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Posterior sub-talar joint (PSTJ). The PSTJ is a synovial joint formed by the articulation of the posterior articular facets of the talus and calcaneum. Intra-articular extension into the PSTJ is often seen in comminuted calcaneal compression fractures and represents an important factor in the surgical classification of these injuries.
Cuboid. The cuboid possesses a proximal articular surface that only articulates with the calcaneum. Distally the cuboid articulates with the fourth and fifth metatarsals.
Neck of the talus. The talar neck is an important review area when evaluating ankle radiographs and CT in the setting of trauma. Missed talar neck fractures can result in avascular necrosis of the talar dome due to its blood supply being derived from vessels that enter the talar head and travel proximally within the neck.
The sinus tarsi. This is a fatty space beneath the talar neck and above the calcaneal body. The sinus tarsi also contains the cervical and interosseous ligaments along with traversing nerves and vessels. Inflammation and cyst formation in this space following trauma may produce a painful ‘sinus-tarsi syndrome’.
Os trigonum. This is present in 10% of individuals and when present, is bilateral in 50%. It may be present as a separate ossicle or be partly fused with the posterior talar process forming a synchrondrosis. The os trigonum may produce repetitive soft tissue impingment in the ankle due to repetitive plantar-flexion resulting in a painful ‘os-trigonum syndrome’.
Transverse ultrasound through stomach pylorus and upper abdomen
Lesser trochanter of the right femur. The iliopsoas tendon attaches here. This is a powerful flexor of the hip.
Greater trochanter of the right femur. Gluteus medius and gluteus minimis attach here. These tendons act to perform hip abduction and lateral rotation. They can produce avulsion fractures of the greater trochanter in trauma.
Left L5 transverse process. The ilio-lumbar ligament attaches here. Traction of this ligament in pelvic trauma can cause an avulsion fracture of the transverse process. It also acts as an anatomical landmark on MRI for identifying the L5 vertebral body.
Pubic symphysis. It is a secondary cartilaginous joint.
Left inferior pubic ramus. Adductor magnus and adductor brevis attach here acting to adduct the hip.
Axial T2-weighted lumbar spine through L5
Left L5 nerve. At the level of the L5/S1 disc, the L5 nerve has already left the neural exit foramen. It may become compromised by a far lateral L5 disc herniation in this position.
Nucleus pulposus of L5/S1 disc. This soft central component of the disc is surrounded by the tough outer annulus fibrosus. Annular defects result in herniation of the nucleus pulposus referred to as protrusions or extrusions, based upon their morphology. On T2-weighted images the nucleus pulposus is of high signal and the annulus fibrosus is of low signal intensity.
Left lamina of L5 vertebra. Each lamina fuses in the midline to form the spinous process. The lamina is partly or completely resected (laminectomy) during lumbar disc surgery to facilitate access to the disc.
Right psoas major muscle. This is a powerful hip flexor. In the clinical setting of lumbar discitis it is common to see infection tracking from the disc space into the psoas muscle to form a psoas abscess.
First FRCR Anatomy: Questions and Answers provides eight test papers modelled on the exam format of the Royal College of Radiologists' anatomy module. Written by a team of consultant and trainee radiologists, the practice questions and answers will give you the advantage you need to succeed and stand out from the average trainee. The questions include images from all modalities – CT, MRI, ultrasound, plain film, screening and angiography, closely correlating with the images you are likely to see both in the exam and in day-to-day practice. Expanded clinical answers also distill clinical radiological knowledge accrued over many years of clinical practice, making this much more than a revision aid. First FRCR Anatomy: Questions and Answers covers the full breadth of curriculum topics including MSK, cardiac, thoracic, genitourinary, gastrointestinal, vascular, neuro and pediatric imaging. An essential resource for all First FRCR candidates.
Popliteus tendon. This point represents the popliteal groove or sulcus within which the popliteus tendon inserts. The popliteus tendon is an important structure that contributes to stability of the postero-lateral corner of the knee.
Styloid process of the fibular head. Biceps femoris, a powerful hamstring muscle, attaches here along with the fibular collateral ligament and the arcuate ligament complex. The fibular styloid process can be avulsed during high energy trauma to the postero-lateral corner of the knee producing an ‘arcuate sign’ on radiographs.
Medial collateral ligament (MCL). The MCL is an important medial stabilizer of the knee, resisting valgus stress. A bony avulsion of the proximal MCL attachment may produce a non-united fragment called a Pellegrini–Stieda lesion, visible on AP radiographs.
Medial tibial spine. The medial tibial spine bears the attachment of the medial meniscal roots along with the footprint of the antero-medial bundle of the anterior cruciate ligament.
Bipartite patella. A bipartite patella is an unfused secondary ossification centre on the supero-lateral corner of the patella. These must not be mistaken for acute fractures, but may become symptomatic if the synchondrosis between the two bone fragments is disrupted following direct trauma.
Main submandibular duct. This is also known as Wharton's duct, and conveys mixed mucinous and serous secretions, which are more prone to form opaque calculi.
Intraglandular duct. On ultrasound scan examination, intraglandular ducts are visualized as small linear hypoechoic stripes.
Hyoid bone. This does not articulate with any other bone, and is held in position by the thyroid ligaments. It is highly mobile, with mobility provided by a number of muscles and ligaments. It develops from the second and third pharyngeal arches.
Condylar process of the mandible. The lateral extremity of the condyle is a small tubercle for the attachment of the temporomandibular ligament.
Coronoid process of the mandible. This is a thin triangular eminence, whose lateral surface affords insertion to the temporalis and masseter muscles.
The reintroduction of an anatomy section heralded a welcome return to the part 1 FRCR examination. Anatomy is the main cornerstone on which radiology rests and without a good grounding, being an effective radiologist is impossible. Clinicians often call upon radiologists to guide them with anatomy in addition to steering them towards better diagnosis and management of their patients.
Our aim with this book was much more than a simple pre-examination self-assessment text. From its inception, we wanted to write a text that would prove equally as useful after the part 1 FRCR examination and therefore endeavoured to include radiological ‘pearls’ that would serve the radiologist well throughout his or her career. Similarly a non-radiologist reading the text would derive significant benefit in their particular field. The authors have chosen these clinical ‘pearls’, from within their own susbspecialties, rather than purely didactic information that might be obtained in other standard textbooks.
The cases in this book very closely match the standard type of cases likely to be encountered in the actual anatomy section of the examination.
Self-assessment gives immediate feedback to the reader which is often lacking in larger texts. Furthermore it gives a framework for further reading in the various subspecialties. We also believe that this text will be invaluable to medical students, foundation doctors and specialist trainees in surgery and medicine.
Ligamentum teres. This strong ligament inserts into the fovea centralis of the femoral head along with important nutrient vessels.
Acetabular labrum. This incomplete fibrocartilaginous ring contributes to hip joint stability. It may undergo traumatic or degenerative tearing leading to hip pain, instability and mechanical symptoms such as clicking.
Gluteus medius tendon. This is an important abductor and lateral rotator of the hip that inserts upon the lateral and posterior facets of the greater trochanter.
Iliotibial band (ITB) or tract. This long dense fascial band is a continuation of the tensor fascia lata muscle. It may undergo friction with resultant thickening and inflammation as it passes over the greater trochanter, producing painful, proximal ITB friction syndrome.
Transverse part of the ilio-femoral ligament. The ilio-femoral ligament is a thickening of the joint capsule and is the strongest of the three hip ligaments, the other two being the ischio-femoral and pubo-femoral ligaments.
Right sacroiliac joint.
Right anterior inferior iliac spine.
Right superior pubic ramus.
Left obturator foramen.
Contrast in bladder.
Cystograms are performed by either hand injecting, or running in a contrast infusion through either a urethral or suprapubic catheter. Both antero-posterior (AP) and lateral views should be taken, and the bladder should be filled as much as a patient can tolerate.
Lesser tuberosity of the right humerus. The subscapularis tendon attaches here. This may rarely become avulsed during hyper-external rotation injury due to traction by the subscapularis tendon insertion.
Greater tuberosity of the right humerus. This forms the bony footprint for the supraspinatus tendon.
Right acromion. The coraco-acromial ligament attaches from here to the coracoid process, forming a roof over the shoulder joint. Bony enthesopathy of this ligament may contribute to subacromial impingement of the supraspinatus tendon and is implicated as a causative factor in the evolution of rotator cuff tears.
Right acromio-clavicular joint. This narrow synovial joint commonly undergoes degenerative changes but may also develop erosions in inflammatory arthropathy.
The antero-inferior glenoid rim. This bears the attachment of the anterior band of the inferior glenohumeral ligament, which is an important static stabilizer of the glenohumeral joint. This region may be fractured during anterior glenohumeral dislocation, producing a bony Bankart lesion.
Coronal T1-weighted MR knee
Medial collateral ligament (MCL). This important ligament arises from the medial femoral condyle and inserts on the medial tibial diaphysis and resists valgus stress of the knee.
Posterior cruciate ligament. This strong ligament arises from the lateral surface of the medial femoral condyle and inserts on the posterior intercondylar fossa of the tibia. It is a central stabilizer of the knee resisting posterior tibial translation.
Iliotibial band (ITB). This long structure originates from the fascia of the iliotibial tract and inserts on Gerdy's tubercle on the antero-lateral tibia. Distally it may undergo repetitive friction over the lateral border of the lateral femoral condyle to produce painful distal ITB friction syndrome.
Articular cartilage of medial tibial plateau. This thick layer of hyaline cartilage is composed of four zones or layers. During the evolution of osteoarthrosis the chondral layers may undergo softening, fibrillation, fissures and progressive thinning, ultimately resulting in full-thickness cartilage loss and sclerosis of the exposed sub-chondral bone.
Discoid lateral meniscus. The lateral meniscus is broad, spanning the whole width of the lateral tibio-femoral compartment. This normal variant, if present, is frequently bilateral and should be examined carefully due to the high incidence of degenerative tears with this variant.
Left brachiocephalic vein. The left brachiocephalic vein forms a silhouette with the adjacent lung. This interface ‘fades’ above the clavicles as it becomes more anteriorly placed and ‘merges’ with the anterior chest wall.
Right atrium (right heart border).
Right cardiophrenic recess.
Azygos fissure. The azygos fissure is seen in 0.5% of chest radiographs. It is formed by the caudal invagination of the azygos vein through the apex of the right upper lobe. It begins as a line in the upper portion and extends in an arc caudally toward the ‘teardrop’ density that is the azygos vein. The azygos vein is outside the parietal pleura – the line is therefore composed of two visceral and two parietal pleural layers. The so-called azygos ‘lobe’ is the segment of lung between the fissure and the trachea. It is not a true separate ‘lobe’ as the total bronchial anatomy in the right upper lobe has not been altered even though there may be minor variations in the bronchial supply to this segment of upper lobe.
Coronal neonatal ultrasound through the anterior fontanelle
Left lateral ventricle. The combined width of the lateral ventricles on coronal imaging should be less than a third of the total width of the intracranial fossa at the same level.
Superior sagittal sinus. Colour flow and Doppler can be used to assess venous sinus patency.
At the time of writing, the anatomy section of the part 1 FRCR examination consists of 20 digital images presented on a computer with a 19″ monitor. Each image has five questions attached, labelled a–e. You will have 75 minutes to answer a total of one-hundred questions.
The images presented are DICOM images, which have been converted into j-pegs or tiffs in order to allow annotated symbols to be applied. These images are then converted back into DICOM and uploaded onto an OsiriX database. It is absolutely essential to familiarize yourself with this software prior to the examination. It should be noted that the OsiriX software is only available for Apple Macs and not on IBM PCs. There is however opportunity prior to the start of the examination to manipulate sample images. The answers are to be written into a booklet.
There is further information regarding the examination available on the Royal College of Radiologists website www.rcr.ac.uk which should be part of your essential revision. There are also sample questions and answers to access.
The basics are true for any examination but need to be reiterated here.
This is not an examination to be taken lightly. The anatomy learned at medical school may be far removed from radiological anatomy in the workplace. However, more and more medical schools are using radiological anatomy to educate their undergraduates. Anatomy has been ‘brought to life’ in the workplace by radiologists. A good way of learning anatomy is to sit at your PACS workstation. On one screen put up a patient's chest radiograph with a CT scan of the thorax on the adjacent screen. Scrolling through the CT study allows easier explanation of the production of interfaces seen on the chest radiograph. This applies equally as well with the abdominal radiograph and CT of the abdomen and pelvis. The anatomy tested in the examination is not beyond the scope of most of the basic radiology atlases and therefore a regular consistent approach to revision is advised.
Posterior column of the left acetabulum. The posterior and anterior columns of acetabulum provide the dominant load-bearing support of the hip joint. It is important to evaluate the integrity of the acetabular columns in the setting of pelvic trauma as fracture involvement of these structures is integral to all classification systems of acetabular fractures.
Left rectus abdominis muscle. This is a strap-like muscle encased in a fascial sheath. It inserts onto the anterior surface of the pubic symphysis and has an aponeurosis which is continuous with that of the gracilis and adductor longus muscles.
Right obturator internus. This arises from the internal surface of the medial acetabulum and inserts on the greater trochanter of the femur. Its action is to produce external rotation of the hip.
Right sartorius muscle. This arises from the anterior superior iliac spine. It has a long muscle belly directed distally and medially spanning the hip and knee joints with an insertion on the antero-medial aspect of the tibia as one of the pes anseurinus tendon group.