evaluated. In addition, ultrasound examination is mucosal surface, submucosa, and subserosa/serosabeing hypere-
less expensiveand quicker to perform than an upper GI series,and choic and the mucosa and muscularis layers hlpoechoic (see Fig.
may be equally sensitive and specific for detection of gastric dis- 47-8). The mean number of peristalticcontractionsobservedultra-
ease.32Gas and ingesta within the stomach may obscure the far sonographically in dogs has been reported to be 4 to 5 contractions
wall and thus limit evaluation of the entire organ, but the lumen per minute.33
F: ! . 1 : : , : ! f : , L o n g i t u d i n a lu | tr a so n o g r a m so fa n o r m a | d o g stomach(A )andnormat"u..
Gas withinthe rumei appea" u'
:Pry.,: asuurisirecho
a u'ig"hi"'i'l
uguin";iilr""i'::d:/:-Tfti3i:ifr3'
iil"";',.osarsurrace. producino l?i;1.IP.:1:.ach is partiatrv
disrended
withsasandruid
:*'J,'lI?
the Jl: of
caudalhalfl1T:i
the stomach provides 'n''i"ii
a window fortidentification
ruga |fo|d s.The bla c k anowheadi' dent if ies he6r ig h i . "of
i othe
i . i rfai
. y "wall.
, . b , iThi
,.,,":n:i,:l
i"*',i:n"",
1 " . if-#.normal
'i . i i n ,
i i::jEjxJ'jilfi:i#H
layersof tr,uito.uli*.il canbe jdentified ?'ff!illl*
t!ii6lil!,T:Jff?.
layered
appearance as wellas several
of the stomach
canbe seen tiiELii ir.*neadidentifiesihe niiint"r"ro..rsurface.
cau-dar
ii toit,u ,,gnr,andventraljs to the rorr.
:1
:j
rlil
Figure 47-1O. Ventrodorsalradiographsof a dog with an abdominalmass.A, The pylorusis displacedto the left; in addition,the cranialduodenalflexureand
proximalpart of the descendingduodenumhavea broadarc aroundthe cranialsurfaceof the mass,which itself is not visible.B, The transversecolon is displaced
and curves caudallyaroundthe caudalsurfaceof the mass. The mass is locatedbetween the proximalduodenum,the pylorus,and the transversecolon. Final
diag n o s i sp:a n c r e a t iacb sce ss.
The Stomach 623
.t
I il'
F igu r e 4 7 - 1 2 , G a s t ricfo r e ig nb o d y ( b a ll)in th e p ylo r icp o r tio nthat i s not seen w el l on the ri ghtrecumbentl ateralvi ew /A / becauseof fl ui d i n the py l orus In
.
the left recumbentlateralview (B),gas risesto the pylorusto better outlinethe ball.
:rlli1,6,j1rl,.;lr:tr
still apply as a means to recognize rotation of the stomach (Figs. Ghronic pyloric obstruction
47-16 and, 47-17).
Compartmentalization is a term that refers to the radiographic Obstruction of gastric emptying at the pylorus may be acute or
appearanceof soft-tissue bands that project into or acrossthe gas- chronic. Causes of acute obstruction include sastric volvulus as
filled lumen of the rotated stomach. These soft-tissue bands result well_as foreign bodies. Chronic pyloric obstruciion is usually the
from folding of the stomach on itself as the folded wall projects result of narrowing of the pyloric orifice secondary to diseases
into the lumen and is outlined by gas within the lumen.'? These affecting the wall or blocking the orifice, such as hypertrophic
bands may become more obvious with greater degreesof disten- pyloric stenosis,pylorospasm, inflammation or fibrosis, neoplisia,
tion. With progressivedistention of the stomach, the stomach wall and mucosal antral hypertrophy. These conditions usually ciuse a
becomes thinner. Gas within the gastric wall has also been de- chronic, partial obstruction at the pylorus, leading to chronic
scribed but is infrequent.'z retention of gastric content.
As the stomach enlarges, other mobile structures within the Chronic, partial obstruction of the pylorus is often manifest on
abdomen are displaced caudally. With severegastric distention, it survey radiographs as fluid-filled gastric distention, as opposed to
is often difficult to visualize other abdominal organs owing to the acute gaseousdistention of gastric vohrrlus (Fig. 47-18). The
crowding. The spleen is also usually involved in gastric volvulus stomach may be quite large with chronic partial obstruction of the
and may shift with the stomach. The spleen is usually enlarged pylorus. However, the enlarged stomach may be more difficult to
owing to impaired circulation, but its location may vary. The identifr on survey radiographs when it is filled with fluid than
greater the gastric distention, the less likely the spleen is to be when it is filled with gas. Even when distended with fluid, the
visualized radiographically becauseof crowding of abdominal vis- stomach still contains some gas. In these instances,however, the
cera. Thus, splenomegaly and splenic displacement may be more gas does not totally outline or fill the entire stomach. Instead, the
easily visualized with less severe gastric volvulus. Other changes smaller amount of gas floats as a bubble on top of the fluid
that may be seenwith volvulus include reflex paralytic ileus of the and should not be mistaken as the limits of the stomach (see
small intestine, esophagealdilation, and microcardia and pulmo- Fig. a7-188).
nary hypovolemia (small vessels)associatedwith shock. The major effect of pyloric obstructive diseasesis to restrict
tl l
gastric. emptying. Survey radiographic findings may vary from It is often difficult to differentiate the pyloric obstructive
normal gastric size to enlargement, depending on the ieverity diseases
radiographically, especiallywithout flrroioscopy. The
and duration of the obstruction. With contrast-rtrrdi"r, the maioi dynamic organ that.rapidly changes
stomach is a
radiographic abnormality is delayedgastric emptying. However, an b.causeof peristal_
tlc waves,and a radiograph captures "pp.aruni"
the morphology of the stom_
initial delay.in gastric emptying may be of no-ciinical significance ach during only a fraction of a second.Thus, the
becauseof the influence of various psychologicalfactors discussed appearanceof
the stomach on a radiograph depends on when th.
previously.This point is especiallyimportant to remember if the .*po.ur.
was made..Although some diseasesmay produce
stomach starts to empty normally after an initial delay or after the characteristic
raolographlcabnormalities,such abnormalitiesmay
animal is allowed to calm down. Of more significanceis a pro_ be visible only
during certain moments within the gastric cycle u'rrdthu,
nounced delay in gastric emptying when only a small u-ourrt of are not
likely to be seenon a randomly ."porla .adiog.aph. the
contrast medium passesfrom the stomach in a few hours. Because advantage
of fluoroscopy is that sequentiai changes 6f ihe .hap.
the normal stomachshould be empty 1 to 4 hours after administra_ of tfr.
stomach can be visualized;thus those "momentary
tion of contrast medium, retention of most of the barium within changesthat
may best demonstratecertain lesionsof the stomachmay
the stomach 3 or 4 hours after administration usually indicates b"edocu_
mented. Even with fluoroscopy, however, it is often
pyloric obstructivedisease(Fig. a7ar. not possible
to differentiate some pyloric obstructive diseases.
For example,
i*=:
6 28 A N IMA L S
A B DO M E N -C OMP AN IO N
Gastric ulcers
Gastric ulcers are very difficult to identify on conventional radio-
graphs. Gastric ulcers produce craters in the wall of the stomach
that appear as outpouchings from the lumen (Fig. 47-22). The
radiographic appearance of a gastric ulcer may be variable, de-
pending on whether the ulcer is projected in profile, en face, or
obliquely.5' The appearanceof the ulcer may be altered further by
gastric peristalsis. Manipuiation of the patient during fluoroscopy
allows a more complete and continuous evaluation of the margin
and contour of the stomach. Double-contrast gastrography may
also be of value becauseulcers that are projected en face may be
visualized with double-contrast studies but are obscured with posi-
tive-contrastgastrography
Gastric ulcersmay be benign or malignant. Benign gastriculcers
may result from a variety of causes.2u'60'61 Use of nonsteroidalanti-
inflammatory drugs has becomea common causeof benign gastric
Malignant gastric ulcers occur in associationwith gastric
ulcers.62-6a
neoplasiaand may be causedby tumor necrosis.u'Criteria have
been established for the radiographic differentiation of benign
and malignant gastric ulcers in humans.te'6s'66 Thus, although
radiography may provide an excellent method for the recognition
of gastric ulcers, infrequent use of single- and double-contrast
gastrography,lack of fluoroscopy, and insufficient views all com-
bine to limit the recognition of gastric ulcers in dogs and cats. In
addition, experience is limited in radiographically differentiating
5 hoursafter bariumwas glven
j
Figurc 47-19. Dorsoventral radiograph
Thereis a pronounced with mostof the contrast benign and malignant gastriculcers in dogs and cats.Ulceration is
delayin gastricemptying,
mediumretained withinthe stomach.Notethe obviousperistaltic
contraction often associatedwith gastric carcinoma,6T'68 and gastric ulcers in
I1 1
l' portion.
of thepyloric dogs that are recognized on radiographs are often the result of
neoplasia.6e Thus, the radiographic recognition of a gastric ulcer
should lead to strong considerationof neoplasiaand further evalu-
hypertrophic pyloric stenosis, neoplasia, and mural scarring all
produce an annular type of stricture of the pylorus that
-iy
preuents the pylorus from opening adequately. Thus, it may-be
more practical to divide obstructive pyloric diseasesinto those that
encircie the pylorus, and are thus restrictive, and those that ob-
struct the pylorus by blocking its orifice.
Restrictive diseasesof the pylorus include hypertrophic pyloric
stenosis,pylorospasm,inflammation or scarring, and neoplasia.If
characteristic abnormalities are present on radiographs, they are
usually those of an annular type of stricture narrowing the pyloric
sphincter. If barium fills only the entrance of the lumen at the
pyloric sphincter, the resultant radiographic appearanceis referred
io as thi beak sign."' If barium fills the length of the narrowed
lumen through the pyloric sphincter, the resultant radiographic
appearanceis referred to as the string sign.t" A tit sign has been
deicribed as a relatively sharp, pointed, outpouching of the pyloric
antrum along the lesser curvature as a peristaltic wave pushes
contrast medium in a peristaltic pouch up against the mass-tyPe
lesion around the pylorus.ssVariations in severity, symmetry' and
radiographic projection all contribute to create variations in the
radiographic appearanceof pyloric restrictive lesions (Fig. 47-20)-
In dogs with chronic pyloric hypertrophy, the hypertrophic muscu-
Iaris may be detected ultrasonographically. It is seen as a thick
hlpoechoic layer.The thickness of the muscularis has been reported
to be greater than 3 mm in mild to moderate hlpertrophy, and
greatei than 8 mm in severely affected dogs. Vigorous peristaltic
contractions that failed to propel contents into the duodenum were Figure 47-2O. Ventrodorsalradiographof the pyloricregionof a dog with
seenin some patients,a6 restrictivediseaseof the pylorus.The "beak" sign /smal/arrow) is causedby
The second group of pyloric obstructive diseasesincludes gastric bari umthatfi l l sonl ythe entranceof the l umenof the pyl ori cs phl nc terbec aus e
foreign bodies, mucosal inflammation or hypertrophy, and some of an annular type of stricture.The peristalticpouch (large arrow) is the
outpouchi ng of the pyl orl cantrumal ongthe l essercurvatu reas a peri s tal ti c
mural lesions of the pyloric antrum. These types of lesions are wave pushes contrastmedium up againstthe mass-typelesionencirclingthe
more likely to produce filling defectswithin the lumen that occlude pylorus.Therewas also a pronounceddelay in gastricemptying(samedog as
the orifice ofthe pyloric sphincter (Fig. a7-21). It is again empha- pyl ori cstenosi sdue to i nfl am mati on
i n Fi g.47-18).Fi naldi agnosi s: c aus edby
sized that radiographic recognition of such a lesion is usually an ul cer.
The Stornach 629
Tirmors that are diffuse and less discrete are more difficult to
identift. Diffuse, infiltrative lesions of the stomach wall mav not
produce distinct filling defects.Instead, they may alter the shaoe of
the stomach and produce decreasedmotility of the involved area.
If such diffuse lesions encircle a portion of the stomach, the
radiographic appearancemay be thai of an annular narrowing, or
one in which the stomach has decreaseddistensibility in thJ af_
fected area (seeFig. 47-Z3B). Becauseofvariations in appearance
of the stomach created by peristalsis, persistence of a luspected
abnormality on sequential radiographs is important. The radio-
graphic-recognition of a gastric ulceishould also suggestthe possi_
Dlrty oI gastnc neoplasia.
Gastric massescan be found on ultrasound examination of the
stomach, thus eliminating the need for radiographic contrast stud_
ies. Common features include thickening of ihe stomach wall.
distortion of the normal layered appearariceof the wall, and de-
echogenicity and motility in the affected area (Fig. 47_
:t:""r-.q
241.2s<z Although such lesions are most often associatedwith eas_
tric_ neoplasia, similar changes have been reported in dogs #ith
pythiosisa3and zygomycosis.T5 Extension of the lesion throigh the
serosal surface of the stomach has been reported in doei with
gastric carcinoma.a,Another reported feature of gastric cariinoma
is "pseudolayering" of the stomach wall, which "is thousht to be
associatedwith uneven distribution of tumor in the layJrs of the
stomach wall.35'37Instead of the five layers normally seen,a central.
moderately echogenic, zone between two lesser eihoeenic lines is
se^en.Concurrent regional lymph node enlargement aid ulceration
or the attected area have been reported in both gastric carcinoma
and lymphosarcoma.a2Reports oi maximum waI thickness range
from 10 to 27 mm in dogirz38,42 and g to 25 mm in cats36,3e with
gastric neoplasia,which is clearly greater than the reported normal
wall thicknessof 3 to 5 mm (dogi) and 2 mm (cats).Gastric wall
Figure47-21. Ventrodorsal radiograph
of the pylorus of a dogwithobstruc- measurements
of thepylorus.
tivedisease Thereis a hemisphericfillingdefectat thepylorus greater than 6 to 7 mm have been proposed as
thatprojects
intothelumen. Therewaspronounced deiayin gastric emptying being pathologic.3s Although gastricwall thickeningis an important
{samedogas thatin Fig.47-19). Thefillingdefectwasdueto mucosa that aDnormalhnding, one must be cautiouswhen assessinq wall thick_
was hypertrophiedin a symmetricbandaround the pylorus. Finaldiagnosis: ness in a contracted, empty stomach as the stomach
chronicplasmocyticgastritis, riall is thick_
Gastric neoplasia
Several types of gastric neoplasms occur in the stomach, and any
region of the stomach may be involved. polyps may often be
clinically silent and are most often found incidentally.ToAdenocarci-
noma is the most common malignant gastric tumor in dogs.68, 7r
This tumor may occur in any region of the stomach but appears
to be found most often in the pyloric porlion.67,72 Gastric neoplasia
occurs less frequently in the cat than in the dog,73and lymphosar-
coma is the most common type of feline gastric neoplasm.t,
The radiographic appearanceof gastric neoplasia is variable and
dependsprimarily on the size, shape,and location of the tumor.
The major radiographic feature is that of a masslesion that projects
into the gastric lumen, creating a filling defect within the contrast
medium. The more nodular and pedunculated the iesion, the easier
it is to recognize it as a distinct mass (Fig. 47-23A). Smaller mass
lesions may be totally obscured by a relatively large volume of
barium. Oblique projections, conformation of the stomach, and Figure 47-22- Lateralradiographof the stomach of a dog with a gastric
ulcer (arrow).The stomachtube is still in place.Mass lesionsof the stomach
peristaltic contractions all may contribute to obscure some mass
are not defi ni ti ve,
and the ul ceri s the onl ydefi ni ti veradi ographiabnormal
c i ty .
lesionsof the stomach. Fi naldi agnosi s:gasrri cadenocarci noma.
630 AN IM AL S
A B DO M E N -C O MP AN IO N
'm
|'"#
Figure 47-23. A, Dorsoventral,double-contrast gastrogramof a cat. There is a nodularfilling defect due to a mass lesionalong the lesser curvature Final
dialnosis: lymphosarcoma. B, Dorsoventralgastrogramof a dog. An annularmas,sencirclesthe pyloricportionand part of the body,This areafailedto distend,
p e r siste dth roughout
a n d th e a b n o r m a lity
e v e n I n s t e r n a rl e c u m o e n cy, gastri cadenocarci noma
the study.Fi naldi agnosi s:
ttl
References
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UJ"*n.t WR, Bartels JE: Co-ntrast
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"-r,
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;j;;,;;;:"
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18. Agut A, SanchezvalverdeMA, Torrecillas FE, et al: Iohexol as a gastrointestinal
contrast medium in the cat. Vet Radiol Ultrasound 35:164' 1994. 49. Watson Pl: Gastroduodenal intussusception in a young dog. J Small Anim Pract
38:163, 1997.
19. Williams L Biller DS, Miyabayashi T, Leveille R: Evaluation of iohexol as a
gastrointestinal contrast medium in normal cats Vet Radiol Ultrasound 34:310,1993. 50. Tanno F, Weber U, Wacker CH, et al: Ultrasonographic comparison of adhesions
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by abdominal radiography and correlation between their gastric emptying rate and
that of a canned food in dogs. Am J Vet Res 58:1359'1997. 52. Agut A, Wood AKW, Martin tCA; Sonographic observations of the gastroduodenal
;unction of dogs. Am I Vet Res 57:1266,1996.
22. Chandler ML, Guilford G, Lawoko CRO: Radiopaque markers to evaluate Sastric
emptying and small intestinal transit time in healthy cats. J Vet Intern Med 1l:361, 53. Goggin IM, Biller DS, Debey BM, et al: Ultrasonographic measurement of gastro-
1997. intestinal wall thickness and the ultrasonographic appearance of the ileocolic region
in healthy cats. J Am Anim Hosp Assoc 36:224, 2000.
23. HaIlJA, Willer RL, Seim HB, et al: Gastric emPtying of nondigestible radiopaque
markers after circumcostal gastroPexy in clinically normal dogs and dogs with gastric 54. Suter PF: Radiographic diagnosis of liver diseasein dogs and cats. Vet Clin North
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Anim Pract 20:73,1979.
25. Jakovljevic S, Gibbs C: Radiographic assessmentof gastric mucosal fold thickness
in dogs. Am J Vet Res 54:1827,1993. 56. Kneller SK: Radiographic interpretation of the gastric dilatation-volvulus complex
ti 26. Twedt DC, Wingfield WE: Diseasesof the stomach. ln Ettinger SJ (ed): Textbook
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of Veterinary Internal Medicine, vol 2, 2nd ed. Philadelphia, WB Saunders, 1983, 57. Frendin l, Funquist B, Stavenborn M, et al; Gastric displacement in dogs without
p 1233. clinical signs of acute dilatation. J Small Anim Pract 29:775, 1988.
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canine stomach. I Small Anim Pract 8:523, 1967' dog. J Am Vet Radiol Soc 6:65, 1965.
28. Gibbs C, Pearson H: The radiological diagnosis of gastrointestinal obstruction in 59. Zboralske FF: Gastric ulcer. In Margulis AR, Burhenne Hf (eds): Alimentary Tract
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29. Gue M, Fioramonti J, Frexinos J, et al: Influence of acoustic stress by noise on 60. Howard EB, Sawa TR, Nielson SW, et al: Mastocltoma and gastroduodenal
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62. fones RD, Baynes RE, Nimitz CT: Nonsteroidal anti-inflammatory drug toxicosis
31. Kunze CR Hoskinson JL Butine MD, et al: Evaluation of solid phase radiolabels in dogs and cats:240 cases(1989-1990).J Am Vet Med Assoc 201:475,1992.
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63. Stanton ME, Bright RM: Gastroduodenal ulceration in dogs. J Vet Intern Med
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to the use on nonsteroidal anti-inflammatory drugs. J Am Anim Hosp Assoc 26:467,
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65. Nelson SW: The discovery of gastric ulcers and the differential diagnosis between
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36. Penninck DG, Moore AS, Tidwell AS, et al: Ultrasonography of alimentary lymph- l Al 20:1, 1973.
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Vet Med Assoc 166:691,1975.
37. Penninck DG, Moore AS, Gliatto J: Ultrasonography of canine gastric epithelial
neoplasia. Vet Radiol Ultrasound 39i342, 1998. 69. Barber DL: Radiographic aspects of gastric ulcers in dogs: A comParative review
and report of 5 casehistories. Vet Radiol 23:109, 1982.
38. Kaser-Hotz B, Hauser B, Arnold P: Ultrasonographic findings in canine gastric
neoplasia in 13 patients. Vet Radiol Ultrasound 37:51, 1996. 70. Willard MD: Diseasesof the stomach. In Ettinger SJ,Feldman EC (eds): Textbook
39. Grooters AM, Biller DS, Ward H, et al: Ultrasonographic appearance of feline of Veterinary Internal Medicine, vol 2, 4th ed. Philadelphia, WB Saunders, 1995,
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40. Rivers BJ, Walter PA, Johnston GR, et al: Canine gastric neoplasia: Utility of 71. Murray M, Robinson PB, McKeating FJ, et al: Primary gastric neoplasia in the
ultrasonography in diagnosis. J Am Anim Hosp Assoc 33:144' 1997. dog: A clinico-pathological study. Yet Rec 91i474, 1972.
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I Small Anim Pract 40.211, 1999' 46 cases.Am I Yet Res 27174,1966.
The Stomach 633
i,n:_TI::_Or, Gastric neoplasia in the dog and cat fAbstract]. Arch Am Coll Vet Surg
6:47, 1977. C. Delayed-definite significance.
D. Delayed-doubtful significance.
75. Burke RL, Ackerman N: The abdomen. In Burk RL, Ackerman N: Small Arimal
Radiology.and Ultrasonography: A Diagnostic Atlas and Text, 2nd ed. philadelphia,
WB Saunders, i996. 4. True or False.Water-soluble, organic, iodinated contrast
media
formulated for the alimentary tract arc tire preferred media
76.. Lamb CR, Forster-van Hijfte M: Beware of the gastric pseudomass. Vet Radiol to use
Ultrasound 35:398, 1994. routinely for gastrography.
77. Penninck DG, Crystal MA, Matz ME, et al: The technique of percutaneous
ultrasound guided fine-needle aspiration biopsy and automated microcore biopsy in 5. Figures 47-27A, B, C, and D are close_upviews of the stomach
small animal gastrointestinal diseases.Vet Radiol Ultrasound 34:433,1gg3. of a cat made during an upper GI series.Ufni.l of the following
78. Crystal MA, Penninck DG, Matz ME, et al; Use of ultrasound_guided fine-needle sequencesmatches the views in the order in which they
are prol
aspiration biopsy and automated core biopsy for the diagnosis of gastrointestinal iected?
diseasesin small animals. Vet Radiol Ultrasound 34t43g, D;3. A. A: Left lateral; B: Right lateral; C: Ventrodorsal; D: Dorso-
1:.
Twedt DC, Magne ML: Diseasesof the stomach. In Etringer SJ (ed): Textbook
of
ventral.
Veterinary Internal Medicine, vol 2,3rd ed. philadelphia, WB-Saunders, 19g9, p I2Bg. B. A: Right lateral; B: Left lateral; C: Ventrodorsal; D: Dorso_
80. Miller RI: Gastrointestinal phycomycosis in 63 dogs. Am Vet Med Assoc
I
ventral.
165:473, 1985. C. A: Left lateral; B: Right lateral; C: Dorsoventral; D; Ventro_
81. Homco LD: Gastrointestinal tract. In Green RW (ed): Small Animal Ultrasound. dorsal.
Philadelphia, Lippincott-Raven, 1996, p I49. D. A: Right lateral; B: Left lateral; C: Dorsoventral; D: Ventro_
82. Barber DL, Rowland GN: Radiographically detectable soft-tissue calcification dorsal.
in
chronic renal failure. Vet Radiol 20:117, 1979.
83. Parfitt AM: Soft-tissue calcification in uremia. Arch Intern Med 1,24:544,1969. 6. Figures 47-28A and B are left recumbent lateral (A) and
right
recumbent lateral (B) radiographs of the abdomen oi
a dog wlth
abdominal distention. Desiribe the radiographic abnormalities
I Ouestions present.
l. Which of the following methods of restraint is preferable for 7. 47-29 is a lateral radiograph of the abdomen of a dog,
performance of a gastrogram in a dog? -Figure
made 15 minutes after administration of BaSOn. Which
A. Psychicpersuasion of the
following radiographic diagnosesis correct?
B. Manual restraint A. Hepatomegaly
C. Chemical restraint with tranquilization B. Hepatic neoplasia
D. Chemical restraint with geneial anesthesia C. Small liver
D. Chronic pyloric outlet obstruction
2...You wish to,radiographically demonstrate a geometric abnor- E. Gastric neoplasia
mality of the pyloric antrum of the stomach of1 dog, However,
the stomach contains a large amount of gas in addiiion to the 8, Ventrodorsal abdominal radiograph, Figure 47_30, was
barium- sulfate you have administered. Whi;h two of the following made
4 hours after initiation of an uppe'r GI seri"esin a dog.
views should be used to best fill the pyloric portion of the stomaci Which of
the following radiographic diagnosesis correct?
with barium? A. Hypertrophic pyloric stenosis
(1 : left recumbent lateral view; 2 = right recumbent lateral B. Pyloric neoplasia
view; 3 : ventrodorsal (dorsal recumbencytviewj 4 : dorsoven_ C. Pylorospasm
tral (ventral recumbency) view.) D. Pyloric foreign body
A, la nd 3a bo ve E. Delayed gastric emptying-probable pyloric disease
B. la nd 4a bo ve
C.2a nd 3a bo ve Figures 47-31A and B, lateral and ventrodorsal radiographs
D. 2 and,4 above .9. of
th-eabdomen of a dog, were made 30 minutes after admiiistiation
ot BaSOn.Describe the radiographic abnormalities present
3. You perform a standard upper GI series on a dog by using and the
most likely causes.
manual restraint, passing a stomach tube, and administerins 1 oi
of liquid barium sulfate per 5 lb of body weight, On subsequent 10. Figures 47-32A and B, lateral and ventrodorsal radiographs
radiographs, the following sequence is olserved: 40 min_ of
th^e_abdomen of a dog, were made 15 minutes after administration
utes-stomach starts to empty; 3 hours-stomach is empry. ot tsaSOn.Describe the radiographic abnormalities present
The above sequenceis: and the
most likely causes.
A. Rapid-definite significance.
B. Rapid-doubtful significance. Answers begin on page727,
634 AN IM AL S
A B DO M E N -C O MP AN IO N
The St om ach
Figure 47-28
636 A N IMA L S
A B DO M E N -C OMP AN IO N
Figure 47-29
Figure 473O
The Stomach 6;3.7
Figure 47-91
638 A B DO N/ I E N -C OMP AN IOAN
N IMA L S
Figure 47-32
\-r1Ar I trFi
48
The Small Bowel
. ElizabethA. Riedesel
639
640 A N IMA L S
A B DO M E N -C OMP AN IO N
cavity; and (5) in obese dogs, the bowel occupying the ventral neous fluid or soft-tissue opacity. In the fasted cat' gas is rareiy
portion of the pendulous abdominal cavity' Positional changesin present in the small intestine, but in fasted dogs, 30oloto 60% of the
ihe small intestine may also be indicative of disease in adjacent small bowel content may be gas.'''2Animals stressedby handling or
organs,as is noted in ChaPter39. with dyspnea frequently are more aerophagic and have increased
ihe nor*al small bowel is recognized in survey radiographs as numbers of intestinal loops filled with air. The bowel wall should
smooth, continuously curving tubes, or as solid circles or rings be of a uniform soft-tissue opacity. This uniformity is most easily
(see Fig. 48-1). These shap-s are produced by the contractile assessed in loops that contain air.
activity*of the smooth muscle. Segmentalcontractions give-rise
to spherical shapes,whereas peristaltic contractions cause long Positive-contrast examination (barium'
tubular shapes. iodinated agents, and impregnated spheres)
The radiopacity of the normal small intestine is variable because
of differing opu.iti.t of material within the lumen' In a nonfasted
Indications
animal, any oi the following may be seenin the lumen: air; ingesta Contrast media added to the small bowel can be used in many
of a grainy or mottled which may include mineral or instances to increase the yield of diagnostic information. Agents
"ppeutun.",
metai opacity; or fluid that is of homogeneous soft-tissue opacity' that increase the opacity of the intestinal tract are used most
The nondiscietionaryeating habits of some dogs and cats result in frequently and include liquid barium products, organic iodinated
mineral/metallic opacities of smail size in the small intestinal lu- liquids, and more recently,barium-impregnatedmarkers' The in-
men. Clay-based cat litter and small gravel -from dog runs are foimation gained from any contrast study is often limited as a
commonly seen.Gastrointestinal medications that contain calcium' result of poor patient selection,poor patient preparation,or inap-
propriate technique. The complete barium or organic iodine con-
magnesium, aluminum, bismuth, qr silicate can impart significant
radlopacityto the intestinal content.rrSome pet vitamin and min- irasi radiographic evaluation of the stomach and small bowel is
eral supplements contain sufficient mineral to be visible' In general' time consuming for the veterinarian and can be expensivefor the
tablets or capsulescontaining minerals, either as active ingredients animal's owner. Becauseof the potential for a low yield of diagnos-
or in the coating process,utJ likely to be visible than liquids tic information from this procedure, a contrast study should be
-or.a fasted animal, the lumen may
containing thesi minerals.tt In reserved for the patient in which a diagnosis or approach to
contain a small amount of ingested air, or it may be of homoge- treatment cannot be made from the combined clinical information
@0@o@o@o
B
I The volume of barium present within the intestinal lumen is a Dogs often have muitiple square-shapedoutpocketings on the
critical factor in interpretation.The intestine should be distended antimesentericside of the descendingduodenum. These are re-
to its reasonablephysiologic maximum. Failure to administer an ferred to as pseudoulcersand are normal (Fig. 8-5). They are
adeouatevolume of contrast medium is one of the most frequent caused by lymphoid tissue in the wall. This effect is not seen in
causesfor nondiagnosticbarium studies.The recommendeddos- the cat, but close to 30o/oof normal cats have strong segmental
agesfor contrast medium are given in Table 48-3- contractions throughout the length of the duodenum that produce
Completedescriptionsof the procedurefor performing a barium a "string-of-pearls"effect during the contrast study (Fig. 48-6).'
upper gastrointestinal tract study and excellent examples of the Both of these latter effectsare seenonly in barium contrast studies,
.roi-ufupp.urance of the contrast-filled small bowel are available not in survey images.In both the normal dog and the normal cat,
elsewhere.tl 13'15'16'2s Examplesof the appearanceof barium and the remaining small bowel should appear to have a smooth mu-
iodine in normal small bowel are presentedin Figures48-3 and cosa-contrastinterface. A very fine brush pattern may occur in the
48-4. A summary of the portions of the gastrointestinal tract dog and be within normal limits, which representsbarium seeping
seen at specific intervals after contrast medium administration is in between the intestinal villi (Fig. 48-7)t.22Concentric narrowing
presentedin Table 48-4. of short lengths of bowel is causedby peristalsis(Fig. a8-8). The
Iocation of such narrowings should vary during the time of study
in the normal animal. Barium and gas may be present simultane-
ously in loops (Fig. 48-9). A double-contrasteffectis presentwhen
Table 48-3. Recommended dose rate for contrast
the distention by gas is greater than that caused by the barium.
medium
The barium-mucosa interface typically appears in such loops as a
Contrast medium Dog Gat thin opaqueline. In other loops, gas may be presentonly as small
B ariu m sulfa tesu s Pens ion* 6-12 mL/kg 12-16 mLlkgl bubbles. Findings on the barium contrast imagesthat most strongly
20lo (wlwl'u correlate with abnormalities are changes in the diameter of the
or bowel, changesin the profiled barium-mucosa interface' and
6-10 mL/kg changes in the rate of passageof barium. However, because the
60% (w/w) intestinal tract normally demonstrates dynamic changes, docu-
Org an iciod ine PrePar at ion 2-3 mL/kgs'15'162 mL/k916 menting a suspicious finding on multiple radiographs over the
(full strength)
(1:2 10 tL/kg'"'" filming sequenceincreasesthe significance of the finding.
Orga niciod ine -no nionic 10 mUkg'?8
(240-300mg l/mL) dilut ion) ( 1 : 2d i l u t i o n ) Barium-impregnated polyethylenespheres(BIPS) (Med-ID,
Radiopaque markerst 10 5- m m and 10 s-mm and Grand Rapids, MI) have been designed and advocated for the
(BIPS) 30 1. 5- m m 30 1 . 5 - m m evaluation of gastric dysmotility and delayed intestinal transit in
spheres sPheres the dog and cat. Advantagesand disadvantagesof the use of these
markers in the assessmentof the small bowel are summarized in
*A large volume of relativety ditute contrast medium is preferred by some
Thble 48-2. The spheresare made in two sizes:1.5-mm diameter
to dislend the intestinal lumen but not to obscure radiolucent luminal
and 5-mm diameter.The larger spheresare designedto become
fitting defects. The author prefers use of full-strength barium suspension
for its superior mucosal pattern definition' trapped at the orad site of an obstructing lesion. This feature
J Fottow manufacturers' specific directions for administration with or with- makes them suitable for the evaluation of partial and complete
out foods. bowel obstructions.33Spheres are typically administered with a
The S ma llBowel 643
.&,
&
#i
ffi,.ryni|rl."
:#
AN IM AL S
6 ,44 A B DO M E N -C O MP AN IO N
Ultrasound
Ultrasound evaluationis a valuablemethod of diagnosticimaging
of the small intestine.The observationsthat can be made include
assessmentof wall thickness,wall layer pattern, and motility' Trans-
ducersof 7.5- to 10-MHz frequenciesenablethe best identification
of individual layers of the intestinal wall. Ultrasound imaging
frequently provides even better assessmentof structures adjacent
to the intestine, such as the pancreas and lymph nodes, thus
disclosinga nonintestinalprimary causefor vomiting, anorexia'or
weight lossthat has not respondedto symptomatictherapy directed
at the gastrointestinaltract. Ultrasound-guidedfine-needleaspira-
tion sampling for cytology and culture evaluation can be done in
many patients.The major obstaclewhen using ultrasound imaging
is the presenceof gasin the bowel.When gasis present,both walls
cannot be assessed. Repositioningthe patient, using gravity-based
transducerplacement,administeringfluid by orogastricintubation'
or repeating the examination at a later time may overcome the
artifactsinduced by gas.When 5- to 7.S-MHz transducersare used,
the normal small intestinal wall of the dog measures2 to 4 mm in
thickness.loWhen a 10-MHz linear transduceris used in the nor-
mal cat, a subtle difference of 2 to 3.2 mm in thickness from the
duodenum through the ileum is found." The normal small intesti-
nal wall pattern consists of alternating hyper- and hypoechoic Figure 48-6. Normalfeline bariumuppergastrointestinal tract study.Proml-
nent ci rcul armuscl econtracti ons causeal mostcompl eteo bl i terati on of the
layers. When no fluid or gas is present, a thin, hyperechoic line duodenall umenduri ngsegmental peri stal sl s.
Thi s stri ng-o f-pearl appearanc
s e
reDresentsthe lumen. From the lumen to the serosa, the layers/ i s commonl yseeni n fel i nebari umstudl esof the smal lbow e l .The l i nearfi l l i ng
echogenicity are as follows: mucosa/hypoechoic;submucosa/hyper- defect i s a normalvari ant,attri butedto a l ongi tudi nal fol d of muc os ai n the
echoic; muscularis/hypoechoic;and serosa/hyperechoic.The hypo- i ncompetel ydi stendedl ntesti ne.Thi s has beencal l edthe ps eudos tri ng s i gn.
The SmallBowel 645
obstruction of the bowel lumen, or functionai (paralysis),in which loops are involved, and luminal distention is qreaterthan 2 times
casethe peristalticcontractionsof the bowel ceaseowinq to vascu- normal.
lar or neuromuscularabnormalitieswithin the bowel wall. In func-
tional ileus, the bowel lumen remains patent. Table 4B-5 lists Mechanical obstruction
considerationsfor the more common pnit.rrl, of bowel dilation.
Patternsof dilation include the following: (i ) focal/mild-one to The small intestinallumen can be occludedby largeforeign objects;
three loops are involved,and luminal distentionsare 1.5 to 2 times by intussusception;by proliferating tissuemasses"fromthe wail of
normal; (2) focal/severe-one to three loops are involved, and the bowel; or by extrinsiclesionsthat compressthe bowel. Mechan_
luminal distention is greaterthan 2 times normal (Fig. a8*10); (3) ical obstruction can be complete or partial. The most consistent
generalized/mild-all loops are involved,and luminal distention is radiographicsign of mechanicalobstruction is variabledilation of
1.5 to 2 times normal (Fig. B-1 1); and (4) generalized/severe-all the bowel loops orad to the level of obstruction. More comolete
and longer-durationobstruction resultsin greaterdistention o? the
loops. More distal (along the length of tf,e small intestine) and
more completeobstruction leadsto a greaternumber of distended
loops. Partial obstructions create the least obvious survey radio-
graphic changes.This is particularly evident when the paitial ob_
struction is of short duration and occurs in the proximal duode_
num. Dilation of such a relativelyshort length of duodenum may
be easily overlooked. This is especiallytrue iT vomiting is frequenl
which removes the accumulated fluid and gas. In these latter
animals,look for abnormal distention of the stimach with gas and
fluid. If an obstruction is complete,the small intestinedistal to the
obstruction is iikely to be empty. As a prediction for the presence
of obstruction in the dog, a measured-ratioless than 1.6 for the
small intestine diameter relative to the L5 vertebral body height
indicatesthat small intestinal obstruction is very unlikely.uVuli".
greaterthan 1.6 are strongly predictiveof obstruction.
Folgign objects composedof mineral or metal are easilyrecog-
.
nized (seeFig. 48-10). Disc-shapedmetallic foreign objecti shouid
be.checked closely for erosion. Such objects u." ,riry likely pennies
minted since 1983 that have a major composition of zinc. These
patients should be evaluated for anemia caused bv acute zinc
toxicityJ? Corrversely,a patient that is presentedfor general malaise
and is found to have Heinz body anemia shouid b! radiographed
so
.that ingestedzinc-containing coins or other zinc-composition
objects(like nuts or bolts) can bi sought.Many small to moderate_
sized rocks are ingested by dogs utrd u.. identified incidentally
Pww
as they.pass through the gastrointestinaltract without causing
obstruction. However, small particles of radiopaque ingesta anj
debris can also accumulate proximal to a chronlic partiaf obstruc_
tlon (Fig. 48-12). In the patient with suggestive clinical signs,
identification_ofopaque objectssmali .ro,rjli to passthrough"the
Figure 48-8. Norma segmentalintestrnalcontractionsdunng a can ne up-
normal bowel should raise the index of suspicion for a
iartial
per g a s t r o l n t e s t t ntar la c t stu d y a r e in d ica te db V svm m e tr icin d entatonsof obstruction. Nonmineralized, nonmetallic foreign objects are much
t he b o w e l w a l l o n e a c h sid e p r o xim a la n d d ista l to th e fo r m ed bol us of more difficult to identif' than mineralized or metallic objects. Fruit
c onlr a s tm e d t u m . pits, corncobs,and other nonopaqueobjectsmay be recognizedby
6 46 A N IMA L S
A B DO M E N -C OMP AN IO N
Fi gure 48-9- N ormal cani nebari um upper gastr oi ntes ti nal trac t
study.The bow el segmentsfi l l edw i th bari umare u ni forml yopaque
(solid white arrow).The mucosalsurface/bariuminterfaceis flat and
smooth. Bowel loops containingair havea double-contrast effect; bar-
ium coatingthe mucosa is seen as a thin opaque/rne,whereas intra-
luminal air is radiolucent(open white arrow). Small intraluminalgas
bubbl esare seenas sharpl vdefi nedfocalradi ol ucen c i es
i n tw o oow er
segments (blackarrows).
Table 48-5. Pathologic conditions by length and relative distention of affected bowel
Focal/mild Focal/severe Generalized/mild Generalized/severe
Regionalenteritis M ec hanic alileus F u n c t i o n a il l e u s M e c h a n i c a il l e u s
R egio na lp erito niti s Foreignobject Enteritis Completeobstruction-distaI
I, Me ch an ica l Intussusception A n t i c h o l i n e r g i cd r u g s bowel
I
ileus-partial Bowel wall neoplas ia Electrolyteimbalance Intussusception
obstruction Granulomatouswall infiltrate Malabsorption Foreignobject
E arlyfun ctio na lile us Bowel stricture Abdominalpain Bowel wall neoolasia
V a scula rco mpro mis e Stenosis/atresia Mechanical F u n c t i o n a il l e u s
Pos t s ur gic aladhes ion Partialobstructions-at ileocolic Recentabdominal surgery
Herniation j u n c t i o n ( u s u a l l yc a t s ) S p i n a lt r a u m a ( n e u r o l o g i ci n j u r y)
Func t ionalileus l n t e s t i n a vl o l v u l u s ( r a r e )
Parovirusenteritis
Dysautonomia
their geometrically shaped radiolucencies on survey radiographs This reduced contrast volume may lead to a false impression of
(Fig. 48-13).38The nonopaque foreign object with irregular zur- narrowed bowel diameter distal to the obstruction.
faces, especially with grooves, can entrap small, minerilized in- The. ultrasonographic appearanceof ingested foreign material is
gested debris and gas, and may become more visible. Careful variable, according to the composition of the materiaFo The acous_
application of abdominal compression may enhance the visibility tic pattern causedby the rigid foreign object may have a shape that
of these foreign objects. Based on clinical signs, the use of 24- can be specificallyrecognized.Objeits that transmit the beam, that
hour serial survey radiographs,a contrast study, or an ultrasound rs, some types of rubber balls, are more readily identified. Those
evaluation may be necessaryto confirm the diagnosis of partial that createa strong reflection with marked acoustic shadowing may
obstruction suggested by abnormal luminal contenis.Ifobstruction be more difficult to define initially. When these objects "cause
is complete, the barium may take a long time to reach the level of incomplete obstruction, they are frequently associated with in_
the obstruction owing to marked reduction in intestinal motility. creased intestinal motility resulting from irritation. With more
Dilated loops typically have a smooth barium-mucosa interface.le complete obstruction, the foreign lU;..t .nuv l. associatedwith
However, at the region of obstruction, the shape of the barium accumulation of fluid in the associatedbowel.
should outline the foreign object, with the object itself creatins a Linear.foreignmaterial (e.g.,string, nylon hosiery) that becomes
filling defect in the barium column. Figure 48-14 schematica"lly trapped in the intestine usually causes'both an abnormal shape
depicts variations in the contrast-intraluminal object interface. and contour of the loops and an abnormal luminal content D;t_
Fenestratedforeign objects that causeonly partial obstruction allow tern.' Typically, some portion of the linear material becomes fixed
barium to pass around or through them. If only a small volume of at an orad location-in the stomach most commonly in dogs, and
barium passesthrough or around such an object, the volume may under the tongue most commonly in cats.arThe remaindeiof the
be insufficient to achieve physiologic distention of the remainder length passesinto the small intesiine. The peristaltic action of the
of the bowel. In Figure 48-15, barium accumulation can be seen bowel causesit to "climb" up the linear foreign body, which results
in dilated bowel orad to a baby bottle nipple, as well as a thin in a pleated, or plicated, appearanceof the-affected loops. These
stream of barium in the bowel distal to the partial obstruction. loops may not become particularly distended, but gas commonly
I:.
648 A B DO M E N -C O MP AN IO N
AN IN /A L S
ll. becomestrapped in pocketsformed by the pleats.The result is an and peritonitis; and the probability of death as a result of linear
abnormal pattern of round, tapered,and short tubular connected foreign body in dogs was nearly double that in cats.ara3
gas shapes (Fig. a8-16). If the linear material is absorptive in Barium contrast studies improve detection of the abnormal
nature, like fabric, it can absorb fluid incompletely and show a shapeand contour of the loops iontaining the linear foreign mate-
mottled-to-linear, streaked gas pattern. A serious complication of rial (Fig. 48-17). Thin linear material such as string or cord may
chronic linear foreign body is laceration of the intestinal wall. If not be particularly visible as a filling defect. However, if the fixed
the laceration is small, serosaladhesion to an adjacent loop can component of the string is in a wad, this should be seenas a filling
occur, resulting in a fixed position of two or more loops. If the defect in the barium, for example, in the pyloric region of the
lacerationis large,septicperitonitis and potential gasleakageoccur. stomach. It is cautioned, however, that such a mass of string in the
A comparative study between dogs and cats noted several signifi- stomach may not be seen in the initial views when a large volume
cant differences:Dogs tended to be older; dogs showedlessirregu- of barium masks the material. However, in later images, when the
larity in the gas pattern; one quarter of dogs had concurrent barium should have exited the stomach, a barium-soaked or coated
intussusception;on both radiographic and surgical assessment, mass remains in the stomach, indicating the retained foreign mate-
dogs revealed greater evidence of bowel trauma-bowel laceration rial. For this reason, 12- to 24-hour postbarium films are suggested
in suspectpatients if standard radiographs are nondiagnostic.
Those patients suspected to have linear foreign bodies that also
have reduced serosal detail have a reasonablelikelihood of lacera-
tion of the bowel wall with secondarvoeritonitis. Contrast medium
may leak from theselacerations(Fig. 4S-t41. Occasionally,enteric
parasites are discovered by positive-contrast examinations (Fig.
48-19). The linearity of an ascarid looks strikingly similar to that
of a linear foreign body. However, with parasites,the bowel is not
likely to be plicated.
The ultrasound appearance of linear material depends on the
amount of gas and fluid accumulated around the foreign material.
Plication (undulating mucosa) of the bowel around an echogenic
line has been described most frequentlv.aOThis differs from the
smooth, straight mucosa normally i..r, on either side of the bright
linear stripe of an empty normal bowel lumen. Thickening of the
Figurc 48-14. Shapesof contrastinterfacewith an intraluminalobject.The wall or obliteration ofthe wall layer pattern has not been described.
ba r i u mc o l u m nb l a c H lillsth e in te stin ea n d o u tlin e so n e o r se veralsurfacesof
t he o b j e c t .P a r t i aol b s tr u ctio o
n f th e lu m e na llo wsa sm a lle rq u anti ty
of bari um Intussusception, the invagination of one portion (intussuscep-
(stippling)topass.With completeobstruction,there is no bariumin the bowel tum) of the gastrointestinal tract into the lumen (intussuscipiens)
distal to it and thereforeno definitionof the caudalsurfaceof the object.A, of an adjacent segment,can be initiated by many events,including
Ru b b e rb a l l ,s p h e r i c am l a ss a r isin gfr o m th e b o we l m u co sa( lei omyoma+are).
plastic,
motility disorders, inflammatory wall lesions, neoplasia, or idio-
8, Flat,straightforeignobject,such as hard leather,and wood splinter.
C Fruitpit or nut. D, Retrogradeintussusception (invagination of bowel in the pathic causes.aa Although intussusceptions can occur anywhere
op p o s i t ed i r e c t i o no f n or m a lin g e stap a ssa g e ) . along the digestive tract, the majority occur in the small intestinal
The SmallBowel 649
*- )
"ai
rl
l
;i
tract and at the ileocolic or cecocolicjunction. The radiographic column of barium can be seen passing through
appearanceof intussusceptionis considerablyinfluenced by^the the narrowed
lumen of rhe intussusceptum.If iuriui .un ,"*p between the
completenessof the occlusionof the lumen of ihe inrussusceotum., rnvagrnatedand outer segments,a filling defect is
Many junction,region intussusceptionsresult in generalizedsevere demonstrated
and a tube-within-a-tube effect, or ..cof,-spring"effect,e
distention of the small bowel (see Fig. 4S-12). lr., is seen.
patrents, Completeobstructiontypica[y showsan abiuptind to the
however, it is not possible to differentiate intussusception
-ort barium
from column with dilation orad.
other causesofmechanical obstructionsolelyon the basisof survey Intussusceptionshave a characteristicultrasound pattern (Fig.
radiographs. 48-20). The. telescoping effect results in a ,,bull,s_eye,,
Left lateral survey viewsr and barium oral or barium enema target, Jr
concentric ring, appearancewhen viewed in the short
contrast studiescan be used to differentiateintussusceptionfrom axis-plane
of the lesion, and a multilinear pattern when viewed
other causesof bowel obstruction. The barium enema may have in the long
nuIrequintly,
axis plane of the lesion.as,
greater successin defining ileo-ceco-coliclevel intussusceptrons, an eccentric, larger hyperel
choic,region is noted in the ioncentric/linear puit.rr,,
especiallywhen there is considerabledilation of the bowei. Orat which is
bf either.gastrapped in the lumen of the intussusceptum
barium may take a very long time to reach this distal level when 1u9ef
or.rntussusceptedmesentericfat. When viewed in the
motility is severeiy reduced. The pattern of barium at the lesion long axis,
fluid distention is seenin the bowel proximal to the
can vary,_depending on the degreeof patencyof the lumen through lesion.
Proliferating tissue massesoriginaiing within the intestinal
the length of the intussusceptum(the invaginatedsegment) and . wall
include tumors, poiyps, and graiuloma"tousinfiltrates.
the spaceremaining betweenthe intussuscepiumand tie intussus_ The devel-
opment of an obstructivebowel pattern from theselesions
cipiens (the receiving sheath). The longer the duration of the depends
on the size of the lesion and whether growth
anomaly, the greater is the edema in the affected bowel walls and of the lesion is
directed toward or away from the lumen."Over time,
the more complete is the obstruction. In some patients, a thin most could
progressfrom no effect, to partial obstruction,
to complete ob_
:", ';'-
"l
.
ll,:,il
;riill
iri, ,grla
:11!l
: 'rrri:r,r'
Figurc 48-17. Felineuppergastrointestina tract study20 minutesatter Figure 48-18. Leakageof contrast medium into the peritonea cavity oc-
admrnistration Thetightlypleated
of barium. or ribbon candyappearance indi- cuned ow i ng to bow el necrosi sat mul ti pl esi tes. l odi ne-contai ni ng,
w ater-
catesthe presence of inearforeign Theproximal
material. endof theforeign sol ubl econtrastmedi a are the agentsof choi cew hen bow e l perforati oni s
materialis oftenwrapped aroundthe baseof the tongueor is caughtin the suspected.A fter thi s cat vomi tedi odi neseveralti mes, bari umw as us ed to
pyloricantrumof the stomach(arraws). achi evea di agnosti study.
c
Functional ileus
When the peristaltic contractions of the bowel cease,owing to
vascular or neuromuscular abnormalities within the bowel wall,
the lumen dilates. In functional ileus, the bowel lumen remains
patent. Diseasesthat causefunctional iieus include viral enteritis
(canine parvovirus-2 in particular), chronic mechanicalobstruc-
tion, peritonitis, vascular compromise (volvulus), spinal trauma
(neurologicinjury), and autonomic nervous systemdiseasesuch as
dysautonomia.aT'a8 In many patients, there are no specific survey
radiographic changesto differentiate the bowel dilation causedby
functional ileus from that of mechanicalileus. The length of bowel
affected may provide some differentiation, with localized dilation
more likely due to a mechanical cause and diffuse dilation more
likely due to functional ileus. However, obvious overlap between
these two occurs. Furthermore, chronic moderate to severeme-
chanical obstruction can eventually lead to functional ileus. Thus,
the vaccination history (parvovirus); geographicregion of origin
of a patient that also has concomitant signs of other autonomic
nervous system dysfunction (dysautonomia); and a thorough his-
tory and physical examination are most useful in ranking these Figure 48-19. The thin, radiolucentfilling defects are ascarids(arrows).
diseasesas having a higher likelihood than the causesofmechanical N ote that the defectstaoerat thei r crani aland caudalends and that there i s
obstruction. no evi denceof abnormalsi ze,shape,or contourof the bow eL.
The SmallBowel 651
Barium contrast study should show distended loops, delayed intestinal loops. Tiaumatic tears or developmental hernias of the
transit, and normal to nonspecific changes in the barium texture peritoneal cavity boundaries can have small intestinal loops dis-
and mucosal border. There are no barium contrast findings spe- placed through them. The identification of such loops ii often
cifically diagnostic of the diseasescausing functional ileus. Floc- quite easy owing to gas within the lumen. The lumen can become
culation of the barium, a cobblestoneappearanceof the barium- enlarged if the hole reduces in size to become constrictive, or if
mucosa interface, and an irregular undulation of the mucosal the loop twists. Mesenteric volvulus results in occlusion of the
border can be seenthroughout the progressionofparvovirus enter- cranial mesenteric artery. The reduced blood supply leads to ische-
itis.aeBecausethese diseasesmimic complete mechanical obstruc- mic necrosis,gastrointestinaltoxin release,and shock.s0The initiat-
tion, the role ofthe barium contrast study is to exclude mechanical ing event for volvulus typically is not known. The majority of dogs
obstruction. reported have been of larger breed size.Many presenting dogs have
No specific ultrasound featureshave been describedto differenti- no distant or immediate prior history of gastrointestinalsigns and
ate functional ileus from chronic comDletemechanical obstruction. are presented in a shock state. However, in other dogs, mesenteric
The finding of peristalsis suggestsexclusion of functional ileus. A volvulus has occurred subsequent to prior treatment for acute
thorough search of the bowel should be done to look for obvious gastric dilatation with volvulus and intussusception. A series of
obstructive causes, such as intussusception, intraluminal foreign dogs had previous clinical diagnosisof pancreaticinsufficiencyand
material, or extrinsic masses. clinical signs of vomiting." The radiographic signs are moderate
Strangulation of the intestine through a hernia, mesenteric vol- to severedilation of the small intestine with fluid and gas. perito-
l'ulus, and intestinal sclerosis with pseudo-obstruction are other neal effusion may be concurrent. Five dogs have been reported to
lesscommon diseaseswhose primary radiographic changeis dilated havea syndromeof intestinalpseudo-obstruction,with histopatho-
logic changesrestricted to the tunica muscularis but apparently not the small intestinal tract have not been shown to causeany specific
involving the myenteric plexuses.52-s' Diagnosis was based on full- radiographic or sonographicchanges,and thus are not discussed
thickness intestinal biopsy, and all dogs had progressivedeteriora- here. Bacterial overgrowth in the small intestine has also not been
tion due to emaciation from malabsorption. These dogs were con- related to specific radiographic or sonographic changes.Bacterial
sidered to have histopathologic changes consistent with systemic abscessescan occur as focal lesions associatedwith the intestinal
scleroderma, similar to those found in humans. wall. These could be a consequenceof partial or complete intestinal
perforation by foreign material, with subsequent adhesions and
lnfiltrative diseases abscessformation. A mottled appearance can be seen in such
abscesses when gas from the lumen replacesexudate draining into
Infiltrative diseasesof the bowel wall include idiopathic inflamma- the lumen. Abscessescan also be associatedwith the small intestine
tory bowel disease(IBD), infectious inflammation, and neoplasia. but may be extrinsic to the wall. This may occur postoperatively
Any of these diseasescan have focal or diffuse involvement of the when surgical spongeshave not been removed, or may be second-
small intestine. Survey radiographic changes caused by these dis- ary to a pancreatic abscess.Inflammation of the proximal duode-
easesare nonspecific and frequently minimal. IBD most commonly num secondary to pancreatitis can causethe duodinum to take on
causes no radiographic abnormalities. Infectious and neoplastic a fixed or rigid appearance demonstrated by mild dilation with
infiltration may lead to signs of dilation, an abnormal gas pattern gas.s6A left lateral view may aid in showing this mild dilation.
with or without dilation (Fig. a8-22), and an abnormal mucosal Although not common, reported mycotic infections of the intesti-
margin with a narrowed lumen. Neoplasia may become large nal tract include histoplasmosis,cryptococcosis,s'and pythiosis.
enough to cause a mass effect. Metastasis to the regional lymph Pythiosis, an opportunistic water-borne fungus, has recently been
node may be large enough to create a mass effect despite a small diagnosedin dogs in Oklahoma (including the northern region),
size of the primary tumor in the intestinal wall. These diseases in addition to its more common endemic localein the statesalong
causecellular infiltration within the layers of the bowel wall; there- the Gulf Coast.s8' sePathologic changesare often quite advancedby
fore, the most anticipated change is that of bowel wall thickness the time of clinical presentation. Pyogranulomatous lesions cause
and uniformity. Bowel wall thickness cannot be reliably determined localized thickening of the intestinal wall that frequently extends
from survey radiographs but can be evaluated in barium contrast through the serosa,along the mesentery, and into the mesenteric
I and ultrasound studies. Survey radiographic findings that should Iymph nodes. This combination results in a palpable abdominal
heighten the suspicion of infiltrative small bowel disease in a mass. The ultrasound features of a series of dogs having pythiosis
I patient with appropriate clinical signs include increasedsmall included thickening of the intestinal wall associatedwith loss of
bowel gasin cats;increasedgas-to-fluidratio in cats;and decreased the layer pattern.60The sonographic features are very similar to
I gas-to-fluid ratio in dogs.'' those of intestinal neoolasia. Histoloeic examination of tissue is
Inflammatory bowel disease refers broadly to gastrointestinal required for diagnosis.
I
tract diseasesfor which a specificetiologic causecannot be found, Common neoplasmsof the small intestine include the malignant
J
and in which the intestinal wall is infiltrated by inflammatory tumors-adenocarcinoma, lymphosarcoma, mastocytoma, and lei-
cells.ssThere are no radiographic features specific to the spectrum omyosarcoma. Atypical tumors reported are extraskeletaltumors,
of this group of inflammatory changes. Survey radiographs are osteosarcoma,fibrosarcoma,carcinoid, neurilemmoma, and hem-
usuallywithin normal limits. BecauseIBD is in part a diagnosisby angiosarcoma.6r 7aBenign adenomatouspolyps of the duodenum
exclusion, the negative radiographic findings aid in the exclusion have also been reported in cats, with an increasedfrequency noted
of other diseases. among Asian breeds.Ts In survey radiographs,no signs unique to
Infectious enteritis includes those diseasescaused by viruses any of these tumors are noted. They may create no changes,may
or bacterial, rickettsial, and fungal organisms. Parvovirus (canine be seen as soft-tissue massesof variable size, or may cause partial
parvovirus-2)-induced radiographic changeshave been discussed to complete obstruction, resulting in bowel dilation signs.Accumu-
in a previous section with reference to a differential diagnosis for lation of radiopaque foreign material may be seenas a consequence
abnormal bowel dilation. An enzyme-linked immunosorbent assay of partial obstruction. Identification of these lesions is improved
(ELISA) test for canine parvovirus-2 in the fecesshould be done with either positive-contrast or ultrasound evaluation.
before barium contrast or ultrasound is used, when there is reason- In barium contrast studies, there may be a contrast contour
able suspicion of this viral enteritis. Other viral diseasesthat infect change,an irregular mucosal interface abnormality, a wall thickness
t"
d"
i
"l
change,or a luminal size effect as a result of any infiltrative disease rounded protrusions toward the lumen (Fig. 48-23). The effect is
process. Unfortunately, no positive-contrast findings, either single an indentation into the barium column. When the proliferations
or in combination, have been discovered to differentiate non- are muitifocal along a length of bowel, they have been likened to
neoplastic from neoplastic infiltrative disease.t,However, the posi- thumb- or fingerprints. These indentations are differentiated from
tive-contrast study may be used to corroborate a suspicion of normal or hyperperistaltic contractions in that they are symmetri-
abnormality from the survey radiographs, and to better define the cal {directly opposite);those from proliferativetissue,however,are
Iocation of a lesion with respect to whether endoscopicversus asymmetrical (Figs. 48-24 through 48-26). Ulceration of the mu-
surgical biopsy would be most effective. This is especiallyvalid for cosa associatedwith infiltrative diseasecan be extremely difficult
the practice that has no availability of ultrasound. Survey radio- to identif' when small. When larger ulceration is present, an
graphic findings that warrant positive-contrast evaluation when irregular mucosal margin is more ikely. Occasionally, ulceration
infiltrative small bowel disease is strongly suspected include in- extendsvery deep into the wall layersand causesa "spiked,'pattern
creased small bowel gas in cats; increased gas-to-fluid ratio in $ig, a8-27). Foci of barium may remain adherentto an ulier and
cats;and decreasedgas-to-fluidratio in dogs.I2Tissue proliferation may be evident after all of the other barium has passeddistally. A
associatedwith intestinal wall tumors typicaliy causes smoothly frequent pattern seenwith annular infiltration by-adenocarcinoma
ffift.lll!lill
q- . . * * q l B
is narrowing of the lumen by offset indentations in the barium. inflammatory infiltrates.There is no ultrasonographicpattern that
This has been called an "apple-core" appearance.ra'66 It is not, is entirely specific for any of the types of small intestinal neoplasia.
however,specificfor a diagnosisof neoplasia,and biopsy must be However, most (75%) cats with alimentary lymphosarcoma have
done for diagnosis.Other diseasesthat can produce secondary transmural circumferential (as is seen in the transverseplane)
ulceration include mast cell tumors, hepatic disease,uremia, and thickening (4-22 mm), with the wall layers replaced by hypoechoic
recurrent pancreatitis.T6-0"
When greaterlengthsof the intestineare tissue.Half of thesecatshaveassociatedenlargementof the mesen-
abnormal, lymphosarcoma,non-neoplasticinfiltrative disease,or teric lymph nodes.8u, 87Intestinal adenocarcin-oma of cats tends to
ischenriaand necrosisshould be suspected(Figs. 48-28 and 48- causetransmural asymmetrical thickening, with the wall layer pat-
r2, 81 8s
)q\ tern lost and repiacedby tissueof mixed echogenicity.r'Much less
When evaluatedsonographically,in general,intestinal neoplasia has been describedfor the intestinal neoplasmsof the dog, with
more typically obliterates the intestinal wall layer pattern and the exceptionof smooth-muscletumors, leiomyosarcomaand leio-
more greatly thickens the wall than do other common types of myoma.8eLeiomyosarcomatends to be found as a large (2-8 cm
q
Figure 48-27. Adenocarcinoma of the jejunum during a bar_
ium u p p e rg a s t r o i n t e stintraal ctstu d y.Ra d io g r a p h.io
ic n ."in .tr O"
soft-tissuemass (whitearrows),mtldtocate"ntargem;itoi
n-o*"t
lum e n ,i r r e g u l acr o n t o u ro f m u co sa a
, n d e xtr a va "sa tio
o fna sm a rr
amountof contrastinto the mass (blackarrows).
ffiry-
o f t h e b a r i u m co r u m n .T h e r u m e n d ia m e te ro T th e descendi ng
narrow e dP o s s i b i ec a u s e sin clu d ech r o n icse ve r ein fla m m a tio n duodenumi s
a n d rnfi l trati ve
,i eoptasi ai rsto-
pat hol o g idc i a g n o s i w s a s l ym p h o cytic_ p la sm a cytic e n te r itis.
656 A N IMA L S
A B DO M E N -C ON /IPA N ION
origin in immunocompromised patients. Neither small intestinal 19. SeltzerSE, JonesB, Mclaughlin GC: Proper choice of contrast agentsin emergency
gastrointestinal radiology. Crit Rev Diagn lmaging 12:79, 1979.
nor colonic pneumatosis has been reported in the dog or cat;
however, the author has seen a case of pneumatosis coli that 20. Allan GS, Rendano VT, Quick CB, et al: Gastrografin as a gastrointestinal contrast
nedium in the cat. Vet Radiol 20:3, 1979.
occurred after numerous enemas.
21. Hsu WH, McNeel SV: Effect of yohimbine on xylazine-induced prolongation of
gastrointestinaltransit in dogs. ) Am Vet Med Assoc 183:297,1983.
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43. Basher AW, Fowler JD; Conservative versus surgical management SD; Adenomatous pollps of the duodenum
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51. Westermarck E, Rinaila-parnanenE: Mesenteric torsion B, M ar gul i s AR : Ex per i m ental i nfar c ti on
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adenocarcinoma and
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:
658 A B DO N/ E N -C O MP AN IOAN
N IM AL S
mittent vomiting of 5 days' duration. A mass in the abdomen and reported to be ill for 5 days with dark diarrhea. On physical
gas-filledloops ofbowel can be palpated.Figures48-30 and 48-31 examination, the cat is depressed,and distended bowel loops are
are right iateral and ventrodorsal survey views. What is your inter- palpable. Describe the appearanceof the gastrointestinaltract.
pretation of the radiographs,recommendationto the owner based What is your interpretation?
on your findings, and rationale for the recommendation?
6. A l-year-old neutered male seal-point Siamesecat had a 1-
4, An ll-year-old male Shih tzu has had chronic anemia and
month history of pyrexia, weight loss, and general debilitation. The
melena for about 40 days.There is a tenseabdomen;pale mucous
owner reported recent onset of diarrhea. The cat was depressed
I membranes; and dark, formed feces.Urinalysis and routine blood
t,' and lethargic with thickened, painful bowel on palpation. Addi-
chemistrieswere unremarkable (hemoglobin : 3.9 g/dl, packed
tional testsincluded fecal (negative),total serum protein = 8.7 gl
cell volume : 12o/o).A barium upper gastrointestinalstudy was
dL, and negativeserology for feline leukemia virus and toxoplasmo-
performed; Figure 48-32 is a right lateral view at 15 minutes,
sis. Figures 48-37 and 48-38 are right lateral and ventrodorsal
Figure 48-33 is a ventrodorsalview at t hour, and Figure 48-34 is
views made 3 hours after barium administration. Describe any
a ventrodorsalview at 2 hours after barium administration. De-
radiographic abnormalities demonstrated by the barium study. List
scribe any significant radiographic abnormality, and list differential
possibleexplanationsfor observedabnormalities.
diagnosticpossibilities.
5. Figures 48-35 and 48-36 are right lateral and ventrodorsal 7, What is one of the most common causesof technically inade-
survey abdominal radiographsof a l5-year-old neutered male cat quate barium upper gastrointestinal studies?
Figure 48-34. Ventrodorsalview at 2 hours after barium admi ni strati on. Figure 48-?6. Ventrodorsalsurveyabdomi nal
vi ew of sam e c at as i n Fi q-
Same dog as in Figures48-32 and 48-33. ure 4a-35.
Figurc 48-35. Rightlateralsurveyabdominalview of a 1S-year-old neutered Figure 48-37. Rightlateralview at 3 hoursafter bariumadministrationin a
male cat that was ill for 5 days with dark diarrhea.Distendedbowel loopsare 1-year-oldcat with a l-month history of pyrexia,weight loss, ano generai
palpable.For interpretation see the answerto Ouestion5. Same cat as that in debilitation.See Ouestion6 for additionalhisioryand lab'oratory
Fiqure48-36. results.Same
cat as that in Figure48-38. See the answerto Ouestion6 for interpretation.
660 A B DO M E N -C OMP AN IO N
AN IM AL S
8. Give the reason why there may be no abnormalities from an 10. Tiue or False. Small bowel wall thickening is more reliably
intestinal obstruction on survey abdominal radiographs. determined by palpation and ultrasonography than by survey radi-
ography.
9. Filling defects in the barium-filled small bowel lumen may or
may not be pathologic. What roentgen signs could be used to
determine whether filling defects are pathologically significant? Answers begin on page 727,
CHA P T E R
49
The Large Bowel
I Darrvl N. Bierv
I lmaging options for large Less commonly used imaging techniques for colonic disease
I bowel disease include rectocolonic lymphangiography, mesenteric angiography,
and colonic transit scintigraphy. These techniques enable assess-
Survey and contrast radiographic procedures have been used to ment of anatomic or functional abnormalities but require special-
assessmany colonic conditions.l-3 After a survey radiographic ex- ized equipment and expertise.8-l0
amination, however, endoscopy (colonoscopy) now has largely re-
placedthe radiographiccontraststudiesof the colon. Most colonic
diseasesare diagnosed using endoscopy,especiallywhen a flexible I Normal radiographic anatomy
endoscopeenablesvisualization of the transversecolon, ascending
colon, and cecum.a The large bowel of the dog and cat is composed of the cecum,
Ultrasound has become a sensitive and practical imaging mod- colon, rectum, and anal canal (Fig. 49-1). The cecum,a diverticu-
ality that is usually less time consuming than many radiographic lum of the proximal colon, has different anatomic and radiographic
contrast studies of the colon; it provides additional and comple- appearancesin the dog and the cat (Fig. 49-2).t The canine cecum
mentary information to the clinical, endoscopic, and survey radio- is semicircular (corkscrew or C-shaped) and compartmentalized
graphic findings.' Although air and fecesin the bowel are limiting with a cecocolicjunction and normaliy containssome intraluminal
factors for ultrasound studies, an ultrasound examination can as- gas. The intraluminal gas and characteristic shape enable easy
sess near-fieid bowel wall thickness and symmetry, mural and recognitionof the cecum in the right midabdomen on most survey
extramural bowel masses,the regional lymph nodes, intussuscep- radiographs. The feline cecum, however, is usually not visible on
tions, and other abdominal viscera. Needle aspiration and biopsies survey radiographs. It is a short, cone-like diverticulum of the
of the colon can also be obtained using ultrasound-guided tech- colon with no distinct cecocolic junction and no compartmental-
niques.6't In addition, new techniquesof endoscopicsonography ization; it rarely contains gas.
are now beginning to be used for detailed evaluation of mural and The colon of the dog ind the car, the longest segment of the
extramural colonic structures. large bowel, is a thin-walled distensible tube thar is divided into
The LargeBowel 661
Figure 49-2. The cecum of the dog (A) and of the cat /B/
are a n a t o m i c a l lay n d r ad io g r a p h ica lly
d iffe r e n t.T h e ca n in e
c ec u m i s s e m i c i r c u l aarn d co m o a r tm e n ta lizeadn d n o r m a llv
c onta i n ss o m e g a s . T h e fe lin ece cu m ,h o we ve r ,is a sh o n ,
conelike structure with no compartmentalization; it rarely
c onta i n sg a s . { F r o mO ' Br ie nT R: Ra d io g r a p h ic Dia g n o siso f
AbdominaiDisordersin the Dog and Cat. Davis,CA, Covell
ParkVeterinary,1981.)
I
6 62 AN IM AL S
A B DO M E N -C O MP AN IO N
the endoscopeprevent examinationof all of the colon and cecum, have lymph follicles in the mucosa, which appear as spicules on a
and (3) a mural or extramural lesion is suspected,and the mucosa barium enema study, or as pinpoint radiopacitieswhen visualized
is found to be normal on endoscopicexamination.aSurveyradio- en face with a double-contrast study. These normal follicles must
graphs should be made not only as a first diagnostic step, but be differentiated from small ulcers.
also prior to the contrast study to determine correct radiographic The large bowel cannot be properly evaluated following oral
exposuretechniquesand to ascertainadequatepatient preparation administration of contrast medium becausethere is usually inade-
for the contrast study. For a high-quality diagnostic study, the quate large bowel luminal distention; intraluminal filling defects
colon should be thoroughly cleansed prior to the contrast study. due to fecesalso occur frecuentlv.
This is best done by withholding food for 24 to 36 hours, and by Complete large bowel contrasi studiesare time consuming and
cleansingthe colon with both an orally administeredcathartic and must be done meticulouslyto assess the mucosa,wall, lumen, and
warm water enemasprior to the procedure.The colonic mucosa adjacent viscera as well as to avoid artifacts, complications, and
and lumen should be free of fecal material with a clear effluent messes,such as contrast medium on the veterinarian,equipment,
visible on an enema immediatelyprior to the study. Generally,the and patient. Partial large bowel contrast studies, which are less
radiographictechniqueshould be increasedby 6 to 8 kVp over the thorough, quicker, and easier,may be performed with the introduc-
surveytechniquewhen barium is used.Although the techniquesof tion of small amounts of air or barium into the rectum via dose
doing a contrast study may vary, barium at room temperature is syringe.Thesestudiesdo not allow visualizationof the entire large
administeredthrough an inflatable cuffed catheter placed in the bowel nor of small lesions,such as mucosalirregularities;however,
distal rectum to prevent the barium from leaking from the colon, they may enable visualization of large intraluminal lesions and
and to obtain adequatedistention of the colon.'' " 'r Generalanes- differentiationof the colon from adjacentorgans and masses(see
thesia is almost alwaysnecessary. Micropulverizedbarium suspen- Fig. 49-aC).
sion is the contrast medium of choice for obtaining a smooth
coating of the mucosal surface.The colon should be slowly filled Gomplications associated with contrast studies
with barium by means of a gravity system, and preferably with Complicationsrelated to contrast studiesof the colon may occur.
fluoroscopicobservation.Becausefluoroscopicequipment may not The most seriouscomplication is perforation and subsequentperi-
be available and the volume of barium needed to fil1 the colon is tonitis (Fig. 49-5). Rupture can occur from a cieansingenema,
extremelyvariable,the contrast medium should be given in several improper selectionor use of a barium enemacatheter,and overdis-
small increments until the desired effect is seen radiographically. tention of weakenedor diseasedbowel, or after a biopsy.ra-','If
Usually the barium dose is 7 to 15 ml of barium per kilogram colonic perforation is suspected,a l5o/o to 20o/oconcentration of
body weight. Multiple radiographicviews-that is, left lateral,ven- nonionic aqueousiodine contrast medium can be substitutedfor
trodorsal, and ventral right-dorsal left and ventral 1eft-dorsalright the barium, but mucosaldetail will be significantlydiminished.r,
oblique views-should be made when the colon is distendedwith A common complication that is inconsequentialis retrograde
barium and again after evacuationof the barium from the colon. filling of the distal small bowel; such reflux may obscurevisuiliza-
The detection of subtle rnucosal lesions may be enhancedby a tion of the colon. This complication has been reported in about
double-contraststudy. In most instances,this is done by removing one third of dogs and may occur without overdistentionof the
as much of the barium as possibleand inflating the colon with colon.rr Spasm,which is usually transient, may also occur when
room air through the catheter. the contrast medium is cold, when narcotic premedicationsare
When distendedwith barium, the normal colon has a smooth used,or when the wall is irritated by the catheter(Fig. 49-6).
contrast medium-mucosa interfaceand a uniform diameter.After
evacuationof the barium, longitudinal mucosalfolds are visible.If
air is then infused, a double-contrast study is obtained, which
I Ra d io g r a p h ic fin d in g s in l arge
provides the most detailedvisualizationof the mucosalsurface.
A variety of radiographicappearancesresult from adherenceof
I bowel disease
barium to mucus, clumping and flocculationof barium, and filling Disease involving or adjacent to the large bowel may produce
defectsof fecesthat are either within the lumen or attachedto the radiographicalterationsin size,shape,location, and radiopacity.ra
wall. The colon of the doe and the cecum and colon of the cat Although function cannot be evaluated radiographically, the quan-
'"
"11&lrrrail
ti:-4
du:::iltl
**
,.',*ljj
1" ,a'
,{ui"*i* i
i-;;-:
ii *-,'-;-'"-'
-";;;
iiel
.r l
tity or location of fecesmay suggestimpaired motility. Most radio- with ineffective motility. Megacolon may be idiopathic or associated
graphic findings in specificlarge bowel diseasesare not pathogno_ wlth numerous underlying causessuch as (l) chronic constipation
monic. Many different diseaseshave similar radiographii findings, and obstipation,(2) feline idiopathic (3) spinal uno-u_
and any particuiar diseasemay havea spectrumofdifferent upp.i._ lies (e.g.,caudaequina syndrome,sacroiccygeal
-.gu.oior,, aqenesisin Manx
ances.In addition, parasitic,dietary,and other inflammatory causes cats),(4) neuromusculardisorders(e.g.,felinJdysaitorro-ru, ug"r,-
of large bowel disease commonly have no visible radiographic glionosis,.or Hirschsprung'sdisease
abnormality. [Fig. 9_g]), (5) metabolic
drsorders( e.g.,hypokalemia,hypothyroidism),(6) surgicaluretero_
In the normal large bowel, the colon containsmost of the feces, colic diversion techniques,(7) perineal hernia, and
with small amounts of or no fecesin the rectum (seeFig. 49_l). 3.r72l fg) anorectal
congenitalanomalies.r'
The diameter of the normal colon varieswith the amouni of feces Congenitalanomaliesof_thelarge bowel are rare in the dog and
present and individual defecationhabits. As a rule of thumb, the .
the cat. Anomalies reported includle imperforate anus, atresia recti,
diameterof the normal colon should be lessthan the lensth of L7.r atresiacoli, fistulation, diverticula, duplication of the 1argebowei
Colonic impaction is characterizedradiographicallyb/ accumu- and rectum, and a short, straight colon with the cecum in the
. left
lation of the feces,which are more radiopique than normal as a hemiabdomen.1,3,22_28
consequenceof constipation,obstipation, or megacolon.Chronic The sizeand shapeof the colon may alsobe alteredby numerous
impaction can also result in generalizedeniargemint of the colon. ,
chronlc mflammatory diseasesof the large bowel and adjacent
Localizeddilation of the colon is usually relited to impaction or viscera. These inflammatory changesmay'result in localized
localizeddiseases suchasmechanicalobstruction(e.q.,ile'ocolic or
and generalizedirregularity and ulceration of the mucosawith
cecocolicintussusception,cecal and colic volvulus] stranqulation diverti,
cula,adhesions, or shorteningof the colon.
by ruptured duodenocolic ligament), narrowed pelvic can"alfrom Abnormal location of the lirge bowel is a common radiographic
fracture,intramural or extramuralcolonic tumorlFig. 49-7), stric_ alteration seen with large bowil diseasein the dog and c"at.'Al_
ture, and foreign body. tnougn therels somenormal variabilityin the locationof the large
Abnormal generalizedenlargementof the colon is commonly bowel, mass lesions,particularly those of organs adjacent to tfre
referred to as megacolon,a condition causedby mechanical or colo^n,cause displacementof the cecum, .olo.r, o, rectum (Fig.
functional obstruction and characterizedby diffuse colonic dilation 49-9; see also Fig. 49-3 and Chapter 39). Massesor enlarsemerit
j-
- : * . _; - ^, :r y:i -
666 A B DO N/ E N -C O MP AN IOAN
N IM AL S
E
:
6 68 A N IMA L S
A B DO M E N -C O MP AN IO N
Figure 49-13. An 11-year-old female,neuteredminiatureSchnauzerhad a 3-yearhistoryof strainingto defecatewith occasionalsoft and bloodystools.Lateral
f A l a n d v e n t r o d o r s a1lBlvie ws o f th e b a r iu me n e m ae xa m ln ati on demonstrate an i negul arand ci rcumferenti narrow
al i ngat the j uncti onof the des c endi ng
c ol on
a n d r e c t u m .A t s u r g er ya n d b io p sy,th is n a r r o win gwa s a b e n ignstri cture,presumedsecondary to prevl ousovari ohysterectomy (notesurgi calcl i ps ).
The LargeBowel 669
g g ?aw-s 14. Seaman WB, Walls ]: Conplications of the barium enema. Gastroenterology
lliilll9lll,,liilllll::l19ll,
lgll..,l119lrr,,
lWi.F
,rl9l . ii6ll,'rii; lHllql1lell:!ll:€$a 48:728,1965.
ffi. ; 15. Toombs JR Canvood DD, Lipowitz AJ, et al: Colonic perforation following
neurosurgical procedures and corticosteroid therapy in four dogs. J Am Vet Med
ffiq
ff-F ,q
.41 Assoc 177:68,1980.
-r
'
& 4 *s.' 16. Toombs ]R Collins LG, Graves GM, et al: Colonic perforation in corticosteroid-
treateddog. J Am Vet Med Assoc 188:145,1986.
17. Washabau Rl, Hasler AH: Constipation, obstipation and megacolon. In August JR
kil
(ed): Consultations in Feline Internal Medicine, 3rd ed. Philadelphia, WB Saunders,
1997.
18. Matthiesen DT, ScaleTD, Whitney WO: Megacolon secondary to pelvic fractures.
Vet Sur g 20:113,1991.
19. Sharp NlH, Nash AS, Griffiths IR: Feline dysautonomia (Key-Gaskell syndrome):
A clinical and pathologic study offorty cases.J Small Anim Pract 25:599,1984.
20. DeForest ME, Gasrur PK: Malformations and the Manx syndrome in cats. Can
Vet I 2i304, 1979.
21. Jones BR, Grufr'dd-Jones Tl, Sparkes AK: Preliminary studies on congenital
hlpothyroidism in a family ofAbyssinian cats. Vet Rec 131:145, 1992.
22. Rawlings CA, Capps WF: Rectovaginal fistula and imperforate anus in a dog. I
Am Vet Med Assoc 159:320,1971.
23. Fluke MH, Hawkins EC, Elliott GS, et al: Short colon in two cats and a dog. J
Am Vet Med Assoc 195:87,1989.
24. Jakowski RM: Duplication of colon in a Labrador retriever with abnormal spinal
column. Vet Pathol 14..256,1977.
25. Bredal WP, Thoressen SI, Kvellestad A: Atresia coli in a nine week old kitten. J
Small Anim Pract 351643,1994.
26. Longhofer SL, Jackson RK, Cooley AJ: Hindgut and bladder duplication in a dog.
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27. Schlesinger DP, Philbert D, Breur GJ: Agenesis of the cecum and the ascending
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32. Carberry CA, Flanders ]A: Cecal-colic volvulus in two dogs. yet Svgery 22t225,
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11. Ticer JW: Radiographic Technique in Veterinary Practice,2nd ed. Philadelphia, cated after survey radiographs?
WB Saunders,1984. A. Pneumocolonography
12. Kleine LJ, Lamb CR: Comparative organ imaging: The gastrointestinal tract. Vet B. Barium enema
Radiol 30:133,1989. C. Ultrasonography
13. Brawner WB, Bartels JE: Contrast radiography of the digestive tract: Indications, D. Endoscopy
techniques, and complications. Vet Clin North Am 13:599, 1983. E. Mesenteric arterio$aphy
The LargeBowel 671
Figure 49-17
2, Tnte or False.The cecum of the dos and that of the cat have B. Intraluminal mass in the descendins colon
similar anatomic and radiographic appea-rances. C. Old pelvic fractures with maluniJn and secondary nar_
rowing of the descendingcoion
3. Which of the following is not recommended prior to a barium D. Perineal and abdominal hernia
enema radiographicstudy? E. Idiopathic megacolon
A. Withhold water for 8 to 12 hours.
B. Withhold food for 24 to 35 hours. 9. In the same cat (refer to euestion B and Figs. 4g_1g, 49-20,
C. Empty the urinary bladder. 49-21, and 49-22), a barium enema and double--contrastbarium
D. Administer gastric lavagesolutions. enema were done. Based on the contrast studies, which of the
E. Administer warm water cleansing enemas. following.conditionsis present?Note: The intraluminal filling de_
rects are clue to feces.
4. Tiue or False.The large bowel cannot be fully evaluatedradio-
graphically with an upper gastrointestinal barium study.
E.-t
672 A B DO ME N -C O MP AN IO N
A N IN /IAL S
Figure 49-19
I
t
I
l.
i
l.
I'
Figure 49-2O
The LargeBowel 673
Figure 49-21
Figure 49-22
RADIOGRAPHICANATOMY
ffi CHAPTER
ffi50
RadiographicAnatomy of the Dog
ffi
* .and Horse
ffi ]amesE. Smallwood . Kathy
Kathy A. Spaulding
Spauldins
To use the roentgen-signmethod of recognizingabnormal radio- 2. Schebitz H, Wilkens H: Atlas of Radiographic Anatomy of the Horse, 3rd ed.
graphic findings effectively, one must first have an understanding Philadelphia, WB Saunders, 1978
of normal radiographic anatomy for the specific area of interest. It 3. Smallwood lE, Shively Ml, Rendano VT, Habel RE: A standardized nomenclature
is the purpose of this chapter to provide the veterinary student for radiographic projections used in veterinary medicine. Vet Radiol 2:9, 19g5.
and practitioner with a limited reference for the anatomy of the
more frequently radiographed regions in the dog and horse. 4. Smallwood JE, Shively MJ: Radiographic and xeroradiographic anatomy of the
equine carpus.Equine Pract I:22, 1970.
By inclusion of labeled radiographs of selectedareasof clinically
normal animals, we have attempted to provide basic resourceinfor- 5. Smallwood JE, Holladay SD: Xeroradiographic anatomy of the equine digit and
mation for veterinarians in support of their more effective utiliza- metacarpophalangealregion. Vet Radiol 28:166, 1987.
tion of the roentgen-signmethod of radiographic interpretation.
For more detailed information, we refer readers to comprehensive 6. Shively MJ, Smallwood JE: Radiographic and xeroradiographic anatomy of the
equine tarsus. Equine Pract 2:19, 1980.
textbookson radiographicanatomy.r,'?
The radiographic nomenclature used in this chapter is that 7. Zontine WJ: Canine dental radiology: Radiographic technic, development, and
approved by the American College of Veterinary Radiology in anatony of the teeth. J Am Vet Radiol Soc 16:75, 1975.
1983.3The xeroradiographs of the equine limbs presented in this
chapter(Figs.50-51 through 50-71) havebeentaken from previous 8. Burk RL, Corwin LA, Bahr RJ, et al: The right cranial lung lobe bronchus of the
publicationsas,6 and are reproducedhere with permission of the dog: Its identification in a lateral chest radiograph. J Am Vet Radiol Soc-:210, 1978.
journals and author. 9. Spencer CP, Ackerman N, Burt lK: The canine lateral thoracic radioqraph. Vet
R adi ol 22:262.1981.
References
1. Schebitz H, Wilkens H: Atlas of Radiographic Anatomy of the Dog and Cat, 4th 10. Thrall DE, Losonsky JM: A method of evaluating canine pulmonary circulatory
ed. Philadelphia, WB Saunders, 1986. dynamics from survey radiographs. J Am Anim Hosp Assoc 12:457, 1926.
675
6 76 RA DI O G R A PH A
ICN A T O MY
anatomYof the
I }S$t"ntaPhic
iro;lllll;,,rl'lllXli;ll19:
. ". ,"'
, .lll'1l.i.tl.'
i:--
678 RA DI O G RA PH AN
IC AT OMY
.,irr:;uri
:iiiuri::iil
ifi
:
F i g u r e 5 O - 7 . M e d io la te r a l Ra d io g r a p h o f F le xe d
C a n i n e E l b o w J o i nt.
1 . M e d i a le p i c o n d yle of humerus
2 . A n c o n e apl r o c esso f u ln a
3. Olecranoo n f u l na
4 . M e d i a lb o r d e ro f h u m e r aco
i n d yle
5 . M e d i a lc o r o n o i dp r o ce sso f u ln a
6 . B o d yo f u l n a
7 . B o d yo f r a d i u s
8 . H e a do f r a d r u s
9 . B o d yo f h u m e r us
1 0 . C o n d y l eo f h u m er u s
.:
6 80 RA DI O G R AP H A
ICN A T O MY
Figure 50-8. Mediolateral Radiograph of Canine Antebrachium. Figure 50-9. Craniocaudal Radiograph of Canine Antebrachium.
1. B o d yo f h u m e r u s 1. B odyof humerus
2. C a u d abl o r d e ro f me d ia e l p ico n d yle
of humerus 2. Medi aieoi condvl of e humerus
3. O l e c r a n o o nf ulna 3. Medi alcoronoi dprocessof ul na
4. M e d i a lc o r o n o i dp r o ce sso f u ln a 4. B odyof ul na
5. B o d yo f u l n a 5. B odyof radi us
6. D i s t a lp h y s i so f u l n a 6. Distalohvsisof radus
7. S t y l o i dp r o c e s s( d i stael p ip h ysis)
o f u ln a 7. Medialstvloidorocessof radius
8. Accessorvcarpalbone 8. Intermedi oradicarpal
al bone
9. D i s t a le p i p h v s i o
s f r a d iu s 9. D i stalepi physi sof radi us
10. B o d yo f r a d i u s 10. S tyl oi dprocess(di stal
epi physi s)
of ul na
11. N u t r i e n ft o r a m e no f r a d iu s 11. B odyof ul na
12. C o n d y l eo f h u m e r u s 12. H eadof radi us
13. A n c o n e apl r o c e s sof u ln a 13. Lateraiepi condvl of e humerus
Radiographic
Anatomyof the Dog and Horse 681
il$jui':,"
I
r ir
I
27. B o d yo f u l n a
Radiographic
Anatomyof the Dog and Horse 6a3
ti
t ')
i_^
it
I'
a lflllrriir,
ii
:
692 RA DI O G RA P H A
ICN A T O MY
rrr:trlr- .iiitl
' ::: .:l::.::'
iil],,,i]]!li:i;l
'llrl
' ))).:t:..
,itlltr,:)).:.
,
iiiliirl
Figure 50-38. Left-Right Lateral Radiograph
of Canine Gervical Spine.
'1. Lateralvertebralforaminaof atlas
2. S p i n o u sp r o c e s so f axis
3. C r a n i aal r t i c u l apr r o ce sse so f C3
.::t 'iiieuu''iiiia
:....\11,))..
4. C a u d aal r t i c u l apr r o ce sse so f C3 ..illlllr''iill!]llll
l$lrr:liii$l'.
5. Intervertebral foraminabetween C4 and C5 ut:1iiliut'iili]
r.,llll:,,,,.1111::
tlillt,...i!11,.
1|]]ill:rlriiirr,
6. S o i n o u so r o c e s so f C 7
7. Trachea
8. Expandedtransverseprocessesof CG
L lntervertebral disc spacebetween C4 and C5
10. C a u d apl h y s i so f C 4
'l 1. Transverseorocessesof C4
12. Transverseprocesses(wings)of atlas
13. Ventraltubercleof atlas
R adi ographiAcnatomyof the D og and Hor se 695
u*'
:-
696 RA DI O G RAP H AN
IC AT OMY
. ..11
lll$11irr
,ri r r ll,
'illrr'
::t:i]',::,
iill,.,l
Ej-
698 RA DI O G R A PH A
ICN A T O MY
t:tiltsu
,,lUr,'i.lll:
F ig u r e 5 O - 4 7 . R i g h t- L e ft L a te la l Ra d io -
graph of Canine Thorax.
1.Trachea
' ;li!r,.
2.
3.
R i g h tc r a n i allo b a rbr o n ch u s8
D e s c e n d i n ag o r t a ;jw#
4.S u p e r i m p o s ecda ud a o b a rb r a n ch e so f
p u l m o n a ra y r t e r i e sa n d ve in s
5 L e f t c r u s o f d i a p h ra g mtyp ; ica llye xte n d s I
"ltdl
c r a n r at lo r i g h tc r u s in le ft la te r arl e cu m b e n cye r .,l l r '
i*
6 R r g h tc r u so f d a p hr a g m
1. L IV E T lrli
:,:ti']:l
8. Ca u d a ve n a ca va
9. A p e x o f ca rd i a c si l houette; fal s away fr om
ste rn u m i n l e ft l a te r al r ecumbency
' 10 . M i d d l el o b a rb r a n c ho f r ig h tp u lm o n a r y
a r te r y
11. R i g h tv e n t r i c u l awr all
12. R i g l - rc r a n , a..o o a rp u l.n o ^ a r ve
y r
'13 .C r a n i a o / b a rb r a n cho f r ig h tp u lm o n a r a y r te r y
t h e r i g h tc r a n i allo b a rb r o n ch u sis lo ca te d
b e t w e e n1 2 a n d 1 31 0
rliilll
'*r
==
7 OO RA DI O G RA P H AN
IC AT OMY
1
. ,::
:l
Figure 50-51. Dorsopalmar Xeroradi-
:; l ograph of Left Equine Carpus.
..r.tr.,liiuu:.iiG 1. Medi alstv oi d orocess
*l 2. Laleralstv oid orocess
3. P rol ecton at proxi momedi al
as pec tof 1
4. V ascul archannel s
5. C audoateral borderof '1
6. Junctonof carpalarti cuar s urfac ew i th
cranl alsurfaceof radi us
7 R adi acarpalbone
8 ntermedl ate carpa bone
I U l narcarpa bone
10 Accessorycarpalbone
11 S econdcarpalbone
12 Thrrdcarpa bone
13 Fourthcarpalbone
14 Medi a borderof pa mar pr oc es sof C 3
q a .^ n /{
15 m a i .^ .r n :l h^na
16 Fourthmetacarpabone
17 Thi rdmetacarpal
bone
18 V ascul ar
channel
19 j oi nt
A ntebrachi ocarpal
a - .^ ^ '_ ^ +^ ^ ^ .^ ^ r i ^ ,^ +^
20 u o ,p u I r Er d L d r Po r luil rrr
21 Mi ddl ecarpalj oi nt
22 S hadowcast by dorsa aspec tsof
carpometacarpa l ornl s
11
S hadowcast by pal maras pec tsof
carpomeTacarpar l ornts
Radiographic
Anatomyof the Dog and Horse 7O3,
,::r,ll F]
.;-;:i #i$a
rugiXlllqlA;X6
s* * l
F ig u r e 5 O - 6 2 . P a lm a r o p r o xim a l- Pa l-
m ar o d i s t a l O b l i q u e Xe r o r a d io g r a p h o f
Left Equine Fotedigit.
1. P r o x i m abl o r d e ro f h o o f wa ll
2. Lateralextremityof navicularbone
3. S o l eb o r d e ro f d i s t alp h a la n x( Pd )
4. Lateralpalmarprocessof Pd
5. F o r a m e no f l a t e r apl a lm a rp r o ce ss
6. Air within centralgrooveof f rog
7. A r t i c u l a t i oonf m i d dlep h a la n xwith
n a v i c u l abr o n e ;p a r to f d ista l
i n t e r p h a l a n g ej oailn t
8. S a g i t t arl i d g eo f n a vicu labr o n e
9. F l e x o rs u r f a c eo f n avicu labr o n e
10. D e e pd i g i t afl l e x o rte n d o n
11. A i r w i t h i n m e d i a cl olla te r aglr o o ve o ffr o g
Radiographic
Anatomyof the Dog and Horse 7ll
6. De-epdigitalflexortendon
7 I4 RA DI O G RA PH A
ICN A T O MY
11i
L'lirisllral
iaill;ii18
ulllilii]],:
:llfr]rr.r11
illll'r1111!rl,
1lillll:,:lllf'l
llplilill
:iilllllll'.lil
Hl;lll
l1$Liili:
lljlirtl.illl
i'rll:il
''rtiril
r,ill,
",
'l
[.lii|,
;ffi
.u
l
"j
' ,
'" ttr' :d
Figure 50-69. Lateromedial Xeroradiograph of Left Equine Tarsus.
1 . L a t e r aml a l l e o lu s 12. P roxi mali ntertarsal j oi nt
2 . M e d i a lm a l l e o l u s 13. A rti cui arfacetsbetw eental usand cal caneus
3 . R a d i o p a q ulei n ep r o d u ce db y r id g eo n ca u d a su
l r fa ceo f t i bi a '14.P l antaraspect
of l 2
4 . M e d l a lp a r to f c au d a su l r fa ceo f tib ia 15. A rti cul ati on
betw eencentraltarsalboneand fi rstand secondtars albones
5 . S u s t e n t a c u l u ta
mi 16. D i stali ntertarsal
j oi nt
6 . T u b e rc a l c a n e i 17. B aseof secondmetatarsal bone (l vl t2)
7. Laleralridgeof trochleata 18. B aseof Mr3
8 . M e d i a lr i d g eo f tr o ch le ata li 19. B aseof Mt4
L L a r g e rn o t c ha s s o cia tewjth d 7 20. Tarsometatarsal j oi nt
1 0 . I n t e r m e d i a tpea r to f tib ia lco ch le a 21. Grooveon proxi mol ateral aspectof Mt3 for dorsalmetatarsal
artery3
1 1. Grooveof trochleatali definedby radiopaqueline 22. C hestnut(torustarseus)
i',"*.
7 IA RA DI O G R A PH A
ICN A T O MY
Figu r e 5 O - 7 1 . D o J so m e d ia l- Pla n ta r o la te r a l
Oblique Xeroradiograph of Left Equine Tarsus.
1. S u s t e n t a c u l u tm ali
2. D i s t a el x t r e m i t yo f me d ia lm a lle o lu s
3. D i s t a el x t r e m i t yo f l a te r am
l a lle o lu s
4. In t e r m e d i a trei d g eo f tib ia lco ch le a
5. Lateralridgeof trochleatali
6. Notch distalto 5
7. M e d i a lr i d g eo f t r o c h le ata li
8, D o r s o l a t e r a sl p e c to f p r o xlm a ln te r ta r salol in t
L D o r s o l a t e r a sl p e c to f d ista iln te r ta r sajol in t
10. D o r s o l a i e r a ls p e c t0 1tl^ i"dta r so m e r a ta r sa Jol ;n t
11. D o r s a a l s p e c to f f o u r thta r sa b o n e
12. P l a n t a r o m e d iaasl p e cto f ce n tr ata l r sa lb o n e ( T c)
13. Plantaromedial aspectof first and secondtarsa
b o n e s( T 1a n d 2 )
14. P l a n t a r o m e d iaasl p e cto f se co n dm e ta ta r sabl o n e
{Mt2)
15. N o n a r t i c u l adre p r e s sio b n e twe e nT c a n d th ir dta r sa l
bone (T3)
16. C h e s t n u t
17. ArticulationbetweenT1 and 2 and Tc
18. ArticulationbetweenT1 and 2 and T3
19. A r t i c u l a t i obne t w e e nT 1 a n d 2 a n d M t3
20. F o u r t hm e t a t a r s abl o n e
21. Third metatarsalbone
22. R a d i o p a q ulei n ep r o du ce db y b o r d e ro f g r o o vefo r
dorsalmetatarsalartery3
7 2O RA DI O G R AP H AN
IC AT OMY
llll.:i11rr,,.
:|,llillillli;r',
I
,
'l ,l
iiil',,lQ
r;lllli!lll
lr..iiii6
:iauu
::. lll'"liirll,,lll
IIIL
'l.. ..ii.l ir ..i
,ili'rlrr,illl,.iill!]l
:rdu:'rriiilll],.'lll1i
]llr,.rrlllil@)),,
- ==-
-I
726 RA D IOGR AP H A
ICN A T O MY
'l
':'l
l!]Ut,
tlliUu
'':11rr,ll ..** t$ur.il
:::t1n::
"a
, ll:'iili!lll
; _ ;;j liillllr,
''l
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''lirlr:
'l
I
in the area. Crimping results when film, particularly large
Section l: format sheets such as 14" x I7,,, is handled only with one
Physics and Principles hand and the frlm drapes over the fingers.
of Interpretation ll. The black arborizing artifacts resulted from static electricity.
Static electricity is likely to be produced when film is .,slid"
along another surface, such as when it is removed from a
Chapter 1: Radiation Physics, Radiation cassette.Rapid movements of the film should not be allowed.
Protection, and Darkroom Theory
12. Gloved hands are in the primary x-ray beam. Lead gloves
r .c 2 .c and aprons are designed to prevent exposure associatedwith
3. (B) Protective aprons and gloves are not designed to protect scattered x-rays. Lead gloves and aprons do not protect the
against the primary beam; they have insuffrcient absorption capa- wearer against the primary x-ray beam and body parts must
bility to do so. never be placed in the primary beam.
4.4 s. B 13. The most likely cause for this artifact is a piece of hair in the
cassette. hair prevents light produced by the intensifying
6. -The
screen from reaching the film. Another cause might bi
Criterion Absorption process
scratching of the emulsion off of the film. These two causes
Independent of atomic number Compton can be differentiated by looking closely at the film. The emul-
Resultsin most exposure to radiographers Compton sion scratch would produce a physical defect on the surface of
Desirableprocessfor diaqnosticradiology the film whereashair in the cassettewould not.
Photoelectric
Provides for differential absorption of x-ravs Photoelectric 14. This artifact was causedby a focused grid being positioned in
by tissue the x-ray beam upside down. This results in a malalignment
between the diverging x-ray beam and the spacesbetwien the
7. mAs, _ (d,), Iead-strips in the grid-see Figure l-28. A similar-appearing
mAs, (d,), artifact could result from a focused grid being used at thi
incorrect focal spot-film distance,but the extent of grid cutoff
would not be as severe.
1 0 _ (4 0 ),.
mAs, (eO;,' Ghapter 2: Basic Ultrasound physics
l. (E) Ultrasound
8. 6. True.
7. False.As the frequency of sound wave increases,the depth of
Best detail No screen penetration of the sound wave decreases.
Poorest detail High-speed screen 8. 5 mm. The velocity of sound in soft tissues is 1.54 mm/usec.
Most film blackness High-speedscreen Using the formula rate X time : distance, the total distance
Least film blackness No screen traveled is 10 mm. Because the sound wave traveled round
trip, the distance between the transducer and the reflector is
9. (A) It was overexposedlunderexposed. 5 mm.
(B) A grid waslwasnot used.
(C) The grid,waslwas not aligned. 9. Hyperechoic.
(D) The developer temperature was too lowlhigh. 10. Acoustic enhancement.
(E) The developer was newlexhausted.
(F) The film was in the developer too longlnot long enough. Ghapter 3: Physical Principles
(G) The screenshad highfl,ow resoiution. of Gomputed Tomography
(H) The film was first placed in the developerlfxer. and Magnetic Resonance-lmaging
10. The black crescentmark was causedby the fllm being mishan- l. CT uses x-rays and a series of detectors to rotate around the
dled before processing.The mishandling could have occurred patient and generatesan image based on relative x-ray atrenua-
727
728 ANSWERS
tion when compared with water. MR imaging takes advantage opacity separating the visceral and parietal pleural surfaces.
of naturally occurring "magnetic" moments within the body in The pleural fluid is present between the lung lobes in the lobar
the hydrogen atom. These atoms are placed in a strong magnetic fissures. These fissures are present in the expected anatomic
field and are pulsed with radiofrequency pulses. The relaxation location of a fissure. A lobar sign occurs when one lung lobe
characteristicsof the hydrogen ions result in signal being given is filled with soft-tissue opacity (cells and fluid) to the lobar
off and image formation. fissure. The fissure becomes apparent because the lung lobe
next to the infiltrated lobe is filled with air and forms a
2. A 3. D 4 .D 5. AandC 6. 8 7. 4 8. E 9. A
contrasting opacity with the soft tissue. This should not be
confused with pleural fluid accumulation.
Chapter 5: Introduction to Radiographic
Interpretation
l. When the thickness of the substancewith the lower effective n Section ll:
atomic number or physical density (or both) is much greater il Axial Skeleton
than that of the other substance
2, Air (gas),fat, water (soft tissue),bone, and metal Ghapter 6: lnterpretation Paradigms for the
3. Size,shape,number, Iocation, margination, and opacity Axial Skeleton-Small and Large Animal
4. (B) l. This is the sixth cervical vertebra from a horse. C6 can be
identified becauseof the large transverseprocesses.
5. The small radiopacity cannot be a tracheal foreign body be-
cause its margin extends beyond the wall of the trachea' The 2. This radiograph is from the lumber region of a cat. Feline
opacity cannot be a tracheal wall mass becausethe wall of the lumbar vertebrae have a larger length-to-height ratio than do
trachea can be clearly seenthrough the mass.This opacity was those of the dog.
created by an engorged tick present on the side of the dog's 3.C 4.D
neck. It appearsso intenselyopaque becauseof the principle
describedin Figure 5-15. The gas superimposedon the dorsal 5. Spinousprocess,lamina, pedicle,transverseprocess,body, ar-
aspectof the opacity is gas in the cervical esophagus,a normal ticular process,and vertebral canal.
finding. The small opacity slightly dorsocaudal to the larger 6. Conventionalradiography,magneticresonanceimaging, com-
opacity is a film artifact createdby dirt in the cassette. puted tomography, and nuclear scintigraphy.
6. No, the dorsal (cranial) aspect of the subject should be facing 7. (1) Frontal sinus. (2) Tympanic bulla. (3) Coronoid process.
to the left, not the right. (a) Soft palate.(5) Nasalturbinates.
7. (D) Distal to the antebrachiocarpal(tarsocrural) joint, the 8. (1) Stylohyoid bone. (2) Epiglottis. (3) Guttural pouch. (4)
front surface of the limb is called the dorsal surface;the back Ethmoid turbinates.(5) Coronoid process.
surface of the forelimb is the palmar surface, and the back
surface of the hindlimb is the plantar surface. 9. Five views are required: Iateral, VD/DV rostral caudal frontal
view, intraoral DV and open mouth VD.
8. (A) This artery would not be visible becauseit silhouetteswith
10. False
the myocardium. The other three structures are surrounded by
air-containing lung and will be clearly visible.
Chapter 7: The Granial and Nasal
9. (A) Intrapericardial lipoma is least likely becausethe fat- Cavities-Ganine and Feline
containing tumor would be visible as a mass of decreased
1. Cortical thinning, doming of the head, open fontanelles,and
opacity in the cardiac silhouette, and separatefrom the heart.
a homogeneous brain appearance are radiographic signs of
The other conditions would result in a homogeneouslyopaque,
hydrocephalus. Congenital hydrocephalus affects small-breed
enlargedcardiacsilhouette.
dogs such as the Yorkshire terrier and the Chihuahua.
10. Tiue. For easily accessibleparts, such as the canine elbow,
2. Renal and nutritional secondary hyperparathyroidism and pri-
reversing the position of the x-ray tube and cassetteresults in
mary hyperparathyroidism (tumor of the parathyroid gland)
minimal differencesin the appearanceof the radiograph.
cause overproduction of parathyroid hormone. Cortical thin-
11. (1) Errors of searchingor scanning,(2) Errors of recognition, ning, decreasedoverall bone opacity, and loss of the lamina
(3) Decision making errors, and (4) Egocentricerrors dura are seen on skull radiographs. In severecases,the teeth
are displaced and the mandible and maxilla are thickened
12. The cone of certainty is a conceptual way to place a degree of
secondary to fibrous osteodystrophy.
confidence on a particular differential diagnostic consideration
when reviewing radiographic abnormalities. If one is low on 3. The most useful radiographic views are the intraoral dorsoven-
the cone of certainty, one is "uncertain" about a specific diag- tral or the open-mouth ventrodorsal view of the nasal cavity
nosis as there are many possibilities and the radiographic and the rostrocaudal frontal sinus projection.
abnormality described is in fact a nonspecific change. If one is
4. Nasal tumors are aggressivewith evidence of bony lysis, which
high on the cone of certainty, the degree of certainty is based
is seen on radiographs as loss of conchal detail. They are often
usually on a number of radiographic abnormalities that in
unilateral with ipsilateral frontal sinus involvement, represent-
combination provide a degree of confidence to the diagnosis
ing either obstructive sinusitis or tumor extension.
of a specific diseaseprocess.
5. Squamous cell carcinoma, fibrosarcoma, and malignant mela-
13. Seetext.
noma are oral tumors that can produce bony lysis of the
14. A radiographic anatomic variant, a mirror, a window or a mandible or maxilla.
picture (see text for details).
6. An intraoral ventrodorsal radiographic view of the mandible
15. The changes associatedwith a pleural effusion include lung would be helpful. Bony proliferation of the mandible in an
lobe retraction away from the thoracic wall with soft-tissue older cat could be consistent with scuamous cell carcinoma.
AN SWER S 7 4
8. The bony infraorbital canal. This structure becomesmore and 10. In this extended view there is compression of the ventral and
more visible as the animal agesowing to the progressivedown- dorsal aspectsof the contrast medium column at C5-C6 and
ward movement of the tooth roots. C6-C7 . The vertebra labeled with the arrow is the sixth cenical
vertebra and is identifiable in the vast majority of horses
Ghapter 9: The Vertebrae-Canine and Feline owing to the large lateral process with the separate center of
ossification at the caudal aspect.
1. Possibleexplanationsinclude (a) the anomalous presenceof
an extra lumbar vertebra, (b) agenesisor partial formation of
the l3th pair of ribs, or (c) incompletefusion of the first sacral Section lll:
vertebra to the sacrum.
II
2. True.
I Appendicular
3. (1) Agenesis,(2) ftacture, (3) fusion failure of the odontoid
I Skeleton-Ganine and Feline
process,or (4) rupture of the stabilizing ligaments between Cl
and C2. Ghapter 12: Interpretation Paradigms for the
Appendicular Skeleton-Ganine and Feline
4, C4-5, C5-6, and C6-7 are the most frequently affected sites.
l.B 2.D 3.D 4.D
5. (1) Subluxation of the sacrum ventral to L7, (2) lumbosacral
stenosis,(3) collapseof the lumbosacral disc space,(4) nar- 5. Endochondral ossification results in bone developm.trl l6ilgrrr-
rowing of the sacral vertebral canal or neural foramina, and ing a cartilaginous model. This is true for long and sho:-
(5) protruding degenerativedisc. bones. Normal physeal development occurs via endochoncri
7IO ANSWERS
ossification. Intramembranous ossification occurs in flat bones Ghapter 14: Fracture Healing
in which bone mesenchymedevelops from a mesenchymalpre- and Complications
cursor tissue without a cartilaee model. r.c 2. E 3.C 4.C s.D 6.D 7.C 8. B 9.D l0.A
6.D 7 .C 8.D 9.E Chapter 15: Bone Tumors Versus
Bone Infections
Chapter 13: Diseases of the lmmature l.A 2. C 3.A 4.B 5.8 6.E 7.D 8 . L e s s 9 .A l 0 .D
Skeleton
Ghapter 16: Radioglaphac Signs of Joint
l. True. The subchondral bone defect seenradiographically is due Disease
to a failure of cartilage mineralization during endochondral
l. The tendons in which each of the four sesamoidbones of the
ossification.Surroundingbone sclerosisis a secondaryresponse
to the primary disease. stifle joint are located include the (1) tendon of insertion of
m. quadricepsfemoris (patella), (2 and 3) medial and lateral
2. False. Osteochondrosis lesions are more often bilateral, al- headsof m. gastrocnemius (fabellae),and (4) tendon of origin
though lesions may not be bilaterally symmetric and clinical of m. popliteus(popliteal sesamoid).
signs may be unilateral. In addition, dogs with osteochondrosis 2. Radiographic signs of joint diseaseinclude (1) synovial effu-
at one anatomic site often have additional lesions at other sites. sion, (2) altered subchondral bone opaciry (3) osteophyte/
3, The anconeusshould fuse to the ulna by 4 to 5 months of age, enthesophyte proliferation, (4) soft-tissue mineralization, (5)
so an ununited anconeus is diagnosed after 150 days of age. intra-articular calcification, (6) bone cyst formation, (7) sub-
chondral bone erosion, (8) joint malformation, (9) joint dis-
4. False.A medial coronoid fragment is often not radiographically placement,and (10) alteredjoint spacethickness.
visible either becauseit is poorly mineralized or superimposed
3. (c) synovial effusion.
on the radius or degenerativenew bone.
4. Types of stress that can be applied to a joint during stress
5. Hypertrophic osteodystrophy(HOD) is the most likely diagno- radiography include (1) traction, (2) rotation, (3) wedge, (a)
sis. The radiographic changesand clinical signs describedare compression,and (5) shear.
characteristic of HOD. Hematogenous osteomyelitis could also
5. The primary joint neoplasm is synovial sarcoma. Other neo-
be considered.
plasms that can appear radiographically similar to it include
6, (A) diaphysis,near nutrient foramina. Medullary sclerosiswith (l) fibrosarcoma,(2) rhabdomyosarcoma,(3) fibromyxosar-
or without continuous periosteal new bone formation is a coma, (4) malignant fibrous histiocl'toma, (5) liposarcoma,
classicchange associatedwith this disease. and (6) undifferentiated sarcoma.
7, Many of the osteochondrodysplasiaslead to disproportionate 6. For shoulder arthrography ofa juvenile Labrador retriever with
dwarfism. In some forms, only the long bones appear to be suspectedOCD of the humeral head,use 2 to 4 mL of a sterile,
affected, whereas in others, the axial skeleton is also involved. aqueouscontrast medium at a concentrationof 100 mgl/ml.
7. Intra-articular calcified bodies occur in the canine elbow be-
8. There is increased medullary opacity in the distal humeral causeof (1) OCD of the medial humeral condyle,(2) ununited
diaphysis (compare the humeral medullary opacity with the anconealprocessof the ulna, (3) fragmentedmedial coronoid
relatively lucent proximal radial diaphysis). Radial-ulnar joint process of the ulna, and (4) avulsion fractures involving the
incongruity is present with a small "stairstep" at the articular joint.
junction of the radius and ulna. Subtle enthesophyte bone
production is presenton the anconealprocess.The areaof the 8. There is a triangular radiolucent lesion in the distal radius that
medial coronoid process of the ulna is not well defined' Mild extends to the radiocarpal joint. Using stressradiography (Fig.
bone sclerosis is present along the subtrochlear bone and 16-35), an articular fracture with a large bone fragment dis-
adjacent to the lateral coronoid process.Changesare consistent placed distally becomes apparent.
with panosteitis in the distal humerus, elbow dysplasia (joint 9. Slight unilateral joint laxity (right) is evident in Figure 16-33.
incongruity), minor degenerative joint disease,and possible \Mhen a distraction (PennHip) view (Fig. 16-36) is taken to
fragmented medial coronoid process.Additional views of the further evaluate the coxofemoral ioints, it becomes evident
medial coronoid process are recommended. The panosteitis is that joint laxity was not disclosed by the extended view Diag-
probably responsible for a major portion of the lameness,but nosis: Hip dysplasia.
the joint incongruity, minor arthritis, and possible fragmented 10. Florid new bone formation is present around the bicioital
coronoid processcould causethe lamenessto persist after the tendon (a) and the caudaljoint pouch (&), indicating synovial
panosteitis has resolved. calcification(Fig. 16-37). Increasedosteolucencyis presentin
9. There is cranial and medial bowing of the radius. There is a the humeral head (c). Interpretation: Septic arthritis.
retained cartilaginous core in the distal ulna. The radial and
ulnar physesappear normal and open. There is mild humeral- I Section lV:
ulnar joint subluxation seen on the craniocaudal view. The
I Appendicular
caudal radial cortex is thickened, probably secondaryto abnor-
mal weight bearing. The angular limb deformity is probably I Skeleton-Equine
secondary to growth interruption of the distal ulnar physis
Ghapter 17: Interpretation Paradigms
by the retained cartilaginous core. Ulnar ostectomy is the
for the Appendicular Skeleton-Equine
recommended surgical procedure.
r.A 2. F 3.A 4.4 5.C 6.8 7.C 8.C 9.B 10.A
10. There is subchondral bone flattening and lucency in the medial
humeral condyle. Bone sclerosisis seenadjacent to the lucency. Ghapter 18: The Stifle
Minor enthesophyteformation is present on the medial aspect l. A 2. C 3. D 4. D 5. E 6. False 7. Tiue 8. False
of the medial condyle. Radiographic diagnosisis osteochondro-
sis of the medial humeral condyle with mild degenerative Chapter 16 answers courtesy of Alice Springs Veterinary Hospital, Alice Springs,
joint disease. Australia.
ANSWERS 73I
Ghapter 19: The Tarsus 3. Distention of the middle carpal joint indicatesthe need for a
l. D 2 .E 3. A 4. Fals e 5. B distal row examination, and distention of the antebrachiocarpal
indicates a need for examination of the distal radius.
Ghapter 2O: The Equine GarPus 4. (B)
l. Five views.Theseinclude the dorsopalmar,lateromedial,flexed 5. Chip, slab, and sagittal fractures.
lateromedial,dorsal 60-degreelateral-palmaromedialoblique'
and dorsal 60-degreemedial-palmarolateraloblique' Dorso- 6. Radial carpal bone.
proximal-dorsodistaloblique views are specialviews. 7, A carpal radiographic examination should be done on a foal
2. (1) Intracapsularsoft-tissueswelling and (2) the radiographic with angular limb deformity for the following reasons: (1) to
findings seenin the five standardprojectionsdo not correlate determine the origin of the deviation (i.e., growth plate of
with the clinical signs or joint capsuledistention distal radius, abnormal carpal bone development, or joint
il
Figure 16-36
7?2 ANSWERS
capsulelaxity); (2) to determine the extent of the bony changes; 9. There is a smooth osseousfragment of bone along the plantar
and (3) to provide a basis for evaluating treatment success. margin of the proximal phalanx, medial to the sagittal groove,
and there has been remodeling and separation of bone of the
8. Treatment may correct growth imbalances associatedwith the
medial plantar eminence. These findings are reported as frac-
carpus as the foal develops. A growth imbalance resulting in
tures or osteochondrosisand siven the classification of tvoe I
bone and joint changesat the metacarpophalangealjoint can-
and type II fragments.
not be corrected if the physes have closed or have limited
growth potential remaining. Radiographic closure of the physis r0. B
of the distal radius occurs at approximately 30 months, and
that of the distal third metacarpus and proximal aspect of the Ghapter 23: The Phalanges
proximal phalanx occurs at approximately 6 to 8 months.
l. (A) The high-ioad/1ow-motion character of the proximal inter-
9. A more complete radiographic examination consisting of five phalangealjoint makes it prone to degenerativijoint disease,
routine views and a dorsoproximal-dorsodistal oblique view is in which subchondral bone resorption is a common feature
needed to determine (1) changesin the slab fracture (i.e., identified by radiography. Selection (B), osteochondrosis,is
displacementor comminution), (2) presenceof additional frac- incorrect becausealthough one form of equine osteochondrosis
tures, (3) size and thickness ofthe slab on the dorsoproximal- is typified by subchondral bone lucency in the distal end of
dorsodistal view, (4) the degree to which the fracture reduces the proximal phalanx, it is uncommon to have more than one
on the flexed lateromedial view or (5) evidence of secondary subchondral defect. |oint space narrowing and osteophytes,
joint diseasein the carpus. however, can be sequelaeof osteochondrosis.Selection (C),
acute, active septic osteoarthritis, is incorrect becausethe initial
10. The intermediate carpal bone is more proximal than the radial
radiographic appearanceof this condition is most often unre-
carpal bone. Therefore, the dorsoproximal intermediate and
markable except for soft-tissue swelling associatedwith joint
the dorsodistal radial carpal bones are seen without being
capsule distention. Untreated, septic arthritis progressesto the
overshadowed.
appearanceofjoint spacewidening owing to cartilageloss and
subchondral bone lysis. As is illustrated in Figure 23-12F,
Ghapter 21: The Metacarpus and Metatarsus
chronic, low-grade septic osteoarthritis could appear as de-
1. False 2. True 3. False 4, Tiue 5, True 6. Tiue scribed for this patient.
7. Distal condyle (sagittal),dorsal-distalcortex (saucer),and pal- 2. A dorsopalmarview (using a horizontal beam) or a dorsal 45-
mar/plantar proximal cortex degreeproximal-palmarodistal oblique view would be the best.
Calcification in the collateral cartilaees would be easilv seen
8. Mach bands.
and would appear within the soft tisi-res medial and lateral to
9. The nutrient foramen the distal interphalangeal joint. If the calcification was wirh-
in the deep digital flexor tendon, it would be superimposed by
10. The suspensoryligament (branches).
the bone opacity of the middle and distal phalangesand would
11. Superficial digital flexor tendon; deep digital flexor tendon; not be readily visible on the dorsopalmar view.
accessory("check") ligament of the deep digital flexor tendon;
3. Common radiographic signs seen with chronic laminitis in-
and suspensoryligament
clude palmar rotation or deviation of the distal phalanx; gas
12, Clarity of image, adequate penetration, and probe design. dissectionbetweenthe laminae;an increasednumber of circu-
lar vascular channel lucencies in the midbody of the distal
13. The following preparation is necessary:a thorough under-
phalanx on the dorsal 65-degree proximal-palmarodistal
standing of regional anatomy; knowledge of published varia-
oblique view; fractures along the solar margin of the distal
tions in sonographic appearanceof tendons and ligaments;
phalanx, especially at the toe region; a long hoof wall at
training and experiencein the use of ultrasound machinesand
the toe; and a domed dorsal margin of the distal phalanx
probes; training in the interpretation of equine limb sono-
(Iateral view).
grams; and a thorough physical examination of the limb.
4. The opacity of the periosteal reaction should be carefully com-
Chapter 22: The Metacarpophalangeal pared with the opacity of the underlying cortex. If similar, the
(Metatarsophalangeal) Articulation opacity (along with the smooth surface margin) would suggest
that this reaction is considerably older than 10 days and is
1.D 2.C
unlikely to be associatedwith the current cause of lameness.
3. There is flattening and excavation of subchondral bone at the Another consideration is whether any soft-tissue attachments
palmar articular radius of MC III with sclerosisand compres- occur in the area of the periosteal reaction. If yes,the periosteal
sion of trabecularbone deep to the areaof flattening.Findings reaction may indicate a previous strain injury, with a recent
are consistent with osteochondrosis. Additional radiographic reinjury to the tendon, ligament, or joint capsulesuperimposed
examination should include dorsopalmar and oblique projec- on the older osseousresponse.
tions. Radiography of the contralateral limb is advised.
5. The linear radiolucency may be a fracture line, or it may be a
4.8 s.A vascular channel in the distal phalanx. The most useful addi-
tional radiographic projection would be a dorsal 65-degree,
6. There is extensivesoft-tissue swelling around the joint; the axis
proximal 45-degreelateral-palmarodistomedial oblique view. If
of the MCP joint is straight and the cartilage space of the
the lucency is a fracture, the primary beam will pass straight
entire joint is wide. There is lysis and destruction of subchon-
through the fracture plane on the oblique view and enhance
dral bone of distal MC III and the epiphysis of the proximal
its visualization. If it is a fracture that extends into the distal
phalarx. Linear bony opacitieswith sharp, distinct margins are
interphalangeal joint, displacement of the subchondral bone
present at the joint surfaces. Findings are an indication of
margin will be visible on the oblique view. A hoof tester should
advancedseptic arthritis with multiple sequestra.
also be used to determine if there is focal sensitivitv to oressure
7.C 8,C in the suspect area.
ANSWERS 73
3. The lesion will be inconspicuous in the right lateral radiograph contrasted by pulmonary air) using relatively high kVp and
becausethe dependent lung lobes will collapse and there will relatively low mAs on initial radiographs (to attempt to reduce
then be lessintrapulmonary air to contrastwith the lesion. the stark contrast between fluid opacity structures and ribs),
4. There are four basic areas that need to be reviewed. These lowering kVp and raising mAs will produce better distinction
include the extrathoracic structures, pleural space,pulmonary among the components of the chest wall (ribs, intercostal mus-
parenchyma, and mediastinum. cles, subcutaneous muscles, subcutaneous fat, and intrafascial
fat).
5. In the geriatric thorax of a dog, there would be degenerative
changesof the vertebral column, degenerativechanges of the 2. (A, B, C, and D) Each of these may produce the "extrapleural
scapulohumeral joint, degenerative changes of the sternebrae sign" by medial displacement of the parietal pleura. Soft-tissue
and costal cartilages,presenceof pulmonary osteomas,in- swelling(i.e.,hemorrhage,edema)associated with fracturedribs
creasedunstructured interstitial lung opacity, and pleural is less dramatic and must be radiographed tangentially to be
thickening (particularly between the right middle and right appreciated fully.
caudal iung lobes, seenbest on the left lateral radiograph). In
3. False.Stippled mineralization of costal cartilagesis a normal
the cat, the additional changes might include a horizontally
aging change,and is common.
oriented heart and a tortuous descendinsaorta.
6. B 4. Image interpretation: The major radiographic signs are in-
creasedopacity, periosteal reaction, and end-plate lysis involving
7. Between the left and right caudal bronchi.
the fourth and fifth sternebrae. There is also a mild associated
8, Air bronchogram;atelectasis
and consolidation. extrapleural sign dorsal to the affected sternebrae. The final
9. The cranioventral reflection is where the ventral portion of the diagnosis was osteomyelitis of the sternum.
left cranial lung lobe (linguia) crossesthe midline from ieft to
right; a second reflection occurs where the accessorylung lobe Chapter 29: The Diaphragm
displacesthe ventral caudal mediastinum to the left. The third
l. (1) The position of the x-ray tube, that is, over the thorax or
reflection is a fold of mediastinum around the caudal vena
abdomen; and (2) The position of the animal, that is, ventral
cava (this reflectionis not visible as a separatestructure).
or dorsal recumbency.
10. A and C
2, The diaphragmaticcrus closestto the table is dispiacedcrani-
Chapter 26: The Larynx, Pharynx, and Trachea ally.
l. D 2. False 3. Faise 4. True 5. True 6. False 7, False 3, Any substanceof soft-tissueopacity adjacent to the thoracic
8. True 9. True 10. True surface of the diaphragm will obliterate the outline.
Ghapter 27 =The Esophagus 4. (1) Cranial displacementof abdominal organs,particularly the
l, C 2, False 3. D liver, stomach,and spleen;and (2) Cranial or lateral displace-
ment of thoracic structuresby a soft-tissuestructure(s).
4. Radiographic findings:
Zone of reduced radiopacity dorsal to and superimposedon 5. Hiatal hernia, pulmonary mass,diaphragmaticmass.
the cervicaltrachea. 6. Esophagram.
Distinct hypaxial soft-tissue interface in cranial thorax. Ventral
7. A scalloped ventral diaphragmatic margin is noted on the
displacementof trachea.
lateral thoracic radiograph.
Paired soft-tissuestripes on caudal thorax between aorta and
caudal vena cava on lateral view and on either side of spine 8. Radiographic signs-lateral view:
converging at the hiatus of the diaphragm on the dorsoven- The cranial diaphragmaticborder is not visibie.
tral view.
Gas-distendedstomach. The caudal cardiac border is not visible.
Reduced airway through larynx with change in shape of hyoid Focal gas opacities are noted in the caudal ventral thorax,
apparatus. suspectfor small-bowelloops.
Radiographic conclusions: Radiographic signs-ventrodorsal view:
Megaesophagus.
Gastric dilation. The mediastinrm (solid arrow) and heart are displaced to the
Soft-tissue swelling of larynx. left of midline.
t0. The following signs confirm the diagnosis: 5. The dog was in dorsal recumbency.If the dog had been in
sternal recumbency,the heart would not be visible becauseof
On the right lateral decubitusview; left side up (seeFig' the effusion collectedaround it.
2g-23A), the thoracic border of the diaphragm is visual-
ized (arrows), and air-filled lung is in the caudal left tho- 6.C
rax. 7. Trre. Visualizationof interlobar fissuresis more common with
On the left lateral decubitusview; right side up (seeFig. pleural effusion.With pneumothorax, the pulmonary collapse
29-238), the thoracic border of the diaphragm is not preventsgas from entering the pleural space.
visualized, and there are soft-tissue and gas opacities in 8. Three radiographic signs of a tension pneumothorax are: (1)
the caudal right thorax. A contralateralmediastinal shift. (2) Caudal displacementof
On the ventrodorsal view made after contrast material the diaphragm,possiblywith visualizationof the costalattach-
administration (see Fig. 29-24), the pyloric antrum and ments of the diaphragm. (3) Complete collapseof the lung
small bowel filled with barium are visualized in the right againstthe hilum.
caudalthorax. 9. Two things that can be confusedwith pneumothorax are: (l)
A skin fold. (2) The thoracic wall conformation of chondro-
Chapter 30: The Mediastinum dystrophoid breeds.
l, (A) The mediastinum is not a closed space'It communicates 10. The concaveaspectof costal is cranial, whereasthe concave
with fascialplanesof the neck and the retroperitonealspace. aspect of interlobar fissuresis caudal.
2, The cranioventraland caudoventralmediastinalreflectionsare
commonly visualized.
Ghapter 32: The Heart and Great Vessels
l. The range of normal patient sizesis large,various breedshave
3. Becausethe mediastinum is essentiallya midline structure, it
markedly different thoracic anatomic conformation, and it is
is much easier to assessit in ventrodorsal or dorsoventral
difficult (if not impossible) to routinely correlateprecisepa-
views. In lateral radiographs,the mediastinum is viewed en
tient positioning, maximum thoracic inflation, and cardiac
face, and it is not possible to tell if a mass is within or
cycle with radiographicexposure.
superimposedon the mediastinum.
2. (A) and (C) are reliableradiographicsignsofleft atrial enlarge-
4. The foltowing radiographicsignsindicate that the opacity seen
ment, provided that the patient was positioned without obliq-
cranial to the heart is in the mediastinum.
urty.
a. Compressionof the tracheaon the lateral view.
b. Mass is on the midline on the ventrodorsalview 3. A decreasein the tracheovertebralangle in the lateral proiec-
c. The tracheais displacedto the left on the ventrodorsalview. tion is not a reliableindication of left atrial enlargementwhen
there is a large volume of free pleural fluid.
5. Pneumomediastinum.There is visualizationof the adventitial
surfaceof the trachea and esophagusand cranial mediastinal 4. False.Enlarged pulmonary veins signifu elevatedpulmonary
vessels.Thesesigns are consistentwith pneumomediastinum. venous pressure but heart failure is not present until fluid
exudes from the pulmonary capillariesinto the lung paren-
6. Peritoneallymphatics drain into the sternal lymph node. In chyma. Many patients with controlled heart diseasehave en-
this dog, barium might have become trapped in the sternal larged pulmonary veins.
lymph node, thereby increasingits radiographicopacity.
5. (B), (E), and (F) are commonly seenin left-sidedheart failure.
7. A horizontal-beamventrodorsalthoracic radiograph of medi- However, (B) and (F) without (E) are also commonly seenin
astinal sonography. dogs with compensatedleft heart enlargement-that is, no
8. An intrapulmonary lacerationwith retrogradedissectionof air left-sided heart failure, whereas alveolar pulmonary infiltrate
along peribronchialand perivascularspacesinto the mediasti- causedby cardiogenicpulmonary edema is a reliable sign of
n um. left-sidedheart failure.
Dilation of the main pulmonary artery some magnification of lesions in the nondependent lung may
be apparent owing to geometric distortion.
Right ventricular enlargement
Obesity-reduces radiographic contrast by increasing scattered
8. Survey radiographic signs associatedwith heartlvorm disease radiation; tends to reduce visibility of intrathoracic structures,
include: such as the cranial lung lobes; necessitateshigher radiographic
Dilation of the main pulmonary artery exposures, which may lead to underexposure or excessively
long exposuretimes.
Right ventricular enlargement Brachycephalicconformation-often associatedwith obesity;
Dilation of the right and left pulmonary arteries with poor conformation of the upper airway in many brachycephalic
truncation ("pruning") and possible arterial tortuosity dogs may contribute to underinflation of the lung.
Prolonged recumbency-may result in collapse of the de-
Possiblesigns of dght-sided heart failure (e.g., ascites, pendent lung, which can obscure lesions.
hydrothorax) Movement-owing to rapid breathing, panting, coughing,
or voluntary patient movement may result in motion blur,
Survey radiographic signs associatedwith mitral insufficiency
which obliterates fine detail on radiographs; hence, small le-
include:
sions may become invisible.
Elevation of the left main stem bronchus and enlargement
There is a rounded soft-tissue mass (or large nodule) in the
of the left atrium
right lung, probably in the caudal lobe; the borders of the mass
Decreasein the tracheovertebral angle (enlarged left ven- are distinct, indicating a sharp demarcation between the lesion
tricle) and adjacent aeratedlung; the mass is located in the periphery
of the lobe, but no lesions are apparent in the adjacent ribs.
Possiblecaudodorsal unstructured interstitial and alveolar Differential diagnosis for a solitary pulmonary mass should
pulmonary infiltrates (pulmonary edema) include (seeTable 32-2):
Possibledilation of pulmonary veins Primary lung neoplasm
9. Radiographic interpretation of Figure 32-27. Left lateral and Pulmonary metastasis
ventrodorsal thoracic radiographs of a 9-year-old neutered
male Golden retriever dog with progressivelethargy and exer- Granuloma
cise intolerance.The major radiographic sign is globoid en- Fluid-filled bulla
largement of the cardiac silhouette. Necropsy revealedthe pres-
ence of a large amount of hemorrhagic fluid in the pericardial Hematoma
sac due to a mass involving the wall of the right atrium Abscess
(histopathologicdiagnosis-hemangiosarcoma).The tracheais
Cyst
displaced to the right in the ventrodorsal view possibly as a
result of the heart base mass. Radiographic diagnosis: pericar- The right caudal lobe was removed surgically.The histologic
dial effusion. diagnosis was bronchoalveolar carcinoma.
10. Tiue. 4. Opacity of the lung is greater at peak expiration than inspira-
tion becauseair (the lucent component) is expelled.An expira-
Chapter 33: The Pulmonary Vasculature tory thoracic radiograph may be useful when a small-volume
pneumothorax is suspected because this maximizes contrast
1. (A) On the left lateral recumbent thoracic view, there is right between the lung and air-filled pleural space.
cranial lobar pulmonary arterial enlargement as the artery is
larger than its counterpart vein. On the dorsoventral view, 5. Pulmonary vesselsseen end on are:
both caudal lobar pulmonary arteries are larger than the 9th Smaller than the nearest side-on vessel
rib at their intersection. The right caudal lobar pulmonary
artery is more enlarged than the left. There is also main Smaller in the periphery of the lung
pulmonary artery enlargement and right heart enlargement. Lessnumerous in the periphery of the lung
The diagnosis is heartworm disease.
In contrast, pulmonary nodules may be:
2. (B) Mitral insuffrciency was documented on two-dimensional
Larger than adjacent vessels
echocardiographyand a mitral murmur was heard on ausculta-
tron. Large in the periphery of the lung
3. (C) Both caudal pulmonary arteries and veins at their site of Anywhere in the lung
intersection with the 9th rib are larger in diameter than the 6. If the appearance of the lesion changes markedly within 24
rib width. A ventricular septal defect was apparent when the hours, it is more likely to be the result of fluid in the lung
heart was examined with two-dimensional echocardiography. (e.g.,edema,hemorrhage)than of cellular infiltrates.
The pulmonary arteries and veins are enlarged because of An increase (or decrease)in size indicates that the diseaseis
volume overload associatedwith the left-to-right shunt. progressing (or resolving) rapidly.
4.c s.B 6 .A 7. A 8. B 9. A r 0. c 7. Tiue. Aspiration bronchopneumonia frequently affectsthe ven-
tral parts of the lung; lesions in the ventral part of the lung
Chapter 34: The Ganine and Feline Lung are often most visible on a ventrodorsal radiograph becauseof
the combined effects of optimal aeration of the nondependent
l. None of these is correct. Localized pulmonary lesions, includ-
lung and geometric distortion.
ing nodules, are normally most visible when the patient is
radiographed with the affected side uppermost (i.e., when the 8. The pulmonary pattern is mixed: the left cranial lobe is uni-
lesion is in the nondependent lung). If the patient is large, formly opacified compatible with an alveolar pattern; the Ieft
ANSWERS 737
caudal lobe has a diffuse interstitial infiltrate that obscuresthe the lungs and subsequentlyextends to the pleura. Pleuropneu-
vesselsand cardiac border; nodules are visible in the left lateral monia is obviously worse than pneumonia becauseof its pleural
radiograph, presumably in the right cranial iobe. Note that the component. Pleurisy (infection of the pleura) directly affectsthe
.onsolidited left cranial lobe is not visible on the left lateral ability of the lungs to expand and indirectly impedes inflation
radiograph. through fluid build-up in the pleural space.When large volumes
The other relevant radiographic sign is mediastinal shift to of pleural fluid are present, radiographic evaluation of the lung
the right; this indicates that the left-sided lesion is expansiie. may not be possible. In such instances-and assuming there is
This dog died. The pathologic diagnosis was primary carci- consolidation of portions of the lung surface-sonography can
noma in the left cranial lobe with intrapulmonary metastasis. be used to confirm lung involvement, although it is not always
possible to differentiate consolidation from atelectasis.
e. (A) 4 (B) 3 (c) 2 (D) 1
2. The visible blood vesselsof the lung are useful indicators of
10. Differential diagnosesfor pulmonary calcificationinclude: both the general and regional circulation. For example, if the
Bronchial calcification lung vesselsare small and few in number, and the heart is also
small, then the cause may be a smaller than normal blood
Heterotropicbone volume (e.g.,shock).If the vesselsare large and more numerous
Calcified mass (e.g., granuloma, primary neoplasm,me- than normal and accompaniedby cardiomegaly,then the blood
tastasis) volume may be increased(e.g.,heart failure).
Pneumonia often results in a regional pulmonary hlperemia.
Diffuse interstitial calcification (e.g., associatedwith hy- Emphysema is usually associatedwith a generalizedpulmonary
peradrenocorticism, hyperparathyroidism, chronic ure- oligemia. The absenceof major arteries implying thrombosis is
mia) extremely difficult to detect using only lateral radiographs. The
Idiopathic(seeTable34-6) assessmentof vesselsize and number is best done subjectively
using two or more normal comparison films of comparably
sized individuals. The measurement of individual blood vessels
I Section Vl: is unreliable.
4. Kidney-2.5 to 3.5 times the length of L2 compared with the 9. (Fig. 39-25) The radiographicsignsinclude poor serosaldetail
VD view. Small intestine-no wider than the central portion of and the suggestion of mass effects in the caudal and lateral
the body of a lumbar vertebra, and not to exceedthe diameter aspectsof the abdomen. Surgicalexploration revealedtorsion
of twice the width of a rib. and hemorrhagic distention of both horns of the uterus. The
patient made a complete recovery after ovariohysterectomy.
5. Kidney-2.4 to 3.0 times the length of L2 compared with the
VD view Small intestine-should not exceedl2 mm and should f0. (Fig. 39-26) The radiographic signs include multiple small
be no wider than the central portion of the body of L4. soft tissue metallic opacities (shotgun pellets-probably an
incidental finding of no current clinical significance)and a
Chapter 39: Abdominal Masses large dorsal left fluid opacity mass displacing the descending
colon and small intestine ventrally and medially. Histopatho-
l. Those structures that are nearly always seen in abdominal logic diagnosiswas renal carcinoma.
radiographs include the stomach, the liver, the urinary bladder,
the small bowel, and the colon. Chapter 4O: The Peritoneal Space
Those structures that are often only partially seen are the
spleen,the kidneys (especiallythe right kidney in dogs), and l. Abdominal effusion
the prostate gland. There is increasedfluid opacity within the abdomen causing
Those structuresthat are seldom seenunlessthey are abnor- severeloss of serosalsurfacevisualization.Also, the abdomen
mal include the pancreas,the adrenal glands, the ovaries, and is pendulous. The final diagnosiswas hepatic atrophy, portal
the mesentericlymph nodes. fibrosis, and intrahepatic and extrahepatic portacaval shunts.
The peritoneal fluid was causedby portal hypertension.
2. The head of the spleen is attached to the stomach by the
gastrosplenic ligament. The rest of the spleen is free to move 2. Sublumbar lymphadenopathy and small liver
around in the abdomen, between the bodv wall and the rest of There is a soft-tissuemass in the retroperitonealspaceven-
the viscera.Therefore,the spleenis better seen (radiographi- tral to the caudal lumbar vertebra and dorsal to the colon,
cally) with the patient in right lateral recumbency becausethis which is displaced ventrally. The stomach and small intestine
position allows the body and tail of the spleento swing across are located more cranially than usual, indicating decreasedliver
the ventral midline where it is seen caudoventral to the body size. Final diagnosis:lymphosarcoma.The causeof the small
of the stomach and cranioventral to the urinary bladder. With liver was not determined,but the primary rule-out was fibrosis.
the patient in left lateral recumbency, the spleen slips between 3. (B) Lateralview, patient in dorsal recumbency
the bowel and the dependentbody wall, where it "disappears"
because no part of its edge is presented tangent to the x- 4. (C) Abdominal mass
ray beam. 5. Blood, urine, inflammation (abscessation)
3. (B) Positionalradiography '6. (A) Mediastinum and (B) pelvic canal
This should be consideredbefore any of the other choices
because it is both cheaper and quicker and because it may 7. (A) Adrenal glands, (B) sublumbar lymph nodes, and (D)
provide displacement information that is significant in the caudal surface of the diaphragm.
differential diagnosis.
8. There is loss of serosal surface visualization in the midventral
4. (C) Upper gastrointestinalseriesand (D) sonography abdomen. Gas is seen in the craniodorsalabdomen outlining
These may provide significant information in differentiai the liver lobes (seeFig. 40-188). Free gas is also seenon both
diagnosticassessment of a right cranioventralabdominal mass. views as thin radiolucent lines between the stomach, liver. and
Neither excretory urography, cystography, nor urethrography diaphragm. Radiographic diagnosis: free peritoneal gas and
is very helpful in assessment of such a lesion. focal peritoneal fluid/peritonitis compatible with intestinal
rupture.
5. The stomach, the urinary bladder, and the uterus all undergo A horizontal-beam radiograph (see Fig. 40-19A) was made
considerablenormal variation in size.
to confirm the presence of free gas. At surgery, a string of
6. (A) Right lateral aspect of the liver foreign body extending from the duodenum to the cecum
None of the other choices should be expected to create was found. It had eroded throueh the mesenteric surface in
the described displacement of adjacent structures. Pancreatic severalplaces.
ANSWERS 73',
t. usually an incidental finding with no clinical signifi- 3. The radiographic diagnosis is multiple, variably sized, radio-
H:.lr paque urethral calculi and a greatly distended bladder that is
Iikely due to urethral obstruction. Calculi are also present in
10. Lesssensitive.
the bladder, and the prostate gland is enlarged.
ll. (A) Biliary dilation, (C) discretehypoechoicnodules,and
(D) peritoneai fluid occur with both conditions, but 4. (D) Barium and oil-basedcontrast media should not be used
(B) diffuselyhlpoechoic pancreasis more common in pancre- for urethrography. Room air and carbon dioxide are negative-
contrast agents.
atitis.
12. Abnormal lymph nodes are usually enlarged, rounded, and 5. True. Distention of the prostatic urethra is especiallyimproved
hlpoechoic. if the bladder is fully distended when the urethrogram is
performed.
13. False.
The contralateral adrenal gland is usually normal in size. 6. False.
7. False. Prostatic hlperplasia would cause extramural compres-
Chapter 41: The Liver and Spleen sion of the urethra, not an intraluminal filling defect.
1.D 2.C 3.C 4.8 s.E 8. Neoplasia, inflammatory disease,and scar tissue from prior
6. Phenothiazines,barbiturates urethral surgery.
T.Aa nd D 9. False.
10. Tiue.
Chapter 42= The Kidneys and Ureters
l.B 2.E 3. E 4.E s.E 6.D 7.8 8. D 9.8 10.E Chapter 45: The Prostate Gland
Ghapter 43: The Urinary Bladder 1. Generally, the prostate enlarges slowly throughout life in the
male dog.
l. No. There is no clinical correlation with abnormal clinical
signs when the urinary bladder of a dog is located partially 2. Displacement with paraprostatic cysts is quite variable and no
within the pelvic canal. set rules can be established. Generally, the displacement is
cranial, but there is tremendous variation in individual pa-
2. Displacement of the bladder caudally or ventrally from the tients.
normal location; or no urine within the bladder post voiding.
3. Loss of a distinct margin of the prostate in patients with acute
3. The lucent area is gas within the urinary bladder. It is in the
prostatitisis due to a low-grade regional peritonitis secondary
center of the bladder becausewith a lateral recumbent position,
to inflammation in the prostate. It is usually not septic but
the highest part of the bladder is the center on the up side.
may be so in some patients.
Calculi are either more opaqueor of the sameopacity as urine;
therefore,this could not representa calculus. 4. Asymmetrical placement of the urethra within the prostate is
a sign of a mass lesion, such as a cyst, abscess,or tumor. This
4. Positive-contrast cystogram.
is not seen with benign prostatic hypertrophy. Conversely, a
5. Complete distention of the bladder may obliterate mucosal and centrally placed urethra is unusual with prostatic mass lesions.
bladder wall lesions.
5. The testiclesand the urinarv bladder.
6. Small air bubbles that may be mistaken for calculi; a large air
bubble that may be mistaken for bladder wall thickening; 6. Fat.
multiple adjacent bubbles producing a "honey comb" pattern. 7. Increased.
7, A pseudofilling defect has a smooth mucosal surface, and the 8. This is a normal finding.
borders of the filling defect taper gradually.
9. A stricture of the prostatic urethra is a poor prognostic sign.
8. No.
Becauseof the central placement of the urethra in the prostate,
9. The fi.lling defect in the dorsal bladder is an attach;d fiiling it is generally not constricted in benign disease.A stricture
defect extending into the lumen from the dorsal bladder wall. may result from scarring but is very difficult to treat in many
The filling defect has a sharply angled border with the bladder cases.Typically, it is a finding associatedwith neoplasia.
wall on the cranial and caudal margins (arrows), indicating an
10, Mineralization.
intramural origin. The most likely diagnosis would be neopla-
sia, and a transitional cell carcinoma would be the common
type of neoplasiawith these radiographic signs.A hematoma Ghapter 46: The Uterus, Ovaries, and Testes
within the bladder wall can also produce such radiographic r.E 2.D 3.E 4. E 5.8 6.E 7. E 8.B 9.D 10.E
changes,but it is an uncommon lesion.
10. The contrast pattern is an extravasationpattern. Contrast me- Chapter 47=The Stomach
dium is leaking into the peritoneal cavtty (arrows) from the l. (B) Manual restraint is preferred if possiblefor routine gas-
urinary bladder. This indicates that the bladder (B) is ruptured trography to avoid effects on the stomach induced by chemical
or perforated. restraint drugs.
Ghapter 44: The Urethra 2. (D) The right recumbent lateral view and the dorsoventral
view made in ventral recumbency both place the pyloric por-
l. True.
tion of the stomach in a dependent position and thus best
2. False.SeeFigure 44-7. No urethrogram is necessaryin this pa- of the pyloric antrum with liquid contrast me-
tient. Xtf;. "ttnt
74O ANSWERS
3. (D) Although at 40 minutes there is a slight delay in initiation verely reduces the amount of intraperitoneal fat (such as ani-
of gastric emptying, the stomach then proceedsto empty in a mals younger than 6 months of age and animals with severe
normal manner. The technical procedure used in initiating the weight loss) causesthe bowel surfaces to be poorly defined.
study most likely accounts for the initial delay through psychic Additionally, peritoneal effusions and crowding of the bowel
factors. Thus the initial delay is of doubtful significance. loops by space-occupyingmassesreduce bowel serosaldelinea-
tion.
4. False. Routine gastrography is preferably performed with liq-
uid barium sulfate.Most water-soluble, organic, iodinated con- 2. False.The string-of-pearlsappearanceofthe duodenum is seen
trast media formulated for the alimentary tract can induce only in the normal cat, not the normal dog.
adversephysiologic effects.Newer iodinated contrast media of
Interpretation: There is extensive dilation of the lumen of a
lower osmolality are expensivefor routine gastrography.
focal portion of the intestinal tract. The diameter of the intesti-
5. (D) The sequenceis as follows: right lateral, left lateral, dorso- nal lumen is 4.5 to 6 times larger than the height of the central
ventral, and ventrodorsal. A, In right lateral recumbency, the part of a lumbar vertebral body. These radiographic signs in a
liquid barium sulfate fills the dependent pyloric portion ofthe young dog with an acute history of vomiting and a palpable
stomach, and gas rises to the fundus. B, In left lateral recum- abdominal mass are most consistent with bowel obstruction
bency, the liquid barium sulfate fills the dependent fundus and (mechanical ileus). Recommendation:Exploratory laparotomy.
body and gas rises to the pyloric portion of the stomach. C In Rationale: Although the source and location of the obstructive
the dorsoventral view in ventral recumbencv,the licuid barium diseasecannot be determined with the available information,
sulfatefills the dependentpyloric portion of the stbmach,and once the diagnosis of obstructive bowel diseasehas been made,
gas rises to the fundus. D, In the ventrodorsal view in dorsal the treatment is the same-surgical intervention. An intussus-
recumbency, the liquid barium fills the dependent fundic and ception was found at surgery.
pyloric portions of the stomach, and gas rises acrossthe body
Abnormal radiographic signs include focal site of irregular,
of the stomach.
thumbprint mucosa-barium interface with narrowed bowel lu-
6. The stomach is greatly distended with gds and some fluid. In men in the midportion of the descending duodenum. The
left recumbency (A), the gas outlines a round portion of the remainder of the small intestine as seen on these images is
stomach representingfundus and body of the stomach, but the unremarkable. The apple-core appearanceof the duodenal le-
pyloric portion of the stomach is not identified becauseit is sion is seen most frequently with abnormalities that originate
filled with fluid. In right recumbency (B), gas rises to outline in the bowel wall and produce ulceration of the mucosa.
the pyloric portion of the stomach, which indicates that the Possiblecausesinclude primary intestinal neoplasia;bowel ul-
pyloric portion of the stomach is located on the left side. Fluid ceration secondary to mast cell tumors, uremia, hepatic disor-
shifts to more uniform distribution throughout the body and ders, recurrent pancreatitis; or granuloma. The diagnosis was
fundus of the stomach. The pylorus is displaced dorsally and bowel carcinoma.
to the left, and the fundus and body are displaced ventrally
There is a generalized, mild distention of the stomach and
and to the right. Changesindicate gastric volvulus.
small intestinal tract with air. Portions of the colon are also air
7. (A) The stomach is shifted in position such that the body and filled. This appearanceis most consistent with functional ileus,
pylorus of the stomach are displaced caudally. This pattern of which may be causedby bacterial or viral enteritis, abdominal
displacement is characteristic of hepatomegaly. Specific cause pain, use of anticholinergic drugs, or malabsorption. Further
of the hepatomegalyis not identified. work-up indicated recent seroconversionto feline immunode-
ficiency virus-positive status. Presumptive diagnosiswas bacte-
8. (E) In this dog, the stomach has emptied very little after 4
rial or viral enteritis secondary to immune suppressionassocr-
hours. A little of the contrast medium has exited the stomach,
ated with feline immunodeficiency virus.
but the bulk of the contrast medium is retained in the stomach.
Thus gastric emptying is significantly delayed. There appears 6. Passageof barium through the stomach and small intestinal
to be an annular restriction around the pyloric sphincter, but segments is abnormally slow. In a normal cat, the stomach
this is not confirmed on this one image. In this dog, changes should be empty of barium by I hour post administration. By
were due to restrictive disease of the pyloric sphincter that 3 hours, the stomach and small bowel should both be empty,
were identified fluoroscopically and at surgery. with the remaining barium located in the colon. Delayed con-
trast passagecould be due to recent administration of parasym-
9. There is a large, round, sharply marginated filling defect within
pathomimetic drugs, inadequate volume of barium (through
the pyloric antrum. At surgery, a large, round rubber ball was
either underdosing or patient vomiting), or functional ileus. In
removed from the stomach.
this cat, barium volume was adequate,and no inhibitory drugs
10. There is an annual mural filling defect encircling the pyloric had been given. Radiographic diagnosis was functional ileus.
antrum. There is also an outpouching of luminal barium The cat was euthanized;necropsy diagnosiswas granulomatous
sulfate on the cranial surface of the annual filling defect. This (noneffusive) feline infectious peritonitis.
outpouching is an ulcer that is located in the middle of the
7. Administration of an inadequate volume of barium at the
annular mass. The duodenum is located more dorsally than
beginning of the study. If the patient vomits the contrast
usual, but no significancewas attached. Endoscopic evaluation
medium, redosing can often be accomplished without subse-
of the stomach confirmed the ulcer, and surgery was per-
quent bouts of vomiting.
formed. Final diagnosis was gastric adenocarcinoma with ul-
ceration. 8. Mechanical obstruction of the intestine could show no radio-
graphic signs on survey radiographs if (1) the obstruction is
Ghapter 48: The Small Bowel only partial; or (2) the obstructing object is radiolucent and is
located in the proximal duodenum. Any air or fluid accumulat-
l. (B) A 14-year-old cat with anorexia and severe weight loss,
ing proximal to this site is evacuatedby vomiting.
and (C) A 4-month-old puppy with vomiting and palpable
abdominal mass. Fat is essential for the contrast that allows 9. Radiographic signs of pathologically significant filling defects
visualization of intestinal serosal surfaces. Anything that se- include the following: (1) Shapeof the filling defects-if round,
ANSWERS 74I
likely to be air bubbles; if elliptical, likely to be ingesta such curate than abdominal radiographs in determining bowel wall
as rice; (2) Other abnormal radiographic signs increase the thickness.
possibility that the filling defects are pathologic (i.e., luminal
distention, irregular mucosa, or abnormal location of the af- Ghapter 49: The Large Bowel
fected bowel segment). l.D 2.False 3.A 4.Tiue 5.D d.A 7 .A 8 .C
10. Tiue. Either palpation or ultrasonography would be more ac- 9.C r0.A
I NDE X
Note: Page numbers followed by the letter f Adrenal glands (Continued) Antebrachium ( Continued)
refer to figures; those followed by t refer to anatomy of, 486f, 487, 533f fracturesof, 166f, 172f, l76f
tables. calcification in, 531-533, 533f Anticoagulants, 437
cortisol output reflected in, 534-536, 535f, lung affected by, 437, 44lf
536f rodenticide containing, 437, 44If
"dumbbell" and "plump," 534, 534f, 535f
-A mineralized tumors of, 490f, 531^533,
Aorta, 408
canine/feline,408, 409f, 4l0f
A B C m n e m o n i c ( b o n e e va lu a tio n ) ,1 4 3 - 1 4 4 533f, 536 diiation of, 407-408, 409f, 4l0f
ABCDS mnemonic (fracture follow-up), pheochromoqtoma of, 498, 509f, 533f, Aortic arch, 408
1 7 1 - 1 7 2 ,r 7 r f , r 7 2 f 535f,536f canine/feline
Abdomen, 483-515 size/shapeof, 534-536, 534f, 535f, 536f dilation of,408
canine/feline, 483*515. Seealso Peritoneal ultrasonography of, 534-536, 534f-536f megaesophagusrole ol 336f, 341*342,
space. Age, fracture healing affected by, 169, 170f, 341f, 342f
anatomy of, 483-488, 485f-488f, 700f,701f 1 7 3t persistent right fourth, 336f, 341-342,
CT scan of,490492,490f Air (atmospheric), sound wave impedance in, 341f, 342f
evaluation steps in, 489-490 2lt Aortic stenosis, 4l1f, 413
f^+ quanLtty qlA ql7' -_^'
lat ^,,^-rit.';- il1, Jta. Jllt, )ZYI Ailgas, 4344,43f, 43t, 44f. Seealso Apophysis, 136
fluid in. SeePeritoneal fluid. Pneumothorax. 'Apple core" appearance
interpretationparadigms for, 483492, in canine/feline patients femoral neck, 167, 168f,202
485f492f, 489r joint spaceinjection and, 189, l90f villonodular synovitis with, 202
massesin, 493-515, 493f-515f kidney with, 561 Aprons, safety requirement for, 4, 5
enteric, 496, 505f, 506f liver with, 544, 547f A rachnoi dmembrane,l l 1, 11l f, 112f
hep atic, 49 549 6, 498f-500f mediastinal,383-388, 387f, 388f Arthritis
mesenteric, 496, 505f, 506f osteochondrosiswith, 146, I47 f canine/feline, 199-202
ovarian, 498, 5lOf prostategland with, 595, 597f polyarthritis in, 200*202, 20If
pancreatic,496,5O6f retroperitoneal,383-388, 388f polyarticular, 199-200, I99f , 200t
renal, 498, 507f-509f small intestine wall with, 655-656 rheumatoid, 200,200f
retroperitoneal, 498, 507f, 509f stomach with, 487-488, 488f septic (infectious), 199-200, 199f, 200t
splenic, 496, 502f, 503f u r i nary bl adderw i th, 573,574f,575f,580f, equine, 2 18-2 19, 242-244, 281-282
s u D l u m D a r),l J , ) lJr 582, 583f septic, 242-2 44, 28 | -282
organ structuresin, 483-488, 4831,4841, u terusw i th,605,608f carpus in, 242-244, 244f
485f-488f, 4891 "vacuum" sign due to, 146,147f phalangeal, 281-282, 283f
radiographictechniquefor, 488-489, 4881 in equine patients stifle in, 218-219,22Of
489f, 4891 foredigit containing, 707f, 708f
rarsusln, zzo, zzor
regions/zonesol 483-488, 4831,484t, guttural pouches with, 455-459, 455f-460f
Artifacts. Seealso Radiographs.
485f-487f mediastinal, 478480
myelographic,l16, l19f
scintigraphyof, 491f, 492 tracheallesionsand, 460-461, 460f,461f
nipples causing,46, 48f
ultrasonographyol 490, 490f radiopacity due to, 43-44, 43f,43t, 44f
skin-fold causing, 39940f , 40lf
Abdominal rvall, 525-528 Airway. See also Trachea.
ultrasonographic, 23-27, 24f-27f
canine/feline,525-528 canine/feline, 3 I 0-3 I 1
h e r n i a i n , 5 2 8 , 5 28 i 6 0 5 , 6 0 7 1 6 5 1 , 6 5 1 f Arytenoepiglotticfolds, 45i-452, 451f,454f,
equine
+ r . , , lf ) r + r a. r , no \,L1_6. 462f
fidl cyst blockage of, 9I-94, 93f, 95f
Abscesses hematoma blockage of, 94, 96f Arltenoid cartilage, 451, 451f, 453f
canine/feline obstruction of, 9l-94, 456, 457f, 458f Ascariasis,648, 650f
liver affectedbv, 5-14,:.17t-,5'18f,549t ALARA principle, 3 Aspergillosis,78, 79f
pancreasaffectedb1',)21i,621, 622f Alpha particle radiation, 3 Astrocytoma,105, l07f
peritoneal spaceatfectedbr', 520f-522f, Aluminum strip grids, 14-15, l4f, l5f Ataxia, equine, 129-133, 129f, 13lf-133f
524f Alveolar cresr,72,72f Atlantoaxial joint
stomachdisplacementby, 621, 622f canine/feline,72,72f, 84, 84f canine/feline, 690f, 692f, 694f
teeth affectedbv, 8t!-81, 82f periodontal diseaseaffecting, 84, 84f sublr.rxationof, 100, 100f
equine Arral canal, canine/feline, 660-662, 661f, 662f, equine,724f
epiglottis affectedbi', 452, '152f 666f ataxia related ro,128-129, l29f
lung affectedby, a69-'170,47Lf,472f,479f Anconeal process,147-149, 149f malformation affecting, 128-129, I29f
teeth affected by, 96f, 9 t-, 97f Angiogenesis,135 Atlantoaxial ligament, 62f
Absorption, 2-3, 2f, 4, 9, 9f Annulus fibrosus, 110-1i1 Atlanto-occipital joint
atomic number relatedto, 9, 4344, 43f,43t, anatomy of, ll0, 11lf canine, 690f, 695f
44f mineralizationof, I I l-112, 113f equine,724f
dose differencesdue to, 2-J. 2f Anode
Atomic number
tissuedifferencesin, 2-3, 2f, 4,9, 9f, 4344, focal spot size related to,7, 7f
absorption effects related Io,9, 4344, 43t
43t, 44f grid positioning reiative to, 14-15, l4f, l5f
photoelectric effect and, 9
Acetabulum pitting of, 6-7
Atrial enlargement, 403, 403f, 404f,406f
canine/feline rolating, 5f, 6-7
anatomy of, 683f x-ray tube with, 5-6, 5f, 7f o %.-
hip dysplasiaaffecting, I9I-194,193f, l94f Antebrachiocarpal joint $tt$
canine, 680f-682f rrriiieullii+
osteophltes of, 193f, I94f
e q u m e ,/ z J r eqluine,702f-706f Baastrup's syndrome, 103, 104f
anatomy of,723f Antebrachium, 678f-682f Balance
Adrenal glands, 531-536 canine/feline canine wobbler syndrome in, 10i, i23
canine/feline, 531-536 anatomy of,678f-682f equine hoof role in, 288-289, 290f
743
7 IA I NDE X
tetralogy of Fallot as, 414, 415f traumatic, 364f, 365f, 366, 366t, 367f Hydrocephalus, 69, 72
tricuspid dysplasia as, 406f, 414 small intestinein, 651, 65lf canine/feline
ventricular septal defect as, 413, 4l4f umbilical, 528,528f breeds affected by, 72
enlargement of, 402406 uterus in, 605,607f calvarium aflectedby, 72, 7JI
breed-related variation vs., 402*406 equine,474, 474f ultrasonography of, 69, 69f
generalized, 403, 406, 4O7f 474, 474f
d ia p hragmati c, Hydromyelia, canine/feline, 124
inspiration vs. expiration and, 408f pleural air d:ueto,474,474f Hydronephrosis, canine/fe1ine,508f, 56 i, 5611
left atrium in, 403, 403f,404f Hindfoot. SeeTarsus. 562t, 563f, s64f
left ventricle in, 403, 405t, 407f Hip, 142t Hydroxyapatite, bone content of, 135
right atrium in, 403, 4O6f canine/feline Hygroma, equine carpus wlth, 230,233f
right ventricle in, 403, 406f,407f anatomy of,683f,684f Hyoid bone
failure of, 408-413 asepticnecrosisaffecting,149, 151f canine/feline, 65f, 689f, 692f, 695f
left-sided, 408, 4llf, 4l2f bone infarct affecting, lSlf foreign body vs., 323, 323f
right-sided, 409,4r3f distraction methods for, 194-195, 194f, equine, 725f
parasitism affecting, 4I0f, 413f, 415 195f, 1961 Hyperparathyroidism, 73, 75f, 1,04,l04f
pneumothorax affecting, 397401, 398f- dysplasia of, 190-195, I93f-195f, I96t canine/feline
40rf incidenceof, 191-194 bone metabolism affected b5 73, 103,
small size of,4l8f,4l9 radiographic technique in evaluation of, 104f, 137
thoracic radiography and, 309f, 318-322, 194-195, 194f, r95f, r96t,207f fracture related to, 165f
3r9f-3211 signs in, l9l, l93f-195f,207f nutritional, 104f, 153, 153f, l65f
valr.ular disorder(s) of Iaxity index for, 194-195,194f,195f, l96t osteodystrophydue to, 73, 75f,103, l04f
aortic stenosisas, 410f, 413 normal mature, I93f, I94f resorption due to, 73, 75f,103, l04f
mitral insufficiency as, 404f, 411f,414- prosthesisfor, lSlf Hypervitaminosis A
4r5, 428f sesamoidbones of, 1881,189 bony proliferation due to, 103
pulmonary stenosis as, 406f, 409, 413 Hirschsprung's disease,in canine/feline feline, 103
tricuspid dysplasia as, 406f, 4L4 patients,665,666f Hypothyroidism, canine/feline, congenital, 153,
vertebral heart score measurement for, "Honeycomb" appearance,urinary bladder r54f
318-319 with, 583f
Heartworm disease Hoof, 708f-710f
canine/feline, 410f, 4I3f, 415 equine
heart failure due to, 408, 413f anatomy of,7\8f-710f Ileus, 644-650
hepatomegaly due to, 620f balance of, 288-289, 290f canine/feline, 644-645, 646f, 646t, 647f
lung affected by, 435, 435f flexural deformity affecting, 286-287, 287f, dilation/distention in, 644-645, 646f, 646r,
pulmonary artery in, 423424, 424f-427f, 288f 647f
424t "founder" distance in, 284-286, 285f functional (paralytic), 647f, 650-652
thromboembolism due to, 424, 424r, 426f front limb, 708f-7I0f mechanical, 645.-650, 646f-651f
Hemal arches,57, 6lf laminitis of, 283-286, 284f, 285f Ilium
Hemarthrosis, canine/feline, 199 "ski-tip" appearancein, 284f canine,683f, 684f
Hematoma "toe dancer" stance in, 286, Z87f equine,723f
canine/feline spleen with, 503f Hormones. Seealso Testes. Infarction, bone, 179, 180i 18lf
equine nasal passageswith, 39, 40f bone metabolism affected by, 137 Infections
Hemorrhage Horse. Seealso specifc anatomic structuresand canine/feline
canine/feline disorders. arthritis due to, 199-200, 199f, 200t
joints affected by, 199 anatomy of, 58f, 702f-726f bone affected by. SeeOsteomyelitis.
fung in, 437440, 44lf joints of. SeeIoint(s), equtne; specificbones nasal passageswith, 77-7 8, 79f
retroperitoneal, 5 I 9f and joints. ribs affected by, 357, 357f-359f
equine lung of. SeeLung, equine. sl ernum In,5>/, JJ9I
diaphragmatic hernia with, 474, 474f nasal passagesof, 87-98. Seealso Nasal pas- urinary bladder with, 573, 574f,575f
exercisecausing, 470, 473f sa8es,equlne. vertebrae affected by, 104, 105f
Iung affected by, 470, 473f skeleton of equrne
Hepatic vein, canine/feiine, 541, 542f appendicular,58f, 209-214, 210f, 2I2f, metacarpophalangeal/metatarsophalangeal,
Hepatitis, canine/feline, 543, 545f 2r3f 264-265,265f
Hepatomegaly, 495, 497f axjal, 57-63,58f, 59f, 63-65, 63f, 65f navicularbone in, 102-303, l03f
canine/feline, 495, 497f, 541-543, 542f-546f, interpretation paradigms for, 209-214, phalangeal, 28 I-282, 28| f-283f
543t 2t0f,2r2f,2L3f stifle in, 218-219,220f
differential diagnosis in, 54I-543, 543t radiographic technique in examination of, vertebrae affected by, 129, 130f, 132
generalizedvs. focal, 5431 209-2rr,2r0f Infraorbital canal, equine, 88f, 89
inflammation with, 543, 545f skull of, 65-69, 67f,68f, 87-98, 725f,726f Infrapatellar fat pad, 685f
stomach displacement in, 485i 543-544, spine of, 57,58f,59f,63, 63f, 65f, 127-133 canine/feline
s45f, 546f, 620f vertebraeof, 57, 58f, 59f, 63,63f, 65f, 127- anatomy of, 685f
Hepatozoonosis, 182 r33,r28f-r33f mineralization in, 203f
osteomyelitis due to, 182 Hounsfield units, 29, 29t syrovial volume indicated by, I87, l99f
Hernia Hourglass appearance Intensifting screens
canine/feline, 364-3 69 disc protrusion causing,122f,123, l23f ..'r^nr/^f t? l?f
abdominal wall in, 528, 528f,605,607f, spinal cord with, I22f, I23, I23f phosphorsin, 13, l3f
6sr,65lf Humerus radiographic effect of, 13-14, l3f
diaphragmatic, 364-369, 364f-369f, 366t canine/feline Intensity (I), x-rays per area expressedas,
clinical signs in, 365 anatomy of,676f480f 10-u, 1l f
congenitally predisposed, 367-368 fractures of, 169f, 174f, l78f Interphalangeal joints, 708f-7 11f
esophagusaffected by, 344-345, 345f, in compl eteossi fi cati onof, 157-158,l 57f eqrline, 272f, 274f , 708f-7 ll f
346f infection of, l81f cartilage of, 27 l, 288, 289f
hiatal, 344-345, 368-369, 369t, 370f , psteochondrosisaffecting, 146-147, l48f flexural deformity of, 286-287, 287f, 288f
37r f tumor of, 180f, l83f osteoarthrosis of, 283f
INDEX 749
Peritonitis (Continued) Plasma, x-ray absorption by, 29, 29r Pregnanry, canine/feline, 603-607, 604f, 605f,
canfne/lelrne,5 16, 5ZUI->Zll Pleura, Seealso Pleural effusion; Pleural space. 607f, 608f
Pes,canine, 687f-689f canine/feline, 376f, 390, 390f Projections, 47, 49f
Phalanges equine,475482 radiographic naming system for, 47, 49f
canine/feline inflammation of, 47747 8, 47 8f, 479f Prostate gland, 592-602
anatomy of, 680f482f, 687f-689f Pleural effusion canine/feline, 592-602
carpal,680f-682f canine/feline, 390-397 abscessof, 592, 599, 600f
infection of, 183f, 185f atypical distribution oi 396, 399f arr l n, 5y5, 5yl I
tarsal,687f-689f causesof, 39lt anatomy of, 486f, 487, 487f, 592, 599, 600f
tumor of, 184f, 185f chondrodysplastic breed and, 397f benign hlpertrophy of, 592,599, 600f
eqine, 269-294,708f-715f. Seealso Hoof. clinical significance of, 397 calcificationin, 595, 596f, 599
anatomy of , 274f, 27 5f, 708f-7 15f diagnostic pitfalls related to, 396, 397f clinical signs and, 593, 593f, 594f
cartilage of, 27 )., 287-288, 289f free, 390-397, 39lt cyst of, 498, slzf,592-593,594f
fr actures affecting, 27 6-280, 278f-281f gravity effect on, 396, 396f enlargementof, 498, 51lf, 5I2f,592-595,
hoof balance and, 288-289, 29Of horizontal-beam radiography of, 392, 394f, 593f-595f, 599, 600f, 666f
hypertrophic osteopathy of, 290 39sf inflammation of, 592, 596f,599, 600f,
infectionsof, 281-282, 28|f-283f lung affected by, 391-392 60rf, 664f
keratoma of,289-290 interlobar fissures of, 39lf-393f, 392 neoplasia of, 592-593, 594f, 596f, 599,
laminitis affecting, 283-286, 284f, 285f margin retraction of, 392, 396f 600f,601f
ligamentsand tendons of, 271, 274f, 275f peritoneal fluid with, 397 normal,592, 597f-599f
mastocltosisof, 290 retrosternal opacification due to, 392-396, organ displacementby, 593, 593f,594f
osteoarthritis of , 281-282, 283f 394t ultrasonography ol 598-599, 599f-60If
osteochondrosisaffecting, 287-288, 289f roentgen signs in, 3911401f, 39Ir, 392-397 urethra and, 593, 595f, 597f, 598, 598f
p e r i o s t e u mo f , 2 7 6 , 2 7 6 f trachea affected by, 381, 382f Prostheses, hip, bone infarct due to, 18lf
radiographictechniquefor examinationof, eqrine, 47647 7, 476f47 9f Protons, MRI role of,29-31,30f
270,270t pathogenesisof, 476 Pseudarthrosis, canine/feline,172
septic arthritis of, 281-282, 283f volume of, 476 "Pseudostring"sign, duodenal,644f
soft-tissuevolume of, 275-276, z75t-277f Pleural space.Seealso Pleval effrrsion; Pulmonary artery, 420430
sprain/straininjuries of, 275 Pneumothorax. canine/feline, 420-430
variations in, 270-27l, 27If-27 5f canine/feline, 390402 anatomy of , 420-423, 420f-422f
vascular channel pattern in,272f anatomy of, 376f, 390, 390f, 39lf decreasedsize of,425, 425r,428f
Pharynx mediastinal, 3lI-312, 312f, 3I3f, 376f, enlargementof, 408, 410f, 423-425,423f-
canine/feline 390f 427f, 423t, 424t"
anatomic factors and, 323, 323f, 324f eqrine, 475-482 heartworm diseaseaffecting, 423424,
functional abnormalities of, 324 air in,474f 424f-427f, 424t
mass lesionso[, 323-324,324f anatomy of,475476 margination loss in, 425, 428f
equine, 455-459 fluid line in, 476477, 476f-479f shape changesin, 425, 425f-427f
gunshot wound affecting, 455, 456f massesin, 478, 479f thromboembolism in, 424, 424t, 426f
guttural pouches and, 455, 455f-460f pneumonia in, 470 tortuosity in, 424, 425, 425f, 426f, 427f
radiographicsigns related to, 455461, ultrasonography of, 476, 477f, 479f Pulmonary stenosis,canine/feline, 406f, 409,
455f460f Pneumomediastinum 413
soft palate and, 455456, 457f canine/feline,383-388, 387f, 388f Pulmonary vasculature. Seealso Pulmonary
Pheochromocytoma equine, 478-480 artery; Pulmonary vein.
canine/feline,498, 509f, 533f, 535f,536f Pneumonia canine/feline
renal displacementby, 498, 509f canine/feline, 437, 439f anatomy of , 420-423, 420f-422f
Phosphors equine,469, 469f-472f radiographic signs related ro, 423425,
calcium tungstatein, 13, l3f Pneumoretroperitoneum, canine/feline, 423f-430f, 423t4251
intensifyingscreencontaining, 13, 13f 3 83-388,388f size/shapechangesin, 423-425, 423f428f,
r a r e - e a r t hf o r m o f , 1 3 , L 3 f Pneumothorax, 397401, 472 423t-425t
Photoelectriceffect,9-10, 9f canine/feline, 397401 Pulmonary vein, 420-430
atomic number of absorberand, 9 chondrodysplastic breed and, 397f, 401 canine/feline, 420430
Photons. SeealsoX-rays. diagnostic pitfalls in, 399-401, 401f anatomy of, 420-423, 420f422f
biologic matter interactionsof, 1-5, 2f, 8-10, heart in, 39740I, 398f-401f decreasedsize of, 425, 425t, 428f
9f ll.ng in, 397-398, 397t, 398f-400f, 442f, enlargement of, 424425, 425t, 427f
definition of, 1 444f margination loss in, 425, 428f
P h y s e s1, 3 5 - 1 3 7 ,l 3 6 f roentgen signs in, 39740I, 397f-401f, mitral insufficienry affecting, 425, 427f
canine/feline 397t shape changes in, 425, 425f427f
closuretime for, 136, 163, l64f skin-fold artifact vs., 399401, 40If Pyelography,canine/feline, 556-557, 558f-560f,
distal ulnar, 136,136f, I64f tension (pressure) form of, 399,400f 562t
"double," 153 unilateral effects in, 399,400f Pyelonephritis, 561, 564f
fractures affecting, 163, 163f, 164f,168f, equine, 472, 473f, 478, 479f Pylorus, 615-618
r97f Pododermatitis, 182-184 canine/feline, 6I5f, 6I6f
inflammation of, 104 canine/feline,182-184, 184f, l85f gas associatedwith, 487-488, 488f, 6l6f-
premature closure of, 163, I64f tumor vs., 182-184,184f, I85f 6r9f, 617
e q u i n e ,2 4 1 , 2 4 2 f ,2 4 4 f Polyarthritis, 200202 normal, 615-618, 6I5f-620f
inflammation of, 241.,242f, 244f canine/feline, 200-202, 20lf obstruction of, 624f, 626-628, 627f-629f
Physitis feline noninfectious form of, 20I-202,20Lf Pyometra, 493
canine/feiinevertebrawith, 104 SLE causing, 200-201 canine/feline, 490f, 493, 494f, 605, 606f
equine carpusrvith, 241, 242f,244f Polydactyly, canine/feline, I 52 ultrasonography of, 49of
y r a m a t e r ,l l l r Polymyelia, canine/feline, 152 uterine stump with, 663f
Piezoelectric crystals Portal vein, canine/feline, 54I, 542f, 544f-546f Pythiosis,629,631
u l t r a s o n o g r a p h itcr a n sd u ce rco
' n ta in in g . Portosystemic shunt, 543-544, 621
canine/feline, 543-544, 546f, 547f, 621, 622f
voltage applied to, 22 scintigraphy of, 491f, 492
Pins, liacture fixation with, 165f, 168f-176f, small liver dLreto, 621, 622f Racing,equine hemorrhage&te to,470, 473f
1 6 9 - 1 7 2 ,l 7 8 f stomach displacement related to, 62I, 622f Rad unit,2-3
75,4 INDEX
CT imaging o1,64,64f, 123-124, l23f sarcoma of,204f,205 cricopharyngeal, 333-335, 334f, 335f, 336t
c n , r i n e i R f 6 3 h 3 f. f1 5 l 1 2 7 - 1 3 3 septic arthritis of, 199-200, t99f,200t oropharyngeal,33 l-333, 333f-315i, 336t
a n a t o m ] 'o f , 5 7 , 5 8 f, 5 9 f,7 2 3 f,7 2 4 f sesamoidbones oi 188t, 189 pharyngeal, 333-335, 334f, 335f, 336t
d i s o r d e r :a f f e c t i n g .1 2 7 1 3 3 . l2 9 l- 1 3 3 f equine,215-222 Symphysis pubis, equine, 723f
myelographvof, 128, 128f anatomy of, 215, 2I6f, 2I7f, 721f, 722f Synovium. Seealso Joint(s).
radiographic technique for examination of, cystJike lesions of, 218, 2I8f, 2I9f canine/feline
63, 63f,65f, r)7 fracture affecting, 219, 220f, 22lt inflammation of, 202
feline osteoarthritis of, 22Of villonodular, 202
a n a t o m vo f . 5 7 . b lf, 9 8 - ca . IIT f osteochondrosis of, 216, 2l8f joint diseaserelated to, 187, 188t, 199-205,
disorders affecting, 99-109, 110-127 patellar changesaffecting, 219, 220f, 22lf 199f, 200f, 200t,203f, z04f
75|'. INDEX
K
Tail
shifting stability phenomena in, 38' 40f
theories of, 3541, 35f4lf
vision searchpatterns in,3941' 4Lf
in,243f
Wobbler syndrome
canine, 101, 123
scattered,9-10, 9f
photon energy spectrum of, 6, 6f
X-ray tubes, 5-10, 5f, 7f,8f, Ilf
Vitamin A, bony proliferation due to, 103 equine, 129-133
collimator for, 10, 10f
Vitamin D, bone metabolism affectedby, 137 filters with, 10, tOf
Voltage, piezoelectric crystals rcceiwng, 22
focal spot size of,12, l2f, l3f
Volvulus, 623-626, 651-652
canine/feline Xeroradiography,equineanatomyn, 702f-726f
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